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Owning Your Telemedicine Options Including Nomadic Life on the Road with Dr. Tom Davis

Podcast, by Jen Barna MD, Work Life Balance

In this episode  Dr. Tom Davis who is an Entrepreneur, mentor, speaker, and author talks about his journey into telemedicine and how this enables him to work from the road, enjoying his freedom while slow traveling.

“I’ve been doing this with specialists and primary care doctors and the innovation there is just amazing. And the opportunity to live the life that you want to lead is more amazing still.” – Dr. Tom Davis MD FAAFP

Telemedicine is a rapidly growing field, and in this episode Dr. Jen Barna speaks with telemedicine expert, Dr. Tom Davis. Entrepreneur, mentor, speaker, and author, Dr. Tom Davis talks about his journey into telemedicine and how this enables him to work from the road, enjoying his freedom while slow traveling. Dr. Davis is an authority on telemedicine and he has the answers to your questions. You will hear why telemedicine is such an attractive option for doctors as well as how it can open you up to do the things you love while still earning a great salary. It has given Dr. Davis freedom to practice while traveling all over the world with his wife and two dogs. Is telemedicine for you? Please let us know!

After hanging his shingle in a small town on the Missouri River in 1994, Dr. Tom Davis and his partners leveraged one of the first total-risk Medicare Advantage contracts into the creation of a regional health system. After 18 years of wonderfully autonomous practice, Dr. Davis sold his health system to a regional competitor for $132m and began traveling the country with one goal, using the lessons learned to mentor other clinicians and their organizations in how to quit the treadmill and practice with joy. Telemedicine, cash-pay revenue streams, value-based healthcare, and Dr. Davis’ unique, practical perspective has helped more than a million patients receive better care and left thousands of clinicians more fulfilled. He currently shares his wisdom in his online community app NewScript, available on Apple and Google play.

Mentor, Speaker, Author—Dr. Davis consistently releases great high-value content across his many channels so clinicians can serve their patients sustainably and with joy.

Another episode you may like: Episode 85 How to Live an Amazing Life on Less with Amy and Tim Rutherford of “GoWithLess” 

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Show notes written by Amanda Taran

Please enjoy the full transcript below

 

Dr. Tom: I’ve been doing this with specialists and primary care doctors and the innovation there is just amazing. And the opportunity to live the life that you want to lead is still amazing.

 

[DocWorking theme]

 

Jen: Welcome to DocWorking: The Whole Physician Podcast. I’m Dr. Jen Barna. I’m so excited that you’re here with us today, because I have a wonderful guest, Dr. Tom Davis, mentor, speaker, author, telemedicine practitioner, entrepreneur, and RV nomad. I’m super excited to speak with Dr. Tom Davis and I know our listeners will be excited to hear your advice. I think for many of us, Tom, you are living the dream and I’m curious to hear about how you’ve made that a reality, why you’ve chosen to do that, and what we might be able to do if that’s something that interests us to move in that direction. So, Dr. Tom Davis, welcome to DocWorking: The Whole Physician Podcast.

 

Dr. Tom: Thank you. It’s wonderful to be here.

 

Jen: Thanks for joining me. Tom, would you mind just giving us an overview of how you have come to be where you are today in your career and in your personal life?

 

Dr. Tom: Well, my partners and I sold our health system back in 2012. I’m a board-certified family physician, and my partners and I created a multi-specialty group that evolved into a health system until finally, we sold into the teeth of the Accountable Care Act. I was still working as an employed clinician to take my expertise on the road and do some business consulting. While I was doing that, I noticed two things. One was how fortunate I was, because we practice in an autonomous way. It was wonderful. But most folks back then were absolutely miserable. They were chained to the treadmill and really felt that they didn’t have any choice. The second is, I was doing this business consulting. I was rubbing elbows with a number of venture capital folks and networking with them after hours after a drink or two is some of the most valuable time that you’ll spend.

