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Artificial intelligence, CNN, and diagnosing melanomas
I have a breakthrough article to share with you. It’s about a technology that detects skin cancer. Before I tell you about that, however, I need to teach you a few things. For example, do you know what AI is? How about machine learning? What about CNN? (This column is a nonpolitical arena, so, no, not that CNN).
AI stands for artificial intelligence. We are surrounded by it everywhere – computers, cars, and cell phones all use AI. AI describes a machine with the ability to problem solve, to create, to understand, to learn. These are characteristics we call “intelligence,” hence, artificial intelligence.
You and I intuitively know that a picture of a chair is a chair. This is true of an folding chair, a Barcelona chair, or a Ghost chair. This ability – to intuit – is a hallmark of humans. Computers don’t intuit, they learn. We don’t need to study 3 million chairs to identify chairs. (Nor could we study 3 million pictures of chairs, a feat that would take years.) Computers, in contrast, can review 3 million pictures of chairs. And learn. In minutes.
Not only do computers learn from millions of examples, they also layer learning. For example, one set of programs will look only for lines that appear to be legs of chairs. This information is then passed on to another layer of programming that can look for seats, then another for backs, then another and another until a final layer puts it together. Do these layers remind you of something we all learned in medical school? It is analogous to the mammalian visual cortex! In the brain, one layer of neurons talks with another. In machines, one layer of programs pushes information to another. We call these machine layers “neural networks.” A convoluted neural network or CNN, therefore, describes a complex network that is analogous to brain cortex. The implications are astounding.
Things get interesting when a CNN is given a complex task to learn and a massive observational data set to learn on. With recent advances in chips called GPUs, deeply nested program layers can accomplish difficult tasks like recognizing faces, understanding voices, and avoiding a bicyclist on a foggy day. Self-driving cars, airport security, and voice-activated assistants all rely on this “deep learning.” And they are getting smarter everyday.
So, now when I say a team at Stanford University has used a CNN and deep learning to diagnose melanoma from pictures, you’ll understand what I mean. And you’ll realize computers can do something heretofore unthinkable – make diagnoses as accurately as a doctor. That story should make you both a little giddy and afraid. But wait, there’s more! Read all about it next time.
Dr. Benabio is a partner physician and chief of service for the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] . He has no disclosures related to this column.
I have a breakthrough article to share with you. It’s about a technology that detects skin cancer. Before I tell you about that, however, I need to teach you a few things. For example, do you know what AI is? How about machine learning? What about CNN? (This column is a nonpolitical arena, so, no, not that CNN).
AI stands for artificial intelligence. We are surrounded by it everywhere – computers, cars, and cell phones all use AI. AI describes a machine with the ability to problem solve, to create, to understand, to learn. These are characteristics we call “intelligence,” hence, artificial intelligence.
You and I intuitively know that a picture of a chair is a chair. This is true of an folding chair, a Barcelona chair, or a Ghost chair. This ability – to intuit – is a hallmark of humans. Computers don’t intuit, they learn. We don’t need to study 3 million chairs to identify chairs. (Nor could we study 3 million pictures of chairs, a feat that would take years.) Computers, in contrast, can review 3 million pictures of chairs. And learn. In minutes.
Not only do computers learn from millions of examples, they also layer learning. For example, one set of programs will look only for lines that appear to be legs of chairs. This information is then passed on to another layer of programming that can look for seats, then another for backs, then another and another until a final layer puts it together. Do these layers remind you of something we all learned in medical school? It is analogous to the mammalian visual cortex! In the brain, one layer of neurons talks with another. In machines, one layer of programs pushes information to another. We call these machine layers “neural networks.” A convoluted neural network or CNN, therefore, describes a complex network that is analogous to brain cortex. The implications are astounding.
Things get interesting when a CNN is given a complex task to learn and a massive observational data set to learn on. With recent advances in chips called GPUs, deeply nested program layers can accomplish difficult tasks like recognizing faces, understanding voices, and avoiding a bicyclist on a foggy day. Self-driving cars, airport security, and voice-activated assistants all rely on this “deep learning.” And they are getting smarter everyday.
So, now when I say a team at Stanford University has used a CNN and deep learning to diagnose melanoma from pictures, you’ll understand what I mean. And you’ll realize computers can do something heretofore unthinkable – make diagnoses as accurately as a doctor. That story should make you both a little giddy and afraid. But wait, there’s more! Read all about it next time.
Dr. Benabio is a partner physician and chief of service for the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] . He has no disclosures related to this column.
I have a breakthrough article to share with you. It’s about a technology that detects skin cancer. Before I tell you about that, however, I need to teach you a few things. For example, do you know what AI is? How about machine learning? What about CNN? (This column is a nonpolitical arena, so, no, not that CNN).
AI stands for artificial intelligence. We are surrounded by it everywhere – computers, cars, and cell phones all use AI. AI describes a machine with the ability to problem solve, to create, to understand, to learn. These are characteristics we call “intelligence,” hence, artificial intelligence.
You and I intuitively know that a picture of a chair is a chair. This is true of an folding chair, a Barcelona chair, or a Ghost chair. This ability – to intuit – is a hallmark of humans. Computers don’t intuit, they learn. We don’t need to study 3 million chairs to identify chairs. (Nor could we study 3 million pictures of chairs, a feat that would take years.) Computers, in contrast, can review 3 million pictures of chairs. And learn. In minutes.
Not only do computers learn from millions of examples, they also layer learning. For example, one set of programs will look only for lines that appear to be legs of chairs. This information is then passed on to another layer of programming that can look for seats, then another for backs, then another and another until a final layer puts it together. Do these layers remind you of something we all learned in medical school? It is analogous to the mammalian visual cortex! In the brain, one layer of neurons talks with another. In machines, one layer of programs pushes information to another. We call these machine layers “neural networks.” A convoluted neural network or CNN, therefore, describes a complex network that is analogous to brain cortex. The implications are astounding.
Things get interesting when a CNN is given a complex task to learn and a massive observational data set to learn on. With recent advances in chips called GPUs, deeply nested program layers can accomplish difficult tasks like recognizing faces, understanding voices, and avoiding a bicyclist on a foggy day. Self-driving cars, airport security, and voice-activated assistants all rely on this “deep learning.” And they are getting smarter everyday.
So, now when I say a team at Stanford University has used a CNN and deep learning to diagnose melanoma from pictures, you’ll understand what I mean. And you’ll realize computers can do something heretofore unthinkable – make diagnoses as accurately as a doctor. That story should make you both a little giddy and afraid. But wait, there’s more! Read all about it next time.
Dr. Benabio is a partner physician and chief of service for the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] . He has no disclosures related to this column.
Alexa
How many calories are there in a cheeseburger? (Yes, I too am looking forward to a svelter 2017). The answer, according to my new assistant, is 300 calories. She knows the dose of acetaminophen for a 10-year-old, 65-pound child is 325 mg every 4-6 hours. She also plays George Michael, reorders my Dentyne Ice gum, and turns off the lights. She is Alexa of Amazon’s Echo, the intelligent personal assistant.
Echo and Google Home are popular voice-assisted home appliances. Amazon has built a natural language processing system, so to use it, you simply say, “Alexa,” pause, then ask your question (What’s the weather in New York?) or deliver your command (Play Spotify). It’s hands free, so you can interface while typing, reading, or cooking dinner.
Some medical centers, such as the Boston Children’s Hospital, are leading the way to make voice-assisted technology useful in health care. Their KidsMD app, for example, gives Alexa the “skill” to offer simple health advice regarding their children’s fever and medication dosing. I found this Alexa skill interesting but rudimentary. Most of the advice was reasonable; however, the scope is small and the responses glitchy. For example, when I asked Alexa what to do for a feverish 2-month-old, it advised me to contact my doctor then immediately followed this with recommended antipyretic medication dosing. Although we physicians understand the child must see a doctor, some parents might be confused and choose only to administer the medication. As with any new digital health technology, the team at Boston Children’s are continually iterating and improving based upon feedback.
