Telemedicine is often in the news and until recently I had only casually glossed over the latest articles. The details I paid little attention to, but the headlines I would remember. “Great for rural areas” I would read! “Extend physician reach!” “Get specialists to greater numbers of patients with unique conditions!”
As a nearly graduated anesthesia resident in a large city with an abundance of doctors, I didn’t think telemedicine would have much impact on my future. None of the above headlines applied. However, I would be surprised one morning to wake up to an email that roughly said: “Thank you for your service to our patients in the past, but we will now be covering your position with telemedicine doctors, effective (nearly) immediately.”
I’m not just an anesthesia resident, I also spent several shifts a month serving as an in-house night physician at two long-term acute care (LTAC) hospitals of the same company. In a long standing tradition called “moonlighting” residents in training often supplement their income by working night shifts in various medical positions.
Going forward, a single physician at home with a telemedicine interface will be covering the two LTACs that each previously had a physician on site at night. Both physicians were previously paid $90 to 100 an hour; now the single telemedicine doctor will make $25 per hour per hospital covered. For the current two-hospital system our moonlighting group was covering, this amounts to a cost savings of about 75 percent. Or using rough hourly wage amounts, our group was being paid ~$72,000 per month while the telemedicine group will be paid ~$19,000 per month to provide the same coverage. I cannot argue with the impressive financial savings that switching to telemedicine will provide from just this small two-hospital system.
The approach also cannot be looked at any other way than a cost saving effort. There is not a lack of physicians for the work and shifts were never unfilled. There are physicians and residents of multiple specialties in our moonlighting group suited for critical care, airway management, and emergency response. The patients had no rural limitations, no particular special expertise needs, and no reason (other than financial) that they couldn’t have access to a 24/7 in-house physician.
What kind of patients were we caring for? Most made up of post surgical or post intensive care patients requiring long-term IV antibiotics or rehabilitation that were too medically complex for a less acute center or skilled nursing facility. Admittedly, most of these patients do not need to be seen by a physician at night. But the eight-bed ICU unit at one of hospitals we covered was nearly always full as well — patients requiring a full range of intensive care needs from ventilator management to vasopressor support. And not entirely infrequently, our group was called in the middle of the night to run codes, intubate patients in respiratory failure, or place central and arterial lines. Despite our best efforts, sometimes patients died at night under our care.
Can telemedicine do all of that? Yes, and no.
I’ll admit, in the year I worked there I personally never had a situation arise during a shift that a telemedicine interface probably wouldn’t have been able to handle. The number of times I had to physically see a patient in the middle of the night was very small — and usually responding to falls. However, while still rare, other members did have significant experiences requiring hands on skill to potentially save lives. Going forward, many of those tasks in emergencies will be handled by nursing or technical staff. Airways, including intubations, will be handled by respiratory. Central and arterial lines will wait in until the morning. Codes will be run by the charge nurse, with telemedicine set up to assist with general direction.
During a small window where both telemedicine was primary night coverage, and there was still in-house physician back-up, a night physician was forced to intervene. A patient was deteriorating, and the decision was made via telemedicine for respiratory to intubate. The night physician, trying to allow telemedicine and RT to manage the situation, was only standing by and did not intervene … until oxygen saturations persisted below 50 percent. That night the in-house physician saved a patients life.
How many times would a situation requiring a hands-on physician come up per year? It’s hard to say, but I’d guess not more than about one every couple months. That’s a small number, unless of course, you are that patient in need. But I’ll admit I have no idea if we are “saving” any of those patients. The mortality of requiring a significant intervention when already sick enough to require LTAC care is certainly high.
The discussion brings the telemedicine expansion in line with the bigger issue of cost saving in medicine. As telemedicine becomes more sophisticated and it’s costs continue to come way down, there will be a growing temptation where patient safety may be marginalized purely for financial benefit. In this example, I don’t know if it was the wrong move — but I’m positive the patients aren’t safer by losing the immediate availability of a physician. The question will be where the line is drawn as the proliferation of telemedicine continues. How many lives are worth protecting with the added expense of a physician in person? Could telemedicine even replace the more permanent day physicians at locations like these and in similar jobs around the country? Surely not: But I never thought I’d lose my own job to telemedicine either.
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