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What Doctors should Know when Joining a Startup – Five Key Books

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By DAVIS LIU, MD

Davis LiuWhat should doctors know before joining a startup? I don’t know if these were questions medical school graduates in the Bay Area asked themselves as they opted to join a startup rather than completing their medical training in residency programs. These new doctors felt they could make a bigger impact on patient care by leaving the system and its current status quo.

Why not? In the Bay Area, small startups and former startups like Facebook, Google, and Apple are literally blocks away from academic medical centers. Everyone knows someone working at a startup. At a healthcare innovation summit, Vinod Khosla, co-founder of Sun Microsystems and venture capitalist reassured technology entrepreneurs that the opportunities to disrupt healthcare were tremendous. After all,

“Health care is like witchcraft and just based on tradition.”

Khosla encouraged attendees to develop technology that would stop doctors from practicing like “voodoo doctors” and be more like scientists. Disruption required having an outsider point of view. Khosla highlighted how CEO Jack Dorsey of Square was able to disrupt and provide services more cheaply than the traditional methods of the electronic payment system accepting Visa and Mastercard because only 2 percent of the employees at Square ever worked in the industry.

health-innovation-summit

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Vinod Khosla: Technology Will Replace 80 Percent of Docs

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By Davis Liu, MD

I recently viewed health care through the lenses of a technology entrepreneur by attending the Health Innovation Summit hosted by Rock Health in San Francisco. As a practicing primary care doctor, I was inspired to hear from Andy Grove, former CEO of Intel, listen to Thomas Goetz, executive editor of Wired magazine, and Dr. Tom Lee, founder of One Medical Group as well as ePocrates.

Not surprising, the most fascinating person, was the keynote speaker, Vinod Khosla, co-founder of Sun Microsystems as well as a partner in a couple venture capital firms.

“Health care is like witchcraft and just based on tradition.”

Entrepreneurs need to develop technology that would stop doctors from practicing like “voodoo doctors” and be more like scientists.

Health care must be more data driven and about wellness, not sick care.

Eighty percent of doctors could be replaced by machines.

Khosla assured the audience that being part of the health care system was a burden and disadvantage.  To disrupt health care, entrepreneurs do not need to be part of the system or status quo. He cited the example of CEO Jack Dorsey of Square (a wireless payment system allowing anyone to accept credit cards rather than setup a more costly corporate account with Visa / MasterCard) who reflected in a Wired magazine article that the ability to disrupt the electronic payment system which had stymied others for years was because of the 250 employees at Square, only 5 ever worked in that industry.

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Doctors, Patients, or Insurers? Who Will Shape Health Care?

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By Davis Liu, MD

At a conference for America’s Health Insurance Plans, Gladwell argued that patients or consumers have been unable to be more empowered because doctors, as the intermediary, held the power of knowledge much the same way chauffeurs did for the early days of the automobile and Xerox technicians did in the early days of photocopying. A person was needed to guide and assist the individual to get the job done. At some point, however, the technology became simpler. People began to drive their own cars and make their own photocopies. The mystique of the chauffeur and technician was lifted. Now everyone could drive. Everyone could make photocopies.

Is it possible that for health care and the health care system, which for many people is a system they interact with rarely and in an area (health / illness) where the uncertainty and stakes many be too “high”, that individuals willingly  defer the responsibility to someone else? Gladwell hints that might be a possibility:

“A key step in any kind of technological transition is the acceptance of a temporary deficit in performance at the beginning in exchange for something else,” said Gladwell. That something else can eventually include increased convenience and lower cost. He offered a number of examples, including the shift to digital cameras where early pictures were not as good as film and the advent of the digital compression of music, which he contends has made the quality of music worse….

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Required Reading for Medical Students, Interns, and Residents

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By DAVIS LIU, MD

I have had the privilege of working at an organization which is actively improving the lives of its members and also was mentioned by the President as a model for the nation.  Over the past few years, I have also demonstrated to first year medical students what 21st century primary care should look and feel like – a fully comprehensive medical record, secure email to patients, support from specialists, and assistance from chronic conditions staff.

But as my students know, there are also some suggested reading assignments.  I’m not talking about Harrison’s or other more traditional textbooks related to medical education.  If the United States is to have a viable and functioning health care system, then it will need every single physician to be engaged and involved.  I’m not just helping train the next group of doctors (and hopefully primary care doctors), but the next generation of physician leaders.