I found Alexa currently has a few other skills for health care. For example, a skill called Marvee functions as a “care companion” to help aging family members and their caregivers. Another skill, Health Care Genius, helps patients decipher healthcare terminology by asking questions such as, “What is a deductible?”
The potential of voice-assisted technology in clinical and home health care settings is limitless, and I expect this segment to grow dramatically. Here are a few examples:
1. Physicians can ask for real-time help such as: What are treatment options for juvenile dermatomyositis? Order doxycycline 100 mg by mouth, twice daily, quantity sufficient 10 days.
2. Physicians might also use it to dictate notes intelligently, and even extract patient instructions directly from the notes to be emailed to the patient.
3. Surgeons could command an MRI to be viewed without having to scrub out.
4. Bedridden or chronically ill patients could use it to refill medications, make doctor appointments, or contact a caregiver in an emergency.
5. Patients could receive customized instructions, such as the answer to “How often do I change my surgical bandage?”
For all its potential, voice-assisted personal assistants have a long way to go. It would be a mistake to think these won’t be integrated into the entire health care chain from care to wellness, but it will be awhile before we get there.
Interestingly, when I asked my Apple Siri how many calories are in a cheeseburger, she reported 500, which is much more than Alexa’s 300. Which is why, for now, devices like Alexa are ideal for ordering a pizza hands free from your recliner. Just don’t ask how many calories are in it.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.
How many calories are there in a cheeseburger? (Yes, I too am looking forward to a svelter 2017). The answer, according to my new assistant, is 300 calories. She knows the dose of acetaminophen for a 10-year-old, 65-pound child is 325 mg every 4-6 hours. She also plays George Michael, reorders my Dentyne Ice gum, and turns off the lights. She is Alexa of Amazon’s Echo, the intelligent personal assistant.
Echo and Google Home are popular voice-assisted home appliances. Amazon has built a natural language processing system, so to use it, you simply say, “Alexa,” pause, then ask your question (What’s the weather in New York?) or deliver your command (Play Spotify). It’s hands free, so you can interface while typing, reading, or cooking dinner.
Some medical centers, such as the Boston Children’s Hospital, are leading the way to make voice-assisted technology useful in health care. Their KidsMD app, for example, gives Alexa the “skill” to offer simple health advice regarding their children’s fever and medication dosing. I found this Alexa skill interesting but rudimentary. Most of the advice was reasonable; however, the scope is small and the responses glitchy. For example, when I asked Alexa what to do for a feverish 2-month-old, it advised me to contact my doctor then immediately followed this with recommended antipyretic medication dosing. Although we physicians understand the child must see a doctor, some parents might be confused and choose only to administer the medication. As with any new digital health technology, the team at Boston Children’s are continually iterating and improving based upon feedback.
I found Alexa currently has a few other skills for health care. For example, a skill called Marvee functions as a “care companion” to help aging family members and their caregivers. Another skill, Health Care Genius, helps patients decipher healthcare terminology by asking questions such as, “What is a deductible?”
The potential of voice-assisted technology in clinical and home health care settings is limitless, and I expect this segment to grow dramatically. Here are a few examples:
1. Physicians can ask for real-time help such as: What are treatment options for juvenile dermatomyositis? Order doxycycline 100 mg by mouth, twice daily, quantity sufficient 10 days.
2. Physicians might also use it to dictate notes intelligently, and even extract patient instructions directly from the notes to be emailed to the patient.
3. Surgeons could command an MRI to be viewed without having to scrub out.
4. Bedridden or chronically ill patients could use it to refill medications, make doctor appointments, or contact a caregiver in an emergency.
5. Patients could receive customized instructions, such as the answer to “How often do I change my surgical bandage?”
For all its potential, voice-assisted personal assistants have a long way to go. It would be a mistake to think these won’t be integrated into the entire health care chain from care to wellness, but it will be awhile before we get there.
Interestingly, when I asked my Apple Siri how many calories are in a cheeseburger, she reported 500, which is much more than Alexa’s 300. Which is why, for now, devices like Alexa are ideal for ordering a pizza hands free from your recliner. Just don’t ask how many calories are in it.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.
How many calories are there in a cheeseburger? (Yes, I too am looking forward to a svelter 2017). The answer, according to my new assistant, is 300 calories. She knows the dose of acetaminophen for a 10-year-old, 65-pound child is 325 mg every 4-6 hours. She also plays George Michael, reorders my Dentyne Ice gum, and turns off the lights. She is Alexa of Amazon’s Echo, the intelligent personal assistant.
Echo and Google Home are popular voice-assisted home appliances. Amazon has built a natural language processing system, so to use it, you simply say, “Alexa,” pause, then ask your question (What’s the weather in New York?) or deliver your command (Play Spotify). It’s hands free, so you can interface while typing, reading, or cooking dinner.
Some medical centers, such as the Boston Children’s Hospital, are leading the way to make voice-assisted technology useful in health care. Their KidsMD app, for example, gives Alexa the “skill” to offer simple health advice regarding their children’s fever and medication dosing. I found this Alexa skill interesting but rudimentary. Most of the advice was reasonable; however, the scope is small and the responses glitchy. For example, when I asked Alexa what to do for a feverish 2-month-old, it advised me to contact my doctor then immediately followed this with recommended antipyretic medication dosing. Although we physicians understand the child must see a doctor, some parents might be confused and choose only to administer the medication. As with any new digital health technology, the team at Boston Children’s are continually iterating and improving based upon feedback.
I found Alexa currently has a few other skills for health care. For example, a skill called Marvee functions as a “care companion” to help aging family members and their caregivers. Another skill, Health Care Genius, helps patients decipher healthcare terminology by asking questions such as, “What is a deductible?”
The potential of voice-assisted technology in clinical and home health care settings is limitless, and I expect this segment to grow dramatically. Here are a few examples:
1. Physicians can ask for real-time help such as: What are treatment options for juvenile dermatomyositis? Order doxycycline 100 mg by mouth, twice daily, quantity sufficient 10 days.
2. Physicians might also use it to dictate notes intelligently, and even extract patient instructions directly from the notes to be emailed to the patient.
3. Surgeons could command an MRI to be viewed without having to scrub out.
4. Bedridden or chronically ill patients could use it to refill medications, make doctor appointments, or contact a caregiver in an emergency.
5. Patients could receive customized instructions, such as the answer to “How often do I change my surgical bandage?”
For all its potential, voice-assisted personal assistants have a long way to go. It would be a mistake to think these won’t be integrated into the entire health care chain from care to wellness, but it will be awhile before we get there.
Interestingly, when I asked my Apple Siri how many calories are in a cheeseburger, she reported 500, which is much more than Alexa’s 300. Which is why, for now, devices like Alexa are ideal for ordering a pizza hands free from your recliner. Just don’t ask how many calories are in it.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.
Digital Doctor
There were many books I read in 2016 that I found relevant and helpful for the practice of medicine as modern physicians. Here were some of my favorites:
”How to Have a Good Day” by Caroline Webb (Crown Business, 2016).
With media headlines screaming about the surge in physician burnout, now is a good time to read “How to Have a Good Day.” The author, Caroline Webb, an Oxford- and Cambridge-trained economist, management consultant, and executive coach, shows how little tweaks in behavior can garner big results in both your workday productivity and your overall well-being. Her science-based techniques are wonderfully practical. She teaches you how to be more effective at work by establishing smart habits, setting appropriate priorities, and pumping up your workplace enthusiasm. She also shows you a path to stronger workplace relationships by learning how to better manage conflict, build rapport, and get the most out of others. My copy is dog-eared. I hope yours will be too.