 

Again, back then they were telling me that they were starting to spread the money around to the state capitals to broaden telemedicine practice authority. They were creating an entirely new market. You have the physical world in which you and I are used to delivering healthcare. They were summoning into existence, a virtual world, where there were no rules, no regulations, where the game was completely new. With my business experience, it was quickly recognized that you could take the organizations that these folks were representing. As a clinician, you can get credentialed with them. Since, at that time, it was almost all synchronous on demand calls, you could really stack them, and then you could sit back, and blow through patient after patient with simple self-limited chief complaints. You could dramatically increase your compensation in that situation compared to the market.

 

These folks got on early with a number of the larger telemedicine service providers or TSPs whose names you recognize. I also worked with some early ones, who weren’t survivors, but I did just that. I designed that practice to see if it would work. What I was motivated by, was how miserable all these other docs were. If you could do that, you could really make yourself a nice little bridge income as you’re transitioning into a new position, a new career. What I didn’t anticipate was the demand for the knowledge of how to do that effectively and how many folks are simply ditching it all and just becoming telemedicine clinicians full time. I did that, Jen. I created it as kind of a proof of concept and then I started mentoring other clinicians to do that. The demand was greater than the supply of my time, but I was still able to do that, and then COVID hit.

 

Suddenly, myself and some of my colleagues were very much in demand, because the whole health system went online virtually overnight. I live blogged that first weekend when everything went online, it’s on my LinkedIn. You should read it because I think it’s hilarious. It was quite a challenge to do that. Since that time, I’ve been spending considerable resources in working with clinicians to try to take this new virtual space in all sorts of different directions to innovate with it, to find opportunities, because the real-world health space is completely dominated by a few large incumbents, who have used their position to isolate themselves. There’s no innovation there. They collude with each other to keep our compensation down. The challenges in that space are huge.

 

Well, this is just like Oklahoma in 1889. The virtual space is wide open and the people that get there first are the ones that are going to do best. My mission is to take clinicians, who are miserable on the treadmill and they are legion. Get them into the space, get them innovating, get them very efficient, and then have them use that space, that opportunity, to see where they want to go. I’ve been doing it with specialists and primary care doctors, and the innovation there is just amazing, and the opportunity to live the life that you want to live is still amazing still.

 

Jen: For the physicians, who are listening and who may be interested in stepping into the telemedicine field, is it something that you’re seeing people do part time in addition to regular work or is it something that you would recommend that someone step out completely to do full time?

 

Dr. Tom: The answer is individual. I personally have clients that I mentor that are just dipping their toes in. I have other clients who’d say, “Man, I’m going to die if I take one more step on the treadmill.” I’ve got to do something different. This telemedicine looks cool, tell me more about it.

 

Jen: Is it as cool as it looks?

 

Dr. Tom: Even cooler. I’ve been mentoring folks now since 2016. I have yet to see someone tell me, “No, this isn’t for me.” They always find their niche. It’s just a matter of getting them going. The big challenge is that, most of the folks that try it that aren’t mentoring with me or my colleagues, they quit. What they do is they sign up with one telemedicine service provider, they get the minimum number of licenses that TSP requires, and they jump in, they say, “Hey, it’s only 25 bucks an encounter,” and then they usually have a bad encounter, which they believe puts them at risk for liability. It keeps them up at night and then they just stop taking calls. That, Jen, is a sin, because the power of this new space is so enormous, the freedom that it offers you and I is so great. All you have to do is have a modicum of business experience, enter it in an intentional way and part time, full time, bridge career, it’s all there for you. You just got to do it the right way.

 

Jen: Wow, you’ve opened up a lot of questions for me. First of all, I’d like to know, is this something that you’re seeing specialties of general practice, family medicine, emergency medicine, perhaps dermatology? I’m curious, what specialties you’re seeing have the most success here and I’m also curious, what is the difference between the bad experiences that you’re seeing? Some people go out on their own and don’t really know how to get into the space versus the correct way to get into the space. So, those are two completely different questions, but I’m wondering what you think about those?

