Telemedicine — Yay Or Nay?

by Grace aka costofcollege

Telemedicine may be the wave of the future for many types of health care.

The same forces that have made instant messaging and video calls part of daily life for many Americans are now shaking up basic medical care. Health systems and insurers are rushing to offer video consultations for routine ailments, convinced they will save money and relieve pressure on overextended primary care systems in cities and rural areas alike. And more people like Ms. DeVisser, fluent in Skype and FaceTime and eager for cheaper, more convenient medical care, are trying them out….

But telemedicine is facing pushback from some more traditional corners of the medical world. Medicare, which often sets the precedent for other insurers, strictly limits reimbursement for telemedicine services out of concern that expanding coverage would increase, not reduce, costs. Some doctors assert that hands-on exams are more effective and warn that the potential for misdiagnoses via video is great.

Legislatures and medical boards in some states are listening carefully to such criticisms, and a few, led by Texas, are trying to slow the rapid growth of virtual medicine. But many more states are embracing the new world of virtual house calls, largely by updating rules to allow doctor-patient relationships to be established and medications to be prescribed via video. Health systems, facing stiff competition from urgent care centers, retail clinics and start-up companies that offer video consultations through apps for smartphones and tablets, are increasingly offering the service as well.

My new doctor has a terrific email system that allows us to conveniently discuss health issues.  I know a person who is very happy with her Skype psychotherapy sessions.  The possibilities are intriguing.

What’s your experience with telemedicine?  Do you welcome the convenience, or fear that it will lead to many errors and lower quality healthcare?


89 thoughts on “Telemedicine — Yay Or Nay?

  1. Well, I can’t let this discussion go without pointing out that the combination of telemedicine and drone delivery might not just be a convenience to busy totebaggers, but could provide life-saving service to the rural poor. There was a test flight to deliver medicine to an annual health clinic deep in Appalachia last week.
    These people wait all year to see a doctor and might drive an hour or more to the nearest pharmacy. Imagine if they could consult with a doctor via Skype and then have medicine delivered to their door by a drone. Now, if we could just get them health insurance…

  2. Legislatures and medical boards in some states are listening carefully to such criticisms, and a few, led by Texas, are trying to slow the rapid growth of virtual medicine.

    I guess I can see the expense angle. Coming back from vacation I noticed a little rash on my arm, if it had gotten worse I would have gone to the doctor but it resolved itself. It might have been an allergy to a new soap, fabric softener, etc. However, if I had an MGH app and I could just send a pic then that would get charged to my insurer as a telemedicine visits. On the other hand, if you have a chronic health problem that’s well controlled with medication I think a video followup would be a lot easier for all involved vs. numerous cursory in person visits.

    I think the easiest thing would be to charge a higher co-pay for the telemedicine visits to mitigate against overuse.

  3. My last three appointments could have been through telemedicine. I went in with symptoms of Lymes disease. Though I didn’t have a bulls eye, doctor put me on antibiotics and ordered blood test. The doctor spent a lot of time with me, but did not do any physical exam – the nurse took my blood pressure, pulse and temperature. They called to tell me my blood work tested positive.

    Went back to doctor because of problems with medication. He put me on another medication and ordered a bunch of ultrasounds because of the pain. Again, no physical exam, only nurse taking vitals.

    Went back to doctor for results of ultrasounds – all good except for my thyroid – just needs fine needle aspirations of some nodules. Again, only contact was nurse taking vitals.

    While it might seem like these were indifferent visits, they were not. He spent a long time with me taking complete history and discussing strategies for overall health. I was glad my regular doctor was unavailable and he took her place. I have moved to his service.

  4. The issue for us has been the time it takes to get seen by a regular doctor for garden variety issues that crop up infrequently. I have ended up taking the in laws to the minute clinic because we don’t want to neglect a cough/cold given their age but it takes too long to get see by their primary care physician. With the kids, I would have ended up at the minute clinic as well but their pediatrician is located near by, so I can work from home and take them there. For us, I guess video consultation would do as a first step.

  5. I would love this.

    For a reason, my Dr. guards his e-mail address like a nuclear code. He wants to see his patients on his own time schedule. He certainly does not want us to bother him at random times.

    I suppose medicine is like every other profession. Most of the battle is training your clients.