In this expansively researched book, Nancy Tomes, Ph.D., professor of history at the State University of New York, Stony Brook, documents the formation and consequences of the consumer economy in American medicine. Unlike other medical historians, who claim that patient consumerism emerged in the 1970s, Dr. Tomes argues that it developed “a full century earlier.” She dismantles the American ideal of the “golden age” of Norman Rockwell doctors and “deferential patients.” In eminently readable prose, Dr. Tomes analyzes numerous developments that have disrupted the doctor-patient relationship, including the growth of drug stores, the ever-changing medical insurance industry, and direct-to-consumer advertising. A skilled historian and writer, she doesn’t provide tidy answers to messy questions. She acknowledges that, despite many technological and social advances, particularly patient empowerment, there is no “magic bullet” to cure what ails our current medical system. This is a good choice for those looking to put digital medicine into historical context.
”Visual Intelligence: Sharpen Your Perception, Change Your Life” by Amy E. Herman (Eamon Dolan/Houghton Mifflin Harcourt, 2016).
How do we see? Not terribly well, according to Amy E. Herman. A lawyer and art historian, Ms. Herman has developed a course called “The Art of Perception” that has helped professionals from physicians to police officers hone their observation and communication skills. The course happens to be based on the class for students and residents of dermatology given by the eminent dermatologist Irwin Braverman, MD. A basic tenet of the book is that even highly intelligent professionals often experience “blindness.” She writes: “For no physiological reason, sometimes we fail to see something that’s in our direct line of sight. We overlook things when they are unexpected or too familiar, when they blend in, and when they are too aberrant or abhorrent to imagine.” Fortunately, correcting such “inattentional blindness” isn’t a gift, it’s a skill that improves with practice. The key is to acknowledge the “blind spots” in our perception and to become more detail oriented. Enter the art. Through analyzing dozens of works of art, Ms. Herman shows you how to “see what matters,” encouraging you to notice every detail and, equally important, every missing detail. The result: Over time, attention to detail becomes second nature, helping you to become more observant and fully present both in clinic and at home.
”When Breath Becomes Air” by Paul Kalanithi, MD (Penguin Random House, 2016).
This posthumously published memoir by Paul Kalanithi, MD, is tormentingly beautiful. In May 2013, the 36-year-old neurosurgeon was diagnosed with stage IV lung cancer; he was a nonsmoker. In a blink, Dr. Kalanithi would don the patient’s gown and relinquish his role as healer. “Instead of being the pastoral figure aiding a life transition, I found myself the sheep, lost and confused. Severe illness wasn’t life-altering, it was life-shattering,” he writes. Dr. Kalanithi battles the cancer valiantly for 2 years, during which time he writes this book and has a child with his wife, Lucy, also a doctor. As someone with a BA and MA in literature from Stanford and a MPhil from Cambridge, his writing is eloquent and compelling, in the vein of Atul Gawande, MD, and Jerome Groopman, MD. He voices his readers’ thoughts perfectly when he writes, “My life had been building potential, potential that would now go unrealized. I had planned to do so much, and I had come so close.” We ache for him, for his unrealized contributions to the worlds of medicine and literature, and for his loved ones. Yet, as Lucy writes in the epilogue, “this book is a new way for him to help others, a contribution only he could make.” When Breath Becomes Air will leave you both deeply saddened and deeply inspired.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.
There were many books I read in 2016 that I found relevant and helpful for the practice of medicine as modern physicians. Here were some of my favorites:
”How to Have a Good Day” by Caroline Webb (Crown Business, 2016).
With media headlines screaming about the surge in physician burnout, now is a good time to read “How to Have a Good Day.” The author, Caroline Webb, an Oxford- and Cambridge-trained economist, management consultant, and executive coach, shows how little tweaks in behavior can garner big results in both your workday productivity and your overall well-being. Her science-based techniques are wonderfully practical. She teaches you how to be more effective at work by establishing smart habits, setting appropriate priorities, and pumping up your workplace enthusiasm. She also shows you a path to stronger workplace relationships by learning how to better manage conflict, build rapport, and get the most out of others. My copy is dog-eared. I hope yours will be too.
In this expansively researched book, Nancy Tomes, Ph.D., professor of history at the State University of New York, Stony Brook, documents the formation and consequences of the consumer economy in American medicine. Unlike other medical historians, who claim that patient consumerism emerged in the 1970s, Dr. Tomes argues that it developed “a full century earlier.” She dismantles the American ideal of the “golden age” of Norman Rockwell doctors and “deferential patients.” In eminently readable prose, Dr. Tomes analyzes numerous developments that have disrupted the doctor-patient relationship, including the growth of drug stores, the ever-changing medical insurance industry, and direct-to-consumer advertising. A skilled historian and writer, she doesn’t provide tidy answers to messy questions. She acknowledges that, despite many technological and social advances, particularly patient empowerment, there is no “magic bullet” to cure what ails our current medical system. This is a good choice for those looking to put digital medicine into historical context.
”Visual Intelligence: Sharpen Your Perception, Change Your Life” by Amy E. Herman (Eamon Dolan/Houghton Mifflin Harcourt, 2016).
How do we see? Not terribly well, according to Amy E. Herman. A lawyer and art historian, Ms. Herman has developed a course called “The Art of Perception” that has helped professionals from physicians to police officers hone their observation and communication skills. The course happens to be based on the class for students and residents of dermatology given by the eminent dermatologist Irwin Braverman, MD. A basic tenet of the book is that even highly intelligent professionals often experience “blindness.” She writes: “For no physiological reason, sometimes we fail to see something that’s in our direct line of sight. We overlook things when they are unexpected or too familiar, when they blend in, and when they are too aberrant or abhorrent to imagine.” Fortunately, correcting such “inattentional blindness” isn’t a gift, it’s a skill that improves with practice. The key is to acknowledge the “blind spots” in our perception and to become more detail oriented. Enter the art. Through analyzing dozens of works of art, Ms. Herman shows you how to “see what matters,” encouraging you to notice every detail and, equally important, every missing detail. The result: Over time, attention to detail becomes second nature, helping you to become more observant and fully present both in clinic and at home.
”When Breath Becomes Air” by Paul Kalanithi, MD (Penguin Random House, 2016).
This posthumously published memoir by Paul Kalanithi, MD, is tormentingly beautiful. In May 2013, the 36-year-old neurosurgeon was diagnosed with stage IV lung cancer; he was a nonsmoker. In a blink, Dr. Kalanithi would don the patient’s gown and relinquish his role as healer. “Instead of being the pastoral figure aiding a life transition, I found myself the sheep, lost and confused. Severe illness wasn’t life-altering, it was life-shattering,” he writes. Dr. Kalanithi battles the cancer valiantly for 2 years, during which time he writes this book and has a child with his wife, Lucy, also a doctor. As someone with a BA and MA in literature from Stanford and a MPhil from Cambridge, his writing is eloquent and compelling, in the vein of Atul Gawande, MD, and Jerome Groopman, MD. He voices his readers’ thoughts perfectly when he writes, “My life had been building potential, potential that would now go unrealized. I had planned to do so much, and I had come so close.” We ache for him, for his unrealized contributions to the worlds of medicine and literature, and for his loved ones. Yet, as Lucy writes in the epilogue, “this book is a new way for him to help others, a contribution only he could make.” When Breath Becomes Air will leave you both deeply saddened and deeply inspired.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.
There were many books I read in 2016 that I found relevant and helpful for the practice of medicine as modern physicians. Here were some of my favorites:
”How to Have a Good Day” by Caroline Webb (Crown Business, 2016).
With media headlines screaming about the surge in physician burnout, now is a good time to read “How to Have a Good Day.” The author, Caroline Webb, an Oxford- and Cambridge-trained economist, management consultant, and executive coach, shows how little tweaks in behavior can garner big results in both your workday productivity and your overall well-being. Her science-based techniques are wonderfully practical. She teaches you how to be more effective at work by establishing smart habits, setting appropriate priorities, and pumping up your workplace enthusiasm. She also shows you a path to stronger workplace relationships by learning how to better manage conflict, build rapport, and get the most out of others. My copy is dog-eared. I hope yours will be too.
