Tag: telehealth limitations

Hands typing on a laptop with a bright blank screen in a dark room at night

When to Use Telemedicine vs. Urgent Care: How I Spot the Sick One

On By Dr. Scott RennieIn Healthcare System & Technology15 Comments

A paper in the American Economic Review this month compared nurse practitioners and physicians across 1.1 million emergency department visits. Physicians came out ahead on average. NPs came out ahead in 38 percent of random head-to-head matchups, and thirty-day mortality showed no significant difference (1)(2). I wrote separately about what that study does and does not say.

This piece is about the setting I actually work in. Every visit I do is a video visit, and virtual urgent care has quietly become one of the largest places in American medicine where the question of who is on the other end of the call gets settled by economics rather than by clinical reasoning. The emergency department findings do not carry over to it cleanly, and the reasons they do not are worth their own article.

What changed about who answers

The staffing model in this corner of medicine changed fast, and most patients never noticed. Direct-to-consumer telemedicine launched staffed largely by physicians and runs now largely on nurse practitioners and physician assistants. The reason was never clinical. An NP costs less per hour and is easier to hire at scale, and when the product is a cheap video visit available at two in the morning, that arithmetic decides the roster. About 13 percent of emergency visits nationwide are now handled by NPs (2). In virtual urgent care the share is far higher, and those platforms are built for volume and speed.

The training gap is worth stating precisely, and I would rather use nursing education’s own accrediting standards than anybody’s talking points. The National Task Force standards that govern NP programs set a minimum of 750 direct patient care clinical hours for a population-focused track (4). No residency is required after that. A physician arrives at the same video visit having done clerkships and then residency, which the AMA puts somewhere between 10,000 and 16,000 hours (3). And about 87 percent of the 461,000 licensed NPs in this country trained in programs focused on primary care (5), which is preparation for the undifferentiated but mostly well patient rather than for the sick one.

Now let me argue against my own instinct, because the data do not go where a physician would expect. If thinner training meant missing sick patients, NPs in the Chan and Chen cohort should have under-admitted the dangerous presentations. They did the reverse. For sepsis, stroke, and heart failure they were substantially more likely to admit (2). The signature of that whole paper is a lower threshold to spend a resource when the picture is murky, which is caution rather than blindness, and it predicts over-referral out of telemedicine rather than under-referral.

Here is why I do not think that settles the question. The emergency department is a rigged environment for this comparison, rigged in a way that flatters everyone working inside it. The patient is physically present. A triage nurse has already taken vitals and assigned an acuity level. Somebody has laid eyes on them before the clinician decides anything, which means most of the signal that says this one is sick arrives free. Take that away, which is precisely what a video visit does, and the task becomes generating suspicion from a history and a small rectangle of video. Chan and Chen did not measure that task, and as far as I can tell nobody has.

Drop that mechanism into a video visit and the two available levers are prescribe empirically or send the patient somewhere with hands, which are exactly the two the study found NPs pulling more often. In telemedicine that shows up as more empiric courses and more requests to be seen in person today.

There is already independent evidence pointing the same direction. Ray and colleagues looked at children treated for acute respiratory infections and found antibiotics prescribed at 52 percent of direct-to-consumer telemedicine visits, against 42 percent at urgent care and 31 percent at a primary care office. Guideline-concordant management ran 59 percent in telemedicine versus 78 percent with the child’s own doctor (6). That was a finding about the modality, not about who was staffing it. Stack a modality that pushes toward empiric treatment on top of a staffing model that also pushes that way, and you have compounded the same bias twice.

The part nobody audits

Every telemedicine urgent care company writes its own clinical practice guidelines. Sinusitis follows this pathway, dysuria follows that one, and here is the list of complaints that must be routed to an in-person evaluation no matter how well the patient looks on camera. The documents are usually sensible. The problem lives downstream of the document.

