Not long ago in a community intensive care unit (ICU) in a midsized American city, I cared for a sick young woman who had just delivered a baby. Part of the placenta, which is supposed to be fully expelled following delivery, remained in her uterus. This condition, known as “retained products of conception,” provided an opportunity for bacteria to infect the retained tissue. The infection spread from her uterus to her blood and pushed her into septic shock, a condition where an unregulated inflammatory cascade causes refractory hypotension and organ dysfunction.

As a traveling ICU doctor, I first met this patient one morning after she returned from the operating room (OR) where the OB/GYN physician had removed the retained pieces of placenta from her uterus the night before. The purpose of the operation was to obtain “source control,” a tenet of sepsis care which deprives the bacteria of an ongoing base from which to mount an attack on the body. Following her trip to the OR, given time, intravenous fluids, antibiotics, and vasopressors (IV medications used to support her blood pressure), I expected this young and otherwise healthy patient to make a full recovery.

When I left the ICU that day around 4 p.m., the patient was improving. She was off the ventilator and on a moderate amount of vasopressors as she recovered from septic shock. That evening she took a turn for the worse. By 9 p.m. her shock had cascaded out of control, requiring three different vasopressors at high doses. Shortly thereafter she arrested.

At home that night, I had no idea that my patient was crashing. Instead of calling me for advice or staffing an in-house nurse practitioner (NP) or physician assistant (PA) who would have worked with me to manage her care, the ICU nurses called the on-call tele-ICU physician. That physician, who simultaneously covered seven to eight ICUs and received no routine sign-out on the ICU patients they covered, beamed in by video and ran the patient’s code. After a short period of CPR, the patient regained a pulse, the tele-ICU physician wrote a brief event note, entered some orders, and then was gone.

Gone from the video feed, gone from the hectic medical fray that comes after a patient survives a cardiac arrest, and off to the next patient. No call to me, no call to the OB/GYN who did the surgery, and no discernable thought to what caused the patient to arrest.

That night the nurses were left to white-knuckle it, caring for the patient without a leader, hoping she’d survive to see the light of day. When I arrived the next morning, the patient was a septic ball of fire. She had developed multisystem organ failure, required a fourth vasopressor, and struggled to maintain an acceptable blood pressure. It took me less than 10 minutes examining the patient, reviewing her medications and laboratory results, to put it together. She had additional retained products of conception that the first operation missed. Her sepsis was not controlled. I called the OB/GYN physician, and they rushed her back to the OR. They found and removed the missed placental tissue. But it was too late. We had missed her window. The organ dysfunction was too far gone, and the inflammatory state was too profound. She lived for a short time after returning from her second operation but died later that day, a victim of our modern solution for staffing our ICUs.

Good critical care is attention to detail. There are thousands of data points in the form of the history, physical exam, hemodynamic monitoring, laboratory results, imaging studies, ventilator settings, medications, and dosing associated with each ICU patient every day. A good ICU team (consisting of nurses, pharmacists, respiratory and physical therapists, and led by a critical care physician) sifts through and synthesizes the data to formulate a clear clinical picture in order to chart the best medical course. In the ICU, knowledge is cumulative. Generally, the toughest day is Monday when the ICU team turns over and the physician must learn all the medically complex patients from scratch. This requires getting sign-out from the prior physician, examining the patient, reading through the chart, reviewing test results, and observing how the patient responds to medications and interventions. The knowledge gained from a patient one day carries forward and informs care the next. Using tele-critical care as a substitute for an in-person physician, NP, or PA undercuts this.

During my years working in the Brown University Medical ICU, morning and evening sign-out rounds were invaluable. The day and overnight physicians, who worked a week straight, had a running knowledge of the patient and signed out at the patient’s bedside. While the diagnosis, daily plan, and lab tests could all be found in the electronic medical record (EMR), sign-out rounds were where we communicated the essence of the case and the important nuances of the previous shift’s events. So much that happens in the ICU is not captured in the EMR, yet today so many in medicine act as if the EMR can replace teamwork and human interaction. With tele-critical care there is no sign-out. Lost with it is the continuity, the details, and the meticulousness that is the foundation of ICU care. When the tele-ICU physician beams in each night, they do so half-blind, scraping the EMR for information without context, hamstrung in their ability to provide good care by what they don’t know.

There is a physicality to good critical care medicine. Its practice requires an experienced physician to listen to the lungs carefully, feel the extremities to assess perfusion, and to palpate the abdomen to determine if it’s surgical. Findings like the dry crackles of interstitial lung disease, the odor of C. diff, or the abdominal pain out of proportion to exam of mesenteric ischemia are often subtle and can take years of training to accurately discern. Tele-critical care splits the exam process which should be contained within a single person into a job for two. It outsources the physical exam to another person whose hands, ears, and nose are not directly connected to the physician’s brain. As a result, the tele-ICU physician is forced to make high-stakes decisions based upon exam data they never know if they can truly trust.