In this expansively researched book, Nancy Tomes, Ph.D., professor of history at the State University of New York, Stony Brook, documents the formation and consequences of the consumer economy in American medicine. Unlike other medical historians, who claim that patient consumerism emerged in the 1970s, Dr. Tomes argues that it developed “a full century earlier.” She dismantles the American ideal of the “golden age” of Norman Rockwell doctors and “deferential patients.” In eminently readable prose, Dr. Tomes analyzes numerous developments that have disrupted the doctor-patient relationship, including the growth of drug stores, the ever-changing medical insurance industry, and direct-to-consumer advertising. A skilled historian and writer, she doesn’t provide tidy answers to messy questions. She acknowledges that, despite many technological and social advances, particularly patient empowerment, there is no “magic bullet” to cure what ails our current medical system. This is a good choice for those looking to put digital medicine into historical context.
”Visual Intelligence: Sharpen Your Perception, Change Your Life” by Amy E. Herman (Eamon Dolan/Houghton Mifflin Harcourt, 2016).
How do we see? Not terribly well, according to Amy E. Herman. A lawyer and art historian, Ms. Herman has developed a course called “The Art of Perception” that has helped professionals from physicians to police officers hone their observation and communication skills. The course happens to be based on the class for students and residents of dermatology given by the eminent dermatologist Irwin Braverman, MD. A basic tenet of the book is that even highly intelligent professionals often experience “blindness.” She writes: “For no physiological reason, sometimes we fail to see something that’s in our direct line of sight. We overlook things when they are unexpected or too familiar, when they blend in, and when they are too aberrant or abhorrent to imagine.” Fortunately, correcting such “inattentional blindness” isn’t a gift, it’s a skill that improves with practice. The key is to acknowledge the “blind spots” in our perception and to become more detail oriented. Enter the art. Through analyzing dozens of works of art, Ms. Herman shows you how to “see what matters,” encouraging you to notice every detail and, equally important, every missing detail. The result: Over time, attention to detail becomes second nature, helping you to become more observant and fully present both in clinic and at home.
”When Breath Becomes Air” by Paul Kalanithi, MD (Penguin Random House, 2016).
This posthumously published memoir by Paul Kalanithi, MD, is tormentingly beautiful. In May 2013, the 36-year-old neurosurgeon was diagnosed with stage IV lung cancer; he was a nonsmoker. In a blink, Dr. Kalanithi would don the patient’s gown and relinquish his role as healer. “Instead of being the pastoral figure aiding a life transition, I found myself the sheep, lost and confused. Severe illness wasn’t life-altering, it was life-shattering,” he writes. Dr. Kalanithi battles the cancer valiantly for 2 years, during which time he writes this book and has a child with his wife, Lucy, also a doctor. As someone with a BA and MA in literature from Stanford and a MPhil from Cambridge, his writing is eloquent and compelling, in the vein of Atul Gawande, MD, and Jerome Groopman, MD. He voices his readers’ thoughts perfectly when he writes, “My life had been building potential, potential that would now go unrealized. I had planned to do so much, and I had come so close.” We ache for him, for his unrealized contributions to the worlds of medicine and literature, and for his loved ones. Yet, as Lucy writes in the epilogue, “this book is a new way for him to help others, a contribution only he could make.” When Breath Becomes Air will leave you both deeply saddened and deeply inspired.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.
Mindfulness
How might mindfulness contribute to your mental collapse? Let’s say your work has become tedious. Tottering toward burnout, you decide to try mindfulness meditation to reverse your downward trend. However, you habitually fail to do your daily meditation. Now, “Meditate today” just piles on to your to-do list, a daily reminder of just how weak and disorganized you have become. Voila! Mindfulness is making you more crazy. There are things you can do to avoid this.
There are plenty of things to tip us doctors into burnout. We are not alone in the burnout epidemic, but we are overrepresented. More than 50% of physicians have burnout symptoms according to a recent Mayo Clinic study. Mindfulness training can help.
According to an interview with the program’s director, Douglas Zeidonis, MD, professor and chair of the department of psychiatry at the University of Massachusetts, most of the physicians reported that mindfulness training significantly benefited their work and personal lives. Mindfulness helped them feel more present and engaged with colleagues and patients and made them better clinicians – they reported showing more compassion toward patients.
Like any desirable habit, the key is to do it again and again and again. Here are a few recommendations to help you become more mindful during your workday.
1. Set random alarms (vibrate mode) on your smartphone to remind yourself to take a moment. When it goes off, do this: Breathe (4 seconds in, hold, then 8 seconds out) and be totally present for one minute.
2. Remove deliciously distracting apps from your phone’s home screen. Instead, tuck them away in a folder to reduce the likelihood you’ll click on them when you’re stressed.
3. Put meditation apps where you easily see them. You might try:
• The Mindfulness App: This app offers guided meditations in varying lengths from 3 to 30 minutes, so you can choose the one that’s right for you at any time of the day. Cool features include tracking your progress and setting reminders.
• Headspace: Headspace is known for helping people learn to meditate in just 10 easy minutes a day. Cool features include the ability to track your progress and to buddy up with a friend to help keep you motivated.
• Omvana: This app offers over 500 “transformative” audios to improve all areas of your life from work to personal relationships. Cool features include tracks to improve sleep, something more than a few of us might appreciate.
• Stop, Breathe, & Think: Quicker than Headspace, this app teaches you to meditate in 5 minutes a day and is easy to use at your workplace. Cool features include customizing meditations based upon your mood.
• Take a Break!: Ideal for the workplace, this app will help you carve out time each day to breathe, relax, and focus. Cool features include the ability to choose meditations with voice, music, or nature sounds.
4. Block a 10-minute mindfulness appointment on your schedule in the afternoon. Becoming more resilient will more than offset the short term lost revenue if you avoid retiring too soon due to burnout!
5. If you have an Apple watch, then try the new Breathe app. It reminds you to stop, breathe, and relax and even reports your heart rate afterward.
So unless you are expecting 2017 to be uneventful, I suggest you start building your mindfulness habit today.
Serenity now, serenity now.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] . He has no disclosures related to this column.
How might mindfulness contribute to your mental collapse? Let’s say your work has become tedious. Tottering toward burnout, you decide to try mindfulness meditation to reverse your downward trend. However, you habitually fail to do your daily meditation. Now, “Meditate today” just piles on to your to-do list, a daily reminder of just how weak and disorganized you have become. Voila! Mindfulness is making you more crazy. There are things you can do to avoid this.
There are plenty of things to tip us doctors into burnout. We are not alone in the burnout epidemic, but we are overrepresented. More than 50% of physicians have burnout symptoms according to a recent Mayo Clinic study. Mindfulness training can help.
According to an interview with the program’s director, Douglas Zeidonis, MD, professor and chair of the department of psychiatry at the University of Massachusetts, most of the physicians reported that mindfulness training significantly benefited their work and personal lives. Mindfulness helped them feel more present and engaged with colleagues and patients and made them better clinicians – they reported showing more compassion toward patients.
Like any desirable habit, the key is to do it again and again and again. Here are a few recommendations to help you become more mindful during your workday.
1. Set random alarms (vibrate mode) on your smartphone to remind yourself to take a moment. When it goes off, do this: Breathe (4 seconds in, hold, then 8 seconds out) and be totally present for one minute.
2. Remove deliciously distracting apps from your phone’s home screen. Instead, tuck them away in a folder to reduce the likelihood you’ll click on them when you’re stressed.
3. Put meditation apps where you easily see them. You might try:
• The Mindfulness App: This app offers guided meditations in varying lengths from 3 to 30 minutes, so you can choose the one that’s right for you at any time of the day. Cool features include tracking your progress and setting reminders.
• Headspace: Headspace is known for helping people learn to meditate in just 10 easy minutes a day. Cool features include the ability to track your progress and to buddy up with a friend to help keep you motivated.
• Omvana: This app offers over 500 “transformative” audios to improve all areas of your life from work to personal relationships. Cool features include tracks to improve sleep, something more than a few of us might appreciate.
