What is the Physician’s Role in a Web-based World?

With all of the super accessible health information now available, consumers have turned into the  equivalent of first year medical students, armed with too much information but not enough objective experience. The ideal doctor patient relationship is a partnership centered around facts and good communication that is based on our experience. The internet has enabled us to communicate in ways which are more and more interesting and, ultimately, more efficient. Except the online doctor, the curator of all these personalized facts, is nowhere to be found.

I spent a few sessions with a psychiatrist my first year of med school because I was convinced I had MS. Well, 11 years later I’m symptom-free and here to tell you all about how I beat that crippling disease called Medical Student Syndrome. But as health professionals all know, it’s the combination of facts, experience, and reason that enables us to do our jobs well.

Fortunately for our ability to earn a living, internet health information is just facts. So our jobs are still needed because, for the foreseeable future, we still offer experience and reason.

All jobs consist of executing the steps within a larger project. Most people have five or six projects at any one time that keep them busy for 40 hours a week. Web apps like Basecamp and Action Method were created to help people get these steps done. They help people organize with a team of people, delegate responsibility to any one of their teammates, and keep track of the project’s progress. They’re absolutely brilliant and a lifesaver for the modern workplace.

Doctors have about 2000 patient projects. And we get, on average, one hour with each patient per year to serve as their project leader, delegating the other 8,765 hours to our patient who manages their health on their own, disconnected from us and unable to receive personalized information or ask questions except during the occasional, all-too-short office visit.

Both Basecamp and Action Method were designed to share information and facilitate goal-oriented, efficient, online communication between teammates who aren’t working in the same geographic area. Awesome! Wouldn’t that be nice to have with our patients?

Ha, in an ideal world. We only get paid for office visits and procedures. We surely don’t get paid for communication and definitely not for prescribing links personalized to each patient. And there isn’t a single profession in the world that works for free.

The reality is this:

Percentage of people age 65 and over online today = 41%

Percentage of docs and hospitals who use computers = 9%

Percentage of people with home computers in 1985 = 15%

Even the elderly are more wired than doctors! And guess what they’re doing? They’re visiting Dr. Google. If their team leader isn’t accessible, well, folks, it looks like patients are on their own turning to really helpful resources like ACORMEDgle, other patients, Your Flowing Data, and rateadrug.com. Without a doctor on the other end of these links, even those cutting edge, senior netizens are leaving us behind blinded by their dust as we’re struggling to write our own chicken scratch paper notes.

Doctors…eating the elderly’s dust isn’t your fault. You can’t work for free. And since the Feds define how we get paid (with this, not for this), we’re going to limp along, weighed down by our paper charts and federal bureaucratic initiatives that will soon face stiff resistance from the people who don’t kill golden geese, while society races past us in this era of profound changes in the way humans communicate. If only the way we get paid could be updated for the 21st Century, our patients wouldn’t be marginalizing our efforts. I can dream, can’t I?

Jay Parkinson, MD is a physician based in Williamsburg, Brooklyn. He works with Hello Health, an innovative healthcare start-up that matches online patient visits with convenient neighborhood locations. Jay will be a featured speaker at Health 2.0 Meets IX on April 22nd-23rd in Boston, where he will discuss the future of the physician practice in a Web 2.0 world and his firm’s vision for the future. Thinking of going? A limited number of passes are still available.

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21 replies »

  1. I totally agree with the data you have mentioned in your blog. The health sector has shown a tremendous growth and it is completely connected to the internet, social media and digital channels. Now patients are just a click away from their needs with the help for internet. Healthcare businesses can also reach to their untapped market of patient through healthcare digital marketing (https://www.gmrwebteam.com/industries-we-serve/healthcare).

