A Doctor Grows in Brooklyn

Doctor Jay Parkinson became a media celebrity last year as word spread about his unconventional practice in Williamsburg, Brooklyn. Instead of maintaining a traditional office and paying support staff, Parkinson’s operation is entirely virtual and requires almost no overhead. (Unless you consider a Mac overhead.)  Using his apartment as a base, He runs a web site loaded with Web 2.0 touches that allows patients to communicate with him easily and explains his services in plain English.  After an initial in-person consultation, exchanges can be online and are conducted through either instant messaging or web chat.

“The healthcare industry is so stuck in 1994,”  he says, “The only way they’ve used the Internet is to provide information.  I look at the Internet as something that provides communication.”

By concentrating on technologies that are inexpensive and readily available, Parkinson is able to focus on usability and efficiency and bypass many of the road blocks that have slowed other doctors trying to wire their practices. The web cam he uses is a standard feature on his system. He uses Gmail to handle his email load and has neatly integrated Google Calendar into his web site – allowing patients to see his schedule at a glance and book their own appointments.  For cases requiring referrals, he has built a simple database of inexpensive providers, creating his own social network of several thousand specialists and other care givers local to Brooklyn and Manhattan.

Parkinson resists the argument that technology has created a new Race to the Bottom in health care, by making medicine less human and the healthcare system increasingly complex. Instead, he argues that when used properly, Web 2.0 tools like mash-ups, mobile devices, instant messaging, digital video and social networking can free doctors to spend more time with patients – not less. 

"It’s really just practicing medicine in an old-fashioned way," he says.

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    Someone in the USA, the last remaining SuperPower, has figured out a way to restore the friendly doctor visits of years gone by (before Nixon the the HMO).
    Of course – much of this was already in use in other countries having forward looking healthcare systems. Even the UK’s NHS had a remote meds dispensor for patients needing controlled dosages keyed to their vitals.(viewed on Beyond 2000 tv show)
    It figures the guy is a Canadian.
    Reminds me also of the Flying Doctor in Oz where people living in Outback sheep stations (not the US restaurant) could get a visit by a GP in a plane and their medical images would be transmitted for review to specialists in the big cities.

  2. Kudos to Jay Parkinson. The comments are even more interesting in that they reflect that practicing medicine is not monolithic at all. I don’t think Jay is saying this is the answer for everyone. He recognizes the limitations..Rbaer…you are mistaken…the internet has revolutionized education for physicians…there are literally thousand of CME course on line…video casts,skill training, Some physicians prefer this mode since it decreases travel expense, time away from home.
    I am curious Jay as to how many housecalls you make a week? Who handles the insurance billing. How do you handle (if you do) managed care. This approach raises more questions (which is a good thing)than answers.

  3. I think he’s onto something. There complications with any doctor patient relationship, whether trying to manage clients paperwork when they come through a clinic or communicating electronically via email & video chat as Dr Parkinson is attempting to do. However taking a different approach to cutting health care costs is worth a shot. It will be interesting to see how he does. It is forward thinkers like Dr. Parkinson that truly make changes in American lives and revolutionize industries.

  4. Hey, I remember this guy from Gawker a few months ago. The comments there were pretty much 1) hey, cute guy, 2) he’s only board certified in peds (if I remember correctly) and he did a preventive medicine residency, and 3) again, how cute is he?
    I think his model works if the doctor’s a GP or pediatrician, but as many of you have noted, this would be a lot more difficult to pull off for a specialist.

  5. Dr. Parkinson is brave for championing this new model of patient care. I’ve discussed this with Jay, and quality of care is truly his motivation. Another physician colleague pointed out that “only 5% of doctors want to be that available to patients…most of us want barriers to patient-initiated communication”. Fee-for-service doctors like Jay are doctors who want to be accountable and available to their patients. My only question is, How are home calls more efficient? The most limited resource is the doctor’s time, so why should he be the one traveling from patient to patient?

  6. Its best we agree to disagree. I think it is easy to get caught up in view points and I am sorry if I seemed to attack. I do think we can leverage tech to do many things and maybe I will blog on my visions later and EBP back them. Patients are consumers and they are human, so they should be treated like both. Except in our health system they are deprived of all the information needed for a free market. I think steps towards transparency in healthcare is important, and I think tech will help bridge the gap… The tech may not be out there now, but looking to the future I think tech will provide many helpful tools for clinicians.
    Of course docs and nurses will always be needed, and tech is only a tool to help facilitate their work. I am not envisioning a Matrix scenario, just moving away from pen and paper and rearranging of the deck chairs on the sinking ship. I think we need bold thinkers to take risks and step outside the respected and traditional norms.
    No disrespect intended in any of my posts. Thank you for a good debate! I look forward to discussing future issues with you, as conversation is the breeding ground for innovation (Jose Fonseca)!