• Stop, Breathe, & Think: Quicker than Headspace, this app teaches you to meditate in 5 minutes a day and is easy to use at your workplace. Cool features include customizing meditations based upon your mood.
• Take a Break!: Ideal for the workplace, this app will help you carve out time each day to breathe, relax, and focus. Cool features include the ability to choose meditations with voice, music, or nature sounds.
4. Block a 10-minute mindfulness appointment on your schedule in the afternoon. Becoming more resilient will more than offset the short term lost revenue if you avoid retiring too soon due to burnout!
5. If you have an Apple watch, then try the new Breathe app. It reminds you to stop, breathe, and relax and even reports your heart rate afterward.
So unless you are expecting 2017 to be uneventful, I suggest you start building your mindfulness habit today.
Serenity now, serenity now.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] . He has no disclosures related to this column.
How might mindfulness contribute to your mental collapse? Let’s say your work has become tedious. Tottering toward burnout, you decide to try mindfulness meditation to reverse your downward trend. However, you habitually fail to do your daily meditation. Now, “Meditate today” just piles on to your to-do list, a daily reminder of just how weak and disorganized you have become. Voila! Mindfulness is making you more crazy. There are things you can do to avoid this.
There are plenty of things to tip us doctors into burnout. We are not alone in the burnout epidemic, but we are overrepresented. More than 50% of physicians have burnout symptoms according to a recent Mayo Clinic study. Mindfulness training can help.
According to an interview with the program’s director, Douglas Zeidonis, MD, professor and chair of the department of psychiatry at the University of Massachusetts, most of the physicians reported that mindfulness training significantly benefited their work and personal lives. Mindfulness helped them feel more present and engaged with colleagues and patients and made them better clinicians – they reported showing more compassion toward patients.
Like any desirable habit, the key is to do it again and again and again. Here are a few recommendations to help you become more mindful during your workday.
1. Set random alarms (vibrate mode) on your smartphone to remind yourself to take a moment. When it goes off, do this: Breathe (4 seconds in, hold, then 8 seconds out) and be totally present for one minute.
2. Remove deliciously distracting apps from your phone’s home screen. Instead, tuck them away in a folder to reduce the likelihood you’ll click on them when you’re stressed.
3. Put meditation apps where you easily see them. You might try:
• The Mindfulness App: This app offers guided meditations in varying lengths from 3 to 30 minutes, so you can choose the one that’s right for you at any time of the day. Cool features include tracking your progress and setting reminders.
• Headspace: Headspace is known for helping people learn to meditate in just 10 easy minutes a day. Cool features include the ability to track your progress and to buddy up with a friend to help keep you motivated.
• Omvana: This app offers over 500 “transformative” audios to improve all areas of your life from work to personal relationships. Cool features include tracks to improve sleep, something more than a few of us might appreciate.
• Stop, Breathe, & Think: Quicker than Headspace, this app teaches you to meditate in 5 minutes a day and is easy to use at your workplace. Cool features include customizing meditations based upon your mood.
• Take a Break!: Ideal for the workplace, this app will help you carve out time each day to breathe, relax, and focus. Cool features include the ability to choose meditations with voice, music, or nature sounds.
4. Block a 10-minute mindfulness appointment on your schedule in the afternoon. Becoming more resilient will more than offset the short term lost revenue if you avoid retiring too soon due to burnout!
5. If you have an Apple watch, then try the new Breathe app. It reminds you to stop, breathe, and relax and even reports your heart rate afterward.
So unless you are expecting 2017 to be uneventful, I suggest you start building your mindfulness habit today.
Serenity now, serenity now.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] . He has no disclosures related to this column.
‘Thank you, EMR!’
“Thank you, EMR!” Said no doctor. Ever.
At least up until now.
For years, we have had to put up with these machines in our exam rooms, distracting data entry devices that offer insignificant contributions to the work we do. That’s starting to change.
Recently, I led a workshop at the annual Kaiser Permanente internal medicine conference in Southern California. I gave one of my more popular sessions on the art of diagnosis and therapy (inspired and borrowed from Dr. Irwin M. Braverman’s marvelous lectures on learning dermatology through art).
What’s more, the listed steroids change automatically based on the current formulary. This ensures the lowest cost to the patient and minimizes rework of having to go back and pick another when the patient balks at unjustifiably high prices. The clinician has only to click and sign to place the order. Now a primary care physician – or even a dermatologist! – needs only to estimate the potency of the therapy, pick a vehicle (cream, ointment, gel, solution), and the EMR guides him or her to prescribe the right medication. It is easy to use, active at the point of care, and helpful to both clinician and patient.
This SRX program was developed by our local physicians in conjunction with pharmacists and the informatics team. It has enormous potential, providing more point of care clinical decision support based on best practice, formulary, and even personalized information automatically gleaned from that patient’s chart. As of now, we can customize our order entry such that if I want to order labs to look for connective tissue disease, I have to type only .CTD, and my personal picks for a lupus workup come up. It saves me time. Yes, I did just say that in reference to my EMR. And it helps ensure high-quality care. Whenever new diagnostics or new treatments become best practice, I can put them on my preference list, thereby making the best thing to do the easy thing to do.
The internal medicine physicians were appreciative for my lecture and loved learning through art. However, the big hit was the SRX DERM. “This will make it so much easier,” said one hospitalist, “thanks for doing this!”
I had nothing to do with it though. Thank you, EMR.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. He is @Dermdoc on Twitter. Write to him at [email protected].
“Thank you, EMR!” Said no doctor. Ever.
At least up until now.
For years, we have had to put up with these machines in our exam rooms, distracting data entry devices that offer insignificant contributions to the work we do. That’s starting to change.
Recently, I led a workshop at the annual Kaiser Permanente internal medicine conference in Southern California. I gave one of my more popular sessions on the art of diagnosis and therapy (inspired and borrowed from Dr. Irwin M. Braverman’s marvelous lectures on learning dermatology through art).
What’s more, the listed steroids change automatically based on the current formulary. This ensures the lowest cost to the patient and minimizes rework of having to go back and pick another when the patient balks at unjustifiably high prices. The clinician has only to click and sign to place the order. Now a primary care physician – or even a dermatologist! – needs only to estimate the potency of the therapy, pick a vehicle (cream, ointment, gel, solution), and the EMR guides him or her to prescribe the right medication. It is easy to use, active at the point of care, and helpful to both clinician and patient.
This SRX program was developed by our local physicians in conjunction with pharmacists and the informatics team. It has enormous potential, providing more point of care clinical decision support based on best practice, formulary, and even personalized information automatically gleaned from that patient’s chart. As of now, we can customize our order entry such that if I want to order labs to look for connective tissue disease, I have to type only .CTD, and my personal picks for a lupus workup come up. It saves me time. Yes, I did just say that in reference to my EMR. And it helps ensure high-quality care. Whenever new diagnostics or new treatments become best practice, I can put them on my preference list, thereby making the best thing to do the easy thing to do.
The internal medicine physicians were appreciative for my lecture and loved learning through art. However, the big hit was the SRX DERM. “This will make it so much easier,” said one hospitalist, “thanks for doing this!”
I had nothing to do with it though. Thank you, EMR.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. He is @Dermdoc on Twitter. Write to him at [email protected].
“Thank you, EMR!” Said no doctor. Ever.
At least up until now.
For years, we have had to put up with these machines in our exam rooms, distracting data entry devices that offer insignificant contributions to the work we do. That’s starting to change.
Recently, I led a workshop at the annual Kaiser Permanente internal medicine conference in Southern California. I gave one of my more popular sessions on the art of diagnosis and therapy (inspired and borrowed from Dr. Irwin M. Braverman’s marvelous lectures on learning dermatology through art).
What’s more, the listed steroids change automatically based on the current formulary. This ensures the lowest cost to the patient and minimizes rework of having to go back and pick another when the patient balks at unjustifiably high prices. The clinician has only to click and sign to place the order. Now a primary care physician – or even a dermatologist! – needs only to estimate the potency of the therapy, pick a vehicle (cream, ointment, gel, solution), and the EMR guides him or her to prescribe the right medication. It is easy to use, active at the point of care, and helpful to both clinician and patient.
