Could Siri be a game-changer for physicians?

Steve Jobs seems to have taken Arthur Clarke’s law to heart: “Any sufficiently advanced technology is indistinguishable from magic”

Oct 25, 2011 - Production Blog Author

Editor’s Note: Henry Wei, MD, is a board-certified internist and a
Clinical Instructor in Medicine at Weill-Cornell Medical College. He is
currently a Senior Medical Director at Aetna, where he leads Clinical
Research & Development for ActiveHealth Management. (The views and opinions
expressed here do not necessarily reflect those of Dr. Wei’s employers.)

By now you’ve probably heard plenty about Siri. Or perhaps Siri has heard
plenty about you. Siri, the speech recognition software Apple’s built into the
iPhone 4S, has been billed as an agile virtual assistant, able to perform
tasks ranging from taking dictation and sending the outcome as an email to
finding facts and scheduling appointments. But here’s something that hasn’t
gotten quite as much popular press: Siri is really good at medical terminology.
And swear words (more on that later).

I unboxed my own iPhone 4S after a recent clinic week. With a backlog of
patient notes, I became curious about dictating these cases–leaving out patient
names for reasons I’ll get into later. After watching some Will Ferrell
(who doesn’t?), I tested out the Siri feature using some very precise
medical terms–language I wouldn’t expect anyone but a physician to be using in
real life. But Siri got every word right off the bat, without any ambiguity–a
task that can be challenging for most humans, let alone a computerized

Impressed, I began testing Siri from the other perspective: the patient’s. What
if I say I have chest pain, or I’m depressed? Parsing through Siri’s replies,
which mostly had to do with finding the nearest hospital, I noticed that
these answers were coming from something more than just speech
recognition–actual meaning was being recognized. That was exciting to me; it
showed a layer of design and consideration beyond the literal. You see, my
day job involves developing clinical decision support and innovating
healthcare IT. When I see a system that’s strong enough with semantic meaning
to, say, take an order at the drive-up window of a fast food joint, I get

Siri’s technology isn’t unique to Apple, which apparently has partnered with
Nuance, the company with the near-monopoly on spech recognition. Elsewhere,
Google Voice and others have made great strides with similar services.

Regardless, this feels magical. That is, Steve Jobs seems to have taken Arthur
Clarke’s law
to heart: “Any sufficiently advanced technology is
indistinguishable from magic.” Siri is a consumer-level tool that starts
working right away–no instruction manual needed–and though most of us have no
idea how, it can match speech and meaning with appropriate tasks. When it works
well, it enables us to skip an entire step in the process of getting things
done. We can move from having an idea to being ready to put it in motion
without needing to search or transcribe.

Imagine, for example, if Siri or a similar service evolves to the point where a
doctor can just say out loud, “please order a CBC with differential, chemistry
panel and a lipid panel,” and the program were smart enough–and had enough data
on you and the patient–to interpret your meaning and remind you that you’d
recently ordered a CBC for this case, and you forgot to order a liver function
test. Having that kind of rapid work-check would be an incredibly valuable
safety and efficiency feature.

What if, even further down the line, Siri (or a device like it) were able to
sit as a fly on the wall, listening to the doctor-patient conversation to a
point where it could act as a second expert opinion for diagnoses. Today,
physicians practice primarily in a vacuum, with little oversight. It’s too
expensive and outright embarassing to have someone observe and coach you, as a
physician. Atul Gawande wrote recently on coaching and the experience of
being coached as a surgeon, noting that “we treat guidance for professionals as
a luxury.” But think if you had a technology that could be watching what
physicians did in real time with the goal of offering real coaching. For
instance, a continuous speech recognition system could notice specific syntax
and nuances of the patient’s wording that might indicate a higher risk of
medication non-adherence, and offering an appropriate strategy to overcome that
risk. This type of computerized guidance is–paradoxically–somewhat offensive to
me as a physician, but incredibly exciting to me as a patient.

Clearly, with further development, something like Siri can be game-changing for
medicine. But here, a caveat. Only if doctors really want it. Change always
seems to come with two elements. One is a profound need, but the other–and this
is the one we in healthcare frequently miss–is an actual desire to change. That
said, the more expert and more successful the workers in any given field
become, the less they’ll actually want any change.

