Can you work fully remotely in neurology?

[Phantom Spike]

Regarding IOM, looks like it could be a fairly lucrative full-time option for those with neurophys/epilepsy training, but one thing I potentially worry about (which was alluded to briefly above) is "dead-ending" your clinical career. You need to get multiple state licenses and hospital privileges (just like with telestroke) but you don't see actual patients. If you do this for a few years, you won't have much of a patient log (or good clinical references in your own specialty). What if you then decide you want to go into clinical neurology again? Is this a major hurdle? Case logs seem to be more and more a requirement in hospital privileging as well as for locums/telestroke work.

---

Members don't see this ad.

 

[Giovanotto]

Anyone know if you can work IOM or telestroke from outside the US? Like can you pick up US time night shifts while being in the EU? this possibility would excite me enough to actually finish my training smiling.

 

[Aldertonghen]

Anyone know if you can work IOM or telestroke from outside the US? Like can you pick up US time night shifts while being in the EU? this possibility would excite me enough to actually finish my training smiling.

I know an attending at a small sized university who regularly goes back to India and does remote telestroke. You need specific VPNs and whatnot, but I think it's doable (have to clearly ask details about this with the company of course).

 

[cerebral edema]

Anyone know if you can work IOM or telestroke from outside the US? Like can you pick up US time night shifts while being in the EU? this possibility would excite me enough to actually finish my training smiling.

There was a company that advertised in the AAN for this. I spoke to them. They were mainly looking for people in Australia/Asia to cover nights on the West Coast.

 

[cerebral edema]

Did they require that applicants be vascular trained?

A lot of them don’t require it if you have relevant experience. For example, I’ve been a Neurohospitalist for years. I’ve interviewed at several tele-neurology companies and it’s never been an issue.

 

[xenotype]

A lot of them don’t require it if you have relevant experience. For example, I’ve been a Neurohospitalist for years. I’ve interviewed at several tele-neurology companies and it’s never been an issue.

Agree. Recent stroke experience is required, and yes they will ask for case logs as was mentioned above. The biggest company was founded and is all run by mostly non-stroke fellowship neurologists that have extensive telestroke experience.

 

[neurochica]

One issue that does come to mind is that if one does not have "face-to-face" patient encounters for extended periods of time, it might become problematic if you then want hospital privileges or apply for locum/telestroke work. Most institutions are asking for patient logs these days.

I think people here are overlooking this. I know 2 docs having trouble getting a job after 1 year of tele work because they can’t get credential because they have not “seen” patients in person.

 

[xenotype]

I think people here are overlooking this. I know 2 docs having trouble getting a job after 1 year of tele work because they can’t get credential because they have not “seen” patients in person.

What type of 'tele work' were they doing? Were they credentialed at a hospital during this tele work with neurology privileges?

 

[Phantom Spike]

What type of 'tele work' were they doing? Were they credentialed at a hospital during this tele work with neurology privileges?

Yes, I hope we can get clarification. I was thinking this would be an issue with IOM or EEG-only remote jobs, but do teleneurology/tele-stroke encounters also not generate patient logs? How does one bill these encounters, with traditional CPT codes?

On a related note, if someone has mostly outpatient experience, is it hard to get a teleneurology/tele-stroke job?

With regard to doing teleneurology internationally, I recall being told that you need to be licensed in both the state you are in and the state the patient is in during the encounter (making international remote work not an option), but then maybe that's where the VPN comes in. Legally might be on shaky grounds, though.

 

[Postictal Raiden]

Yes, I hope we can get clarification. I was thinking this would be an issue with IOM or EEG-only remote jobs, but do teleneurology/tele-stroke encounters also not generate patient logs? How does one bill these encounters, with traditional CPT codes?

On a related note, if someone has mostly outpatient experience, is it hard to get a teleneurology/tele-stroke job?

With regard to doing teleneurology internationally, I recall being told that you need to be licensed in both the state you are in and the state the patient is in during the encounter (making international remote work not an option), but then maybe that's where the VPN comes in. Legally might be on shaky grounds, though.

I can’t imagine one being comfortable managing acute stroke after a year or more of doing only outpatient.

My non-stroke attendings are absolutely brilliant. They are experts in their fields. However all of them acknowledge that they are not comfortable with managing acute stroke.

 

[neurochica]

What type of 'tele work' were they doing? Were they credentialed at a hospital during this tele work with neurology privileges?

100% tele stroke. Not working at any other place other than telemed. They were credentialed with at least 50 hospitals but what I been told, hospitals are requiring at least 6 months of “in person” boots in the ground experience.

I am surprise no one has brought up the non-compete issue - Perhaps someone can clarify but how I understand it is the following:

1. You can not work with previous, current or future hospitals in which they have contracts with for a few years.

2 most importantly, you can not engage in any telemedicine, of any kind for a few years. This one is important because if you want to go back to a major hospital that performs telemed, they can go after you and your new hospital. And believe you me, they will absolutely enforce this.

My advice is to read the contract carefully and clarify everything.

 

[xenotype]

100% tele stroke. Not working at any other place other than telemed. They were credentialed with at least 50 hospitals but what I been told, hospitals are requiring at least 6 months of “in person” boots in the ground experience.

I am surprise no one has brought up the non-compete issue - Perhaps someone can clarify but how I understand it is the following:

1. You can not work with previous, current or future hospitals in which they have contracts with for a few years.

2 most importantly, you can not engage in any telemedicine, of any kind for a few years. This one is important because if you want to go back to a major hospital that performs telemed, they can go after you and your new hospital. And believe you me, they will absolutely enforce this.