  7. Dan, I don’t want to turn this into anything personal, not even on an anonymous level.
    I still think you have unrealistic expectations what the discussed technologies can and cannot achieve. However, that is your position, and you are entitled to it. However, you try to push me into the corner of the technology fiend, just because I dare to show skepticism about some obvious red hot hype here. None of my comments are in any way hostile or obstructive towards new technologies, just read them closely (BTW, I consider myself an early adopter for EMR and PDA use and actually wrote an article in a peer reviewed journal about the introduction of new technology to physicians in training). Therefore, I ask for a little consideration with your assumptions/interpretation of my opinion (sorry about the facetious “telephone”). But: you still have to make the case why an Email or instant message is greatly superior to a telephonic request.
    Further, I want to ask you (seriously): Do you really consider a patient (like in your scenario with your hypothetical mole) just being a consumer?

  8. rbaer, thank you for spelling telephone for me, I appreciate that. I think you are taking the roll of the devil advocate and in so doing you are attempting to stop the innovation process. (I suggest reading Quantum Leadership by Tim Porter-O’Grady and Kathy Malloch) Dr. Parkinson is an early adopter (suggest reading Diffusion of Innovation by Everett Rogers) and is providing a new way to deal with an old and broken system
    Will technology solve everything? NO! Technology is a tool, but the processes need to be perfected for them to aid us. That’s why EMR and computer charting are so hard to adopt, the process of charting and record keeping is broken, technology only serves to complicate the system.
    So no, I will not pick up the “t” “elephone”, that is the third most ancient tool for communication behind the hammer and feather pen. Waiting 3 hours past an appointment time for you to look at the abnormal mole on my back is a waste of my time. Get a web cam, or ill send you a high res picture, but stop wasting the consumer’s time by having office visits that can be done with telemedicine technology!
    Look at E-ICU concepts. Technology from that can be used to set up virtual offices! Just one example!
    Dr. Parkinson, I am glad you have a vision to help change the broken system with technology. Never mind the devil’s advocate.

  9. The real problem is that Jay is not offering things much different than many of us do already, although I do wish I had his website. Many of us call in for xrays when people think something is broken, handle lots of stuff on the phone (email is always a HIPAA issue), and, as opposed to Jay, actually accept insurance (UCR is NOT as good as that website says).
    also, what does jay do with an HMO plan with no out of network. is it $150 or $250?? If someone has a $3000 out of network deductible what does he do? How about patients with medicaid who w
    As someone who takes care of a lot of younger patients, I agree that a lot can be done with a little; I just wish some of us old timers got credit for doing a lot of similar stuff, too. While taking many insurance plans, I should add.

  10. For a better description of my ventures and to alleviate many of the allegations against my practice style, please see this recent post on my blog:
    That should help in much of the confusion. Of course there are critics. I’ve been used to criticism all my life. Is this the cure for healthcare? Hell no! Is it smart utilization of resources for a certain percentage of the population? I think so.
    Does this help overutilization? Sometimes. Restructuring reimbursement policies away from procedures and diagnostics and reimbursing more for a medical home, accessibility, communication, and rational primary care quality indicators…now that would do wonders for the healthcare system. Myca and myself hope to be sitting pretty on the platform and practice style that will be optimized for that type of healthcare delivery when these changes someday take place. But for now, to have any sort of legitimacy in the Healthcare industry, we have to have proof that the system works. Fortunately, for the sake of streamlining healthcare in the future, there are over 50 million people in America who are true healthcare consumers (meaning, they have to pay cash for healthcare). We’re their doctors and their healthcare financial consultants who help them spend their money wisely. Consumers will decide the future. We’re arming them with that opportunity.

  11. Let’s give Dr. P a couple of years and see how this works. (He may get tired of using his bed as a desk, for example). His smugness may also have put some people off, but there are a lot of interesting elements in this practice model. The core of a good doctor patient relationship is continuity and good communication. Most young people communicate electronically (and continuously). So making email, iChat and a cleverly designed EMR the core of the practice makes a lot of sense. I think a lot of older and sicker people would go for this model if it were available to them.
    Don Berwick has spoken of the “tyranny of the visit”, inveighing against forcing all aspects of the relationship through an office. This model speaks directly to bypassing the office, and using the home and neighhborhood as the first point of contact. Now all we need is to pay him a “subscription fee” per month and we’ve arrived in the 21st century.
    I too detect a lot of freefloating grumpiness in this string of posts that have sources other than this particular innovation. More power to him.

