Editor’s note: Doximity Advisory Board member Peter Alperin, MD, is a
board certified internist currently practicing at the San Francisco VA Medical
Center. 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
management.”

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.

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
48.3% 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
half 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.

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
specialists 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
inefficient.

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
it.

Editor’s note: Doximity Advisory Board member Peter Alperin, MD, is a
board certified internist currently practicing at the San Francisco VA Medical
Center. 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
Association. 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
Medicine.

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
heading.

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,
MD, 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
Research 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
"Crackerdoc71."

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.

A very warm welcome to Doximity Blog! Since our company’s beta launch in
April, we’ve had the opportunity to talk a lot about what Doximity is; that
we’re a private, HIPAA-compliant network where verified physicians and
medical professionals can connect, refer, and securely communicate on the
iPhone, Android, and Web.

A blog is a way to engage more frequently, more diversely, and–if we do the job
right–with more fodder for discussion. For all those reasons, we wanted to set
the tone and kick things off with a post that focuses the conversation on not
just our product but also the group of individuals behind it.

As a team, we at Doximity are:

Physician-centric. Many of us are physicians, and those who aren’t wish we
were. As such, we’ve used the leading hospital/clinic software systems, and
we’re generally annoyed by how ugly and inefficient they are. They seem to be
made primarily for CFOs and CIOs. That’s because, more often than not, they
were.

Technophilic. We’re all Silicon Valley immigrants and while we hate the
housing prices here, we love the technology. We geek out about the latest sites
and gush over elegant design. Our 2 year-old kids know how to say “iPhone,”
“iPad,” and “Android,” and we secretly like it.

Pragmatic. We lack the patience to be political. That’s not to say health
policy isn’t important, it’s just not our cup of tea. We’re practical “do’ers”
and there’s lots that can be done right now to improve medical communications.
Our beta product is testament to that.

Several of us hail from Epocrates, where we had the same founding ideals and
spirit–we just never had a place to write about them back then. There’s a lot
to dig into in this space, and we’ve configured our blog so that individual
team members can take the floor. Ideally, this will afford you a breadth and
depth of information and points of view. We couldn’t be more excited to get
started...

— Jeff Tangney, CEO & the Doximity Team