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.