They are not always followed, and at these volumes nobody is checking most of the time. Chart review is a sampling exercise and the sample is thin. A clinician who has drifted off the pathway, who has learned that the fastest route through a shift is a prescription and a click to the next patient, can drift a long while before anything notices. That is not a nurse practitioner problem. I have watched physicians do the same thing under the same incentives. It does interact badly with a workforce carrying fewer residency-trained reps for the case the guideline did not anticipate, and those are the visits that hurt people.

If I ran one of these companies, the number I would want on the dashboard is one I have never seen a platform publish. What fraction of visits departed from the pathway, broken out by clinician, with the bad outcomes tracked forward past the end of the encounter. Visit volume gets measured continuously. Guideline adherence gets measured occasionally. What happened to the patient afterward gets measured close to never.

Spotting the sick one is the whole job

Strip a virtual urgent care shift down to its clinical core and it is one decision repeated all day. Not what is the diagnosis. Does this person need to be somewhere with hands, equipment and a laboratory, and do they need to be there now.

Nearly everything else is forgiving. Choose the wrong antibiotic for a sinusitis and the patient is annoyed and books a second visit. Miss the atypical presentation of an acute coronary syndrome, or a subarachnoid bleed, or an ectopic pregnancy, or the child whose respiratory rate nobody counted because nobody asked, and that visit becomes the first line of a malpractice complaint or worse.

The instruments available for that decision are thinner than patients realize. No vitals unless the patient owns a cuff and a pulse oximeter and knows how to use them. Nothing to palpate. No chance to watch someone walk across a room, which is one of the most informative things I ever did in person. What remains is the history, and a history taken properly is the entire safety margin. The questions that carry weight cost time a productivity dashboard works against.

Now add the payment model, which pulls the wrong way all shift. Most virtual urgent care pays by the visit, or by the hour with a visit target attached. Nobody gets paid extra for the encounter where you spent eleven minutes on a history, decided something was off, and sent the patient to an emergency department without writing a prescription. On the dashboard that was your least productive visit of the day. It may have been the only one that mattered.

That visit scores badly a second time after you log off, because the patient rates you and at many platforms the rating feeds into your pay. Satisfaction scores capture real things, whether you listened and whether somebody felt taken seriously at eleven at night, and they are worth measuring. The trouble is timing. Satisfaction can be measured the second a visit ends. Whether the decision was correct often cannot be measured for weeks. The fast signal gets attached to the paycheck and the slow one does not, which is a design problem rather than anybody being a villain.

That pull is documented, and the study documenting it looked at physicians rather than nurse practitioners, which is rather the point. Across 8,437 direct-to-consumer telemedicine visits for respiratory infections handled by 85 physicians, 66 percent ended with an antibiotic. Patients who received one gave five stars 90.9 percent of the time, against 72.5 percent for those who left with no prescription (7). Individual physicians prescribed antibiotics anywhere from 19 to 90 percent of the time, and the heavier prescribers scored better. None of this is a telemedicine invention. Fenton and colleagues reported more than a decade ago that the most satisfied patients in a national cohort carried higher expenditures and higher mortality (8), an association rather than a mechanism and argued over ever since.

Nobody should stop asking patients what they thought. But a rating collected sixty seconds after the video ends cannot see whether the person who needed to be sent somewhere actually got sent. Until that number sits beside the satisfaction number, the clinician who declines the antibiotic and recommends the emergency department absorbs a cost nothing credits back.

A specific failure mode grows out of that, and it has nothing to do with anybody’s credential. You see forty upper respiratory infections across a shift. Thirty-nine are exactly what they appear to be. Your threshold quietly resets, because it has been rewarded for resetting all day, and the fortieth looks like the other thirty-nine right up until you ask the question that separates them. Volume does this to everyone. I have felt it happen to me.

This is where inpatient training earns its keep, and the claim is easy to overstate so let me be precise. I am not saying patients should see only physicians. I am saying the particular skill at issue, sorting the person who needs closer evaluation from the person who can be managed at home, gets built by having been responsible for patients who were admitted and then deteriorated overnight. Residency is years of exactly that, with somebody senior checking your reasoning. It is not the only route to that skill. It is the most reliable one we have.

