Article In Brief
The field of teleneurology offers doctors flexibility and is expected to grow rapidly. But those working in the field say the jobs vary dramatically—and telemedicine is not for everyone. They share the pros and cons of working in teleneurology.
Teleneurologist Elaine C. Jones, MD, FAAN, works a night shift—typically 10 p.m. to 6 a.m. or midnight to 8 a.m.—and has a sweet commute. “I get up 15 minutes before my shift, turn on my computer, and log in,” she said.
Dr. Jones is licensed to practice in 22 states and credentialled in more than 200 hospitals, mostly smaller community ones, around the country. In the seven years she has worked as a teleneurologist, she has seen considerable changes in the field.
“When we first started, it was pretty much acute stroke care, but because of the neurologist shortage, we basically take care of all neurology that comes into the ER now,” she said. “We see everything from migraine to vertigo to stroke to MS and whatever they need us to help with.”
Dr. Jones ran her own solo practice for 17 years and finds the teleneurology lifestyle liberating. “You don't have call, so you work when you work and you're off when you're off,” she said. “And you can work anywhere in the country that you have an internet connection, so I've worked while traveling around the US.”
Teleneurologists have many opportunities, and their field is expected to grow rapidly. But the jobs vary dramatically, and telemedicine is not for everyone, Dr. Jones and other neurologists told Neurology Today. They shared their perspectives on the pros and cons of this career option.
The Diversity of Teleneurology
Stroke specialist Theresa Sevilis, DO, became interested in telestroke during her residency and joined TeleSpecialists in 2017 after a brief stint in academic medicine. Licensed in 35 states, she works 12-hour shifts treating patients arriving in emergency departments ranging from comprehensive stroke centers to small rural hospitals with no stroke certification.
“I don't think I ever felt as valued practicing in person as I have practicing in this manner, which is something most people probably wouldn't expect,” said Dr. Sevilis, director of academic advancement and regional medical director for TeleSpecialists. “We will often be on screen before the patient even gets to the hospital and, especially in the more rural locations, they just can't believe their local hospital has a stroke expert for them the second they walk in the door.”
Leslie Reynolds, MD, who trained as an epileptologist, works two types of teleneurology positions. For Eagle Telemedicine, where she is the neurology medical director, she works 24-hour shifts, conducting general neurology consults, code stroke consults, and EEG reads to hospitals that contract with the company. She is also on stroke call for Sentara Healthcare, a 12-hospital system in Virginia and North Carolina, for which she works eight-hour shifts—typically 1 a.m. to 9 a.m.—a few days each month.
“When we first started, it was pretty much acute stroke care, but because of the neurologist shortage, we basically take care of all neurology that comes into the ER now. We see everything from migraine to vertigo to stroke to MS and whatever they need us to help with.”—DR. ELAINE JONES
Dr. Reynolds, who previously owned her own practice, moved into teleneurology after a stint as a locums tenens revealed the dearth of access to specialty care.
“Until then, I had not realized just how many pockets in the United States \had no access to neurology,” she said. “It became clear to me that unless more of us got involved in telemedicine, there was no way, based on the staffing that we have in neurology, that we would be able to reach a good portion of this country to provide the special services that are needed.”
Eric Anderson, MD, PhD, MBA, FAAN, was a resident at Emory University School of Medicine when he conducted a small trial to prove the feasibility of using an iPhone to conduct remote stroke assessment. Involved in telemedicine ever since, he serves as vice president of clinical operations and care delivery for Synapticure, a company that provides care for patients with amyotrophic lateral sclerosis (ALS) and Parkinson's disease via telemedicine.
“With telemedicine, you don't have to organize a patient into a multidisciplinary ALS clinic in a single day,” he said. “You can see them on their own terms, when they're not at the end of their rope with fatigue or unable to communicate anymore because they are exhausted.”
Meanwhile, self-employed teleneurologist Maria Hubbard, MD, FAAN, provides neurology consults for two centers that rehabilitate patients with brain injury. She negotiated contracts—one client pays on a per diem basis, the other pays per patient—that increased her income compared to her previous traditional clinic practice, without worrying about whether insurers would pay claims.
“I provide a report to show what I did and I submit that to their human resources office, and that's it,” she said. “No need to bill or wait for insurance payments.”