This SRX program was developed by our local physicians in conjunction with pharmacists and the informatics team. It has enormous potential, providing more point of care clinical decision support based on best practice, formulary, and even personalized information automatically gleaned from that patient’s chart. As of now, we can customize our order entry such that if I want to order labs to look for connective tissue disease, I have to type only .CTD, and my personal picks for a lupus workup come up. It saves me time. Yes, I did just say that in reference to my EMR. And it helps ensure high-quality care. Whenever new diagnostics or new treatments become best practice, I can put them on my preference list, thereby making the best thing to do the easy thing to do.
The internal medicine physicians were appreciative for my lecture and loved learning through art. However, the big hit was the SRX DERM. “This will make it so much easier,” said one hospitalist, “thanks for doing this!”
I had nothing to do with it though. Thank you, EMR.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. He is @Dermdoc on Twitter. Write to him at [email protected].
Quality or convenience: Pick one
A 35-year-old male with a 5-year-history of a changing mole on his back sends a picture of the lesion to a telemedicine website for advice. The photo reveals a black nodule. The clinician replies, advising the patient that the lesion is benign.
To most dermatologists, the above scenario would occur only in a bizarre nightmare, never in real life. In real life, if the words “black” and “nodule” are used to describe a lesion, they are followed by the verb “biopsy.” Most dermatologists would recognize this as a high-risk growth and recommend additional investigation.
Unfortunately, a recent study of direct-to-consumer (DTC) telemedicine in JAMA Dermatology showed that 21% of the time, the patient was wrongfully reassured that a lesion was benign (JAMA Dermatol. 2016;152[7]:768-75). The study examined how 16 DTC telemedicine websites and apps handled six standardized dermatology cases designed to test the quality of the services. While some provided good care, others missed important diagnoses such as syphilis, eczema herpeticum, and melanoma. If these cases had been actual patients, the consequences for such mistakes could have been dire.
“The services failed to ask simple, relevant questions of patients about their symptoms, leading them to repeatedly miss important diagnoses,” Jack Resneck Jr., MD, a dermatologist at the University of California, San Francisco, and lead author of the study, told the Wall Street Journal.
The study is timely, as telemedicine is accelerating explosively. The low cost of connectivity, viable business models, and changing consumer behaviors are fueling its rocket growth. Startups in digital health and telemedicine have raised over $700 million already this year, indicating that there is more fuel to be burned and more money to be made.
DTC telemedicine describes the model when a patient sends photos directly to a clinician without a prior history with that provider. A teleconsultation, in contrast, is an interaction between two doctors. In DTC, the episode of care is usually isolated from the patient’s record, and the information is not transferred to the primary care physician. Patients pay a fee, which can range from $1.59 to $250.
Advocates of DTC cite its low cost and extraordinary convenience as arguments for its adoption. However, these disconnected visits are notable exceptions to the current trend toward better care coordination and information sharing among providers.
Quality is also a concern. Although consumers were often promised answers from board-certified physicians, the JAMA Dermatology study was unable to verify this in many cases. The researchers also found that nondermatologists, physician extenders, and physicians practicing in India were often the providers, facts that were not obvious to users.
Worse, the study found both the quality of the diagnoses and the recommendations were poor. All the providers missed the cases of syphilis and most missed eczema herpeticum. Risks of prescription medications were not disclosed two-thirds of the time. Worse yet, three services mistakenly advised that a nodular melanoma did not need further treatment. Had these been real patients, such wrongful recommendations could have resulted in deaths.
In an effort to ensure safety and reliability for consumers, the American Telemedicine Association has begun credentialing telemedicine providers. Such credentials are not required, however, and consumers are likely to be unaware of which providers have or have not met this standard. The American Academy of Dermatology addresses DTC teledermatology in its position statement, updated in 2016: “Dermatologists providing direct-to-patient teledermatology must make every effort to collect accurate, complete, and quality clinical information. When appropriate, the dermatologist may wish to contact the primary care providers or other specialists to obtain additional corroborating information.”
Currently, patients remain on their own in choosing telemedicine and other digital health services: caveat emptor. Do they want quality and convenient care? For now, it seems, they must pick only one.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. He is @Dermdoc on Twitter. Write to him at [email protected].
A 35-year-old male with a 5-year-history of a changing mole on his back sends a picture of the lesion to a telemedicine website for advice. The photo reveals a black nodule. The clinician replies, advising the patient that the lesion is benign.
To most dermatologists, the above scenario would occur only in a bizarre nightmare, never in real life. In real life, if the words “black” and “nodule” are used to describe a lesion, they are followed by the verb “biopsy.” Most dermatologists would recognize this as a high-risk growth and recommend additional investigation.
Unfortunately, a recent study of direct-to-consumer (DTC) telemedicine in JAMA Dermatology showed that 21% of the time, the patient was wrongfully reassured that a lesion was benign (JAMA Dermatol. 2016;152[7]:768-75). The study examined how 16 DTC telemedicine websites and apps handled six standardized dermatology cases designed to test the quality of the services. While some provided good care, others missed important diagnoses such as syphilis, eczema herpeticum, and melanoma. If these cases had been actual patients, the consequences for such mistakes could have been dire.
“The services failed to ask simple, relevant questions of patients about their symptoms, leading them to repeatedly miss important diagnoses,” Jack Resneck Jr., MD, a dermatologist at the University of California, San Francisco, and lead author of the study, told the Wall Street Journal.
The study is timely, as telemedicine is accelerating explosively. The low cost of connectivity, viable business models, and changing consumer behaviors are fueling its rocket growth. Startups in digital health and telemedicine have raised over $700 million already this year, indicating that there is more fuel to be burned and more money to be made.
DTC telemedicine describes the model when a patient sends photos directly to a clinician without a prior history with that provider. A teleconsultation, in contrast, is an interaction between two doctors. In DTC, the episode of care is usually isolated from the patient’s record, and the information is not transferred to the primary care physician. Patients pay a fee, which can range from $1.59 to $250.
Advocates of DTC cite its low cost and extraordinary convenience as arguments for its adoption. However, these disconnected visits are notable exceptions to the current trend toward better care coordination and information sharing among providers.
Quality is also a concern. Although consumers were often promised answers from board-certified physicians, the JAMA Dermatology study was unable to verify this in many cases. The researchers also found that nondermatologists, physician extenders, and physicians practicing in India were often the providers, facts that were not obvious to users.
Worse, the study found both the quality of the diagnoses and the recommendations were poor. All the providers missed the cases of syphilis and most missed eczema herpeticum. Risks of prescription medications were not disclosed two-thirds of the time. Worse yet, three services mistakenly advised that a nodular melanoma did not need further treatment. Had these been real patients, such wrongful recommendations could have resulted in deaths.
In an effort to ensure safety and reliability for consumers, the American Telemedicine Association has begun credentialing telemedicine providers. Such credentials are not required, however, and consumers are likely to be unaware of which providers have or have not met this standard. The American Academy of Dermatology addresses DTC teledermatology in its position statement, updated in 2016: “Dermatologists providing direct-to-patient teledermatology must make every effort to collect accurate, complete, and quality clinical information. When appropriate, the dermatologist may wish to contact the primary care providers or other specialists to obtain additional corroborating information.”
Currently, patients remain on their own in choosing telemedicine and other digital health services: caveat emptor. Do they want quality and convenient care? For now, it seems, they must pick only one.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. He is @Dermdoc on Twitter. Write to him at [email protected].
A 35-year-old male with a 5-year-history of a changing mole on his back sends a picture of the lesion to a telemedicine website for advice. The photo reveals a black nodule. The clinician replies, advising the patient that the lesion is benign.
To most dermatologists, the above scenario would occur only in a bizarre nightmare, never in real life. In real life, if the words “black” and “nodule” are used to describe a lesion, they are followed by the verb “biopsy.” Most dermatologists would recognize this as a high-risk growth and recommend additional investigation.