More broadly, we should think of Daniel Pink, who speaks to the keys behind
motivation as Autonomy, Mastery, and Purpose. Doctors have for generations
performed medicine in a very autonomous manner; it’s one of the things we’re
good at. How good are we at relinquishing control, or even accepting external

Still, something like Siri has a leg up because it’s intuitive. Our own brains
spend a good deal of time decoding words and sounds, so speech-based
communication is more intuitive to us than a keyboard or even a touchscreen.
This type of user interface should bear a sense of satisfaction when we notice
the job is being done right. This intuitive component is something we just
don’t get from a lot of healthcare technology today, which suffers from the
“clicky-clicky problem,” a term that my wife (also a physician) coined when
describing the irritating way that most EMRs force doctors into drop-down
menus, radio buttons, and dozens of text entry boxes–death by clicks.

While I don’t foresee an immediate conversion to Siri-like decision support
services among the majority of physicians anytime soon — our desire for
autonomy is too strong–I do believe that its ability to slip into iPhone users’
everyday patterns will translate to longer-term adoption. I’d see its course
going something like this: We begin by using it in our personal lives.
Insidiously, it works its way into the administrative sphere of offices and
hospitals–not the doctors at first. From there, it makes its way into the
operating room, where, in an environment not dissimilar from driving a car,
we’d prefer not to have to type or touch anything to express our ideas,
queries, and commands. Finally it becomes truly pervasive not just among
early adopters
, but also those older doctors–particularly those used to
dictating already–who are so adept at what they’re doing that the effort of
change seems unnecessary.

One of our rate-limited steps may be the interoperability aspect. Nobody wants
a technology that functions in a vacuum; if you take a dictation, you’re going
to need it to be stored somewhere, and its semantic meaning interoperable with
other systems. We’ll need apps, and those take time to take from a concept in
someone’s head to actual living, breathing code and user interfaces. That said,
the SMART platform championed by Zak Kohane and Ken Mandl at Harvard, and
the iNexx platform from Medicity on the private side, are both very
promising at establishing an easier way to interoperable “apps” in the
healthcare environment.

Some people, like the good Dr. Alexander Blau at Doximity, have raised
important concerns about security and potential HIPAA violations with Siri.
It’s my sense that the patent for the technology suggests that the data are
either encrypted or have the option of being encrypted. Either way, I suspect
that Apple or Nuance will be asked to make this part a little more transparent
by healthcare IT companies interested in levering their technology–particularly
if they’re using any data as training data for the system. For the time being,
though, the possibility of HIPAA-insecurity well worth keeping in mind.
Longer-term, we’ll have to see if the FDA will start playing a larger
in regulating medical technologies that employ speech recognition.

Oh, the part about swear words? Well, believe it or not, back in medical
school, my roommates and I invented a game where we would call and swear at
toll-free automated voice response systems (e.g. MovieFone and airlines) to see
what the system would do. The smart systems would actually direct you to a live
human operator right away. Well, Siri actually recognizes a lot of obscenities,
and even has some pretty humorous responses. And at the end of the day, if
speech recognition technology in medicine starts to be able to pick up on the
emotional intent of users–not just the semantic meaning of, say, medical terms
or swear words–then my bet is that we’ll have entered a truly magical era of
Healthcare IT.

Debate: Is Kaiser good for medicine? (Part 1)

With over 8.7 million health plan members and 167,178 employees, Kaiser is the biggest managed care organization in the country.

Oct 19, 2011 - Doximity Blog

Editor’s note: Doximity Advisory Board member Peter Alperin, MD, is a
board certified internist currently practicing at the San Francisco VA Medical
. He previously led informatics at Brown and Toland Medical Group,
and has also worked at Epocrates.

In 2010, the New England Journal of Medicine published a study conducted
by the Kaiser Permanente Division of Research showing that since 2000, heart
attacks among a group of over 46,000 of its Northern California patients had
declined by 24%. To be sure, some of this could be attributed to possible broad
public health trends in that area, but the researchers also noted that the
decline coincided with improved control of cardiovascular risk factors at

This alone might not be quite so remarkable, but for the fact that
consistently, Kaiser scores at the top of almost every single quality care
measure it’s in. Just recently, it was one of nine health plans awarded
five stars by Medicare Advantage. Time and again I’ve seen the organization
take a rigorous approach toward analyzing what it’s doing well and what it’s
not doing well in the interest of improving processes of care. In other words,
the NEJM story reflects something of Kaiser’s DNA.