  6. Oh, god, this is a topic I actually have to TEACH. Want my Powerpoint slides on the pros and cons?

  7. Telemedicine technology has been around since the 90’s. While there have been a few successful projects, there are some huge reasons why it hasn’t taken off. The two big obstacles are lack of a reimbursment model, and state licensing jurisdictions.

  8. Our drs. office seems to just push you to the NPs, which is honestly fine for most things. I don’t think I’d like telemedicine but I really go to the drs. pretty infrequently. We had physicals this week (which we usually only do every two or three years) and it was a four month wait to see the actual doctor. Our pediatrician’s office always has same day appointments if you’re sick but with our dr. it is never same day.

  9. MM. Yes.

    I have a ton to say about this, but am playing tour guide today, so I will have to go on and on and on later.

    On the drone, regulation makes it incredibly difficult for a er to dispense rx meds. Ina rural area, we can give you two puffs of the inhaler, and an rx, and throw the inhaler away. Or one dose of liquid meds, an rx, and throw the bottle away. Before we bring in drones, we could fix the dispensing of drugs problem with tools we already have.

  10. Doctors don’t want to use email because they know they would quickly find themselves, like us professors, inundated by email at all hours. There are also huge problems with HIPAA. While some facilities, like MSKCC, just blithely ignore the HIPAA issues and email away, most providers have refused to use it until highly secure portals are developed. My provider, which is a large network of doctors that have all the fanciest health IT software, only started doing email this year, and only through a secure portal that is incredibly clunky and slow, and is down half the time.

  11. On a related topic, did you guys see this article on grading doctors?

    I had two reactions: First, doctors, welcome to the club. Teachers get rated on ridiculous high stakes tests, professors get rated by their ignorant students, and employees in private industry get rated by their pointy-haired bosses. Why should you guys be any different?

    Two, personally I think that frail elderly guy with the many health problems may not have been the best candidate for high risk surgery. We always talk about not treating the frail elderly with aggressive medical procedures because it can lead to worse problems and extend suffering. Perhaps the rating mechanism did its job, by forcing the surgeon to consider.

  12. The other thing I like from my general doctor and one specialist is that they post info like medications, lab reports, recommendations, instructions, etc. on the portal. This is tremendously convenient. But yes, there should be a way to compensate for this. OTOH, isn’t this ultimately a cost saver if it saves the time of office staff and of the doc?

  13. When lawyers answer emails, they can bill for them. I know some lawyers in smaller practices will bill you at a lower rate if you interact with them by email. OTOH, engineers, professors, non-profit managers, etc., are expected to answer emails 24×7 for no extra compensation. And compensation for physicians is so bizarre anyway because of the way the insurance system developed after WWII that it’s hard to know what model to apply to it.

  14. My doctor visits for the past few years have been for obstetrics. Most women could stick a paper in their own urine to check for gestational diabetes, weigh themselves and take their blood pressure with an automated cuff. It would have saved me a lot of time if some of my visits could have been completed that way. Providers, whether OB’s or midwives, don’t have time to answer specific questions and the information they provide is often outdated. (A colleague pointed out that she was advanced maternal age and the information they provided on epidural risk had been gathered before she was born- has their been no change in the past 35 years in epidurals?)

    On the other hand, when Mr. WCE was diagnosed with atrial fibrillation last fall, he called me from the hospital parking lot, unsure of whether to visit ER or urgent care for weakness and racing heart. I told him I didn’t know and suggested he call his primary care office to ask. (It was a weekday afternoon.) His primary care office (mostly religious doctors who don’t like our main healthcare conglomerate, I think) had him in within 20 min, did an EKG and got the information into his medical record, which facilitated a future visit to a cardiologist. He has had other same-day appointments with his primary care office because they have a doctor-on-call who sees the people who need to be seen same-day.

    For some issues, and especially for medication management or patients with weak immune systems, telemedicine is ideal. Patients like my mom are drained by having to leave the house to go to the doctor, and unless you’re doing a scan, you’re probably not going to learn more about where her cancer is by a physical examination.

