Tag: virtual care

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What Should You Do If a Lab Result in Your Patient Portal Looks Critical?

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

If a result in your patient portal is marked critical, or you see a number that looks dangerously high or low and you feel unwell, do not wait for a callback. Call the clinician who ordered the test right now. If you also have chest pain, trouble breathing, confusion, fainting, or severe weakness, call 911 or go to the nearest emergency department.

If you feel fine and the result is only flagged high or low, it is usually not an emergency. A message or phone call during business hours is the right speed.

The hard part is telling those two situations apart when the result lands on your phone at 9 p.m. and nobody has explained it. So here is how it works, which numbers matter, and what to do.

Why results show up before anyone has called you

The 21st Century Cures Act information-blocking rules changed the default. The prohibition began applying on April 5, 2021, and from October 6, 2022 it covered the full electronic health information in the designated record set rather than a narrower list of data elements (1). Federal guidance does not tell health systems to push every result to you the moment it posts. It does say that once a patient asks for access, the response has to be timely, and in practice you may see a result at about the same time the ordering clinician does (2).

Holding results back for clinician review is hard to defend as a blanket policy. The same federal FAQs say a routine several-day delay across a broad range of results does not qualify for the Preventing Harm exception (3). An individual clinician can make a specific determination that releasing one result would put someone’s life or physical safety at risk, and a patient can ask for a delay on their own results (3,4). Enforcement is no longer theoretical either. Provider disincentives tied to Medicare programs were finalized in July 2024, and HHS announced in September 2025 that information-blocking enforcement is a priority (5).

Patients, for what it is worth, mostly like this. In a four-center survey of 8,139 people, 95.7 percent wanted results in the portal immediately, even before a clinician reviewed them. But 16.5 percent of people with not-normal results reported being more worried afterward, against 5.0 percent of those with normal results (6). That worry is what this post is for.

What does “critical” actually mean?

A critical value is a lab result that suggests something imminently life-threatening. Federal lab regulations under CLIA require the laboratory to immediately alert the person who requested the test when a result indicates an imminently life-threatening condition, or a panic or alert value (7). The Joint Commission describes a critical value as one requiring immediate communication of results (8).

Notice who gets the call. The lab calls the ordering clinician, not you. One hospital laboratory described its rule as a technologist phoning the ordering practitioner within 30 minutes, with escalation if that person cannot be reached (8). Each lab builds its own list and its own cutoffs, and accreditors including the College of American Pathologists and the Joint Commission expect an alert system to exist (8). That obligation runs separately from whatever your portal shows you.

What the portal shows is a different matter. ONC’s safety guide for test result reporting recommends that critical values be flagged differently from ordinary abnormal values in the record clinicians use (9). Whether your portal does the same depends on the system. Do not count on a special color or the word “critical” appearing.

Flagged does not mean dangerous

Reference ranges are built from the central 95 percent of results in a healthy group. By definition, that labels 5 percent of healthy people as abnormal on any single test (10). Order a panel of 20 tests and about 64 percent of healthy people will have at least one result flagged (10). MedlinePlus puts it plainly: it is common for healthy people to sometimes have results outside the reference range (11).

So the red H or L next to your result is a prompt to look, not a verdict. A potassium of 5.6 mmol/L, for example, sits in the mild band (5.5 to 5.9) of the UK Kidney Association’s hyperkalaemia grading, and the same guideline says most mild or moderate cases found in the community can be managed without admission unless the person is acutely unwell (12). A sodium of 132 falls in the mild hyponatremia band, 130 to 135 (13). Both are real findings that deserve a conversation. Neither is a 911 call in a person who feels well.

One more trap. A hemolyzed blood sample can make potassium read falsely high, and that guideline recommends paired samples when this pseudo-hyperkalaemia is suspected (12). A surprising potassium in someone with no symptoms and normal kidney function is a reasonable one to repeat before anyone panics.

Which numbers can be truly urgent?

Labs call a wide range of analytes. Electrolytes, especially potassium, hemoglobin, high blood glucose and positive blood cultures were all on one laboratory survey’s list of commonly called values (8). I am not going to hand you a universal cutoff for each, because your lab sets its own. But the published guidelines give a sense of where the danger starts.