Referral also assumes a mechanism exists, which is something you learn fast working inside one of these services. A good deal of virtual urgent care cannot order anything at all. Not a basic metabolic panel, not a chest film, not a cardiology consult. Payers frequently will not honor an order originating from a telemedicine encounter, reserving that authority for a primary care physician or an in-person urgent care, and platforms understandably do not build plumbing for something insurers will not pay for. Some services do have that capability. Several large national ones do not, and a patient cannot tell which sort they have reached before the visit begins.

Which narrows the toolkit further than most patients imagine. If I cannot send someone for a troponin, the disposition decision stops being one tool among several and becomes the only one. Every bit of uncertainty has to collapse into a single sentence. This can wait. Go be seen today. Go now.

That may loosen. Curbside specialist consults built into the encounter, where a cardiologist or a dermatologist can be pulled onto the call while the patient is still sitting there, are beginning to appear and would change this arithmetic considerably. They are not part of everyday practice yet. Plan around what exists today.

One more piece gets ignored. Referring is not the same as protecting. When a telehealth visit generates a recommended test or referral, patients complete it less often than when the same recommendation comes from an in-person visit. Across 4,133 orders, completion inside the expected window ran 58 percent for in-person against 43 percent for telehealth (9). That study looked at elective primary care work rather than emergency escalation, so do not stretch it. The direction still matters. Telling somebody to go to the emergency department is a recommendation, not a handoff, and a real fraction will not go.

Which brings me to the one staffing opinion I will state without hedging. Virtual urgent care is a poor first job. A nurse practitioner or physician assistant fresh out of school should not be making disposition decisions alone, on camera, without vitals, at production speed. Neither pathway requires a residency, so nobody has yet watched them be wrong somewhere it got caught and corrected. Spend a few years somewhere with a hallway and a colleague in it.

So when patients ask whether it matters that they drew a nurse practitioner instead of a physician, this is my honest answer. On the ordinary complaint, which is most of them, it does not matter much, and the 38 percent figure is why I say that with a straight face. On the visit where something is quietly wrong and nobody has said so out loud yet, training and repetitions matter more, and the average NP has fewer of both. That is not about anybody being careless. It is what 750 hours buys against several thousand, and any NP a decade into acute care has closed most of that distance.

For patients

You can ask who you are seeing and what their background is, and no reasonable clinician will take offense. Do not treat the letters after the name as the whole answer, because a randomly chosen NP outperforms a randomly chosen physician 38 times out of 100 (1). How long they have been doing acute care is the more useful question.

Two practical things. If you call with chest pain, a severe headache, abdominal pain, or a child who is breathing fast, expect to be sent somewhere with hands and equipment, and understand that this is the visit working rather than failing. And if you are told to be seen in person today, go. On many platforms that instruction is the entire product of the encounter, and it only helps if you act on it.

For clinicians

If you build or run these services, the actionable finding from the emergency department data is the complexity gradient rather than the average effect. Route sore throats and rash checks broadly. Route diagnostic ambiguity and high-acuity complaints to whoever has the most reps with them, and make that assignment on individual performance data rather than on license class. That is a solvable engineering problem and almost nobody is solving it.

If you work in them, two suggestions. Keep a private count of how many visits in a shift you closed without writing a prescription, because that number tells you something a satisfaction score cannot. And treat your last hour differently from your first, since threshold drift is worst when you are tired and the pattern has looked the same all day.

The Bottom Line

Virtual urgent care asks one question of a clinician, over and over, all day. Does this person need to be somewhere with hands, equipment and a laboratory, and do they need to be there now. Nearly everything else about the visit is forgiving.

The pressures working against that question are structural rather than personal. Payment by volume. Ratings collected sixty seconds after the video ends. Guidelines nobody has the capacity to audit at scale. And on many platforms no ability to order a test or generate a referral at all. None of that is a nurse practitioner problem and none of it is anybody being a villain. It is what happens when the fast measurements get attached to the paycheck and the slow ones never get taken.