 

Dr. Tom: Well, as far as the breadth of the specialties, obviously, the more that your specialty emphasizes physical contact with the patient, cardiothoracic surgery, the more challenging it is to generate an income using telemedicine. That said, the space is so new and the innovation is changing day-to-day that by the time this airs, somebody may have come up with a model to do that. I don’t know how, but then I’m not an innovator. However, the less that your specialty depends on physical contact with the patient, the greater the advantage of entering the space and utilizing your expertise efficiently. Clearly, family physicians, general practice, the infrastructure is already there, it’s very well-funded, you can create your own practice, boom, boom, boom, boom, boom, and double your hourly revenue.

 

For non-touch specialists like infectious disease, who I worked with before the pandemic, they scaled themselves. They use telemedicine to become infectious disease officers for a wide variety of hospitals around the country in ways that they could never have done without the virtual infrastructure. Another is folks who read tests, the sleep specialists. I worked with a sleep specialist, who now has every state license, which I think is 54 now. He basically just sits down and reads sleep studies for all these contracted folks. There’re the laboratory readers. Now, you’re starting to get physiatrists, who you would think would need to be in physical contact with the patient, but apparently not. I’m working with one now that has a very innovative model. I’m working with an orthopedist, I’m working with a general surgeon, who specializes in burns. I worked with a dermatologist, who specialized in hair loss, an African-American woman.

 

The sky’s the limit because this is a brand-new space. It’s completely unregulated. Jen, the advantage here is that. When you sign an employment contract, the law is pretty settled about locking you down in a non-compete for 15 miles from your office. That is completely inapplicable in the virtual space. Honestly, before COVID, the hospital systems didn’t really know what to do with it and they’re too busy making their money developing commercial real estate and selling our private information. But now, post-COVID, they’re really not all that interested. They don’t know what to do with it, they don’t have the legal resources to try to craft the space to their advantage. It’s wide open for anybody with an ounce of innovation to think about how they want to change.

 

As far as your second question goes, the experience of going in there with intention versus just dipping your toe in, there is really a difference between night and day. It’s the difference between success and failure. If you enter it in an intentional way, you can really create a nice sustainable revenue stream. Right now, it’s easy to do that with primary care, but again, the pain medicine specialists and the radiologists that I’ve worked with, they’re finding it to be very straightforward, too. It just takes a little bit of more effort, because they’re actually creating the infrastructure as they go along.

 

Jen: Now, let’s just pause for one second. I’m curious about the limitations of telemedicine. What has been your experience with that?

 

Dr. Tom: Well, the limitations are based on your own clinical acumen. The idea that there is a certain subset of medical problems or chief complaints, that you can take care of a patient with whom you don’t have a prior relationship and who you can’t touch and who you have a limited amount of sensory bandwidth to get information from, there is a subset of chief complaints that you can do that safely. What you have to understand or develop is that there’s also a significant subset, where that’s not appropriate. In order to do the visit safely, and efficiently, as well as effectively, you have to learn what that space is as quickly as possible. Then, as soon as they hit it, it’s like hitting bingo, boom. You know what? You deserve to have someone do a physical exam, because of this, so go to an urgent care right now.

 

Honestly, that is one of the challenges when you work with or select your telemedicine service providers. Because some of those service providers are selling their services to employers or insurers and saying, “Hey, we can take care of everything over the phone.” Well, as physicians, you and I both know that that’s wrong. Sometimes, you get pushback from the TSP. “Hey, you should have sent this person, you should have treated that person,” and then you go, “You’re off, you’re done. You’re fired. You’re gone. I’m never working for you again.” You have to create a system, so you can do that, so it doesn’t really negatively impact your revenue. Really, it’s the point of developing an instinct. I was very fortunate, believe it or not, in 1991, my first year as a family practice residency at University of Missouri Columbia, which by the way is the best family practice residency in the country.

 

We did our first month and all was telemedicine, all 12 of us covered the 50,000 patients by phone. That was our first rotation. Then every sixth day or so we took turns being the first or second call for that panel of 50,000 patients. We learned specific telemedicine techniques. That was actually unique among all the residency programs at the time. I was able to bring that into my experience of private practice, because as your small-town doctor, that’s what you do, is a lot of telemedicine, and then I was able to bring that for telemedicine. The key is finding a model that allows you to be free to use your clinical judgment. The moment that your clinical judgment is questioned, they’re fired.