  15. I have the perspective of a well served middle class health consumer in eastern MA, who can get seen after work hours or during daylight hours on weekends by most group practices and for whom numerous walk in options are less than a fifteen minute drive away. Telemedicine for immediate complaints is no particular convenience to me at all, especially if it follows the office call back method where you have to be glued to your computer, just as now you have to be prepared to answer the phone immediately (despite work or other constraints) at any time after the leaving the message to close of business. Three weeks ago we had the experience of my husband calling into his practice after feeling very bad, but he did not answer the cardiac nurse’s thorough questioning on the call back with the correct buzz words or severity, and was given an office appointment six days later. I insisted he mention to the check in desk when he went to the eye doctor later that day that he wanted his heart listened to, and he was quickly whisked off to the emergency room. So patients cannot be relied upon to report their symptoms correctly – sometimes you need hands on.

    By the way, we just returned from an overnight at Tanglewood. He expired neither from the uphill trudge from the muddy parking lot to the concert hall, nor from ecstasy at the virtuoso performance of the last three Beethoven piano sonatas. And I didn’t mind driving, (I think my limit would be 4 hours a day), so I am more hopeful about our future ability to vacation together at something other than geezer cruises or bus tours.

  16. One problem that I see is that the populations who would be best served by telemedicine – the isolated rural poor, and the homebound elderly – often lack the technology or the expertise in using the technology that would be needed. A lot of people in deep Appalachia do not have Internet connections or data plans on smartphones. In some of those areas, just picking up cell service can be tricky. My 92 year old MIL does not have a smartphone or an Internet connection (she had dial up at one point, but rarely used it). One research study that I discuss with my students when we do UI design assessed a series of interfaces for transmitting pulse and blood pressure stats to doctors via the Internet as well as communicating. The researchers studied how very elderly heart patients reacted to the different interfaces. They found that the elderly patients in the study preferred a console that hooked up to the patient’s TV over the smartphone and tablet interfaces they studied. Yet, designers of these types of applications always assume everyone wants to do it via smartphone.

  17. I’ve been thinking lately about how people interact with technology as a function of age and background. MyDad is heavily represented in the Iowa presidential candidate polls, thanks to their corded telephone and need to answer it for medical reasons in the past few weeks. My Mom would never get an answering machine, but my Dad just got and hooked up my brother’s old answering machine so we can leave him messages. My parents are not that old, my mom (in particular) just hated dealing with technology. My Dad isn’t much of a typist and is willing to learn- he quit typing to us in all caps a few years ago. (They used all caps at his plant for years for all communication.)

    Mooshi’s point is an argument for workplace diversity. As a middle aged woman, I think about and interact with different issues than young, male software engineers do. If technology is going to be truly mainstream, or accessible to those with less-than-average technology aptitude, software engineering will have to change. As it is, the top 20% account for 80% of revenue, so 80% of the population can be ignored… I suspect.

  18. There are also huge problems with HIPAA. While some facilities, like MSKCC, just blithely ignore the HIPAA issues and email away,

    Good, I applaud them. I wish you could opt out and just get regular e-mail. I’m tired of have to log into a portal (ops you’re on a new device please answer the following questions – What was your first grade teacher’s cat’s middle name?)

  19. I’m all for it. And we should comp for it. Like, Meme, I have no access issues when it comes to healthcare, so in the immediate term I don’t see much benefit for me/our immediate family.

    Back when we were in the baby-having stage, mid-late 90s, DW’s high-risk OB ran a telemedicine program out of our local med ctr to consult on cases that were from rural areas 45-100 miles away. This was pre-HIPAA, so maybe things were easier then for him, but as I understood it at the time, this was a very valuable service for people who couldn’t readily travel 1+ hours to see a specialized doc.

  20. Rhett, there must be some point at which the copay discourages people from getting necessary treatment – our copay is now $75 and going to $100 soon, with a $4k individual deductible.

    What would you charge for a telemedicine appointment?

  21. Sky,

    A quick googling says the national average co-pay is $21.13. I was thinking $35/$40.

  22. In my neck of the woods there is a telemed option. It is $40 regardless of insurance. A lot of my friends use it that have high deductible medical plans. For their child’s ear infection or pink eye, it is a lot cheaper than paying the $125 doctor visit.

