OK, buckle up folks--some of you aren’t going to like what I have to say, and with good reason.

Journalist Maryn McKenna pointed me toward a telehealth ad, and what it has to say about our medical system is pretty damning.¹ In this ad (which I won’t link but you’ve probably seen plenty like it) a young, classically-attractive influencer laments how hard it is to just get an antibiotic when you’re sick. Cut to this amazing service where all you have to do is call and presto! you’ll get your antibiotics. For your cold.

My first thought was, “Dammit this is such bullshit!”--and it is. Sort of. Look, part of this is cultural—we want what we want, and we want it now. That’s fine, we are who we are. But part of it is a rebuke of our broken medical system.

First things first: you don’t need an antibiotic for your cold, and if you are sick enough to need an antibiotic, you should be seeing a doctor—pneumonia's no joke. Most of the respiratory infections we see every day are caused by viruses and all the antibiotics in the world won't fix them. Pneumonia, however, kills people.

Now that we've got that out of the way, what, besides are own impatience and need for immediate gratification, is the problem here? And is this even legal? Can I really just message someone and get a medicine I want?

In the US, medical care is very, very expensive, even with insurance, and there are shortages of primary care doctors in many areas. People just don’t have reliable access to care. And even if you have a doctor, people often complain they can’t get in when they need to. This is even more true in other parts of the world. Telemedicine can provide a crucial service to those most in need.

I like to think we do better in our office, but especially at the height of flu season, we are slammed. So let’s say you’re an average American who’s gig job doesn’t provide health insurance and you’re home for your unpaid sick day. You need to get better—now. And because of our failures to educate people well in the sciences, you think there’s a magic pill for that. There isn’t.

Telemedicine—being able to speak to a provider remotely, in real time—really took off during covid, and we’re all thankful for that. Since then, the rules have been ever-shifting and as a doctor, it’s been a bit frustrating and confusing. So how is this legal?

When you conduct a telemedicine visit, the visit “happens” in the state the patient is. The US doesn’t have a national licensing system, so if, for instance, my patient wants to have a telemedicine visit with me when they’re in Florida, I can’t do that—I’m only licensed in Michigan.

So there are companies now that do only telehealth, and they contract with providers all over the US. They’ll help you get licensed in multiple states, and pay you for your time. This allows a doctor to make some money for their work, and gives a patient access to care they might not otherwise have. Telehealth is also critical for elderly and disabled people. We do a lot of it in our office—but only if the patient is in Michigan.

(There’s no rule against having a casual conversation between two people, one who happens to be a doctor and the other a patient, but you can’t “practice” medicine, and you can’t bill for the services. Most doctors can’t afford to give away what little time they have that way.)

Telemedicine is a very important tool, especially for people with limited access to care. But it is also prone to various sorts of abuse. You know the provider on the other end of the phone doesn’t know you well. They may meet the legal definition of a doctor-patient relationship, but it’s not the same. If my patient decides to use one of these services for, say, a hair growth product, I might know that they’re at risk for having a dangerous reaction, but the telemed doc might not get that information.

And there is the need to please the customer, something we see in urgent care, telemedicine, and in regular doctors’ offices. People are in a hurry, we don’t want to argue, and we give the patient what they want, whether or not it's truly the proper treatment.

And a decision to give antibiotics isn't always wrong—there are subjective reasons to decide if a sinus infection does or does not need antibiotics. But most of the time, antibiotics are the wrong choice.

But for a telemedicine company, customer service is the first priority. You want repeat customers, you want the word to get around—call us, we've got you. I am, as your “real” doctor, much more likely to say “no" and to spend the time explaining why my plan is better.

In my own mind, I divide telemedicine into three categories: legit, predatory, and all the stuff in between. The clearest legitimate sort is what your own doctor does which, as we know, isn't always a choice. The predators are the companies that you pay to give you whatever you want. They keep it legal, but it’s all about the money. They usually provide the medical service and find a way to legally sell you the medicine as well.

I think most telemedicine falls into the in-between category—it’s not perfect, it's often done wrong, but it provides a service people need and can’t get elsewhere due to our crappy medical system.

Do I blame people for getting their antibiotics, weight loss meds, and hair growth aids from telemed companies? Of course not. But I do blame the companies for providing services based on profit rather than good, science-based patient care.

The ultimate answer is wholesale reform of our healthcare system, but I can’t hold my breath that long.

-pal