Here are the books listed in order of recommended reading, from easiest to most difficult.  Combined these books offer an understanding the complexity of the problem, the importance of language in diagnosing a patient, the mindset that we can do better, and the solution to fixing the health care system.

Which additional books or articles do you think current and future doctors should know?Continue reading…

The Disappearing Family Doctor – Is It a Bad Thing?

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By DAVIS LIU, MD

The New York Times recently published an article titled the Family Can’t Give Away Solo Practice wistfully noting that doctors like Dr. Ronald Sroka and “doctors like him are increasingly being replaced by teams of rotating doctors and nurses who do not know their patients nearly as well. A centuries-old intimacy between doctor and patient is being lost, and patients who visit the doctor are often kept guessing about who will appear in the white coat…larger practices tend to be less intimate”

As a practicing family doctor of Gen X, I applaud Dr. Sroka for his many years of dedication and service.  How he can keep 4000 patients completely clear and straight in a paper-based medical system is frankly amazing.  Of course, there was a price.  His life was focused solely around medicine which was the norm of his generation.  Just because the current cohort of doctors wish to define themselves as more than their medical degree does not mean the care they provide is necessarily less personal or intimate or that the larger practices they join need to be as well.

The New York Times article and many patients typically confuse high quality care with bedside manner.  Not surprising.  In the November 2005 survey by the Employee Benefits Research Institute, 85 percent or more of the public felt that the following characteristics were important in judging the quality of care received:

The skill, experience, and training of your doctors
Your provider’s communication skills and willingness to listen and explain thoroughly
The degree of control you have in decisions made regarding your health care
The timeliness of getting care and treatments
The ease of getting care and treatments

The first three items relate to the ability of a doctor to translate knowledge, training, and expertise into the ability to listen, communicate, and partner with a patient.  This is bedside manner.  The last two items relate to whether a patient can be seen quickly and easily when care is needed.Continue reading…

Why Consumer-Driven Health Care Will Fail

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By DAVIS LIU, MD

The creation of consumer-driven health plans (CDHPs), health insurance policies with high deductibles linked to a savings option and with more financial responsibility shouldered by patients and employees and less by employers, was completely inevitable. The American public likes to have everything, whether consumer electronics or other services, as cheap as possible. With escalating health care expenses rising far more rapidly than wages or inflation, it’s not surprising employers needed a way to manage this increasingly costly business expense.

In the past, companies faced a similar dilemma.  It wasn’t about medical costs, but managing increasingly expensive retirement and pension plan obligations. Years ago, companies moved from these defined benefit plans to defined contribution plans like 401(k)s. After all, much like health care, the reasoning by many was that employees were best able to manage retirement planning because they would have far more financial incentive, responsibility, and self-motivation to make the right choices to ensure a successful outcome.

How did that assumption turn out anyway?

Disastrous according to a recent Wall Street Journal article titled Retiring Boomers Find 401(k) Plans Fall Short.

The median household headed by a person aged 60 to 62 with a 401(k) account has less than one-quarter of what is needed in that account to maintain its standard of living in retirement, according to data compiled by the Federal Reserve and analyzed by the Center for Retirement Research at Boston College for The Wall Street Journal. Even counting Social Security and any pensions or other savings, most 401(k) participants appear to have insufficient savings. Data from other sources also show big gaps between savings and what people need, and the financial crisis has made things worse.Continue reading…

Why This Primary Care Doctor Loves His EHR

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By DAVIS LIU, MDPicture 53

A recent post in the Wall Street Journal Health Blog noted that a study found electronic medical records don’t improve outpatient quality. The authors of the Archives of Internal Medicine article, Electronic Health Records and Clinical Decision Support Systems, correctly points out that we should be skeptical and “doubt [the] argument that the use of EHRs is a “magic bullet” for health care quality improvement, as some advocates imply.”

This should surprise no one.  Were we that naive to think that simply installing health information technology (HIT) in the medical field would generate significant improvement in outcomes?  Does simply installing computers in our classrooms improve educational test scores?

Of course not.

The excellent commentary after the article makes some plausible reasons why the clinical decision support (CDS) didn’t seem to improve outcomes on 20 quality indicators.  First, it isn’t clear that the CDS implemented across the various doctors’ offices and emergency rooms actually addressed the indicators studied.  Second, the data studied is already dated (from the 2005 to 2007 National Ambulatory Medical Care Survey), a long time in technology terms (iPhone first debuted in 2007).  The authors of the original article also point out that there is some evidence that institution specific use of CDS actually improves quality.  Whether this can be scaled to the national level is the question.

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