  23. Rhett, that seems more reasonable :)

    What I would like is a way to keep my glasses prescription current without having to see an optometrist or ophthalmologist once a year. My kids just broke my last pair. (To be fair I got them online for $9, so they weren’t the best made glasses ever.)

  24. Lemon–do I recall correctly that you are in life insurance? If so, would you be willing to answer a “hypothetical” question regarding qualification procedures (with the caveats that it is not official advice, etc, etc.)?

  25. About the elderly, a family member works in hospital IT. We were guinea pigs for a service that was like Skype that you hooked up to your TV. I dont remember the details. But the setup was clunky. I could tell that they had tried to make it really easy to understand, but even we had some trouble setting it up. And if you are like my parents and have almost no IT knowledge then the program would be a flop. I think there will just be a segment of the population that can’t utilize IT changes and have to physically see a doctor. The Rhetts of the world will be fine with a hologram doctor.

  26. Anon, that is correct. CoC has my email if you don’t want to post a hypothetical question.

  27. In Texas defense, they are asking that you see the doctor in person and then you can do follow up for up to a year. Or, you can have a healthcare mid level on site and a doctor remotely from the get go. When you have never been in physical contact with the patient, it is hard to do things like listen to their heart etc.

  28. Thanks. I’m ok to post if you’re ok to answer. :)

    Hypothetically, an early 30s man who is in excellent health is trying to get term life insurance. His vice is occasionally smoking cigars (~6 per year); this was disclosed to his broker, who suggested a carrier that was lenient about that. His urinalysis showed 0.000 nicotine metabolites and read “Negative” for smoker; for some reason, the insurer also did an MS analysis that came up “positive” but won’t share the specific number. The insurance co. wants to classify him as a full-on smoker. What is going on? Is that common?

  29. Anon, my initial thought is that the insurer has reviewed their overall risk and is no longer considered lenient. With this result on his medical records other carriers will probably see he is a tobacco user. You may want to consider appealing the decision and your decision paperwork should have contained info on how to do this. With the appeal you should be able to see his full results. In fact, im surprised they didnt release this to you already. You should also request another round of tests (moat likely at your expense).

    My experience is that you are classified as a tobacco user if you have used any tobacco in the last 12 months. So even a once a year cigar would be a tobacco user. In the event that you pass away and the autopsy, tox reports, and police report (if necessary) indicate tobacco use the carrier could deny the claim. Saying that you lied on the application when you indicated you were a non tobacco user. Of course the beneficiary can appeal that deniel.

  30. Sky – I order glasses online all the time (and lose them all the time) – and they don’t require an updated prescription. I just enter the values off of my (embarrassingly old prescription).

  31. Although I haven’t used the official telemed option provided by my insurer, I have several friends and relatives who are nurses and I either Facetime or send photos several times a year to determine if the rash, swollen finger or other condition warrants a visit to a doc or if we should just wait and see. I don’t have a good instinct for this kind of thing, and we’ve gotten caught in some situations that were more serious than I would have initially thought. Like Meme, the docs are all nearby and most of the time, if it’s urgent, I get an appointment.

  32. Attorneys or people generally familiar with separation & divorce – I’m looking for a rule of thumb on spousal support calculations. The best I’m finding in VA was designed for temporary support and puts me at zero. However, I’m now making a salary almost half of H’s, after supporting him for many years, and I feel like I should ask for something while I get back on my feet. Since we’re both engineers, it would be easier to justify something based on a formula, even if not for our state.

  33. Telemedicine seems well suited for HMOs. When I was an HMO member, they did all sorts of things to minimize the number of office visits we made, and the number of times we saw doctors. We’d get a medical handbook every year, and there was a 24/7 call the nurse hotline that would deal with routine stuff.

    It’s been a while, but I’d be surprised if they aren’t using email and/or telemedicine consultation now.

    “Our drs. office seems to just push you to the NPs, which is honestly fine for most things.”

    The HMO had a team approach, so in addition to a PCP, I had a PCNP (to coin an acronym). I liked that arrangement, in part because I liked, my NP, but I really liked the continuity it provided.

  34. “the insurer also did an MS analysis”

    What’s MS in this case? Middle school? Mass spectrometry? Multiple Sclerosis?

  35. SWVA, I’m no attorney but I saw this link to state-by-state divorce law summaries by blogger nerd Philip Greenspun and thought of you. He has an odd fixation with women who game the system with one-night stands, but given the divorces in our family, I found the summaries interesting.

