Telehealth companies
Started by Attending1985
Some grads from my program spoke about their experience at one of the major telepsych companies. About 50% of their panel were on stimulants. So that's one thing you'd probably have to be okay with. These grads were not interested in setting up their own private practices and were working fairly intense 40ish hour weeks for 60-75th percentile comp. I think appointment lengths were 60/30. Felt they had good IT support and EMR was decent.
FWIW, we're currently 1 day in office and 80-90% telehealth appointments. The demand for in-person just isn't there.
Advertisement - Members don't see this ad
I have a higher demand for in person is higher at my job if say at least 60% want in person
I'm at one day per month in person and the rest Zoom. So many people seek me out because I offer in-person but even then there just isn't the interest for more than one day a month, as those patients decide they would rather do Zoom anyway.
From what I understand, Talkiatry doctors who work the hours I work make about 1/3 of what I make and those who persistently meet the performance metrics make about what I make working 18 hour weeks.
My small telehealth practice is a side gig right now, and most of my growth has come from word-of-mouth referrals. Recruiting telehealth patients from scratch is tough — the psych market is saturated, and companies like Talkiatry are absorbing a lot of the demand. My hope is that once I transition to full-time private practice, quality of care and word of mouth will keep the referrals coming.
How does that work with uds, ekg, vitals?
Maybe it’s location dependent. I would love only one in person day a month.
EKG is not something that is routinely ordered for stimulants. Anyone who says otherwise is a deep shade of red. I have never, ever, ever heard of a psychiatrist having an EKG machine in their office.
vitals are easy to check remotely. You ask the patient to check their vitals.
UDS is done the same way remotely as in-person: send them to a lab.
vitals are easy to check remotely. You ask the patient to check their vitals.
UDS is done the same way remotely as in-person: send them to a lab.
How did you do with the office place? Is that a rental at someone else's clinic? I considered doing that but did not find many options. Found one psychology clinic that would allow me to rent 1 day off a week. I forgot the price but it wasn't that cheap.
Will comment more later on tele health companies
I rent from an IT service that is a landlord for a "we-work" style place but for therapists and doctors and lawyers. They have a plan for hourly rentals all the way through monthly offices. I have a monthly office just to have somewhere to keep the computer and samples. $1k/month for 90 square feet without windows downtown in a city where that would usually be at least double.
These telepsych companies are really a catch 22. The support staff is often hit or miss; you may still end up having to respond to a multitude of patient messages. You don't have to think about any of the business end of it though, which is by design and some people like not having to worry about that (I heard Talkiatry charges patients' insurance like $700 per 30 mins?).
Just be prepared to be underpaid for the amount of work you do. Honestly, some academic places you can skate by doing half the work for 80% the money, then probably supplement with 1099 or your own clinic on the side. Thats the way, if you're looking for highest monetary efficiency.
Just be prepared to be underpaid for the amount of work you do. Honestly, some academic places you can skate by doing half the work for 80% the money, then probably supplement with 1099 or your own clinic on the side. Thats the way, if you're looking for highest monetary efficiency.
So I work in one of those companies, the biggest one. Every tele health company is basically a ADHD company, some are better at pretending they are not, some are too open about like, like Cerebral. They will throw you some fake numbers in the initial presentation, they are not a lie but it is like what your salary would like if every single patient shows up and stays long enough in the appointment. Doesn't happen. You will be making around 300k ish for 8h of work, considering that you will have no shows, so you might be seeing patients for 6h or around that.
Pros:
- Depending on where you live, 300k is higher than the median in the city.
- Fully remote, low acuity
Cons:
- Very hard to climb up from those 300k ish, you will have to work much more
- I did not find support team to be very good, only use is to fill FMLAs. I get several useless messages daily from patients
I plan on leaving before the end of the year. I would recommend IF you live in a city that pays less or if you are moving soon, something like that. Good temporary gig. Where I am, places pay 240-270k, no nearby Locums, so yes Telehealth companies are good. In other places you can very likely find something better.
Pros:
- Depending on where you live, 300k is higher than the median in the city.
