Can you work fully remotely in neurology?

[Phantom Spike]

Is the 30 minutes for a new consult inclusive of chart review/documentation time? Or are you doing a lot of that before/after your shift? Apart from the fact that you don't have to commute or walk from room to room, the time taken for teleneurology patient care shouldn't be significantly different compared to an in-person encounter, should it?

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[xenotype]

Is the 30 minutes for a new consult inclusive of chart review/documentation time? Or are you doing a lot of that before/after your shift? Apart from the fact that you don't have to commute or walk from room to room, the time taken for teleneurology patient care shouldn't be significantly different compared to an in-person encounter, should it?

Depends greatly on complexity. Depending on which outfit you work with they really aren't setting a 'time limit' on you- you control the pace but seeing more patients = more $$. 20-24 new and f/u would be typical for a rounding day, maybe slightly on the low side- vast majority of this is follow-ups (25% new, 75% f/u would be typical). The good companies will accomodate you if you are slower as needed.

 

[Phantom Spike]

Thank you, as a follow-up question ... do you get to decide whether to "follow-up" a patient or just sign off? I understand that if you are paid per patient you might want to follow-up, but perhaps would want to prune your list if you are being paid per shift. However, considering that most consults are uncalled-for in the first place (obvious cardiogenic syncope, stable dementia, toxic-metabolic encephalopathy due to UTI, etc.), do telemedicine companies give you the freedom to just sign off or can you expect some pushback during performance reviews?

 

[Neurogeneral]

Thank you, as a follow-up question ... do you get to decide whether to "follow-up" a patient or just sign off? I understand that if you are paid per patient you might want to follow-up, but perhaps would want to prune your list if you are being paid per shift. However, considering that most consults are uncalled-for in the first place (obvious cardiogenic syncope, stable dementia, toxic-metabolic encephalopathy due to UTI, etc.), do telemedicine companies give you the freedom to just sign off or can you expect some pushback during performance reviews?

The teleneurology companies I talked to indicated that the vast majority of their consults are acute/hyper acute - mostly the ERs consult you for stroke, acute change in mental status, seizures, etc. I was told that once these patients are admitted, they aren’t typically followed by the teleneurologist.

Telespecialists, in particular, told me that you would need to see 22-24 NEW acute consults to make the $440k compensation they were pitching. Obviously, you can see less and make less which could still be very reasonable compensation, but the job itself seemed much more like stroke call and not like a “tele-neuro hospitalist” role where you actually “follow” the patient.

 

[Aldertonghen]

The teleneurology companies I talked to indicated that the vast majority of their consults are acute/hyper acute - mostly the ERs consult you for stroke, acute change in mental status, seizures, etc. I was told that once these patients are admitted, they aren’t typically followed by the teleneurologist.

Telespecialists, in particular, told me that you would need to see 22-24 NEW acute consults to make the $440k compensation they were pitching. Obviously, you can see less and make less which could still be very reasonable compensation, but the job itself seemed much more like stroke call and not like a “tele-neuro hospitalist” role where you actually “follow” the patient.

Is telestroke full time or can one pick like maybe 4-5 shifts a month (part time)- say on every Friday night?

 

[Neurogeneral]

Is telestroke full time or can one pick like maybe 4-5 shifts a month (part time)- say on every Friday night?

Most tele companies allow you to work part time (4-5 shifts per month). They also pay you more for taking a night or weekend shift.

 

[Postictal Raiden]

The teleneurology companies I talked to indicated that the vast majority of their consults are acute/hyper acute - mostly the ERs consult you for stroke, acute change in mental status, seizures, etc. I was told that once these patients are admitted, they aren’t typically followed by the teleneurologist.

Telespecialists, in particular, told me that you would need to see 22-24 NEW acute consults to make the $440k compensation they were pitching. Obviously, you can see less and make less which could still be very reasonable compensation, but the job itself seemed much more like stroke call and not like a “tele-neuro hospitalist” role where you actually “follow” the patient.

Is this a 1099 income (you pay for your own benefits)?

 

[deathmerchant]

The teleneurology companies I talked to indicated that the vast majority of their consults are acute/hyper acute - mostly the ERs consult you for stroke, acute change in mental status, seizures, etc. I was told that once these patients are admitted, they aren’t typically followed by the teleneurologist.

Telespecialists, in particular, told me that you would need to see 22-24 NEW acute consults to make the $440k compensation they were pitching. Obviously, you can see less and make less which could still be very reasonable compensation, but the job itself seemed much more like stroke call and not like a “tele-neuro hospitalist” role where you actually “follow” the patient.

Yup one of the companies mentioned 20-25 patients a day plus EEGs. You also have to work atleast one full weekend a month. That seems like a lot. They said most of their doctors do notes in between patients as the COW is being rolled in-between patient rooms. I think theoretically it should be doable but still seems like a lot to me. Esp if you had to do it regularly.

 

[Neurogeneral]

Is this a 1099 income (you pay for your own benefits)?

This was with benefits but they also have an option to work part time (without benefits).

 

[xenotype]

Thank you, as a follow-up question ... do you get to decide whether to "follow-up" a patient or just sign off? I understand that if you are paid per patient you might want to follow-up, but perhaps would want to prune your list if you are being paid per shift. However, considering that most consults are uncalled-for in the first place (obvious cardiogenic syncope, stable dementia, toxic-metabolic encephalopathy due to UTI, etc.), do telemedicine companies give you the freedom to just sign off or can you expect some pushback during performance reviews?

