Telemedicine is on the rise, but many physicians still have reservations. In this episode, Dr. Leo Damasco and Phoebe Gutierrez break down common concerns—from income potential to compliance risks—and share insights on overcoming these barriers.
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As telemedicine expands, more physicians are considering leaping—but not without questions.
Following a thought-provoking conversation with Dr. Hussain Mithaiwala in our last episode, Dr Leo and Phoebe tackle some of the biggest hesitations doctors have about telemedicine.
Can you make a sustainable income?
How do you navigate compliance risks?
What about the trust factor when collaborating with mid-level providers?
They discuss real-world experiences, misconceptions about earning potential, and why mindset is key to success in digital health. They also touch on the growing issue of physician burnout and how telemedicine can offer both freedom and fulfillment—if approached the right way.
Thinking about transitioning into telemedicine but have doubts? This episode might just change your perspective.
Telemedicine isn’t just a side gig—it’s a movement. Telemedicine Talks empowers physicians to explore digital health, find sustainable work-life balance, and make informed decisions about their careers—without the hype.
About the Hosts:
🔹 Dr. Leo Damasco – A pediatrician and emergency medicine doctor who transitioned into telemedicine, finding flexibility and new opportunities along the way.
🔹 Phoebe Gutierrez – Former state regulator turned startup executive, now helping companies and physicians build smarter, compliant, and sustainable telemedicine businesses.
LinkedIn: https://www.linkedin.com/in/pkgutierrez/
Email: phoebe@telemedicinetalks.com
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[00:00:00] Aloha, everybody. Welcome back to another episode of Telemedicine Talks. I'm Dr. Leo Damasco and my partner in crime, Phoebe Gutierrez. Yes, welcome back. I'm excited to be back and talk about what we talked about last week. We had our first guest appearance in our show, and it was a great talk.
I think we had Dr. Usain talking to us about what he thought about telemedicine. And as we are very pro telemedicine ~That's the telemedicine talk. ~But we brought along ~a ~what I like to call an anti telemedicine doctor, right Phoebe? ~What do you think that, ~how would you characterize kind of his thoughts about telling this?
Yeah, so I think that, based on the conversation, he didn't have enough information to really be able to assess if it's a viable option or a solution for him. And, I know myself I'm a very methodical person. I like to have all the answers. I think we all do. ~And ~My take on it is that, because it's so new, he's also really early in his career, and he's also a specialist, he's an anesthesiologist, how could he even [00:01:00] make this work for him?
I don't even think it was an option or a thought that popped into his head before, I hassled him about it. No absolutely. And I joke about it. He's actually an awesome person, the more we talked about it. definitely said, hey, yeah, there is a role. And actually pitting them as the anti telemedicine doctors is not that fair, but it's good saying for the podcast, right?
~But ~but no it definitely brings up those some issues, right? So we have been an opportunity to talk to some doctors and coach them along into telemedicine there's definitely been questions that have come up where we've had to add to multiple times. And, talking to Dr.
Hussain, reminded me of those questions, right? It's what is going on in people's heads as barriers to actually getting into telemedicine? So for this session, especially looking back with the last session, we want to address those questions and just bring up those questions.
I think it'd be very useful. We're gonna start with the question. Number one. One of the things that he brought up early enough was, Hey, can you actually make [00:02:00] enough money to support yourself on telemedicine? A lot of people, what they see in telemedicine firsthand is, Hey, okay, you're gonna sit in front of the computer.
You're gonna sit in front of the video. You're gonna make what? 15 20. encounter. And you're gonna have four encounters an hour. The math just doesn't add up there, right? So Phoebe, what have you seen in terms of kind of income, intake, so forth and so on? Yeah, I've seen a lot of physicians be able to like double, triple, quadruple their income.
I think, again, a lot of it has to do with having the right mindset. And the way I like to think about this is the same way I operate, right? Like, when I left my W 2 job and kind of jumped into this, independent consulting industry, you got to find your own ~Clint, ~clients, you got to find your own jobs, you got to negotiate your own rates, but once you're able to get a good balance, you're able to make more than like what one w two job would make, even though you're spending the same amount of time on those things.