There are many factors at play here but one of the clear incentives is
financial—Kaiser realizes that it makes good financial sense to invest in
prevention and the systems needed to provide preventive care in a
cost-effective manner. Last year, Kaiser reported a combined net income of
$2 billion, and $44.2 billion in operating revenues. With over 8.7 million
health plan members and 167,178 employees, Kaiser is the biggest managed care
organization in the country. Large technological and programmatic investments
make more sense in an integrated system such as this, one that simultaneously
controls insurance, hospitals, and doctors–effectively, all three legs of the
healthcare stool.

Thirty years ago, Kaiser was cynically viewed as a place for doctors who
couldn’t make the cut of private practice. How misguided that view was. I’ve
found it interesting to see how far the pendulum has now swung: Not long ago, I
was asked to talk at a residency event at UCSF. Among the seven of us on
our panel, the vast majority of the questions went to the person from Kaiser.
To me, this spoke volumes of the changing face of medicine. The residents in
our audience (a large number of whom were women) were asking about quality of
life and flexibility of day care.

Much of this has, of course, been enabled by the fact that private practice
simply isn’t as lucrative as it once was. And I would argue that growing pains
notwithstanding, there are notable advantages to this new landscape. Physicians
tend to go to medical school because they like medicine, not because they want
to be business people. One big advantage of an integrated system like Kasier is
that doctors don’t have to think about making payroll, renting office space, or
finding a call service. Furthermore–and this is the secret sauce—working in a
group environment forces collaboration, something at which doctors have perhaps
not historically thrived, but from which ideas and progress can spring.

Is Kaiser perfect? Of course not. It isn’t the most nimble. By dividing itself
into regions, Kaiser works hard at mitigating the inevitable bureaucratic
slowdowns that come with size, but even so, each individual Permanente group
remains much larger than an average medical group. It can take a long time to
implement best practices across an organization of such size and complexity.

I do worry that Kasier is so dominant in some markets that without the promise
of growth or the threat of competition, there’s the risk that progress will
slow, and that the goal becomes more about making the cut than breaking new
ground, be it in patient care or keeping costs affordable. However, Kaiser has
to date consistently performed and it remains, in my opinion, the gold standard
for healthcare delivery in the US. In fact, if we broaden our view to
incorporate other health systems that are on the vanguard of change, like the
Mayo Clinic, Geisinger, or Intermountain Healthcare to name a
few, what is apparent is that a great deal of overall innovation action is
currently in integrated delivery systems, what’s apparent is that a great
deal of innovation action is currently in integrated delivery, suggesting a
real relevance for these systems as healthcare continues to change.

Come November, we’ll revisit this issue–from the opposing perspective.

The business of practice: Are resumes the new roadmap?

New and evolving paradigms of healthcare provision have already led to some large-scale shifts—hospitals buying up private practices

Oct 04, 2011 - Doximity Blog

Editor’s note: Alex Blau, MD, is Doximity’s Medical Director.

In 2000, nearly 60% of physicians were practicing independently. Compare that
to two years from now, when it’s predicted that just 33% will continue to
practice solely outside of a larger health system. According to a report from
, the global consulting company that released those figures,
between now and 2013, the rate at which independent doctors are being employed
by larger systems will increase by 5% per year.

You probably don’t need numbers to tell you that practice models are changing
dramatically. New and evolving paradigms of healthcare provision have already
led to some large-scale shifts—hospitals buying up private practices, for

The incentive for such large scale practice consolidation is clear from the
hospital perspective, as it allows them to capture referrals and keep
lucrative procedures (e.g. endoscopies, elective surgeries) in-house. But what
is driving so many physicians to abandon the private practice model?

Hospital-based employment offers stability in an uncertain economy,
particularly for young doctors entering the job market with considerable
educational debt. According to the Association of American Medical Colleges,
new physicians are leaving medical school with an average debt burden of

In addition, work-life balance is becoming increasingly important for newer
generations of doctors. Hospitals offer better call coverage and more
predictable schedules. Moreover, they allow doctors to offload countless
administrative responsibilities, such as billing and staffing, while
simultaneously providing access to state-of-the-art IT tools and equipment. All
of this helps physicians eliminate much of the noise in their daily workflow,
allowing them to focus on patient care.

The consequences of the changing landscape of clinical practice has been the
subject of a great deal of discussion. There is one outcome, however, that
hasn’t gotten much coverage. The way in which physicians think about and
develop their careers is undergoing a fundamental shift.

