Has EM gotten so bad that now you guys want to invade my field (pediatrics)?

[Birdstrike]

Listen guys, I don't want to get into a debate about how qualified EM docs are to practice peds.

My question is WHY would you want to?

This is like asking someone who just threw themselves out of a moving vehicle going 70 mph, "Why would you want to throw yourself out of a moving care, dummy?" as if there could never possibly be a valid reason. Then when you find out the reason, all of a sudden, you feel like the dummy,

"Because the only thing worse would have been to stay in the car with the guy who was gonna kill me."

---

Members don't see this ad.

 

[Taurus]

All this talk about telemedicine reminds of the early days of teleradiology and how some people were freaking about images being read by radiologists in India or China.

So I will pose the same question. What’s to stop some doc in India or China from doing telemedicine for this country? Let’s play devil’s advocate and say was US trained and has active state license.

The saving grace for radiology is that CMS requires final reports have to be issued by radiologists who are on US soil. Because no one cares much about prelim reports, teleradiology by foreign radiologists never took off. It pretty much fizzed out now.

 

[calvnandhobbs68]

more like calvnandhobbs69

Dammit why didn't i think of that

 

[Socrates25]

All this talk about telemedicine reminds of the early days of teleradiology and how some people were freaking about images being read by radiologists in India or China.

So I will pose the same question. What’s to stop some doc in India or China from doing telemedicine for this country? Let’s play devil’s advocate and say was US trained and has active state license.

The saving grace for radiology is that CMS requires final reports have to be issued by radiologists who are on US soil. Because no one cares much about prelim reports, teleradiology by foreign radiologists never took off. It pretty much fizzed out now.

Damn that must be nice to get special protection from the government

 

[Fox800]

more like calvnandhobbs69

 

[RustedFox]

Late to the party; but OP answered his own question in the thread title.

Yeah; many EPs see EM as such a hot mess that we'd rather do other things; and seeing as how the attitude of "well; ANYONE can work in the ER you know" is still around and even gaining traction, then many EPs are saying "well, that's a two-way street then, amigo."

If the powers that be don't care, then we'll take that and run the other way with it.

I forget who it was who said it first on here (I won't take credit); but it was posted that "the only good thing to come out of this is that it seems like board certification won't matter so much in the outpatient world in the near future".

EPs are gonna do other things; and be damn good at them. And be damn fast at them.

 

[Iamnew2]

Clothes off costs extra. Need that tip money for that Z-pac prescription and some skin.

I agree re the uber for doctors. The rates are so low it's outright offensive. it'd be simpler for a doctor to just set up a telemed platform themselves.

 

[VA Hopeful Dr]

Guys can we stop. This is getting a little too close to the truth

So Hooters but with prescription pads?

 

[Socrates25]

I agree re the uber for doctors. The rates are so low it's outright offensive. it'd be simpler for a doctor to just set up a telemed platform themselves.

It's not that simple. Where are you going to get the patients?

I'd say the telemedicine market is pretty saturated.

The primary care market is freaked out about teladoc and these other places but they shouldn't be.

Teladoc means MORE $$$ for me even though I refuse to participate in that garbage system.

When little Johnny is still coughing after finishing his zpack from Teladoc, his parents are going to come to me and say "why didnt my child get better? The teladoc idiot said the zpack would cure him"

I did my own little study a few months ago -- every time I get a notification from a telemed company that one of my patients was "seen" by them for URI symptoms, I advised my nurses to call the patient 3 days and 7 days after the telemed visit to find out how they were doing.

We did this for 6 months and captured 279 encounters.

Out of those 279 encounters, 248 of them were prescribed antibiotics FOR NO JUSTIFIABLE REASON. No evidence of pneumonia. No evidence of strep. No evidence of otitis.

Better yet, patients reported that 3 days post antibiotics, there was no discernible improvement in condition.

At 7 days, the people who did not get antibiotics were just as likely as the people who did to report improvement in their condition.

 

[Socrates25]

Late to the party; but OP answered his own question in the thread title.

Yeah; many EPs see EM as such a hot mess that we'd rather do other things; and seeing as how the attitude of "well; ANYONE can work in the ER you know" is still around and even gaining traction, then many EPs are saying "well, that's a two-way street then, amigo."

If the powers that be don't care, then we'll take that and run the other way with it.