The biggest hurdle, of [00:03:00] course, is like learning new workflows and figuring things out and going through so many different onboarding experiences. But like, all the physicians, or at least the physicians that I know that are successful in telemedicine have been able to find a really good income.
And, really something that has been able to, replace their brick and mortar income or, like their, whatever they're making now into, something that's a little bit more like an independent contractor almost like a consultant. No, absolutely.
Absolutely. And personal experience here is that, yeah, I was able to, make more than what I would make in brick and mortar. And it's not just about the money either, right? It's about really for me it's the money is a means to do something else. And really it was for fulfillment.
It was for freedom. It was really to gain time, freedom to gain location, freedom, just to do what I want when I want to do it. And it definitely gave me the means. And of course, money's an important part of that, the means to do that. So yes, we can [00:04:00] definitely, make a pretty good living off of telemedicine.
But you're right, have to have that mindset, you have to get your feet dirty, and you have to get a little uncomfortable sometimes. ~Yeah, ~and ~I, again, I think it's the same thing, ~I find it really interesting, like a lot of the physicians that I work with, they went through the same stuff that ~like, ~I personally went through I'm not a doctor, I'm not a clinician, but I'm somebody who also took the leap, got tired working for, the man, and had to go and ~like ~figure out my own way ~and, part of it again is like just, ~it is a really freeing and validating feeling being able to do something on your own.
And I think that's what telemedicine has created for, ~like almost like ~this new wave of ~like ~physicians. Absolutely. Because, we're in ~this, ~what I like to call an age of burnout, right? It's a big thing with doctors nowadays. And one of the big reasons is because there's no control, right?
~They've lost, ~we've lost control of what we're doing, we're being told what to do. And getting that control back is very freeing. Getting people that actually appreciate you is very freeing. Being able to walk in and being told, Hey, we definitely want you part of our team. [00:05:00] This is what we're going to do to have you.
~That, ~that is, it was mind blowing, mind opening when that happened. I was like, Oh, wow. Okay. ~This is cool. ~This is cool. We could carry this on for years. But, ~talking about this, so ~talking about the mindset, talking about, getting into something new also brought up another subject that Hussein was talking about.
~One, ~one of his questions was an anesthesiologist, right? There's not that many. Things I could do clinically in telemedicine, I'm going to have to try to find something new. How do I do ~that? It's, how do I go on doing ~that? Can I do that? Phoebe, do you think and what have you seen when you ask doctors?
Yeah, I think that there's, I think there's two ways, right? I think the biggest thing in telemedicine is always going to be standard of care, right? If you, as a physician, cannot clinically diagnose or treat the patient from a computer, then you just shouldn't do it, right? Common sense would tell you you're not supposed to do those things.
Now on the flip side, right? There's a lot that you can do virtually now. There's, telemedicine dermatology, [00:06:00] companies, there's, tons of aesthetics where they're being able to diagnose from a screen. But, for me, ~I, again ~I think that the beauty in all of this is as a physician You are all trained to use your clinical judgment and you should.
And if it's something that you're not comfortable doing, then by all means you refer out, ~you shouldn't, ~you shouldn't take that piece on. And that's always my I'm really big on just you got to trust yourself, and you got ~to try ~to, trust your gut, and you have to do things the right way.
You have to make sure that the patient is always number one. No, absolutely. I agree. You're right. We're doctors first, right? ~We're doctors first. ~And we all went through medical school. ~We all ~most of us went through a generalized internship. So we know the breadth of medicine.
And a lot of us ~to you ~are at the latter end of our careers. So we know what's right, what's wrong, what we can and can't do. even though we're going into maybe a new subset of medicine that we haven't necessarily practiced a lot before, we could take those principles, ~right? ~Take the principle of standard of care and apply it to ~the kind of ~the new field that [00:07:00] you're in.
And, we're all smart people too. We know how to learn new things, right? We know how to learn new things fast. A lot of us do cram the heck out of it. ~And learn ~and, Soon enough, we could be the experts in it, right? ~See one, teach one, or ~see one, do one, teach one, right?