Specifically, the business of being a doctor is becoming less dependent upon
the horizontal connections between specialists and referral sources, and more
dependent upon vertical relationships within an organizational heirarchy.
Resumes are replacing business plans, and time once spent on marketing and
cost-management is now being devoted to the pursuit of career-building
opportunities, like taking on leadership and administrative roles, conducting
internal research or developing QI initiatives.

As this trend continues, the growth challenge for doctors will be more about
career management and less about business development, a change that may favor
residents and young attendings, who are more accustomed to the competitive
landscape of academic medicine. Competition for chief resident spots,
publication opportunities and stage time at grand rounds and specialty
conferences may prove to be the ideal training for a new generation of
career-oriented physicians.

Facebook for physicians: a primer from Mayo Clinic's Lee Aase

The broader question is what can we say and where can we say it when we talk in a professional capacity about health

Oct 03, 2011 - Production Blog Author

Editor’s note: Alex Blau, MD, is Doximity’s Medical Director.

Type “Facebook” into a PubMed search and you’ll get 19 academic articles,
letters or reviews, all from the last three years. For Twitter, there are 105.
Social media has tremendous potential to improve the way physicians
communicate, yet we’ve all read the stories of doctors being censured by
employers or licensing boards
because of errant comments on Facebook. Though
rare, each such incident underscores a lack of understanding of what these
tools are for. Indeed, we’re just beginning to define their utility in the
healthcare sphere.

There are, of course, some very clear contexts in which social media is not
appropriate. Neither Facebook nor Twitter are HIPAA-compliant environments, for
example, and it’s mainly discussions of patient care that have led to problems.
(There’s clearly a need among physicians to communicate about clinical issues.
We’re building Doximity specifically to allow those kinds of conversations.)
But the broader question is what can we say and where can we say it when we
talk in a professional capacity about health.

This week, I asked Lee Aase, Director of the Mayo Clinic’s Center for
Social Media
to offer his insights on Facebook use, in particular. Here, he
took a little time away from preparing for the Mayo Clinic Social Media
(Oct 17-21) to weigh in with some well-tested insight:

Anything you put online has the potential to be seen. I always say that you
shouldn’t have anything on the Web that you would be mortified to read in
your local newspaper. Fortunately, Facebook still has privacy settings, so
you can really be thoughtful about whom you accept as friends. For example,
we recommend that in most cases you shouldn’t accept a friend request from a
patient. Nor should you have to: You can communicate on Facebook without
having a friend relationship.

Not long ago, in a blog series we do for the Center for Social Media
called Friday Faux Pax, we covered the story of a woman in Scotland who
posted a picture from the operating room on her Facebook profile. That would
have been a privacy violation in real life, so putting it on Facebook is an
extension of that. Advice like this seems so obvious in hindsight, but what
often happens is that people are caught up in something and they’re letting
off steam so they confuse a post with a conversation. It’s understandable:
Facebook’s whole tone is conversational. For that reason, it can really help
to take a ten-second pause before you post something. Ask yourself whether
what you want to say is productive and helpful to be posting, or whether it’s
just venting.

This isn’t to say you should shy away from posting anything–the way things
work these days, you will have an online footprint no matter what. That’s not
something you can control. What you can manage, though, is your opportunity
to make it good. Strong professional posts tend to consist of content in your
area of expertise. You always want to be talking in general terms; don’t get
into practicing medicine online. Even if you’re not using names or
identifiable information, remember that complaining about patients almost
always lowers the esteem of physicians in the public eye.

The broad rule-of-thumb is to keep it positive. Laughing at yourself rather
than making jokes about anybody else makes you seem trustworthy and credible.
More importantly, have a sense of what your personal boundaries are as you go
in. The physicians who have taken a little time to assess this question tend
to have the most rewarding experiences.

How doctors connect: mapping physician networks

This week, we’re sharing a tool we’ve put together that we think does that job especially well

Sep 20, 2011 - Doximity Blog

Editor’s Note: Jey Balachandran is a software engineer at Doximity.

For some time, we’ve been playing around with different kinds of data visualizations designed to help Doximity members learn more about how their peers are interacting with each other. To wit, this week, we’re sharing a tool we’ve put together that we think does that job especially well.

Sample size: Over 600,000 physician colleague connections made through Doximity.

Top 5 Most Connected:

  1. Internist
  2. Family Medicine
  3. Psychiatrist
  4. Ob / Gyn
  5. Pediatrician

Top 5 Least Connected:

  1. Radiation Oncology
  2. Infectious Disease
  3. Thoracic Surgeon
  4. Endocrinology
  5. Rheumatology

The graphic you see above represents the typical number of connections made for and between an array of medical specialties, each component circle sized according to how many members it has on our site. Our thinking is that this can be used as a comparison tool–a way for individual users to think about how they’re building their network relative to others in their field.

