A patient called my office at 9 p.m. on a Tuesday. She had a UTI. She knew she had a UTI. She’d treated the same thing twice before that year and could probably have diagnosed it faster than a med student. What she needed was a one-minute conversation and a prescription. What she got was my voicemail, a suggestion to call back in the morning, and an appointment slot 17 hours out.

She was in the emergency room by midnight. Not because she was that sick. Because the system gave her no other option.

I’ve been a family doctor in rural Indiana for more than 30 years, and that story gets repeated every weekend. It happens thousands of times a day, in every state, in cities and small towns alike. Not because of bad doctors. Because of a structural assumption we stopped questioning a long time ago: that every clinical interaction, regardless of complexity, has to be routed through a scheduled appointment slot for an in-person visit.

Ask yourself when you last did anything else that way. Unless, of course, you were texted by a friend or family member who knew how to hack the system.

The world moved on. Medicine didn’t notice

Think about how your patients manage the rest of their lives. They check their bank balance and move money between accounts at 11 p.m. without calling a branch. They book a flight to Denver without speaking to a travel agent. They order groceries from their phone and have them on the porch in two hours. They get dinner delivered by a stranger they’ve never met, tracked in real time, with no phone call involved at all. They arrange for a ride to the theater on an app that lets them choose a time and price and then track the encounter.

None of that is remarkable to them anymore. It’s just Tuesday.

Then that same patient gets a sore throat, and we ask them to wait three days for an opening, drive to an office, sit in a waiting room next to someone with the flu, and take half a day off work, all to have a five-minute conversation that could have happened over text.

We didn’t design that experience on purpose. It’s a holdover. The appointment slot made total sense when a diagnosis required physical presence. If a physician needs to listen to a chest, palpate an abdomen, or look down a throat, the patient has to be in the room. Full stop. But for a defined category of common, low-acuity acute conditions, physical co-location stopped being the rate-limiting step a while ago. A UTI, strep throat, a sinus infection, yeast infection: These are diagnosed through symptom pattern, duration, history, and structured red-flag screening. A physician reviewing that data asynchronously reaches the same clinical conclusion that a physician in the exam room would reach. That’s because there are evidence-based guidelines for making symptom-based diagnoses. The appointment and exam aren’t clinical requirements in that scenario. It’s a scheduling artifact we’ve mistaken for a standard of care.

Three generations of telehealth, and only one that actually breaks the mold

I’d argue telehealth has moved through three distinct generations, and most people conflate the second with the third.

Generation one was the nurse triage line. You called, got screened, and if it warranted a visit, you got an appointment. It solved for access, sort of, but the bottleneck never moved.

Generation two put a camera on the same architecture. Video visits, scheduled slots, synchronous interaction. It was more convenient, no argument there, but it preserved the exact skeleton of in-person care. Two clocks still had to align. The provider still had to be live. The patient still had to wait for an opening, just in a browser tab instead of a waiting room chair.

Generation three is the one that actually entirely restructures the model instead of relocating it: asynchronous, physician-governed, AI-assisted intake that decouples clinical work from real-time scheduling and physical exam entirely. The patient starts a visit whenever the symptom starts, at 2 a.m. if that’s when it starts, no camera, no calendar. Structured intake collects the history and red-flag data a physician actually needs. Automated intervention routes to an ER if red-flag symptoms arise, and a licensed physician reviews encounters asynchronously, makes the clinical decisions, and either treats, defers to in-person care, or escalates. Minutes, not days.

That third category is where the rest of the consumer economy has been living for a decade. Medicine is just late to it.

What this isn’t

I want to be precise here because this is the part physicians rightly get nervous about. I am not describing an app that lets an algorithm write a prescription. Autonomous AI prescribing is a different category of risk entirely, and I think most of us should be deeply skeptical of it. What I’m describing keeps a licensed physician as the final decision-maker on every single case: reviewing the intake, making the diagnosis, authorizing or declining treatment. The AI does the unglamorous work of structured data collection, triage, and clinical decision support. The physician still carries the license, the liability, and the judgment call. That accountability isn’t a compliance checkbox we bolt on afterward. It’s the entire reason this model is defensible instead of reckless.

