Tele, just a fad or here to stay?

[futuredo32]

I thought COVID sped up telepsychiatry. I know some who take cash never plan to go back to in person. They are tightening in Michigan with some insurances my biller says. Any idea? I'm guessing it will be regional

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[Monocles]

Lower overhead costs. Don't have to rent office space, insurance for the location, coffee machines, security guards(?), etc.

Best of all you can work in a nice professional jacket and gym shorts.

If I ever start a private practice I'm doing 100% virtual. This is the future.

 

[TexasPhysician]

Some patients like it and some hate it. Children are much harder online. You can’t see their behavior well. Many that pay cash want the full experience in person. Others appreciate the convenience. With controlled meds requiring in-person after the national emergency, that’s another positive of an office.

 

[Bartelby]

I'm sure telepsychiatry is here to stay, but for most people probably in a hybrid model. I suspect some will make 100% video eval practices work, but for many it will just become another tool in the arsenal.

 

[Sushirolls]

I'm on the verge of opening up my office fully. So far the preliminary looks like 40% are going to opt for in office. Or be required because of AIMS, UDS for stimulants, UDS for suboxone. All others get to choose. Granted we'll see if any insurance companies or the state have anything to say about this. Verbal surveys show most of my patients preferencing the logistic positives of telemedicine.

I'm keeping track and plan to be able to report back to SDN folks at the end of Q3 what my pt panel opted for regarding tele versus office.

 

[robellis]

I'm on the verge of opening up my office fully. So far the preliminary looks like 40% are going to opt for in office. Or be required because of AIMS, UDS for stimulants, UDS for suboxone. All others get to choose. Granted we'll see if any insurance companies or the state have anything to say about this. Verbal surveys show most of my patients preferencing the logistic positives of telemedicine.

I'm keeping track and plan to be able to report back to SDN folks at the end of Q3 what my pt panel opted for regarding tele versus office.

You’ll force anyone on an antipsychotic to have an in person visit?

 

[wolfvgang22]

UDS's don't necessarily require an in office visit, either, if you are just sending the patient to a lab.

 

[Alemo]

Rambling incoming. I for one do not welcome our Zoom overlords. I think it cheapens and degrades the interactions with patients. It’s hard to stay fully present with the patient and pick up on subtle affective changes (I realize not everyone has this problem). The act of “going to the doctor” is a complicated ritual that has real and symbolic meaning beyond “let’s exchange words about your symptoms so that I can map them into diagnostic categories and prescribe a class of medication to pick up at the Walgreens nearest you.” So much of the therapeutic connection and understanding is lost. The office is a canvas in and onto which patients present; a call into their bedroom is not neutral enough. Of course there’s the opposite side of the coin re: anxiety about healthcare setting and “white coat hypertension.” Some people say “Oh but you can see their living room!” like it’s some kind of heretofore unseen diagnostic revelation. Is something lost if our patients don’t come to see us, but rather “meet us” somewhere? Maybe I’m grandiose and like the feeling of people waiting outside my door to come see me, I don’t know. The AJP had a decent article about telepsychiatry a few months ago. I’d love to read more about criticisms of anyone else has links.
Don’t even get me started on psychiatry via the phone....

 

[FlowRate]

In residency we used the healthcare version of Zoom and the vast majority of visits had good video and audio quality and the majority of patients joined from appropriate locations (spaces where they were virtually guaranteed privacy). I really didn't mind that at all.

With my new attending job we have some sort of branded video app and I'm convinced that there's something about it that makes it hyper sensitive to any sort of bandwidth issues. The majority of visits have some sort of video or audio issue. That's not even counting the 10-20% of patients who join while driving, while in a common workspace at their job, etc. If I was running a practice and doing video I would definitely have it in my policies that we won't conduct the visit if you're driving or in a space that doesn't allow you to speak privately. The video/audio issues really limit my ability to respond empathically (I'm still waiting for the video/audio to sync or I'm trying to decipher what the pt just said or I can't really see their affect because of video glitching etc.)