To give an example, say you’re a gastroenterologist and you find that your peers are on average linked to twice as many primary care physicians as you; that knowledge might well hold value in how you pursue future connections. More broadly, it can lead to some interesting questions about hospital/clinic layout, and which specialities might be best served sharing space in order to facilitate the most needed communication. For non-doctors, seeing which groups connect most frequently and robustly can also be pretty fascinating.

Is early hospital discharge worth it?

Patients receiving hospitalist treatment initially experienced shorter stays and cost $282 less than those seen by primary care physicians.

Sep 13, 2011 - Production Blog Author

Editor’s note: Doximity Advisory Board member Peter Alperin, MD, is a
board certified internist currently practicing at the San Francisco VA Medical
. He previously led informatics at Brown and Toland Medical Group,
and has also worked at Epocrates.

Last month, the Annals of Internal Medicine published a report
challenging the notion that hospitalist medicine is more cost-effective than
the traditional model of inpatient care. According to data culled from nearly
60,000 Medicare subscribers, patients receiving hospitalist treatment initially
experienced shorter stays and cost $282 less than those seen by primary care
physicians. Yet during the month following their discharge, those same patients
were more likely to be readmitted and averaged medical bills about $332 higher
than their counterparts–an overall net loss.

One of the compelling arguments in favor of using hospitalists has been that if
you have somebody on hand who is versed in inpatient medicine and can react to
information more quickly, better results will follow. For example a blood test
ordered at 8 AM can be responded to at 2PM, with subsequent therapy being
instituted more efficiently–ultimately leading to an earlier patient discharge.
Money is thereby saved. But this study poses a provocative question: By cutting
down the length of stay, are hospitalists short-circuiting that truism of
“tincture of time,” that it often just takes time for a patient to get better?
By completing the work more efficiently and discharging patients earlier, they
might simply be letting people out before they’re ready.

Another place to look for possible causes for these readmissions is the patient
handoff: Back in June, the American Medical Association blogged about a
perceived rise in handoff-related liability claims, citing a recent Archives
of Internal Medicine study
that highlighted significant disparities in
perceived communication among primary care doctors and specialists. For
example, 69.3% of PCPs say they nearly always notify specialists of patients’
histories–but only 34.8% of specialists report they receive them. While this is
far from conclusive, it warrants further investigation.

There’s no question that there are a lot more people involved in care now than
there have been before, and care itself is more complicated. Much of this has
to do with the fact that, today, many of the less acute cases are treated in
outpatient settings. This means that the patients who are admitted to acute
care hospitals are considerably sicker than they were 30 years ago, and the
need for specialized treatment is greater. Moreover, even when a specialist
might not be needed, there’s no disincentive on the part of a hospitalist
doctor to make such a referral. The referring physician loses none of his or
her own money on the arrangement. Indeed, it’s a move that diffuses individual
liability and might even be encouraged in the interest of ”relationship

Taking all these factors into consideration, I’d argue that the core problem
appears to revolve around misaligned incentives. Therefore, I’m predicting that
a key step toward ultimately rectifying these issues is the adoption of
integrated delivery networks such as the proposed Accountable Care
Organizations or other integrated organizations. We need to move to a model
where one health care organization is responsible for the entire continuum of
care–where no money will be saved by discharging people who are sicker and
physicians themselves have a stake in both the quality and financial well-being
of the system. ACOs and other moves towards clinical integration are steps in
the right direction but are only the beginning. We also need physicians trained
to work in these integrated systems, which they traditionally have not been–but
that is a topic for another day.

Hail to the Chief: a demographic look at physician leaders

What goes into making a physician CEO?

Aug 24, 2011 - Doximity Blog

Editor’s note: Alex Blau, MD, is Doximity’s Medical Director.

A few months ago, LinkedIn published a great blog post called “Top CEO
Names.” Who knew that Peters and Sallys are most likely to be found atop a
masthead? Or that sales forces are rife with Chips and Todds? The findings were
so intriguing, we decided to do an analysis with our own data to see what a few
similar breakdowns look like among our member physicians.