Potassium first. The UK Kidney Association grades severe hyperkalaemia as 6.5 mmol/L or higher and recommends urgent hospital assessment for anyone with that level found in the community (12). Sodium next. The European hyponatraemia guideline calls a serum sodium below 125 mmol/L profound, and notes that symptoms become more common below that level. Nausea, confusion and headache count as moderately severe symptoms. Vomiting, seizures, deep sleepiness and coma count as severe (13).

Glucose runs both directions. The American Diabetes Association defines level 2 hypoglycemia as below 54 mg/dL, and level 3 as an event with altered mental or physical status that needs another person’s help, whatever the glucose number says (14). On the high side, the ADA says to seek immediate care if you cannot keep fluids down, have ongoing vomiting, or have altered mental status (14). Those symptoms matter more than the number.

Hemoglobin is context-heavy. In the 2023 AABB guideline, the transfusion threshold for stable hospitalized adults is below 7 g/dL (15). That is a transfusion trigger and not a lab’s critical cutoff, but it tells you what kind of low is alarming. A slowly developed anemia and a bleed produce very different pictures at the same number.

Troponin deserves its own warning because patients see it more often now. Each assay has its own 99th percentile cutoff, reported in ng/L, and a value above it means myocardial injury. It is sensitive for a heart attack but not specific for one (16). If you see an elevated troponin in your portal and you have chest pressure, shortness of breath, or pain spreading to the arm or jaw, call 911 immediately (17). My view is that an unneeded trip to the emergency department is a much better outcome than a delayed one.

Some results always get a phone call from me: a critical blood sugar, a critical potassium, a critical kidney function result, or another electrolyte in the critical range. It is easier to reach someone during office hours, but I treat a critical result as urgent no matter what time it comes in. A critical number can occasionally be a mistake, too. A lab error, or a hemolyzed sample, where red cells broke open after the draw, can show an artificially high potassium. That is one reason earlier results help so much. For new patients I try to get their previous lab work, so I have something to compare against when I order new tests. It isn’t always possible.

What to do, in order

Start with how you feel, not with the number. Any chest pain, trouble breathing, fainting, new confusion, seizure, or severe weakness means 911, whatever the result says.

If you feel okay, check the reference range printed on your own report and read the lab’s comment, if there is one. Then call the office that ordered the test. Portal messages are the wrong tool for anything you think might be urgent. Pick up the phone.

After hours, call anyway and ask for the on-call clinician. If no one can be reached and the value is in the range described above (a potassium of 6.5 or higher, or a sodium under 125), go to an emergency department. A drawn glucose is old news by the time you read it, so for glucose, how you feel right now decides. Bring the result, your medication list, and the name of the ordering clinician.

Do not wait for the next business day with a severe value because you assume someone has already been called. The lab alert exists, but a phone number can be wrong and a message can sit in a queue.

When a virtual clinician ordered the test

Telehealth adds a wrinkle. The lab you walked into is probably near your home, while the clinician who ordered the test may be in another city or time zone. The ONC guide says the ordering clinician is responsible for follow-up of outpatient results unless that responsibility is delegated to someone else, and the delegation should be documented and accepted (9). That is the right principle. You want to know that someone actually holds it.

Ask which phone number the lab has on file for the ordering clinician, and whether that number is monitored when the clinician is not in a visit. Make sure the lab has your current cell number. And know where you are during a video visit, because a clinician who needs to send help has to know your physical address.

When a lab I ordered comes back critical, I try to reach the patient directly, especially after hours, because they need to know. They may know before I do, since the lab sometimes releases the result to them first. I also try to loop in their primary care physician if they have one. And a local emergency contact in the chart helps in the situations where the patient can’t be reached.

Ask before the blood draw

The single best question is “Who calls me if a result is critical, and from what number?” Ask it when the test is ordered, not when the portal pings you.

Follow with three more. Will I see results before you have read them? Who covers if you are unavailable? And if I would rather talk first, can the release wait? Federal guidance treats a patient’s own request to delay as likely not an interference, as long as the delay lasts no longer than necessary to meet that request (4). Some people genuinely prefer to hear a frightening result from a person first. That is a legitimate choice.