  36. “What I would like is a way to keep my glasses prescription current without having to see an optometrist or ophthalmologist once a year.”

    I’m guessing someone will come up with an app to do that.

  37. SWVA – I will comment as a tax professional. Alimony is taxable to you, so you only get 70% or less of the gross amount, plus all of the bracket effects. Commenting solely as a divorced person with no legal expertise, I personally would rather deal with redress for inequity by getting a little bit more in the property settlement – more assets to invest to generate income or more down payment on the next house to reduce expenses. Your attorney can advise whether under the fairly specific VA statute (which forbids repayment as a basis) a spousal support award would get by the judge and is even permitted or enforceable.

  38. Lemon–Thanks. Interesting about the “lied on application”–how far would that extend? E.g. If you weighed 150 at time of application and 200 when your beneficiary needed to claim the policy, would that also be considered lying? (Because you had presented yourself as being a better risk than you ultimately were, and was potentially a lifestyle choice vs, say, genetically higher cholesterol levels?)

    Finn–I believe MS=mass spectrometry.

  39. “For a reason, my Dr. guards his e-mail address like a nuclear code. He wants to see his patients on his own time schedule. He certainly does not want us to bother him at random times.”

    I thought one of the advantages of email is being able to respond at your convenience.

    This is why at a previous job, we used email a lot to communicate with people in the same room, even at the next desk. We didn’t want to disturb the chain of thought of someone else, so we would email our questions, so the response could be made at the convenience of the responder. If a discussion was called for, we’d email that request, so the discussion could occur after the chain of thought was complete.

  40. “Alimony is taxable to you, so you only get 70% or less of the gross amount, plus all of the bracket effects.”

    Is alimony paid with after-tax dollars?

  41. SWA – Child support is not taxable and I have a hard time believing if he makes twice as much as you and assuming you split time with your daughter, that he would not owe anything. CA has a strict formula based on household income, some debts such as mortgage I think, and custodial time. There is a specific software that makes the calc and has to be attached to the court filing.

    Other things that can be added are half of child care costs, medical expenses etc.

    Google – California child support calculator and some options for general calcs come up.

    I don’t have experience with spousal support/alimony

  42. I believe alimony is deductible to the payer (not income) and taxable to the recipient – it shifts the tax burden. Child support is paid after tax and is not taxable to the recipient.

  43. I believe above certain income levels, fed tax deductions get phased out, which would mean that a high income alimony payer might not get to deduct the alimony, which could then be taxed twice.

  44. I have no personal contact with telemedicine (never a provider nor a patient be?), but I have seen how it sorts itself out at my hmo.

    I am highly skeptical of the figure that 40% leave with a prescription. 2 out of 2 examples in the article got antibiotics. I have a feeling that a parent who just put in their credit card at 2am is not receptive to the new AAP guidelines that a healthy 4 year old does not need antibioitcs for her ear infection and should be treated with a dose of ibuprofen. More and more, people go to the doctor for the treatment they have already decided that they need. A good doctor that you trust and have a respectful relationship may be able to convince you that you don’t need what you think you do, but some random person that you just handed $99 to is unlikely to have that kind of rapport.

    My HMO allows patients to use a secure portal for email and people use it frequently. It seems to work very well – though many don’t seem to realize it is part of their medical record. So, when they follow up with their pmd about their gout attack and go on and on about how Obama is ruining America, the ER doc that they are seeing for their sprained ankle may peruse that email as part of a quick chart biopsy. It does seem to keep people out of the office for things like simple follow up, med refills, med escalation, etc.

    The HMO also allows people to schedule telephone visits. So, if you have some concerns about lab work that was done, or think you need a referral, etc. you can schedule phone time. That seems a good use of resources. I believe the doctors have the ability to decline to allow things to be phone visits if they think it can’t be handled well that way. Since the docs are all salaried, they are indifferent to the time cost of such visits (their calendar gets filled up by someone else), and somewhat vested in saving the system money.

    HMOs are ideal for this (at least the one that signs my paycheck) because they require every patient in the system to be assigned a primary care provider.