I forget who it was who said it first on here (I won't take credit); but it was posted that "the only good thing to come out of this is that it seems like board certification won't matter so much in the outpatient world in the near future".

EPs are gonna do other things; and be damn good at them. And be damn fast at them.

Nobody is good at telemedicine. Everybody in that game is a charlatan and it doesn't matter what your training is.

 

[Iamnew2]

It's not that simple. Where are you going to get the patients?

I'd say the telemedicine market is pretty saturated.

The primary care market is freaked out about teladoc and these other places but they shouldn't be.

Teladoc means MORE $$$ for me even though I refuse to participate in that garbage system.

When little Johnny is still coughing after finishing his zpack from Teladoc, his parents are going to come to me and say "why didnt my child get better? The teladoc idiot said the zpack would cure him"

I did my own little study a few months ago -- every time I get a notification from a telemed company that one of my patients was "seen" by them for URI symptoms, I advised my nurses to call the patient 3 days and 7 days after the telemed visit to find out how they were doing.

We did this for 6 months and captured 279 encounters.

Out of those 279 encounters, 248 of them were prescribed antibiotics FOR NO JUSTIFIABLE REASON. No evidence of pneumonia. No evidence of strep. No evidence of otitis.

Better yet, patients reported that 3 days post antibiotics, there was no discernible improvement in condition.

At 7 days, the people who did not get antibiotics were just as likely as the people who did to report improvement in their condition.

that's because the teladoc was most likely a tela-NURSE!

 

[RustedFox]

Nobody is good at telemedicine. Everybody in that game is a charlatan and it doesn't matter what your training is.

I agree.
Telemed is for hair loss and erectile dysfunction med refills.

But I think you're underestimating how radioactive the EM landscape is - causing docs to do anything... anything else.

 

[calvnandhobbs68]

Nobody is good at telemedicine. Everybody in that game is a charlatan and it doesn't matter what your training is.

"Oh you say you have strep throat? K then, would you like a Z-pack or amoxicillin?"

It's like the ADHD platforms that are basically taking advantage of the Ryan Haight act suspension (Done, Ahead, etc).

"Oh you say you have ADHD? K then, would you like Adderall or Ritalin?"

 

[Iamnew2]

I agree.
Telemed is for hair loss and erectile dysfunction med refills.

But I think you're underestimating how radioactive the EM landscape is - causing docs to do anything... anything else.

Lol - really just for hair loss and erectile dysfunction med refills?
Has EM gotten that bad? I remember the days where it was super competitive.

 

[Arcan57]

If you have an army of MD/NP/PA employees at your disposal doing the calls for you then sure you can make a lot of money.

At that point though, why go into EM at all? If being an entrepreneur and running a business is your goal, EM (or any of the hospital based specialties) seems like a very poor choice.

I get the distinct impression that many of the EM people start these companies don't work in EM anymore and have abandoned your field.

You go into EM because the idea of going through a surgical residency didn't spark joy and you hear you could make s%#^ tons of money after doing a 3 yr residency and still have plenty of time off to pursue your true passion (parasailing in Uruguay, making artisanal cheeses, doing rails off of hookers). You start looking elsewhere as the money and work conditions get worse. One day it hits you that your work life is controlled by the whims of people that are crazy, stupid, or both. And then you move into peds because the adult space for ancillary services is increasingly scrutinized. People with fewer morals and more money have been busy re-enacting the cattle rancher vs. rainforest dynamic for years on the adult side and the payors are starting to wise up, Getting hit with Medicare fraud charges ends your career in medicine outside of the penal system, so it makes sense to wander into kiddie land where the competition and the regulatory spotlight are less harsh.

 

[Socrates25]

It's like the ADHD platforms that are basically taking advantage of the Ryan Haight act suspension (Done, Ahead, etc).

"Oh you say you have ADHD? K then, would you like Adderall or Ritalin?"

I just looked this company up. $199? That's a joke. Amazon will run them out of business with a $9.99 monthly special very soon.

And you know what's sad?

There are apparently plenty of doctors (not just midlevels) out there so desperate for work they will gladly work for Amazon and feel fortunate to make their 50k income

Here's what these internet telemed companies don't understand -- on the internet, there's always somebody cheaper than you are and it's impossible to build a trusted relationship. It's strictly transactional. The ONLY thing that matters is how cheap you are. When you can't build a relationship, you are easily dispensable.