For patients, and for clinicians

If you are the patient

Know your own phone number on file, keep your ringer on after a blood draw, and decide ahead of time who you will call. Write the question “who calls me if it is critical” in your notes app before the next lab visit. Treat symptoms as the deciding factor.

If you are the clinician

Tell patients when you order that results may post before you have seen them, since the evidence shows abnormal results raise worry more often (6). Keep your critical-value contact information current with every lab you use, and make sure patients know who is covering when you are not. The SAFER guide asks organizations to have policies for timely patient notification of both normal and abnormal results, with the timeliness monitored (9).

When I order labs, I tell patients which tests are on the list. For my patients that usually means a fasting lipid profile, a comprehensive metabolic panel, a TSH, a hemoglobin A1c, and a high-sensitivity C-reactive protein, plus two special lipid tests: lipoprotein(a), which the 2026 ACC/AHA dyslipidemia guideline recommends measuring at least once in every adult (18), and apolipoprotein B.

The Bottom Line

A result marked critical, or a very high or low number paired with symptoms, means call the ordering clinician now, and call 911 for chest pain, trouble breathing, confusion, or fainting. A result that is merely flagged high or low is common even in healthy people and can usually wait for a conversation.

Cures Act rules mean you will often see results first, so ask before the blood draw who calls you if something is critical, from what number, and what happens when they cannot reach you. For telehealth patients, that answer matters even more.

Related Reading

When to Use Telemedicine vs. Urgent Care: How I Spot the Sick One
Emergency Room vs Urgent Care: Which Should You Choose?
Chest Pain: Could It Be a Warning Sign of a Heart Attack?
Why Some Conditions Need an In-Person Visit, Not Virtual Care
More on Healthcare System & Technology

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. Department of Health and Human Services. Information Blocking and the ONC Health IT Certification Program: Extension of Compliance Dates and Timeframes in Response to the COVID-19 Public Health Emergency. Federal Register, November 4, 2020. https://www.govinfo.gov/content/pkg/FR-2020-11-04/html/2020-24376.htm
  2. ASTP/ONC. FAQ: Are actors (for example, health care providers) expected to release test results to patients through a patient portal or API as soon as the ordering clinician can see them? https://healthit.gov/faq/are-actors-example-health-care-providers-expected-release-test-results-patients-through-patient/
  3. ASTP/ONC. FAQ: Would the Preventing Harm Exception cover a blanket several-day delay in the release of laboratory or other test results? https://healthit.gov/faq/would-preventing-harm-exception-cover-blanket-several-day-delay-release-laboratory-or-other/
  4. ASTP/ONC. FAQ: Can an actor grant a patient’s request to delay the release of the patient’s test results? https://healthit.gov/faq/can-actor-grant-patients-request-delay-release-patients-test-results-eg-laboratory-or-image/
  5. Liebler AJ, Sullivan S, Boyer MD, Doe K. Information Blocking Enforcement Enters a New Phase: What Digital Health Stakeholders Should Expect in 2026. Alston & Bird Health Care Advisory. February 23, 2026. https://www.alston.com/en/insights/publications/2026/02/information-blocking-enforcement-2026
  6. Steitz BD, Turer RW, Lin CT, et al. Perspectives of patients about immediate access to test results through an online patient portal. JAMA Netw Open. 2023;6(3):e233572. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2802672
  7. 42 CFR 493.1291. Test report (CLIA), paragraph (g). https://www.law.cornell.edu/cfr/text/42/493.1291
  8. Association for Diagnostics & Laboratory Medicine. Critical result notification preferences. Clinical Laboratory News. September-October 2024. https://myadlm.org/cln/Articles/2024/SeptemberOctober/Critical-result-notification-preferences
  9. ONC. SAFER Guides: Test Results Reporting and Follow-Up. August 2024 self-assessment. https://www.healthit.gov/sites/default/files/topiclanding/2025-01/8.%20Test%20Results%20Reporting%20Final.pdf
  10. Doles N, Ye Mon M, Shaikh A, et al. Interpreting normal values and reference ranges for laboratory tests. J Am Board Fam Med. 2025;38(1):174-179. https://pmc.ncbi.nlm.nih.gov/articles/PMC12096374/
  11. MedlinePlus. How to Understand Your Lab Results. Updated September 4, 2025. https://medlineplus.gov/lab-tests/how-to-understand-your-lab-results/
  12. UK Kidney Association. Clinical Practice Guideline: Management of Hyperkalaemia in Adults. Updated July 2026. https://www.ukkidney.org/sites/default/files/documents/FINAL%20VERSION%20-%20UKKA%20CLINICAL%20PRACTICE%20GUIDELINE%20-%20MANAGEMENT%20OF%20HYPERKALAEMIA%20IN%20ADULTS%20-%20UPDATED%20JULY%202026_0.pdf
  13. Spasovski G, Vanholder R, Allolio B, et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol. 2014;170(3):G1-G47. https://doi.org/10.1530/EJE-13-1020
  14. American Diabetes Association Professional Practice Committee. 6. Glycemic goals, hypoglycemia, and hyperglycemic crises: Standards of Care in Diabetes-2026. Diabetes Care. 2026;49(Suppl 1):S132-S149. https://doi.org/10.2337/dc26-S006
  15. Carson JL, Stanworth SJ, Guyatt G, et al. Red blood cell transfusion: 2023 AABB international guidelines. JAMA. 2023;330(19):1892-1902. https://doi.org/10.1001/jama.2023.12914
  16. Sandoval Y, Apple FS, Mahler SA. High-sensitivity cardiac troponin and the 2021 guidelines for acute chest pain. American College of Cardiology. July 14, 2022. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2022/07/14/18/12/high-sensitivity-ctn-and-2021-chest-pain
  17. Centers for Disease Control and Prevention. About Heart Attack Symptoms, Risk, and Recovery. October 24, 2024. https://www.cdc.gov/heart-disease/about/heart-attack.html
  18. American College of Cardiology. Lower Sooner: How the 2026 Dyslipidemia Guideline Changes Practice. July 1, 2026. https://www.acc.org/latest-in-cardiology/articles/2026/07/01/01/prioritizing-health
Unlabeled blister pack of six white oval antibiotic tablets beside a plain paper pharmacy bag on a kitchen table

