What can be accomplished in a 10 minute phone or video conversation between a random doctor and a random patient?

First, some assumptions about the process.

• Once the conversation is over, neither party can reconnect for ongoing care.

• Because there’s no follow-up, no tests can be ordered to confirm suspicions.

• Because it's a phone or video conversation, no examination can be done.

• The diagnosis can only be made based on an oral conversation.

• Video can show images but quality is dependent on connection speed.

• When given the option, patients choose phone over video 90% of the time. Because patients choose this option, doctors can’t visualize anything with a photo or video.

Next, some assumptions about the mind of an online doctor practicing with the above constraints:

• “Since I can’t actually confirm my suspicions with anything more than this current conversation, I can’t feel comfortable with a diagnosis, unless it’s ridiculously obvious to me.”

• “If I’m not 100% positive with a diagnosis, I will never diagnose something that isn’t 100% clear. Doing so jeopardizes my license and my career and I don’t want to be sued for malpractice.”

• “I’m doing this because I need money. Full stop.”

• “I’m doing this because I’m a PCP and I’ve got free time for any number of reasons.” (I’m a young, inexperienced doctor and my practice is not yet full. Or I’m a stay at home mom. Or I’m retired and want to stay in the game. Or I can’t get a job due to something wrong with my training. Or I can’t get a job due to personal reasons like alcoholism or drug use.)

• “I’m doing this because I’ve got free time and I’m curious about online healthcare delivery.”

• “Oof...another pink eye. This is getting pretty boring and routine. I didn’t go to medical school + at least 3 years of 80 hour weeks in residency to practice such simple medicine. This is why I hire nurses and physician extenders in the real world. Doing this is kind of humiliating now and I can’t imagine myself doing this for much longer unless I just need the money.”

• “Hey that was easy! Someone had an obvious UTI and reported that they never had previous complications with a UTI and I prescribed them an antibiotic and they’ll probably be feeling better fast. But hold on. What if their infection is resistant to this antibiotic? Well, that’s not my problem and this company I’m working for won’t let me reach back out to this person to see if everything has resolved. Ugh, this isn’t ideal. Hopefully they’ll be ok.”

• “If I’m anything but 100% positive of the diagnosis, the only thing I can do is encourage the person to be seen in-person because that’s what protects me from liability— nevermind if this video/phone visit wasn’t recorded to actually prove that I did this should anything bad happen.”

And, finally, some assumptions about the patient:

• They're looking for a prescription for a problem they think they have.

• They're looking to be told if they should worry enough about something to do something expensive about it now, later, or never.

• They value convenience over in-person relationships with local providers.

• They're curious and early-adopters

• They're cost-conscious consumers and understand the financial risks of getting any kind of in-person care (Is this office, urgent care, or ER visit going to be $50 or $5,000?).

While these 10 minute transactions are a thing and the internet has unlocked this capability, because of the limitations due to how their process was designed and because of how conservative doctors are in fully eliminating their risk, they are restricted to a very finite number of diagnoses that can be made by most any low-level health professional. Some of these companies market their services based on convenience with messages like “Talk to a doctor now!” and downplay their limitations (Doctor on Demand and TelaDoc). This is taking advantage of consumers hoping that consumers have used the service correctly for one of the 30 likely diagnoses. If they haven’t, they’ll pay for the advice and be told they need to be seen in-person. Others like Lemonaid and Hey Doctor are honest and up-front with their limitations and capabilities and present a finite list to start from. This is by far the best way to think about these services. They’re helpful for a finite list of simple issues for people who want convenience. However, these are the same 30 issues a nurse practitioner can handle in a retail health clinic. But because an NP in a clinic can do an exam and tests, they can diagnose and treat a total of ~70 simple issues. Compare this to a traditional PCP in an office. They routinely manage ~1,500 diagnoses. But that’s because they can order tests and do an examination to confirm suspicions, and manage conditions over time.