  12. Remember the days before educated consumers….before patients were expected to ask questions, to come in and ask about meds and procedures…when they came in and compliantly set through whatever tortuous thing they were asked to tolerate. Think back to the days of being admitted for a barium prep before the procedure…back to the days of 7-10 days post-partum. And you talk about over-utilization now! Most the changes that have been made have been due to educated consumers. The rest due to regulations at the top by insurance or Medicare Regulations. It is refreshing to see a provider attempting change. As they say if you keep doing what you’ve always done…you’ll keep getting what you’ve always gotten.

  13. I do think that there is slight confusion with the “appointments for picking up prescriptions” part. I haven’t seen (or practiced) it personally, although it may exist when doctors who are not busy fell that they need to fill their slots. Most clinics/offices have a policy of at least yearly visits (otherwise telephonic refills), and that is quite reasonable:
    -does the patient understand the medication and is compliant? Is the drug still well tolerated?
    -does the pt. have obvious health problems? As long as a doc is still writing prescriptions, he probably has a greater legal obligation to look after the patient as opposed to a truly inactive pt.
    -is the problem (e.g. hypertension, seizures) well controlled? If not, the doc may be negligent in just refilling indefinitely.
    I don’t deny that there is innovation in Dr. P’s office, but I have seen “no overhead” offices already in Germany, in the early 90s … just by phone/answering machine (usually, but not exclusively psych/psychotherapy). To a large degree, Dr. Parkinson is just substituting the phone by other means of commnunication.

  14. web/tech have given us more access to information and people in every other part of our lives why not in the doctors office? Nothing worse than a doctor that has to have you come in to pick up a requisition and sit with you for 2 sec so that they can submit it for billing. It’s better for them and me if some things can be done electronically. Parkinson is taking it to the extreme and I think they’re will be costs to it (when you have only you’re stethoscope and penlight there’s only so much you can do). I’m sure he has to refer everything except the most basic problems because he has no clinic equipment to deal with it so in the end his patients may still end up spending just as much time in the doctors office — just not his.

  15. I want to set one thing straight (again): I have nothing against new communication and organization tools, and Jay (Dr. Parkinson), you seem to be in some respect the avantgarde, which is appreciated, of course we need early adopters. Unfortunately, I set a rather irritated tone with my first post, I am afraid.
    So what did I in fact intend to criticize? Unrealistic expectations and hype, the somewhat naive belief that technology will transform everything and solve all the massive problems … does anyone remember all the unrealistic claims that were made about how the internet is going to revolutionize education? And did most of this materialize?
    Does this use of technology “break the mold”? Not much more than the IPhone did, in my opinion, because it does not do anything against overutilization. What would a true mold breaker? A network of salaried providers committing truly to EBM standards (that means e.g. reasonable end of life care, no scans for migraines, no antibiotics for URIs), with well educated PCPs playing the central role, with insured patients giving up the right to sue for noneconomic damages unless this is determined by an independent review board (I know, probably illegal) and a formulary heavily tilted towards the right generics. And yes, with providers using the latest technology, at least EM and PACS, and everything else that helps, after some reflection and piloting.
    Dr. Parkinson is a pioneer and certainly deserves attention, but the revolutionary potential is, in my opinion, limited and all the hype is rather distractive … what we desperately need to do is to curb overutilization and to lower administrative costs in healthcare as a whole.

  16. “but it is a good step to finding a way to provide care to people with lower incomes.”
    How does a $175 house call do that? As for being cynical, I don’t have enough information yet not to be cynical, and anyway, I like turning the rocks over.
    Jay, there’s a doc here in Raleigh who only deals in cash, no insurance. He does his own labs as well. His office visit cost is $45, can you beat that?. I agree that cutting out to huge hassle and cost of dealing with the insurance system is a first step, but I don’t think on-line hospital visits are coming any time soon. The real cost of healthcare starts when you enter a hosptal. How about dealing with one insurer with one set of rules – it’s called single pay.

  17. Thank you for the kind comments and for the criticism. At least people are talking about the issues. Unfortunately, change will never originate in the payors. It will only be brought about by educated consumers who will change institutions (albeit slowly) with their pocketbooks. My target market is currently the cash paying consumer but my future market is everyone. This is just a stepping stone toward redefining a bankrupt system that can’t sustain itself for much longer. Criticize all you want. But being “stuck in our current state” will get us nowhere without some of us trying to break the mold.

  18. It is amazing that people are so cynical about a transition like this. Of course it is not a perfect technology, but it is a good step to finding a way to provide care to people with lower incomes. This technology may help youngsters as someone put it first, but as technology filters through society it can help more people.