I hear it almost every day now. “I think I just need a Z-Pak.”

On By Dr. Scott RennieIn Infectious DiseaseLeave a comment

Sometimes it’s phrased as a question. Sometimes it isn’t. In telemedicine especially, many patients request azithromycin by name within the first minute of the visit. The symptoms are familiar. Runny nose. Congestion. Post-nasal drip. Scratchy throat. Maybe a cough that started yesterday. No fever. No shortness of breath. No focal findings anyone could reasonably point to as bacterial.

But they’re convinced the Z-Pak will help them get better faster. They’ve taken it before. It worked last time. Or at least they felt better a few days later and connected the dots.

This didn’t happen by accident.

Azithromycin earned its place in outpatient medicine because it was easier to tolerate than older antibiotics like erythromycin, had fewer drug interactions than clarithromycin, and came packaged in a way that felt efficient. Six pills. Five days. Done. The Z-Pak became a symbol of modern medicine that didn’t slow you down.

Over time, it also became the antibiotic people expected.

In telemedicine, that expectation is even stronger. There’s no exam table. No stethoscope. No labs. No chest X-ray down the hall. The visit is brief by design. When a patient feels sick and wants something tangible, the Z-Pak becomes the path of least resistance. Prescribing it can shorten the encounter. It avoids a long explanation. It reduces the risk of a bad review. It keeps patient satisfaction scores high. It keeps supervisors and clinic managers happy. Everyone moves on to the next visit.

I understand why this happens. I’ve seen it from the inside.

But convenience doesn’t make a treatment safe or appropriate.

Azithromycin does not treat viral infections. It does not help the common cold. It does not clear post-nasal drip. It does not shorten the course of uncomplicated upper respiratory infections. When patients feel better after taking it, they almost always would have improved anyway.

What it does do is expose people to real risk.