 

Jen: How is malpractice insurance influenced in this space? Is it more expensive, less expensive, more risky, less risky?

 

Dr. Tom: That is a fantastic question. One of the things that I did as part of the leadership of our health system is we created our own insurance product. I have more than the average amount of experience with insurance than most doctors. In order to have the actuaries price these malpractice policies, they have to have experience. Since they don’t have any data, they can’t put it in their Boolean equations and figure out what their risk is. Telemedicine was so new early, there were very few adverse events that ended up to be actionable. Now, during COVID, the courts have shut down, so they really don’t have any knowledge about that. I’m told from my attorney friends, the dam is about to break. I was just interviewed for a legal publication where they’re talking about exactly this issue and they believe there’s a tsunami of malpractice cases that are coming.

 

Usually, what the malpractice insurers do is they will mark this to typical office practice and then they discount it about 20%. That is a very volatile situation. Here’s an actionable tip. When you sign up with a telemedicine service provider, the gold standard is 1 million, 3 million, that’s fine. Anything less than that, that’s suspect. Either the system is underfunded or something else is going on and we talk a lot about that on our various educational sites. The expectation is that they’re going to take care of the malpractice insurance. If you’re doing it as an independent contractor, you shouldn’t have to pay a nickel for your malpractice insurance.

 

Jen: So, that also brings up the question of compensation. You mentioned earlier that you can see patients more efficiently, but how does the compensation compare on a patient encounter basis?

 

Dr. Tom: In January 2016, while I was still a full-time family physician in the office, I was able to have about 400 billable encounters. I worked 200 hours that month. If I was under the normal compensation plan for my employer, I would have grossed about $20,000. That includes the employer’s contribution to healthcare. So, that’s pure growth. The reason I know that is because in January 2017, when my practice was going on all cylinders, I worked that same 200 hours, which I don’t advise. I actually had 1600 billable encounters and I grossed $40,000. The difference is, especially for the family physicians out there, in January 2016, I had 1,600 encounters. Only 400 of them were defined as billable. The other 1,200 were kind of the price of admission of my employer in order to be able to bill those 400. For 1,200, I got no compensation even though I assumed the risk and put the work out.

 

When you go to 2017, I had1,600 encounters, but I got paid for every one. Every one was limited. Essentially, the compensation was about half of what you would earn if you saw him in the office, but I was able to see four times more patients, because I was able to cherry pick the benign chief complaints and blow through them very safely.

 

Jen: Would you say that compensation in the field of telemedicine has evolved in the past couple of years with the demand going up so exponentially with COVID?

 

Dr. Tom: Well, the business folks that are running the TSPs now, either have a healthcare background or they smell that healthcare background, because one of their primary goals is to hold down the cost of their labor. Unfortunately, they can’t really do that. They can’t really collude because the space is so wide open. It’s becoming increasingly difficult for them to hold down comps. What you’re seeing them doing is, they’re offering spot bonuses and they’re also offering bonus payments if you take a certain number of calls or commit to a certain number of hours. The industry is brand new. They’re struggling to create models where they can meet demand and supply.

 

Unnamed TSP, one of my favorites, they offered a reverse Uber. They put out their pages, “Hey, we got a call,” and then if nobody responded, then the compensation went up a dollar and then it went up $2 and then $3. One of my best experiences for them is, I just happened to wake up in the middle of the night, and I was in one of my low volume states, boom. I had a $300 call. It was just some one-year-old that wouldn’t stop crying, it took 10 minutes. That’s 300 bucks, for a phone call that I would have gotten paid nothing for in private practice. It was wonderful. It was a wonderful experience. Most organizations don’t do that, but the challenge is for them to match supply and demand and they’re coming up with all sorts of innovative models.

 

Jen: Wow, how interesting. I am super excited to also hear about the concept of the flexibility that working telemedicine could potentially offer. One way that you have taken advantage of that flexibility is by being nomadic, and traveling, and living in your RV, and doing telemedicine on the road. So, I would love to hear about your experience doing that and I have a few questions, but first, I just want to hear about how you decided to do that and how you’re managing it currently?