Because video has become the convenient norm for this patient population, video will remain the expected option for most pts so I don't see going back to the office more than 2 days a week--the demand just isn't there for in-person visits at the moment. Overall I really like saving a commute and getting to be comfortable at home, it's just a frustrating cost that our institutional set up doesn't make it a higher quality experience.

 

[TexasPhysician]

In residency we used the healthcare version of Zoom and the vast majority of visits had good video and audio quality and the majority of patients joined from appropriate locations (spaces where they were virtually guaranteed privacy). I really didn't mind that at all.

With my new attending job we have some sort of branded video app and I'm convinced that there's something about it that makes it hyper sensitive to any sort of bandwidth issues. The majority of visits have some sort of video or audio issue. That's not even counting the 10-20% of patients who join while driving, while in a common workspace at their job, etc. If I was running a practice and doing video I would definitely have it in my policies that we won't conduct the visit if you're driving or in a space that doesn't allow you to speak privately. The video/audio issues really limit my ability to respond empathically (I'm still waiting for the video/audio to sync or I'm trying to decipher what the pt just said or I can't really see their affect because of video glitching etc.)

Because video has become the convenient norm for this patient population, video will remain the expected option for most pts so I don't see going back to the office more than 2 days a week--the demand just isn't there for in-person visits at the moment. Overall I really like saving a commute and getting to be comfortable at home, it's just a frustrating cost that our institutional set up doesn't make it a higher quality experience.

Interesting. I could easily fill 40 hours in-person. People are vaccinated and anxious to be back to normal.

 

[Merovinge]

Rambling incoming. I for one do not welcome our Zoom overlords. I think it cheapens and degrades the interactions with patients. It’s hard to stay fully present with the patient and pick up on subtle affective changes (I realize not everyone has this problem). The act of “going to the doctor” is a complicated ritual that has real and symbolic meaning beyond “let’s exchange words about your symptoms so that I can map them into diagnostic categories and prescribe a class of medication to pick up at the Walgreens nearest you.” So much of the therapeutic connection and understanding is lost. The office is a canvas in and onto which patients present; a call into their bedroom is not neutral enough. Of course there’s the opposite side of the coin re: anxiety about healthcare setting and “white coat hypertension.” Some people say “Oh but you can see their living room!” like it’s some kind of heretofore unseen diagnostic revelation. Is something lost if our patients don’t come to see us, but rather “meet us” somewhere? Maybe I’m grandiose and like the feeling of people waiting outside my door to come see me, I don’t know. The AJP had a decent article about telepsychiatry a few months ago. I’d love to read more about criticisms of anyone else has links.
Don’t even get me started on psychiatry via the phone....

I generally agree although I exclusively see a CAP population so there are several differences. I do think the remote visits overall continue to commoditize medicine along with the MBA/NP/PA pushes of the past few decades. Families that have made the effort to come in person often are more involved and shockingly this correlates to better outcomes for the children. I do see some families where remote visits allow them to make appointments they otherwise would not due to lack of transportation/work schedules/sick siblings or specific pathology (usually ASD) that the option is a big benefit for.

My biggest take away where I going into PP is to see everyone in person for an intake with essentially zero exceptions. I have tried to do this and the few patients where I did make an exception, the rapport is clearly not the same. I would generally encourage patients to make appointments in-person but if they needed to convert to remote last minute or schedule remote for a percentage of the visits and adhered to rules about an appropriate location/bandwidth for the visit, would be fine with some remote visits. This gives no benefits to the doctor (still need overhead and pants) but seems the best we can do for our patients.