- Fully remote, low acuity
Cons:
- Very hard to climb up from those 300k ish, you will have to work much more
- I did not find support team to be very good, only use is to fill FMLAs. I get several useless messages daily from patients
I plan on leaving before the end of the year. I would recommend IF you live in a city that pays less or if you are moving soon, something like that. Good temporary gig. Where I am, places pay 240-270k, no nearby Locums, so yes Telehealth companies are good. In other places you can very likely find something better.
Talkiatry pitched full time work as 37.5 clinical hours / 40 hour work week and for billing 2 codes.
Basically, if you dropping 90833, and they autocode that if you pass X amount of minutes in the encounter, they are making bank with a commercial insurance panel and that many clinical hours.
30 clinical hours still gets benefits. Which equates to 7.5 clinical hours x4 days...
Normal psych jobs are 32-36 clinical hours for full time work. And no pressure to 90833 everyone.
Basically, if you dropping 90833, and they autocode that if you pass X amount of minutes in the encounter, they are making bank with a commercial insurance panel and that many clinical hours.
30 clinical hours still gets benefits. Which equates to 7.5 clinical hours x4 days...
Normal psych jobs are 32-36 clinical hours for full time work. And no pressure to 90833 everyone.
i heard bennies are good, 401 match and health insurance etc..i agree its a good placeholder gig in some markets
Advertisement - Members don't see this ad
This is wild to me that you've never even heard of this and honestly feels like just more evidence to the old stigma that psychiatrists aren't real doctors. All but one of the outpatient offices (guy only did psychotherapy and didn't prescribe meds) I rotated through at least had a machine there. Now whether they actually still use it regularly...
As for telehealth, my outpt clinic is all telehealth but through a large academic center. There are 2 major issues I have continued to encounter after doing this for almost 4 years.
1. The quality of referrals is extremely variable and I cannot count the number of times I have gotten referrals that were completely inappropriate. I get plenty of very good referrals, but I'd say a solid 30-40% of them either need a higher level of care than what outpatient telehealth can offer or need better medical work-ups first. That all said, problematic referrals for typical telehealth companies are much more likely drug-seekers wanting stims and benzos when other docs either refuse to prescribe or require them to actually show up to appointments like an actual patient instead of someone looking to walk down to the corner to get their candy. I'd probably do terrible at these companies because I wouldn't be willing to prescribe stims after a 30 minute appointment and a positive ASRS 4+ times a day.
2. Patients don't seem to take these clinics as seriously as in person clinics. My no show rate for both new patients and follow-ups is frustratingly high (sometimes 30-40% in a quarter). Granted, I'm a consultation clinic so my goal is to refer patients back to their PCP, but even when I first took over and the clinic was being run as a continuity clinic in the first year, the no show rate was around 20-25%. In our PD-riddled academic outpatient clinic that does combined in-person and telehealth appointments the no-show rate is around 6-8%. Patients just don't seem to feel as bad about cancelling an appointment that's "basically just a facetime" compared to an in person appointment. I think the convenience of telehealth attracts a population that is likely to care less when something isn't convenient for them.
This has not been my experience at all. I had one no-show for 13 patients yesterday, which is in that 6-8% range. I am sure patient populations are a big part of the difference (people with OCD being super conscientious? No, how could that be?) but I do think that seeing people a bit more frequently than the 10-12 weeks that seem to be standard for some is a big part of it. If you're meeting with someone monthly, it's a different proposition to no-show versus someone you see a 3-4 x a year.
I could see that perspective, but isn’t the case in my clinic. My follow ups are typically 4-8 weeks unless they’re stable, then it’s 10-12 weeks 1-2x before I refer back to PCP. Some of these people have been in my clinic for 3-4 years (previous doc ran it as a continuity clinic, so for those patients I continue to see them as that’s what was initially agreed on with the PCPs). They don’t care until I tell them I will not provide further refills until they see me and then don’t get their meds. I have just started firing/referring these patients back to PCPs this year as demand for my clinic is to high to tolerate patients with a 40% no show rate (which some of these patients have).
