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In this episode, we welcome Diana M. Girnita, a rheumatologist and founder and CEO of Rheumatologist OnCall. We discuss the challenges facing patients with arthritis and the shortage of rheumatologists. Despite the growing need for specialized care, geographical and licensure barriers limit access. Diana believes telemedicine is the solution, offering increased access, convenience, and avoiding unnecessary travel for patients in pain. With the number of arthritis patients projected to rise, Diana started her own telemedicine company to offer every American fast, convenient, and safe care.
Diana M. Girnita is a rheumatologist and founder and CEO, Rheumatologist OnCall. She can also be reached on Facebook, Instagram, and YouTube.
She shares her story and discusses her KevinMD article, “Why expand telemedicine for arthritis patients?”
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Transcript
Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today we welcome back on the show Diana Girnita. She’s a rheumatologist and the founder and CEO of Rheumatologist OnCall. Her KevinMD article is titled “Why expand telemedicine for arthritis patients?” Diana, welcome back to the show.
Diana M. Girnita: Thank you so much for having me back, Kevin. It’s a pleasure to be here.
Kevin Pho: So we’ll get into the article a little bit, but for those who didn’t listen to our first episode, which I want to say was about a year and a half ago, just briefly share your story and journey to where you are today.
Diana M. Girnita: Yes. I’m a rheumatologist, and I’m currently based in Irvine, California. About three years ago, I started my journey as an entrepreneur, a physician entrepreneur, to build a telemedicine company that would offer patients access when they need it the most. I used telemedicine to approach access to medical care, and I expanded from one state to multiple states. I’m now active in eight states across the United States.
Kevin Pho: Wonderful. When we think about these telemedicine practices, we often think about either primary care or urgent care, but you’re doing it in the specialty of rheumatology. So how have the last few years gone?
Diana M. Girnita: I think there is this misconception that as a specialist you cannot pursue telemedicine, or that it’s harder to pursue telemedicine. But I’m here to prove that it’s possible, and I’m here to prove that after three years of practice, the practice is growing. This is a valuable tool both for physicians and for patients, and especially for patients.
Kevin Pho: In terms of the people you get referrals from, where do you find patients, or how do patients find you?
Diana M. Girnita: I think the misconception as a specialist is that you have to have referrals, that your patients have to be referred to you. That was my initial approach: to call my colleagues and tell them about my services. They did try to refer patients, and I have patients referred from colleagues. But most patients these days are very proactive in finding solutions for their problems. Somebody said at some point that patients are not like sitting ducks, and that’s very true. Patients are actively searching for solutions because of the lack of access.
My specialty is one of those specialties where you have to wait between four and six months to see a specialist. Can you imagine a patient in pain, severe pain, waiting six months to see a specialist? Or can you imagine a patient who is told, “You might have lupus,” or, “You might have rheumatoid arthritis,” waiting six months? They will not wait. They will find solutions. So patients will find me, and Google is the best resource for our patients.
Kevin Pho: Before we go into your article, just tell us: What are the most common conditions that you typically see in your telemedicine practice?
Diana M. Girnita: In my specialty, I see a lot of people who are referred to me for abnormal labs, like a positive ANA. That’s very, very common. But I also see patients who have rheumatoid arthritis, psoriatic arthritis, many of them Sjogren’s syndrome, and polymyalgia rheumatica. As I said, a lot of positive tests: “I don’t know what this is or what that is.” So those are the common pathologies that I see. From time to time, I will see a patient with vasculitis, which is stressful, but you do see those patients showing up.
Kevin Pho: All right. We’re going to talk more about this in your KevinMD article. It’s titled “Why expand telemedicine for arthritis patients?” Now, how did your article come together?
Diana M. Girnita: I have seen a lot of fear from my colleagues about offering telemedicine services. And when I look at patients with arthritis, and I want to refer to my specialty because that is where I know the most, you probably know, or for those who do not know, there are many, many people with arthritis in the United States. It was estimated that last year there were about 62 million, and this number is going to increase. By 2040, the CDC says there are going to be about 78 million people with arthritis, just arthritis, not autoimmune diseases. So I thought there is a huge need to serve these people.
On top of that, there are about 6,500 of us rheumatologists practicing in the whole United States, and most of us are located in the big metropolitan cities on the West Coast or on the East Coast. In Middle America, north or south, there are very few specialists located. So what is going to happen with these people? How are they going to access proper care, specialized care? So I saw telemedicine as a valuable solution for our patients who are in need, and I wanted to expand this idea and put it in front of other physicians.