That's how fast you become an expert, right? When you're training. The same thing. but I think a lot of us are set in our ways where, we just don't make that initial jump in, right? So you just have to get over that initial hurdle and get going. Yeah. ~Yeah.~
I think one other question too, that when I talk to physicians that are like in this weird thing that I get and I can't answer the question because again, like I'm not a clinician. ~It's ~don't doctors ~like ~miss sometimes being just brick and mortar? Don't you just miss it?
And so Leo do you? What? A layered question there. Worked in the ER. I was a nocturnist and I worked with the same people over and over again, right? We had our team, right? And it was a very close knit team. And those that know the nocturnal ER [00:08:00] community were like family, right?
We know each other real well. And so I miss the personalities and working with the personalities. I miss my friends, right? Do I miss actually working brick and mortar, working face to face with patients? There's, there's definitely some things I don't not miss, you miss all the poop ~in the ER. Yeah, that's something I had to learn about. I did not realize how much poop was ~in the ER. Yes. There is definitely a lot less poop being thrown at me when I'm working telemedicine in my office. I think the only thing I have to worry about is my six year old son trying to, play a joke on me.
And that's the worst thing, right? If he's slinging poop, then we got problems. But, no, right? I don't miss the long nights, right? I don't miss You know, the patients that were yelling at me, I don't miss, just the churn and burn of it. And, over time, it's, it was cool, and it still is cool to, to do that.
But over time, it's, there's just other things that I found fulfillment in. And I was able to do that with telemedicine. There's other things that I could do that make me happy [00:09:00] with telemedicine. I get to reach out to a population that is underserved. That makes me feel great.
~These, ~these patients are more or less very happy that you're taking care of them and they show it so it's nice. It's nice to get that feedback back, instead of just shade all the time, right? So no, overall, there are some aspects that I do miss. But overall, I have found a nice little place in telemedicine where, yeah I am very fulfilled.
And, the lack of the actual brick and mortar and the lack of actual physical interaction is really less, think one question I get asked a lot, and it's probably just because of like my compliance hat, is always around the risk. the malpractice. How do I stay on top of rules? How do I stay on top of regulations?
What? Oh my gosh, it's overwhelming, right? And, on my side, I, sympathize, I really sympathize with physicians. You all have gone to school way longer than I have, you've all been taught a very systemic approach to, [00:10:00] assess certain things and how to You know, figure, figure it out, through just all your schooling, residency, then you're finally working in a hospital and actually doing the stuff.
And so for me, it's like in telemedicine it's treated very differently. There's a lot more rules and regulations that people have to pay attention to. You have different regulation packages and when you're operating for yourself as like your own, your own boss, you don't actually have somebody mitigating and managing that risk on your behalf.
And I think that's the piece where, I always like to try to educate of the biggest thing is, like, how do you deal with compliance and malpractice is you really need to try to understand the rules for the states that you're practicing in, and you have to understand there's prescribing rules, and there's telemedicine modality rules, and there's, different rules if you're, delegating care to NPs and PAs.
There's different rules if you're, providing care to [00:11:00] Medicaid and Medicare patients. There's different rules ~if, ~depending on the different setting that care is being delivered. And so to me, the biggest thing is the way that you protect yourself is you stay informed on those rules, you ask lots of questions, and you talk to the right people, and there's tons of free resources.
online where you can actually understand what the rules are. But again, it takes that piece of that education~ that, ~that desire to learn, that desire to understand in order to just, fully have a full grasp of what you're getting yourself into. No, absolutely. Cause That's just doctors, right?
We are in the business of risk mitigation, right? And Dr. Hussain said it specifically, right? ~I, ~it's a risk. You have these licenses, you practice across state lines, ~how many patients, ~you could see up to hundreds of patients and each one in a patient is a potential risk.
How do you mitigate that risk? And you're right. ~It's, it. ~It's a different risk. Yes, there's a risk of malpractice, doctors are always accustomed. And when we think about risk is malpractice risk. But I think in [00:12:00] telemedicine, the acuity of care is so low, right?