My advice is to read the contract carefully and clarify everything.

That's absurd. How are those two docs getting around this? Did they apply widely or just narrowly in the region they are located? How far out from residency/fellowship?

 

[Phantom Spike]

That's absurd. How are those two docs getting around this? Did they apply widely or just narrowly in the region they are located? How far out from residency/fellowship?

I wonder if it's just one hospital/hospital system that's unfamiliar with the whole concept of telemedicine? Hopefully as telemedicine becomes more and more widespread this will cease to be an issue.
Are these physicians attempting to apply for privileges so as to provide physical in-person care? Are they leaving their tele-stroke practice?
Again, are telemedicine encounters billed with traditional CPT codes? If not, perhaps that's why this issue is arising since from what I can see case logs are generated based on CPT codes.
And this has been discussed elsewhere, but having hundreds of hospital privileges certainly slows down credentialing at new facilities. No way around this, I suppose.

 

[neurochica]

That's absurd. How are those two docs getting around this? Did they apply widely or just narrowly in the region they are located? How far out from residency/fellowship?

They apply widely. They been practicing for 6 and 8 years.
In fact, they got the same response from a few locum agencies- need actual patient contact of at least 6 months.

This might be a regional thing- don’t know, just reporting what I been told.

 

[Giovanotto]

Is there any way for me to obtain telestroke experience in residency and parlay that into a telestroke job out of residency sans fellowship?

 

[Aldertonghen]

Is there any way for me to obtain telestroke experience in residency and parlay that into a telestroke job out of residency sans fellowship?

Exposure to telestroke in residency is something I have asked on my interview trail and only some programs provide it. I mostly interviewed at lower-tier programs though.

As mentioned above one can go into telestroke straight out of residency, although a vascular fellowship helps.

Off-topic, but on this forum, there's a poster who does 15 telestroke shifts a month on nights and weekends, making around $400k a year, and combines it with essentially a bench postdoc research fellow job in the daytime (its post 54 of this thread: Salary Survey)

Seems super busy, but it was an extremely interesting way to be able to do research without sacrificing pay by being in academia. I wonder if someone else has done this too.

 

[OddNath]

Regarding IOM, looks like it could be a fairly lucrative full-time option for those with neurophys/epilepsy training, but one thing I potentially worry about (which was alluded to briefly above) is "dead-ending" your clinical career. You need to get multiple state licenses and hospital privileges (just like with telestroke) but you don't see actual patients. If you do this for a few years, you won't have much of a patient log (or good clinical references in your own specialty). What if you then decide you want to go into clinical neurology again? Is this a major hurdle? Case logs seem to be more and more a requirement in hospital privileging as well as for locums/telestroke work.

For this reason, I do Locums 1-2 times per year to keep up clinical skills. (Though if I never did clinical work again, it wouldn’t really be a big loss for me)

 

[Phantom Spike]

For this reason, I do Locums 1-2 times per year to keep up clinical skills. (Though if I never did clinical work again, it wouldn’t really be a big loss for me)

Thanks for your input. Do you have any issues getting locums jobs given the lack of clinical contact the rest of the year?
I assume you're doing full-time IOM ... may I ask if you had experience in it as a Neurophys fellow? Do companies train you if you don't have any but are Neurophys-boarded?
Teleneurology and/or IOM seem very attractive but potentially having trouble getting hospital privileges later scares me ... not sure if I'm ready to close that door quite yet (tempting though it may be). I'm less worried about keeping up my clinical skills, I think I'd get back on track pretty quickly even if I were out of practice for a year or so. But hospitals apparently do not think so (with teleneurology, where you are actually seeing patients, that's ridiculous, but as you can see from the discussion above, it's a concern).

 

[Neurogeneral]

They apply widely. They been practicing for 6 and 8 years.
In fact, they got the same response from a few locum agencies- need actual patient contact of at least 6 months.

This might be a regional thing- don’t know, just reporting what I been told.

So they have 6-8 years of in-person (i.e. non-remote) clinical experience after training? And then took a temporary detour of 6 -12 months doing purely teleneurology and since then, they can’t get privileges at most other hospitals?

I can understand if someone has been only doing teleneurology long term since training and then wants to jump back in to in person clinical work after many years, that some employers may be a little apprehensive about hiring them. But short term telemedicine work shouldn’t mean that you should be black balled from most other jobs.

 

[curiousneuro]

So they have 6-8 years of in-person (i.e. non-remote) clinical experience after training? And then took a temporary detour of 6 -12 months doing purely teleneurology and since then, they can’t get privileges at most other hospitals?

I can understand if someone has been only doing teleneurology long term since training and then wants to jump back in to in person clinical work after many years, that some employers may be a little apprehensive about hiring them. But short term telemedicine work shouldn’t mean that you should be black balled from most other jobs.

Yeah I've never heard of this myself. I know of at least one person who did pure tele for more than two years and had no problem going back to part-time in person to clinical work. So that seems a bit odd.

 

[xenotype]

Yeah I've never heard of this myself. I know of at least one person who did pure tele for more than two years and had no problem going back to part-time in person to clinical work. So that seems a bit odd.

Yes I think its bizarre and while I have no doubt the story is true in part what we lack is details. There should be a billion ways around this, like simply rounding a few weekends at one of the hospitals nearby one is already tele-credentialed, getting an academic or a VA job for some time. I suppose it means if you are planning to leave a tele job get some in person billing done before you relinquish hospital privileges or in part time clinic.