If I were staffing one of these services, I would not put anyone into this work as a first job. And if I were the patient, I would care far less about the credential on the screen than about how many years the person behind it has spent deciding who was sick.

Sources

  1. Chan DC Jr, Chen Y. The Productivity of Professions: Evidence from the Emergency Department. American Economic Review, August 2026. https://www.aeaweb.org/articles?id=10.1257/aer.20241007
  2. Berkeley Research. New study upends traditional thinking about doctors versus nurse practitioners. August 22, 2026. https://vcresearch.berkeley.edu/news/new-study-upends-traditional-thinking-about-doctors-versus-nurse-practitioners
  3. American Medical Association. Nurse practitioners’ care linked to 11% longer stays in the ED. https://www.ama-assn.org/practice-management/scope-practice/nurse-practitioners-care-linked-11-longer-stays-ed
  4. National Task Force on Quality Nurse Practitioner Education. Standards for Quality Nurse Practitioner Education, 6th edition, 2022. https://www.aacnnursing.org/Portals/0/PDFs/CCNE/NTFS-NP-Final.pdf
  5. American Association of Nurse Practitioners. Nurse Practitioners in Primary Care (2025 NP count). https://www.aanp.org/advocacy/advocacy-resource/position-statements/nurse-practitioners-in-primary-care
  6. Ray KN, Shi Z, Gidengil CA, Poon SJ, Uscher-Pines L, Mehrotra A. Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics. 2019;143(5):e20182491. PMID 30962253. https://pubmed.ncbi.nlm.nih.gov/30962253/
  7. Martinez KA, Rood M, Jhangiani N, Kou L, Boissy A, Rothberg MB. Association Between Antibiotic Prescribing for Respiratory Tract Infections and Patient Satisfaction in Direct-to-Consumer Telemedicine. JAMA Internal Medicine. 2018;178(11):1558-1560. PMID 30285050. https://pubmed.ncbi.nlm.nih.gov/30285050/
  8. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Archives of Internal Medicine. 2012;172(5):405-411. PMID 22331982. https://pubmed.ncbi.nlm.nih.gov/22331982/
  9. Zhong A, et al. Completion of Recommended Tests and Referrals in Telehealth vs In-Person Visits. JAMA Network Open, November 2023. PMID 37966837. https://pubmed.ncbi.nlm.nih.gov/37966837/

Related Reading

The judgment call in this post is easier to see in specific conditions. These are the ones I get asked about most, each updated for 2026 with what a camera can and cannot settle. Abscesses and MRSA: What To Do About a Skin Infection Skin Burns: First, Second and Third Degree Tick Bites: Will I Get Lyme Disease? Scabies Infection: The Mite Bite Am I Truly Allergic to Penicillin? Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Large red EMERGENCY sign on the exterior of a hospital emergency department

Nurse Practitioners vs. Doctors in the ER: What the Research Actually Shows

On By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment

A paper landed in the American Economic Review this month that is going to get quoted badly by almost everyone who quotes it. Physician groups will pull three numbers out of it. Nursing organizations will pull a different three. Both sets are in there, which is exactly why the paper is worth an hour of your attention instead of a headline.

David Chan and Yiqun Chen looked at 1.1 million emergency department visits across 44 Veterans Health Administration sites, involving 156 nurse practitioners and 1,348 physicians (1)(2). What makes it different from the usual scope-of-practice study is the design. VA provider schedules are set months in advance. Patients show up when they show up. That mismatch means the question of whether you got an NP or a physician on a given night was close to a coin flip rather than a reflection of how sick you looked, and it lets the authors claim causation instead of the correlation that plagues most of this literature.

What the numbers say

Patients seen by NPs had emergency stays 11 percent longer and cost about 7 percent more, roughly 66 dollars per visit (1)(3). Thirty-day preventable hospitalizations ran 20 percent higher. The AMA ran the arithmetic forward and estimated that routing a quarter of VA emergency patients to NPs adds about 129 million dollars a year net, after accounting for the salary difference between the two groups (3).