Azithromycin can prolong the QT interval. That matters. QT prolongation can predispose patients to dangerous heart rhythms, including torsades de pointes and sudden cardiac death. This risk is higher in people with underlying heart disease, electrolyte abnormalities, or those taking other QT-prolonging medications, but it is not zero in otherwise healthy adults. Large observational studies have shown an increased risk of cardiovascular death during azithromycin treatment compared with other antibiotics or no antibiotics at all.

That risk is invisible to patients. They don’t feel their QT interval getting longer. They just know they want something to help them feel better.

Antibiotics also carry more familiar side effects. Nausea. Diarrhea. Abdominal cramping. Yeast infections. Rashes. Allergic reactions. These are not rare, and they are not trivial when the medication wasn’t needed in the first place.

Then there’s resistance. Every unnecessary antibiotic course applies selective pressure. Azithromycin resistance is already a growing problem in common respiratory pathogens. When we reach for it reflexively, we make it less useful for the patients who actually need it.

The harder part of these visits is the explaining.

It takes longer to walk someone through why their symptoms are viral. Why time, fluids, nasal saline, antihistamines, or intranasal steroids actually help. Why rest matters. Why antibiotics won’t fix inflammation or mucus production. Why feeling miserable does not automatically mean something dangerous is happening.

It’s much faster to send a prescription.

But faster is not better medicine.

I get patients asking for Z-Paks every day that I work in telemedicine. It’s so common that it happens at least once a day, if not three or four times a day. One example sticks with me. A patient requested a Z-Pak for congestion and sinus pressure that had been present for two days. No fever. No facial pain. No worsening course. When I explained why antibiotics wouldn’t help, they were frustrated at first. We talked through what sinus infections actually look like and when antibiotics are appropriate. We discussed symptom control instead. Two days later, they messaged to say they felt better and were glad they didn’t take an antibiotic they didn’t need.

That outcome required time. It required education. It required saying no.

Not every visit goes that smoothly. Some patients remain disappointed. Some leave poor reviews. That pressure is real, especially in high-volume telemedicine environments.

But prescribing antibiotics to keep the peace comes at a cost. It shifts risk onto the patient. It shifts harm into the future. And it reinforces the idea that medicine should always offer a pill, even when the best treatment is patience and support.

Azithromycin became dominant because it was easy. That same ease is why we need to be more careful with it now.

Related Reading

Why Won’t Antibiotics Cure a Viral Infection? Doctor Explains Why Antibiotics Don’t Work for Colds, Flu, or Viruses Antibiotic Resistance Could End Modern Medicine, WHO Warns The Doctor Says You Have Bronchitis: Is That Really Bad?

Scott Rennie, D.O.

Sources:

Ray WA, Murray KT, Hall K, Arbogast PG, Stein CM. Azithromycin and the risk of cardiovascular death. New England Journal of Medicine. 2012;366:1881-1890.

Sax PE. How the Z-Pak Took Over Outpatient Medicine. Substack lecture notes and essay.

Svanstrom H et al. Use of azithromycin and death from cardiovascular causes. New England Journal of Medicine. 2013;368:1704-1712.

FDA Drug Safety Communication. Azithromycin and risk of potentially fatal heart rhythms. US Food and Drug Administration. 2013.

CDC. Antibiotic use in the United States: Progress and opportunities. Centers for Disease Control and Prevention.

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.

A laptop open on a desk beside a bright window, with a glass carafe of water and a small plant

Menopause Care by Telemedicine: What a Virtual Visit Can and Cannot Do

On By Dr. Scott RennieIn Menopause & Women's HealthLeave a comment

You are 51. You have not had a period in fourteen months, you are waking at three in the morning soaked through your shirt, and the first opening with a gynecologist near you is in March. That gap is most of the reason virtual menopause care exists.

The question comes up in the first couple of minutes of a lot of my video visits. Can this actually be done over a screen? Fair question, and the answer is mostly yes, with one category of exception that matters more than everything else on this page combined.

The diagnosis is a conversation, not a lab draw

If you are 45 or older, your periods have stopped or gone erratic, and you are having hot flashes and night sweats, the diagnosis is clinical. No blood test required. For women in that age group with typical symptoms, routine hormone testing is not recommended, and that is not a corner being cut for the sake of convenience (1).

