The rebirth of primary care

Medicine has clearly evolved to favor specialists

Mar 27, 2012 - 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 Center
. He previously led informatics at Brown and Toland Medical
, and has also worked at Epocrates.

By 2015, according to the American Association of Medical Colleges, the
U.S. health care system will be short approximately 30,000 primary care
doctors. Yet, everything we read says that primary care physicians are the
linchpins of the new (really rediscovered) coordinated care models being talked
about by health care policy cognoscenti. What gives?

Since the mid-1990s the number of medical students pursuing a career in primary
care has been on a steady, sinking decline, a trend likely fueled by the
realization that the traditional Marcus Welby-style primary care practice
doesn’t pay the bills. Throw in hefty malpractice insurance fees and the
average overhead often hits 60 percent. There’s also the question of boredom
and prestige. In medical school, future physicians are exposed to a breadth of
compelling cases; in primary care, they’re asked to refer the majority of those
away. And if you are interested in interesting procedures, medicine has clearly
evolved to favor specialists.

And about the pay disparity–it is stark. Most residents looking at a career in
primary care can expect to earn about $29.58 an hour. This, compared to $74.45
per hour as a specialist (by retirement, specialists will have earned about
$3.5 million more). The main reason is that the options for reimbursement in
traditional primary care practice are limited. Much of what PCPs do is
cognitive work–checkups, simple diagnoses, referrals–and that just doesn’t pay
as well. As for the reimbursable procedures that PCPs are able to perform,
they’re few, but of a wide variety; getting such a breadth of claims paid is
often a job in itself.

So here’s something surprising: In 2010 and 2011 the number of primary care
residency matches increased by ten percent per year. For 2012, those gains were
at least maintained, when the National Resident Matching Program last week
reported a one percent rise in such matches.

Two factors may be accounting for this welcome change of tide. First, there’s
accountable care. Within this premise of having one group–an accountable health
care provider network–hold all the risk and be paid on quality measures and
outcomes, primary care physicians can be even more effective quarterbacks,
coordinating care for a team of specialists. Even more targeted are
patient-centered medical homes, currently being tested within a number of ACOs.
Here, PCPs are available for consultation, and for mapping out care, which is
then put into action by a staff of physician extenders.

The second development is the Direct Care (also referred to as
Concierge) model, such as One Medical and MD VIP, which have
become a viable economic model for PCPs who want to maintain a
traditional primary care practice. While the exact structure of direct
care practices can vary widely–whether insurance is accepted, or scope
and kinds services a patient can expect, for example–they all rest on
the idea that patients pay annual or retainer fees to their primary care

If these trends continue, the primary care doctors of the future will
have to be experts at communication, system change and quality
improvement. They will need to focus less on traditional hospital tasks
like putting in a central line (already largely atrophied skills given
the widespread use of hospitalists), and more on skills like promoting
teamwork, being able to build consensus and persuasively articulating
ideas. Many will become experts in healthcare IT. What’s interesting is
that already we’re seeing more young doctors and residents who possess
these skills. We find them every day on Doximity, coordinating
referrals and patient care–using a state of the art platform for
communication. It is these physicians who will lead the charge of
translating medicine into the digital age.

Doximity Notes from the Road: SXSW Recap

We had a great time catching up with some of our favorite physician leaders

Mar 20, 2012 - Production Blog Author

On March 9, the Dox Blog packed up and trekked out to Austin for the SXSW
conference. We had a great time catching up with some of our favorite physician
leaders, including Bryan Vartabedian and Wendy Sue Swanson, both of
whom we bumped into at one of the week’s seemingly endless stream of happy

We learned about some nifty products, among them, iTriage, an app enabling
patients to look up their symptoms and get guidance on what steps to take next,
and Basis, a device to be worn like a watch that tracks heartbeat,
temperature, and more–all to be tabulated into daily feedback for its user.

