Telemedicine Neurology vs. IM

[davidBA]

Which of these specialties is better suited for a telemedicine career? Which of them has more job opportunities/availability in telemedicine?

I'm an IMG applying for either Neurology or IM next year, and idea of doing telemedicine from my home country one day is quite appealing. I understand that not all companies allow doing telemedicine from abroad, and that's why I'm asking about telemedicine job availability.

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[xenotype]

Either one will have substantial opportunities in my opinion going forward. For IM you will need to subspecialize for reliable, well paying, interesting telemed work eg cards, pulmCC. Gen IM does not have great telemed opportunities unless you consider cranking through urgent care phone app visits intellectually rewarding work. Try to figure out clinically what you enjoy more.

 

[davidBA]

Either one will have substantial opportunities in my opinion going forward. For IM you will need to subspecialize for reliable, well paying, interesting telemed work eg cards, pulmCC. Gen IM does not have great telemed opportunities unless you consider cranking through urgent care phone app visits intellectually rewarding work. Try to figure out clinically what you enjoy more.

Thanks a lot for your reply. I have seen lots of companies advertising Tele-Hospitalist/Tele-Nocturnist jobs. Are these jobs not as common as eg. Tele-Stroke and Tele-ICU jobs?

 

[xenotype]

Thanks a lot for your reply. I have seen lots of companies advertising Tele-Hospitalist/Tele-Nocturnist jobs. Are these jobs not as common as eg. Tele-Stroke and Tele-ICU jobs?

I'm not knowledgeable about the reimbursement model for those, the IM forum would know better on what the future potential would be. Logistically once you get a hospital to a certain size it makes more sense to have the hospitalist physically there. There is also a lot of midlevel encroachment to worry about in hospital medicine. Tele-ICU for example is often additional on top of NPs being physically in the unit- would you see the same with hospitalist workflow? Not sure. IM will always have an advantage of flexibility, but the good fellowships are competitive. This is irrelevant though- the main factor should be whether you like clinical neurology or not. If you don't care much for clinical neurology, you probably won't like doing stroke alerts all day.

 

[davidBA]

I'm not knowledgeable about the reimbursement model for those, the IM forum would know better on what the future potential would be. Logistically once you get a hospital to a certain size it makes more sense to have the hospitalist physically there. There is also a lot of midlevel encroachment to worry about in hospital medicine. Tele-ICU for example is often additional on top of NPs being physically in the unit- would you see the same with hospitalist workflow? Not sure. IM will always have an advantage of flexibility, but the good fellowships are competitive. This is irrelevant though- the main factor should be whether you like clinical neurology or not. If you don't care much for clinical neurology, you probably won't like doing stroke alerts all day.

I'm very sorry for the late reply due to studying. Neurology is my main area of interest. But I was worried about the lack of opportunities in telemedicine since it's a small field compared to IM.
Do you think the lack of neurological exam would be a problem in telestroke?
Would an exam done by a bedside nurse be enough?

 

[xenotype]

I'm very sorry for the late reply due to studying. Neurology is my main area of interest. But I was worried about the lack of opportunities in telemedicine since it's a small field compared to IM.
Do you think the lack of neurological exam would be a problem in telestroke?
Would an exam done by a bedside nurse be enough?

95% of inpatient and probably 60% of outpatient neurology can be done entirely remote. The bedside nurse is an extension of your exam. Stroke especially works well via telemedicine- NM complaints are challenging via telemed in comparison. If you like neurology, do it and the rest will work out.

 

[Phantom Spike]

Doing teleneurology with any of the large companies requires one to obtain multiple state licenses, often as many as 10-15. I can't quite say why, but the very idea makes my skin crawl. The companies pay for these licenses, of course (provided you stay with them for a contractually-directed amount of time), but I still find it a major aspect that makes me hesitate. For those who have actually done it, did you face any major issues? Having to get credentialed at multiple hospitals is similarly a daunting prospect.

 

[davidBA]

95% of inpatient and probably 60% of outpatient neurology can be done entirely remote. The bedside nurse is an extension of your exam. Stroke especially works well via telemedicine- NM complaints are challenging via telemed in comparison. If you like neurology, do it and the rest will work out.