Patients ask me to check their hormone levels constantly. Almost always they have read something first and done real work on their own, and what they are after is a number that explains why they feel the way they do.

I understand that request better than I used to. It is not really about the lab. It is about wanting proof that this is happening and that she is not imagining it.

Which is exactly why ordering it can backfire. FSH swings week to week in perimenopause, so a single value lands wherever it happens to land that morning. Hand a woman a normal result while she is exhausted and soaked at four in the morning, and you have taken away the validation she came for and given her nothing in exchange. So I tell her what the test can and cannot settle, and then I treat the symptoms, which is what she needed either way.

Under 45 is a different conversation. Early menopause and primary ovarian insufficiency change the stakes, and there I do want labs.

What I can prescribe without ever being in the room

Systemic estrogen, as a patch, gel, spray or tablet. A progestogen alongside it if you still have a uterus, because unopposed estrogen is what drives endometrial risk. Low dose vaginal estrogen for dryness and painful sex, which barely registers systemically and is the most underused prescription in midlife women’s health.

The non-hormonal side has moved recently and plenty of people have not caught up. Fezolinetant (Veozah) was approved in May 2023 and blocks the NK3 receptor (2). Elinzanetant (Lynkuet) followed on October 24, 2025, and blocks NK1 as well as NK3, which is why the OASIS trials picked up an effect on sleep disruption and not only on hot flashes. Dosing is 120 mg daily (3). Where sleep is the dominant complaint rather than the flashes themselves, the agent with an actual sleep signal behind it is the more logical place to start.

Paroxetine at 7.5 mg and gabapentin are both still reasonable, particularly for women who cannot take estrogen at all.

One boxed warning came off. One did not.

On November 10, 2025, the FDA moved to strip the boxed warnings for cardiovascular disease, breast cancer and probable dementia from estrogen-containing menopause products (4). The endometrial cancer warning on systemic estrogen-only products stayed exactly where it was, and that is the part the coverage mostly dropped.

My read is that this fixed a labeling problem rather than a science problem. Nothing underneath changed in November. What changed is that a warning drawn from a trial population averaging 63 years old had spent two decades frightening 52 year olds away from a treatment whose risk profile depends enormously on how old you are when you start it. I wrote about that separately.

The thing a video visit cannot do, and it just got harder

Bleeding after menopause needs an in-person evaluation. Not a phone call, not reassurance, not wait and see.

ACOG updated this in April 2026 and it moved in the stricter direction. Transvaginal ultrasound on its own is no longer considered adequate initial triage for postmenopausal bleeding. The recommendation now is ultrasound together with endometrial tissue sampling in most patients (5). Relying on ultrasound alone appears to miss 5 to 12 percent of cancers, and the old 4 mm endometrial thickness cutoff performed especially badly in Black women, with a sensitivity around 47.5 percent (5).

Read that number again. A triage rule that caught fewer than half the cancers in one group of women was standard practice until this year.

So when a patient tells me on video that she is a year past her last period and bleeding again, the visit stops being about hot flashes and becomes about getting her seen and scanned quickly by someone who can put instruments on the problem. That is not telemedicine failing. That is telemedicine doing the one thing it can do in that moment, which is recognizing what it is looking at and moving.

Same goes for a new breast lump, for pelvic pain, and for anything needing a speculum, an IUD, a mammogram or a bone density scan.

What the visit actually looks like

Expect questions, a lot of them. When your last period was. What the flashes are doing to your sleep and your work. Whether sex has become painful, which almost nobody volunteers unless asked directly. Your personal and family history of breast cancer, clotting, stroke and heart disease. Whether you get migraines with aura.

I will ask what your blood pressure has been running, and if you do not own a cuff I will ask you to get one, because starting systemic estrogen without knowing that number is not something I am willing to do. I will ask when your last mammogram was, and I will ask again at follow-up. The biggest failure mode in virtual menopause care is a woman who feels wonderful on therapy and quietly slides three years behind on screening.

Labs, when they are warranted, get ordered to a draw site near you. Prescriptions go to your pharmacy the same day.

For clinicians

Licensure is the whole ballgame. You need a license in the state where the patient is physically sitting during the visit, not where she gets her mail, and telehealth prescribing of estrogen is otherwise permitted across all fifty states on that basis.