If this weren’t bad enough, tele-critical care has a pernicious way of diminishing the level of physician ownership of and devotion to their patients. The act of showing up each day, repeatedly interacting with patients and their family members, and attending in real time over the medical victories and setbacks forges an important bond between physician and patient. If I am working in the ICU and I hear that another patient across the hospital who I haven’t cared for has died, it won’t personally impact me. But if one of my patients who we believed should have pulled through dies, I’ll care deeply and the loss can be devastating. Tele-critical care turns the ICU physician into a virtual consultant, always partly removed, present for only a fraction of the day, and never fully invested in the care of any ICU patient. The medium itself makes a genuine interpersonal connection between patient and physician a near impossibility.

In the waning days of the COVID-19 pandemic, I worked on the other side of the tele-ICU exchange. As part of an urban-based critical care group, we provided tele-ICU coverage to the smaller rural surrounding ICUs. Every day we’d beam in and make our recommendations: Lower the tidal volumes to achieve a lung protective strategy, lighten sedation to perform a neuro exam, trial pressure support, and attempt to extubate the patient. Sometimes our advice was followed; often it was not. After we left the video rounds, the nurses would have questions or fears and deviate from the medical plan. Being present, in real life, in the ICU gives the physician an opportunity to assuage fears and support the staff. If a patient needs a CT scan before surgery but the nurses are afraid that the patient is “too sick to travel,” your job as an ICU physician is to go with the patient and nurses to radiology. A physician in the flesh ensures the patients’ daily care plans are faithfully executed and the care is advanced. Tele-critical care creates a gaping hole in clinical leadership. It’s like fielding your quarterback for the first play after kickoff and the start of the second half, but pulling him for all the remaining downs. The in-between really matters.

Tele-critical care’s negative effects on health care are now measurable. The specialized training ICU physicians receive was long ago shown to save ICU patients’ lives when compared to care provided by non-ICU trained physicians. In the largest and best quality study on the subject to date, a 2024 randomized trial of more than 17,000 patients compared tele-critical care to ICU care provided by nonspecialty trained physicians and found no difference in mortality or ICU length between the groups. In effect, the benefits of specialized ICU expertise were lost with the practice of tele-critical care.

Taken together, the break in handoffs, the lack in continuity of care, the shoddy exams, the depersonalization of the doctor-patient relationship, and the absence of a clinical leader leave patients and physicians wondering how they got wrapped up in this farce. Arriving one morning in an ICU that used tele-ICU physicians to cover the night shifts, I caught an anesthesiologist who had been called to the unit in the early morning to manage a sick patient’s airway. “I just intubated the patient in bed 14. The TikTok Doc beamed in and left some orders. You’ll probably want to check over those.”

The disdain was palpable. In tech-bro parlance, we’ve moved fast and enshitified medicine.

In that same ICU, the most common response on the annual nursing survey for years running is that the nurses don’t want to be a patient in their own hospital. They see physicians and the administration abandoning patients when they’re at their most vulnerable to save money. I can’t count how many times physician colleagues have told me that they would never want their families or themselves to be a patient in an ICU that used tele-critical care. Yet too many physicians are actively complicit or have tacitly accepted the expanding presence of tele-critical care in our modern health care landscape.

In 2010 less than 8 percent of ICU patients received tele-ICU care. By the onset of the COVID-19 pandemic, that number had grown to 15-20 percent. Since the pandemic, while public-facing statistics are scarce, anecdotally the use of tele-critical care has exploded. Yes, there is a role for tele-critical care in remote critical access hospitals where hiring specialty-trained physicians, NPs, and PAs is difficult or impossible. Ideally, this is to manage low-complexity ICU level patients at those hospitals and stabilize the sick ICU patients prior to transfer to better-equipped institutions. But the rapid expansion of tele-critical care isn’t just happening in the remote parts of America; it is happening in the medium and larger-sized cities. Multibillion-dollar health care systems have taken advantage of the post-COVID climate and rapidly expanded the use of tele-critical care medicine in towns and cities because they want to avoid paying an in-person MD, NP, or PA. The young mother who I cared for who died because tele-ICU medicine couldn’t deliver the basics of ICU care didn’t die in some remote critical access hospital. She died in a city.

Regrettably, as I approach 20 years in medicine my experience is that most health care administrators don’t care if the quality of care physicians deliver to patients is a 10 out of 10 or a two out of 10, just so long as it’s a billable encounter. Now that the door of tele-critical care has been flung wide open, many health care systems will resist returning to in-person care models even when they are aware that patient care has deteriorated. Frontline medical workers who show up each day and care for patients in the ICU must not make the mistake of looking to health care administrators for moral leadership. We are not helpless in this. Specialty-trained critical care physicians control a key choke point in the tele-critical care business model. Aside from providing tele-critical services to hospitals that have an official critical access designation, critical care physicians should refuse to work tele-ICU shifts or support tele-ICU programs which substitute for in-person coverage. Moreover, the Society of Critical Care Medicine, the American Thoracic Society, and the American Medical Association should adopt policy positions sharply curtailing the use of tele-critical care. If privately many of us remark that we’d never want our mother, spouse, or child to be a patient in an ICU that uses tele-critical care, then it’s past time we take a public stand against it.

Keith Corl is a critical care and emergency physician.