Kevin Pho: In a typical rural setting, give us an example of one of those patients who came to you, and give us an example of the shortage of rheumatologists that this patient may have encountered before seeing you.
Diana M. Girnita: Oh, yes, I have so many of these stories. You would be surprised to see how limited the patients are in their access to medical care. I had this patient, a young guy in his 40s with a lot of joint pain. He tried to get help from his primary care physician, who gave him a referral. He went to his insurance panel and was trying to find someone. He called every single doctor in his area, and they were not able to see him for about six months. Then he looked in a 100-mile radius and called again, and most of these practices were not taking his insurance, so that was another type of limitation, or they were not able to see him, period.
His wife went online to search for a rheumatologist, and they found my practice. They read about the practice, but they couldn’t believe they could be seen in less than a week. The wife called, and my assistant gave her information, and then the gentleman called, and we gave him information. He researched my name. He researched everything about me. He knew everything, where I was and where I trained, because he could not believe he would be able to be seen in such a short amount of time. I saw him, I made a plan for him, we ordered tests, we ordered everything that we had to do, and in one week he was on treatment. In two weeks, he was back to his normal life. This is only one story out of the many stories that I could give you.
Kevin Pho: So take us into one of your virtual sessions. This gentleman, for instance, meets you for the first time on some type of virtual platform, I assume.
Diana M. Girnita: Yes.
Kevin Pho: Without giving away too many details, take us into what that session is like: how long it takes, what kind of questions you ask, and how you examine virtually. Give us an idea.
Diana M. Girnita: Sure. My new patient encounters are 60 minutes, and during that time I do a very, very thorough evaluation of where he was and what kind of symptoms he had. It’s a normal, typical conversation, but in a more relaxed environment, because most of the time those people are in their own house and they feel comfortable. They don’t feel stressed. They don’t see the white coat. They don’t see other people gravitating around them. They see me, and it’s a very intimate relationship, I would say, because it’s only the patient and the doctor, and you don’t have the stress of the environment around you.
And then the physical exam is always done. I do the physical exam. Maybe you would say that it’s a limited exam, but you can still see. If the patient points their hands to the camera, if you ask the patient to do certain moves, if you also distract the patient by having them do something while you talk to them, you will realize that what they do is basically what you would do with the patient in a typical exam room.
And then you make the plan. I order the tests and the imaging, whatever they are. I am able to do that because I have a national contract for labs and for imaging. I can order tests for them, and they can do them where I have contracts, or they can choose wherever they want to do their labs, and I can fax the orders there, and it is done. Then, when the results are ready, the patient comes back and we make the plan again. So it’s very, very similar to what you do in real life.
Kevin Pho: What about medications? If you need to prescribe immunosuppressants, steroids, or anti-inflammatories, what are the limitations there, if any?
Diana M. Girnita: I don’t see any limitations. If the patient needs a medication, I will send the medication to whatever pharmacy they have. If I need to get a medication approved, I will take their card, I will contact their insurance, and I will get the medication approved. I do the exact work that I would do in the typical practice that we have. There’s no difference. The only difference is that you don’t touch the patient and they are not able to touch you. I mean, that’s the only difference.
Kevin Pho: Now, what are some of the barriers for other physicians? Why don’t more physicians do a virtual practice or a telemedicine practice like you? What are some of the barriers facing the majority of physicians today?
Diana M. Girnita: I think the major barrier for most physicians is this fear of liability. And not only that, but there are physicians, believe it or not, who are also afraid of new technology. In the beginning of telemedicine, and telemedicine has been here for 20 years already, but let’s say in the years before the pandemic, the other limitation was the fact that they could not collect payment from insurance companies.
I’m going to tell you that I had a discussion with my former employer, and I was presenting telemedicine to them as an option to optimize care, especially for patients who had to travel two hours to see me, when I could have done the exact same thing on telemedicine in five minutes rather than the patient traveling two hours to see me. But the fact that they could not collect payment from the insurance companies, that they couldn’t bill for it, was a huge limitation. The other big limitation for physicians these days is that they have a license in only one state, or they have noncompetes that will not allow them to cross out of the area where they are. The license problem is huge for many of us.
Kevin Pho: Now, do you accept insurance, or are you under some type of direct-pay model?
Diana M. Girnita: My practice is the direct specialty care model, where I contract directly with the patient. If the patient wants to take the invoice and get reimbursed through their insurer, they are more than welcome to do that. Or if the patient wants to use their insurance to pay for laboratory services, medication, or imaging, they can do that, but they also have the ability to see the cash price that I can offer.
