Flipping the Doctor’s Office

Consider the doctor’s office: the sanctum of care in American medicine, where a patient enters with a need — a question or an ailment or a concern — and leaves with an answer, a diagnosis or a treatment. That room, with its emblematic atmosphere of exam table and tiny sink and bottles of antiseptic, is in many ways the engine of our health care system, the locus of all our collective knowledge and all our collective resources. It’s where health care happens.

But in a less sentimental light, the doctor’s office doesn’t seem so exalted. Yes, it remains the essential hub for clinical care. But what occurs in that room isn’t exactly ideal, nor state-of-the-art. The doctor-patient encounter is fraught with tension, asymmetrical information, and flat-out incomprehension. It is a high-cost, high-resource encounter with surprisingly limited value and limited returns. It is too cursory to be exhaustive (the infamous fifteen-minute median office visit), too infrequent to create an honest relationship (one or two times a year visits at best), and too anonymous to be personal (the average primary care doc has more than 2,300 patients).

At best, it offers a rare personal connection between doctor and patient. At worst, it is theater. The doctor pretends she remembers the patient, and that she has actually had the time to read the patient’s chart in full; the patient pretends that he hasn’t spent hours on the Internet trying to diagnosis himsef, half-admitting what he’s really doing day to day, and pretending he won’t second- guess the doctor’s orders the moment he gets back to a computer.

As woeful as that sounds, we know that there’s real value here. This encounter can be meaningful; it should and must be meaningful. The doctor is a necessary interface to medicine, and his office is a source of care, expertise, and trust. The patient is eager and receptive to learning, primed for guidance and direction. Pragmatically, the doctor’s visit is a powerful part of modern medicine. The problem is that we, collectively, are not optimizing this resource; we have not reconsidered and re-evaluated how we might exploit the visit to its full advantage.

So how can we improve this situation? How can we fix this thing?

This might be one more nebulous problem left unarticulated, except for the inspiration of Sal Khan, founder of Khan Academy. Earlier this year, Sal visited the Robert Wood Johnson Foundation, and explained the premise and power of Khan Academy. Sal explained how and what he’s accomplished by putting simple, clear explanations of academic subjects in online videos. Khan Academy is often described as “flipping the classroom,” insofar as it reverses the normal flow of instruction. In a “flipped” classroom, the lectures happen at home (in video form) and the homework gets done in the classroom, where the teacher can give individual attention to individual students. This flipped classroom, the idea goes, maximizes the teacher-student encounter and puts the teacher’s expertise to its best effect.

But that’s only one of two flips in what Sal has done. In the second flip, he explained, the fixed and variable conditions are reversed. Traditionally, the progress of instruction is fixed: The coursework moves ahead on the teacher’s schedule, and at year’s end, the entire class — or at least those who’ve fulfilled minimum requirements–graduates. What’s variable is the proficiency of each student. Some have mastered the material, some glean parts but not all, and some are left behind. In Sal Khan’s vision, these are reversed. Each student should reach a high level of proficiency with all the material, but should proceed at his or her own pace, not the teacher’s.

Together, these two flips represent a significant reimagining of the student-teacher experience in the classroom. Suddenly, the classroom becomes a hub in a broader network of resources and information. Suddenly, the teacher’s expertise is reasserted, treated less as a commodity and more as a precious resource.

Sal Khan inspired us, and the similarities between the classroom and the doctor’s office were obvious: Why not “flip the clinic” the way Sal has flipped the classroom? Later that day, I was talking with Anne Weiss, team director of RWJF’s Quality/Equality team. What exactly, we wondered, would a flipped doctor’s office look like? What would a new sort of doctor-patient encounter involve? Is video content required? What are the resources, and the players, beyond the doctor (nurses, nurse practitioners, other staff) and on the patient’s side (family, co-workers)? And how could you bring this new approach to both care providers and patients alike?

As with any good idea, it turns out many people are already working on these notions. In New Jersey, the Camden Coalition of Healthcare Providers has aligned to change the way they deliver primary care, leveraging data from across the coalition to coordinate resources and improve the efficiency of care. At the brand new The Betty Irene Moore School of Nursing at UC Davis in California, the faculty is rethinking the role of the nurse in care delivery, training a new generation in informatics, resource management, and interdisciplinary innovation. And HealthLoop, a San Francisco-based startup, is addressing the episodic nature of clinical medicine by turning follow-up — the essential but often overlooked post-visit status check — into a feedback loop, engaging the whole physician practice (doctors, nurses, support staff) in the end-to-end needs of patients.

These are all inspiring projects, and we’re hoping that we can learn from each of them, and start fostering a community of change. For the next few months, part of my mission as the Foundation’s Entrepreneur in Residence involves working with an amazing team of program officers and gather string on where innovation is happening. We want to capture it and consolidate it, with the goal of creating a robust resource for all physicians, their practices, and their patients, to improve the most potent resource in medicine. The end result, we hope, will be a toolkit for flipping the clinic, offering a specific source for new ideas, better tools and best practices. An important part of this project is to engage the broader community of stakeholders — patients of all kinds, providers at all levels, and experts of every niche — to share their ideas and feedback.

Right now, flipping the clinic is just an idea (for one thing: should we call it “flipping the doctor’s office,” which is more explicit, or “flipping the clinic,” which is more catchy?). In a few months, we hope to propose a new framework for administering effective health care for all Americans, and others worldwide, with the goal of improving understanding, efficiency, and outcomes.