The models might differ based on what company it is. Signing off is generally entirely within your control (these companies will not dictate the actual practice of medicine to you) and there are always a ton of patients to be seen in almost any setup so if you can sign off, you should.

Yes, these all tend to be 1099s. As for the discussion of income, I would not expect to make more money than a private practice in person neurology position. $400k is only doable if one is at the 75th percentile of productivity (or just taking more shifts). The average is going to be just above $300k for full time, like any other job. However, unlike other jobs, in most of these setups you have the option of going part time at will (without benefits), you can take up extra work/extra shifts/extra volume on demand for extra pay in a very granular fashion in a way that you simply cannot in the average neurology employed job, and while night/weekend shifts are expected most of these will not have uncompensated overnight call.

Compare to the average neurohospitalist job- $325k, 7 on 7 off with overnight call when one is on required and uncompensated, typically 1-2 calls minimum a night while one is asleep and possibly worse depending on the size of the hospital, no option to go part time, hopefully is W2 with lower taxes but some of these will be 1099. The average neurohospitalist job is not at $400k today unless it is literally in the middle of nowhere or has crazy productivity baked into it, or more than 15 shifts a month expected somehow by abusing weekends.

Outpatient is more variable but may have no call, no weekends. To get to the $325k above or better one is going to a) need to be in the middle of nowhere or b) be hustling >22 patients a day. Clinic message inbox crap uncompensated. If one is efficient at managing that and notes maybe you can be out of there at 6pm every day with nothing pending.

Locums- have to travel but largely don't have to deal with any of the above. If one is shrewd you'll make more money than the above for less work, but you'll either be driving or flying away from family/home for weeks at a time when on.

Pick whichever one you want. There is no perfect job, but some positions are better for some than others.

 

[Giovanotto]

If you're someone that simply cannot stomach a fellowship, how feasible is it to expect to work with a tele company for 3-4 12 hr shifts per week and make around 250k?

Conversely, do in person neurohospitalist gigs exist where you're 7on/7off without nights in that ~250k range?

 

[Postictal Raiden]

If you're someone that simply cannot stomach a fellowship, how feasible is it to expect to work with a tele company for 3-4 12 hr shifts per week and make around 250k?

Conversely, do in person neurohospitalist gigs exist where you're 7on/7off without nights in that ~250k range?

Regarding the second question, yes. They exist and pay is much better than 250. However you need to be flexible geographically. I only found these opportunities in the Midwest.

A different model is 7/7 mostly days but you would cover some nights only once in a while.

 

[xenotype]

If you're someone that simply cannot stomach a fellowship, how feasible is it to expect to work with a tele company for 3-4 12 hr shifts per week and make around 250k?

Conversely, do in person neurohospitalist gigs exist where you're 7on/7off without nights in that ~250k range?

Tele companies strongly prefer fellowship trained or at least 1-2 years of neurohospitalist/locums experience. Neurohospitalist jobs however will take you straight out of residency at $325k average. Some tele companies specifically require stroke or neuroICU.

Personally I still recommend fellowship of some kind. Most fellowships aside from stroke offer better hours/less or no call/home call that is actually from home and greatly expand your procedural skill set and overall knowledge base. There is some income loss but its only a year and there is just so much crap to know in practicing modern general neurology.

 

[Giovanotto]

Tele companies strongly prefer fellowship trained or at least 1-2 years of neurohospitalist/locums experience. Neurohospitalist jobs however will take you straight out of residency at $325k average. Some tele companies specifically require stroke or neuroICU.

Personally I still recommend fellowship of some kind. Most fellowships aside from stroke offer better hours/less or no call/home call that is actually from home and greatly expand your procedural skill set and overall knowledge base. There is some income loss but its only a year and there is just so much crap to know in practicing modern general neurology.

Agreed with the second point, to some extent. For example, I see stroke fellows and all they do is triage acute neurology, mostly stroke. Wouldn't their general neurology skills and knowledge set decrease when they're no longer seeing the rest of neurology? In that case, isn't this comment indirectly promoting neurohospitalist fellowships (not trying to get political, im legitimately curious)?

 

[xenotype]

Agreed with the second point, to some extent. For example, I see stroke fellows and all they do is triage acute neurology, mostly stroke. Wouldn't their general neurology skills and knowledge set decrease when they're no longer seeing the rest of neurology? In that case, isn't this comment indirectly promoting neurohospitalist fellowships (not trying to get political, im legitimately curious)?

Yes, particularly atrophy with managing epilepsy and neuromuscular disease. However, doing something like a movement disorders fellowship with plenty of EMG guided botox/DBS, a neuromuscular or epilepsy fellowship with lots of procedures etc adds a lot of depth to one's knowledge and capabilities coming out of residency. Most straight out of residency are not really competent at EEG, not at all competent at EMG, not knowledgeable about peripheral anatomy and how to approach with EMG or botox, and not really that great at weird movement disorders outside of straightforward IPD. If one does teleneurology you still see all of this stuff in the ED and in hospital rounding/'stat' consults. One of the biggest teleneurology companies was founded by a neuromuscular guy who ran an ALS clinic before getting into it. The reality of doing community general neurology or teleneurology is that you are expected to see all types of cases with no capability to dump certain cases elsewhere/on colleagues like it is easy to do in academic neurology. When I was in residency one of the stroke boarded neurologists (trained at a brand name program) didn't know how to dose dilantin and asked a headache boarded doc running the general service to do it. That kind of crap is not going to fly in teleneurology or private practice.

