We Should Not Be Routinely Doing Telemed For Radiation Weekly Management
Simul was wrong. First time since '09
First published on LinkedIn
I was wrong. Big time. And, I'm not sure our specialty recover from this.
I have always been a champion of general supervision for radiation treatment delivery, but then there has been "scope creep". Recently, I had been supportive of allowing 77427 (weekly management of radiation treatment patients) to be allowed to be done via telemedicine. This was pushed by large centers (especially those with "hub and spoke" models of community care) and companies offering virtual and hybrid services.
Looking back at my priors, I was valuing convenience (patient and physician) over everything else. This made a lot of sense - I look at my own life and how busy I am. I think about patients and how many other appointments they have and what else they have on their plate - family, jobs and just living life. It made sense from that perspective.
Yet, what is the one thing that everybody feels we are lacking in this modern world ... connection. What do I love about my job? Direct patient care, face to face, person to person, in the sacred space of an exam room. Does this wording seem too flowery? It does to me, but I own it.
Patients are going through perhaps the worst weeks and months of their lives when they are undergoing cancer treatments. Their world closes in on them, it is a lonely time, because nobody really understands. People distance themselves, doctors visits take precedence over coffee dates and pickleball. And yet, here is a weekly opportunity when the patient is already in the facility to connect with them.
It is their time to open up, to talk about what's going on, about side effects, about sadness, about the future. Without seeing the whole face and body, without noticing that their hands are shaking, without body language - how can we connect with our patients? If I give bad news and I can't hold their hand or hug them, how do I share with them that I care? I do care and I cannot do it from behind a screen or on the phone.
There are centers that will use this judiciously (patient literally cannot wait or emergency for the doctor), but there are centers that will use this exclusively. There will be patients that are seen via a screen for consults, weekly management and follow ups. They may never see a physician in person. They may never have the doctor lay hands on them. They will think of us as a head on the screen, a stranger that doesn't really know them.
I will never do 77427 virtually for a cancer patient unless it is an emergency for the patient and they simply cannot make it. I encourage my colleagues to do the same. If you are a patient, I would request that your weekly visits be in person - ask the treatment team: "How can the doctor examine me or really understand what's going on from behind a screen?"
We are fallible - I messed up here. I promise my patients will always see me in person for their visits. It is my duty, my privilege and my honor. I'm here for them and it will not be behind a screen.
Love you all,
Sim
Lurking SDN brought me here as I can no longer use that forum due to a few toxic posters that dominate the conversation. I appreciate your substack and commentary with an alternative to share thoughts in our field.
Unpopular opinion: Practicing medicine through a screen on wheels cheapens our profession. I support eliminating the E&M codes for telehealth "visits." I have thoughts on WFH in general, but won't go there. There's a sad reality about the real reason why so many want to cling on to the temporary covid measures (which were widely regarded to be extreme measures at the time in a time of emergency) in work, education, healthcare, social freedoms, etc and drag them out for as long as possible if not completely normalize them.
We already have this problem with scope creep of midlevels and the now prevalent use of the term "provider" instead of physician. Amazon is providing medical care now. You can get basically anything you want prescribed online by a "provider" that has never even met you. The QuikTrip gas stations in the midwest literally have their own "QuikMed" doctors offices with MDs wearing gas station polos and name badges. When is it enough?
Of course, a 77427 is not an E&M code. There is no documentation of a physical exam. There are plenty of rad onc specific codes that do not need in-person interaction (77014... my precious). This is a gray area and general supervision is the right answer. In person is always preferable. However, we all know that many of these visits are completely pointless from a purely medical standpoint. Other ones are critical.
There was a comment on SDN I agree with regarding locums in rural areas. This is a huge problem in our field and I would love to see you discuss it more in depth. I have spent most of my career in rural centers so am very familiar with it. I have seen it all: legally blind rad oncs who require a driver, rad oncs with parkinsons that take 3 minutes to shuffle to the machine to check films, felons, bottles of jack daniels in the file cabinet, pathologic personality disorders, dosimetrists seeing patients with a white coat on and drawing target volumes for locums to sign off on, sexual harrassment, and of course the ubiquitous "never got around to taking my boards because I was too busy working." So many rad oncs never want to fully retire, so we end up with these 70, 80, and 90+ year olds (seen it) continuing to take these short term assignments at daily rates far less than the median full-time employed daily compensation (a totally unique feature of rad onc). The only winner in this scenario is the locums agency middleman. This results in flat out bad care. There are so many rural hospitals that refuse to properly compensate to recruit and retain in an undesirable location (75%-tile + MGMA, <5 day workweek, 8+ weeks PTO, technical profit sharing/joint venture, 1099/PSA. etc) and would rather overpay a locums agency than deviate even a single word in a contract from the standard W2 median MGMA, RVU-capped, 5 day week, 6 weeks PTO, press ganey quality "bonus" job offered in metro areas. These hospitals get away with it because the 70+ yo locums pool with 8 figures in the bank but still working for $1600/day are enabling them to do so. Doing locums is generally a backup option for people who need to make a living in a pinch. Anybody considering rad onc as a career needs to understand that their backup option in this field is going to require traveling far away and competing for bids at $1600/day or less from people who don't need the money.
Bridge Oncology has entered the chat.