Telemedicine: My Origin Story

From Skeptic to Startup: How a Telemedicine Idea Survived—and Thrived—in a Broken System

In this reflective solo episode, Dr. Bagares shares the untold backstory behind his early adoption of telemedicine, the struggles of launching a cash-based virtual practice, and how he handled rejection from both peers and the healthcare system itself. A must-listen for anyone frustrated with traditional healthcare or curious about innovation in musculoskeletal care.

🎧 Topics include:

• The inefficiency of follow-ups and how email/telehealth filled a gap
• Navigating non-competes creatively
• Facing industry skepticism
• When COVID changed the rules overnight
• Lessons learned—and how they shaped MSK Direct

Whether you're a patient, provider, or healthcare entrepreneur, this origin story shows what's possible when you're willing to bet on a better way.

🕰️ Timestamps:

• [00:00:00] | 🎶 Intro & Welcome
• [00:00:20] | Why I started this podcast
• [00:00:50] | Two types of visits: new vs. follow-up
• [00:01:31] | Follow-up inefficiencies and the email solution
• [00:02:06] | Early thoughts on telemedicine (2013!)
• [00:03:18] | The non-compete challenge that pushed me toward virtual care
• [00:04:27] | Could an online orthopedic practice work?
• [00:05:39] | The inefficiencies of the traditional system
• [00:06:23] | How I performed virtual physical exams
• [00:07:00] | Why not everyone needs to be seen in person
• [00:08:00] | Waitlists, delays, and missed windows for care
• [00:08:55] | Presenting my model to skeptics (and being laughed at)
• [00:09:51] | Proving it works: walking exams and patient engagement
• [00:10:20] | The surgeon who tried to talk me out of it
• [00:11:02] | Launching anyway—cash pay, no insurance
• [00:11:59] | Building slowly… until COVID hit
• [00:12:45] | “You hit the jackpot!”… or did I?
• [00:13:57] | The collapse of my model (ironically due to insurance)
• [00:15:07] | COVID proves it can work
• [00:15:55] | Helping those who doubted me
• [00:16:21] | Patients I still care for today
• [00:17:04] | How this experience led to MSK Direct
• [00:17:43] | 🎧 Outro and invitation to connect

#TelemedicineJourney #DirectCareDoctor #MusculoskeletalMedicine #RehabRedefined #HealthcareInnovation #OriginStory #Physiatry #TalkingRehabPodcast 💡💬💻🦴💥

💬 Question for listeners:
Have you ever experienced a healthcare visit that felt like a waste of time? What do you wish was different?

Transcript

Intro with music

[00:00:00] What is rehab or rehabilitation? My name is Fred, be Garris, a board certified sports and spine medicine physician in Virginia Beach, Virginia. After 10 years of practice, I still find musculoskeletal medicine both fascinating and challenging. I. This podcast is about the lingering thoughts and questions I've had after residency and fellowship.

[00:00:20] My hope is to spark discussion, challenge, dogma, and share my experiences in musculoskeletal medicine. Welcome to The Talking Rehab Podcast. I.

[00:00:31] When I first started practicing, one of the issues that, one of the issues I always thought was

[00:00:31] when I first came outta practice.

[00:00:31] When I first came outta Fellowship, you know, I was super excited and I was luckily enough to land a, an amazing private practice job with a lot of new patients right off the bat, which is kind of like, you know, it's kind of like the dream as a new graduate. And so yeah, there was like kind of two types of visits.

[00:00:50] So you have the new patient. Where you meet the patient for the very first time and you typically spend a little bit more time with them to get to, not just to get to know them, but also [00:01:00] review imaging and come up with a game plan. And the follow-up visits were always, you know, shorter, you know, so usually my new patients were like 30 minutes.

[00:01:08] Um, and then my follow-up visits were around, you know, 10 to 15 minutes long and, you know, I. I noticed that at some point, you know, the followup visits were fairly educational and counseling based versus like something that I needed to actually see, you know, in person. And so, you know, from a, from a financial standpoint, you know, the new patients tend to tend, tended to pay a little bit more compared to the followups.

[00:01:31] You know, uh, I think it's also because of the amount of time involved in the initial evaluation, but, uh, from an efficiency standpoint, you know, some of the questions that I would answer during the follow ups were really kind of like. Maybe five minutes, you know, less than five minutes worth of, of questions.

[00:01:48] And I thought, you know, why, why can't we just email some of this stuff? Um, or, you know, rather than having them drive to come see me. 'cause where I was practicing at the time, some of the folks would've to drive like [00:02:00] 30 to 45 minutes just to see me. And then I'd, I would give them all the time in the world, but they only really had five minutes worth of questions.

