Emergency medicine and urgent care are reactive by their very nature, and, as in many areas of medicine, clinicians have no control of their time. By 2015, I understood that if I was to remain active in medicine into my 70s, I had to respect the inevitable flow of time and develop a new vision. I also wanted to be more proactive in health care. So in July of 2017, 36 years after completing my internal medicine training and a fulfilling medical career, I finally completed a fellowship — in telehealth (TH).
I had seen the emergence of telehealth and was intrigued. I recall attending in the ED about 3 years ago when rescue announced they were transporting a stroke patient, and I saw him upon arrival. He had a dense left-sided paralysis and couldn’t speak. He appeared to be a superb candidate for chemical thrombolysis — a procedure to break up blood clots. We had a 3-hour envelope to treat him with relative safety. I communicated with the patient as best as I could, but it was a struggle. In frustration, I looked up and saw that the three nurses gathered around the gurney were all intently tapping their smartphones. My initial reaction was to admonish the staff for not helping, but I quickly realized they were actually using social media to find family so we could get the information we needed to treat. They were successful, and the patient’s brother arrived 15 minutes later. We constructed the timeline, reviewed risks, and obtained consent, and the patient had thrombolysis. An hour later, he was talking and showed no weakness.
This scenario played out again in the following few years as I encountered roadblocks in providing care that could have been removed — and came to be removed — by the evolving presence of telehealth. The electrocardiogram (ECG) that previously took hours to get from medical records, for example, was directly accessible from a primary care physician in the community who sent it electronically that evening through the EMR. In several instances, this would avert an admission. As I followed the TH literature, it was clear these tools were evolving, and the game change they provided was compelling. I saw the potential for this to evolve into a new clinical tool capable, via algorithms, to provide diagnostic insights. I tried during the following few months, without success, to talk to the folks doing the research. Then, in an issue of Telemedicine, I learned about a new TH fellowship at Thomas Jefferson University in Philadelphia.
I wrote a letter to Judd Hollander, MD, as a kind of an application. It was only a few paragraphs. It started: “Although I doubt sincerely that I am the kind of candidate you envisaged for your TH leadership program, I would like to lobby for my appropriateness.” After an interview in Philadelphia, I was offered and gladly accepted the position.
After we set up our temporary apartment in the summer of 2016, I headed off to the University and Emergency Medicine department. Though thrilled with the opportunity, I also faced several challenges. For one, I was the first such fellow at Jefferson and had no predecessor to show me the ropes. Most of my clinical experience was on my own; I had only trivial exposure to the academic, cooperative practice that was now expected. Lastly, I had little experience doing clinical research. My PhD research was in basic, bench-top science. Now, I was to do clinical research as part of an academic EM department where I was simultaneously the oldest faculty member and a neophyte clinical researcher.
Studying TH’s Value
TH speaks strongly to value — the holy grail of health care reform — by presenting the opportunity to reduce cost and improve communication. What is not clear is whether that diminished cost compromises quality or improves outcomes. If both cost and quality are diminished, so too is value. Proof of concept studies are needed. I joined members of Judd’s team doing a quality assessment of JeffConnect, a service that offers the patient immediate access to providers through a HIPAA-compliant videoconferencing hookup. In this mode, many questions and minor illnesses can be dispatched quickly and inexpensively. Our project asked whether the care provided was at least equivalent to other forms of health care on demand. If so, then the reduced cost speaks to value.
My research partner, Anuj Shah (now Dr. Shah), was a smart, tactical, and engaging 4th-year medical student who left me in the data-processing dust. My clinical experience was of little use, as my partner frequently caught me implying into the patient record, not taking it on face value, as I should. Eventually we reviewed almost 600 records for the study, which involved comparing quality among the Emergency Medicine department’s three access points for unanticipated health care: the emergency department, an urgent care center in the community, and JeffConnect, a service that delivers face-to-face care and consultation via video technology. Quality indicators had yet to be described for telehealth, although the National Quality Forum (NQF) has since outlined a path to them. Using the “Choosing Wisely” recommendations from the American Board of Internal Medicine Foundation as quality indicators, we showed that, for the diagnosis and treatment of sinusitis, all three services delivered essentially equal adherence to the indicators.
A New Purpose
This late-career fellowship was really about professional sustainability. It gave me the opportunity to develop skills that are consistent with continued, scalable, and productive professional work. I found what I needed: a piece of the future, a new horizon that offers me purpose and flexibility. Telehealth will allow me to stay thoroughly engaged in medicine without the minute-to-minute productivity of emergency medicine that requires energy I could not count on for the future.
Now, I am looking at ways to use what I learned during my fellowship year to assess the value and quality of telehealth efforts around the country. Quality assurance/quality improvement (QA/QI) has been a front-and-center issue for me ever since my 12-year stint on the board and eventual presidency of Rhode Island Quality Partners (now Healthcentric Advisors), the state’s quality improvement organization. There is important work to be done: validation of telehealth using the newly released NQF QA/QI indicators. We need to look retrospectively to see what has worked as evidenced by outcomes. Understanding what has worked (and what has not) will go to verifying the TH indicators of value. Programmatic modifications can be made and the resulting indicators folded into developing new TH programs and redefining current programs. In order to promote objectivity, QA/QI is an activity often done best by observers outside of the enterprise, usually answering directly to the C-Suite. I am currently working to join such an organization.
Many people ask why I just don’t just retire. First, for me, the practice of medicine is a delight and privilege, so why give it up? Second, we need all the knowledge and enthusiasm we can get to bring about real change as we struggle with a health care system that consumes 18% of the gross domestic product but gives us health care inferior to many other nations. As we continue to struggle with professional shortages and rightsizing medical costs, the house of medicine should consider attractive professional fellowships designed to leverage older physicians’ skills. Developing late-career opportunities in such areas as efficient health care delivery and value management will be effort well spent. Instead of letting valuable skills retire away, let’s make it fun, challenging, and rewarding for physicians to stay productive. We will all benefit.