In a brick and mortar clinic, I build relationships. People want to see ME, not some random face on a computer. The ONLY reason they choose telemed sometimes is because it's 2 AM and I'm closed. Period. I've actually studied this too. A couple of years ago I ran a system report to show me how many telemed visits were done while I was open during office hours. On a panel with approx 10,000 patients and average 20 patient encounters per day, only 3 patients in the last 12 months consulted telemedicine when they had me as an option instead.

Doctors don't understand their own power. If you build a strong relationship with a patient base, they will choose you over a random internet person every time.

The county health department is down the street from my clinic and has a peds clinic. You can walk in there with your child and be seen by an NP or PA at ZERO cost. It's all funded by the state.

Yet curiously, I have several hundred patients with no insurance who choose to pay me $100 out of pocket for a visit and never go to the health department despite the fact that I'm a lot more expensive.

 

[Iamnew2]

I just looked this company up. $199? That's a joke. Amazon will run them out of business with a $9.99 monthly special very soon.

And you know what's sad?

There are apparently plenty of doctors (not just midlevels) out there so desperate for work they will gladly work for Amazon and feel fortunate to make their 50k income

Here's what these internet telemed companies don't understand -- on the internet, there's always somebody cheaper than you are and it's impossible to build a trusted relationship. It's strictly transactional. The ONLY thing that matters is how cheap you are. When you can't build a relationship, you are easily dispensable.

In a brick and mortar clinic, I build relationships. People want to see ME, not some random face on a computer. The ONLY reason they choose telemed sometimes is because it's 2 AM and I'm closed. Period. I've actually studied this too. A couple of years ago I ran a system report to show me how many telemed visits were done while I was open during office hours. On a panel with approx 10,000 patients and average 20 patient encounters per day, only 3 patients in the last 12 months consulted telemedicine when they had me as an option instead.

Doctors don't understand their own power. If you build a strong relationship with a patient base, they will choose you over a random internet person every time.

The county health department is down the street from my clinic and has a peds clinic. You can walk in there with your child and be seen by an NP or PA at ZERO cost. It's all funded by the state.

Yet curiously, I have several hundred patients with no insurance who choose to pay me $100 out of pocket for a visit and never go to the health department despite the fact that I'm a lot more expensive.

Agreed. Many doctors are plain stupid and don't know their worth. Some salaries that are offered out there are outright pitiful. i was recently offered slightly over $200 to do a review, write up and review over 80 pages of documents - when I said it's too low, I was told how some doctors review 200 pages in 1 hour. I said yeah no reasonable doctor would do that. Sme of the telemed companies pay like $20 per consult. No thanks.

 

[doctalaughs]

I agree.
Telemed is for hair loss and erectile dysfunction med refills.

But I think you're underestimating how radioactive the EM landscape is - causing docs to do anything... anything else.

Lol. Telemed is actually terrible for hair loss as exam of the scalp is essentially impossible over video or photos (can’t comment on erectile dysfunction since I’m a dermatologist).

You’d think telemed would be good for derm - but one thing the pandemic taught me is that it’s pretty terrible care for about 90% of what we do. It’s borderline ok for acne but that’s about it.

 

[Socrates25]

Lol. Telemed is actually terrible for hair loss as exam of the scalp is essentially impossible over video or photos (can’t comment on erectile dysfunction since I’m a dermatologist).

You’d think telemed would be good for derm - but one thing the pandemic taught me is that it’s pretty terrible care for about 90% of what we do. It’s borderline ok for acne but that’s about it.

Even for mental health which is supposed to be the holy grail of telemedicine, its' not that great. I find that even with a good internet connection there's just a slight pause or lag and I'm a lot less likely to be able to get a depressed teenager to crack a smile because nuances in facial expression are lost on the monitor.

It's just not the same as in person and it never will be.

To borrow a Top Gun analogy, a doctor choosing to do telemedicine is like an F16 fighter pilot deciding that he'd rather "fly a cargo plane full of rubber dog **** out of Hong Kong" instead.

 

[Apollyon]

To borrow a Top Gun analogy, a doctor choosing to do telemedicine is like an F16 fighter pilot deciding that he'd rather "fly a cargo plane full of rubber dog **** out of Hong Kong" instead.