 

[wolfvgang22]

Rambling incoming. I for one do not welcome our Zoom overlords. I think it cheapens and degrades the interactions with patients. It’s hard to stay fully present with the patient and pick up on subtle affective changes (I realize not everyone has this problem). The act of “going to the doctor” is a complicated ritual that has real and symbolic meaning beyond “let’s exchange words about your symptoms so that I can map them into diagnostic categories and prescribe a class of medication to pick up at the Walgreens nearest you.” So much of the therapeutic connection and understanding is lost. The office is a canvas in and onto which patients present; a call into their bedroom is not neutral enough. Of course there’s the opposite side of the coin re: anxiety about healthcare setting and “white coat hypertension.” Some people say “Oh but you can see their living room!” like it’s some kind of heretofore unseen diagnostic revelation. Is something lost if our patients don’t come to see us, but rather “meet us” somewhere? Maybe I’m grandiose and like the feeling of people waiting outside my door to come see me, I don’t know. The AJP had a decent article about telepsychiatry a few months ago. I’d love to read more about criticisms of anyone else has links.
Don’t even get me started on psychiatry via the phone....

I felt like this when I was a less jaded student. Now, I would agree if I was mainly doing psychodynamic therapy or analytic therapy, or in an ideal world. I think your comment is most appropriate for those in private practice who are not concerned with maximizing "productivity" (RVUs).

Since I, like most employed outpatient psychiatrists, mainly provide medication management with eclectic brief supportive therapy incorporating elements of motivational interviewing, interpersonal, and CBT techniques in a 30 minute follow up that includes of 15 minutes of documentation, writing prescriptions, making referrals to counselors and other specialties, telepsychiatry seems not worse in outcome than in person visits in my experience with telepsychiatry either part time or full time since 2013.

On a personal note, since I am hospital clinic based, what I like most about telepsychiatry from outside the hospital is that it greatly reduces the amount of non-paid responsibilities the hospital tries to push on to me (ER and floor consults, walk-ins essentially turning the clinic into a psychiatric urgent care, getting ambushed with unceasing curbside consults, etc.)

 

[deleted1100659]

For sure here to stay, and will only increase in popularity. The people it currently targets are people who werent born with a smart phone in their hand. People forget, kids today six years old when their parents give them an ipad or some other equivalent. When I was a kid, I remember thats when AOL became popular and it was mind boggling. Most kids today are quite tech savy and welcome stuff like this. As they transition into adulthood telemedicine will only become more popular because the audience is more familiar/accepting of it. The old way will decrease substantially, imo.

 

[FlowRate]

Interesting. I could easily fill 40 hours in-person. People are vaccinated and anxious to be back to normal.

Also interesting. I can't recall, do you take insurance or just cash? And all child or mixed?

 

[clausewitz2]

The gig I am ditching soon made us use a similar branded app that is just absolutely awful and works optimistically about 70% of the time. I end up having a lot of telephone appointments at that job, which are always terrible. At my other side gig I use Zoom or doxy.me and of the two doxy.me is smooth as butter.

In private practice I use HIPAA-compliant business version of Google Meet and the only problem I have is with the 60+ crowd who struggle with the idea of finding invitation links in their emails.

I have been doing 80% tele since the relatively early days of COVID and I too struggled with rapport-building at first. The tricks that work in person are just not effective via a video link and I didn't think I'd be able to keep it up very long for the first few months. I felt like what I was doing was pointless, awkward, and kind of ridiculous.

Now, though, most patients are I see are PP folks who are all tele without exception and it is honestly great. You do learn how to build relationships even through a video screen. You also end up getting a lot more people with busy schedules or a lot of other obligations who might not be able to carve out a big chunk of time to go to an appointment on the regular but can squeeze one into their lunch break, or before they start work in the morning, etc.

One other massive benefit has been that suddenly I am no longer a psychiatrist for the local metro but am open to taking patients from across the whole state. I have multiple patients from hours away and several college kids who are locals but are at far-flung places for school who I would never be able to see on a regular basis otherwise. The other big advantage of tele is scheduling flexibility. I can fit patient appointments in around other commitments that I have. Have a side-gig that doesn't start until mid morning? Knock out 2-3 appointments before then. Need to fit a therapy client in on short notice? Sure, see 'em in the evening after I wrap up with something else. I would never go to an office for only a couple of patients but this is perfectly doable.