    Telemedicine is ideal for pinkeye and earaches — as is homeopathy, chiropractic care and pedicures. Most “pinkeye” is viral conjunctivitis, and most earaches are viral otitis media – both are self-limited conditions that usually resolve without treatment. If everyone with typical symptoms of these conditions painted their toenails pink and waited 3-5 days to see a doctor (though certainly they could go sooner if conditions are worsening!), then the vast majority can by cured through pedicures.

    The above should not be construed as medical advice.

  45. “For a reason, my Dr. guards his e-mail address like a nuclear code. He wants to see his patients on his own time schedule. He certainly does not want us to bother him at random times.”

    I thought one of the advantages of email is being able to respond at your convenience.

    Exactly. The doctors and providers I’ve dealt with recently are all encouraging patients to use the secure portals so they can communicate via email. It is much easier than playing phone tag with the nurses. As a provider, I’m not in a situation where communication like this is an issue, but if I were, I would definitely want to use email instead of the phone.

  46. I am highly skeptical of the figure that 40% leave with a prescription. 2 out of 2 examples in the article got antibiotics. I have a feeling that a parent who just put in their credit card at 2am is not receptive to the new AAP guidelines that a healthy 4 year old does not need antibioitcs for her ear infection and should be treated with a dose of ibuprofen. More and more, people go to the doctor for the treatment they have already decided that they need.

    I think I mentioned that one of the MDs I worked with in urgent said that he would like to see the docs at the AMA and AAP who come up with these guidelines work in primary care and urgent care for a few days and see how long they can stick their guidelines and not give antibiotics to these patients.

  47. As for telemedicine, I think it can be very useful. There are a lot of visits that don’t require a hands on exam that can be done much more efficiently. People have mentioned not wanting to wait around for the call. Would you rather wait in the comfort of your home, or in the waiting room or exam room at the office? As for copays, it should be lower for these appointments because they are more efficient.

  48. Ada, one of the big drivers of antibiotic overuse for ear infections is daycare rules. Everyone blames parents, but the standard rule at daycares is that a kid can go back in after 24 hours on an antibiotic. Same for pinkeye. That is why parents are desperate to get the prescription. For some people it can mean their job.

  49. DD, my doctor doesn’t do phone calls either. If he’s not going to take insurance of any kind, he’s certainly not about to answer a phone call. An e-mail is out of the question.

    One can, of course, talk to his NP on the days she is in.

    My doctor has an excellent reputation. By no means is he user friendly.

  50. Old mom – So you do have Lyme disease? I am so sorry to hear that! I hope the new medication works better than the first one.

  51. Mooshi, a doctor’s note stating the child is cleared to return to daycare works just as well for that purpose as antibiotics do.

    PTM, I’ve worked with a few doctors who actually do phone calls, but most have their MA or nurse call. But I’ve seen more of them using email (once they get the secure portal set up) because it does save them time. Exchanging a few emails with a patient is quicker than dealing with the MA-patient loop.

  52. Anon, in your example that wouldn’t be lying because at the time of signature you were telling the truth of your weight. Now if you weighed 350 and wrote down 150 and when filing a claim it was determined that the manner of death was a decade of obesity then the benefit analyst may take a look. In regards to tobacco use policy may have a clause that requires you to notify them you if you go from a non user to a user. Its important to read those policies.

  53. “People have mentioned not wanting to wait around for the call.”

    Is that even an issue now? It’s not like the old days when you had to wait at your landline.

  54. In some schools/day cares, if the school sent the kid home, the kid has to have a doctor’s note saying when they can return to school. Our day care did this for a while and it made me bonkers. My DD#2 spiked a fever EVERY SINGLE TIME she got a new tooth. And, that required me to pay a $25 co-pay, when she this happened in day care instead of at home. If it happened at home, the next day, I could just say – Oh she is teething, doctor recommended tylenol for the pain every 4-6 hours as needed. Everything was fine.

    Yes, pinkeye can return after 24 hours on antibotic. From a working parent’s perspective, the cost of the doctor visit and prescription is usually less than a day’s pay vs 2-5 days off for it to run its course enough to go back.

  55. The other problem with email is the scenario where the patient expects immediate or almost immediate response from the doctor because the patient is using email in lieu of an urgent care or ER facility. Doctor doesn’t respond timely which leads to a poor result for the patient and patient sues.