That said, newer patients seeing me continue to have higher no show rates than I consider acceptable. I had 9 patients scheduled for today and 3 no-showed including a new consult that had 90 minutes blocked out due to medical complexity and 2 follow-ups. 2/3 of those patients even confirmed yesterday with our scheduler that they would be here today. One who I’ve seen twice before did show up 25 minutes into a 30 minute appointment and still wanted to be seen though. So I guess technically she showed up 🙄
All the major medical societies say that an EKG is unnecessary for a patient of average cardiovascular risk before prescribing stimulants. If the patient is at above average risk, might be best to skip the stimulants all together. My residency did not have an EKG machine anywhere near the psych clinic. Patients had to walk all the way across the hospital to some cardiology tech. It was done rarely and more related to QTc obsession.
If you are worried about cardiac risk in prescribing stimulant; send to pcp or cards for Clearance..... an ekg in a psychiatry office won't be helpful for this purpose
I wasn’t saying they’re needed for stimulants specifically. There’s plenty of other reasons to order and EKG involving psych meds. I just find it very surprising that someone said they’ve “never ever, ever” heard of psychiatrists having an EKG in office. Not to derail the thread, but really makes me wonder how much of our medical training psychiatrists forget once they’re out in practice for a while.
I agree with this approach. I can find a QTC on an EKG, but reading EKGs is not part of my usual practice. I would be pretty concerned that I might obtain an EKG that shows a problem (not related to psychiatric medication monitoring) that should have been identified and acted upon, but that I failed to identify it.
If a psychiatrist genuinely is as competent reading EKGs as the average internist then I applaud them, but if not I think they need to realize they could be putting themselves at risk of liability.
This is a frustration of mine. Because EKGs are at least somewhat important in psych, I have gone back to review/relearn EKG’s several times but I use them so rarely (outside of QTc) I never really apply or remember it. There are just so many patterns to remember, and correlating it to what the heart is actually doing in that moment is only so helpful. Out to cards or pcp I guess.
I actually think EKGs are the best well ran scam in American medicine. Cardiologists were able to convince everyone that they are needed for a bunch of medications. In a lot of countries, Zofran is OTC. In the US I've seen many patients get an EKG to get Zofran. I have had attendings order EKG for increasing Lexapro from 10 to 20mg, and when you go and look at the data about qtc prolongation and psych meds, patients who had issues were all in the ICU with several problems, besides massive anti psychotic doses. QTC going from 450 to 460 makes no clinical difference.
I have never seen an EKG machine at a psych office either, if I did I would find it a little bit funny and useless. Might as well just use a ENT head lamp to look cool then.
I have never seen an EKG machine at a psych office either, if I did I would find it a little bit funny and useless. Might as well just use a ENT head lamp to look cool then.
I don't think our no-show rate is very different between in-office and telehealth but the level of seriousness is much more variable with telehealth. So many patients join while driving / hiding in a corner somewhere (didn't make time to find an appropriate spot for an appointment / still on the clock) / laying down in bed / while doing the dishes.
Similar practice here. The main sticking point for getting patients back to PCP is that our repatriation agreement requires the patient's actually seen their PCP in the last year (often not met) and there are also a good number of medications that are unrepatriable (AED's, AP's, Li, Benzos more than a small once a year flight phobia Rx, etc.)
It's been very rare for cards to actually weigh in against stimulant use in most cases when I've consulted them. They do mention that it may increase risk but also that the main endpoints are ultimately manageable (BP, HR).
There were two points in my life in which I was somewhat competent at reading EKG's--after my consult cards rotation in med school and after my consult cards rotation intern year. I feel like I forgot how to meaningfully interpret them within 6 months of each due to the infrequency of use outside of that setting.
100%
Stop Twisting Yourself Into Knots About QTc
I've personally seen TdP several times since residency and being an attending and every time it's been someone on multiple illicit substances, under acute physiologic distress (read ICU or in the ED waiting for the ICU), and maybe 1-2 QTc prolonging meds on board (usually methadone as I'm addiction psych).
Last edited:
It doesn't matter whether or not we remember our medical training. What matters is our answer to the questions "and how many EKGs do you read in a day?" and "how many EKGs did you interpret in your residency training for this purpose?" And the answer will be either zero or a number that makes it obvious that we were doing something we aren't experts in.
As others have said, it's not indicated, so why do it? The only justification I can think of is a clozapine clinic where EKGs are actually part of the baseline workup. Even then, it takes a ton of patients for the scale to make sense for an EKG machine.