 

[Phantom Spike]

I can understand if someone has been only doing teleneurology long term since training and then wants to jump back in to in person clinical work after many years, that some employers may be a little apprehensive about hiring them.

But why? You see the same kind of cases, make the same decisions, order the same tests, manage the same way you would if you had been standing next to the patient. I think it's just lack of familiarity on the part of most hospitals. No-one has answered yet: how are teleneurology consults billed? With traditional CPT codes? If not, maybe that's why hospitals aren't accepting teleconsults as "patient logs", they're looking for those consult/admit CPT codes. That information would be very useful to have.

Yes I think its bizarre and while I have no doubt the story is true in part what we lack is details. There should be a billion ways around this, like simply rounding a few weekends at one of the hospitals nearby one is already tele-credentialed, getting an academic or a VA job for some time. I suppose it means if you are planning to leave a tele job get some in person billing done before you relinquish hospital privileges or in part time clinic.

Would it be easy to get into the VA if you did pure teleneurology for a couple of years? Academics may not be all that easy in that scenario.

 

[OddNath]

Thanks for your input. Do you have any issues getting locums jobs given the lack of clinical contact the rest of the year?
I assume you're doing full-time IOM ... may I ask if you had experience in it as a Neurophys fellow? Do companies train you if you don't have any but are Neurophys-boarded?
Teleneurology and/or IOM seem very attractive but potentially having trouble getting hospital privileges later scares me ... not sure if I'm ready to close that door quite yet (tempting though it may be). I'm less worried about keeping up my clinical skills, I think I'd get back on track pretty quickly even if I were out of practice for a year or so. But hospitals apparently do not think so (with teleneurology, where you are actually seeing patients, that's ridiculous, but as you can see from the discussion above, it's a concern).

I do locums like once a year, and get offers from lots more. No issues there.

And- to do IOM, you have to have hospital privileges, so, I currently have hospital privileges in dozens of hospitals. It’s a special type of telemedicine status (so no admitting privileges), but, this is “clinical” in everyone’s eyes.

And, LOL my neurophys fellowship had hardly any IOM teaching at all. It’s been a lot of googling and curbsiding my buddies in anesthesia and neurosurgery!

 

[neurodoc]

I do a lot of NCS/EMG studies, and unless they invent autonomous or virtual reality guided robots I don't see tele-EMG being available very soon. I continued seeing my patients face-to-face during the COVID-19 pandemic. Some of my colleagues are still conducting patient visits via video conferencing.

 

[ProReduction]

Nothing good in medicine that is favorable to physicians lasts. TeleNeurology has changed greatly over the last 5 years. It has become a hyper corporate sprint to the bottom where you have dozens of Telehealth companies all courting and placating the worst hospitals in America with the worst doctors. Oddly, these local facilities have zero self-awareness and try to treat expert TeleNeurologists like "vendors". "STAT Stroke consult for a LKW of 3 months ago . . . if you are not on the camera within 3 minutes of us paging you we are emailing your Business Administrator and threatening to not renew with your Tele company for failure of timely evaluations . . . there are 10 other Tele companies calling us daily wanting our business."
To find any longevity doing full-time TeleNeurology you either have to be a simpleton or a mercenary. Most doctors I know that persist in Tele are the latter. If you are neither, then Tele is short-lived and most doctors get in and out quickly. I would caution any trainee seeking to have his/her first attending position be full-time TeleNeurology. In 5 years I do not know what he/she will be doing for work, but it will certainly not be TeleNeurology and more than likely will not be clinical Neurology at all. It is that bad.

 

[xenotype]

Nothing good in medicine that is favorable to physicians lasts. TeleNeurology has changed greatly over the last 5 years. It has become a hyper corporate sprint to the bottom where you have dozens of Telehealth companies all courting and placating the worst hospitals in America with the worst doctors. Oddly, these local facilities have zero self-awareness and try to treat expert TeleNeurologists like "vendors". "STAT Stroke consult for a LKW of 3 months ago . . . if you are not on the camera within 3 minutes of us paging you we are emailing your Business Administrator and threatening to not renew with your Tele company for failure of timely evaluations . . . there are 10 other Tele companies calling us daily wanting our business."
To find any longevity doing full-time TeleNeurology you either have to be a simpleton or a mercenary. Most doctors I know that persist in Tele are the latter. If you are neither, then Tele is short-lived and most doctors get in and out quickly. I would caution any trainee seeking to have his/her first attending position be full-time TeleNeurology. In 5 years I do not know what he/she will be doing for work, but it will certainly not be TeleNeurology and more than likely will not be clinical Neurology at all. It is that bad.

Your post is not untrue in many respects but skips over all of the very significant positives, particularly not being on call, not having to travel, and not having to deal with uncompensated work like prior-auths and filling out forms. Many neurologists in the NH world and locums world are mercenaries, as that is the best way to ensure you get paid fairly for your work and being willing to walk away from a bad deal. Many neurologists in outpatient jobs on the daily treadmill of trying not to fall behind, trying to have all of their documentation completed so they don't have to take work home, trying to keep up with their inbox are miserable. Many neurohospitalists are miserable from heavy daily volume and then being on call overnight all week. Some of these people leave clinical neurology too. Your post is essentially the prototypical sky is falling declaration. Medicine in general is increasingly hyper corporitized everywhere and this is difficult to avoid anywhere in our specialty.