  2. A very true suggestion by you. Your article is clearly indicating the current situation that patient are facing. Beyond the fair price, the other most important thing that patient can come to know is the authenticity of the doctor. You can search over the internet regarding the information related to particular doctor. Their reviews from the existing or ex-patients help you determine the ability and excellence of the doctor. Beyond that website help patient fetch important information regarding the health issues they are facing. They can post their experiences with the situation and may get the reviews from the doctors and patients who have similar issues all over the world. This helps the patient to know the disease better and help them ameliorate in the recovery. And for the doctors it has been very important these days to have a good and informative website. This helps doctor to be in the contact with the patients so that they don’t need to come to the clinic for daily health issues. Also, patients can gain more information regarding your expertise in the field by reading the articles, the reviews of the existing patients. In today’s world it has been the case that most of the patient used to search for the medical doctors over the internet, and hence your website proves out to be the effective tool for the doctors to attract the patients. Many prominent website designer companies are increasingly becoming popular these days because of the increased involvement of doctors in the field of internet marketing. Website companies like http://www.medicalwebexperts.com being in the medical website designing fields since years, their designing and marketing techniques have led many doctors to attract the patients in a legitimate manner. The facilities provided on the website that allows keeping the medical records of the patients over the internet, streaming latest videos on the latest inventions in the field of medicine. This all facilities somehow creates a better relationship between doctors and patient, making a better planet to live.

  3. More often than not my pediatric patients’ parents show up in the office with an arm load of internet print outs about their child’s problem (or they call me in a panic later, after they “research” the diagnosis I made on their child). Invariably they read about some extreme case and I have to explain in detail why their child’s case is different from what they read. Patients should be directed to physician monitored and edited websites like PhysiciansForPatients.com, which can serve almost like a reference librarian and guide them to accurate information about their condition.

  4. Patient-centered medical homes in the primary care setting are moving decision making to the patient along with the use of electronic medical records, e-prescribing and registries. So, there is a considerable amount of IT communication involved. Many of the details are succinctly explained on the TransforMED site.

  5. On line communications between doctors and patientss is actually a complicated issue, given the variety of services that can be provided, and types of practices. Its therefore important that any system that’s set up is sufficiently flexible to accomodate the needs of the different patients and doctors. One on line service that does that is http://www.housedoc.us. Its open to everyone, easy to use, and lets physicians decide on the types of services to offer, whether or not to charge for them, or how much. It also bills the patient if there is a charge. That way the patient can be assured of good service.

  6. I am an internist/geriatrician. I love the concept of project management applied to health care. A problem arises and tasks need to be prioritized and accomplished. This comes up so often, but the fragmentation and lack of coordination that is inherent in our individual services design creates a challenge. When care is complex, the result is often confusion for patients, and rework for providers- reimbursed for providers, but expensive and sometimes unsafe for patients. The burden of coordinating falls on the patient or for the fortunate patient, a healthcare savvy family member who can put it all together. Yesterday, I met a patient for the first time for just a few minutes on my busy clinic schedule. He had questions about his care. He had seen a number of specialists and had an amazing number of imaging and invasive tests, but remained confused about his condition. The nonspecific, indeterminate test findings of each test lead to yet another, and another. The problem was depression- and no primary physician.
    On the other hand, this week, using our electronic health record, I was able to support nurses on my care team, to coordinate care from a remote site, for a patient I know well with complicated medical problems needing assessment for urgent surgery. The team received thanks for “jumping into action” from his family. That was satisfying. We do have the tools required for this transformation.
    I am a fan and look forward to attending Dr. Parkinson’s session at the Institute for Clinical Systems Improvement meeting- Journey to a New World of Health Care next month! JB

  7. Solution to docs not getting paid for other than office visit and procedure – put them on salary. Jay, would you support salaried docs, or does that not fit with your business plan?

  8. The online doctor should not just have a one-to-one connection with an individual patient. We need to break down the mindset of Health 2.0 communities being patient-only clubs, and find ways to get doctors helping in such communities.
    At the initiative of patients I’ve been helping in such ways on the Periodic Paralysis Association listserv. It is clear that patients are very appreciative of having doctors involved in such settings. We’re now preparing an “Owners’ Manual” FAQ for the most common of the diseases to help the patients get appropriate care, for example avoiding being treated as nuts with hysterical paralysis when they show up in hospitals.
    BTW, Jay, the profiles of you, me and two others in the “Doctor of the Future” article in Fast Company (http://www.fastcompany.com/magazine/135/the-doctor-of-the-future.html?page=0%2C0) came out pretty well. It is good that people are starting to focus on those of us who are working on innovative approaches to health care reform.