In the meantime, please offer your ideas and reactions below, or send them to me at TGoetz AT RWJF.org . We can’t wait to get this started.

Thomas Goetz is an Entrepreneur-In-Residence at the Robert Wood Johnson Foundation, correspondent at The Atlantic, the former executive editor of Wired, and author of The Decision Tree. His latest upcoming work, The Remedy, will be released in early 2014.

14 replies »

  1. My mom works in a pediatrician’s office where children are vaccinated daily. These knowledgeable doctors follow CDC recommendations and help protect children from many preventable diseases. I thank all those doctors and their staff for doing their part in protecting so many. I have heard many entertaining and interesting stories involving the administration of vaccines. Thankfully I do not work in a doctor’s office, but I’m glad for those who do. Also, I do agree with you on the content of this article.

  2. What this article and many healthcare providers seem to forget is that there needs to be a 2-way dialogue. That not only does the provider need to put out information, they need to also take in information. They must LISTEN and absorb what they are told. I am a provider and have been assisting my mother in her travails with her multiple providers and have to admit much frustration with attempting to communicate with the different consultants in a meaningful way and achieving a dialogue of progressive exchange that meets all of my mother’s care needs. The silo approach of care does not work! The cardiologist cannot only care for the CV system as the GI provider must look at more than the gut! There are interactions between meds and diagnoses. Think about coordination of care and simplification of treatment routines for patient and family!

    • Great point!

      I’m a geriatrician & agree with you finding a way to get providers to coordinate and synergize their care is very important…not quite sure how it would happen with a flipped clinic, but it’s sorely needed.

      My own hope is that when as they work on the flip the clinic concept, they’ll specifically consider the case of someone like your mother, who is older, has multiple medical problems, and has family caregivers actively involved.

      I do think that if we were better at getting certain things done before and after the visit, doctors might be better able to focus on listening and dialoguing during the visit.

  3. A great article…. This concept could be integrated nicely with a Lean approach. It seems to fit with some of the Concierge and Membership model approaches that I’ve heard and read about recently . Of course those models have the luxury of removing the Fee For Service control which unfortunately gets in the way of doing things in a better way.

  4. Hello Thomas you write nice post– one thing we like that you describe the relation b/w doctor and patient. There are rare cases that you will get both facilities in one pack means in one clinic. This is really great article! I like you views that ” instead of the patient needing to proactively remember when to come in for a check-up, the doctor’s office would proactively call the patient to setup the appointment”.

  5. Nice post, Thomas. It’s also interesting to consider flipping the exam experience to look at it from the patient perspective. Traditional exam room layouts tend to be focused on what makes sense for the physician or caregiver, rather than what makes the experience best for the patient. Looking at the exam space from the patient perspective means thinking about the time spent moving from waiting room through vitals acquisition and in to the exam room, and how that experience can be improved.

  6. “The patient is eager and receptive to learning, primed for guidance and direction”

    I understand the intent of this hyperbole – it is hyperbole, right? If not, then you are wasting your time. You are going to have to understand a lot more about what motivates the patient to be in that exam room, and when you do, you will no longer summarize it in the same manner.

    It is also pointless to proceed without also addressing the payment model. This is one area (maybe the only area) in which I see the medical home as having an impact.

  7. Great article! For me, a flipped encounter is about “flipping” the burden of proactivity. That is, instead of the patient needing to proactively remember when to come in for a check-up, the doctor’s office would proactively call the patient to setup the appointment. Instead of a patient reporting after 3 months that they haven’t been taking a medication, the doctor’s office would check-in with the patient after the pharmacy notified them that the medication was never refilled. Instead of nutritionists giving a newly-diabetic patient a list of healthy foods and a recipe list, the nutritionist at the neighborhood grocery store would walk the patient through affordable, healthy options. There are many more examples and many of these already exist in some form or another. The key is to combine these flipped services so that the patient’s experience is more about a system that supports their improved health rather than causes a new headache. Thank you for a stimulating paradigm shift!

    • Thanks Marcel – one thing we like about the Flip the Clinic idea is that it works both specifically and conceptually – in other words, there are some physical parts of the clinical encouter that can be moved outside the clinic’s walls. AND there are some conceptual shifts that can be pursued. Hopefully we’ll be able to map out several options & strategies on both levels.

  8. hi Tom,

    Nice post and neat to think about applying the flip concept to healthcare. (Is this very different from flipping healthcare so that it revolves around patients’ needs/interests rather than providers needs/interests?)

    Suggestion: don’t lump the outpatient high-utilizers with the relatively healthy patients who need prevention (and maybe a check-in on 1-2 stable chronic conditions). The first group has a lot of need and many come in to clinic more than 1-2x/year (those who don’t prob should), although you are right that these encounters aren’t enough and could be more productive.

    The second group is larger numbers-wise, has historically gotten less intensive attention from clinicians, could and should get more from the healthcare system, and surely would also benefit from a flipped office. But perhaps needs a different type of flip than do the more medically intensive patients.

    Am looking forward to following the progress of these projects. thxs!

    • Great point about the different groups & different needs. Indeed the challenge will be to make sure this idea both stratifies & scales at once. That’s never easy, of course…

      And yes, the idea is akin to ‘flipping healthcare’ – but we think there’s something iconic and focused about the clinic itself as a hub for healthcare that bears special scrutiny.

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