Aaah!! You pain me so! The F16 is Air Force. The Navy had F14s at that time (and, you know who still flies them? Iran), but have now moved to the F18, while, sometime in the future, transitioning to the F35. If you knew this, apologies. But, ye pained me so!!

 

[GeneralVeers]

Regardless what you guys think, and I agree most telemedicine is a scam, it's going to be the future. Sure there will still be doctor's offices, but the vast majority of non-specialized, non-urgent care is going to be Telemedicine paying physicians pennies on the dollar.

I only do it because I've been with the current company since day 1, and they pay me very well relative to the amount of work/risk involved. The second they cut pay significantly I'm out and done.

 

[GeneralVeers]

Aaah!! You pain me so! The F16 is Air Force. The Navy had F14s at that time (and, you know who still flies them? Iran), but have now moved to the F18, while, sometime in the future, transitioning to the F35. If you knew this, apologies. But, ye pained me so!!

My Father-In-Law flew for UPS and made $450K per year, has a great retirement and a ton of stock purchased at the equivalent of USD50. That beats an F-16 any day.

 

[sylvanthus]

Regardless what you guys think, and I agree most telemedicine is a scam, it's going to be the future. Sure there will still be doctor's offices, but the vast majority of non-specialized, non-urgent care is going to be Telemedicine paying physicians pennies on the dollar.

I only do it because I've been with the current company since day 1, and they pay me very well relative to the amount of work/risk involved. The second they cut pay significantly I'm out and done.

Any recs on reputable companies that wont hose you?

 

[Rekt]

Any recs on reputable companies that wont hose you?

Isn't it ridiculously saturated right now? Last I heard there's teams of docs sitting at their computer waiting for a single pt.

 

[Iamnew2]

Isn't it ridiculously saturated right now? Last I heard there's teams of docs sitting at their computer waiting for a single pt.

Yep I have heard this. So perhaps it's time for a reduction in physician work force. It seems there's more docs than there are positions no?

 

[Birdstrike]

If you build a strong relationship with a patient base, they will choose you over a random internet person every time.

True

 

[Birdstrike]

To borrow a Top Gun analogy, a doctor choosing to do telemedicine is like an F16 fighter pilot deciding that he'd rather "fly a cargo plane full of rubber dog **** out of Hong Kong" instead.

 

[Birdstrike]

My Father-In-Law flew for UPS and made $450K per year, has a great retirement and a ton of stock purchased at the equivalent of USD50. That beats an F-16 any day.

Good for him. I'd take that job. Not sure that that exists anymore, but I'd jump at it even now in my late 40's.

 

[Pokedoc]

Yep I have heard this. So perhaps it's time for a reduction in physician work force. It seems there's more docs than there are positions no?

Genuine question, why is this always the solution suggested here? Instead of reducing the physician workforce and putting more qualified physicians out of work, why not suggest reducing the mid-level workforce first? They were created to help extend physician care and fill gaps because of a healthcare shortage. Now there's plenty of docs, so that need is no longer there.

 

[Dr Mantis Toboggan]

Genuine question, why is this always the solution suggested here? Instead of reducing the physician workforce and putting more qualified physicians out of work, why not suggest reducing the mid-level workforce first? They were created to help extend physician care and fill gaps because of a healthcare shortage. Now there's plenty of docs, so that need is no longer there.

Either would work but neither will happen.

 

[sloh]

Genuine question, why is this always the solution suggested here? Instead of reducing the physician workforce and putting more qualified physicians out of work, why not suggest reducing the mid-level workforce first? They were created to help extend physician care and fill gaps because of a healthcare shortage. Now there's plenty of docs, so that need is no longer there.

We can certainly make an argument for a gentle undersupply—but flooding the market with clinicians whether they be MD/DO's or APP's will only worsen job security and income if supply exceeds demand.

There was a good discussion on this in the rads forum:

What is causing the resurgence of the radiology job market?

At a certain volume of work, even the best radiologist will produce reports approaching a mid level quality not sure if the recent imaging surge is short lived from Covid. But if this is here to stay, we need more radiologists trained I think part of the surge is Covid related-easier/more...

forums.studentdoctor.net

"The main point is that in this age of health care you can sink yourself with oversupply, but you can’t protect yourself with undersupply because big health systems are absolutely motivated to “innovate” you right out of existence.