Thirty-day mortality showed no statistically significant difference (2).

Hold onto both of those. People are going to publish articles this fall that mention one and not the other.

The number everyone is going to skip

Here is the finding I think actually matters, and it is the one I expect to see least in the press coverage. It needs a slow walk, because it is the part that gets garbled every time.

Everything in the section above compares two averages. Add up all 156 NPs and take the mean. Do the same for the 1,348 physicians. Compare the two. Physicians win that comparison, and I am not waving that away.

Now throw the other profession out and look at physicians alone. We are not all the same. Some of us order a great deal of testing and some order very little. Look at length of stay instead, or at thirty-day bouncebacks, and the same wide scatter turns up. The NP group has an equally wide scatter inside it.

What Chan and Chen found is that the spread inside each profession is larger than the distance between the two averages. The gap between a low-resource physician and a high-resource physician is wider than the gap between the typical physician and the typical NP.

Put those two facts together and the distributions overlap most of the way. The strongest NPs sit well inside the physician range. The physicians at the expensive end sit well inside the NP range.

So the authors ran the obvious test. Pull one NP at random. Pull one physician at random. Compare what each of them actually did, and repeat that many times over. The NP is the better performer in 38 out of every 100 draws (1)(2).

That is not a rounding error, and the number is worth calibrating against the two ends it could have landed on. If the professions were genuinely separate tiers, with the weakest physician still ahead of the strongest NP, you would expect something near zero. If they were interchangeable you would expect 50. Thirty-eight sits far closer to interchangeable than to separate.

Two things it does not say. It does not say NPs are 38 percent as good. It does not say that 38 percent of NPs outperform physicians across the board. It describes random one-to-one matchups and nothing wider than that.

And physicians still take 62 of those 100 draws. The average difference did not evaporate. Both of those are true at the same time, and holding both at once is the whole trick with this paper.

The gap also moved around depending on what walked in the door. For the least complicated cases, the extra cost attached to NP care fell by roughly 80 percent compared with the average case (2). It narrowed further as NPs accumulated years, and narrowed again as they accumulated reps with a specific condition. Chan framed the takeaway as a question of “which patients they should see” rather than whether NPs should practice at all, and I think that is the honest reading of his own data.

The mechanism looks like uncertainty, not carelessness. NPs ordered more diagnostic testing and more specialist consults. For sepsis, stroke, and heart failure they were substantially more likely to admit. They wrote fewer opioid prescriptions and more antibiotic prescriptions (2). Read that list as a set and a pattern shows up: when the picture was ambiguous, the threshold to spend a resource dropped. Anyone who has been six months out of residency recognizes that behavior in themselves, because we all did it, and the thing that fixed it was not a different diploma but two thousand more patients.

An aside, because the word keeps getting misused. “Productivity” here is an economics term. It means outputs relative to inputs consumed, not effort expended and not how hard someone works. Nothing in this paper says NPs work less hard. It says a given clinical result cost more to produce.

Where I think it is weakest

One health system. One care setting. One hundred fifty-six NPs, against a national workforce of more than 461,000 licensed NPs (4)(5). The AANP’s objection that you cannot generalize from that sample to every emergency department in the country is fair, and I would make the same objection if the finding had gone the other way.

The VA population is also not America. Older, more male, more comorbidity, and enrolled in an integrated system with a shared record. The VA also grants full practice authority, which means these NPs were working without the collaborative arrangement most of my colleagues in private systems actually have. What the paper cannot see is the physician who glanced at a chart, said one sentence in passing, and quietly changed a plan. That interaction leaves no data trail and it happens constantly.

None of that makes the effect estimates wrong. It makes them local. An 11 percent length-of-stay difference in a VA emergency department is a measurement of that department, and treating it as a national verdict on a profession is a category error.