We first pulled together all of our registered members who have entered titles
for themselves (these are free-text, so examples might be “solo practitioner,”
“resident,” “CMO,” etc.). That amounted to about half of our users. Among
those, 8.2% of them have leadership titles (chief, chair, director, CMO, CEO,
etc.). Making the very conservative assumption that the other half of our
user-base—those who have not entered title information—have no leadership
roles to publicize, we can say that at least 4% of our users are medical
leaders. This strikes us as a high number. Yet it stands to reason that
physicians in leadership positions may be more likely to adopt tools, like
Doximity, that offer career management benefits.

We then went on to compare the average age of the leaders we identified to that
of other physicians. It turned out to be 51.4, a little more than two years
older than the mean age of our users. We would have expected leaders to be
older, on average, than non-leaders. Perhaps, given the rapid pace of change in
healthcare—with legislative overhaul, technologic advances, and restructuring
into larger practices and hospital systems—institutions are increasingly
turning to new blood, fresh ideas, and younger energy to navigate these
turbulent waters.

In terms of gender, women represented 22% of physician leaders. While this
number is low, it should be noted that it speaks to the lingering
underrepresentation of women among physicians as a whole; the latest American
Medical Association data
show that as of 2006 only 28% of US doctors are
women. This imbalance is quickly reversing, however, with women making up
of last year’s graduating MD classes, according to the Association of
American Medical Colleges.

Another question we had was how academic publications played into the mix.
Physician leaders publish more frequently than their peers—nearly three times
as often, with 3.7 PubMed citations versus 1.4. This is unsurprising, as the
road to medical distinction (and lofty titles) often winds through the
mountains of academia.

Lastly, we took a look at the most common surnames among physicians and
physician leaders. We all know that the face of medicine is changing; almost
of practicing physicians are now of non-white, foreign, or unknown
ethnicity, according to the AMA. We were pleased to see these shifts
represented in the range of names on the list of US physicians, though the
ranks of physician leaders seem to have been slower to diversify.

Paging Dr. Rainman: physicians and referral management

Any doctor within the medical system is only one degree away from a primary care physician, and PCPs are often the first office visit a patient makes.

Aug 16, 2011 - Production Blog Author

Editor’s note: Doximity Advisory Board member Elise Singer, MD, is a
practicing primary care physician in San Francisco and the Chief Medical
Officer at California Health Information Partnership & Services Organization.

In a single year, the average primary care physician refers patients to 229
working in 117 separate practices, according to the Annals of
Internal Medicine. On paper, it’s a staggering number. Yet in context it makes
more sense. Any doctor within the medical system is only one degree away from a
primary care physician, and PCPs are often the first office visit a patient
makes. As such, PCPs acquire an extensive understanding not only of how the
healthcare system works, but also of who the players are. And that extends to
subspecialties–the neurologist who does Parkinson’s, for example.

My own first practice outside of my formal training was in Camden, New Jersey.
From the beginning I was seeing extreme things. Half of my patients were
diabetics, many coming in with glucose levels of 400 for first-time diagnoses.
Most didn’t speak English. I needed quite a few referrals, and the situations
were so acute, I needed them quickly. I was calling everyone–the operator, my
residency (which was back in Seattle), our GI guys. Ultimately, another
physician practicing in Camden became my savior. He knew everyone.

For PCPs, there are countless permutations of this story, be it a matter of how
serious the cases, how varied their nature, or how heavy the patient load. All
really represent a gateway challenge in our profession: Building referral
networks. Indeed, when physicians need to move they have an intuitive
understanding that they’ll lose all those contacts. That loss is a big deal.
Especially in primary care, where the volume just gets so high.

With this in mind, what’s baffling perhaps isn’t so much how we get to 229,
it’s how we keep it up. Getting someone on the phone–when you need to–is just
so painful. First you get a receptionist, then you’re transferred to a medical
assistant, then you wait while that MA finds the doctor. Then, the MA calls you
back–which sometimes involves your receptionist or MA getting you, and finally
once the MA hears you on the line, that person can finally go ahead and connect
you with the doctor. In my experience, the least amount of time all this can
take is 15 minutes, and realistically it can often be hours. If you’re
determining whether a patient needs to be seen that day or not, that’s pretty

Now, too, there’s a whole new layer starting to build. We’re trending toward
hospitalist medicine, and PCPs and specialists alike are getting absorbed into
larger systems that are by nature more insular. I especially wonder how these
changes will impact PCPs moving to new communities, where mixers, social
events, and grand rounds helped facilitate connections. What we do have today,
of course, is technology.