[00:02:06] And so. And I was, I always thought about like, well, what is there a different way, you know, that we can do this? And I started to adopt email. I would email my patients all the time, and that's when I first started thinking about telemedicine. But at that particular time, and we're talking about 2013 or so, uh, um, insurance was not paying for it even though it was exactly the same kind of counseling.

[00:02:27] Like the person would come in to see me. And I would give them, you know, my time and my attention, um, again for the follow-up, not necessarily the new patient piece of things. And, uh, I felt like I could give the same level of care because I knew them fairly well. But, you know, I, the system is what it is, and I would have to physically see them in the clinic in order to get paid.

[00:02:45] So. But at the end of the day I was like, you know, I wish there was just, I wish there was another way. You know, I don't wanna waste people's time. Um, and I certainly wanna be more efficient because other half of this is really, you know, the more follow up patients that I see it actually, um, you know, can it actually.

[00:02:58] Impacts my overall access. I [00:03:00] could see more new patients and I just wanted to be super efficient to see as many new people as I could. Now, um, if I were to fast forward, um, this whole story kind of dove is essentially what led me into the idea of telemedicine Now, um. You know, I consider myself one of the early adopters of telemedicine.

[00:03:18] I mean, I'm certainly not the original, but, uh, I definitely started brainstorming about this, you know, fairly early on, 2013, 2014, at least in the orthopedic world. And, uh, what really made me dive into trying to figure this out was, uh, I was in a position where I was. You know, looking for essentially a different way of practicing.

[00:03:41] It was not necessarily, you know, a specific issue, but I wanted to look at a different way of healthcare, a different way to deliver care. At the time, I had a position where I signed a non-compete, which basically says that I can't practice within a certain radius for a certain amount [00:04:00] of time, and. You know, I was looking, I was thinking about, look, well, how am I gonna, you know, how, how am I gonna make money in the meantime?

[00:04:06] Um, and without violating my non-compete. So I took, I made the effort to meet with my lawyer and try and figure out a way I. And, you know, essentially the answer was like, well, you just can't physically have a clinic. But at the time there was really no, there was no stipulation that said that I could open up a telemedicine practice.

[00:04:27] And telemedicine at this point in time was really limited to like, primary care stuff, you know, um, colds, rashes, you know, things like that. Not really in the orthopedic world. Um, but you know, at that time I was like, well, you know. This might be a way, because the contract that I signed didn't really say anything specifically about being online and you can't really limit someone online.

[00:04:47] So I really dove into it and I started to develop a telemedicine practice, uh, which was a, essentially an orthopedic and spine practice that I could do online because a lot of the people that I was trying to [00:05:00] attract or people that have, you know. You know, seeing, seeing people with back problems and continue to have back pain or spine pain and I could help them, or, you know, kind of the, the busy person that, you know, valued access.

[00:05:12] They just wanted someone to see them right then and there, and I felt like I could essentially help them.

[00:05:17] And so I started, you know, essentially trying to break this down and figure out like, okay, what. You know, what does a, what does a telemedicine practice look like? And the, a layer deeper from that is, you know, what, why is this system even necessary? So it really, it really made me start to look at the current system, which is, you know, the typical traditional insurance based system, which is volume-based.

[00:05:39] Um, you know, it's the very busy seven minute visit clinic. And, um, you know, aside from the actual clinical visit, you know, there's the time to check in in the beginning. There's a time to check out at the end, and I just felt like with telemedicine, at least for a lot of this stuff, we could just, you know, essentially be more efficient.

[00:05:58] The patient [00:06:00] could, you know, send me their records, I could review them a lot of times that they had already seen the physical therapist. And at that point, you know, imaging would be necessary and I felt I could just, you know, do a formal assessment, have them do some physical examination maneuvers online, where I would have them essentially, you know, you know, reach, reach the floor, lean backwards, try and touch their calf, and I could do a formal assessment and, and order imaging as necessary.

[00:06:23] And then. Um, review the imaging 'cause I had access online and that just seemed to make sense to me. Like there's so much stuff that I can do, you know, I, I hated having patients, you know, do physical therapy come in to see me. And then ultimately I was gonna order an MRI, and the only difference was that they just said, I didn't respond to the MR mri.

[00:06:38] I, I didn't respond to the physical therapy. So they come in just to tell me they didn't respond to the physical therapy and then I would order that order an MRI anyway. So I always felt like if they could just. Find a, if there was a way that they could just tell me that ahead of time, as opposed, I could save them an extra visit where they would just, you know, tell me over email, tell me via telemedicine, how they responded to the therapy.[00:07:00]

[00:07:00] Skip the in person, I could order MRI and then I could see them back of the clinic. That just seemed to make a lot of sense to me, and so I really started to dive into. You know, trying to figure out is this idea, you know, not necessarily a good one, but is this an idea that could actually, you know, fit in, fit in, uh, a need in the current system?