Unfortunately, a recent study of direct-to-consumer (DTC) telemedicine in JAMA Dermatology showed that 21% of the time, the patient was wrongfully reassured that a lesion was benign (JAMA Dermatol. 2016;152[7]:768-75). The study examined how 16 DTC telemedicine websites and apps handled six standardized dermatology cases designed to test the quality of the services. While some provided good care, others missed important diagnoses such as syphilis, eczema herpeticum, and melanoma. If these cases had been actual patients, the consequences for such mistakes could have been dire.
“The services failed to ask simple, relevant questions of patients about their symptoms, leading them to repeatedly miss important diagnoses,” Jack Resneck Jr., MD, a dermatologist at the University of California, San Francisco, and lead author of the study, told the Wall Street Journal.
The study is timely, as telemedicine is accelerating explosively. The low cost of connectivity, viable business models, and changing consumer behaviors are fueling its rocket growth. Startups in digital health and telemedicine have raised over $700 million already this year, indicating that there is more fuel to be burned and more money to be made.
DTC telemedicine describes the model when a patient sends photos directly to a clinician without a prior history with that provider. A teleconsultation, in contrast, is an interaction between two doctors. In DTC, the episode of care is usually isolated from the patient’s record, and the information is not transferred to the primary care physician. Patients pay a fee, which can range from $1.59 to $250.
Advocates of DTC cite its low cost and extraordinary convenience as arguments for its adoption. However, these disconnected visits are notable exceptions to the current trend toward better care coordination and information sharing among providers.
Quality is also a concern. Although consumers were often promised answers from board-certified physicians, the JAMA Dermatology study was unable to verify this in many cases. The researchers also found that nondermatologists, physician extenders, and physicians practicing in India were often the providers, facts that were not obvious to users.
Worse, the study found both the quality of the diagnoses and the recommendations were poor. All the providers missed the cases of syphilis and most missed eczema herpeticum. Risks of prescription medications were not disclosed two-thirds of the time. Worse yet, three services mistakenly advised that a nodular melanoma did not need further treatment. Had these been real patients, such wrongful recommendations could have resulted in deaths.
In an effort to ensure safety and reliability for consumers, the American Telemedicine Association has begun credentialing telemedicine providers. Such credentials are not required, however, and consumers are likely to be unaware of which providers have or have not met this standard. The American Academy of Dermatology addresses DTC teledermatology in its position statement, updated in 2016: “Dermatologists providing direct-to-patient teledermatology must make every effort to collect accurate, complete, and quality clinical information. When appropriate, the dermatologist may wish to contact the primary care providers or other specialists to obtain additional corroborating information.”
Currently, patients remain on their own in choosing telemedicine and other digital health services: caveat emptor. Do they want quality and convenient care? For now, it seems, they must pick only one.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. He is @Dermdoc on Twitter. Write to him at [email protected].
Tips for using EMRs effectively
All young physicians are adept at using electronic medical records. Do you agree? If so, you’d be wrong. It’s true that young, so-called “digital-native” physicians have more training and experience using EMRs, compared with those who trained in the days of paper charts. But young physicians are also inexperienced at caring for patients, and using a keyboard adds complexity to an already difficult task. Some struggle with the sheer volume of work that EMRs create, while others wrestle with the intrusive computer in the exam room. The former is a complex problem, and solving it involves improving both system and individual work flows. The latter is one I’ve had great success with when coaching inexperienced doctors.
One of my roles at Kaiser Permanente, San Diego, is to coach new physicians to help them perform at their best. In particular, we provide one-on-one help for physicians to optimize the quality of service they provide. More often than not, young physicians benefit from optimizing their work flow as much as from modifying their bedside manner.
Here are five common tips I share with them to improve their service while using EMRs:
• Preview coming attractions. High-quality interactions require that prep work be done before the visit begins. Before seeing your patient, review his or her record to learn about the medical history, particularly any recent important health issues. This is true even if the problem is not related to your specialty. This sends a strong signal to your patient that you know and care about him or her as a person.
• Connect with your patient first, then turn to HealthConnect (our version of the EPIC electronic record). For every patient, every visit, spend the first few minutes giving your undivided attention to them while in the room. Conversely, entering the room and logging on the computer immediately diminishes the quality of the experience for patients.
• Ask permission, not forgiveness. When you must use the EMR to review or to chart, ask permission first. Try something like, “This is important. Do you mind if I start typing some of this to be sure it is captured in your record?” I’ve never seen a patient object if you start typing. If they did, then the time isn’t right for you to go to the EMR, and it would best for you to address their concern first.
• Share the screen. Many patients love to see their chart. It’s like giving them a backstage pass. It’s also a great way to keep them engaged while you talk about their issues. Point things out to them and use it to engage in discussion. The better informed your patients are, the more likely they will evaluate you favorably, and the more likely they are to adhere to your advice.
• Complete diagnoses and write any prescriptions while in the room. This is a wonderful opportunity to engage with your patients on the risks and benefits of what you recommend, to review your specific instructions, and to allow them to see their diagnoses written out. Close with a printed copy of what just transpired. The act of giving something tangible makes the encounter feel complete, while also increasing patients’ retention of key information and their likelihood of following up as directed.
As more young physicians join us in the workforce, we know that it doesn’t matter much if you grew up with Facebook and Snapchat; using EMRs effectively is a learned skill that all of us can improve upon.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
All young physicians are adept at using electronic medical records. Do you agree? If so, you’d be wrong. It’s true that young, so-called “digital-native” physicians have more training and experience using EMRs, compared with those who trained in the days of paper charts. But young physicians are also inexperienced at caring for patients, and using a keyboard adds complexity to an already difficult task. Some struggle with the sheer volume of work that EMRs create, while others wrestle with the intrusive computer in the exam room. The former is a complex problem, and solving it involves improving both system and individual work flows. The latter is one I’ve had great success with when coaching inexperienced doctors.
One of my roles at Kaiser Permanente, San Diego, is to coach new physicians to help them perform at their best. In particular, we provide one-on-one help for physicians to optimize the quality of service they provide. More often than not, young physicians benefit from optimizing their work flow as much as from modifying their bedside manner.
Here are five common tips I share with them to improve their service while using EMRs:
• Preview coming attractions. High-quality interactions require that prep work be done before the visit begins. Before seeing your patient, review his or her record to learn about the medical history, particularly any recent important health issues. This is true even if the problem is not related to your specialty. This sends a strong signal to your patient that you know and care about him or her as a person.
• Connect with your patient first, then turn to HealthConnect (our version of the EPIC electronic record). For every patient, every visit, spend the first few minutes giving your undivided attention to them while in the room. Conversely, entering the room and logging on the computer immediately diminishes the quality of the experience for patients.
• Ask permission, not forgiveness. When you must use the EMR to review or to chart, ask permission first. Try something like, “This is important. Do you mind if I start typing some of this to be sure it is captured in your record?” I’ve never seen a patient object if you start typing. If they did, then the time isn’t right for you to go to the EMR, and it would best for you to address their concern first.
• Share the screen. Many patients love to see their chart. It’s like giving them a backstage pass. It’s also a great way to keep them engaged while you talk about their issues. Point things out to them and use it to engage in discussion. The better informed your patients are, the more likely they will evaluate you favorably, and the more likely they are to adhere to your advice.
• Complete diagnoses and write any prescriptions while in the room. This is a wonderful opportunity to engage with your patients on the risks and benefits of what you recommend, to review your specific instructions, and to allow them to see their diagnoses written out. Close with a printed copy of what just transpired. The act of giving something tangible makes the encounter feel complete, while also increasing patients’ retention of key information and their likelihood of following up as directed.