Stagg, do you have an EKG in your office? Or do you just think of them as available because you work in a hospital system and could send them to the appropriate building? Do you order EKGs and interpret them and feel confident you don't miss any of the less psychiatric findings in the EKG? How much money do you make / save having this EKG machine in your office?
Do you calibrate this EKG machine? Who is certified to place the leads? Will you be placing the leads under the breasts of your female patients? Those of us in solo private practice clearly have nobody we can have do this for us and there's a zero percent chance I'm placing those leads.
I read multiple per day. Probably 4-6 on my own. Frankly it's not a hard skill to learn to at least be competent and I'm not worried about missing something the average IM doc would need an electrophysiologist to catch. We are experts in psych meds and every med student is required to learn how to read EKGs, it's not surgery. Per the APA document on on QTc guidelines:
"In resource-poor settings ECGs may not be easily accessible. Practitioners should not let the absence of© Copyright, American Psychiatric Association, all rights reserved. 25an ECG preclude the prescription of a psychotropic medication; rather they must carefully consider known risks vs. benefit of prescribing the medication. In settings where clinicians have access to an ECG machine in the absence of a cardiology overread, clinicians of any medical specialty should feel comfortable with measurement, calculation, and documentation of the QTc interval."
The whole "I'm not an expert so I shouldn't be doing this" is a cop out. We're physicians. We should act like it or admit that we're not better than psychologists with a prescription pad.
Clozapine is a great example. APA also recommends patients over 50 yo on antipsychotics also get an EKG before starting an antipsychotic. There's also multiple psych groups (ACLP, AMP, APA) that recommended that elderly patients starting a TCA get an EKG to be screened for cardiac pathology and have regular monitoring, some groups (AMP) recommend initial EKG screening for anyone over 40 yo being started on a TCA. There's also some suggestions that anyone on "high doses" of TCAs (example amitriptyline over 100mg) should get an EKG. Multiple societies (in psych and other fields) recommend EKG monitoring for patients on methadone as well. There are also reasons to monitor this in inpatient settings as well (ie, patients getting large volumes of IM/IV haldol). So yea, there's several indications where it is recommended, even if I think the risk of QTc prolongation is often overblown.
My only outpatients are telehealth referred from specific PCP clinics (where I can ask their PCP to get an EKG) or the 1-2 days a month where I supervise resident clinic where we can do EKGs in office. I do order and interpret them myself. That was the expectation where I trained and where I currently work (both have robust med/psych programs affiliated). If I have any concerns outside of basic stuff related to my meds, I message the PCP or refer to cardiology. And yes, I bill a 93000 if I order and interpret the EKG, even if cardiology also signs off. No idea about all the financial details, but I care a lot less abut that than missing something that will potentially kill my patient (I've caught WPW a few times and have had patients not know they had QTc's in the low to mid-500s). I also had a co-resident have a patient die a few weeks after starting ziprasidone due to cardiomyopathy that wasn't monitored and a patient (not mine) died on-unit from an unrecognized cardiomyopathy 4-5 days after starting an antipsychotic. So I don't f*** around with that stuff when it's so easily avoidable where I'm at.
To the last paragraph of questions, those are all fair and I agree that it's not reasonable to expect every independent psychiatrist to have that capability. Plenty of places don't have the staff or patient population to make this practical or sometimes possible. Even the APA document above recognizes that. That said, if you're in a large practice with multiple clinical support staff it's not that difficult to justify having an EKG machine and a few practices I worked with had them.
I'm not really disagreeing with you all that much and realize that I have a lot more capabilities in my C/L role at a big academic center than most outpatient docs will have access to. Otoh, I've seen patients die from this being ignored both by their inpatient and outpatient docs and I take it seriously. I wouldn't expect independent docs or small clinics to have machines there, again I was just surprised that you've so adamantly never even heard of it.
Advertisement - Members don't see this ad
While I agree with you about being able to read EKGs and personally keep up on that skill for myself, you should read the link I posted above. Also, I wouldn't take the above guidelines to heart. For example, SAMHSA justifies their guidelines around QTc monitoring for MMT citing a 2% incidence of QTcs >500msec in individuals receiving MMT, which is exceptionally high if you're familiar with the literature around QTc and MMT (mind you the chances of developing TdP with a QTc of 540msec is 1/16,229 or 0.0062%, roughly the incidence of PKU in the general population). I did some digging only to find out that they cherry picked a tertiary citation in their references of a poorly designed cross-sectional study of 138 individuals... not that impressive for an organization making national guidelines especially when a 2013 Cochran Review article concluded the following around MMT and QTc monitoring “It is not possible to draw any conclusions about the effectiveness of QTc screening strategies for preventing cardiac morbidity/mortality in methadone treated opioid [dependent patients].”