A well-designed asynchronous system should also be conservative by default. If it’s working correctly, a meaningful share of patients who go through it won’t get a prescription at all, because the evidence doesn’t support one, and they’ll be told plainly they have a virus or that they need in-person evaluation or a higher level of care. A system that prescribes every time a patient shows up isn’t practicing medicine. It’s a vending machine with a medical license attached. Any physician-led model in this space has to be built and evaluated on how well it says no, not just how fast it says yes.

Why rural medicine makes the case loudest

I know what it looks like when the nearest urgent care is 45 minutes away, and the clinic closes at 5 p.m. In a rural community, the appointment-slot model doesn’t just create inconvenience. It creates a hole that patients fall straight through. Someone who gets sick on a Friday night in a small town has a frustrating experience with the health care system. They are stuck, and often their only solution is an expensive ER visit that is rarely medically necessary, or worse, they choose no care at all.

Fabric Health published market data showing that more than 90 percent of members who have access to asynchronous-first care choose it over other modes. That’s not a novelty preference. That’s a latent demand that’s been sitting there for years, waiting for a clinically sound way to express itself. Patients didn’t suddenly start wanting convenience. They’ve wanted it since the first time they sat in a waiting room with a toddler and a sinus infection. We just never gave them a legitimate alternative.

The argument I’m not making

I’m not arguing that appointments should disappear. High-acuity presentations, complex chronic disease management, anything requiring a physical exam or a longitudinal relationship: All of that still needs real-time, often in-person, care. Nothing about asynchronous triage replaces a cardiologist managing heart failure or a surgeon doing a post-op check. I’m arguing something narrower and, I think, harder to dispute: We’ve been forcing an entire category of low-acuity acute problems through infrastructure that was designed for something else, and we’ve been calling it the only standard of care, mostly out of habit rather than clinical necessity.

Why this is a physician leadership problem, not a business problem

Here’s what worries me more than the technology itself. Patients are not waiting for organized medicine to bless this transition. They’re already using consumer AI tools to symptom-check, self-diagnose, and occasionally self-treat, with zero clinical oversight and zero accountability if something goes wrong. Why do you think those infomercials for “emergency antibiotic kits” have so much traction and consumer interest? This is happening right now, in the absence of physician-designed alternatives, not because patients are reckless, but because we left a vacuum and something always fills a vacuum.

The question in front of us isn’t whether asynchronous, AI-assisted care arrives. It’s already arriving, badly, in unregulated corners of the consumer internet for ED meds, GLP-1s, and others. The real question is whether physicians design the version that has clinical judgment, liability, and red-flag discipline built into its architecture, or whether we sit this one out and let it get built by marketing companies and tech people who’ve never taken a call at 3 a.m. about a patient who couldn’t breathe.

I didn’t get into medicine to defend a scheduling system. I got into it to take care of people, including the ones who can’t get in to see anyone for three days. If our profession keeps treating on-demand, physician-governed care as a threat to be resisted instead of a category to be led, we’ll spend the next decade reacting to tools we had no hand in designing.

That patient and the thousands like her are why I moved beyond writing about this problem and built a solution. Not because I think algorithms should practice medicine. Because I think physicians should be the ones deciding what this next generation of care looks like, instead of leaving that decision to people who have no clinical experience.

The patient with the UTI at 9 p.m. on a Tuesday isn’t an edge case. She’s the whole argument. And she’s why I’m not waiting on the sidelines to see how this plays out.

Tod Stillson is a board-certified family physician, medical device inventor, and health care entrepreneur focused on redesigning how care is delivered in the digital age. He is the founder and CEO of ChatRx, a national asynchronous telemedicine company providing safe, efficient, direct-to-consumer care for common acute conditions. Through ChatRx, Dr. Stillson developed an FDA-listed software medical device that combines structured clinical pathways with AI-supported decision tools to preserve physician judgment while reducing friction for patients.

Dr. Stillson holds an academic affiliation with the Indiana University School of Medicine and a hospital affiliation with McPherson Center for Health. After nearly three decades practicing rural family medicine, he shifted from traditional employment to building physician-led digital systems that expand access, efficiency, and professional autonomy.

He is the author of Doctor Incorporated: Stop the Insanity of Traditional Employment and Preserve Your Professional Autonomy and has published more than 400 essays on physician entrepreneurship, micro-business, digital health, and the future of medical practice. He contributes nationally to conversations on AI-enabled care delivery and physician leadership in digital transformation.

Dr. Stillson shares ongoing insights on LinkedIn, Facebook, Instagram, and YouTube.