Working a long day is also much more palatable if I can walk to my kitchen on my lunch break and, say, open a Responsible Unit of Alcohol within five minutes of finishing my last appointment of the day.

 

[Sushirolls]

You’ll force anyone on an antipsychotic to have an in person visit?

At least once every 6 months, for the AIMs, which requires a physical exam, which means in person.

 

[Sushirolls]

UDS's don't necessarily require an in office visit, either, if you are just sending the patient to a lab.

When you have your own CLIA lab they can be knocked out expediently in the office where there is 1-2 person exposure versus a large health system with a lot more people running around.

 

[clausewitz2]

At least once every 6 months, for the AIMs, which requires a physical exam, which means in person.

not so:

The reliability of telepsychiatry for a neuropsychiatric assessment - PubMed

Reliable neuropsychiatric assessments can be conducted using telemedicine even if primarily visual input is evaluated.

pubmed.ncbi.nlm.nih.gov

 

[Sushirolls]

Video quality is variable between people's connections / devices. Variability in video quality also varies from session to session for a person.

I can do a better AIMS in person than by telemedicine, therefore for my patients I'll see them in the office. I seldom prescribe antipsychotics with my population, and the majority come to me from ARNPs - especially vrylar and rexulti. I mostly spend the time to get people off them and point out how the ARNP mis diagnosed the bipolar.

But I'm glad to see there is positive data for telemedicine AIMS.

 

[Sushirolls]

Telemedicine is here to stay. A lot distills down to what the patient values, and as we are in more of customer service era this can't be discounted. I'm surrounded by a sea of ARNP and the local market is saturated, so if you don't offer this option patients will go else where. I have some people who do preference and value in patient more, but the reality of the frequency of the visits in conjunction with their other medical appointments, not needing to take a whole or half day off of work trumps their preference for in person.

To one of the points above, I've also started to get consults from the reaches of the state. I'm scratching my head on whether to require in person first time consult visits, which would restrict to the local metro area, or continue to offer telemedicine consults.

 

[robellis]

Is documenting an AIMS the standard of care? I seldom see it done..

 

[TexasPhysician]

Also interesting. I can't recall, do you take insurance or just cash? And all child or mixed?

Cash mixed

 

[FlowRate]

Cash mixed

Intuitively it would make sense to me that cash patients would be more interested in the full experience. I have a ton of lower-middle and middle-class insurance patients who don't want to take any time off of work. Pts have also been allowed to prioritize availability over location so I have pts from the entire expanded metro area who would be very reluctant to drive potentially upwards of an hour to see me.

 

[whopper]

It really will depend on the insurance companies. Seriously. So many things really depend on them.

 

[fluorescent colors]

A psychiatrist who I went to med school with mentioned that a bunch of his patients were not interested in doing telehealth. So, they are just waiting for him to start seeing patients in his office again.

 

[whopper]

Pros with telemedicine: Patients don't want to do the small talk thing. If they're stable and just need refills they're quick in and out. Also almost all of them are on time. When patients came in more than half of them were at least a few minutes late. If the patient is stabilized and just needs refill it made these appointments even easier.

Cons: Connection problems, a general sense of feeling less of a connection. Some things are not as readily apparent to the naked eye. If it's a tough case it can make it even harder. In general when I know cases are tough I tell the patient to come into the office anyway.

 

[comp1]

I don't think it'll be regional. It'll be tied to reimbursement ultimately for most people. Where things aren't fee for service and you aren't beholden to insurance rates, it's certainly here to stay. May not be a majority of encounters always, but will be 10x what it was pre-COVID permanently.

 

[nexus73]

One telehealth negative is now they are tracking the exact amount of time you have face to face with a patient. This data can only be used for evil I imagine, by insurance or large health system employers, to justify lower payments or demand shorter appointments and more patients per day.

 

[futuredo32]

It really will depend on the insurance companies. Seriously. So many things really depend on them.

This was really what I was asking will the major insurance carriers continue to have telepsych covered.

