It’s been about two years since Dr. Ian Tong has seen a patient — in person, that is.
But Tong treats patients all the time through a secure video-chatting application on his laptop, from the San Francisco headquarters of Doctor On Demand, the telemedicine company he helps lead as chief medical officer.
The same goes for the roughly 150 physicians employed by Doctor On Demand who primarily work from home from all over the United States.
The expansion of telemedicine — the remote delivery of health care services through technology — has spawned a growing cohort of doctors like Tong who spend the vast majority of their time practicing medicine through screens, sometimes guiding patients through self-exams.
Tong, a University of Chicago-trained internist, recently instructed a patient to do a brief abdominal exam on her toddler son who was experiencing bloody stools. As she did so, Tong scanned the boy’s face for discomfort and peppered his mother with questions: Has he eaten anything red, like beets? Is the blood dark or bright red?
The call lasted 12 minutes — a bit longer than the nine minutes Tong says is the average appointment time for Doctor On Demand. Soon after, he headed into a meeting with the company’s product team on how to improve the app for patients.
Telemedicine is making urgent care faster and more accessible for many patients but, as Doctor On Demand shows, it’s also changing the way doctors work. Gone are the instruments of the familiar exam room, like thermometers and blood pressure cuffs — and the daily commute.
“I’d never have imagined this is a job I’d be able to do from home,” said Dr. Heather Hawthorne, a family doctor who works for the company from Overland Park, a suburb near Kansas City, Kan. “It definitely did take some getting used to, (like) not being able to put a stethoscope to their chest to see if it’s bronchitis and not pneumonia.”
On a recent November afternoon, while Hawthorne’s 15-month-old son napped nearby, she picked up an impromptu two-hour shift because there was an unusually high volume of patient calls coming in. Later, when her husband came home from work, she worked her usual four-hour shift.
“That flexibility just isn’t there in a traditional brick-and-mortar practice,” said Hawthorne, who did her residency in Phoenix and practiced for several years at a hospital group in Scottsdale, Ariz.
This new workplace setup, Hawthorne says, is freeing but can be isolating.
“If you talk to physicians in other settings, a big part of taking care of patients is (talking to) your colleague like, ‘Hey, I don’t know what this rash is,’ and you’ll ask the doctor in the next exam room. It’s kind of isolated here. I don’t have that.”
Doctor On Demand, founded in 2014 with funding from Google Ventures, Goldman Sachs and Andreessen Horowitz, is not the first company to experiment with employing remote doctors. Other firms based in Florida, Boston and New York have been around longer, and traditional health care providers have long offered patients 24/7 advice lines staffed by nurses.
But Doctor On Demand’s inroads into the health care system — its medical visits are covered by major commercial insurance plans like UnitedHealth Group and Humana, and it contracts with a growing number of large self-insured employers that pay for some or all of the services for their workers — offers a glimpse into a local company that is riding the telemedicine boom. The firm, which is privately held, hit 1 million patient visits in May, leaders said, and is on track to hit 2 million next year.
“Over the last decade we’ve seen significant growth in telemedicine, and in the last five years we’ve seen significant growth in consumer-generated telemedicine where the patient is at home or on vacation,” said Dr. Steven Waldren of the American Academy of Family Physicians, a medical society that represents about 130,000 family doctors. Most doctors who work for telemedicine firms are family, primary care or emergency care physicians.
In 2014, about 15 percent of the group’s members reported practicing telemedicine in some fashion, Waldren said. By 2017, that had jumped to 20 percent.
Tong, the Doctor On Demand executive, says the more predictable and manageable hours help with physician burnout, a well-documented problem within the medical field. The company’s physician retention rate, he says, has been over 90 percent for each of the last three years.
“In the ER, I worked daytime, evenings, nights, weekends,” said Dr. Tony Yuan, Doctor On Demand’s medical director who was an emergency medicine physician for 20 years, most of it at San Jose Regional Medical Center. “It was super-busy with lots of trauma. The toll of the schedule, the stress of work, it made me pretty unhappy about continuing to practice medicine. When this opportunity came up, I immediately jumped on it.”
Yuan splits his week between his Union City home and Doctor On Demand’s San Francisco headquarters. On days he doesn’t have to commute, he saves about two hours.
Some of the clinical limitations to virtual visits are obvious: Doctors can’t do physical exams, take X-rays, administer injections, treat wounds or do a host of other things. They can, though, prescribe medications and order lab tests. But it’s hard to build the type of practice they could in a more traditional setting because many telemedicine patients call in with a one-off problem, like a cough or urinary tract infection, and ask to see the first available doctor, who usually has never treated them before.
The emerging model isn’t totally free from the ways of traditional medical practices. Physicians at Doctor On Demand, for example, get paid depending on how many patients they see — similar to the way it works for office visits. They work in shifts, usually for eight hours at a time, and rotate for holiday, weekend and night shifts. Doctors have to be licensed in the state where the patient lives.
“With the advent of technology and how we’ve developed personal devices, this will be the future of medicine,” said Yuan, the medical director.
But barriers remain. States have different rules for what they will allow insurance companies and government insurance programs like Medicaid to cover when it comes to virtual patient visits. And paying for the services out of pocket — Doctor of Demand charges $75 for a medical visit without insurance — is still out of reach for some of the poorest and neediest populations. In California, Medi-Cal covers limited visits done by video and allows private insurers to cover telehealth services, though the details are left up to health plans.
“It’s definitely accelerated in the last couple years, but there’s still some catching up to do,” Waldren said. “Hopefully, we’ll see the (insurance) plans paying for this and not out of patients’ pockets.”