 

[ProReduction]

Your post is not untrue in many respects but skips over all of the very significant positives, particularly not being on call, not having to travel, and not having to deal with uncompensated work like prior-auths and filling out forms. Many neurologists in the NH world and locums world are mercenaries, as that is the best way to ensure you get paid fairly for your work and being willing to walk away from a bad deal. Many neurologists in outpatient jobs on the daily treadmill of trying not to fall behind, trying to have all of their documentation completed so they don't have to take work home, trying to keep up with their inbox are miserable. Many neurohospitalists are miserable from heavy daily volume and then being on call overnight all week. Some of these people leave clinical neurology too. Your post is essentially the prototypical sky is falling declaration. Medicine in general is increasingly hyper corporitized everywhere and this is difficult to avoid anywhere in our specialty.

If we are at the point where saying that "our job at a minimum should entail dignity and a lack of threats from know-nothing local hospitals that are abusing our clinical services" is saying that the "sky is falling", then we have clearly lost all of our professional pride and dignity.

Many Neurohospitalist jobs have banker hours now, with in-house coverage from 8-5 (or less depending on what time rounding is over), then overnight TeleNeuro coverage. I have over 12,000 TeleNeurology encounters with three different companies. In the last 5 years I have seen more and more "Local Neurologists" either completely pull out of inpatient coverage or seek to have all weekday nights + weekends covered by TeleNeuro.
I am not sure if you have any experience in TeleNeuro, but during all of my in-person Neurohospitalist work I have never had a consulting provider demand that I be at bedside in < 3 minutes for evaluation (or even evaluate over video) for a LKW of three months ago. It has never happened. There are indignities abound in all of Neurology, but they are especially potent in TeleNeurology, where the Neurologist is treated like a STAT lab test by many local facilities. Much of this comes from the local providers never having to face you in the hallway and much of it comes from the customer-service approach of corporate TeleNeuro.
Pay has been flat in TeleNeuro for the last 5 years as well with an exponential increase in the demands of local client hospitals and in the indignity of the work.

 

[elanmorin]

I get where you're coming from ProReduction. The barriers to entry for new Teleneuro groups, or telemedicine groups in general is low, with relatively little overhead compared to opening your own B&M practice, hospital, infusion center, etc. Not surprising that we would start to see a race to the bottom in terms of pay and/or working conditions there.

That said, at least at my current hospital, in-person stroke codes are initiated occasionally in lieu of STAT neuro consults (both on the floors as well as in the ED) and neurologists have gotten flak for not responding to them within a few minutes. People have also gotten in trouble for trying to explain why it was a poor utilization of resources to call the code, etc. So, this type of situation isn't limited to tele encounters only, at least from my experience. That said, I don't think anyone has threatened to fire and replace with another neuro group (since that's basically impossible here). A teleneurologist would probably be a lot easier to replace.

 

[xenotype]

If we are at the point where saying that "our job at a minimum should entail dignity and a lack of threats from know-nothing local hospitals that are abusing our clinical services" is saying that the "sky is falling", then we have clearly lost all of our professional pride and dignity.

Many Neurohospitalist jobs have banker hours now, with in-house coverage from 8-5 (or less depending on what time rounding is over), then overnight TeleNeuro coverage. I have over 12,000 TeleNeurology encounters with three different companies. In the last 5 years I have seen more and more "Local Neurologists" either completely pull out of inpatient coverage or seek to have all weekday nights + weekends covered by TeleNeuro.
I am not sure if you have any experience in TeleNeuro, but during all of my in-person Neurohospitalist work I have never had a consulting provider demand that I be at bedside in < 3 minutes for evaluation (or even evaluate over video) for a LKW of three months ago. It has never happened. There are indignities abound in all of Neurology, but they are especially potent in TeleNeurology, where the Neurologist is treated like a STAT lab test by many local facilities. Much of this comes from the local providers never having to face you in the hallway and much of it comes from the customer-service approach of corporate TeleNeuro.
Pay has been flat in TeleNeuro for the last 5 years as well with an exponential increase in the demands of local client hospitals and in the indignity of the work.

You seem burned out and your other posts indicate you are leaving clinical medicine. There are some nice NH jobs out there with bankers hours but it would be quite inaccurate to refer to the average NH job as banker's hours, and >90% of these require overnight call often the entire week one is on (even if stroke is covered with tele). Pay is flat or decreasing in most areas of clinical medicine right now. Tele jobs are very similar to NH jobs in terms of pay especially when accounting for volume both on the high and low end. As far as the ED or consulting hospitalists being rude, admin being overbearing, this can be an issue anywhere- tele insulates from some of this as one is not subject to internal hospital politics.

 

[ProReduction]

You seem burned out and your other posts indicate you are leaving clinical medicine. There are some nice NH jobs out there with bankers hours but it would be quite inaccurate to refer to the average NH job as banker's hours, and >90% of these require overnight call often the entire week one is on (even if stroke is covered with tele). Pay is flat or decreasing in most areas of clinical medicine right now. Tele jobs are very similar to NH jobs in terms of pay especially when accounting for volume both on the high and low end. As far as the ED or consulting hospitalists being rude, admin being overbearing, this can be an issue anywhere- tele insulates from some of this as one is not subject to internal hospital politics.

The purpose of the warning for trainees seeking to have their first attending job be exclusively Tele is exactly what you noted. It will lead to rapid and intense burnout that will make that doctor want to leave clinical work entirely. It is not a clinical practice setting where there can be any fulfillment other than financial, hence why it attracts mercenaries. I was lucky to see the writing on the wall years ago and I have other job prospects outside of clinical work as you noted by reading my past posts. However, most Neurologists do not have these opportunities and need to construct their career trajectory with care in order to avoid burnout. It has been tragic to see so many Neurohospitalists burned out and leaving in-person NH work only to take a Tele job and realize that the burnout factors are 10X worse in Tele.