It kind of seems like a ***gentle undersupply*** would be the best way to go."

 

[docB]

Guys can we stop. This is getting a little too close to the truth

So true.

Me: Dilaudid? Sure enuf. Just fill out this state mandated opioid information form (we actually have that) and mark 5 in every box.
Patient: What's press gagney?

 

[Iamnew2]

Genuine question, why is this always the solution suggested here? Instead of reducing the physician workforce and putting more qualified physicians out of work, why not suggest reducing the mid-level workforce first? They were created to help extend physician care and fill gaps because of a healthcare shortage. Now there's plenty of docs, so that need is no longer there.

I think it is already understood that there are too many midlevels. But unfortunately a lot of doctors themselves have created this monster. Recently I even received an email from a recruiter asking regarding training NP/PAs to do injections. I didn't even respond. If we don't fight back more forcefully, the "private equity backed" healthcare nonsense will destroy healthcare as it is.

There is a lot of power that we have as physicians, but we are frequently too spineless to use it. No, I won't "train" midlevels to do injections that a physician should be doing. No, I won't work for $200 to review close to 100 pages of documentation.
Lawyers for example, while frequently delusional in their self-worth, charge a small fortune - 300-500. While most people can't and wont afford that and many lawyers will end up working for far less, these are rates quoted. Us? We train for years. We make nothing as residents. We take the scraps that administrators give us and take abuse like no other.
It's ok to say "no, thank you." It's time that doctors take back the system.

 

[GeneralVeers]

Any recs on reputable companies that wont hose you?

I just signed on for a second telemedicine job.

The jobs I look for involve a "lab review" with recurring subscriptions for a medication. The patients are assigned to me indefinitely and I have to do their monthly/quarterly lab reviews and the yearly telemedicine visit. I am paid for each lab review and visit. The great thing is that it's like building up a practice. Every month I have more and more patients, and get a bigger check as there are more lab reviews.

I won't do a job where I have to sit in front of a computer and compete with others to click on a patient for $25.

 

[Birdstrike]

Recently I even received an email from a recruiter asking regarding training NP/PAs to do injections.

These people are a cancer upon humanity. When will they stop?

Oh, wait. I already know the answer to that.

 

[Iamnew2]

These people are a cancer upon humanity. When will they stop?

Oh, wait. I already know the answer to that.

Not as bad as expecting physicians to do massive loads of work for next to no money. The statement of "we have some physicians reviweing 200 pages an hour" still bugs me as I was told. Ugh. Recently asked a lawyer to review a contract, 20 pages or so and was told it would be like $700 bucks - but we are expected to review 200 pages an hour. The problem is the third parties - so many third parties. Why can't hospitals and practices directly work w physicians? It's like a cancer.

 

[Birdstrike]

Not as bad as expecting physicians to do massive loads of work for next to no money. The statement of "we have some physicians reviweing 200 pages an hour" still bugs me as I was told. Ugh. Recently asked a lawyer to review a contract, 20 pages or so and was told it would be like $700 bucks - but we are expected to review 200 pages an hour. The problem is the third parties - so many third parties. Why can't hospitals and practices directly work w physicians? It's like a cancer.

What kind of review work is this? The last time I did a chart review I charged $350 per hour and worked at a pace necessary to do quality work. The lawyers that asked me, gladly paid it. Tell them what you charge and if they're not willing to pay a fee worthy of an expert, they can call back when they're willing to pay for quality work.

 

[Iamnew2]

What kind of review work is this? The last time I did a chart review I charged $350 per hour and worked at a pace necessary to do quality work. The lawyers that asked me, gladly paid it. Tell them what you charge and if they're not willing to pay a fee worthy of an expert, they can call back when they're willing to pay for quality work.

Yep, they wanted to pay me $225 for reviewing 80 plus pages of notes, plus writing a report. I said that would take many hours, and they got upset that I wouldn't take the $225 TOTAL pay for that. One of the nurses said that some physicians review 200 pages of notes in one hour. I said I don't know a single physician who would do that and asked them to take me off the list of panelists. No thanks.

 

[Birdstrike]

Yep, they wanted to pay me $225 for reviewing 80 plus pages of notes, plus writing a report. I said that would take many hours, and they got upset that I wouldn't take the $225 TOTAL pay for that. One of the nurses said that some physicians review 200 pages of notes in one hour. I said I don't know a single physician who would do that and asked them to take me off the list of panelists. No thanks.