As for 'neurohospitalist' fellowships it is just an extension of residency that adds nothing and is to be avoided. Stroke fellowship has a few advantages in terms of building more depth/comfort with acute stroke and complex cases like vasculitis, adds some legitimacy for medical directorship roles but again I do see it as also somewhat of an extension of residency compared to many other fellowships given the amount and balance of acute stroke most neurology residents are hammered with. Doing something like a neuromuscular fellowship puts you in the deep end of the pool and really forces you to learn the neurology you never did in residency.

 

[sharkbaitwhohaha]

Yes, particularly atrophy with managing epilepsy and neuromuscular disease. However, doing something like a movement disorders fellowship with plenty of EMG guided botox/DBS, a neuromuscular or epilepsy fellowship with lots of procedures etc adds a lot of depth to one's knowledge and capabilities coming out of residency. Most straight out of residency are not really competent at EEG, not at all competent at EMG, not knowledgeable about peripheral anatomy and how to approach with EMG or botox, and not really that great at weird movement disorders outside of straightforward IPD. If one does teleneurology you still see all of this stuff in the ED and in hospital rounding/'stat' consults. One of the biggest teleneurology companies was founded by a neuromuscular guy who ran an ALS clinic before getting into it. The reality of doing community general neurology or teleneurology is that you are expected to see all types of cases with no capability to dump certain cases elsewhere/on colleagues like it is easy to do in academic neurology. When I was in residency one of the stroke boarded neurologists (trained at a brand name program) didn't know how to dose dilantin and asked a headache boarded doc running the general service to do it. That kind of crap is not going to fly in teleneurology or private practice.

As for 'neurohospitalist' fellowships it is just an extension of residency that adds nothing and is to be avoided. Stroke fellowship has a few advantages in terms of building more depth/comfort with acute stroke and complex cases like vasculitis, adds some legitimacy for medical directorship roles but again I do see it as also somewhat of an extension of residency compared to many other fellowships given the amount and balance of acute stroke most neurology residents are hammered with. Doing something like a neuromuscular fellowship puts you in the deep end of the pool and really forces you to learn the neurology you never did in residency.

spot on. neurology residents are not competent to practice a lot of EMG/NCS straight out of residency. Neuromuscular neurology feels like true neurology (neuroanatomy, detailed exam providing exact localization, etc)

 

[Postictal Raiden]

Yes, particularly atrophy with managing epilepsy and neuromuscular disease. However, doing something like a movement disorders fellowship with plenty of EMG guided botox/DBS, a neuromuscular or epilepsy fellowship with lots of procedures etc adds a lot of depth to one's knowledge and capabilities coming out of residency. Most straight out of residency are not really competent at EEG, not at all competent at EMG, not knowledgeable about peripheral anatomy and how to approach with EMG or botox, and not really that great at weird movement disorders outside of straightforward IPD. If one does teleneurology you still see all of this stuff in the ED and in hospital rounding/'stat' consults. One of the biggest teleneurology companies was founded by a neuromuscular guy who ran an ALS clinic before getting into it. The reality of doing community general neurology or teleneurology is that you are expected to see all types of cases with no capability to dump certain cases elsewhere/on colleagues like it is easy to do in academic neurology. When I was in residency one of the stroke boarded neurologists (trained at a brand name program) didn't know how to dose dilantin and asked a headache boarded doc running the general service to do it. That kind of crap is not going to fly in teleneurology or private practice.

As for 'neurohospitalist' fellowships it is just an extension of residency that adds nothing and is to be avoided. Stroke fellowship has a few advantages in terms of building more depth/comfort with acute stroke and complex cases like vasculitis, adds some legitimacy for medical directorship roles but again I do see it as also somewhat of an extension of residency compared to many other fellowships given the amount and balance of acute stroke most neurology residents are hammered with. Doing something like a neuromuscular fellowship puts you in the deep end of the pool and really forces you to learn the neurology you never did in residency.

I agree that residency doesn’t provide anywhere near sufficient exposure to NM, but I can’t agree with you on its usefulness in the inpatient setting.

One of my residency attendings who sporadically covered the inpatient service is NM trained. Brilliant guy. I gotta say, he was pretty useless on the service. The residents pretty much ran the show and he was simply babysitting us. Even for acute true NM consults, he didn’t really offer any “earth-shattering” input. Always rule out central lesion vs peripheral compression (due to hematoma in trauma cases), then PT/OT and EMG outpatient.

In addition, the NM guy can’t read EEGs or handle stroke. These alone are two thirds of inpatient consults.

Now for outpatient, NM is hands on the most useful subspecialty.

 

[xenotype]

I agree that residency doesn’t provide anywhere near sufficient exposure to NM, but I can’t agree with you on its usefulness in the inpatient setting.