On my own panel, roughly 25 percent of the women arrive already on hormone therapy started somewhere else, usually a direct-to-consumer platform. That number tells you what kind of visit you are actually having. Much of the time you are not initiating therapy, you are inheriting it, and the first job is working out what she is on, at what dose, and whether anyone ever screened her for a contraindication.

Two things worth tightening. Document the contraindication screen explicitly rather than letting it sit implicitly in the note, because the labeling change has patients arriving expecting a prescription and expecting it that day. And build a real handoff to a local gynecologist before you need one. After the April 2026 update, a postmenopausal bleeding referral carries a specific expectation about what the workup should include, and telling someone to go see somebody is not a plan.

The Bottom Line

Most of menopause care transfers to video without losing anything. The diagnosis is clinical, the history is the test, and hormone therapy, the two neurokinin antagonists and the non-hormonal alternatives can all be started and adjusted remotely by someone licensed where you are.

What does not transfer is anything needing hands. Bleeding after menopause is the one to take seriously, and as of April 2026 the standard for evaluating it went up, not down.

If you have been waiting until March to ask someone about this, you do not have to.

Related Reading

FDA Removes Black Box Warning From Menopause Hormone Therapy

Perimenopause and Menopause Symptoms and How to Manage Them

Vaginal Dryness After Menopause: Why It Doesn’t Go Away

Does Menopause Cause Weight Gain, or Is It Just Aging?

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

More on Menopause & Women’s Health

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. National Institute for Health and Care Excellence. Menopause: identification and management. https://www.nice.org.uk/guidance/ng23

2. U.S. Food and Drug Administration. FDA Approves Novel Drug to Treat Moderate to Severe Hot Flashes Caused by Menopause. May 12, 2023. https://www.fda.gov/news-events/press-announcements/fda-approves-novel-drug-treat-moderate-severe-hot-flashes-caused-menopause

3. FDA Approves Elinzanetant as First Nonhormonal Therapy for Menopause Vasomotor Symptoms. Pharmacy Times, October 2025. https://www.pharmacytimes.com/view/fda-approves-elinzanetant-as-first-nonhormonal-therapy-for-menopause-vasomotor-symptoms

4. U.S. Food and Drug Administration. HHS Advances Women’s Health, Removes Misleading FDA Warnings on Hormone Replacement Therapy. November 10, 2025. https://www.fda.gov/news-events/press-announcements/hhs-advances-womens-health-removes-misleading-fda-warnings-hormone-replacement-therapy

5. American College of Obstetricians and Gynecologists. ACOG Publishes Updated Guidance on Evaluation of Postmenopausal Bleeding. April 2026. https://www.acog.org/news/news-releases/2026/04/acog-publishes-updated-guidance-evaluation-postmenopausal-bleeding

Shifting to Telemedicine: Reflections for Fellow Physicians

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

Not long ago, two of my medical school classmates reached out to me. One is an emergency room physician. The other is a dermatologist. Both wanted to talk about telemedicine and whether they should make the transition. Their questions reminded me of my own when I started, and it got me thinking about how different this kind of work really is compared to in-person care.

Telemedicine has real upsides. The flexibility is genuine: you can work from anywhere with a reliable internet connection, from home while helping with your kids, or on the road while staying productive. The lack of a commute alone changes your day. No traffic, no wasted time. Hours flex more easily when family emergencies or illnesses come up. Exposure to infectious disease drops significantly too, a lesson plenty of us learned the hard way during COVID. On top of that, paperwork drops. Charts are streamlined and forms are lighter, which frees up the time you’d otherwise spend on documentation to actually talk with patients; if you’re efficient, the pay is good, and seeing more patients per day brings a sense of making a difference on a large scale. You can meet people from all over the country, provided you are licensed in multiple states. For many providers, this is one of the best work-life balance opportunities in medicine.

Some patients treat telemedicine like a transaction, logging on expecting a specific medication and pushing back when your judgment doesn’t match what they came for. That’s one of the real downsides. You lose the camaraderie of the clinic or hospital, the in-person interaction with colleagues that a lot of physicians miss. Hands-on procedures disappear entirely. Loved draining an abscess, suturing a laceration, placing a central line? You won’t get that satisfaction here. Some days it feels like you’re redirecting more patients than you’re treating, sending people in for care you’d rather deliver yourself; and the liability is identical to an in-person visit, just with fewer tools to manage it.