With Doximity, we’re getting at some of these challenges by developing a
precision referral system, meaning that our data can help you quickly hone in
on what you need: such as specialty, location, insurance accepted, and
languages spoken. To make results even more specific, we’ve appended PubMed
profiles, so within that same search you can find and reach a doctor who’s
worked on something incredibly specific, like retinoblastoma. To underscore
what we’re trying to do, the Dox programmers and I thought we’d have a little
fun and illustrate the current PCP referral process for you as I’ve experienced

Hospitals and PCPs: it's the referrals

It’s well known that for most hospitals, taking on a new doctor translates into hefty costs. So why the hiring frenzy?

Aug 09, 2011 - Doximity Blog

Editor’s note: Doximity Advisory Board member Peter Alperin, MD, is a
board certified internist currently practicing at the San Francisco VA Medical
. He previously led informatics at Brown and Toland Medical Group,
and has also worked at Epocrates.

The number of doctors on hospital payroll has shot up by almost 75% over the
past decade, according to data from the Medical Group Management
. More than half of practicing physicians are now employed by a
large hospital or integrated medical group, a figure that’s poised to grow:
Almost three-quarters of hospital leaders say they plan to add more doctors
within the next three years.

It’s well known that for most hospitals, taking on a new doctor translates into
hefty costs. Over the first three years of employment, these can run as high as
$250,000 a year (and they rarely dip below $150,000), After that, losses tend
go down by about half, but they never full disappear. To break even, a newly
hired primary care physician has to increase his or her patient volume by about
30%. This, according to a recent report in the New England Journal of

In light of so much loss, then why the hiring frenzy? The data lays it out:
It’s the referrals. Traditionally, hospitals have been set up to profit from
treating the sick rather than preventing illness in the well. But now we’re
seeing a radical shift in the system–one that requires hospitals themselves,
ironically, to become the focal point in keeping people out of hospitals. The
prospect of a single national payer coming down the line is shifting systems
more toward the model we now have in Kaiser or the VA. In other words, we’re
asking institutions that for 100 years have been set up to handle illness to
get into the prevention business. Faced with this radical change of course,
hospitals are betting on patient flow. By bringing more doctors into the fold,
tests and procedures that would otherwise be done privately or at other
hospitals will take place on-site, and specialist referrals are more likely to
be made internally.

Thanks to their broad patient pool, primary care physicians tend to be the main
target in these initiatives–and hospitals are willing to bid high. PCPs now
typically earn compensation of $192,116 in such a network, according to the
NEJM research. That’s over $12,000 more than the $179,688 expected for those
who choose to stay private. Another incentive to join: The increasing
challenges of maintaining a practice and a income. For many, the choice really
does feel like it boils down to this or forming a concierge practice. Moreover,
as opposed to the 1990s, when we saw a rapid hiring boom, followed by a bust,
primary care physicians can expect a fair amount of job security from these
deals: Already in 1998, less than half of internal medicine residents went
on to practice primary care. Now, those numbers are dramatically lower. By
2025, the American College of Physicians is anticipating a shortage of
between 35,000 to 44,000 PCPs.

For specialists, it is slightly different set of issues. In many locales, there
are too many specialists, so they need to be careful to be part of the large
systems that are forming so that they don’t find themselves without a chair
when the music stops. For example, if a hospital had two competing groups of
cardiologists, one group could lose out. This is, in part, because the more
specialists currently practicing at a given hospital, the greater the risk of
being frozen out when it comes to the referrals from PCPs that belong to
particular hospital system. Already, I know specialists who are asking
themselves not whether they should join, but when they should.

All these developments mean doctors will have to adopt new ways of thinking
about their jobs. In many respects, physicians are starting to resemble highly
compensated technical workers, such as airline pilots. Issues such as work
hours, and contracts with employers rise to the forefront. Because individual
doctors generally represent the weaker negotiating force in these
relationships, it will be critical to really scrutinize these employment
contracts, defining questions such as “what is productivity,” “how is my bonus
calculated,” and “what exactly does it mean to ‘be available’.”

If you choose not to join you need to think hard about where your referrals
will come from in the future. It’s difficult for a hospital to totally exclude
people because of anti-trust, but I wouldn’t be surprised if in the longer-run
those laws may be relaxed or changed. One final note: I predict that doctor
unions can and will become more prominent. It is a natural evolution of payer
and hospital consolidation. As a newly minted doctor 20 years ago, I would have
never thought this possible, but it’s the reality of where today’s market is

Physician Anonymity: No room for aliases

There’s logic behind why the convention of anonymity has dominated healthcare forums for so long. Until now.