 

[Neurogeneral]

It has been tragic to see so many Neurohospitalists burned out and leaving in-person NH work only to take a Tele job and realize that the burnout factors are 10X worse in Tele.

I interviewed and got an offer from one of these teleneurology companies. Supposedly reputable company but the pace seemed too hectic for me and the hours seemed worse than in person job. They pitched compensation of around $400k but you had to see at least 20 STAT consults to get there in a 12 hour shift. They also want you to do at least 5 overnight shifts per month.

Remote work still interests me, but it will have to be the right type of set up. And probably will only want to do it part time to avoid burnout.

 

[neurochica]

There is nothing wrong with being a neuro- mercenary. The average neurologist is 46 years old and looks like the picture below. Give them a couple more 🖊 pens, to use as weapons, and they will Take over medicine

 

[curiousneuro]

If we are at the point where saying that "our job at a minimum should entail dignity and a lack of threats from know-nothing local hospitals that are abusing our clinical services" is saying that the "sky is falling", then we have clearly lost all of our professional pride and dignity.

Many Neurohospitalist jobs have banker hours now, with in-house coverage from 8-5 (or less depending on what time rounding is over), then overnight TeleNeuro coverage. I have over 12,000 TeleNeurology encounters with three different companies. In the last 5 years I have seen more and more "Local Neurologists" either completely pull out of inpatient coverage or seek to have all weekday nights + weekends covered by TeleNeuro.
I am not sure if you have any experience in TeleNeuro, but during all of my in-person Neurohospitalist work I have never had a consulting provider demand that I be at bedside in < 3 minutes for evaluation (or even evaluate over video) for a LKW of three months ago. It has never happened. There are indignities abound in all of Neurology, but they are especially potent in TeleNeurology, where the Neurologist is treated like a STAT lab test by many local facilities. Much of this comes from the local providers never having to face you in the hallway and much of it comes from the customer-service approach of corporate TeleNeuro.
Pay has been flat in TeleNeuro for the last 5 years as well with an exponential increase in the demands of local client hospitals and in the indignity of the work.

The purpose of the warning for trainees seeking to have their first attending job be exclusively Tele is exactly what you noted. It will lead to rapid and intense burnout that will make that doctor want to leave clinical work entirely. It is not a clinical practice setting where there can be any fulfillment other than financial, hence why it attracts mercenaries. I was lucky to see the writing on the wall years ago and I have other job prospects outside of clinical work as you noted by reading my past posts. However, most Neurologists do not have these opportunities and need to construct their career trajectory with care in order to avoid burnout. It has been tragic to see so many Neurohospitalists burned out and leaving in-person NH work only to take a Tele job and realize that the burnout factors are 10X worse in Tele.

As someone who is currently doing full-time telestroke, I can't disagree with your analysis more. I certainly would not consider myself a "mercenary" (although simpleton can be argued...). I love my job. I feel like the schedule of true shiftwork is really nice. I had extensive experience with telemedicine/telestroke during residency/fellowship, so I knew what I was getting myself into. I enjoy taking care of patients this way, and I feel patients appreciate it as well (for the most part).

Is it for everyone? Would certainly say no. But for me and my family, it's really nice. I don't feel like the workload is too bad; certainly not that much different than if I was doing full-time neurohospitalist or clinic work.

It sounds like you got heavily burned-out, which is unfortunate, and I'm sorry about that.

Just wanted to give my 2-cents in case anyone else was reading this thread that the above poster's opinion is not representative of myself or most of my teleneuro colleagues.

 

[Phantom Spike]

Just wanted to give my 2-cents in case anyone else was reading this thread that the above poster's opinion is not representative of myself or most of my teleneuro colleagues.

Do you think, though, that it might be company-dependent ... there are indeed a lot of teleneurology companies out there, and a lot of new ones seem a bit shady (their websites feature generic pictures of groups of young people in white coats, and their description of services seem cut-and-pasted). Should someone interested in teleneurology stick with the big name companies? Is the scenario of being lambasted for not beaming in immediately for a clearly non-emergent consult truly widespread?

 

[xenotype]

Do you think, though, that it might be company-dependent ... there are indeed a lot of teleneurology companies out there, and a lot of new ones seem a bit shady (their websites feature generic pictures of groups of young people in white coats, and their description of services seem cut-and-pasted). Should someone interested in teleneurology stick with the big name companies? Is the scenario of being lambasted for not beaming in immediately for a clearly non-emergent consult truly widespread?

If you pick the right company you manage your own volume and pick when you are ready to take a case, so who cares if they want you to log in within 5 minutes for all the cases. You can just refuse extra business when you can't manage it in a timely fashion. Also, if the ED/hospitalist/floor RN/EMS/whoever were great at figuring out LKW and tpa criteria we wouldn't have a job. Maybe I am a simpleton like curiousneuro. Tele has no call, comparable pay per hour to NH gigs volume to volume, and cuts out all of the unreimbursed crap from outpatient (eg prior auths, patient messages, excessive billing requirements in notes). The simple 'inappropriate' cases are how you get paid because the tough ones can easily take 2-3 times the amount of time with multiple phone calls to NIR, family, getting back on camera for tPA in an initially unclear situation etc. Low ball AMS, first time seizure, and obviously no intervention stroke consults are how almost every community neurologist pays the bills in the hospital setting because they only take 20 minutes to do. It is not only not worth it to get upset about these consults, it actively hurts your relationship with the ED/etc in getting new consults when you are hard to deal with/have a bad attitude.