Pros and Cons
The biggest benefit of teleneurology, in Dr. Sevilis' view, is the quality of life. “I can still do stroke care, which I love, but not have to be on all the time, which is exhausting,” she said. “The number of physicians we have [in the company] and the way the shifts work makes it much more manageable to balance your personal and professional life.”
Dr. Reynolds also appreciates the flexibility of a teleneurology career. “If you foresee, say, a six-month period of time when maybe you have something personal going on and you want to work, but not extensively, for that period of time, you can do that in remote neurology, and that's much harder to do in face-to-face neurology,” she said.
That flexibility can cut both ways, Dr. Anderson said. Fast-growing teleneurology companies may ask their physicians to extend their hours so they have adequate coverage, and some people may find it hard to say no when they are planning to be home anyway.
“It can create a problem with time management for people who have difficulty separating their personal lives and their work lives,” he said. “You have to be diligent about how you allocate your time.”
For some, a work-at-home teleneurology stint can be lonely, personally and professionally. Dr. Jones' company tries to mitigate that with a chat feature that lets the physicians working on a given shift communicate with one another. It's nice not just for chatting about things like the latest Netflix binges, but also for cases, she said.
“If you have a case that you're not sure about, you can throw it out to colleagues that are on that shift and ask, ‘What would you do in this situation?’” Dr. Jones said.
Still, it's not the same as running into colleagues in the halls of a hospital or clinic. Dr. Sevilis missed the personal connection with colleagues especially when she started teleneurology.
“While you still develop relationships—the nurses that you work with and the stroke coordinators, for example—it definitely isn't the same as seeing someone at work every day,” she said.
Many physicians who provide in-person care use their at-home time to escape the cacophony of a busy hospital or outpatient clinic. But neurologists who work at home must be intentional about getting out of the house.
“You need to have some activities and extracurriculars outside of the home, because working at home can be very isolating, and that doesn't lead to good mental health,” Dr. Reynolds said.
The inability to establish an in-person contact with a patient also can be frustrating at times. “When there's that weird case where you want to do something a little different and you have to try to talk a nurse through an unusual exam component, that can be challenging sometimes,” Dr. Sevilis said. “You just want to reach your hands through the screen and do it yourself.”
Still, other upsides exist. Dr. Reynolds likes not having the pressure of making sure hospital shifts are covered and a medical practice is succeeding. “As a teleneurologist, you really are not caught up in things like whether the billing is being compensated for appropriately,” she said. “You are just dismissed from that.”
And there's less paperwork. “When I was in practice, one of the things that really began to be a burden was all the forms that had to be filled out,” she said. “That all goes away because I'm in North Carolina and the patient might be in North Dakota, so they have to go to a local physician for that. It does take away a lot of things that make the practice of medicine unpleasant these days.”
A downside for some is that teleneurologists who provide emergency care do not develop ongoing relationships with their patients. “You don't have a lot of continuity of care, and you don't know outcomes,” Dr. Jones said. “A lot of times you see a patient and you never know what happens to them.”
Some other teleneurology care models, however, prioritize longitudinal relationships between patients and their care team members. “When patients come into our system, they have the same physician, the same care coordinator, and the same staff that will be assigned to them throughout the duration,” Dr. Anderson said. “In the outpatient world, people don't want to have to explain their story over and over again, so building those relationships over time is important.”
How Is the Pay?
Neurologists who work full-time for teleneurology companies are typically paid by the hour or on a productivity basis, similar to the relative value unit (RVU) system that is standard for in-person care.
How the pay compares to standard in-person neurologist positions depends on the job, Dr. Anderson said. “Teleneurologists who work in emergency departments can certainly make more if they are focused on generating volume,” he said. “But I would say overall physicians make less in teleneurology because they are no longer able to do procedures.”
“If you have two candidates who are identical and one comes to the table with a bunch of licenses in states where it's hard to get a license, it's a pretty clear decision for the employer. I've seen some people spend a year or so doing a bunch of locums to acquire strategic licenses so that they are an excellent candidate for a telemedicine position.”—DR. ERIC ANDERSON
“I had not realized just how many pockets there were in the United States that just really had no access to neurology. It became clear to me that there was no way, based on the manpower that we have in neurology today, that we would be able to reach a good portion of this country to provide the special services that are needed unless more of us get involved in telemedicine.”—DR. LESLIE REYNOLDS
Salaries for neurologists who provide in-person care vary dramatically from one region of the country to the next. National teleneurology companies, on the other hand, use a pay scale that reflects the entire country. In Dr. Sevilis' case, her teleneurology salary is greater than comparable in-person positions in her region.