Last edited:
My ED MDs do that IM olanzapine and Ativan too often even after I provide education. I've never seen an adverse event, but if one did happen, it'd be a bigger thing than an adverse event from haldol, ativan and benadryl. I think it would be a good to do like some sort of massive record review done to really remove that as a contraindication more formally.
I mean, there was a study showing something like 50 incidents of severe respiratory depression with several deaths out of ~1300 reviewed cases. So there was significant reason for concern at one point.
However, I agree that this risk is overblown and several subsequent studies have shown risk to be far lower than that. Kind of seems like the same thing as the initial agranulocytosis studies with clozapine. I also find it interesting that the warning is specifically for parenteral administration of them both, yet there’s no warning for zydis.
Either way, Comp brings up the great point that if you’re going to go against guidelines or recommendations (or standard of care) and there’s a bad outcome, are you going to be ready to defend that? I can think of plenty of situations where Lance’s peanut and Ativan is necessary for my patients, but we always make sure we document why we’re doing that instead of alternative options that would not be as problematic.
That logic can lead to an appeal to authority fallacy. I can think of a number of instances where I regularly go against guidelines but I obviously document why and occasionally cite literature in my documentation when I do.
Last edited:
Right, I go against guidelines fairly often due to medical complexity of my patients. Strict adherence is my biggest gripe with EBM, but guidelines are still there for a reason. Like you said, if we’re going to go against them we should at least drop a line about why.
Stagg, your answer was that you don't have an EKG machine in your office. So please remember that you were calling me out for saying I had never seen a psychiatrist have one in their office, and even though for some absolutely deviating from standard treatment reason you are reading 6 EKGs a day you still don't have an EKG in your office.
You list some very fringe cases that have nothing to do with outpatient psychiatry and, yet again, think that your experience as a CL physician has anything to do with outpatient psychiatry.
It is not a "cop out" to say I don't have an EKG machine because I'm not an expert in reading them. I've directly asked the board of medicine where I ask and they say it would be a deviation in standard of care for me to read and interpret my own EKGs. I also reviewed with multiple attorneys prior to the board who all said "they would get you because an EKG requires a shirtless patient. You're a psychiatrist. You should never look at a shirtless patient."
Again, CL psychiatry really isn't relevant to the actual practice of psychiatry by people who practice it. Consider that you have a 30% no-show rate and the rest of us it's well below 10%. Different patients with different problems. It sounds like if 3x as many of them can't make appointments they have a lot more going on, for one thing.
You list some very fringe cases that have nothing to do with outpatient psychiatry and, yet again, think that your experience as a CL physician has anything to do with outpatient psychiatry.
It is not a "cop out" to say I don't have an EKG machine because I'm not an expert in reading them. I've directly asked the board of medicine where I ask and they say it would be a deviation in standard of care for me to read and interpret my own EKGs. I also reviewed with multiple attorneys prior to the board who all said "they would get you because an EKG requires a shirtless patient. You're a psychiatrist. You should never look at a shirtless patient."
Again, CL psychiatry really isn't relevant to the actual practice of psychiatry by people who practice it. Consider that you have a 30% no-show rate and the rest of us it's well below 10%. Different patients with different problems. It sounds like if 3x as many of them can't make appointments they have a lot more going on, for one thing.
Last edited:
Curiosity. I honestly was really into EKGs in medical school and internship and wanted to have one and was told not to and wanted to understand why. In residency the only thing we ever did was hear about the QTc, but we never ordered an EKG to assess QTc. We would actually have had to consult a medicine colleague and ask them to order the EKG at most of our hospitals we rotated at for inpatient. At our home site each patient had a medical provider and a psychiatrist, so the medical provider was responsible for all labs and tests. We weren't allowed to order anything there but medications and the psychiatry attending could also order physical holds, but that was it.