What this means for a virtual urgent care visit

Most of my work is telemedicine, so this is the setting I thought about first. Virtual urgent care now runs largely on nurse practitioners and physician assistants, and the mechanism Chan and Chen identified does not carry over to a video call cleanly. I cannot order a CBC in the middle of an encounter. I cannot walk anyone down the hall for imaging. When uncertainty rises the levers available are prescribe empirically or send the patient somewhere with hands, which happen to be the same two the study found NPs pulling more often (2).

There turned out to be more to say about that than belongs inside a piece about an economics paper. What the payment and rating structures do to the decision. Why recognizing the sick patient matters more in this setting than almost any other. What happens when the platform cannot order a test at all. I put all of it in its own article: Spotting the Sick One: The Only Decision That Really Matters in Virtual Urgent Care.

Virtual weight management is a different problem, and a more forgiving one.

Weight management is a different animal, and I think the gap mostly closes

Obesity medicine breaks almost every condition that produced the ED result. There is no undifferentiated chest pain arriving at 2 a.m. The diagnosis is usually made before the visit starts. Care is longitudinal, protocol-heavy, and forgiving of a decision revisited in four weeks. The study’s own results predict a smaller gap here, because it found the difference shrinking by about 80 percent on the least complex cases and shrinking again with condition-specific experience (2). An NP who has titrated a thousand patients through semaglutide dose escalation has more relevant pattern recognition than a physician who has titrated forty.

That said, the complexity in this field is real. It just shows up in different places than people expect. Sorting expected GLP-1 nausea from something needing imaging. Recognizing that a patient on 30 units of basal insulin and a sulfonylurea will need those doses coming down as the weight comes off, before the hypoglycemia arrives rather than after. Pancreatitis history. Family history of medullary thyroid carcinoma. Restrictive eating patterns that look like excellent adherence on a video call and are not. Secondary causes, and the long list of psychiatric medications that drive weight gain and never get revisited.

So the risk in virtual weight management is not the credential on the screen. It is the eight-minute refill visit, whoever is running it. A physician doing rushed protocol care and an NP doing thorough protocol care are not close, and I would put my patients with the second one.

The tell is what got asked. Did anyone go back through the medication list once the weight started coming off, or was the box checked and the refill sent? Did anyone ask what the patient is actually eating on the days the nausea is bad, which is the question that separates a tolerable side effect from six weeks of accidental starvation. Nothing on that list has a degree attached to it. It has time attached to it, and time is a scheduling decision made by somebody in an office who has never met the patient.

For patients

You are allowed to ask who you are seeing and what their background is, and no reasonable clinician will be offended. What you should not do is treat the letters after the name as the whole answer. This study says a randomly chosen NP outperforms a randomly chosen physician 38 times out of 100. Experience with your specific problem is the more useful question. If you are starting a GLP-1, ask how many patients they have managed on it. If you are calling a virtual urgent care with chest pain or a severe headache, understand that any competent clinician in that setting is going to send you somewhere with a CT scanner, and that is the correct answer rather than a failure of the visit.

For clinicians

Two things I would take into practice from this paper. First, the within-profession spread being wider than the between-profession spread should change how we think about quality improvement. We spend enormous political energy on scope-of-practice fights and almost none on identifying and coaching the outliers inside our own group, and the data says the second one has more room in it.

Second, the actionable finding for anyone designing care is the complexity gradient rather than the average effect. Straightforward cases should route broadly. Diagnostic ambiguity and high-acuity complaints should route to whoever has the most reps with them, assigned on individual performance data rather than on license class. That is a solvable engineering problem and almost nobody is solving it.

The Bottom Line

This is a serious paper with a genuinely strong design, and its central finding is not the one being headlined. Physicians came out ahead on average in a VA emergency department. NPs came out ahead in 38 percent of head-to-head matchups, the difference nearly disappeared on straightforward cases, and thirty-day mortality was a wash. The spread inside each profession was wider than the gap between them, which is the part worth carrying around.

