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Cideous

I got a Teledoc email today saying: Don't go to the ER or Urgent Care, use us....

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Shocking was all I could say.  I've received these notices before but they were subtle and for very minor issues.  This was a full on ad blitz showing you (in $$$) how much you could save by using Teledoc instead of the ER or Urgent Care.  All I could think of was:

1.  Teledoc is going to make a crap ton of money...and

2.  This is the future

3.  A lot of jobs are going to go virtual in the next 5 years

 

It's a brave new world.

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31 minutes ago, Cideous said:

Shocking was all I could say.  I've received these notices before but they were subtle and for very minor issues.  This was a full on ad blitz showing you (in $$$) how much you could save by using Teledoc instead of the ER or Urgent Care.  All I could think of was:

1.  Teledoc is going to make a crap ton of money...and

2.  This is the future

3.  A lot of jobs are going to go virtual in the next 5 years

 

It's a brave new world.

until they can reduce fxs, suture, and do other urgent/emergent procedures over the phone I think we are ok. It would not bother me too much if folks who should not be in the ER at all use this service. what would bother me(and what will burn them) is when emergent folks call teledoc for "heartburn after a taco" and it ends up being an MI, etc

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11 minutes ago, EMEDPA said:

until they can reduce fxs, suture, and do other urgent/emergent procedures over the phone I think we are ok. It would not bother me too much if folks who should not be in the ER at all use this service. what would bother me(and what will burn them) is when emergent folks call teledoc for "heartburn after a taco" and it ends up being an MI, etc

I'm not concerned about ER's.  Urgent Care on the other hand it could, and I believe will decimate.

Here's why:

Urgent care does not survive on lacerations, fractures and other procedures that can not be done through Teledoc.  Those things are what set UC apart from say Family Practice.  That and accessibility...no appointment needed.  Urgent Care succeeds and is profitable because of the little things like Strep, Flu, coughs etc.  Without those as "filler" between procedures, an UC center will close faster then you can say, "Skype!".

 

 

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I don't know that I would trust someone over the phone to decide strep vs mono vs viral vs peritonsilar abscess.

I can see the appeal for the nuisance" I need a work note because I partied too hard last night" kind of thing, but you can't do any real medicine over the phone. I can see doing follow up visits with established pts for psych counseling and things of that nature that are all about talking and not physical exam.  I am not disagreeing with you. I don't even think retail medicine is particularly appropriate as it erodes the relationship(or need in many cases) for a pcp.

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The ART of medicine shall not die.

Telemedicine can't do a UA with culture and treat the right bug. Can't tell mono from strep or pneumonia from CHF from asthma sometimes. 

Telemedicine can't do a monofilament exam or palpate a joint for warmth or ligamentous stability.

MAYBE a stable diabetic or even some psych stuff but - really - Hands on can't be replaced.

I think it is fraught with danger and the licensure issues have NOT been ironed about between states. 

I will stick with my patients in the room - body odor, foot odor and halitosis and all that - can't freeze a wart over the telly either.

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We are looking at this from the wrong perspective......the patient and their peers are looking for the quick and easy plus cheap answer to their concerns. To heck with good medicine, I want what I want NOW and don't inconvenience me. How many UC patients of yours got PO'ed because you said they need to go to the ED or didn't need antibiotics? Your good medicine wasn't on their agenda. Yes there will be some bad outcomes, but my suspicion is these Telemedicine folks lawyers have some disclaimer up their sleeves for CYA . For years I joked that the ED needed a drive up window, now there's the sit at your desk instead!!! God forbid a patient be  visualized in person and actually touched during an encounter!! Rub that rash with the screen for me or palpate your belly with that tablet!!!! Retirement from what medicine is becoming looks better every time I read stuff like this.

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2 hours ago, CAdamsPAC said:

We are looking at this from the wrong perspective......the patient and their peers are looking for the quick and easy plus cheap answer to their concerns. To heck with good medicine, I want what I want NOW and don't inconvenience me. How many UC patients of yours got PO'ed because you said they need to go to the ED or didn't need antibiotics? Your good medicine wasn't on their agenda. Yes there will be some bad outcomes, but my suspicion is these Telemedicine folks lawyers have some disclaimer up their sleeves for CYA . For years I joked that the ED needed a drive up window, now there's the sit at your desk instead!!! God forbid a patient be  visualized in person and actually touched during an encounter!! Rub that rash with the screen for me or palpate your belly with that tablet!!!! Retirement from what medicine is becoming looks better every time I read stuff like this.