That the malpractice risk is less. It's not absent, but it is less, right? You talk to lawyers. There's not that many malpractice litigation cases out there, if any. that involve malpractice. Or maybe one just showed up, what, last month. Maybe we can talk about that a little later as well. But really, where the risk lies is what you're talking about, right?
The compliance issue. And, it seems daunting. It really does, right? Do you really have to memorize 50 states? So forth and so on. Is it really as daunting as it sounds? Or, can we go about that? And, you talked about education, right? You talked about talking to different people, is it doable?
Is it doable? I've seen lots of physicians make it doable. But again, I think it all goes back to the transition from outside of a hospital to you're in a new territory, a new environment where you got to protect yourself. And that just means, [00:13:00] again, staying up to date.
Making sure that you have the right research and information and that you're just making informed decisions. You're not operating in a state of Oh, I have a medical license in the state of Georgia. So I guess I can, supervise an NP there, right? You just want to make sure that you have the full picture of what you're doing and that you build in a little bit of a buffer before saying yes to all the jobs that are coming your way so that you have an opportunity to, again, just You know if I paid all those money, that money for those licenses, I would want to make sure that I, take a minute or five minute pause ~before ~to, assess the risk and understand should I do this or should I not?
And that to me is like the biggest, probably one of the biggest questions I get as physicians are, working with me is like how do I, how can I do this compliantly? And then, the second question is like a really good segue is do I know if a company is legitimate and how do I know if the company has my best interests in [00:14:00] mind when it comes to compliance?
And I think you got to assess both in the same way. I'm sure Leo, like I know you've asked me, ~companies about, or ~questions about companies, that you wanted to work with, or were like trying to vet and, I think that like ~your, ~your approach to how you handled that, I think is ~the right ~The perfect approach of I'm going to go talk to somebody who's a little bit more knowledgeable about this stuff.
What questions should I ask? ~Should I, ~how could I assess it? And, for me, ~like ~the biggest thing is if you're working with a company and they don't have a compliance officer, I don't know. ~Dread fly, right? ~But see as doctors, we don't know that, right? If you're coming from brick and mortar.
You're not taught to be like, Hey, how about you ask about their compliance officer, it's assumed already. It's already built in, right? It's built in. It's part of the process. It's already ingrained. And we're not necessarily clued in to ask about that. You bring a great point like these startups.
don't necessarily have your best interest in mind as a doctor, right? They want somebody to practice and they want somebody to help their business along, right? [00:15:00] But you cannot assume that they're going to have your full best interest in mind. And I think that's where a lot of doctors in the past who found themselves in trouble that's how they got themselves in trouble.
We were, most of us are trusting people to begin with anyways, right? So we're like, okay, great. Yeah, it sounds great. There's a lot of fancy words behind it. I'll sign it, right? And it sounds good. ~I, ~you tell me that everything's kosher. Perfect. Let's go for it. Yeah. And I also think too, like I'm really big on, and ~I, ~it's probably just like my policy and regulatory background of I overshare.
I try to be really clear with what I'm talking about because, like we all, all physicians throw around the term credentialing, but That's just a term. Companies define that completely differently. It could mean different levels of credentialing, how deep they're gonna dive. The same thing goes with compliance.
So whenever a person goes Oh yeah we covered. Yeah, we're completely compliant. Compliant with what? Are you compliant with The telemedicine rules. Are you [00:16:00] compliant with D. E. A. Prescribing guidelines. Are you compliant with Medicare billing? There's so many layers. And again, it's all just about asking those questions and making sure that you have the information.
And, Leo, to your point, right? I do want to be like, really, from somebody who's been in, in the startup world, when you're building from something from the ground up, you can't do something if you don't know about it, right? And half of the startups that, I've worked with or, that I, gotten to, consult for, it's, they just simply don't know.
And for anybody who has done any sort of regulatory research or understands that process, go try to figure out if there is a rule or a regulation, it is an investigation, you are diving into this stuff and half of it is they just, some of the companies don't even know where to start or they don't know where to look to get the answers and so they're operating in a space of, I'm okay, and then you're [00:17:00] like, you forgot that CFR or you forgot that, that very specific rule that completely shatters, your compliance structure.