    This is very different from – hey can you explain what my blood test results mean? or I’ve been talking XYZ medication and I just read it affects your liver. I am concerned about my liver, are there any other options to this medicine. – which are all important, but not urgent. I think this is why they use patient portals that allow for limited types of electronic communication AND do not lead the patient to believe that he/she will get an immediate response.

  56. “Mooshi, a doctor’s note stating the child is cleared to return to daycare works just as well for that purpose as antibiotics do.”

    Not in my experience! The daycares and school nurses have their protocols and will not deviate

  57. Did you see the big kerfuffle over when a kid with lice can go back? Evidently, the AMA is now recommeding almost immediately, but the school nurse association is saying no way, no how. Which of course leads to lots of business for lice ladies.

  58. Finn, even with a cell phone sometimes you are still unable to take the call, especially since most of them come during working hours.

    Austin, they use the portals because regular email does not meet the security requirements of HIPAA.

  59. Mooshi, that’s interesting. We never had an issue with our day cares accepting dr notes. But in any event, what was stopping you from just saying the kid was taking antibiotics? Did they actually ask for proof?

  60. Yeah, Uber was running ads everywhere against NYC. I wonder how much they spent on that campaign. Welcome to the gig economy folks. Of course, their ultimate aim is to do away with human labor, which is why they hired away CMU’s top robotics researchers.

  61. I couldn’t see how an uber doc app would ever get off the ground – it requires density, surely NYC is as well served by drug store clinics as is eastern MA, and you still have to leave the house to get the scrip filled. Not at all – Google could only find a dozen or so in all of Manhattan, with fairly limited hours and services.

    I guess the mature government mandated universal coverage model in Mass has resulted in a free market solution to physician availability, even in a highly regulated state.

    The CVS minute clinic bills insurance, covers all the usual minor complaints for patients over 18 mos old, routine inoculations, camp physicals, and most importantly is able to fill the prescription in the same location. There are three within 2 miles of my house, reachable on a bus line.

    MinuteClinic® hours:
    M-F: 8:00 AM – 7:00 PM
    Sat: 9:00 AM – 5:30 PM
    Sun: 10:00 AM – 5:30 PM

  62. The mother of a friend on Facebook said she didn’t believe the charges against Cosby because “he doesn’t have the face of a rapist” and “I am a very good judge of character”. And I thought, THIS is why you never, ever have a jury trial if you can possibly help it.

  63. I grew up with our family doctor making house calls. It was great. As a family the only two instances when we used a hospital was when my mother went to a hospital for delivery and my Dad had to spend a few days. Everything else, including measles, chicken pox, typhoid, fevers were handled by our family physician.

  64. “their ultimate aim is to do away with human labor, which is why they hired away CMU’s top robotics researchers.”

    Perhaps they’re conspiring with NY politicians.

    New York Plans $15-an-Hour Minimum Wage for Fast Food Workers

  65. Thanks for all the spousal support replies. I wish it could just be an easy formula based on years of marriage, hours of labor for child birth, number of times the in-laws visited (ok, I would lose on that one!), etc. I definitely will get some child support, so that will help. I’m trying not to be a jerk and ask for too much or anything too complicated. We both need the funds from selling our house to put into our new homes (renting is not really an option here because of student demand), so I’ve agreed to split that equally. For now, we’re just going to keep the rental property together since it’s occupied and pays for itself. But I don’t think it’s fair for me to have to lower the standard of living to which I have become accustomed because he decided he didn’t want to live with me anymore.

    Sorry, I’ve just been feeling sad as all of this becomes more real – home inspections next week on both the old house and my new one, trying to figure out which furniture I want now that I know where it will be going and my mom trying to dump the contents of her attic on me. It helps to know I have a place where I can vent to my virtual friends!

  66. “I couldn’t see how an uber doc app would ever get off the ground”

    Yeah, I agree. But those CVS-type clinics are great. I have three within about a mile. They have come in handy.

  67. Meme, CVS down here won’t even touch my son until he is 18. Not even for a flu shot.

    They are reluctant (but will) touch me because I am over 60. For some reason that seems to be their cut-off.

