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Yalda Jabbarpour, MD, a family medicine physician in Washington, DC, has a sometimes months-long waiting list for patients. But often, patients have pressing symptoms, as was the case with one female patient who contacted a direct-to-consumer (DTC) telemedicine company. 

Her telemedicine physician diagnosed the patient with a urinary tract infection after hearing her symptoms of frequent and painful urination. The DTC physician did not require lab cultures, a follow-up appointment, and did not recommend that she see Jabbapour. 

For the next 9 months, Jabbarpour's patient sought care through other direct-care companies, which would call in a prescription that fit her symptoms without advising her to see her usual clinician. The lack of coordination between the DTC clinicians and Jabbarpour masked a larger issue that could have been caught earlier if the woman had been seeing one physician or, at the very least, if her medical records were being shared. 

After 9 months, the patient finally went in for her annual wellness exam with Jabbarpour, who made a new diagnosis: type 2 diabetes. 

"If no one is there to put that picture together, it can be dangerous," Jabbarpour said, noting that although the patient's diabetes is now managed with medication, nearly 1 year passed before her insulin went back to normal. 

Among a growing shortage of primary care physicians, many clinicians recognize that DTC models such as Amazon Clinic and Hims & Hers Health can increase access to care. But many also worry that the lack of continuity between these online-only providers and in-person clinicians can put patients in danger of missed diagnoses or on unnecessary drugs, especially antibiotics. 

Some in-person clinicians are rethinking their own care models to ensure that patient needs are being met in a new era of healthcare. 

"Our reflexive response when we hear this is how our patients are getting care is that this isn't a good idea, but we need to take a balanced view," said Richard Wender, MD, a family physician and chair of the Department of Family Medicine and Community Health in the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. 

Wender believes that patients need broader access to health services in the face of primary care physician shortages. But he and others say telemedicine services are not a replacement for primary care visits. 

"It's all related to not having enough medical personnel available to take care of the population," said Jesse Bracamonte, DO, a family physician at Mayo Clinic in Arizona. "People are looking for healthcare where they can get it in a timely fashion." 

A Fragmented Model

A recent poll from the University of Michigan found that although less than 8% of patients between ages 50 and 80 years had used a DTC health platform, of those who did, one third had been prescribed a medication that their primary clinician did not know about. 

Though current use of DTC platforms was not high, more than 42% of those surveyed between ages 50 and 64 years said that they would be interested in seeking care through online-only providers in the future. 

Meanwhile, the American College of Physicians issued a statement in early January expressing concern over DTC websites that employ physicians to prescribe prescriptions for specific medications. The statement followed the launch by Eli Lilly of LillyDirect, a digital pharmacy that links patients with independent telehealth clinicians who can write prescriptions for the company's drugs, including tirzepatide, its popular medications for obesity. 

"Telehealth is most beneficial when it strengthens the patient-physician relationship, but the direct care model doesn't do that," said Steven Furr, MD, a family physician in Jackson, Alabama, and president of the American Academy of Family Physicians. "They may not understand all the medications a patient is on, and without having their records, they won't know if they have any chronic conditions." 

Direct-care models could be made safer if electronic records from these visits were shared with the patient's primary provider, Jabbarpour said. Had she been updated on her patient's recurring direct-care visits for a urinary tract infection, Jabbarpour could have identified the underlying problem sooner. 

Clinicians Reworking Their Own Care Model

Nathaniel DeNicola, MD, an ob/gyn with Caduceus Medical Group in Orange County, California, has adapted his private practice. He now keeps slots open every day for emergency telehealth appointments in an attempt to offer patients an alternative to DTC competitors. 

"The promise of these telehealth options is to augment our necessary and still very important brick-and-mortar care," he said. "A lot of patients say they use these companies in a pinch." 

He said that the pandemic pushed clinicians to expand their virtual services that address major pain points in the healthcare system, including patients needing to book appointments weeks or months out. 

"On-demand services are becoming the norm," he said, adding that in his experience, patients still want an ongoing relationship with a clinician. "The future is a hybrid model." 

A recent survey by the American Medical Association found that nearly 75% of physicians reported telehealth was part of their practice in 2023, which is nearly three times as many as in 2018. Some DTC services are also moving to a hybrid model. Amazon's One Medical, a subscription-based primary care company, has partnered with clinics that can provide in-person visits when telehealth is inappropriate. 

DeNicola said that in his experience, the virtual-only direct-care model can leave patients with questions or without an understanding of the risks associated with medications, such as certain types of oral contraceptives. Offering patients ways to get quicker access to care with a hybrid model can ensure the convenience of the direct-to-consumer model while ensuring patients are seen in-person when appropriate. 

If a patient who has had a birth control prescription in the past wants to start again, a prescription can be safely provided through a telehealth service with their regular clinician who can review the patient's electronic records, DeNicola said. But issues such as a suspected vaginal infection would require an in-person appointment. 

Jabbarpour has also shifted her model to better accommodate sudden health issues, such as UTIs, for patients who may not be able to be seen for weeks. 

She tells her patients to message her through the patient portal regarding any issues that arise so she can help determine the best course of action. Sometimes Jabbarpour recommends a patient go to an urgent care clinic. Other times, if a patient has had the same health problem before, she will prescribe a drug that worked in the past on the same day, without the need for any kind of visit. 

"I understand the patient point of view. They need to get care when they need to get care," she said. 

Jabbarpour added that she does have to answer requests on her own time, after her clinic hours are over. Most insurers will not pay for this time, she said, so she does not recommend other physicians work off-the-clock. 

"You can burn out faster and then we have even fewer physicians," she said. 

Kaitlin Sullivan is a health, science, and environmental journalist.