And so part of it is this and again, I think I said this on a past episode of compliance is always an evolution. But you gotta make sure that you have a team and a company that's willing to meet that versus oh no, we're just gonna ignore it and continue to perceive like everything's okay.
Yeah. And when I vet companies, that's one of the big kind of important factors that I take in, are they willing to change their practices? Are they willing to spend money to be compliant? Or. Are they just going to ignore it and really lay somebody else out on the line? Now, I may have misspoke a little.
Okay, so not all startups, don't care about the docs or whatnot. Actually, I found that most startups do, and they do want to partner with the doctors to do good and to do, the right things. But really the point is, you ~just can't assume ~just can't assume that every single one is like that [00:18:00] so yes, you have to vet these businesses you have to ~bet who you partner or ~vet who you partner with and Just be very critical before you sign on that line But again, this is scary talk sometimes but it is possible and it's very possible and once you get used to it and once you start You know, getting accustomed to knowing what to look for, it becomes almost second nature, right?
It's almost like another job interview. So yeah, not that daunting. ~It is something different. ~It is something different that we as docs are not used to. Yeah. And I always say what's the scariest thing that anybody in the United States can hear? It's can I audit you? So my only thing is worst comes to worst, you have nothing else to ask them.
Go, hey, would you be okay bringing in an outside auditor to just come in and look at your compliance? And if there's hesitation or if there's an immediate no that's a really good indicator. And you don't even have to mean that you want to do it. But to me, it's a good indication of how transparent they're willing to be with you as a [00:19:00] physician.
To open up their books and let you take a look, so I always like to use that tactic and that's what I tell, some of my, physician clients worst comes to worst just throw that out there and see how they take it. What's been the responses? Oh, man, ~it's, ~the responses have been all over the place we've had companies be like, absolutely not we would never, which to me, I'm That's a Medicare company, man I wouldn't be comfortable, proceeding if I were you, but you do what you want.
The majority of them are completely like, yeah, absolutely, we'd love to, most of them go, we would love to sit down with you, with our compliance team, or our compliance officer, and walk you through our stuff. And then they always go if there's something missing, or there's a gap, because again, when you talk to a real compliance person, like me, We all know there's probably a bunch more gaps, so it's okay that everything's not perfect, but you got to make sure that you're working with a team that understands that and is willing to make the changes.
Kind of what you said earlier, Leo. Yeah. Yeah. No it's really the [00:20:00] willingness to help out, the willingness to be transparent versus, hey, I'm going to just shut down and this is what you got and take it or leave it. In those cases, you may want to consider it. Yeah. So one other topic that came up was collaboration.
The big part of telemedicine is nurse collaborations, maybe PA collaborations. And Dr. Sen was like I'm not that comfortable doing it. I, one, I'm not there in person. So how do I know that this person that's using my license is actually, doing the right thing?
Also, am I going to be on the hook? What is, again, coming back to risk, what is my risk for this? You know what? What's your thoughts about that? I think there's definite risk, right? I think like Hussein also said like he doesn't even supervise mid levels like in the hospital He's if I'm here, I'm just gonna do it, so I think like you might have some trust issues I've talked to his wife about it.
~She's I don't know. ~But you know for me, I think again The risk always comes [00:21:00] when You are not necessarily doing your due diligence to stay on top of it, right? I think it's, and I think that goes like end to end in all of it. If you don't want to learn the rules, you don't want to understand the workflows.
You don't want to actually do the stuff that you're supposed to do with collaborating. I think it's dangerous territories. And I actually was recently talking to a physician who got into collaborations and she got a board action. She was new at it. She was working with a company.
She, Didn't realize all the rules and regulations and she got a board complaint and you know to her point She's I just didn't know and you know to me I always like to go back if you really think about what a supervising physician is supposed to be like they're supposed to be a mentor and they're supposed to educate the practitioners.