^^^  Could not agree.  I see this mentality every single day in Urgent Care.  If they can get an antibiotic, muscle relaxant or whatever while never leaving home for cheaper then UC?  Every single indication is that they will.  Whether it is bad medicine or not in their mind is not the point.  Hence, my entire point for this thread.  

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The name of the game is "customer service".  And in a service oriented industry, the customer is always right.  And if management wants more flair on your lab coat, better have more than 15.  And you need to focus on the customer "experience", "Cx", because that's better than making sure you address cardiovascular risk factors, which no one wants to hear about, because "my granmawmaw lived to be one hunert and thirty seven by smoking fifty packs a day, and those pills cause diabetes and don't work for me".

We should also start with a joke, because test patients responded better to a provider customer service representative who told jokes.

The best news is we can sit an home in our skivvies while seeing customers.  People get a little wierded out if you do it in the office.

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The name of the game here is that TeleDoc has realized, and monetarily taken advantage of, the fact that the VAST majority of what one sees in a non-emergent, non-surgical patient encounter are minor illnesses which self resolve without ANY treatment.  It's the same thing in my clinic.  If I throw some Disney-sponsored pixie dust at them, and that's their treatment, the vast majority will self-resolve within a couple of weeks.  As long as you advise them to watch out for XYZ, and see the PCP should that occur, you're golden.

Edited by GetMeOuttaThisMess
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6 hours ago, Cideous said:

Shocking was all I could say.  I've received these notices before but they were subtle and for very minor issues.  This was a full on ad blitz showing you (in $$$) how much you could save by using Teledoc instead of the ER or Urgent Care.  All I could think of was:

1.  Teledoc is going to make a crap ton of money...and

2.  This is the future

3.  A lot of jobs are going to go virtual in the next 5 years

 

It's a brave new world.

Telemedicine will kill retail clinics and seriously impact urgent cares 

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There are a few things that render themselves rather nicely to telemedicine, but plenty of others that do not. For the sake of easy money, misdiagnoses will occur.

Here are some sensible uses:

Follow up appointments for chronic problems that are under reasonable control.

The Acne guy (about 10 + years ago). a dermatologist who would have you take a photo of your face on your phone and he would prescribe acne treatment based on what he saw.

Triage, "1. Okay, that can wait, 2. Okay, that needs to go to urgent care or see your PCP,  or 3. OMG, get the hell to the ED before you bleed to death!

Maybe a handful of other simple issues.

 

But here is what's going to happen. Someone gets an uncomplicated URI. They call pocket-doc. He/she feels obligated to do something to make it worth the patient's 50 bucks. So, he/she sends in a Z pack, This already happens in Urgent Care. I had a cough two weeks ago and the two nurses and two MAs in my clinic kept telling me to go upstairs to the urgent care clinic to get a z pack before it gets away from me. I took it as a moment of education.

 

 

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Curious to see how this whole thing shakes out. Someone with knowledge has to be on the other end of that phone call. Honestly, if you could pay me to armchair quarterback medicine for $50 per patient (just making stuff up here...), then maybe I would log on for a few hours a night and be the Uber driver equivalent of a provider. Without doing a physical exam, it's pretty easy to CYA in your note (as best based on history alone, it is most likely xyz, although bla bla bla covering my ass here...). Is it good for medicine? No. But since when did Americans ever do things that were in their best interest? 

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Let's be honest, how often do you actually need a UC?  Especially when you go to a lot of these places and it's an automatic Z pack for any cough regardless of a physical exam.  I'd use something like this if it was available...

 

It's mainly an issue if the PCP doesn't have urgent openings.  My ideal place is a PCP.  If I can't get a same day or next day urgent appointment, I'd go to the ER.

Edited by lkth487
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On 9/8/2018 at 12:51 PM, CAdamsPAC said:

We are looking at this from the wrong perspective......the patient and their peers are looking for the quick and easy plus cheap answer to their concerns. To heck with good medicine, I want what I want NOW and don't inconvenience me. How many UC patients of yours got PO'ed because you said they need to go to the ED or didn't need antibiotics? Your good medicine wasn't on their agenda. Yes there will be some bad outcomes, but my suspicion is these Telemedicine folks lawyers have some disclaimer up their sleeves for CYA . For years I joked that the ED needed a drive up window, now there's the sit at your desk instead!!! God forbid a patient be  visualized in person and actually touched during an encounter!! Rub that rash with the screen for me or palpate your belly with that tablet!!!! Retirement from what medicine is becoming looks better every time I read stuff like this.