[00:07:20] Because again, I'm not looking for the person, you know, the person that has like, you know, severe acute back pain. Those were not the folks that I wanted to, to necessarily track with telemedicine. Those folks. I do think. Need to, to likely be seen in person, but not everyone with back pain needs to be, is at that level of pain.

[00:07:37] And maybe that was the particular patient type that I would eventually see, uh, or would be attracted to my model. So I really leaned into, I. Uh, you know, that kind of patient, um, you know, uh, archetype. But, uh, I also leaned into the convenience of things. So it really kind of, I started doing a lot of more research about, you know, the average wait time to see the physician and, um, [00:08:00] delays in continuance of care because of, you know, the, let's say that a, a patient.

[00:08:07] You know, CS an Cs, a physician, they get referred to physical therapy. They get, um, they're not improving and they're told to follow back up. But the next time they could actually see their physician was like essentially six weeks from their last therapy visit. So, you know, I kinda really lean into that aspect of things.

[00:08:25] So I really started diving into to how can I make this work? And I came up with a system that worked. I, I developed a business, um, um. A business structure website, you know, electronic medical records. And, you know, at this point in my career, I had already kind of transitioned out of that. I was at a different job position, uh, where I, the non-compete was in effect.

[00:08:38] And, you know, I had to really start to market this idea. But before I did that, I. I thought, you know, let me just kinda run this past, some people see what they have to say. And so, you know, just timeframe wise, this was essentially 2018, maybe 2019, and you know, so I went to a couple people, some local folks, and.

[00:08:55] You know, you should have seen the kind of looks that people had when I would present this idea. I mean, [00:09:00] some people really thought it was super innovative and, and really ahead of its time. Um, at least from the orthopedic standpoint. Um, but when I would talk with, you know, a majority of the physicians, they were just like.

[00:09:11] You know, what are you doing? This is like, essentially, you know, this, how does this even work? How can you be an orthopedist and, and not put hands on people? And you know, I have answers for that. I, I, I think ultimately in my clinical experience, yes, the hands are super important, but I do think that if you have, I developed a system where I could tell people how to move on camera and I could gather a lot of information.

[00:09:33] And so, you know, that's not really the point of today's. Uh, episode, but, um. I can dive into that a little bit deeper, but on the whole, with time with experience, there's, I, I feel like every C clinician whittles down and focuses on certain things that gives us the moan amount, most amount of information.

[00:09:51] And I could do that with a musculoskeletal system. You know, I could have someone walk on camera, I can have them reach, and I can get in just enough information to [00:10:00] figure out where to start. And that was really my goal. That being said. I, I've had a lot of opposition. In fact, one, one particular surgeon, um, very well-meaning essentially called me and was like, you know, I, I can tell you're super passionate about this project, but, and I'm, and I'm not trying to be.

[00:10:20] You know, I'm not trying to, to, to be harsh, but I'm going to be, um, for your sake, because I, you know, you obviously have a family and basically they just laugh. They didn't laugh, but they, they said like, do you essentially, do you really think that this idea is good? Like almost in a concerning way? And they really shot, shot down my idea in, uh, in a very constructive way.

[00:10:37] They gave me every reason why my idea would not. Really work. And, you know, I could list the, all the reasons, but it's not really the point. You know, I, at the end of the day, I just said, thank you. I appreciate your input. Um, and I launched anyways and I just, I just kind of did it. And so, you know, aside from trying to, you know, build the business, you know, now I [00:11:00] had to go into the marketing piece of things.

[00:11:02] And when it, when it came to the consumer, I think, you know, it was really kind of black or white. Some people thought it was a great idea, some people didn't get it. And you know, the kicker with my particular model was that I didn't take any insurance. And so, um, that was, that was the thing I would see people.

[00:11:19] For a cash rate, um, they could pay by a cash credit card. Um, and um, that was that just a simple, simple transaction. Uh, and

[00:11:27] you know, I thought at that time I was like, oh, this, I'm in the clear. I. You know, this, this is such a simple model. Like I was charging like something very, very reasonable. You know, I think I started off at like $89 or something like that, and I mean, you think of the, the general service industry, you know, people will drop, you know, a hundred dollars on a meal.

[00:11:45] You know, between two people. So 89 I didn't think was too bad. And so, you know, my business started to grow little by little by little. You know, most of my referrals were not by physicians or from physicians. They were from other, other clinicians in the community, which I'm super, super thankful for. Um, but you know, now we're into two th 2019.

[00:11:59] You know, I'm [00:12:00] still slowly, slowly building the business. There is a rumble going, and all of a sudden we start getting, you know, we, we start getting, um, news reports about COVID and, and again, this is the end of December, and then all of a sudden. E everyone knows this. Everything's shut down. Everything's shut down.