The monotony can creep in too. During winter, you may see upper respiratory complaints on repeat. You have to be skilled at quickly identifying the patient who sounds much sicker than they realize. That judgment call, who can be safely treated virtually and who needs in-person evaluation, has to be made fast and accurately. Get it wrong and the consequences can be serious.

Guidelines from telemedicine companies like Teladoc, MDLive, and Amwell are conservative for a reason: they steer providers toward in-person evaluation whenever there’s doubt. It keeps patients safe. It protects the practice of telemedicine itself, too. You have to be comfortable following those guidelines, even if it feels restrictive at times.

I have had both frustrating and rewarding cases.

One that stands out was a patient who logged on for hives. Her husband was telling the story while she was in the background, but when she finally spoke, her voice was high-pitched and strained. I realized she was in anaphylaxis. She had access to her child’s epinephrine auto-injector, used two doses, and her breathing improved almost immediately. EMS was called. She got the care she needed. That visit was one of my first telemedicine visits. I was still working 1099, part time, treating telemedicine as something on the side. Walking away from that call believing I might have just saved someone’s life is what changed my mind, and I went looking for a full-time W2 telemedicine role not long after.

Rashes and Telemedicine: A Special Challenge

One of the trickiest areas of telemedicine is dermatology. Rashes seem like they should be simple. A patient shows you a patch of red skin or bumps, you identify it, and you prescribe a cream. The reality is that it is rarely that easy.

The biggest issue is image quality. Patients often upload photos that are poorly lit, out of focus, or taken from too far away; sometimes they only capture a tiny area of skin without showing the bigger picture; diagnosing a rash accurately takes more than a photo: distribution, texture, timing, and whether there are associated systemic symptoms all factor in; and without good photos and without the ability to do a full physical exam, we are often working with incomplete information.

I ask for photos for telemedicine rashes rather than relying on video alone. Video is generally not as good quality as a high-resolution image. The challenge is getting a patient to take that photo well: right distance, multiple angles, not blurry. I like a distance shot and a macro shot up close if I can get one.

History-taking matters just as much: was the rash itchy or painful, did it spread quickly, was there a recent medication change, a new detergent, an insect bite, or outdoor exposure? Even careful questioning doesn’t always yield the full story. Some rashes are harmless. Others can be signs of serious systemic illness. Sorting out which is which over video can be challenging and sometimes unsafe. One diagnostic call that turns entirely on photo quality: angular cheilitis. It can be hard to distinguish from perioral dermatitis without a close-up image. A good macro shot of the corners of the mouth and the two conditions look different. A blurry photo taken from three feet away, and you are guessing between them.

That is why tele-dermatology has emerged as a subspecialty. Some telemedicine companies, including Teladoc, now offer patients access to board-certified dermatologists who can focus exclusively on skin issues; having a dermatologist review high-resolution photos, sometimes with dermatoscopic images, makes accurate diagnosis and treatment more reliable. Even so, patients need to understand that when the photo quality is poor or the history is incomplete, a referral for in-person evaluation may still be necessary.

Would I tell my classmates to make the switch? Yes, eyes open. Real flexibility and real reach, but you give up procedures, in-person camaraderie, and full control over what you can safely rule out on a screen. Know the limits, tell patients the truth about them, and telemedicine works, for them and for you.

Related Reading

Why Are Some U.S. Physicians Moving to Canada to Practice? Why Some Conditions Need an In-Person Visit, Not Virtual Care When to Use Telemedicine vs. Urgent Care: How I Spot the Sick One

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.

A stethoscope and a tablet on a desk beside a small plant

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.

Related Reading

When to Use Telemedicine vs. Urgent Care: How I Spot the Sick One Can Telemedicine Diagnose Strep Throat and Ear Infections? Emergency Room vs Urgent Care: Which Should You Choose? Nurse Practitioners vs. Doctors in the ER: What the Research Actually Shows

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.