I think I told you this before, but I’m going to reinforce it: Initially, patients would not believe that the cash prices I offer are lower than what they would get if they went through their insurance. But actually, many times they are 10 times lower, because after you pay the copayment and the insurance pays a part, you are still responsible for paying about 20 percent of the bill. And 20 percent of $1,000 is different from 20 percent of $100.
Kevin Pho: How about a response from your colleagues? Do you get any response from your fellow rheumatology colleagues? Do they raise their eyebrows, or are they wholly supportive of what you’re doing?
Diana M. Girnita: I think there are people on both sides, and it’s absolutely normal. But I see them embracing telemedicine more and more and more. Once they see you validate the model and that it is working, there are so many other people calling me and asking me, “How can I do this? Is this possible to do? Where are the patients coming from? How do you do the contracts?” So I get tons of questions. Every week I get emails from rheumatologists across the United States asking me if they can do this in their community, or if they can do this as a practice in multiple states.
Kevin Pho: So take us in that direction. Let’s say a rheumatologist calls you and wants to do something similar to what you’re doing. What would be their next steps, or what are some questions they need to ask themselves to make sure that they’re the right person for this?
Diana M. Girnita: I think the first question is: Do you really want to do this? And why do you need to do this, or why do you want to do this? I think in your shows I’ve seen many times that physicians are burned out, and physicians are looking for ways to continue to practice medicine on their own terms.
I’m going to tell you a story. Over the years, I have been the mentor of many, many medical students and residents, and I have promoted many of these residents into rheumatology fellowship. I’m very proud that these people got into rheumatology. I infused this passion for practicing rheumatology in these people. Yesterday I got a phone call from one of my former mentees. He has been in practice as an attending physician for one and a half years, he already feels burned out, he doesn’t like what he sees, and he’s looking for a way to get out.
So we had a long discussion about what I’m doing and what he can do, and I was trying to convince him to remain in medicine, because I know there were 100,000 physicians last year who left medicine. Who’s going to treat us in five years or 10 years? It’s such a pity, because all these people invested so much time and so much effort, and they had the passion to be there, to be the doctors, and now they feel defeated. This is not what I want to see, not even for my kids. One of my children wants to go into medicine, and I don’t want to stop her from doing that. I want her to believe in it. Like me: I’m the only doctor in my family, and I was the first doctor in my family, and I had so much passion for practicing medicine. So I want that to be preserved, and I want those people who got into medicine to be physicians to remain there and continue their mission.
Kevin Pho: Just give us an idea of the scope of direct specialty practices. How many of you are there in the country?
Diana M. Girnita: There are many. I have to tell you that about two years ago, I started an organization called the Direct Specialty Care Alliance. The scope of that organization is to help other physicians understand the model and be able to practice as a direct care practice. We expand this idea that you can still practice medicine on your own terms, that’s for physicians, but also give patients access and the quality of medical care that you want to give.
This organization grew very much, and right now I think there are more than 100, if not more, direct specialty care practices. Many of these people got help or got the idea from us, and this is amazing, because you not only offer them a solution, but you offer them the support. I have also created a map. We have this map on our website, dscalliance.org, and every week you’re going to see practices popping up across the country. This is absolutely great, because when I started this three years ago, I had no idea about anybody practicing this way in the country as a specialist. Direct primary care physicians, I knew many, but as a specialist, I had no idea where to look for my peers or where to find resources for specialty care.
Kevin Pho: Now, what other specialties are there other than rheumatology?
Diana M. Girnita: Yes, many. Rheumatology, but there are nephrology, cardiology, allergy, pain, regenerative medicine, hematology, podiatry, many podiatrists, orthopedics, and what else? I have to think. There are many, many specialties. So basically, from almost every specialty, we have someone.
Kevin Pho: We’re talking to Diana Girnita. She’s a rheumatologist and the founder and CEO of Rheumatologist OnCall. Her KevinMD article is titled “Why expand telemedicine for arthritis patients?” Diana, tell us some of the take-home messages that you want to leave with the KevinMD audience.
Diana M. Girnita: I would like to say that telemedicine is here to stay. Telemedicine changes lives, and telemedicine makes the care of the patient fast and convenient. It’s very comfortable for patients, and it’s also safe for patients, and it will allow every American to receive the care that they need when they need it the most. That’s very important. So I would say that we have to ask the federal government, and whoever is out there who could help us, to help us lead this path to future health care, incorporating telemedicine as a viable solution for our patients.
Kevin Pho: Thank you, Diana. Thank you so much for coming back on the show and sharing your time and insight.
Diana M. Girnita: Thank you so much, Kevin.
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