 

Dr. Tom: Well, the idea came from the restorative power of getting on the road after being under the fluorescent lights. It was just naturally meshed with the idea that you can work as long as you get a quality signal, you can work wherever you want. Basically, my wife and I hit the road in our RV with our two dogs, and we have been all over the Florida Keys, all the way up to Alaska and the Glaciers. We’ve done a few international trips with the specific TSPs. The idea there is that you grab a signal, and then you sit down, and you create your own practice, so that as soon as you turn on all your portals, there’s just an infinite line of patients just waiting for you. They all have supposedly benign problems and you just blow through them really quick. For the one out of 10 or two out of 10 that don’t have benign problems, you learn to recognize that quickly and you’re firm to an in-person encounter. If you’re skilled and you’re lucky, get between 10 and 14 an hour, at 25 to 28 bucks per, for a normal day, after four hours you’re earning eight hours of income.

 

Generally, what I do is I get up early in the morning, make sure that I’ve scouted around, so I can know where I can grab a signal. Sit down with my laptop or my cell phone, and just go ahead, and do that, and then go about our day, doing whatever we do, and then in the evening, do the same thing. Sometimes, your campsite doesn’t have a good signal, so you can look at the maps and you climb to the top of a nearest hill, and sit down, and take a leisurely hike, and you just do it there. It’s wonderful. There were years when we did it nine months out of the year, and I was able to easily make an average FP salary on a monthly basis doing that, and it was very re-energizing. I have a number of clients who do that and they have taken it full time. They go hit Amazon campground parking lots just to hang out their shingle and the folks just pay in cash and it’s just wonderful.

 

Jen: Now, when you say hang out their shingle, you mean that they’re actually practicing medicine in person or do you mean they’re doing telemedicine cases?

 

Dr. Tom: Well, they do telemedicine. Then, for example, with this one individual, she walks her dog around this infinitely large Amazon campground, where lots of Amazon folks work. She just walks her dog around and says, “Hey, I’m a physician, licensed to practice in this jurisdiction. If you need any help, come by sight 152 or what not.” She’ll do telemedicine for a couple hours and then to satisfy her need for personal contact, the people will come by and charge them cash, or brownies, or chickens, or whatever you get when you practice in those situations. She loves it. That’s her life. She’s been doing it for two years now. She really enjoys it.

 

Jen: If I understand correctly, you’re saying that she’s combining that old fashioned medicine of local medicine within her temporary community wherever she’s staying, local medicine in addition to telemedicine. She’s really making her living off of the telemedicine services as she’s traveling and then she’s just offering her skills to those who are staying nearby, is that correct?

 

Dr. Tom: Yeah, that’s correct. That’s the nice thing about telemedicine. Standalone in primary care, you can earn a very nice living without overwork. But it also frees up so much time for you to innovate other service lines that you enjoy. People do telemedicine, they do expert witnessing. People do telemedicine and they do some medical science liaison on the side. But it provides that foundation of compensation that allows you the freedom to do and explore these other things. But one thing it does in every case is, again, get you off the treadmill and the treadmill is what’s killing us.

 

Jen: Thank you very much. This is Dr. Tom Davis, DocWorking: The Whole Physician Podcast. Tom tell us how people can find you, if they’re interested in learning more about telemedicine, stepping off the treadmill, or maybe just finding a way to be on the treadmill part time, and do some telemedicine, and have control of their schedule during the rest of the time?

 

Dr. Tom: My business partner, John Jurica, and I have created a community off of Facebook. It’s called NewScript. You can download the app on the Apple Store and Google Play. Come and join us. The first seven days are free. Let you peruse all the expertise that’s on there. Talk to me directly there.

 

Jen: Fantastic. I am enjoying the NewScript platform myself, and I’m excited to have you in our Thrive group as well, and it’s terrific to talk with you on the podcast. I look forward to talking with you again. Thank you so much for joining me.

 

Dr. Tom: Thank you. It’s been a privilege.

 

[music]

 

Amanda: I’m Amanda Taran, producer of DocWorking: The Whole Physician Podcast. Thank you so much for listening. Please don’t forget to like and subscribe and head over to docworking.com to see all we have to offer.

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