Seed accelerator Rock Health wowed us with its ZenDen (they had us at
coffee and a free chair massage), and the health initiative StartUp Health
introduced us to an impressive lineup of health entrepreneurs. We also had some
time to talk Doximity shop. That Saturday, Nate Gross, Doximity’s Product
Manager, had a chance to talk with NBC Austin about some of what we’re
doing on the site. Here’s what he had to say about technology and physician

Now that the dust has settled a little, we’re interested in hearing your
impressions of the conference, whether as an attendee or from what you saw on
Twitter, Facebook and various blogs. In your view, what were the big takeaways
this year?

Getting to a Better Patient Handoff

There's a need for training in how to communicate better

Mar 06, 2012 - Production Blog Author

Editor’s Note: Vineet Arora, MD, MPP, is an Associate Program
Director for the Internal Medicine Residency and Assistant Dean of
Scholarship & Discovery at University of Chicago’s Pritzker School of
. She blogs about medical education at FutureDocs.

My work studying handoffs began back in 2003, after I was chief resident at the
University of Chicago. Through our research, we found that even in optimal
situations (dedicated room, dedicated time, attending supervision, etc.), 60
percent of the time, the handoff receiver was not able to name the top issue
for the patient as determined by the sender–despite having access to the
written record. Part of the problem may be information overload; people simply
cannot decipher the importance of various items when faced with so much
information. Therefore, there’s a need for training in how to communicate

Imagine you’re writing a shopping list for somebody. If you’re putting it
together for a stranger, chances are you’ll be much more detailed in your
instructions than you would be with your spouse, who implicitly knows whether
“buy milk” means 2% or skim, thanks to your rich history of shared experiences.

What may be going on in hospital handoffs is that people are assuming that
they’re seeing the same things–so there’s that illusion of shared
experiences–but since those experiences are in reality happening successively,
there’s no opportunity to create a shared mental model of them. As a result,
directions may be vague and not precise enough for someone who does not
know a patient sufficiently to understand what to do.

In addition to verbal communication issues, there are also problems with the
written records. Eighty percent of handoff notes, for instance, contain a
medication omission of some kind. Electronic health records that integrate with
medications can certainly solve this problem. However, there are downsides to
integrating with EHRs. The ease of the copy-paste function means that handoff
notes are getting longer and longer. What you see is text that looks more like
a wiki than it does a synthesized problem list.

The best handoffs, both verbal and written, are concise and strike the right
balance between pertinent and thorough. They’re composed of a one-liner
diagnosis, followed by clear and specific anticipatory guidance that include
enough rationale so the recipient doesn’t have to guess at what the sender was

Along with in-hospital shift handoffs, effective handoff communication is also
the cornerstone for continuity between a hospital-based physician and a primary
care physician. Mobile HIPAA-secure messaging, such as what’s used on
Doximity, has the potential to promote real time physician communication
during these care transitions, such as keeping primary care physicians
up-to-date during a patient’s hospitalization, or to alert them that their
input is needed on a specific question. Some of our other work has shown that
hospital-based physicians spend a lot of time looking up contact information
for primary care physicians–so certainly there is also potential to tighten up
that side of the process and facilitate timely communication. So, whether
it’s in-hospital or out of the hospital, it’s important to remember to handle
the handoff with care.

5 Health Technology Trends to Watch in 2012

Dr. Felasfa Wodajo, an orthopedic oncologist in metro Washington, DC and mHealth editor at iMedicalApps, shares his predictions for the new year.

Jan 05, 2012 - Production Blog Author

One of the most personally rewarding sides of my role at iMedicalApps is consistent and early exposure to the many ways technology is influencing and in some cases changing the way we physicians think about healthcare.

In particular, the proliferation of medical apps has opened doors we just a few years ago wouldn’t have thought possible. Some represent huge opportunities, others are as yet more vague. I’d argue that much of that gray is due to the fact that doctors and medical societies are only just beginning to engage with the task of evaluating what’s feasible and what isn’t in this relatively new landscape.

Given our exposure to what’s needed in the field, I think the conversations we doctors initiate and participate in play a critical role in this process. To that end, I’m devoting this post to a cribsheet of the health tech trends that have proven robust in the past year.

1. Patient education programs

You interact with patients for a brief amount of time, but their questions keep going. We’re starting to see a few good apps, as exemplified by the Orca MD series, that are trying to offer the kind of credible answers that might be tough for patients to find on google or through their social networks.