Good for you

 

[Apollyon]

Yep, they wanted to pay me $225 for reviewing 80 plus pages of notes, plus writing a report. I said that would take many hours, and they got upset that I wouldn't take the $225 TOTAL pay for that. One of the nurses said that some physicians review 200 pages of notes in one hour. I said I don't know a single physician who would do that and asked them to take me off the list of panelists. No thanks.

That's when you ask if they called that doc.

 

[Iamnew2]

That's when you ask if they called that doc.

They said they were having trouble finding someone to do the review. Not shocking. I guess no that I'm board certified and have more experience it would be nice to do some legal type work but not sure where to start.

 

[Splenda88]

Well, the extra 50-70k/yr I was planning to make is not gonna happen.

 

[sloh]

I just signed on for a second telemedicine job.

The jobs I look for involve a "lab review" with recurring subscriptions for a medication. The patients are assigned to me indefinitely and I have to do their monthly/quarterly lab reviews and the yearly telemedicine visit. I am paid for each lab review and visit. The great thing is that it's like building up a practice. Every month I have more and more patients, and get a bigger check as there are more lab reviews.

I won't do a job where I have to sit in front of a computer and compete with others to click on a patient for $25.

This sounds like a pretty sweet gig. How much do you get paid per patient? How long does it take per patient? How much are you grossing per month with this?

 

[FrkyBgStok]

I know you guys have moved on with joking but....as a pediatrician, I am outraged and need to give these companies a piece of my mind.

Who specifically do I talk to about this and how much money (per hour or per call) are they robbing me? Asking for a friend.

 

[GeneralVeers]

This sounds like a pretty sweet gig. How much do you get paid per patient? How long does it take per patient? How much are you grossing per month with this?

2-3 minutes per patient grouped in a 2 hour window. Saw about 45 patients today in that time frame at $10/patient.

Lab reviews are extra $$$ and actually pays more than the interviews. There are a few jobs out there like this. Much better than the bogus, scammy urgent care stuff.

 

[turkeyjerky]

I know you guys have moved on with joking but....as a pediatrician, I am outraged and need to give these companies a piece of my mind.

Who specifically do I talk to about this and how much money (per hour or per call) are they robbing me? Asking for a friend.

There are few investigative healthcare reporters out there who seem to like stuff like this.

 

[RocDoc12]

I don't know, it seems to be more than just that.

My specialty is doing fine, there's no great oversupply of peds who cant get jobs across the country. Sure there's a few cities where job opps are harder but for the most part it's easy to find a job.

But even in peds I see people who are taking **** jobs like telemedicine WHEN THEY DONT HAVE TO. It's like they don't want to go through the effort of seeking out better options. They would rather just make $100k per year working part time at home when 250-300k is out there.\

IMO people who choose that pathway are not professionals. They wasted their education and racked up debt for nothing.

I don't get it.

If you’re older, semi retired, FI, you may just want a bit of nice easy work to keep your hand in the fire.

 

[DeadCactus]

I just signed on for a second telemedicine job.

The jobs I look for involve a "lab review" with recurring subscriptions for a medication. The patients are assigned to me indefinitely and I have to do their monthly/quarterly lab reviews and the yearly telemedicine visit. I am paid for each lab review and visit. The great thing is that it's like building up a practice. Every month I have more and more patients, and get a bigger check as there are more lab reviews.

I won't do a job where I have to sit in front of a computer and compete with others to click on a patient for $25.

Testosterone clinic?

 

[GeneralVeers]

Testosterone clinic?

Yes. Seems like a reasonable job but I haven't started yet.

 

[Fart Daddy Smooth]

Lol. Telemed is actually terrible for hair loss as exam of the scalp is essentially impossible over video or photos (can’t comment on erectile dysfunction since I’m a dermatologist).

You’d think telemed would be good for derm - but one thing the pandemic taught me is that it’s pretty terrible care for about 90% of what we do. It’s borderline ok for acne but that’s about it.

Even for androgenic alopecia? I've gone to a few derms to talk treatments and they all just kinda eyeballed my hairline from their stool. Don't want to marginalize your specialty, I just figured stuff like dxing MPB and writing a Rx for finasteride required little clinical judgement and therefore one of the appropriate uses of telemedicine