One of my residency attendings who sporadically covered the inpatient service is NM trained. Brilliant guy. I gotta say, he was pretty useless on the service. The residents pretty much ran the show and he was simply babysitting us. Even for acute true NM consults, he didn’t really offer any “earth-shattering” input. Always rule out central lesion vs peripheral compression (due to hematoma in trauma cases), then PT/OT and EMG outpatient.

In addition, the NM guy can’t read EEGs or handle stroke. These alone are two thirds of inpatient consults.

Now for outpatient, NM is hands on the most useful subspecialty.

I agree that comfort with both stroke and EEG/epilepsy is the best approach for broad capability with inpatient neurology, but the hardest, most complex cases in neurology are very often movement or neuromuscular, and neuromuscular covers differentials like spinal epidural abscess that are very tricky and carry extremely high liability. The 'brilliant guy' has a way better differential and localization than yours when a patient with foot drop shows up in the ED. And yes, they do still show up. It might not be 50% of your cases, but there is some serious deer in the headlights when a stroke attending is forced to give an opinion on a foot drop. Is it fair to bill a patient when one has no clue? Anyone can give tPA and call an NIR center to arrange a transfer, it really is not rocket science. It isn't the percentage of cases that matters, it is the depth of differential that one can generate as a neurologist.

 

[sharkbaitwhohaha]

I agree that comfort with both stroke and EEG/epilepsy is the best approach for broad capability with inpatient neurology, but the hardest, most complex cases in neurology are very often movement or neuromuscular, and neuromuscular covers differentials like spinal epidural abscess that are very tricky and carry extremely high liability. The 'brilliant guy' has a way better differential and localization than yours when a patient with foot drop shows up in the ED. And yes, they do still show up. It might not be 50% of your cases, but there is some serious deer in the headlights when a stroke attending is forced to give an opinion on a foot drop. Is it fair to bill a patient when one has no clue? Anyone can give tPA and call an NIR center to arrange a transfer, it really is not rocket science. It isn't the percentage of cases that matters, it is the depth of differential that one can generate as a neurologist.

You mean when NPs see new patients?

 

[Postictal Raiden]

I agree that comfort with both stroke and EEG/epilepsy is the best approach for broad capability with inpatient neurology, but the hardest, most complex cases in neurology are very often movement or neuromuscular, and neuromuscular covers differentials like spinal epidural abscess that are very tricky and carry extremely high liability. The 'brilliant guy' has a way better differential and localization than yours when a patient with foot drop shows up in the ED. And yes, they do still show up. It might not be 50% of your cases, but there is some serious deer in the headlights when a stroke attending is forced to give an opinion on a foot drop. Is it fair to bill a patient when one has no clue? Anyone can give tPA and call an NIR center to arrange a transfer, it really is not rocket science. It isn't the percentage of cases that matters, it is the depth of differential that one can generate as a neurologist.

This logic can apply to every neurology subspecialty.

Personally, I believe movement disorder training is more helpful in an inpatient setting than NM. Serious nerve/spinal compressions can be ruled out with imaging.

Similarly, neuroimmunology can offer very valuable input regarding different etiology of myelitis and atypical white matter lesions.

I agree with you that being trained in a subspecialty helps you broaden your differentials and provides the ability to offer valuable input on atypical presentations. However, I feel you are overselling the NM fellowship for someone interested in pure inpatient/teleneuro work.

 

[deathmerchant]

In my over 5 years of Inpatient practice I have never needed/wished for an urgent NM specialist input. As Outpatient? Yes several times.

 

[Aldertonghen]

This logic can apply to every neurology subspecialty.

Personally, I believe movement disorder training is more helpful in an inpatient setting than NM. Serious nerve/spinal compressions can be ruled out with imaging.

Similarly, neuroimmunology can offer very valuable input regarding different etiology of myelitis and atypical white matter lesions.

I agree with you that being trained in a subspecialty helps you broaden your differentials and provides the ability to offer valuable input on atypical presentations. However, I feel you are overselling the NM fellowship for someone interested in pure inpatient/teleneuro work.

Can movement specialists do teleneuro even if say they’re a few years out of residency?

 

[Postictal Raiden]

Can movement specialists do teleneuro even if say they’re a few years out of residency?

I’d defer to deathmerchant to answer this. He’s a movement specialist.

 

[sharkbaitwhohaha]

This logic can apply to every neurology subspecialty.

Personally, I believe movement disorder training is more helpful in an inpatient setting than NM. Serious nerve/spinal compressions can be ruled out with imaging.

Similarly, neuroimmunology can offer very valuable input regarding different etiology of myelitis and atypical white matter lesions.

I agree with you that being trained in a subspecialty helps you broaden your differentials and provides the ability to offer valuable input on atypical presentations. However, I feel you are overselling the NM fellowship for someone interested in pure inpatient/teleneuro work.

Strong disagree. There are essentially no real (legitimate) inpatient needs for a patient with a movement disorder.

Myasthenic exacerbation? GBS vs vasculitis vs other? That’s the value of a NM doc.

I’d think epilepsy and movement trained are the least helpful for in patient neurology.

 

[Postictal Raiden]

Strong disagree. There are essentially no real (legitimate) inpatient needs for a patient with a movement disorder.

Myasthenic exacerbation? GBS vs vasculitis vs other? That’s the value of a NM doc.