 

[curiousneuro]

Do you think, though, that it might be company-dependent ... there are indeed a lot of teleneurology companies out there, and a lot of new ones seem a bit shady (their websites feature generic pictures of groups of young people in white coats, and their description of services seem cut-and-pasted). Should someone interested in teleneurology stick with the big name companies? Is the scenario of being lambasted for not beaming in immediately for a clearly non-emergent consult truly widespread?

Yes totally agree with xenotype above. The easy consults are simple, take a few minutes, and I have no problem having to log in within 3-5 minutes of call time, especially when I'm home playing with the kids or watching Netflix while waiting for a call to come in. I used to get upset about these consults during training when obviously they were just a drag to the day, but being productivity based makes it much easier.

The way I look at it is - If I was a NH I would have have to also see the lowball SA or at least answer the pager/phone within that timeframe as well; logging in to televideo is really not that different.

And yes - I would really only look at the bigger, well-established companies if I were you. There seem to be more and more companies getting into this field, and I don't know how well their quality is. I think the most important thing to have with a telestroke company is a well-oiled admin team and good tech that helps make everything easier, which thankfully is the case at my company.

And fyi - while there is of course the expectation that you log in quickly, there is no push to see more and more consults. I always feel comfortable with the speed I'm going; if another consult comes in and I'm not ready for whatever reason they are more than happy to give me as much time as I need.

And when I'm done with the SA with a LKN 3 months ago that took me 15 minutes to do...I go back to spending time with the family. Which obviously you just can't get with a NH gig....!

 

[ProReduction]

I think there are two big differences between Curiosneuro's experience and my experience with Tele which informs our difference in opinion. Not to call you out by company Curious and I may be wrong, but you are probably at SOC or one of the very few Tele companies that still allows a TeleNeurologist to go at his or her own pace when on-call. At SOC you are able to only take-on one consult at a time. This is rare in today's Tele landscape, and the minute PE or big changes come to SOC that probably ends. I have worked at numerous TeleNeuro companies and none of them allow you to see one patient per hour when on emergency call. This includes huge national Tele companies that are top 3 in volume and also smaller boutique companies. Yes, you have back-up, but you can get hit with 6 consults an hour.

I think the bigger and more important difference in our opinions of Tele is how you handle nonsults when you are mid-career as a Neurologist. I will readily admit that I am in the 99.99th percentile of frustration/intolerance with these consults relative to other Neurologists. I have come to see myself as a piece in the medicine machine at-large, and I cannot continue to do these nonsults for any amount of money if they are completely unnecessary box-checking formalities where myself and the local consulting provider both know that my emergent involvement in the case will provide no use to the patient whatsoever in improving his/her health. Also, and this is absolutely not to belittle or demean how we spend our non-clinical time as I also have a family/kids and that is where my best moments exist, but even when on-call I am usually doing research work. I have no issue getting paged for a legit neurologic emergency where my input will impact patient care. But being paged with a STAT stroke alert for a LKW 3 months ago for bilateral face tingling that pulls me away from the flow of research work that I am passionate about and that I believe can truly have a huge impact on millions of patients is really frustrating. Pair that with the indignity of some rural nurse writing an email saying I was negligent for beaming in on said face tingler at 5 minutes from being paged instead of 3 minutes, and that frustration goes from annoying to intolerable.

 

[xenotype]

I think there are two big differences between Curiosneuro's experience and my experience with Tele which informs our difference in opinion. Not to call you out by company Curious and I may be wrong, but you are probably at SOC or one of the very few Tele companies that still allows a TeleNeurologist to go at his or her own pace when on-call. At SOC you are able to only take-on one consult at a time. This is rare in today's Tele landscape, and the minute PE or big changes come to SOC that probably ends. I have worked at numerous TeleNeuro companies and none of them allow you to see one patient per hour when on emergency call. This includes huge national Tele companies that are top 3 in volume and also smaller boutique companies. Yes, you have back-up, but you can get hit with 6 consults an hour.

I think the bigger and more important difference in our opinions of Tele is how you handle nonsults when you are mid-career as a Neurologist. I will readily admit that I am in the 99.99th percentile of frustration/intolerance with these consults relative to other Neurologists. I have come to see myself as a piece in the medicine machine at-large, and I cannot continue to do these nonsults for any amount of money if they are completely unnecessary box-checking formalities where myself and the local consulting provider both know that my emergent involvement in the case will provide no use to the patient whatsoever in improving his/her health. Also, and this is absolutely not to belittle or demean how we spend our non-clinical time as I also have a family/kids and that is where my best moments exist, but even when on-call I am usually doing research work. I have no issue getting paged for a legit neurologic emergency where my input will impact patient care. But being paged with a STAT stroke alert for a LKW 3 months ago for bilateral face tingling that pulls me away from the flow of research work that I am passionate about and that I believe can truly have a huge impact on millions of patients is really frustrating. Pair that with the indignity of some rural nurse writing an email saying I was negligent for beaming in on said face tingler at 5 minutes from being paged instead of 3 minutes, and that frustration goes from annoying to intolerable.

Maybe your problem is that there is no way 6 consults an hour is safe or a good experience for the patients, ED staff especially with the usual expected response times. Also, SOC is not the only big place that allows control over volume. What, do you just tell the ED MD to give tPA and jump to the next case? You tell the ED MD to call NIR and never make the call yourself? Tell the ED MD to call the nursing home because you have 2 other cases to triage? You can't be honestly spending more than 5 minutes on camera if enough volume gets dumped to you at once, let alone doing the other time consuming things many of these places expect like blood pressure management, talking to NIR etc. That pace also exposes you to significant extra liability should you miss anything due to the time pressure.