“I don't think that is true for all teleneurologists,” she said. “But if you are working for the right company, you should not be taking a pay cut to practice remotely. That's a common misconception that you are going to get paid less—and in outpatient teleneurology that may be true—but for inpatient care, it is not.”
When Dr. Reynolds owned her own practice in North Carolina, the state would sometimes withhold reimbursement for months. “I don't ever have that problem when I do telemedicine because I'm paid for what I do, whether it is shift pay or per-click pay,” she said. “It's very easy to get your salary where you want it to be doing remote work—it just depends on how much I want to work.”
Is Teleneurology Right for You?
Many residents get experience with teleneurology but moving immediately into a teleneurology position might not be the best idea, Dr. Reynolds said.
“If you're coming straight out of training, teleneurology is probably not the right path for you because you have to get to the point in practicing neurology where you're comfortable not having direct contact with a patient,” she said.
Interacting with patients through a screen is different than in person. “So if someone has trouble interacting with patients in person, they are going to have a much harder time over video,” Dr. Anderson said.
Being able to communicate effectively is essential. Teleneurologists are supported by nurses who assist with patient exams. In an ideal situation, the nurse is trained to do neurology exams and dedicated to teleneurology support. But in some cases, nurses are pulled from other duties to help with an exam.
“You are reliant fully on other people to do your patient assessment, so you must be able to express yourself articulately and remain very patient, especially in these times where hospitals are understaffed and people are exhausted,” Dr. Sevilis said. “It is a skill that must be learned: how to verbally direct people to do what you need them to.”
Getting Started in Teleneurology
“Everyone is desperate to hire more neurologists—both live and telehealth—so I think there's a lot of opportunity,” Dr. Jones said.
But that doesn't mean a neurologist can immediately walk into a teleneurology position. Most companies serve several states or perhaps the entire country, and they need teleneurologists with licenses in multiple states.
“If you have two candidates who are identical and one comes to the table with a bunch of licenses in states where it's hard to get a license, it's a pretty clear decision for the employer,” Dr. Anderson said. “I've seen some people spend a year or so doing a bunch of locums to acquire strategic licenses so that they are an excellent candidate for a telemedicine position.”
Dr. Jones worked part-time for a teleneurology company for about two years while still in private practice. By the time she moved to teleneurology full-time, she had enough licenses and hospital credentials to be a valuable asset to the company.
“The bigger companies can't really bring you on and pay you a salary until you have enough volume of work to do and getting enough licenses and credentials can take six months,” she said. “So the transition can be complicated to figure out because most people can't quit their other job and wait six months.”
Because smaller teleneurology companies work with fewer hospitals, the licensing and credentialing process may take less time. But if a company has just enough neurologists to cover its existing contracts and is trying to bring in new business, the workload can become too demanding.
“I have colleagues who work at smaller companies, and they are constantly being asked to work more hours and getting called in to do backups when someone has to be out,” Dr. Jones said.
Choosing the right teleneurology company to work for requires considerable research. “There are so many companies out there, and how they practice—how your day would go, how you get paid, how shifts are done, how patients are distributed—are variable in the different companies,” Dr. Sevilis said.
Find out about each company's quality program, how they work with hospitals, and how many neurologists share the workload. “One schedule type may fit you better than another, so looking at all of them is what I would recommend,” she said.
Dr. Jones recommends networking with neurologists who have worked with various teleneurology firms to get their insights. “There's enough folks who are doing this now, and there are people who have moved from one company to another for various reasons that you can learn a lot that way,” she said.
Before accepting a position, have the contract reviewed with a lawyer familiar with teleneurology. Do not accept non-compete clauses. “If I had a non-compete, I couldn't work anywhere in any state,” she said, adding that you should ask for what you need.
“Everything is negotiable. If you only want to work two weeks a month, these days you could probably get that because places are desperate [for coverage],” she said. “If you have specific needs or wishes, work that into your contract right away just like you would for any job.”