I’d think epilepsy and movement trained are the least helpful for in patient neurology.

We all have our biases. However to imply that NM training is more useful for inpatient neurology than epilepsy is just objectively wrong.

MG exac? Anyone with PGY-2 neurology training should be able to handle

GBS vs neuropathic vasculitis? Again, you don’t need NM for that

 

[xenotype]

This logic can apply to every neurology subspecialty.

Personally, I believe movement disorder training is more helpful in an inpatient setting than NM. Serious nerve/spinal compressions can be ruled out with imaging.

Similarly, neuroimmunology can offer very valuable input regarding different etiology of myelitis and atypical white matter lesions.

I agree with you that being trained in a subspecialty helps you broaden your differentials and provides the ability to offer valuable input on atypical presentations. However, I feel you are overselling the NM fellowship for someone interested in pure inpatient/teleneuro work.

Serious nerve/spinal compressions can be ruled out with imaging if you think of it and obtain it. Again, epidural abscess can be extremely tricky and one of the most common reasons neurologists get sued and lose. Additionally, cervical myelopathy can be quite subtle on exam and gait abnormalities can be complex/multifactorial. All things a good neuromuscular base can help with. But I do agree teleneuro is best served by epilepsy or stroke on the inpatient side.

Strong disagree. There are essentially no real (legitimate) inpatient needs for a patient with a movement disorder.

Myasthenic exacerbation? GBS vs vasculitis vs other? That’s the value of a NM doc.

I’d think epilepsy and movement trained are the least helpful for in patient neurology.

We all have our biases. However to imply that NM training is more useful for inpatient neurology than epilepsy is just objectively wrong.

MG exac? Anyone with PGY-2 neurology training should be able to handle

GBS vs neuropathic vasculitis? Again, you don’t need NM for that

Epilepsy/CNP is probably the most useful fellowship for inpatient. Stroke is pounded into your head in residency, and as a result you don't get enough epilepsy training. Then a patient on 5 seizure meds shows up to the ED in ?status and you are in over your head. Not knowing how to read an EEG, or what certain EEG reads even mean is not going to help the situation when it comes time to adjust meds.

As for 'not needing' NM to diagnose neuropathic vasculitis, I think this is a bit ridiculous. True mononeuritis multiplex is an extremely rare diagnosis that most neurology residents get zero exposure to whatsoever. The odds of correctly recognizing it in the ED/an inpatient consult are vanishingly small without an NM background. Sure it is easy to pick out on a board exam, but in the typical patient with several other chronic issues affecting the exam it is not going to be that easy.

I'm not arguing that NM fellowship is the best fellowship to do for one ultimately doing Teleneuro. I'm arguing that people should do a fellowship of some kind. Epilepsy or CNP provides the most flexibility in my opinion but people should do what they want to do. There are also those on here that'll argue one shouldn't be doing any telestroke without a stroke fellowship or neurocritical care fellowship, but I don't agree and I know several very experienced teleneurologists who also do not agree with this opinion.

 

[Postictal Raiden]

Serious nerve/spinal compressions can be ruled out with imaging if you think of it and obtain it. Again, epidural abscess can be extremely tricky and one of the most common reasons neurologists get sued and lose. Additionally, cervical myelopathy can be quite subtle on exam and gait abnormalities can be complex/multifactorial. All things a good neuromuscular base can help with. But I do agree teleneuro is best served by epilepsy or stroke on the inpatient side.



Epilepsy/CNP is probably the most useful fellowship for inpatient. Stroke is pounded into your head in residency, and as a result you don't get enough epilepsy training. Then a patient on 5 seizure meds shows up to the ED in ?status and you are in over your head. Not knowing how to read an EEG, or what certain EEG reads even mean is not going to help the situation when it comes time to adjust meds.

As for 'not needing' NM to diagnose neuropathic vasculitis, I think this is a bit ridiculous. True mononeuritis multiplex is an extremely rare diagnosis that most neurology residents get zero exposure to whatsoever. The odds of correctly recognizing it in the ED/an inpatient consult are vanishingly small without an NM background. Sure it is easy to pick out on a board exam, but in the typical patient with several other chronic issues affecting the exam it is not going to be that easy.

I'm not arguing that NM fellowship is the best fellowship to do for one ultimately doing Teleneuro. I'm arguing that people should do a fellowship of some kind. Epilepsy or CNP provides the most flexibility in my opinion but people should do what they want to do. There are also those on here that'll argue one shouldn't be doing any telestroke without a stroke fellowship or neurocritical care fellowship, but I don't agree and I know several very experienced teleneurologists who also do not agree with this opinion.

I agree

 

[deathmerchant]

Can movement specialists do teleneuro even if say they’re a few years out of residency?

Most companies don't ask for fellowships of any kind, but they do require 3-5 years post residency experience. And being comfortable with strokes. So in short yes you can do tele. Obviously it won't be movement disorders but general inpatient neuro/acute neuro.

 

[neurolddoc]

You can absolutely deduct home expenses, working with my accountant on that now (this is my first tax season with this). That's one of the major perks with this job and being 1099 over W2. Mortgage, home improvements, utilities, phone, etc.

In terms of the other questions: yes, at least at our company they have been able to really minimize physician work for hospital credentialing, and they handle nearly everything. Sometimes I need to sign something or do something but usually very minimal.

