Telehealth: How Clinicians Decide When to Switch to In-Person Care

The threshold I use is simple: if the clinical decision depends on something I can't reliably evaluate through a screen, the visit becomes an in-person appointment.

Telehealth is excellent for reviewing test results, adjusting medications, monitoring chronic neurological conditions, and following symptom trends. But neurology still depends heavily on the physical examination. If a patient reports new weakness, worsening balance, an abnormal gait, loss of coordination, or a new sensory deficit that I can't confidently assess over video, that's my cue to bring them into the office.

I also pay close attention to whether the story and the visual findings match. For example, if a patient describes significant functional decline but appears very different on camera, or if the video quality prevents me from assessing facial symmetry, eye movements, or motor function with confidence, I don't try to "make telehealth work." Uncertainty should lower, not raise, the threshold for an in-person evaluation.

One principle has served me well: telehealth should improve access, never compromise diagnostic confidence. If the screen leaves an important clinical question unanswered, the safest and most appropriate next step is a hands-on neurological examination. That approach protects both patient safety and the quality of medical decision-making.

The final choice between using telehealth or in-person visits will be based on how confident I am in my ability to assess both the symptoms and safety of the patient over video. In those cases where a patient has become increasingly disordered, family have expressed concern about behaviors that are different than what I see, or I am uncertain regarding the patient's adherence to their medications as well as potential side effects, then I would make recommendations for an in-office assessment. Video assessments are a wonderful tool but should never substitute a higher level of care if significant clinical issues remain unclear.

I look at the client's symptoms as well as if the virtual environment will be conducive to their therapy. When a client repeatedly has difficulty finding private space, has continued interruptions from family members or partners at home, expresses increased levels of hopelessness without available support systems locally, and/or if I am no longer able to provide an emotional sense of safety for my clients via video screens, then it is typically best to either transition the client into in-person care or access other resources that offer more elevated levels of service. A good rule-of-thumb for me is if I am not able to assist the client in maintaining some level of emotional containment/safety throughout our screen-based interactions, then in-person care is most likely going to be the better clinical option.

In telehealth, I ask whether I have enough clinical information to make a safe decision, not just whether the visit is convenient. Many psychiatric concerns can be managed well by video, but I lower the threshold for in-person evaluation when there is acute safety risk, new confusion, possible medical instability, significant medication side effects, or a change that does not fit the patient's usual pattern.

One cue I use is diagnostic uncertainty with risk attached: if I can't confidently tell whether the issue is psychiatric, medical, medication-related, or safety-related through video, the next step should be in-person assessment or urgent local care.