2. Phones as medical devices

The image is especially appealing–physicians and patients walking around with these incredibly powerful computers right in their pockets. Radio-frequency identification and bluetooth will be a huge component of how this technology develops, enabling doctors to do things such as use a phone as a pressure sensor to find out if a cast is too tight. Another application: Instead of having an ICU where patients are monitored, scannable monitors could be used on their bodies.

3. Networking services for information sharing

HIPAA-compliant networks such as Doximity are benefiting from the two obvious features already on smartphones–cameras and location services. Both are making it easier to discuss cases and make referrals.

4. Apps as prescriptions for behavioral change

On iMedicalApps we’re getting ready to publish some interesting early research on centers that are harnessing existing technology to develop behavior change programs. These apps can track behavior patterns through location services, text prompts asking users to evaluate state-of-mind, and even offer facetime counseling. This is place for great opportunity as mobile phones, as truly personal devices, could help modify behavior at the time and place where it counts the most.

5. Data flow for health records

Health data is shifting toward becoming less and less human-centered. Imagine a patient having his or her weight taken, with that measurement flowing into the medical record passively and immediately from the scale. The implications for data aggregation are profound.

Online physician reviews: 6 essential actions

Word-of-mouth is the number one referral-driver among patients, and that’s no less true online, where testimonials really can reward you for a job well done

Dec 29, 2011 - Production Blog Author

Editor’s Note: Howard Luks, MD, is Chief of Sports Medicine and
Arthroscopy at University Orthopaedics, PC and Westchester Medical
, and blogs at

Digital content has profoundly changed the way we think of patient feedback and
referrals; what used to be private has now become very public, thanks to the
proliferation of review sites like Yelp and Angie’s list. This is
largely positive. Word-of-mouth is the number one referral-driver among
patients, and that’s no less true online, where testimonials really can reward
you for a job well done.

Nevertheless, like it or not, negative feedback is also part of this landscape.
No matter how hard you try, you’re never going to please absolutely everyone.
For example, you may have someone in your office with whom on a normal day
you’d get along extremely well, and you’re just running late. That person may
well go online and share that.

Patients have a right to freedom of speech, and you can’t practice as if each
case is a potential bad review. You can, however, take this newer, more public
feedback loop as an opportunity to assess how strong your communication lines
are–not just in the context of the broad social media universe, but also among
your existing patient base. Here, six factors to consider:

Make sure you’ve educated your staff on how to treat patients properly: A
well-managed practice is the easiest way to keep patients from being
disgruntled. Do a careful assessment of the experience in your office, thinking
about how well you and your staff handle common bottlenecks such as intake and
wait times.

Designate an on-site point-person to deal with patient dissatisfaction as it
In our office, we have a point person who has actually gone through
HR training for patient complaints. We’ve designated a comfortable room off of
the examining area, and if someone is unhappy, we bring him or her there to air

Give patients a way to reach someone directly after the fact: All of my
patients leave with an email address at which they can reach me. I make it
clear to them that I check it often, and if there’s a complaint, I’ll address
it directly.

Show who you are, online: Think about what your message is, how you’re
going to portray to yourself and select your site and topics carefully. I’m a
big believer in generating meaningful content, and giving other people a chance
to share it. One obvious benefit is that your online presence will drive down
any negative reviews, but more importantly, this kind of communication offers
patients additional ways to get to know you.

Remember that one bad comment won’t kill you: No matter how hard you try,
you’re inevitably going to annoy a patient or two. But you know what? It’s okay
to have a bad review. The world will hardly stop spinning. In fact, given that
75 to 85 percent of people never go past the second page of a search, it will
most likely not change course at all.

Let patients know you welcome positive reviews: The real message: Rather
than worrying about bad content, it’s much easier (and more rewarding) to focus
on generating the good. There’s absolutely no harm in being proactive about
engaging happy patients in supporting your public reputation, so be it through
your website or your office, be sure to invite them to post reviews on sites
like Yelp, or even a Testimonials page directly on your own site.