  9. I wrote below in 1995-
    New Roles for Physicians in the Information Age
    -Information sorters, guides and interpreters
    -Decision specialists/coaches
    -Motivators of Behavioral Change
    -Integrating patient’s values into health care
    -Spiritual guides
    -Care coordinators (especially primary care)
    -Patient advocates
    -Providers of emotional support (being there)
    Dr. Rick Lippin

  10. It is nice article. Medicine, as I have taken, is an art and science mixture. There are things logical and then we have things that current knowledge is not sufficient to explain logically.
    It makes docs very vulnerable as they have only so much knowledge. Internet can help patient enhance med’s knowledge too. Why is it needed? Because, as smart as a physician may be, there is no checklist of items to do for every visit or disease. There is bound to be some misses and also they are bound to miss some of the information about disease and drug. Patient can fill the gap.
    I have a great PHP. Having said that, I have expereince with specialist whose whole claim to diagnostic was that someone else said so. I told him if his whole idea is what someone with high school education observation, I did not need to come to him. So after few days of hospital stay, and lots of money on testing, all I got was diagnostic based on hearsay.
    I think these are the type of people who destroy the image of medicine.

  11. Uhmmh … it is hard to offer a note of caution after all this unmitigated enthusiasm.
    First off all, Dr. Parkinson’s claim that only 9% of docs and hospitals use computers seems misleading. The link clearly refers to EMR, not computer use. I could be wrong (all hospitals I worked at in the last decade happened to have EMR), but I would bet that more than half of the hospitals have at least some partial computerized functions (e.g. labs) and easy web access to good sites like emedicine (free) or up to date (subscription). I don’t know how many doctors are truly computer illiterate, I think it is a tiny minority only.
    Being a (good) physician is more than just having access to medical literature, and to understand its vocabulary. For some conditions (for instance, you have a clear cut tissue/receptor diagnosis of cancer and rock solid staging), nearly anyone might be able to get useful information that is applicable to an individual’s situation (as some above testify). For most medical information, however, it is CONTEXT and JUDGMENT that matters. This new therapy X that has excellent results in one pilot study, is it better than the established therapies? Study Y reads promising, but do you know about a negative study of the same therapy that was published just a month later? I have read and I am afraid of side effect C of therapy W, therefore I prefer therapy V; but maybe side effect C is transient only and seen only 3% more often than in placebo treated patients …
    A lot of people seem to succumb to the illusion that “the truth is out there”, and all you have to do is thorough googling. But just take a deep breath and remember, for instance, that there are tumor boards where specialists discuss cases … or that many medical journals have a “controversy” section, where excellent experts of the same field voice largely contradictory opinions about one issue, both sides feeling backed up by good evidence … or that physicians do a fellowship after years of residency, pass their specialty boards and yet they still ask senior colleagues that they respect for advice?
    Both patients and physicians have to be humble, because everyone’s knowledge and foresight is limited … and yet both patients and doctors bring important knowledge to the table, from a variety of sources including the internet. And if both the patient and the doctor are smart, treatment will be as effective as humanly possible. Internet based smugness will only carry you so far.

  12. You’ve got to handle that patient (ok it me) gently, because we really think we know something when we come in. I have a great, well informed, well read Dr., and I now get it. His approach is lead – let me know we have a process, first, what is the chief complaint and the next two in line, I see him busy at the desktop entering data, he then doesnt let me go into my newly gathered google data, he starts asking me millions of questions, and honestly thats when I start to get it. He knows best and is more intuitive then WebMD. Now dont get me wrong, its great for a new Mom to learn how to get a bee sting out since these days familys are spread out all around the country and you dont have Granny or an Aunt down the street to teach you these things. But I know in my heart the only true knowledge lie with the man in the white coat. Oh, he doesnt wear one of those either.

