The skeptical cardiologist drove to California last week. The former eternal fiancee’ and I loaded half of our St. Louis belongings into our green Mini Countryman and set off down the semi-lethal I-44 early Monday morning.
This move was possible because I have changed the manner in which I work for my employer St. Louis University. As my wife and I had grown tired of the cold St. Louis winters and the hot and humid St. Louis summers and besotted with the beauty and climate of the San Diego area I proposed that I work remotely for 8 months and in person for 4 months of the year. This, I believed, would be a win-win situation as it would allow me to maintain (a somewhat smaller) practice for many years while continuing to provide for my employer assistance in the areas in which I have great expertise and experience.
With the arrival of a new chief of cardiology at SLU, Dr. Kishore Harjai, who had the wisdom and foresight to work with me to achieve a new physician work paradigm, we changed my contract late last year. Since then, I’ve been doing telehealth visits with the patients in my practice who are appropriate for remote visits and reading echocardiographic studies remotely. For two months in the spring and two months in the fall, I will be doing in-person office visits in St. Louis along with weekly rotations seeing cardiology consults in SLU hospital.
Medical Licensing and Telehealth
Medical licensing in America is a state-based, tiresome and expensive process. Although I have been fully licensed in Missouri (and before that in Illinois, Ohio, and Kentucky) and have practiced medicine for 30 years without any issues, a patient from Belleville, Illinois, which is across the Mississippi, just east of St. Louis would not be allowed to do a telehealth visit with me.
There was some relaxing of this mandate at the onset of the COVID-19 pandemic. This allowed me to see patients who had sought my consultation who lived in states other than Missouri, including New Jersey, Washington, and Louisiana. However, over time, individual states changed or eliminated the COVID-19 waivers and determining whether it was OK for me to see a patient from a state in which I did not have a license became more and more difficult.
There is hope for a country-wide approach to medical licensing and 34 states have adopted the Interstate Medical Licensure Compact (ILMC.) This is an agreement among participating U.S. states to work together to significantly streamline the licensing process for physicians who want to practice in multiple states.
The Interstate Medical Licensure Compact is “an agreement among participating U.S. states to work together to significantly streamline the licensing process for physicians who want to practice in multiple states. It offers a voluntary, expedited pathway to licensure for physicians who qualify.” It is one approach to facilitating telemedicine across state lines.
The IMLC website describes its mission as follows:
The mission of the Compact is to increase access to health care – particularly for patients in underserved or rural areas. The Compact makes it possible to extend the reach of physicians, improve access to medical specialists, and leverage the use of new medical technologies, such as telemedicine. While making it easier for physicians to obtain licenses to practice in multiple states, the Compact also strengthens public protection by enhancing the ability of states to share investigative and disciplinary information.
The Compact currently includes 34 states, the District of Columbia and the Territory of Guam.
I now have three state medical licenses (Missouri, North Carolina, and California) and with any luck one of them would be from a state which participates in the Compact but unfortunately as this map shows, I am out of luck.
Missouri and North Carolina have introduced legislation to join the Compact but California hasn’t even reached that step.
Telehealth Visits With The Skeptical Cardiologist
If you live or work in California, Missouri, or North Carolina you can be a telemedicine patient of mine. No matter where you live you can see me in person as a patient during the time I’m in St. Louis in the spring and fall.
For eight months out of the year, I will be in sunny Encinitas, California. We drove 1861 miles over 5 days to get here, stopping in Tulsa, OK to visit my sister and brother-in-law in Roswell, NM, and dipping south to Tucson to spend a day.
I was able to check another National Park off my list as we stopped at White Sands NP and spent some time hiking on and between giant white gypsum sand dunes.
Peripatetically Yours,
-ACP
35 thoughts on “Gone To California:Telemedicine and Medical Licensing”
Hi Dr Pearson,
I love your approach to life and to medecine. I’m a fan of Cinque Terre also.
I’ve been reading your blog ever since I developed AFIB and have had 2 ablations.I’m AFIB free after 4 months of the last.