 

[ProReduction]

Maybe your problem is that there is no way 6 consults an hour is safe or a good experience for the patients, ED staff especially with the usual expected response times. Also, SOC is not the only big place that allows control over volume. What, do you just tell the ED MD to give tPA and jump to the next case? You tell the ED MD to call NIR and never make the call yourself? Tell the ED MD to call the nursing home because you have 2 other cases to triage? You can't be honestly spending more than 5 minutes on camera if enough volume gets dumped to you at once, let alone doing the other time consuming things many of these places expect like blood pressure management, talking to NIR etc. That pace also exposes you to significant extra liability should you miss anything due to the time pressure.

You nailed it. It is a big liability risk (which all of the Tele companies will try to minimize), but getting 6 consults an hour is not unusual and many TeleNeurologists handle it without a problem and actually welcome it because 5/6 are usually nonsults. Fewer Tele shops allow for volume control than not, and my colleagues that have left my groups for those that allow it feel that it will be going away very soon. The probability that more than 1-2 of those 6 consults are legit and actual emergencies is usually very low. I've rarely had to juggle 2-3 tPA+MTs but it does happen.
Yes, it leads to things like having the ED call the Nursing Home as I will never have time to do things like that. Also, I hope that no Neurologist has ever said this is what is best for patients. Hence why I call it a race to the bottom. These are for-profit Tele companies. They could care less about quality and liability risk to the physician. Volume equals money to them.

 

[xenotype]

You nailed it. It is a big liability risk (which all of the Tele companies will try to minimize), but getting 6 consults an hour is not unusual and many TeleNeurologists handle it without a problem and actually welcome it because 5/6 are usually nonsults. Fewer Tele shops allow for volume control than not, and my colleagues that have left my groups for those that allow it feel that it will be going away very soon. The probability that more than 1-2 of those 6 consults are legit and actual emergencies is usually very low. I've rarely had to juggle 2-3 tPA+MTs but it does happen.
Yes, it leads to things like having the ED call the Nursing Home as I will never have time to do things like that. Also, I hope that no Neurologist has ever said this is what is best for patients. Hence why I call it a race to the bottom. These are for-profit Tele companies. They could care less about quality and liability risk to the physician. Volume equals money to them.

So don't work for those crappy companies. Juggling 3 tPA at once is ludicrous and completely unsafe, especially when you add in a lot of these places will wheel the cart back to a dark closet if you go off video even 30 seconds. You shouldn't have compromised your happiness, satisfaction as a neurologist, and actual patient care to make a few more bucks- at 6/hr I am guessing you clear >>$600k if you do this even close to full time. I am not trying to be condescending or offensive- you clearly are very experienced but very unhappy and unfulfilled. The standard at reputable firms averages 1.2 per hour, as does a real neurohospitalist job and pays like it too. I think your original gripe is because a small hospital got pissed off that you didn't respond fast enough, probably weren't nice enough to anyone when you were on video/the phone, probably spent hardly any time with the patient/RNs. Psychogenic patients deserve reassurance and education too, even if we don't like dealing with them and have little to offer. Not helping the ED MD out doesn't help the case either in terms of not calling facilities or NIR- they are busy too. It's quantity care, it's making you money, but it lacks much real human connection and cuts a whole lot of corners.

 

[curiousneuro]

I can't imagine doing 6 consults an hour -that would be absolutely crazy. All the companies that I interviewed with (and yes, they were the bigger companies) all allowed the neurologist to work at their own pace. I usually average around 1-2 an hour; sometimes less, sometimes more.

I actually don't know any companies that force you to see that many patients an hour - I can't imagine those companies will last, because the neurologist can easily either switch companies or just go back to in-person neurology.

 

[ProReduction]

So don't work for those crappy companies. Juggling 3 tPA at once is ludicrous and completely unsafe, especially when you add in a lot of these places will wheel the cart back to a dark closet if you go off video even 30 seconds. You shouldn't have compromised your happiness, satisfaction as a neurologist, and actual patient care to make a few more bucks- at 6/hr I am guessing you clear >>$600k if you do this even close to full time. I am not trying to be condescending or offensive- you clearly are very experienced but very unhappy and unfulfilled. The standard at reputable firms averages 1.2 per hour, as does a real neurohospitalist job and pays like it too. I think your original gripe is because a small hospital got pissed off that you didn't respond fast enough, probably weren't nice enough to anyone when you were on video/the phone, probably spent hardly any time with the patient/RNs. Psychogenic patients deserve reassurance and education too, even if we don't like dealing with them and have little to offer. Not helping the ED MD out doesn't help the case either in terms of not calling facilities or NIR- they are busy too. It's quantity care, it's making you money, but it lacks much real human connection and cuts a whole lot of corners.

You are presuming a great deal. Six an hour is not average as I said. It is on the high end but happens. I have explicitly said I am moving away from Tele solely because I am not a mercenary, yet your post says that I would sacrifice patient care for a "few more bucks". This is an absurdity if you have read anything I've actually said where I have said that the money is not worth the indignity and lack of patient-care in the quality of these encounters. I am always professional with the local facilities despite your assumption, but that professionalism is frequently unidirectional. The point of any of my posts on this topic was to share my > 12,000 Tele encounter experience with trainees that are considering full-time Tele as their first job, with a warning that the field is getting worse not better. If your omniscience extends to both being able to observe my level of professionalism during Tele encounters and to more than 12,000+ other Tele encounters so you have equal experience to my own, please let us know. What is more likely is that you have not spent a large chunk of the last 5 years in Tele encounters and cannot speak to the logistical trajectory of TeleNeuro. If you had, then you would know that the patient care issues I raise are legitimate and are the norm not the exception.