Then in PGY-3 nobody ever ordered them. I had a few patients who warranted them and it was a major hassle to obtain one. Was told to just ensure the PCP obtains the EKG. If the patient doesn't have a PCP then either assist them with obtaining one or don't provide medications that require EKGs.
If it's an older patient or one where I would need an EKG due to medical history or issues like that, then that patient needs to have a PCP and if they have actual medical problems related to their heart they also tend to have a cardiologist prior to my treatment, anyway. Again, if they had that, I probably wouldn't be giving them things that need EKGs. If I did, they'd probably have to be seen by someone like Stagg who has access to it.
Last edited:
Don’t misquote me. Our physical office has EKGs and we order them AND expect our residents to be able to read them. This is the standard where I’m at. My personal outpatients are all 300+ miles away and I don’t see them in person but require they have PCPs and I do order EKGs on them. If I had my own office I may or may not have one, but if I owned a large practice I would. Again, there is a practical component as well.
For the third or fourth time. NO ONE called you out for not having an EKG machine. I just still find the insistence that you’ve “never ever, ever” heard of this bizarre. And if you’re prescribing antipsychotics or TCAs you should be aware that multiple large psychiatric organizations recommend EKGs even if we can’t do them or read them or have them immediately available ourselves. That is NOT limited to practice in a CL setting.
If that’s what your boards and lawyers say then cool. Listen to them. In my state people have been censured for outcomes related to meds and lack of monitoring (including EKGs). One of my colleagues is on the state board and I talk to them about this stuff fairly often as I’m semi-interested in pursuing that position at some point. So ymmv depending on state, especially since the standard of care in psych in general is such joke.
Either way, practice however you want. Most legal issues are overblown on here anyway. Again, I just think most people, likely including the lawyers you talked to, don’t even look at psychiatrists as physicians. I don’t care to add to that stigma or the further lowering of the standard of care (NPs and pill mill schills have done enough damage there) by forgetting a very basic test that every physician is required to be competent at during their training. In terms of legal concerns, I still go by the very astute advice that I and another on here received of, “you’re allowed to be wrong, but you’re not allowed to be negligent.” If you’re not comfortable, then don’t do it, just make sure you know who should be doing it and when. If you can competently do it, then you should or at least make sure it’s done and refer out when it’s past your competence.
Unless there’s a specific law saying what you can and can’t do lawyers are always going to tell you to protect yourself, even if it harms your patients.
If the attorney has problems with an EKG being done is a psychiatric office (even if a tech/nurse and not the psychiatrist is seeing them shirtless); I wonder what they would say about patients dropping their pants to receive a long-acting antipsychotic injection
I gave them in residency because we didn’t have nurses in our outpatient department.
I'm not doing EKGs in my office or anything but that's the dumbest reasoning.
If a patient tells me they have a rash on their chest after starting lamictal or an SSRI am I just gonna go "sorry I can't look under your shirt I'm a psychiatrist after all".
I always assumed (based on nothing) that having an EKG in your office would increase liability simply because I do not trust anyone here to read EKGs. Yes, anyone here can calculate qtc, but what if a more rare or odd ekg shows up, and you miss something? That seems to me a very clear flaw, although I could be wrong. Considering there is a fellowship post cardiology to read EKG, I assume there are things any of us would easily miss.
This is different than CL, specially since EKGs are often ordered and read by multiple professionals, including hospitalist and cardiologist if needed.
This is different than CL, specially since EKGs are often ordered and read by multiple professionals, including hospitalist and cardiologist if needed.
Advertisement - Members don't see this ad
Some larger clinics have a nurse to give injections. And I do know of psych np's who have administered LAIs
Since we're on the topic, if anyone wants to self-test their ECG skills... https://ecg.bidmc.harvard.edu/maven/mavenmain.asp
I gave them in both adult residency and child fellowship (I think my CAP training may have been a bit different than most attached to a quaternary care center). I have given a few as an attending and would consider doing it again in my new private practice for the right patient (there's something to the intervention being so visceral with LAIs), but nowadays it's pretty easy to just have them done at the pharmacy and that seems preferrable to me.
Edit: I should add that I only ever gave the deltoid LAIs. Something about having a patient pull their pants down with a psychiatrist that seems wrong.
Last edited:
