Sunday, August 23, 2015

Next Stop: Tinder for Docs

I've been thinking about patient-physician relationships.  After all, Annals of Internal Medicine published a shocking piece about bad physician behavior towards patients, and ZocDoc, the online physician appointment service, is valued at $1.8b after their most recent funding round.

I'll talk about each of those shortly, but first I want to talk about a phrase that started me thinking about the topic.

Noted entrepreneur/innovator/physician Jordan Shlain recently described the doctor patient relationship as "the atomic unit in medicine."   I assume he's using "atomic" in the original sense of being the smallest unit (although he also references data being the electrons orbiting the atomic unit, which means the metaphor really should be "nuclear").

Dr. Shlain urges that language should be specific and precise, so two things about his phrasing struck me: the order in which he describes the two parties, and the reference to medicine rather than to health.

In his description, it is a "doctor patient" relationship.  Maybe it is quibbling to pay attention to which party is listed first, but, come on, even the AMA uses "patient physician relationship" rather than "physician patient."  Even so, how many of us truly believe the physicians we deal with always "place patients' welfare above their own interest and above obligations to other groups," as the official AMA policy suggests?

Which leads to the Annals of Internal Medicine article.  I won't recount the specifics here, other than to say that in it describes two graphic instances of inexcusable physician behavior towards unconscious patients.  In an accompanying editorial, the editors say that the article "exposes medicine's dark underbelly."

The problem is less the appalling behavior -- there are badly behaving jerks in every profession -- as it is that none of the other medical personnel present even spoke up in protest.  The Annals editorial urged physicians to have the courage to "call our colleagues “assholes” when that label is appropriate."  And that, in itself, speaks volumes.  Verbally chastising them seems necessary but nowhere near sufficient.  Why not call upon them to report bad behavior -- to the hospital, to the state medical board, even to the police when "appropriate"?

It's supposed to be about protecting patients, not doctors.

The article has received widespread coverage -- e.g., The New York Times and U.S. News & World Report -- but, sadlyit is not the only story of its kind.  For example, an anesthesiologist in Virginia was caught on tape repeatedly verbally abusing her unconscious patient.  At least she was ordered to pay $500,000 in damages.

One wonders how many similar cases simply don't get caught.

I was dismayed by what the chair of committee on ethics for the American College of Obstetricians and Gynecologists said to The New York Times about the Annals article:  "What was the point of publishing this article?  No harm was done."  Seriously?  And this was the chair of their ethics committee?  No lay person could read the descriptions of what was done to the patients and view that "no harm was done."

Our relationship with our doctors must not be a very equal one.

Dr. Shlain also refers to the relationship in the context of medicine, rather than health.  We all like medical care when we need it, but, by legislative edict, the only people who are allowed to prescribe it for us are physicians, so of course physicians are part of medicine's "atomic unit."

However, we only care about medicine in the context of seeking better health.  That's the real goal, not more medicine -- and it's a stretch to say that the doctor-patient relationship is the cornerstone of our health.   It's part of good health, to be sure, but there are a lot of other important factors -- the person's attitudes and activities, their family's and social network's effects, and so on.

People are spending over $30b annually out of their own pockets on alternative and complimentary medicines, close to $50b on exercise equipment, even some $36b on organic foods.  These efforts don't seem to be doing much to make us healthier, mind you, but it shows that when it comes to our health, we're not just relying on what our physicians prescribe for us.

Our doctors aren't our only partners in health -- or necessarily our most important ones.

So how does any of this relate to ZocDoc?  Keep in mind that ZocDoc is a subscription-based service, with physicians paying a rumored $3,000 annual fee to belong.  It doesn't have a huge network of physicians.  It doesn't allow patients to see those physicians via video or online visits, as TelaDoc and other vendors do.  All it does is offer online appointment scheduling, and user-generated physician reviews.

And that appears to be worth $1.8b.

Surveys indicate that patients increasingly want their physicians to offer digital services, especially online appointment scheduling and bill pay, yet fewer than 20% say their current doctor offers those.  The rise of both retail clinics and telehealth further illustrate that more patients are choosing immediate access to medical professionals they do not know rather than waiting to see physicians they do know.  

I would be very curious to know how many of ZocDoc's patients make appointments with doctors with whom they already had relationships, or if they use the service for a one-time appointments, much like they might order a ride from Uber.

A 2012 survey found that 22% of American adults didn't have a primary care doctor, and the percentage drops off rapidly by age -- 90% for 55+ versus 64% for those 18-34.  If I were a primary care physician I'd be pretty worried about getting those younger populations into a relationship -- or keeping them in one.

The people who talk most reverently about the patient-physician relationship these days seem to be either physicians or politicians, not patients  On average, people supposedly see 19 doctors over the course of their lives, with whom they have different types of relationships for varying durations.  They're not always all that special.

If doctors are going to treat patients disrespectfully, be more interested in medicine than health, or treat patient encounters like transactions (e.g., visits of fifteen minutes or less), then they shouldn't be surprised if patients start not placing much value on the relationship.

If we're not careful, we may get to the point where we pick our physicians like we were picking a date on Tinder, based purely on proximity and superficial characteristics.  Let's hope not.

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