And then they're also supposed to tell them when they're doing stuff wrong before it gets to where it harms a patient or somebody [00:22:00] complains about it. And I think those are the pieces where. If you want to do collaborations, you got to make sure that you're reviewing charts because that's a good indication of whether they're doing things the correct way.
You want to meet with them because do they have questions? Do you have questions? How are assessing them? For me, it's it's all those pieces that I think sometimes In some of these leadership roles for, in telemedicine, I think the doctors forget what I think they, they sometimes focus too much on the regulatory nature of oh, ~there's, ~I have to review 5 percent of charts, and I have to have ~one, ~once a month meeting I tell them you should review 10 percent of charts and you should meet with them twice a month and that just protects you.
If somebody's using my license, I want to talk to that person every single day and be like, what did you prescribe? What did you do? So to me, like, and I, Leo, you know this, I'm super passionate about, delegation. I'm super, passionate about independent practice for NPs because I really think it's that.
really interesting place where physicians can get out of doing the care and actually [00:23:00] become teachers. And so for me I think the doctors that do it, if you do it the right way you actually mitigate the majority of all of your risk as long as you're just, being a good collaborator.
Yeah. The key is being an active participant in that, right? There's definitely some collaboration agreements where They just say, Hey, we we'll forward you the cases and you say you review them and then that's that, and we could talk asynchronously. That's maybe not the best answer for that.
And on the flip side too, for the docs, some people see these collaborations as, negative for the docs, we're teaching the people that may be taking our jobs. And we go further into that. But. There's an also another way to look at it. It's like you are the teacher.
You are now dictating the level of care, right? And sometimes, the mid levels the patients that don't have access, that's the only time they get to see somebody, right? And that's the way that you can extend your care and extend your reach. So that's one way. It's funny because, ~I, ~I grew up as a [00:24:00] doctor in the military system.
And one of the first things that I had to learn and be comfortable to do was supervise not just nurse practitioners, nurses, but also medics and to do, yeah, they were running sick call all by themselves sometimes out in the middle of nowhere. And even going down to that level. So I got very comfortable.
I had to be. very comfortable, very quick, but also develop internal processes on how to review and give feedback so forth and so on. So it was a little bit easier for me to trust and transition to that because that's basically my first three station was Yeah, here's your medics. And I was like, Oh, my gosh, what?
Okay, and then you had to learn that real quick and learn the trust part real quick. So yeah, I think you hit the nail on the head though, right? Like you can get It's all about trust, right? Like the majority of all of this is about trust. And again, ~like we do. ~We live in this culture where nobody wants to do anything because [00:25:00] everybody's so nervous about getting sued all the time.
And ~it is, ~it is interesting when you can find people that you have mentored, right? You have taught them everything. They have Demonstrated that they're doing great work it does turn into some I don't know, it warms your heart a little bit, you do have a sense of trust, and even with the companies if a company is transparent with you, you do feel a little bit more I can trust them a little bit more, there's this mutual, respect that you have, and I think, again it's all about getting those right things for you.
In order to build that trust and to make it work. Yeah, no absolutely. And a key there is you're the actor participant into it, right? You can't just sit and wait for trust to be built between the, right? You have to play in a big role ~in, ~in building that trust between, right?
It just doesn't come along, right? Like in most relationships. You have to build that trust and foster it. So, yeah, ~no ~no, these are definitely interesting, thought provoking questions that came out of Hussein's talk, and it was [00:26:00] very interesting because, again, when he was talking and we were talking about it, these are the questions ~that, that, ~that people come to us a lot when they are thinking about going to telemedicine.
Super useful. And it's awesome that you were able to talk about it. Yeah. And I think if you have questions, be sure to comment. Add those and we will address them in a future episode. ~We'd love we, ~the questions that you give us helps us drive content and make sure that we're giving you all the things that you all want.
Absolutely. And definitely check out the show notes. Subscribe. Also, if you want further talking we could discuss further. Drop us a line on our website. And we could definitely help you, direct you the way to find your answers. And if we don't know the answers hey, we know people that do.
So subscribe, follow, and we'll see you again next time.