For virtual weight management I expect the gap to be small, and I care far more about how much time the visit gets and how deep the protocol runs than about which degree is on the screen.

Match the case to the clinician. That is the finding.

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Sources

  1. Chan DC Jr, Chen Y. The Productivity of Professions: Evidence from the Emergency Department. American Economic Review, August 2026. https://www.aeaweb.org/articles?id=10.1257/aer.20241007
  2. Berkeley Research. New study upends traditional thinking about doctors versus nurse practitioners. August 22, 2026. https://vcresearch.berkeley.edu/news/new-study-upends-traditional-thinking-about-doctors-versus-nurse-practitioners
  3. American Medical Association. Nurse practitioners’ care linked to 11% longer stays in the ED. https://www.ama-assn.org/practice-management/scope-practice/nurse-practitioners-care-linked-11-longer-stays-ed
  4. Clinician.com. Organizations Take Issue with Data Regarding Nurse Practitioner Care in the ED. https://www.clinician.com/articles/organizations-take-issue-with-data-regarding-nurse-practitioner-care-in-the-ed
  5. American Association of Nurse Practitioners. Nurse Practitioners in Primary Care (2025 NP count). https://www.aanp.org/advocacy/advocacy-resource/position-statements/nurse-practitioners-in-primary-care
  6. Chan DC Jr, Chen Y. The Productivity of Professions: Evidence from the Emergency Department. NBER Working Paper No. 30608, issued October 2022, revised August 2026. https://www.nber.org/papers/w30608

Why Some Conditions Need an In-Person Visit, Not Virtual Care

On By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment

Telemedicine has become part of everyday care, and for good reason; it allows patients to connect with a physician from home, from work, or while traveling; and many problems can be managed safely and effectively through video visits. But not everything belongs in a virtual setting.

I follow guidelines, like the ones Teladoc, MDLive, and Amwell use, that help decide what’s safe to manage online and what has to be seen in person. Those rules aren’t arbitrary. They’re built around safety, the limits of a video encounter, and the risk of missing something serious.

What Actually Keeps a Visit Off Camera

Some diagnoses depend on a tool or a test that doesn’t exist on a video call. An ear infection needs a direct look at the eardrum through an otoscope. Ear pain alone could just as easily mean wax buildup, dental pain, or referred throat irritation, and without visualizing the drum, the real cause gets missed (swimmer’s ear is the exception, along with cases where a family can upload a high-quality otoscope photo). A suspected blood clot in the leg, deep vein thrombosis, has exactly one way to confirm or rule out: an ultrasound, which no video visit can provide. Pneumonia works the same way. A cough that persists, worsens, or comes with fever and shortness of breath needs a chest x-ray and sometimes labs. Neither of which exists on a screen. Pediatric urinary tract infections need a urine sample tested before treatment. And abnormal uterine bleeding, which can signal serious gynecologic issues, usually needs labs or imaging to sort out.

Other conditions need hands-on assessment. Looking is not enough. Post-operative pain that’s worsening rather than expected can mean infection, bleeding, or a wound problem, and a physical exam is needed to check for swelling, drainage, or fever. Post-op patients are safest going back to their surgeon. Mastitis is similar. Breast pain and redness in a breastfeeding patient could be simple mastitis or could be an abscess that needs drainage. And a virtual exam cannot reliably tell the difference. Any laceration or wound that needs stitches has to be assessed and repaired in person; so do animal bites, dog, cat, or human, because of the infection risk and sometimes rabies exposure; and wound care, tetanus updates, and rabies prophylaxis all have to happen in the room.