 

[PikminOC]

Insurers are starting to drop tele appts for compensation

 

[deleted1100659]

interestingly enough, I do 50-50 telehealth/in person and a lot of people who were intially reluctant are starting to like it. Sometimes there are connection issues, usually its the patient in their car driving in the middle of nowhere trying to do a quick appt....

 

[MedMan80]

One telehealth negative is now they are tracking the exact amount of time you have face to face with a patient. This data can only be used for evil I imagine, by insurance or large health system employers, to justify lower payments or demand shorter appointments and more patients per day.

my health system has its own video app (which luckily sucks) and i get to use zoom instead, but i thought 100% they are tracking video time and can use it against me

 

[calvnandhobbs68]

One telehealth negative is now they are tracking the exact amount of time you have face to face with a patient. This data can only be used for evil I imagine, by insurance or large health system employers, to justify lower payments or demand shorter appointments and more patients per day.

Yep anything that can be tracked will be tracked.

I wouldn’t be surprised if they negotiate something like this to keep reimbursing telemedicine but only if they have access to their authorized platform for “quality assurance” purposes or some bull****

 

[Stagg737]

I think it's here to stay, at least to a certain extenet. However, I think this has just further divided the disparities in care to those most in need. It's great for the relatively stable middle-class individuals with good internet connection. But those struggling financially with lack of adequate technology, those in group homes/gov housing with crap internet, and those too sick to work the video correctly (more common than I thought) end up with even worse care d/t video communication issues. I'd say in a given day 25% of my patients have some form of connectivity issue which either makes it difficult to understand them, or makes the appointment very disjointed because the call keeps dropping or they just can't connect in the first place. I actually end up behind much more in our clinic that has primarily doing telehealth than the ones which are mixed and more in-person.

One other massive benefit has been that suddenly I am no longer a psychiatrist for the local metro but am open to taking patients from across the whole state. I have multiple patients from hours away and several college kids who are locals but are at far-flung places for school who I would never be able to see on a regular basis otherwise. The other big advantage of tele is scheduling flexibility. I can fit patient appointments in around other commitments that I have. Have a side-gig that doesn't start until mid morning? Knock out 2-3 appointments before then. Need to fit a therapy client in on short notice? Sure, see 'em in the evening after I wrap up with something else. I would never go to an office for only a couple of patients but this is perfectly doable.

I realize this would be a plus for most, but this sounds like an absolute nightmare to me. When I'm not working, I don't want to be thinking about scheduling impromptu appointments or more work responsibilities. Maybe it's because I'm a resident and this has enabled our schedulers to slip patients into open slots 5 minutes before the appointment time for an urgent issue, but it's just one more thing that's made me loathe outpatient work.

Is documenting an AIMS the standard of care? I seldom see it done..

I mean, it should be....

 

[pisekar]

I had an interview with a child (&mother) yesterday and they were at the swimming pool

 

[clausewitz2]

Yesterday I had to tell a patient I see through one of my agency jobs that we were going to have a couple new rules for future tele sessions, namely that he needs to a) be sitting upright and b)have his eyes open during our appointments.

 

[wolfvgang22]

This past week I had to tell one telepsychiatry patient that we cannot proceed with the interview because he is intoxicated with alcohol. At 8:00am. He said it was ok because he had just had a few drinks and wasn't shaking anymore.
Immediately after that I had to tell another telepsychiatry patient that it is not appropriate to conduct his psychiatric appointment hanging from a harness attached to a commercial windmill 300 feet in the air. The wind noise was atrocious.

I think we are going to have to start sending out letters listing settings, dress (yes, clothing is required), and behavior appropriate and inappropriate for telehealth visits, because verbal education in person or over the phone prior to the appointment isn't getting the job done. May need to include an infographic drawing. We honestly should have done that from the beginning, but you all know how COVID caught us all by surprise last year and telepsychiatry is relatively new to us. Currently, if I have to tell a patient about proper video etiquette a third time, I require they come in to the clinic.