.My life is between France and India. I’m followed by cardiologists in both places, but even though I am happy with the care they provide, often I find myself up against a block when I ask more probing questions.
Your recent blog mentioned how you were going to spend a good amount of time in S Calif, near San Diego., and that tele-medecine would become an integral part of your practice.
Would there be the possibility of my benefiting from your opinions?
Yours, inquisitvely
Richard Holkar
Richard,
Thank you. Cinque Terre one of my top 5 places on the planet!
I am doing telemedicine extensively and will contact you by your email .
Dr Pearson
Good luck to you both in SOCAL. I am not surprised you moved to a warmer climate, I am beginning to loathe winters too and would welcome year around warm weather that was conducive to being outside.
Your post did make me think back about a study I read a while back on weather and incidences of cardiac events. It was an observational study published in JAMA utilizing a combination of the SWEDEHEART registry and correlating events to weather data from a meteorological source. I would imagine the stability of temperature and baro pressure would play a bigger part in CVE, but I’m guessing, any anecdotal experience with “better weather” and reduction of CVE?
Here’s the study https://jamanetwork.com/journals/jamacardiology/fullarticle/2706610
Christian, health in
I may have touched on this topic somewhere on TSC. It is intriguing that observational studies definitely shower risk of MI associated with colder temperatures and less sunshine. Now that you have reminded me of this, I will submit my moving expenses to my health insurance company.
The authors of SWEDEHEART appropriately identify multiple factors that could explain their findings beyond the cold’s vasoconstrictive effect on coronary arteries.
A number of conditions associated with an increased risk of MI are more prevalent during colder weather. Respiratory tract infections and influenza are known risk factors for MI that have a clear seasonal variation that may contribute to our findings.27 A 2018 study showed a 6-fold increase of MI 7 days after a respiratory infection.28 Ongoing randomized trials are currently evaluating the role of influenza vaccinations in patients after MI and risk of reinfarction and mortality.29 Season-dependent behavioral patterns, such as reduced physical activity, dietary changes, and depression, may also contribute to the increased occurrence of MI during cold weather.30 Vitamin D has been proposed to play an important role in the seasonality of cardiovascular disease and mortality, and this could explain the associated risk of MI and sunshine duration. Previous studies have reported that blood pressure as well as cholesterol levels are minimally lower during summer, possibly contributing to the lower associated risk of MI in our study.31-37 However, randomized studies have failed to show any effect of vitamin D supplementation on MI risk.38,39 Seasonal analyses and analyses adjusted for time of the year are therefore plausible but should be interpreted cautiously because weather is strongly correlated with time of the year.
I can’t make much of my anecdotal experience but I have seen a lot of patients go to ERs with MIs while shoveling snow
Dr P
I’ve been reading your blog, with interest for quite some time. My daughters emigrated from Cape Town South Africa and live in California. They love it – I still live in Cape Town at the seaside which has a mild climate almost year round. Nothing like lovely summers and easy winter weather as we age! Best of luck to both of you and try and make lots of outdoor time
Jen,
Thank you. Spending time outdoors is very therapeutic and the San Diego weather and natural beauty allows me to maximize it.
Dr P
Welcome to California. I will look forward to becoming a patient once you are settled. I have been an active follower of your blog. You helped me when I was rushed into surgery at Scripps Memorial in SD after an angio indicated I had 85% blockage in my left main artery resulting in 3 x bypass. Ia.so live in Encinitas for 33 years and it’s awesome.
John,
Thank you. You likely have seen many changes in this town. There are still some areas that have retained the sleepy surfer/beach vibe which we appreciate,
Dr P
So happy for you both. Enjoy, Don’t forget to check out Lake Tahoe,Dee
Congratulations on a successful move. But California? Having lived here since 1959, I can no longer recommend California as a go-to place for anyone who has at a minimum, one conservative bone in their anatomy. However, politics and asinine government administrations aside, it’s a reasonable place to spend the winter months. It’s been strange having a few February days exceed 90 degrees here in Central California, especially since my broccoli and brussels sprouts can’t decide whether to bolt during the day or freeze at night. At any rate, hope you enjoy success while you are here, and stay out of trouble down south.