State licensure: when you start you sign a bunch of paperwork and fill out a very thorough internal app that essentially allows for the company to file for licensure on your behalf with again minimal input from the physician.

LOR: yeah this sucks especially in the beginning. Your LOR writers get a bunch of LOR requests which is annoying...doesn't seem like there's a way around that part 😔

I don't have a tele-neurology practice, but my only advice based paying taxes for a long time is to be super scrupulous/conservative with the whole home office deduction thing. My understanding is that this is a huge audit trigger, so go in with an informed risk/benefit analysis.

 

[Phantom Spike]

Most companies don't ask for fellowships of any kind, but they do require 3-5 years post residency experience. And being comfortable with strokes. So in short yes you can do tele. Obviously it won't be movement disorders but general inpatient neuro/acute neuro.

What if you have inpatient experience seeing the usual neurohospitalist things (seizures, headaches, altered mental status, etc.) but not acute stroke because you worked where there was already telestroke in place (not you)? Can you get a teleneurohospitalist job, or even telestroke?

 

[deathmerchant]

What if you have inpatient experience seeing the usual neurohospitalist things (seizures, headaches, altered mental status, etc.) but not acute stroke because you worked where there was already telestroke in place (not you)? Can you get a teleneurohospitalist job, or even telestroke?

There are Telestroke jobs and there are some TeleNeuro jobs where you round on inpatient neuro wards and not see acute strokes typically. For the former they will obviously ask you if you are ok handling 12-15 acute strokes per shift and will probably need some references. Should be ok as long as you are comfortable.
Should be ok for the latter position.

 

[Neurogeneral]

Does anyone know if you can work part time at two teleneurology companies at the same time? Is this typically allowed or do they typically have strict non-compete clauses that forbid it?

 

[curiousneuro]

Does anyone know if you can work part time at two teleneurology companies at the same time? Is this typically allowed or do they typically have strict non-compete clauses that forbid it?

No, usually they have strict non-compete clauses, at least that the larger companies.

 

[elanmorin]

Does anyone know if you can work part time at two teleneurology companies at the same time? Is this typically allowed or do they typically have strict non-compete clauses that forbid it?

Depends on the companies. I'm planning to do just this, no clauses against it in my contracts.

 

[deathmerchant]

Does anyone know if you can work part time at two teleneurology companies at the same time? Is this typically allowed or do they typically have strict non-compete clauses that forbid it?

One of the companies I talked to have a specific non-compete for 2 years with 3 other large companies only. You could work with any other tele company or any other job.

 

[ProReduction]

Does anyone know if you can work part time at two teleneurology companies at the same time? Is this typically allowed or do they typically have strict non-compete clauses that forbid it?

Yes. I did this for years. Although I am aware of at least one company that makes you sign a Tele non-compete.

Tele companies cannot afford to be that picky with 1099 independent contractors. If they reach too far, they will have to classify their doctors as employees, and this is the last thing they want as they would have to offer benefits. They want all their doctors to be the "Uber drivers" of medicine.

Also, Neurologists are leaving TeleNeuro en masse. The turnover rate is very high. It has changed greatly over the last 5 years into a hypercorporate customer-service-driven race to the bottom. It is largely becoming a practice setting filled with new fellowship grads trying to pay-down debt, physicians who have left in-person clinical for jobs in industry and research who are doing minimal clinical to keep their skills active, and FMGs.

 

[sloh]

Yes. I did this for years. Although I am aware of at least one company that makes you sign a Tele non-compete.

Tele companies cannot afford to be that picky with 1099 independent contractors. If they reach too far, they will have to classify their doctors as employees, and this is the last thing they want as they would have to offer benefits. They want all their doctors to be the "Uber drivers" of medicine.

Also, Neurologists are leaving TeleNeuro en masse. The turnover rate is very high. It has changed greatly over the last 5 years into a hypercorporate customer-service-driven race to the bottom. It is largely becoming a practice setting filled with new fellowship grads trying to pay-down debt, physicians who have left in-person clinical for jobs in industry and research who are doing minimal clinical to keep their skills active, and FMGs.

Can you elaborate on how it is customer service driven and why the turnover rate is so high?

 

[ProReduction]

Can you elaborate on how it is customer service driven and why the turnover rate is so high?

The "customer" is the local hospital, its physicians, and its administration. It is not the patients you are seeing on TeleNeuro consults. Basic quality issues are not addressed or are swept under the rug in the name of keeping the customer happy. Securing contracts is competitive in TeleNeuro. Maintaining contracts is equally competitive. Every Tele company is threatened quarterly with "Tele Company X is offering us A,B,C and we are thinking of switching to them." Clinical Leadership within Tele is constantly on eggshells with the local hospitals when it comes to addressing the major quality issues of care you encounter, because if they rock the boat too much then the local hospital will simply take their business elsewhere. And since it is Tele, the local hospitals (customers) are almost always bad. This is why they need Tele in the first place.

The turnover is driven by many things and I cannot claim to know for each doctor why he/she leaves Tele. I can tell you that most mid-career Neurologists that I have known that switched to Tele as an escape from the burdens of in-person have all left Tele within 2-3 years. Several identifiable factors: stagnant pay for the last 5 years, extremely high medicolegal risk in partnering with such bad local doctors/hospitals (Yes, TeleNeurologists get sued no matter what the Tele companies tell you), lack of dignity in the encounters, abuse of "STAT" consults given ease of Tele use for the local facilities. The list goes on.