Thank you for your advice and guidance. I understand that CMS cannot be billed if the telemedicine provider lives abroad. Do you see any potential in telestroke/teleneurology where the telemedicine provider is entirely dependent on privately insured patients?

 

[xenotype]

Doing teleneurology with any of the large companies requires one to obtain multiple state licenses, often as many as 10-15. I can't quite say why, but the very idea makes my skin crawl. The companies pay for these licenses, of course (provided you stay with them for a contractually-directed amount of time), but I still find it a major aspect that makes me hesitate. For those who have actually done it, did you face any major issues? Having to get credentialed at multiple hospitals is similarly a daunting prospect.

The skin crawl factor is real, and some of the medicolegal risks with telemedicine cannot be fully known at this time given the amount of complexity. With that said, the big companies doing this at this point are very experienced at it, and very good at anticipating and overcoming problems. An academic job in most states has way less risk (especially VA, although VA it is a misconception that VA is risk free), but a community job in a high litigation state might be a similar amount of risk to a tele job regardless.

Thank you for your advice and guidance. I understand that CMS cannot be billed if the telemedicine provider lives abroad. Do you see any potential in telestroke/teleneurology where the telemedicine provider is entirely dependent on privately insured patients?

Yes. Inpatient teleneurology reimbursement is mostly directly contractually provided between the hospital/hospital system and the teleneurology company who then pays the neurologist at contractual rates. The patient may or may not get a bill depending on the agreement or lack thereof regarding billing between the teleneurology company and the hospital- essentially I as the neurologist do not care whether the patient gets billed or not, and whether the hospital ultimately gets paid or not as the hospital will pay my company (and me) no matter what. The hospitals like it because even quite small hospitals can avoid transfers/unnecessary admissions which patients also dislike.

 

[Prehealth1011]

2020 FM Physicians - what do you earn?

Ok I posted earlier but I got new jobs and I know upcoming graduates are looking... $190,000 working in a community health center. All appointments are 30 min. I work 4 days a week, 1 day is admin. $1000 a day abortion care (I usually do 2-3 shifts per month, hours are usually 9-3 or 4)...

forums.studentdoctor.net

FM doc doing tele 8 pt/hr. I'm assuming you can do this as IM as well

 

[Phantom Spike]

Yes. Inpatient teleneurology reimbursement is mostly directly contractually provided between the hospital/hospital system and the teleneurology company who then pays the neurologist at contractual rates. The patient may or may not get a bill depending on the agreement or lack thereof regarding billing between the teleneurology company and the hospital- essentially I as the neurologist do not care whether the patient gets billed or not, and whether the hospital ultimately gets paid or not as the hospital will pay my company (and me) no matter what. The hospitals like it because even quite small hospitals can avoid transfers/unnecessary admissions which patients also dislike.

Some of the companies have models where they pay you a salary with benefits (i.e., full-time job) doing teleneurology, but the expected hours seem to be quite brutal. Contracted positions, with the neurologist being paid per-patient and where you set your own schedule, seem to be the norm, and there are posts on other threads suggesting that one could earn enough to make a living rivaling any traditional practice this way.

 

[elanmorin]

Can you guys elaborate on what you mean by "skin crawl" related to telemed and obtaining lots of licenses? Is it the fact that your info is out there for lots of boards to review in detail?

 

[curiousneuro]

So yes, I actually do full-time teleneurology now (has now been a few months). So far, it's been great. I'm not sure if there are more/less medicolegal risks by doing telemedicine over traditional practice. Company handles all licensure/credentialing which makes things much smoother. Feel I am very well compensated for what I do.

 

[Phantom Spike]

So yes, I actually do full-time teleneurology now (has now been a few months). So far, it's been great. I'm not sure if there are more/less medicolegal risks by doing telemedicine over traditional practice. Company handles all licensure/credentialing which makes things much smoother. Feel I am very well compensated for what I do.

Thanks for posting, it's always good to hear from someone actually engaged in this type of work. Hope it's okay to ask a few questions ...

Do you see just acute strokes or also inpatient neurology?
Are you compensated per patient or per shift? If the latter, how long are your shifts and how busy?
If someone were to do around 15 shifts/month, do you think they could earn at least $150k per year?

