Medical Virtualists

Medical Virtualists? Why Create More Telehealth Barriers to Entry?

Medical Virtualists

The history of healthcare is the history of specialization from barber-surgeon to thoracic surgeon, from phrenologist to neuropsychiatrist. As science advances, specialties are created. In a recent online article Nochomovits and Sharma (Nochomvits, M. and Sharma, R. 2017) “Is it Time for a New Medical Specialty?” present an argument for the creation of a new specialty – the Medical Virtualist. The proliferation of virtual care in numerous medical disciplines underscores the need for a practitioner who will devote significant amounts of time interacting with patients using a virtual medium.  Nochomovits and Sharma note that the Medical Virtualist specialty will require the development of a set of core competencies that can be refined over time.  The authors call for a certification standard that, regardless of the specific discipline, “include knowledge of legal and clinical limitations of virtual care, competencies in virtual examination using the patient or families, ‘virtual visit presence training,’ inclusion of on-site clinical measurements, as well as continuing education.” The need for a Medical Virtualist specialty will be validated through rigorous research that demonstrates the value of this new discipline.

While we agree that professionals face many challenges with regard to remaining current with technology, we question the attempt to define a new specialty area as the solution. The definition of a new specialty has many profound impacts, including that of creating yet another barrier to entry for many who seek to partake in an area. Telemedicine has historically eschewed such attempts for telemedicine and telehealth, led by the American Telemedicine Association, who has consistently taken a strong stance against such a stance position.. In fact, it is their very movement away from such a stance that may well have led to the current widespread adoption of telemedicine and telehealth today. Their view has been that professionals need to consider telehealth as an extension of what they normally do, rather than an entirely new field. The cardiologist practices cardiology, whether it is in person or via telephone and a remote monitoring station in the patient’s home. A psychologist then, practices psychology, whether it is in a clinic or office, or via videoconferencing and an app. This argument has found widespread acceptance with many legislators in the United States and worldwide.

Much as the advent of antibiotic medicine in the 1930’s created division and turmoil in the medical world, it was resolved by a steady adoption of antibiotic medicines into everyday practice. Today, a physician who does not offer antibiotic medicine for strep throat would be considered as operating below the standard of care, and subject to scrutiny by both regulatory and civil courts. Echoing a stance we took in 2014 (Maheu, Pulier, McMenamin, Wilhelm and Brown-Connolly), it is our prediction that this same fate will soon befall professionals who don’t use technology to properly diagnose and treat patients in the years ahead.

More specifically, a social worker in an urban private practice conducting an intake with a 9-year old patient presenting symptoms of a neurological disorder would be remiss if the child were not referred to a physician and/or other professionals for specialized assessment. With the rapid advancement of technology, there soon will be a day that, if an intake professional fails to flip on a monitor to ask for assistance from an on-call specialist, the clinician will also be remiss. The ease with which such access to care is already being delivered is noteworthy (Luxon, Nelson & Maheu, 2016). Adding additional barriers to entry for professionals seeking such access should not be supported. Rather, the focus for professionals seeking to improve the system is to put their energies into competency-based telebehavioral health training to extend the reach of specialists who can work with generalists in local communities.

Another area left unaddressed by Nochomovits and Sharma is the need to develop metrics to measure the success of training programs (see Callan, Maheu & Bucky, 2016). In 2001, the Institute of Medicine (IOM) took the position that all healthcare training in the United States should be grounded in evidence-based competencies. Maheu and colleagues redressed the lack of competencies in telehealth by breaking this ground with their 2017 telebehavioral health competencies (Maheu, Drude, Herlein, Lipshutz & Hilty), who proposed 51 telebehavioral health objectives and 149 telebehavioral practices to be expected of behavioral professionals using telehealth. Such a specific, focused efforts are more likely to lead to  

Needed next are studies that answer questions such as, “Do certified practitioners have higher rates of patient satisfaction?” “Can they deliver competent services at reduced costs?” “Will legal and regulatory health care institutions recognize the added value of partnering with certified providers?”

In addition, while the authors discuss medical specialties they do not recognize the existence of non-medical professionals. To ignore the presence of behavioral professionals in discussions of healthcare reform is short-sighted. With mental illness effecting at least 20% of the US population annually (National Use of Mental Health Services, 2017), and addictions impacting an additional overall 10% of the American population (Substance Abuse and Mental Health Services Administration, 2014), it is time that professionals writing about healthcare reform recognize the foundational role played by behavioral professionals in today’s healthcare arena by including them in the discussion.