 

[xenotype]

stagnant pay for the last 5 years

I ask you this every time. Where in neurology is the pay not stagnant?

 

[ProReduction]

I ask you this every time. Where in neurology is the pay not stagnant?

I do not do locums but have several former colleagues that do. Anecdotal, but pay is up more than 30% on an hourly rate within the last 2 years for them. Also, former colleagues that are renewing in-person Neurohospitalist positions are seeing 75-100k more in their offers than they were seeing 3 years ago.
The issue with Tele is that the companies sell their services with long, locked-in contracts for the local facilities that are guaranteed to not increase within that contract length. That also means that physician pay does not increase at all over that same time period.
Even new hires in academic shops are being started off at higher salaries than junior faculty hired three years ago. So pay is up pretty much everywhere in Neurology except Tele.

 

[Phantom Spike]

The idea that a company can forbid you from practicing virtual medicine anywhere if you leave them seems legally untenable to me. Geographic non-competes may be somewhat understandable, but do teleneurology companies actually get away with saying you can't do teleneurology anywhere in the country when you part ways?

Also, would definitely like to hear more about why people are getting burned out with teleneurology ... most people on this forum at least who have done it seem happy with it.

 

[deathmerchant]

I do not do locums but have several former colleagues that do. Anecdotal, but pay is up more than 30% on an hourly rate within the last 2 years for them. Also, former colleagues that are renewing in-person Neurohospitalist positions are seeing 75-100k more in their offers than they were seeing 3 years ago.
The issue with Tele is that the companies sell their services with long, locked-in contracts for the local facilities that are guaranteed to not increase within that contract length. That also means that physician pay does not increase at all over that same time period.
Even new hires in academic shops are being started off at higher salaries than junior faculty hired three years ago. So pay is up pretty much everywhere in Neurology except Tele.

Definitely agree that salaries (esp for Neurohospitalists) have increased in the past 5 years mostly due to low supply; I don't think if it has increased by 75k-100k in 3 years though. Outpatient neurology salaries have gone down; esp pp due to decrease medicare rates, increasing overheads and decreasing RVUs almost every year. Im not sure how much academic salaries have changed.

But even though I am not a big fan of teleneuro- I don't know if it is sustainable for small hospitals to hire neurohospitalists at these higher pays and keep them from leaving, hence more and more hospitals are signing up with Telecompanies. IMO a small town hospital with 2-4 new consults a day can't hire 2 neurologists at 350k plus benefits. I don't know how much tele companies were paying before, but one of the companies I talked to said 100/hr plus 25 per RVU. So if you saw 2 acute neuro patients in an hour, that would be abt 270/hr from home. Not a bad deal in my mind.

But I do agree with you on other points you made about burnout from Tele. I don't know if its worse than regular neurology practice which is high on burnout in most surveys year after year. And obviously everything in medicine has become a race to the bottom these days, trying to save money and provide low quality care- think midlevels!! It'll be a disaster the day midlevels start doing telestroke/teleneuro- seems inevitable to me.

 

[deathmerchant]

The idea that a company can forbid you from practicing virtual medicine anywhere if you leave them seems legally untenable to me. Geographic non-competes may be somewhat understandable, but do teleneurology companies actually get away with saying you can't do teleneurology anywhere in the country when you part ways?

Also, would definitely like to hear more about why people are getting burned out with teleneurology ... most people on this forum at least who have done it seem happy with it.

Yup they do have noncompete clauses against other tele-companies. I have looked at couple contracts recently.

Look at burnout data from Medscape etc. Neurology is usually in the upper middle of the list, but burnout is high in general in medicine due to multiple issues. I think most specialities range between 45-55% for self reported burnout with some outliers.

 

[ProReduction]

Definitely agree that salaries (esp for Neurohospitalists) have increased in the past 5 years mostly due to low supply; I don't think if it has increased by 75k-100k in 3 years though. Outpatient neurology salaries have gone down; esp pp due to decrease medicare rates, increasing overheads and decreasing RVUs almost every year. Im not sure how much academic salaries have changed.

But even though I am not a big fan of teleneuro- I don't know if it is sustainable for small hospitals to hire neurohospitalists at these higher pays and keep them from leaving, hence more and more hospitals are signing up with Telecompanies. IMO a small town hospital with 2-4 new consults a day can't hire 2 neurologists at 350k plus benefits. I don't know how much tele companies were paying before, but one of the companies I talked to said 100/hr plus 25 per RVU. So if you saw 2 acute neuro patients in an hour, that would be abt 270/hr from home. Not a bad deal in my mind.

But I do agree with you on other points you made about burnout from Tele. I don't know if its worse than regular neurology practice which is high on burnout in most surveys year after year. And obviously everything in medicine has become a race to the bottom these days, trying to save money and provide low quality care- think midlevels!! It'll be a disaster the day midlevels start doing telestroke/teleneuro- seems inevitable to me.