 

[xenotype]

You are presuming a great deal. Six an hour is not average as I said. It is on the high end but happens. I have explicitly said I am moving away from Tele solely because I am not a mercenary, yet your post says that I would sacrifice patient care for a "few more bucks". This is an absurdity if you have read anything I've actually said where I have said that the money is not worth the indignity and lack of patient-care in the quality of these encounters. I am always professional with the local facilities despite your assumption, but that professionalism is frequently unidirectional. The point of any of my posts on this topic was to share my > 12,000 Tele encounter experience with trainees that are considering full-time Tele as their first job, with a warning that the field is getting worse not better. If your omniscience extends to both being able to observe my level of professionalism during Tele encounters and to more than 12,000+ other Tele encounters so you have equal experience to my own, please let us know. What is more likely is that you have not spent a large chunk of the last 5 years in Tele encounters and cannot speak to the logistical trajectory of TeleNeuro. If you had, then you would know that the patient care issues I raise are legitimate and are the norm not the exception.

Sure I presume, am making some guesses, and you are experienced in the tele realm. I don't think it's an absurd claim. You have to be making a very large amount of money at the pace you are working (again >>$600k at 50hr/wk) and to say that 3 tPA at once, 6 consults an hour is perfectly safe or amounts to quality care strains your credibility- it is under the maximum stress and bolus load that patient safety gets compromised. You've stretched the limits here and have gotten burnt out doing it. There are plenty of large companies that don't force or require this pace, and accordingly don't pay the amount of money you are likely making. Your overall points about tele paying less are true, but that is a broad general trend in medicine regardless. Again I am not trying to be offensive but I think doom and gloom for future graduates is not helpful, and these graduates need to understand you are a 95th percentile productivity guy that takes on a lot of liability and makes a whole lot of money- this colors your advice. Tele is a perfectly viable route where one can be happy, but you have to be careful about the job, realistic about the pay, liability, and credentialing challenges, and plenty of people would certainly be happier with an all outpatient subspecialty job, academics, an NH gig, or locums (and some will get paid better in those save for academics relative to time spent in tele, depending on the job).

 

[Giovanotto]

Is the future of telestroke in jeopardy by future policy changes? I'm being recommended not to got his route by my peers.

 

[deathmerchant]

Can anyone with recent experience update about going rates for Telehospitalists? Permanent and part-time? The main companies I talked to are offering something around 120-140$ per consult or little over 2000 for a 12 hour shift with 20-24 patients?

Also has anyone been able to negotiate salaries with them or do they have fixed compensations?

 

[xenotype]

Can anyone with recent experience update about going rates for Telehospitalists? Permanent and part-time? The main companies I talked to are offering something around 120-140$ per consult or little over 2000 for a 12 hour shift with 20-24 patients?

Also has anyone been able to negotiate salaries with them or do they have fixed compensations?

That seems like a typical rate. You might be able to do slightly better mixing some stroke/EEG into it. Big groups are not going to negotiate at all, including on nasty parts of the contract. $2500 to $3k is possible if you are fast, but a lot of days that turns into a lot of prerounding/finishing notes outside of that 12hrs. The main benefit is not being on call outside of the shift, which is extremely, extremely valuable to me and my sleep.

 

[Phantom Spike]

The main companies I talked to are offering something around 120-140$ per consult or little over 2000 for a 12 hour shift with 20-24 patients?

20-24 patients per shift seems quite high and a recipe for early burnout. Most of the bigger companies give you an hour per patient for telestroke consult. Not sure if it's any different for non-stroke teleneurology consultations.

 

[xenotype]

20-24 patients per shift seems quite high and a recipe for early burnout. Most of the bigger companies give you an hour per patient for telestroke consult. Not sure if it's any different for non-stroke teleneurology consultations.

You can do more tele versus in person. 20-24 per 12 hours including new and f/u is quite doable. If all new, then not possible obviously. Average for a new consult tele is about 30 minutes if its not acute stroke and 40 minutes if it is- but that is generally less if no tPA and potentially much longer if tPA+ arranging NIR. The best companies will give you whatever time you need to make sure the patient is safe.

 

[Drhappyface]

Can anyone with recent experience update about going rates for Telehospitalists? Permanent and part-time? The main companies I talked to are offering something around 120-140$ per consult or little over 2000 for a 12 hour shift with 20-24 patients?

Also has anyone been able to negotiate salaries with them or do they have fixed compensations?

Isn't that quite low for patient load? I wonder how much the company is making per patient? How is this rate vs seeing someone in the office?

 

[xenotype]

Isn't that quite low for patient load? I wonder how much the company is making per patient? How is this rate vs seeing someone in the office?

This is inpatient telemedicine, so unless you are willing to start up your own network and provide 24/7 coverage for that network you'll have to accept the going rate. That rate translates into competitive pay versus just taking a neurohospitalist job, but of course most of those want you to be on call 24/7 the entire week you are on so you can be harrassed by the ED for free all night. Locums pays better if you choose the right gigs but you have to travel of course. Pick which set of tradeoffs you want, there is no perfect job.