Also, and this has nothing to do with telepsychiatry: if the patient shows up to an appointment without his or her hearing aids three times in a row, I am starting to make them reschedule. I'm done shouting. It's been happening a lot this year, I don't know why.

 

[Stagg737]

Yesterday I had to tell a patient I see through one of my agency jobs that we were going to have a couple new rules for future tele sessions, namely that he needs to a) be sitting upright and b)have his eyes open during our appointments.

My favorite is when they obviously walk into the bathroom and set their phone down...

 

[calvnandhobbs68]

This past week I had to tell one telepsychiatry patient that we cannot proceed with the interview because he is intoxicated with alcohol. At 8:00am. He said it was ok because he had just had a few drinks and wasn't shaking anymore.
Immediately after that I had to tell another telepsychiatry patient that it is not appropriate to conduct his psychiatric appointment hanging from a harness attached to a commercial windmill 300 feet in the air. The wind noise was atrocious.

I think we are going to have to start sending out letters listing settings, dress (yes, clothing is required), and behavior appropriate and inappropriate for telehealth visits, because verbal education in person or over the phone prior to the appointment isn't getting the job done. May need to include an infographic drawing. We honestly should have done that from the beginning, but you all know how COVID caught us all by surprise last year and telepsychiatry is relatively new to us. Currently, if I have to tell a patient about proper video etiquette a third time, I require they come in to the clinic.

Also, and this has nothing to do with telepsychiatry: if the patient shows up to an appointment without his or her hearing aids three times in a row, I am starting to make them reschedule. I'm done shouting. It's been happening a lot this year, I don't know why.

Yeah I’ve had it. I’m setting out very clear telepsychiary rules at the job I’m starting. Including such basic things as, yes both the parent and the child must be present for the appointment, and, no you can’t be at the swimming pool/store/driving/hanging from a windmill/etc. We bill no show fees so I’m making it clear that patients who don’t adhere to the policy will be considered no shows.

My intakes are all also gonna be in person because I’m done with parents calling from the car driving with their 6yo in the back seat trying to figure out if he has ADHD or not, then handing the phone back to the kid while the connection cuts in and out and I can’t hear 1/3 of what they’re saying.

Im also sick of patients thinking they can call an office saying they can’t make it to their in person appointment today, they’d like to do a tele appointment instead. One time, I get it everyone has an off day every now and then or something happens but i have people who did that multiple times over the past several months. Uh no I had you coming in person for a reason, that’s gonna be a no show for me. Or there’s this expectation that we’re gonna track people down for their tele appointments or they call the office asking if I can do a “call” in an hour because they forgot about their appointment and they’re busy right now. It’s like people forgot that they actually had to physically come to doctors appointments before a year ago and somehow managed to make that work. The data is actually pretty convincing that we haven’t reached a significant new population with telemedicine, we’ve just converted a lot of in person patients to tele visits, which kinda tosses that idea of “more access” out the window and I feel like just results in poorer quality care.

If you can’t tell I’m not particularly happy with most tele appointments. I think they’re usefully for a very particular subset of fairly high functioning technologically literate patients/parents who can afford a good internet connection. That’s about it.

 

[wolfvgang22]

I must say, even though I complain about the minority problem people, the majority of my patients do fine with telepsychiatry. Most of them do sit at a desk or a kitchen table or in a chair dressed properly for their appointment. For me, the same people that frequently no showed their in person appointments before and had minimal engagement in following their treatment plan are usually the same ones that expect McDonald's drive through medicine, as well.
You know how it is, 10% of people cause 90% of the problems in life. I'm at least trying to get some humor out of it.

I don't know if this is due to the serious burnout I suffered a while back, but anymore if patients don't show up and I know they probably aren't in crisis I just don't care too much - unless clinic admin start getting on my back about productivity. I'm not private practice, so I'm not as concerned as they get about billing. If they let me go, who are they going to have see the most complex patients? I'm sure the world won't stop spinning, but the ride might be bumpier around here.