A third group can turn dangerous fast and needs hospital-level resources. A fever over 103°F, or any systemic illness, can point to sepsis, meningitis, pneumonia, or another serious infection needing immediate labs, imaging, or IV treatment. Suspected meningitis, headache with fever and a stiff neck, needs immediate hospital evaluation with spinal fluid testing and IV antibiotics. It cannot be managed on a screen. Croup in a child, the barking cough and stridor, can worsen quickly enough that treatments like racemic epinephrine or oxygen have to happen in person and urgently. A skin abscess on the face, or periorbital cellulitis, can spread to deeper tissue including the brain and needs urgent evaluation, often with IV antibiotics. Suspected sepsis or a bloodstream infection has to be treated urgently in a hospital, full stop. Unexplained abdominal pain could be appendicitis, gallbladder disease, a bowel obstruction, or another emergency. And usually needs imaging and labs to sort out. Chest pain gets taken most seriously of all. It can represent a heart attack, a pulmonary embolism, or another life-threatening problem, and it gets an urgent in-person evaluation every time. The same logic covers a headache described as the worst of someone’s life, which can mean bleeding in the brain or meningitis; a concussion or closed head injury, which needs a neurologic exam and sometimes imaging; and eye problems like a foreign body, a chemical burn, sudden vision loss, or trauma, all of which need immediate in-person evaluation.

A last group has nothing to do with how sick someone looks and everything to do with what has to happen in a room. Controlled substances, stimulants, opioids, benzodiazepines, carry real risk of misuse and dependence. So regulations require in-person visits for initiation and refills. Some STD treatments need an in-office procedure; genital warts are the clearest example. And anything tied to a work-related claim, FMLA paperwork, workers’ comp, a disability determination, usually needs physical documentation and an in-person exam to be valid.

What About Rashes?

Rashes are a gray zone in telemedicine. Sometimes they are straightforward, like ringworm or athlete’s foot, and can be treated virtually with antifungal creams. Other times they are difficult to interpret. Safely treating a rash through telemedicine depends heavily on two things. The quality of the photo the patient uploads and a detailed medical history.

If the picture is blurry, poorly lit, or taken at the wrong angle, it may be impossible to tell the difference between something benign and something serious. Something like shingles or cellulitis. Even with good photos, asking the right questions, when it started, whether it itches, spreads, or comes with fever, can take time to sort out.

Diagnosing rashes virtually can sometimes be challenging, which is exactly why tele-dermatology has become its own field. Companies such as Teladoc now offer access to board-certified dermatologists who specialize in skin conditions. Patients can upload high-quality images and receive expert input, which improves accuracy and treatment options.

Conditions That Can Often Be Managed Virtually

Plenty of complaints are safe to handle over video: viral upper respiratory infections, sinus infections, uncomplicated urinary tract infections, mild to moderate asthma exacerbations, vaginal yeast infections, bronchitis without red-flag symptoms, most pink eye, cold sores, sprains and strains, seasonal allergies, skin conditions like eczema, ringworm, and jock itch, uncomplicated headaches or low back pain, and early or uncomplicated dental infections.

When a “Simple” Complaint Turns Out Not to Be

Patients don’t always see the warnings that some conditions can’t be managed online, and even when they do, some push back because getting to a clinic in person is inconvenient or expensive. Sometimes what looks straightforward at first turns into something else once the clarifying questions start: a “sinus infection” complaint that turns out to be severe facial swelling, a “back pain” complaint that turns out to come with fever and urinary incontinence. In my own practice, abdominal pain is the one that converts to an in-person visit almost every time, because it needs a hands-on exam. Boils and abscesses, febrile urinary tract infections, and rashes I can’t visualize well enough on a photo make up most of the rest.

Where These Guidelines Come From

Companies such as Teladoc, MDLive, and Amwell built their red-flag lists after years of clinical review. The goal is to prevent missed diagnoses and keep telemedicine a safe, effective model of care. These rules protect both patients and providers.

Telemedicine is powerful. It expands access and provides convenience. But it has boundaries. When I recommend that a patient be seen in person, it’s because safe, thorough care sometimes needs tools and testing. A video screen simply can’t provide them. When a patient pushes back, I tell them plainly that an in-person evaluation is needed for their own safety. If they keep insisting on staying virtual, I decline and explain that telemedicine has its own standards of care, similar to an in-person visit, built around guidelines that protect patients. Most understand. Not all of them agree.

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.