The future of telehealth is rapidly expanding and the need for trained and certified practitioners will continue to grow. The well-equipped healthcare provider of today is an invaluable asset to the patients they treat and the communities they serve. Empowering them all with adequate tools and non-restrictive laws that allow free access to those tools is the wave of the future, not creating additional artificial barriers to serving the people who need them the most.


Callan, J., Maheu, M. & Bucky, S. (2017). Crisis in the Behavioral Health Classroom: Enhancing Knowledge, Skills, and Attitudes in Telehealth Training. In M. Maheu, K. Drude, & S. Wright (Eds.) Field guide to evidence-based, technology careers in behavioral health: Professional opportunities for the 21st Century. New York: Springer.

Luxton, D., Nelson, E. & Maheu, M. (2016). Telemental Health Best Practices. Washington, DC: American Psychological Association.

Maheu, M. M., Pulier, M. L., Wilhelm, F. H., McMenamin, J., & Brown-Connolly, N. (2004). The mental health professional and the new technologies: A handbook for practice today. Mahwah, NJ: Erlbaum.

National Use of Mental Health Services. BHSIS Series S-90, HHS Publication No. (SMA) 17-5033. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2017.

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Mental Health Annual Report: 2014.



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2 comments on “Medical Virtualists

  1. There are issues that are different in seeing a patient in your office than in working with someone virtually. If professionals are not trained to lookout for the various concerns that can come up there will be situations that will occur that can put a patient at risk in behavioral health situations. Many times these are subtle issues that practitioners with good intention, may not consider- or even be aware of, when seeing a client virtually. When I see a client in my office I am clear about who is hearing the session, only the client, when it is a virtual situation I may not have thought about asking who else is in the house, is the area secure, etc.

    It would be nice to be able to have a specialty program where the mental health tele-behavioral specialist can work with people to help them understand what their options are and to identify what the clients needs. Would it be useful and cost effective to have someone in the role to bridge interactions between doctors and people trying to obtain help. Often doctors are excellent at what they do but not always at explaining things to people. If you add the virtually aspect of that to a medical field of anything but behavioral health I wonder if it will allow the patient to have their needs met or will people feel more lost if there isn’t a process of an interface to make sure a person understands then needs of what is being diagnosed? Would having the intermediary of behavioral health insure that people are getting their needs met and not feeling like they are a victim of a not-human system? Dr. Maheu has many valued points that others may want to ignore because of the cost of training. Isn’t our goal to provide help to those that need help, meaning good quality help?

    • Thank you for your insightful and kind comments, Dr. Marshall.

      The reality that I see is that many professionals don’t know what they don’t know. Like the authors of the article we critiqued, they haven’t stopped long enough to consider the whole picture. They don’t know the legal/ethical modles and why their assumptions are incorrect. (Their assumption is that digital service delivery is the same as in-person in most ways, and that’s good enough.)

      This fallacy is much akin to ethnocentrism, whereby we may tend to see everyone as sharing our values, beliefs, traditions, but in fact, many cultural and language issues can make us experience the same event in quite different ways. It wasn’t until the voiceless were heard that the government actually imposed sanctions on discrimination, and required multi-cultural diversity training became not only popular. That “ignorance is bliss” stance is now happening with telehealth too. Luckily, we are seeing leadership in national and state associations take a stand, as well as state regulators because they are hearing of the many errors that are occurring, and clients/patients are filing more and more complaints. Many of them have appracohed us for training and consultation – which is a good sign, indeed.

      In reality though, it all boils down to money. The fundamental questions create a tension: how much can I make, how much can I keep and how much do I have to pay in training and other required expenses for the privilege of earning my living this way?

      Money tension is also at the core of the funding for an interim “educator” role that you mentioned. It of course is a good idea (and actually is required through informed consent) to educate your client/patient ahead of time about possible issues. The ways telehealth can go wrong are much more involved than many professionals imagine. But, who would possibly pay for such visionary education by a third party? If a company builds such a service, where will they get their return on their investment (ROI)? The truth is that clients/patients don’t usually want to pay more for a bit of pre-telebehavioral health education, Insurance companies are not looking for new services to reimburse, and clinicians don’t generally want to give a portion of their income to another party to educate their clients/patients. There are many needs, but payment only flows for the essential. In the United States today, we don’t even have enough payment to cover the essentials.

      As you may have concluded, I have been thinking and discussing this topic with my colleagues for more than a decade. And so, I created a webinar to share the ideas with clinicians. If anyone wants to hear an hour recording of a webinar that outlines the client/patient education considerations in detail, we have a very good one available 24/7 at TBHI. It is entitled, 7 Tips for Introducing Telemental Health to Clients / Patients Let me know what you think!

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