 

[FlowRate]

Or there’s this expectation that we’re gonna track people down for their tele appointments

This is the one I have the most mixed feelings about. It's combined with most patients trying to join the appointment exactly on the minute so that, if anything goes wrong, they start burning appointment time instead of having time to troubleshoot. Our video app is not sufficiently reliable (in combination with the varying devices patients try to use) so sometimes they're trying to get in to the appt but the app just isn't working. Our organization needs better guidance/messaging around video appointments.

 

[Sushirolls]

I've had a patient attempt to blame our office for their no show and that we need to call them during the telemedicine appointment to be like where are you - despite already having one electronic means of pre-appointment notification several days in advance.

No, no we won't do that.

 

[calvnandhobbs68]

I must say, even though I complain about the minority problem people, the majority of my patients do fine with telepsychiatry. Most of them do sit at a desk or a kitchen table or in a chair dressed properly for their appointment. For me, the same people that frequently no showed their in person appointments before and had minimal engagement in following their treatment plan are usually the same ones that expect McDonald's drive through medicine, as well.
You know how it is, 10% of people cause 90% of the problems in life. I'm at least trying to get some humor out of it.

I don't know if this is due to the serious burnout I suffered a while back, but anymore if patients don't show up and I know they probably aren't in crisis I just don't care too much - unless clinic admin start getting on my back about productivity. I'm not private practice, so I'm not as concerned as they get about billing. If they let me go, who are they going to have see the most complex patients? I'm sure the world won't stop spinning, but the ride might be bumpier around here.

Yeah I mean the issue is within a larger health system, there's no ability to set a telemedicine "policy" without it being a systemwide thing that goes through 100 levels of bureaucratic approval. Admin's incentive is obviously to make things as "customer friendly" as possible, so they'd love for us to scrounge as much as possible to get a patient on zoom for at least 10 minutes so they can bill for it. They also couldn't care less about our own perceived quality of care, let's be real, as long as the customer is happy. Plus of course I was just a fellow in this system so nobody gives a crap about what I think and my pay doesn't get dictated by the amount of patients who show up to clinic anyway at this point. Then admin people get mad at you because you didn't see the patient or they're calling the clinic asking to just "have a call with the doctor" sometime.

In child I'd say that probably half my visits have some kind of problem which makes them less than ideal (missing appointments, kid not present, parent not present, child and parent in car together or out in some public place together, etc etc). It also makes it reallyyy difficult for a lot of the kids/teenagers to have any real privacy in the appointment. I have multiple times caught parents lurking in the background or in the other room trying to overhear what we're talking about and told them they need to leave/be out of earshot/let the kid go somewhere private. Or coaching the kids through what to say. And then there's the problem with bad connections which affects a significant portion of my patients. Really tough to have a serious discussion about events in the patients life when you're going "sorry I couldn't hear you" 5 times.

I think a lot of these problems could be mitigated by a signed policy that we could go back to and say "no see you agreed to this here, this is what we expect, otherwise you need to come into the office for your visits". I also think telemedicine is a useful consultation tool in the way it was originally designed, for example, in a primary care office where otherwise they don't have much access to psychiatry, the office has a telemedicine setup where they have a dedicated space, computer, decent quality webcam/microphone, good internet connection.

I've had a patient attempt to blame our office for their no show and that we need to call them during the telemedicine appointment to be like where are you - despite already having one electronic means of pre-appointment notification several days in advance.

No, no we won't do that.

Right exactly. This is like this weird expectation now with some patients. Or the classic "oh I didn't check my email"...consistently from patients who have literally been doing this for a year now.

 

[splik]

I had a pt zoom in to therapy session from a Mexican beach with a margarita in her hand

 

[octopuszebra]

The data is actually pretty convincing that we haven’t reached a significant new population with telemedicine, we’ve just converted a lot of in person patients to tele visits, which kinda tosses that idea of “more access” out the window and I feel like just results in poorer quality care.

Would you please link to the data that you are referring to? I would like to read about it.