  68. SWVA — You can vent here any time. I’m feeling very sympathetic for you, and I imagine the emotional and mental toil is tough to manage. Also, I didn’t realize you supported him for many years.

  69. I have never tried the CVS clinics, mainly because my medical practice has three urgent care facilities where I can get seen right way – and they have all the diagnostic type equipment right there. When I had pneumonia, I went to the urgent care, and they were able to do a chest Xray right away. The whole thing took me about 30 minutes and I was out of there with a prescription. My kids also go to a pediatric urgent care which is just fantastic. They have sewn up so many injuries over the years

  70. PTM – CVS was quite Ok treating the in laws. I have been tempted to ditch the pediatrician for flu mist for the kids because it is always such a big deal to get a flu mist appointment. The same for well child appointments – such juggling to get a well child appointment. Then the pediatrician’s office told me that insurance would not pay until 365 days had lapsed since the last well child. It turned out not to be true – I can go anytime in a calendar year.

  71. SWVA – you have virtual friends who send you good wishes and hope your situation on all fronts improves.

  72. “Meme, CVS down here won’t even touch my son until he is 18. Not even for a flu shot.”

    Wow, quite different from their policy here. I’m not sure how young they’ll go, but certainly they treat young teens. It’s easy to pop in for a flu shot, strep test, etc.

  73. SWVA – I wish you luck. I hope everything is as seamless as possible. {{Hugs!}}

    telemed – I could get behind it. I tend to use the urgent care clinic if I’m sick and know it (i.e. the summer sinus infection I had last month), and see my PCP for the annual check up (though it’s been like 2 years… so maybe it’s time to see him again). For those who mentioned the TV option – why not plug and play like Roku or Chromecast? If ports for that unavailable, why not the old 3-cable system?

    Well visits – they only do them in the middle of the afternoon for babies at my ped. Luckily I have a flexible job (as does DH), because it’s a chore to drive to get kid, bring kid to pediatrician, bring kid back, go back to work. It turns out to be a 2-3 hour slot out of my day. I lucked out last week that I was able to just work late and hit a late yoga class at the Y on my way home. If I had a position where I couldn’t get that time off, that would be a half day of lost wages at least.

  74. The walk in clinics are staffed by physicians or another level of licensed provider with diagnostic privileges. This may not be allowed in every state. The service that is usually available nationwide is pharmacist-administered immunization – no on site nurse required.

  75. I wish it was easy to pop into CVS for a flu shot and thus and such. I have no clue if it’s a Florida licensing thing or due to something else. But they absolutely do not treat anyone under 18. And for me, I have to sign a waiver for anything and they practically require that I be strapped into a wheel chair.

  76. Mooshi, I actually travel to the CVS minute clinic in your town to get flu shots every fall. We discovered it a few years ago during the swine flu panic because CVS is able to get vaccines when there are shortages since they order so many doses. That location is the only minute clinic around here that receives every kind of age appropriate flu vaccine for children. They also have the proper staff to vaccinate a child vs. an adult.

    I haven’t been to the clinic for anything else, but my experience in that location has always been
    positive. I would go back for simple stuff if I ever need something when my doctor isn’t available.

  77. “Of course, their ultimate aim is to do away with human labor”

    Yes, I can see Uber buying a fleet of driverless cars. Think about how much easier that would make the juggle, being able to order a car to get your kids to practice, lessons, etc.

    If Uber, Lyft, et al don’t put taxis out of business with their current model, I can see those companies using driverless cars doing it.

  78. “But I don’t think it’s fair for me to have to lower the standard of living to which I have become accustomed because he decided he didn’t want to live with me anymore.”

    I’m not sure how to put this nicely, but fairness aside, is that a realistic expectation? You and your family, including soon to be ex, will have higher total living expenses when you split, but the same income (or perhaps more accurately, same income trajectory, at least in the short term).

    I suppose your soon to be ex could mitigate this by improving his income trajectory, especially if the split means he has fewer home responsibilities and can thus devote more time and energy to increasing his income trajectory. That’s what one of my relatives did, and that, in addition to his ex having a good income trajectory and remarrying, allowed all parties involved to not give up much in standard of living (in this case, using an acronym might not be appropriate).

  79. Longs Drugs (CVS-owned) here won’t give flu shots to under-18s either.

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