 

[Postictal Raiden]

Thanks for posting, it's always good to hear from someone actually engaged in this type of work. Hope it's okay to ask a few questions ...

Do you see just acute strokes or also inpatient neurology?
Are you compensated per patient or per shift? If the latter, how long are your shifts and how busy?
If someone were to do around 15 shifts/month, do you think they could earn at least $150k per year?

15 shifts a month for 150k a year???

The rate my friend got was 2k for a 24hr shift for cap of 15 encounters plus a additional $400 for being on backup in case he’s needed to take on more consults. So if you do 15 of those a month, you should clear 430k

It’s not an easy job, keep in mind. You’re dealing very time sensitive, high acuity cases.

 

[curiousneuro]

Thanks for posting, it's always good to hear from someone actually engaged in this type of work. Hope it's okay to ask a few questions ...

Do you see just acute strokes or also inpatient neurology?
Are you compensated per patient or per shift? If the latter, how long are your shifts and how busy?
If someone were to do around 15 shifts/month, do you think they could earn at least $150k per year?

So for me - about 15 shifts/month, 12 hour shifts, mostly stroke (about 60-70 stroke and the rest general). Can pick up more shifts and call if desired.

Based on how things are going, on track for 450-500k this year.

 

[curiousneuro]

15 shifts a month for 150k a year???

The rate my friend got was 2k for a 24hr shift for cap of 15 encounters plus a additional $400 for being on backup in case he’s needed to take on more consults. So if you do 15 of those a month, you should clear 430k

It’s not an easy job, keep in mind. You’re dealing very time sensitive, high acuity cases.

Yup every company/job is different. I happen to love it (stroke fellowship trained), but certainly not for everyone.

 

[Phantom Spike]

So for me - about 15 shifts/month, 12 hour shifts, mostly stroke (about 60-70 stroke and the rest general). Can pick up more shifts and call if desired.

Based on how things are going, on track for 450-500k this year.

How many patients do you see per shift on average?
Do you have enough time to chart? Do you read your own CTs/CTAs for the acute strokes?
Do you ever feel overwhelmed, or do you think burnout might be an issue? I'm wondering if someone early in their career might cope better with these high-volume teleneurology jobs than someone mid-to-late career. I probably wouldn't have been as apprehensive about burnout ten years ago.
(Thanks again for the insight, it's invaluable.)

 

[curiousneuro]

How many patients do you see per shift on average?
Do you have enough time to chart? Do you read your own CTs/CTAs for the acute strokes?
Do you ever feel overwhelmed, or do you think burnout might be an issue? I'm wondering if someone early in their career might cope better with these high-volume teleneurology jobs than someone mid-to-late career. I probably wouldn't have been as apprehensive about burnout ten years ago.
(Thanks again for the insight, it's invaluable.)

So I see about 17 patients/shift on average. However, it all depends on how efficient you are, you are not pushed to see more/less, which is nice. I feel like I definitely have enough time to chart, etc. I do read my own CT/CTAs to a degree for acute stroke care as you would in the hospital setting for tPA decisions, but always have radiology to verify things.

Honestly, I don't feel burned out at all. I feel very comfortable with this, but again, everyone is different. I think you do need to be tech savvy to be comfortable with teleneuro, especially to be efficient at it.

The way I look at it also - if I was in clinic I might be seeing close to that number of patients anyways, so I don't think that this job will burn me out any more than other jobs would (except for I guess really cush jobs).

But that's my 2 cents...!

 

[Postictal Raiden]

How many patients do you see per shift on average?
Do you have enough time to chart? Do you read your own CTs/CTAs for the acute strokes?
Do you ever feel overwhelmed, or do you think burnout might be an issue? I'm wondering if someone early in their career might cope better with these high-volume teleneurology jobs than someone mid-to-late career. I probably wouldn't have been as apprehensive about burnout ten years ago.
(Thanks again for the insight, it's invaluable.)

Varies by company but my friend sees about 15 in 24hr shift. Ofc you would have to review images/labs/vitals yourself just like you would in a normal encounter. If each encounter takes, say, 45mins on average, you’d need 11-12 hrs of pure work. However, these encounters are scattered over a 24-hr period. You may have few occurring back to back or may go few hours without a single consult.