  19. “2. The website does post his estimated fees and methodology”
    Seems only for house calls.
    “he’s doing it by redefining the norms that keep us stuck in our current state (the current state is doomed).”
    The current state is a system that’s way too expensive, haven’t seen where he’s blazing a new trail to less cost, just less overhead and patient interaction. Wonder if he gets kickback for those referrals?

  20. Let’s set the record straight:
    1. Jay Parkinson does see patients face-to-face. He goes to them.
    2. The website does post his estimated fees and methodology (http://www.jayparkinsonmd.com/myprices-without.html)
    3. The nay-sayers above display the same sort of mentality that has kept healthcare in the stone ages. Fail to change or adapt, and get ready to wither away into oblivion. The kids of today are our future patients…and even e-mail is passe for them, in favor of text and IM. Want to care for your community? Vibrant communities exist online (Facebook, My Space, etc.).
    4. Disruptive innovation is so readily accepted in the scientific realm of our profession (even…usually…without evidence), yet attempts at innovation in the realm of delivery and redefining the image of the physician-patient relationship are shunned. Physician-patient relationships are two-way. Patients want to evolve the relationship.
    5. Criticize all you want…he’s a lot happier than most physicians, and he’s doing it by redefining the norms that keep us stuck in our current state (the current state is doomed).
    I definitely get the sentiments expressed by rbaer in regards to the risk of becoming a “…hyperefficient distribution system of specialist care, medications and scans…”.
    Public health, population-based needs, and the issues around cost/quality aren’t clearly or purposefully addressed in this model. But then again, they currently aren’t in a lot of physician practices…
    I guarantee you, however, that there will be aspects of his approach that will become mainstream.

  21. I’m a physician and my own personal physician (an internist) has a website and uses it for the things it is appropriate for: answering questions (he provides links), refilling prescriptions, and the like. If it takes him more than 15 minutes he charges $10.00 for it. But as folks have said, it’s pretty hard to assess things like cough and shortness of breath over the internet. Still, to the extent it can free up a doc’s time I think it’s a good trend. I do see the danger of a doc’s web page being just a store front where patients can click on whatever they want, from a chemistry group to an MRI scan–it would be temptingly easy to set up such a internet medical mill.

  22. “requires almost no overhead”
    So why doesn’t this “new” kind of doc publish his fees on his web site? Isn’t this great technology supposed to save us from the high cost of healthcare or is it just to pad the profit side some more? He says he “knows” health costs and quotes some typical fees like MRI, which are supposed to, I guess, show us how cheap a GP he is. Trouble is I can’t get an MRI on line. Hey doc, what’s an online visit cost, come on, just tell us.

  23. Oh, by the way, Dan, re. “Human contact is not needed for question answering and drug refills” – there is some old fashioned technology that addresses this problem, and it is in good routine use throughout the US … starts with a “t” and ends with “elephone”. No, I have nothing against patients writing Emails. It just can’t replace office visits for most patients.

  24. I can’t believe what I am reading (Jason, Renata, Dan) … I would be curious how much of the favourable posters are physicians.
    I also want to stress that I have nothing against alternative means of communicating with physicians as Dr. Parkinson practices par excellence, as well as I am advocating EMR, PACS and whatever comes next … but the idea of running a TYPICAL primary care practice efficiently (i.e. providing good care cost effectively) in a “virtual office” is laughable. I don’t want to speculate on Dr. P’s practizing patterns, but I know for sure that a lot of physicians would run a virtual office as a hyperefficient distribution system of specialist care, medications and scans, based solely on low threshold patient communication (or worse, direct requests). I am sure that this will bring down health care costs.

  25. Yes, but is he a good doctor? And how does he check BP, temperature, and other visual/tactile symptoms?
    So, could I link with a doc in India and get a “virtual” office visit for say, $10? Maybe that would get the attention of the AMA.

  26. This is great. The first comment appears to be from a resistor. Human contact is not needed for question answering and drug refills. It would interesting to see how technology can be used for physical examinations and my “critical tests”. Why not have the leader in cardiology able to access your EKG the moment it is posted. Going to an office for routine matters is not only a waste of patient time, but physician time as well. AS the web develops we will see more and more technology integrated into hospitals and practice. Resistors beware…it will happen! Way to go Dr. Parkinson!

  27. Dr. Parkinson: Kudos! We’re waiting for you to expand to MANHATTAN! Sent a link to your site to the new Governor of New York, a family friend and advocate for quality healthcare and the disabled!

  28. This is just childish. Of course you need person to person follow up visits, for reasons of physical exam, counselling … of course you can do without if you have a practice consisting of tech savy youngsters who mainly deal with wellness concerns.
    The challenge is not how to deal effectively with patients who are smart and have good judgement as is the case with Dr. Parkinson’s self-selected clientele; it is the demented, uneducated, partially compliant individual.

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