Abstract
Many disadvantaged communities lack sufficient numbers of local primary care and specialty physicians. Yet tens of thousands of physicians, in particular those who are retired or semiretired, desire meaningful volunteer opportunities. Multiple programs have begun to use telehealth to bridge the gap between volunteer physicians and underserved patients. In this brief, we describe programs that are using this model and discuss the promise and pitfalls. Physician volunteers in these programs report that the work can be fulfilling and exciting, a cutting-edge yet convenient way to remain engaged and contribute. Given the projected shortfall of physicians in the United States, recruiting retired and semiretired physicians to provide care through telehealth increases the total supply of active physicians and the capacity of the existing workforce. However, programs typically use volunteers in a limited capacity because of uncertainty about the level and duration of commitment. Acknowledging this reality, most programs only use volunteer physicians for curbside consults rather than fully integrating them into longitudinal patient care. The part-time availability of volunteers may also be difficult to incorporate into the workflow of busy safety net clinics. As more physicians volunteer in a growing number of telehealth programs, the dual benefits of enriching the professional lives of volunteers and improving care for underserved communities will make further development of these programs worthwhile.
Introduction
In the United States and abroad, many disadvantaged communities lack sufficient numbers of local primary care and specialty physicians. Yet tens of thousands of physicians, in particular those who are retired or semiretired, desire meaningful volunteer opportunities. The key obstacle preventing supply from meeting demand is geography. Although in the past this barrier was difficult to surmount, telehealth has the potential to transform care delivery for the underserved. Multiple programs have begun to use telehealth to bridge the gap between volunteer physicians and underserved patients. In this brief, we describe programs that are using this model and discuss the promise and pitfalls that we have uncovered through interviews with program administrators and volunteer physicians.
There are ∼275,000 active physicians between the ages of 55 and 75 years who are nearing retirement and more than 100,000 physicians of all ages who are currently inactive. 1 Although many of these physicians may have the time and desire to volunteer, family and personal commitments make it difficult to provide care in the communities facing the most severe workforce shortages. Fortunately, telehealth is opening up new opportunities.
Current Programs Leveraging Volunteers for Telehealth
Several programs have begun to leverage volunteers through telehealth. The MAVEN Project is an independent nonprofit that recruits retired and semiretired physicians from the alumni of leading medical schools. 2 MAVEN physician volunteers deliver remote care to safety net clinics that serve underserved patients regardless of ability to pay. In some cases, on-site providers use volunteers for curbside consults. In other cases, volunteers provide direct patient care in which the patient presents to the safety net clinic for a scheduled visit and interacts with the volunteer through videoconferencing. MAVEN has offered a range of specialties tailored to local needs from cardiology to pediatric endocrinology, with the ultimate goal of expanding to safety net clinics across the United States.
AccessDerm is sponsored by the American Academy of Dermatology. 3 Referring primary care providers in participating safety net clinics in 16 U.S. states submit a consult request through a HIPAA-compliant app on their smartphone. The consult request is then sent to a group of volunteer dermatologists licensed to practice in the state. An available dermatologist then responds, diagnosing the skin condition where possible and offering a treatment plan.
Multiple telehealth programs are focused abroad. For example, the Swinfen Charitable Trust, a charity headquartered in the United Kingdom, hosts a Web-based messaging system in which referring healthcare workers can request an asynchronous curbside consult from a pool of volunteer specialists. 4 Swinfen has created telehealth partnerships with 320 hospitals in 75 countries.
Although MAVEN, AccessDerm, and Swinfen were explicitly developed to increase access to volunteer physicians through telehealth, there are other long-established volunteer programs that are experimenting with telehealth. For example, Doctors Without Borders and Project Access of Northern Virginia are adding telehealth to their existing services.
Promise of Using Physician Volunteers Through Telehealth
If these programs become widespread, they could both improve the health of the underserved and enrich physicians' careers. Although physicians have long participated in volunteer medical service trips and disaster relief efforts, those opportunities require significant commitments of time, and can be dangerous and too strenuous for older physicians. Physician volunteers in telehealth programs report that the work can be fulfilling and exciting, a cutting-edge yet convenient way to remain engaged and contribute. Potentially such programs can encourage inactive physicians to re-enter the workforce.
For underserved communities, a volunteer telehealth model has immense potential to increase access. Although experts frequently claim that telehealth more broadly is a solution to workforce shortages, the argument, as it is usually presented, is too simplistic. Telehealth helps with “load balancing” across communities—fixing a problem in the geographic distribution of clinicians. However, in both the United States and globally, there are concerns that there is an absolute shortage of physicians. The Association of American Medical Colleges predicts a shortfall of 46,100 specialist physicians by the United States in 2025. 1 Therefore, load balancing of active physicians will not suffice in meeting the demand for care in underserved areas. Given the projected shortfall of physicians in the United States, recruiting retired and semiretired physicians to provide care through telehealth increases the total supply of active physicians and the capacity of the existing workforce.
Pitfalls of Using Physician Volunteers Through Telehealth
There are several challenges to engaging volunteer physicians. Programs typically use volunteers in a limited capacity because they generally work part-time and may be unable to make long-term commitments. Older physicians may have their own health conditions to manage or have caregiving responsibilities. Acknowledging this reality, most programs only use volunteer physicians for curbside consults rather than fully integrating them into longitudinal patient care. As a result, volunteer physicians may not have the opportunity to work at the top of their license or follow patients over time, which can impact satisfaction and ultimately, volunteer retention. Program representatives also report that older physicians have challenges with the technology required for telehealth, requiring extra resources to be spent on recruitment, training, and implementation.
Additional challenges may include convincing on-site providers in safety net clinics to refer to telehealth volunteers, even when there is a clinical need. Because volunteers are practicing remotely, they may have few opportunities to build rapport and trust with referring providers. The part-time availability of volunteers may also be difficult to incorporate into the workflow of busy safety net clinics. Finally, when engaging a physician volunteer through telehealth, the on-site provider is in effect making a decision to retain responsibility for the patient. Programs report that some primary care providers prefer to transfer patients rather than obtain a curbside consult, given that in the latter case they are left to implement the care plan.
Conclusions
In part because of these challenges, many of the volunteer programs are in their infancy and relatively low volume. MAVEN has trained 29 volunteers and completed just under 200 visits as of June 2016. AccessDerm dermatologists had completed 1,611 consults by 2015. However, early experiments suggest that most of these challenges are surmountable. Telehealth programs can develop standardized workflows to facilitate referrals for health problems best suited for volunteer specialists. Programs may also encourage or require occasional in-person interactions between remotely located telehealth physicians and on-site clinic staff to build rapport. As more physicians volunteer in a growing number of telehealth programs, the dual benefits of enriching the professional lives of volunteers and improving the care for underserved communities will make the effort to develop and sustain these programs worthwhile.
Footnotes
Acknowledgment
This research was funded by the California Healthcare Foundation (CHCF). CHCF had no role in the design and conduct of the study, collection, management, analysis, and interpretation of the data, preparation, review, or approval of the article, or the decision to submit the article for publication.
Disclosure Statement
No competing financial interests exist.