Agree with everything you said. I also do not know anyone doing outpatient exclusively anymore so my salary data sampling does not include that setting. Yes, the momentum of TeleNeuro in the rural and low-volume setting is unstoppable like you said. It is the only financially viable option for these centers. Those encounters can be very high risk medicolegally. One of the most frightening trends in the last 3 years of TeleNeuro is centers only having one-off emergency TeleNeuro consultation services, with no local in-person Neurologist follow-up and no local TeleNeuro follow-up. These centers are also unwilling to transfer patients aggressively for Neuro care. They seem to want to keep them for the volume/$. So you as the Emergency TeleNeurologist are the only Neurologist on the chart when something goes bad with the patient on hospital day 3-5, and you end-up getting named in the lawsuit along with the rest of the chart. TeleNeuro has a role, but it is in no way ready for broad use in the absence of local in-person Neurology follow-up.

Also, there are more open TeleNeuro spots than Neurologists to fill them. Anyone and everyone can try Tele out for himself/herself to see if this is all doom-and-gloom talk or if there is any truth to it.

 

[deathmerchant]

Agree with everything you said. I also do not know anyone doing outpatient exclusively anymore so my salary data sampling does not include that setting. Yes, the momentum of TeleNeuro in the rural and low-volume setting is unstoppable like you said. It is the only financially viable option for these centers. Those encounters can be very high risk medicolegally. One of the most frightening trends in the last 3 years of TeleNeuro is centers only having one-off emergency TeleNeuro consultation services, with no local in-person Neurologist follow-up and no local TeleNeuro follow-up. These centers are also unwilling to transfer patients aggressively for Neuro care. They seem to want to keep them for the volume/$. So you as the Emergency TeleNeurologist are the only Neurologist on the chart when something goes bad with the patient on hospital day 3-5, and you end-up getting named in the lawsuit along with the rest of the chart. TeleNeuro has a role, but it is in no way ready for broad use in the absence of local in-person Neurology follow-up.

Also, there are more open TeleNeuro spots than Neurologists to fill them. Anyone and everyone can try Tele out for himself/herself to see if this is all doom-and-gloom talk or if there is any truth to it.

Agreed. I think it's not for everyone and the key point for physicians is not to sell yourself short.
Just to add on- I am currently talking with some Tele companies to understand their model, at least one of the big companies said they only provide TeleStroke AND Tele-neurology rounding together as a combined service to a hospital. If a hospital just wants one, they don't accept it. I don't know how true that is with them or with other companies.

 

[xenotype]

Agree with everything you said. I also do not know anyone doing outpatient exclusively anymore so my salary data sampling does not include that setting. Yes, the momentum of TeleNeuro in the rural and low-volume setting is unstoppable like you said. It is the only financially viable option for these centers. Those encounters can be very high risk medicolegally. One of the most frightening trends in the last 3 years of TeleNeuro is centers only having one-off emergency TeleNeuro consultation services, with no local in-person Neurologist follow-up and no local TeleNeuro follow-up. These centers are also unwilling to transfer patients aggressively for Neuro care. They seem to want to keep them for the volume/$. So you as the Emergency TeleNeurologist are the only Neurologist on the chart when something goes bad with the patient on hospital day 3-5, and you end-up getting named in the lawsuit along with the rest of the chart. TeleNeuro has a role, but it is in no way ready for broad use in the absence of local in-person Neurology follow-up.

Also, there are more open TeleNeuro spots than Neurologists to fill them. Anyone and everyone can try Tele out for himself/herself to see if this is all doom-and-gloom talk or if there is any truth to it.

Agree with all of this but I still think tele is worth considering over neurohospitalist depending on one's preferences. I do think the legal liability with tele is far above any other modality, even locums for a wide variety of reasons most of which you've touched on- its probably the single biggest negative. Insurance doesn't protect one's NPDB record or ability to get credentialing going forward. The non-competes are the second major negative.

 

[curiousneuro]

Is it actually true that telestroke neurologists get sued more often? At least in my group it's certainly not common and I haven't been (yet), but curious if there's actual data on that.

Also - I don't think the non-competes are actually enforceable at all. Hard to see how it would be if you are 1099.

 

[xenotype]

Is it actually true that telestroke neurologists get sued more often? At least in my group it's certainly not common and I haven't been (yet), but curious if there's actual data on that.

Also - I don't think the non-competes are actually enforceable at all. Hard to see how it would be if you are 1099.

Based on what I am told/have heard it is not necessarily common at all, but based on common sense the risk is high. I've been quoted somewhere between 1 in 3 to 1 in 6 odds of a lawsuit over a 5 to 10 year period, which is higher than the average 1 in 6 lifetime rate for most neurologists.

As for non-competes this is highly state dependent. One should never assume the non-compete will not be enforceable when signing an agreement, especially without speaking to an attorney knowledgeable in physician contract law in their state.

 

[Neurogeneral]

I recently signed on with a telemedicine company to do teleneurohospitalist rounding and EEG reading. Hoping this works well for me as I have geographical constraints and needed a job with some flexibility in terms of scheduling.

 

[Drhappyface]

I recently signed on with a telemedicine company to do teleneurohospitalist rounding and EEG reading. Hoping this works well for me as I have geographical constraints and needed a job with some flexibility in terms of scheduling.

If you don't mind, are you able to mention any details of your contract? I believe it important for others to know what they are receiving is fair or unfair. Thanks.