  13. Dr. Luther,
    all the data from around the world fully support your point of view regarding the value of non-episodic relationships between patients and primary care physicians/family medicine practitioners. It is just too bad that the current reimbursement system is pushing medical students to the specialties instead of promoting family medicine & primary care. I wonder when the American public is going to wake up and demand a change in the system.
    There are many good reasons why patients seek information on the internet, regardless of the lack of primary care they receive. We have enough data to show that patients suffering from any unusual condition can easily benefit from looking for answers on their own. There is nothing wrong with that. In many cases these informed patients become much better patients for their treating physicians. Besides, self-help has always been an important part of what people do to stay as healthy as they can and the Internet is providing great tools to facilitate self-help.
    After witnessing the impact that patient empowerment has had over more than 1/2 million cancer patients since 1995 I can assure you that the majority of patients actively looking for medical information on the Internet are the best patients a good doctor can expect. It is also true that they are the worst patients for any mediocre doctor. Just as it should be.

  14. Dear Dr. Parkinson:
    Your post today provides a good description of barriers standing between physicians and patients in our mutual quest for great health care outcomes. As our nation addresses health care reform, family physicians nationwide are pursuing an excellent way to remove those barriers – by redesigning the health care delivery system to provide each patient with a ‘Patient Centered Medical Home,’ where care is coordinated by a primary care practice team.
    We know the best care is provided not in episodic, illness-oriented, complaint-based care, but through patient-centered, physician-guided, cost-efficient, longitudinal care encompassing the art and science of medicine.
    Primary care physicians focus on preventing illness and managing diseases, keeping patients as healthy as possible. With the number of Americans with a chronic disease projected to increase from 125 million in 2000 to 157 million in 2020, it’s increasingly important to ensure strong disease management.
    Primary care saves money as well. For each 1% increase in primary care physicians, an average-sized metropolitan area in one study experienced a decrease of 503 hospital admissions, 2,968 emergency room visits and 512 surgeries.
    We have plenty of scientific evidence that the medical home model works to improve health care and decrease costs. See the ABC News April 10 report on the Mayo Clinic’s recent success, for example: http://abcnews.go.com/Video/playerIndex?id=7302887. We also have plenty of backing from patients and their families for this model. See Ellen Goodman’s April 3 column, for example: http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2009/04/03/put_care_in_healthcare.
    You’re correct that patients seek volumes of health care information on the Web. There’s nothing we can do to change that. What we can do is ensure that they have a strong relationship with a primary care physician who can coordinate their health information, from whatever sources, and coordinate their care, working together for the best possible outcomes.

  15. It all comes down to money and incentives. Doctors simply dont have financial incentives to go online and take their presence their.
    But that doesn’t mean they aren’t using the internet as people.

