Telehealth is good for many things and useless for others. Knowing the difference can change outcomes. This page covers the symptoms that should never start with a video visit, the conditions that need a physical exam to evaluate, and what to do when a remote clinician is dismissing something that does not feel right.
The short version
- Some symptoms — chest pain, sudden weakness or speech change, severe shortness of breath, suicidal intent — are not telehealth situations. They are 911 or 988 situations.
- Anything requiring physical exam (palpation, auscultation, otoscopy, neurological testing) cannot be fully resolved over video.
- Async messaging is inappropriate for new, severe, or rapidly changing symptoms.
- If a remote clinician is dismissing a concern, ask explicitly for a differential and document the conversation.
- You can request a different clinician, a second opinion, or in-person referral. None of those are unreasonable.
- 988 is the US Suicide and Crisis Lifeline; 911 is the emergency number for medical, fire, and police.
Symptoms that need emergency care, not a remote visit
The following are situations to call 911 or go to the nearest emergency department, not to schedule a telehealth visit. This list is not exhaustive; the principle is "new, severe, or rapidly worsening" plus the specific patterns below.
Cardiovascular
Chest pain or pressure, especially if it radiates to the arm, jaw, or back, is associated with sweating, nausea, shortness of breath, or weakness. New onset palpitations with lightheadedness or syncope. Severe leg pain and swelling on one side, especially with shortness of breath or chest pain (possible deep vein thrombosis or pulmonary embolism). The American Heart Association and American College of Cardiology consistently emphasize that "time is muscle" for heart attacks and "time is brain" for strokes; delays cost outcomes.
Neurological
Sudden weakness, numbness, or facial droop on one side. Sudden confusion, trouble speaking, or trouble understanding speech. Sudden severe headache, especially "the worst headache of my life." New seizure. Sudden vision loss in one or both eyes. Loss of consciousness. The mnemonic FAST (Face, Arm, Speech, Time) covers most stroke red flags.
Respiratory
Severe shortness of breath at rest. Inability to speak full sentences. Bluish lips or fingertips. New wheezing not relieved by usual rescue inhalers. Choking or stridor.
Mental health
Suicidal intent with a plan, intent to harm others, or psychosis with disorientation. In the US, call or text 988 for the Suicide and Crisis Lifeline; chat is also available. For an active crisis where someone is in immediate danger, 911 is appropriate.
Other
Severe abdominal pain, especially with vomiting, fever, or rigid abdomen. Heavy uncontrolled bleeding. Severe burns. Trauma involving head, neck, or back. Anaphylaxis (rapidly developing rash, swelling, breathing difficulty after exposure to a known or suspected trigger). Severe dehydration in a young child. Fever above 100.4°F (38.0°C) in an infant under three months old.
Conditions that need a physical exam
Even when not emergencies, many problems cannot be diagnosed without hands and instruments. A reasonable telehealth clinician will recognize these and refer rather than treat blind.
Ear, nose, and throat
Suspected otitis media in a young child requires otoscopy and assessment of eardrum mobility. Severe sore throat with high fever, drooling, or muffled voice may suggest peritonsillar abscess or epiglottitis. Sudden one-sided hearing loss is a same-day in-person ENT problem.
Cardiac and respiratory exam
A heart murmur, an abnormal lung sound, an irregular rhythm — none of these can be assessed by video. They need a stethoscope on skin.
Abdomen
Abdominal pain that needs palpation to localize, to assess for guarding, or to evaluate for tenderness in specific areas (right lower quadrant for appendicitis, right upper quadrant for gallbladder, periumbilical or epigastric patterns) is in-person work.
Neurological exam
New weakness, sensory changes, balance problems, or coordination concerns require a clinician to test reflexes, strength, sensation, and gait directly.
Musculoskeletal
Joint injuries usually need range-of-motion testing and stability assessment. Back pain with neurological signs (weakness, numbness, bowel or bladder changes) is urgent in-person evaluation.
Skin
A full body skin check for cancer screening cannot be done remotely. Atypical, changing, or rapidly growing lesions need in-person evaluation and likely biopsy. See dermatology remotely.
Gynecologic and genitourinary
Pelvic exams, prostate exams, breast exams, hernia evaluations, and many sexually transmitted infection workups require in-person assessment and testing.
Where async messaging is inappropriate
Asynchronous platforms — where you message symptoms or upload photos and a clinician replies hours later — work well for stable issues, follow-up of known conditions, and refills. They are inappropriate for new, severe, or rapidly changing symptoms. A platform that is willing to "diagnose and prescribe" for whatever you message in, regardless of presentation, is operating outside reasonable practice. See red flags in any remote care service.
How to escalate when a remote provider is brushing you off
Sometimes the symptom is not a clear emergency, but the clinician is dismissive and you remain concerned. The following escalations are normal and reasonable.
On the same visit
State your concern explicitly: "I want to make sure I understand. You think this is X. What else could it be? What would change your mind?" Asking for a differential — the list of possibilities the clinician considered and ruled out — moves a vague exchange into a documented one. Ask what specific symptoms or test results would prompt them to revisit the diagnosis. Ask whether the case warrants in-person evaluation.
If the visit ends without resolution
Send a portal message summarizing what was discussed and asking the same questions in writing. Written communication is part of the medical record. If the clinic offers different clinicians, ask to be seen by another. If the practice will not accommodate that, you can seek care elsewhere; insurance does not require you to stay with a clinician you do not trust.
If the situation worsens
Do not wait through a portal message thread. Use urgent care, a same-day in-person appointment, or the emergency department depending on severity. The fact that you are already "in the system" with a remote provider does not make you locked in.
What to know about urgent care vs. ER
Urgent care can handle most non-emergency issues that need a same-day exam: lacerations, simple fractures, minor burns, urinary tract infections, ear infections, mild pneumonia, mild asthma exacerbations. Urgent care cannot handle suspected stroke, suspected heart attack, severe abdominal pain, major trauma, severe shortness of breath, or any condition that may need imaging beyond plain x-ray, IV medications beyond basics, or surgical evaluation. When in doubt about chest pain, severe shortness of breath, neurological symptoms, or any "worst ever" symptom, the emergency department is the right setting.
Mental health crises
For acute suicidal thoughts with a plan, suicidal intent, harm to others, or any situation where someone may be in immediate danger, 988 (US) is the Suicide and Crisis Lifeline — call, text, or chat. Many cities also have mental health response teams that are dispatched in lieu of police for non-violent crises. If you are in active emergency or someone has already taken steps to harm themselves, 911 is appropriate. See mental health telehealth for routine care; crises are different.
What to do, in order
- Recognize the red-flag pattern: new, severe, or rapidly worsening; the specific symptoms above; or "something is very wrong."
- If it fits the red flags above, call 911, go to the ER, or call 988 — do not start with a remote visit.
- If it needs a physical exam but is not an emergency, request in-person evaluation through your primary care or an urgent care.
- If a remote clinician is dismissing a concern, ask for the differential and request in-person referral or a different clinician.
- Document the encounter in writing through the patient portal.
- If concerns persist, get a second opinion. See getting a second opinion remotely.
Related reading
Not medical advice. This site provides general educational information about navigating remote healthcare. It does not diagnose, treat, or recommend treatment for any condition. For personal medical questions, talk to a licensed clinician. If you are experiencing a medical emergency, call 911 or your local emergency number.