Agreed, Greg. We left SoCal for KY about 15 years ago and have never felt like going back. CA weather is the best on the planet, but the rest is madness. Congrats on a successful move, Dr P, and hope you do well there.
Mike,
Having lived in Prospect, KY for nearly a decade and raised my kids there I can understand your love of KY.
Hopefully the climate and natural beauty of CA will overcome the madness.
Dr. P
Wow, the world seems pretty small sometimes. I live near Zorn Ave now, and surfed Swami’s a few times growing up. Thank you for your writing here. It’s made a difference in my way of thinking.
Greg,
I have several conservative bones in my body. One is in my right ear. At one time the majority of my bones were conservative. I voted for George Bush twice! I was a big fan of fiscal conservatism and balanced budgets. My philosophy makes me an independent as I approach all issues, scientific, medical or public policy, from an unbiased perspective, focusing on the real data and facts underlying recommendations. Sometimes this approach makes me appear conservative, other times progressive.
Dr. P
I’ll chose to believe one of those two times was for George HW Bush. It softens the blow . . . a bit. : )
Marcus,
HW looks fantastic in retrospect
Dr P
Well welcome to sunny Southern California! Since we live in Temecula, we are almost neighbors. The beaches of Encinitas are my favorite! We spend a lot of time in Encinitas all year round.
Cheryl,
Good to hear. So many beaches and so little time!
Dr P
Best to you and your eternal fiance–hope it works out even better than expected.
Incidentally, my late dad was stationed at White Sands when the first A-bomb blast went off at Alamagordo. He told me it knocked him out of bed.
Steven,
Thank you. Cool White Sands story. We really wanted to go by the obelisk that marks the spot where the first A bomb was detonated.
Unfortunately, you can’t visit the Missile Base (or see this monument) until later in the summer.
Dr. P
Looking forward to seeing you in the spring or fall of this year. Just tore my Quad Tendon so I may not be rehabbed enough for travel this spring.
Tom,
Hopefully the quad tendon will be healed enough for in person visit but given your extensive self-monitoring apparati, telehealth is always a good option.
Dr P
Welcome to CA! I have read your site with interest for many years and hope for more to come. The climate, beaches, mountains and the varied people make this a great place to live. I grew up near St Louis and don’t miss the winter ice and the summer humidity. I have been in Chico in Northern CA for 35 years. Welcome and keep up the good work.
Steve,
Thank you!
Dr P
How do we book an appointment with you in Encinitas?
Dan,
Good question. I am eyeing a potential office across the street. I will have to see if SLU is open to “SLUcare West”
I note lots of “integrative” doctors offices, chiropractors and massage therapists around here but haven’t seen a cardiologist office yet.
Dr P
Welcome to California! While our high taxes are an issue for most, the climate, the great universities and other options for higher education, and the varied scenery make it all worthwhile. Do be aware of ‘June gloom’ – can be cold down there when the fog rolls in. I’m in northern CA, but my younger son is down your way with one home in beautiful Laguna Beach. The San Diego area is culturally excellent (OK, not San Francisco, but still very appealing). May you enjoy many years in this part of the USA!
Thank you!
I am enjoying the climate, the beaches, the culture and the people. I am steeling myself for the taxes, high gas prices and the June fog.
Dr P
Sad, California? I thought you had better judgement
My non-medical judgement is often questionable.
Dr P
oh well, enjoy the weather. Been there, done that !
Nice weather becomes more and more important to me as I age
Dr P
That’s why I’m in FL(and no state taxes)
Hello Anthony, I sold my private Orange County practice in 2007 after 20 years of administrative hoop jumping while enduring the insufferable traffic snarls between the 5 hospitals where I was on staff. It was quite a relief to finish my career as a traveling locums in the far more professionally friendly NW. Now happily retired, I have kept my WA residency while spending the winters in Laguna Beach. My advice would be to avoid CA residency by spending less than six months of the year there and learn to surf!
Ok then! We are in Sedona at the moment. Soon we will be returning to STL. I have an appointment in June.