Jul 31, 2011 - Production Blog Author

Editor's note: A few weeks ago, the American Medical Association published
a blog post discussing the pros and cons of online physician anonymity.
Around that same time, a group of influential doctors who’ve previously written
about the issue, among them Bryan Vartabedian, MD, and Wendy Sue Swanson,
, teamed up with the Mayo Clinic Center for Social Media to record
their viewpoints in a YouTube video.

Since then, the dialogue’s been enriched even further (we especially enjoyed
reading this essay by Mark Ryan, MD and this one from Jen Gunter, MD).
Here, Michael Nierenberg, MD, Clinical Professor of Medicine, Emeritus at
Stanford University and member of Doximity’s Advisory Board, offers his opinion
on what’s at stake, including how a verified community such as Doximity can
benefit doctors.

There’s logic behind why the convention of anonymity has dominated healthcare
forums: Anonymity protects us from retribution, makes it easier for us to feel
confident making bold arguments, and helps flatten status differences. But
anonymity comes with a price. A few years ago a team of researchers argued in
the journal Communication
that the
unintended consequences—specifically, fostering a culture of mistrust
surrounding participants’ motives and expertise—may outweigh the benefits. I’m
inclined to agree. Here are five reasons why we need to kick anonymity to the
curb and how a real-name network like Doximity can radically improve
doctor-to-doctor communication.

Accountability promotes credibility
Adding your name to a comment affords you an opportunity to pause and make sure
you really stand behind what you are saying. Anonymity suspends real-world
judgment and emboldens us to jump into a dialogue, to express strong opinions,
and to stick to our guns in the face of peer pressure. But it also fosters
hasty, sloppy reasoning, making mistakes more likely. As healthcare providers,
we have an ethical responsibility to be sure what we’re saying is true. This is
especially important on the Internet, where an offhanded slip can live on
forever (racking up pageviews all the while). Put simply, accountability
increases veracity.

Anonymous conversations can get unruly
Why do bank robbers wear masks? Because their identities make them accountable
for bad behavior. Accountability holds people up to a certain standard of
conduct. Not everyone needs that reminder, but it takes only one or two
disruptive individuals to spark hostility in a debate. When this happens,
otherwise productive conversations lose focus—and participants—fast.

Identifying yourself demonstrates expertise and expedites dialogue
Allowing people to see who you are and what you’ve done can actually help get
your point across. It gives readers a frame of reference to interpret your
comments. One is more inclined to trust a statement about an anemia made by J.
Archer, Stanford hematologist, than one made by a physician with the handle

Knowing who-and what-is involved brings people to the conversation
Online conversations are a little like buying a car. You want to check out the
product before you invest. Say you’re reading a discussion about a
controversial weight surgery device. As much as the commentators’ experience
and expertise matters to you, you’re also going to want to evaluate their
involvement and any conflict of interest. Wondering whether doctor X—an
enthusiastic proponent—is a bariatric surgeon with a financial interest in the
company may keep you from fully trusting what they have to say. Once you know
with whom you are dealing, you can start looking at their comments on their own
merits. Ultimately, knowing who’s participating and what’s at stake improves
the level of communication and builds trust that’s essential for community.
Trustworthy dialogue draws more people into the conversation and makes the
interaction more robust.

Letting people know who you are opens up opportunities to network, collaborate, and build your reputation and practice
Good comments get good attention; it’s as simple as that. By going public you
have an opportunity to get your opinion out there, and to make connections. The
beauty of participating in online conversations is that it lets us all go
beyond the social and geographic parameters we already know to forge new
connections and make new discoveries. Say I have a patient moving to Stanford,
California, and I don’t know a lot of physicians in that area to refer him to.
I’m far more comfortable referring to Dr. J Archer, Stanford hematologist, with
whom I have interacted online, than to “Crackerdoc71”. The same goes for
clinical studies. If I’m working on a study and I come across a forum with an
insightful group of physicians, I can contact them about a way to collaborate.

Physicians all too often act in isolation because of the logistical
difficulties of communication. Letters and phone calls are time-consuming. The
internet can solve this problem but interaction needs a foundation of trust and
openness to succeed. Doximity is trying hard to provide this environment. I’m
eager for all of us to take advantage of this powerful tool to facilitate
physician-to-physician communication without the need for aliases.