  16. Jay, while I understand and appreciate the underlying point you’re making here, I’m troubled by your post. Asking doctors to engage patients via information versus holding that knowledge themselves isn’t asking a doctor to work for free. It’s true that this may not be the way that physicians have done business in the past and physicians have built their daily routines around the way things are. We both know that doesn’t make the path of least resistance the right way.
    Asking doctors to engage patients in a way that isn’t paternalistic or information-hoarding is simply new. Telling doctors not to worry that their technological adoption rate is behind that of the elderly is simply giving the folks resisting a cultural shift yet another reason to not be accountable for their own behavior. All blaming the payor does is shift responsibility and not make any effort to effect change in a pretty broken healthcare system.
    Hello Health is a great example of working around the problem. I wish your post would have done more to encourage doctors to find novel ways to work around broken bits of the system instead of justifying the choice to limp along in the status quo.
    My second concern here is your description of doctors as project managers. Again, I understand the point you’re making but I think the idea that physicians are responsible for project managing those they treat plays right into one of healthcare’s big problems. It is part of why some physicians are struggling to adapt to the Health 2.0 enabled consumer.
    My doctor isn’t my project manager or team leader; I am. I go to a physician because I temporarily require specific expertise and advice; if that expertise includes management of a chronic condition, then the doctor becomes part of my team. The team, however, is mine. Doctors are not the ones ultimately responsible for my health; that weight should always fall on me.
    Health plans, physicians, disease management, and a variety of other entities have been falling into this trap for far too many years. How do we expect consumers to take responsibility for their own health if the healthcare system doesn’t interact with consumers as the “project owner.” I’m not going to say that consumers always behave like the responsible party because frankly, we don’t. However, long-term behavioral change doesn’t happen because someone is playing healthcare Big Brother. Behavioral change happens because people learn and grow. Until the healthcare system starts to engage a consumer as the person truly responsible for their own health, the problem is going to persist.
    The irony here is that in consulting “Dr. Google,” consumers are taking charge of their health. Going to a doctor visit armed with information means that person does want to know about their health. The trick for the physician is to properly tap into that teachable moment. Even if the physician simply makes a suggestion about a reliable, accurate place for the consumer to find information in the future, that simple interaction encourages the person to continue learning and seeking information. It also provides some implicit clues about what reliable resources look like.
    Bottom line, it’s time to stop saying that physicians don’t get paid to engage patients and information-share. They do. It’s the same as saying that physicians don’t get paid to say hello, shake my hand, or contact me about test results. Those things happen anyway.
    Yes, initially, it will take physicians time to build up the skills and recognize reliable resources to share, but that isn’t a sufficient reason for physicians to not take advantage of the online resources literally staring their patients in the face. It takes less than a minute to do a Google search and scan the results. Use Healia or another health-related and filtered search, it’ll take even less time. There’s no excuse for physicians to lag behind.

  17. Jay, interesting post. I want to tell you how I worked with my medical team and you tell me if it works for your model.
    I was diagnosed with breast cancer at age 38 with no family history and quickly developed a medical team that included my referring OB/GYN, medical oncologist, surgeon and radiation oncologist. I had copies of all scans provided to all of them. When we were discussing whether oophorectomy or hysterectomy was the right path (strongly hormonally positive cancer) I refused to make a decision until my medical oncologist and GYN had a discussion. My GYN called me one evening to review what they had discussed and we decided that oophorectomy was the way to go without hysterectomy.
    Twice during my treatment course I came across research that I thought was worth investigating and discussing with my oncologist. I faxed a copy of the research to the office with a note stating that i would like to review this at my next scheduled appointment. In one case we followed the new research and in the other case we did not but these decisions were made with discussion and respect.
    Each time that one of my medical team came into see me for an appointment I briefly reminded them who I was and why I was there. I do not expect my medical team to be up to date on all of the research but I do expect them to be willing to learn. I see it as my responsibility to help to educate my medical team about things that directly effect me.
    None of these appointments took any more time than a standard appointment and I hope that not too much additional time was spent when I was not present. If I could have I would have happily had this communication via e-mail but I understand that physicians time is not unlimited and they need to have time to have a personal life.
    So is this effective? Can we train patients to be effective self advocates? I think we may be able to for some but not for all. What do you think?
    Kate@ http://aftercancernowwhat.blogspot.com

  18. Jay, thank you for your post!
    And in particular for starting to surface the odious scandal of the RUC and the RBRVS. I have said it previously and will repeat it here: it is high time to get medicine out of the stranglehold the AMA has so successfully built around billing/reimbursement. It is, IMVHO, the main reason we see the galloping cost of healthcare close to double what it is in most other advanced countries.
    e-Patient Dave’s story with the defective data transmitted is just another example of the corrupting influence a single organization can have on a single segment of the national economy coming dangerously close to 2)% of GDP. If CPT codes were not required and if doctors and hospitals could escape the tyranny of the critical relationship between ICD-9, used for diagnosis and CPT, used for procedures associated with the diagnosis, we would have a much better chance of building an effective and efficient system who would be much more respectful of the patient, engaging and empowering.