[00:12:20] And in my mind I was like, oh no. Oh no. What happened? And it's funny because everybody else was like calling me like, oh my God, like you hit the jackpot. And I was like. Because at that time, if, as we all remember, you know, once everything shut down, the only thing available was telemedicine. And, um, all of a sudden, you know, I was getting all these people saying, oh, this is it.

[00:12:45] You know, you're, you hit the jackpot, you know, you, you were ahead of the curve. And I just smiled. I just smiled and laughed because I knew at that point. My business model has had died, you know, was or not died, had, [00:13:00] was now one of the victims of COVID. Um, because my whole business model was really banking on two things.

[00:13:08] Number one is the fact that, um, telemedicine for the entire history of insurance was never really a service that was going to be, um, covered. Uh, a, a covered benefit. And uh, number two is that, you know, the world essentially shuts down and telemedicine is the only way to go. And both of those things actually happen.

[00:13:33] And why you tanked my business was because now that when COVID actually happened, um, the insurance company started to pay for telemedicine visits and so I got a flood of people calling me. Asking if I can see them and their first question automatically was. Are you taking insurance? And so I was not taking insurance at that particular time.

[00:13:57] I was completely out of network. I didn't, because I had [00:14:00] gone all into this particular model. I didn't, but I did not credential myself with insurances. And so as a result, they said, well, why don't you just go ahead and re re credential with insurances? And so aside from like me just not liking insurance, how they, how they, how they do business.

[00:14:17] If we all remember, COVID was a very special time. You know, businesses were skeleton crews, so even if I wanted to get re credentialed, it would've taken, you know, a year plus because not everybody was working at the time. And I just knew at that point if I were to get any type of steam it was going to it.

[00:14:41] It would take me way too long and the boat has sailed, but it, it was an amazing, it was a great experience, uh, for me. Um, and at the end of the day, I just laughed. But what I took away from it, what is that? It was essentially a. A proof in concept. [00:15:00] Everybody told me, essentially everybody, but maybe less than five people told me that this was a great idea.

[00:15:07] Um, everybody else said this idea was never gonna work. It was in fact a bad idea. And COVID proved that this, this actually works. Telemedicine actually works. It's not for every condition, but at the same time, it just. Fits into this healthcare system. And so ironically, you know, at this time, the folks that were doubting me and calling my idea bad one started asking me for advice.

[00:15:38] And so, you know, I talked with, you know, you know, my wife was like, well, why are you trying to help them? They. You know, they really, you know, they weren't so kind to you, you know, and, and at that time, you know, it was COVID. I was like, you know what? I'm gonna help 'em. I'm gonna give 'em what I know. I'm gonna give them the systems that I had already developed and it's gonna help people, you know.

[00:15:55] And at the end of the day, like I was, you know, it wasn't a big [00:16:00] deal to me at that point. I sure it was kind of frustrating to see how things played out, but. At the same time, it was more satisfying knowing that my idea was actually. Was actually being proven to work. Um, so that being said, you know, with my current practice, of course I have an extension, um, in the clinic.

[00:16:21] Um, some of the patients that I met through telemedicine have continued to be my patient, um, currently. Um, so it's, it, it, it definitely. Served a purpose. You know, it showed me that, you know, my ideas and my vision of healthcare. Can work. You know, I think at that particular point in my career, I, you know, I was still building my confidence.

[00:16:42] I was still fairly shaky. But now I know, now I know that my vision is solid. It can work. And, you know, telemedicine just happened to be a, a vehicle that eventually drove me into my current direct care practice. And, uh, for that, I'm, I'm forever thankful that it actually happened. Um, [00:17:00] but. You know, I, I've, I did this episode because I've been getting a lot of questions about.

[00:17:04] Uh, you know, essentially how I opened my practice, but more importantly, for patients, I kind of wanted them to know, you know, my, my origin story. This is essentially kind of how I came about. I've, I've always had this vision of a different healthcare, you know, not model, but a different pathway because not everybody, you know, not everybody is.

[00:17:21] Wanting the current, the current, uh, delivery system. So I'm, I'm always looking for new ways to deliver excellent care. Uh, but at the end of the day, ire, you know, it was a great experience. I don't regret it for a second. Um, if anything, I just laugh and, you know, I'm, I'm happy that it happened. So, um, if you guys have any questions, you know where to find me.

[00:17:40] Thanks again for your attention. Take care.

[00:17:43] Thank you for listening to The Talking Rehab podcast. I hope that this podcast stimulates you to question your own practice and how you approach rehabilitation. I truly appreciate your time and attention. If you enjoyed listening, make sure to like and subscribe to the podcast. I [00:18:00] wish you a movement filled day.

[00:18:01] Take care.