This ^^   It is a rare day I don't see someone who "saw" teledoc and got a treatment they didn't need or got the wrong treatment. None of them get no treatment. I am yet to have someone come in and say "I called teledoc for my cold and they wouldn't give me an antibiotic." I'm sure there are good ones out there somewhere but mostly it is prostitution medicine. Pay your money and dictate your treatment.

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This ^^   It is a rare day I don't see someone who "saw" teledoc and got a treatment they didn't need or got the wrong treatment. None of them get no treatment. I am yet to have someone come in and say "I called teledoc for my cold and they wouldn't give me an antibiotic." I'm sure there are good ones out there somewhere but mostly it is prostitution medicine. Pay your money and dictate your treatment.

 

I actually saw a trifecta from one family last week who were given no love by TD. “You have a virus” per parent.

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Webb MD, Google and Telemedicine = " I know what's wrong and I paid good money for you give me a prescription"!!!!

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3 hours ago, CAdamsPAC said:

Webb MD, Google and Telemedicine = " I know what's wrong and I paid good money for you give me a prescription"!!!!

Don’t forget my neighbor’s sister’s boyfriend who is a chiropractor........

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I guess my point was as an Urgent Care PA, I think telemed is going to push a lot of clinics over the edge.  Maybe that's a good thing, and maybe not, but it is something to think about as it will = less jobs.

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Possibly. I think it has such a limited meaningful use people who probably didn't need to be in UC (I need an antibiotic for my cold) will be fewer but I see a fair number of "I got this from the Tele Doc and it didn't work". Its probably too early to tell how telemedicine will change the landscape. It may be a puff of wind and gone in this iteration. It still has lots of good uses in remote consultations etc.

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1 hour ago, sas5814 said:

Possibly. I think it has such a limited meaningful use people who probably didn't need to be in UC (I need an antibiotic for my cold) will be fewer but I see a fair number of "I got this from the Tele Doc and it didn't work". Its probably too early to tell how telemedicine will change the landscape. It may be a puff of wind and gone in this iteration. It still has lots of good uses in remote consultations etc.

I practice out in remote Alaska sites where we can and do use telemedicine for some patients previously seen by various specialist, these visits include the on site clinical staff. I myself have sent many different images to the ED or specialist for consultation on many occasions. But in all events , the patient was physically seen by  clinician previously as part of the treatment process.

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13 hours ago, CAdamsPAC said:

I practice out in remote Alaska sites where we can and do use telemedicine for some patients previously seen by various specialist, these visits include the on site clinical staff. I myself have sent many different images to the ED or specialist for consultation on many occasions. But in all events , the patient was physically seen by  clinician previously as part of the treatment process.

^^^ Wow, that is pretty interesting.  I hope it's going well up there!

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I once told a patient who wanted Norco for his sore throat for a whole twelve hours “No, narcotics are not indicated” and after they changed their tone to the “I know what I want and I want it now” I reminded them that I am not a kiosk at McDonalds and their reply was “ Not yet your aren’t”. Still left with no narcotic and surprisingly (insert sarcasm here) gave me a 2/5 stars on a yelp review. True story. 😉

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7 hours ago, EMSGuy1982 said:

Still left with no narcotic and surprisingly (insert sarcasm here) gave me a 2/5 stars on a yelp review. True story. 😉

 

I wish I had the ability to do that.  If I got 2/5 stars on a review, I would be required to write an explanation to corporate explaining why I got the low review and a list of things I would do different to prevent any further low reviews AND call the patient and apologize while asking (begging) them to remove the review.  Welcome to corporate Urgent Care.

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1 hour ago, Cideous said:

 

I wish I had the ability to do that.  If I got 2/5 stars on a review, I would be required to write an explanation to corporate explaining why I got the low review and a list of things I would do different to prevent any further low reviews AND call the patient and apologize while asking (begging) them to remove the review.  Welcome to corporate Urgent Care.

I guess writing back that the person in question was a manipulative O2 thief and you could keep your ratings up by refusing to see anyone who demands opioids or antibiotics for no good reason would upset them?

SK

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