As more young physicians join us in the workforce, we know that it doesn’t matter much if you grew up with Facebook and Snapchat; using EMRs effectively is a learned skill that all of us can improve upon.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
All young physicians are adept at using electronic medical records. Do you agree? If so, you’d be wrong. It’s true that young, so-called “digital-native” physicians have more training and experience using EMRs, compared with those who trained in the days of paper charts. But young physicians are also inexperienced at caring for patients, and using a keyboard adds complexity to an already difficult task. Some struggle with the sheer volume of work that EMRs create, while others wrestle with the intrusive computer in the exam room. The former is a complex problem, and solving it involves improving both system and individual work flows. The latter is one I’ve had great success with when coaching inexperienced doctors.
One of my roles at Kaiser Permanente, San Diego, is to coach new physicians to help them perform at their best. In particular, we provide one-on-one help for physicians to optimize the quality of service they provide. More often than not, young physicians benefit from optimizing their work flow as much as from modifying their bedside manner.
Here are five common tips I share with them to improve their service while using EMRs:
• Preview coming attractions. High-quality interactions require that prep work be done before the visit begins. Before seeing your patient, review his or her record to learn about the medical history, particularly any recent important health issues. This is true even if the problem is not related to your specialty. This sends a strong signal to your patient that you know and care about him or her as a person.
• Connect with your patient first, then turn to HealthConnect (our version of the EPIC electronic record). For every patient, every visit, spend the first few minutes giving your undivided attention to them while in the room. Conversely, entering the room and logging on the computer immediately diminishes the quality of the experience for patients.
• Ask permission, not forgiveness. When you must use the EMR to review or to chart, ask permission first. Try something like, “This is important. Do you mind if I start typing some of this to be sure it is captured in your record?” I’ve never seen a patient object if you start typing. If they did, then the time isn’t right for you to go to the EMR, and it would best for you to address their concern first.
• Share the screen. Many patients love to see their chart. It’s like giving them a backstage pass. It’s also a great way to keep them engaged while you talk about their issues. Point things out to them and use it to engage in discussion. The better informed your patients are, the more likely they will evaluate you favorably, and the more likely they are to adhere to your advice.
• Complete diagnoses and write any prescriptions while in the room. This is a wonderful opportunity to engage with your patients on the risks and benefits of what you recommend, to review your specific instructions, and to allow them to see their diagnoses written out. Close with a printed copy of what just transpired. The act of giving something tangible makes the encounter feel complete, while also increasing patients’ retention of key information and their likelihood of following up as directed.
As more young physicians join us in the workforce, we know that it doesn’t matter much if you grew up with Facebook and Snapchat; using EMRs effectively is a learned skill that all of us can improve upon.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Digital snake oil?
In what might have been a lecture from the early 19th century, CEO of the American Medical Association James Madara gave a fire and brimstone address railing against snake oil hucksters, at the AMA annual meeting. The quacks he attacked, however, are of a 21st century kind: those peddling digital health wares.
Dr. Madara claimed, “Appearing in disguise … are other digital so-called advancements that don’t have an appropriate evidence base, or that just don’t work that well – or that actually impede care, confuse patients, and waste our time. From ineffective electronic health records, to an explosion of direct-to-consumer digital health products, to apps of mixed quality. This is the digital snake oil of the early 21st century.”
Dr. Madara listed telemedicine as an example of “positive” digital products, then spent the bulk of the speech admonishing health app and EMR vendors. “American physicians have become the most expensive data entry workforce on the face of the planet,” he said to resounding applause from his audience of AMA delegates. In what was most likely a reference to Dr. Eric Topol’s work, he criticized, without naming, a book for touting a future where patients order their own labs and treat their own diseases, an ostentatious prediction that Dr. Madara pointed out sells books but fails to resonate with real medicine. There are digital tools that “impede care, confuse patients, and waste our time,” he added. So, is Dr. Madara right? Is all digital medicine just snake oil?
Dr. Madara used his time on the dais to defend doctors and patients. His voice trembled and brow furrowed as he spoke; no doubt many of us feel the same frustration with the practice of medicine today. And digital tools are as fine a scapegoat as any. His snake oil analogy, however, is misleading. While no physician loves his or her EMR, and all physicians wish they could spend more time caring and less time typing, EMRs, unlike snake oil, are not without benefit. From a population health and patient safety perspective, they are as efficacious as any quality evidence-based medicine. The fact that EMRs have increased drudgery and decreased patient time for physicians is an undesirable, but predictable side effect – one that we ought to mitigate as we take a more active role in designing future versions.
As for the innumerate apps, wearables, and websites that promise more health than they deliver, Dr. Madara pointed out: “Only in the fine print [do they] say ‘for entertainment purposes only.’ ” While this is true, these apps aren’t the real problem. There have always been and will always be alternative health products of dubious benefit that patients love. I’m quite sure randomized controlled trials don’t exist for apple cider vinegar cures, but it doesn’t seem to hurt their popularity, or us. Dr. Madara argued that we should be working to leverage, not eliminate, physicians. The real threat here is that we fail to appreciate and to meet our patients’ needs and wants.
We want to spend more time with our patients and believe that a deep doctor-patient relationship is a key factor in good medicine. But a profound connection with their doctor is not always what our modern patients want. The proliferation of $1.99 health apps is not the evidence here; rather, it is the proliferation of retail health clinics and virtual health. On-demand telephone and video appointments are exploding in popularity. This type of growth cannot be from slick sales pitches; rather, the growth stems from true patient demand.
We have throughout our history stayed close to our patients and adapted to their changing desires. In antiquity, we were spiritual; in the 18th and 19th centuries, we were personal (picture the family doctor arriving in horse and buggy to see the patient, pat the kids on the head, and do little more than listen). In the 20th century, we became scientific, accurate, and effective. Today, patients have added demands for us to be convenient, current, and affordable. For us to meet these changing requirements, we must add digital tools to our black bag. It is up to us to design and deploy them.
I disagree with Dr. Madara when he says that other industries have benefited from digital tools whereas medicine has not. Digital killed Borders and Blockbuster. Digital has saved radiology and rural medicine. Compelling and competing arguments are being made from many industries as to whether digital technology has either decreased or increased U.S. productivity. I am glad this speech has incited so much discussion in health care. We have a lot to talk about.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter.
In what might have been a lecture from the early 19th century, CEO of the American Medical Association James Madara gave a fire and brimstone address railing against snake oil hucksters, at the AMA annual meeting. The quacks he attacked, however, are of a 21st century kind: those peddling digital health wares.
Dr. Madara claimed, “Appearing in disguise … are other digital so-called advancements that don’t have an appropriate evidence base, or that just don’t work that well – or that actually impede care, confuse patients, and waste our time. From ineffective electronic health records, to an explosion of direct-to-consumer digital health products, to apps of mixed quality. This is the digital snake oil of the early 21st century.”
Dr. Madara listed telemedicine as an example of “positive” digital products, then spent the bulk of the speech admonishing health app and EMR vendors. “American physicians have become the most expensive data entry workforce on the face of the planet,” he said to resounding applause from his audience of AMA delegates. In what was most likely a reference to Dr. Eric Topol’s work, he criticized, without naming, a book for touting a future where patients order their own labs and treat their own diseases, an ostentatious prediction that Dr. Madara pointed out sells books but fails to resonate with real medicine. There are digital tools that “impede care, confuse patients, and waste our time,” he added. So, is Dr. Madara right? Is all digital medicine just snake oil?
Dr. Madara used his time on the dais to defend doctors and patients. His voice trembled and brow furrowed as he spoke; no doubt many of us feel the same frustration with the practice of medicine today. And digital tools are as fine a scapegoat as any. His snake oil analogy, however, is misleading. While no physician loves his or her EMR, and all physicians wish they could spend more time caring and less time typing, EMRs, unlike snake oil, are not without benefit. From a population health and patient safety perspective, they are as efficacious as any quality evidence-based medicine. The fact that EMRs have increased drudgery and decreased patient time for physicians is an undesirable, but predictable side effect – one that we ought to mitigate as we take a more active role in designing future versions.
As for the innumerate apps, wearables, and websites that promise more health than they deliver, Dr. Madara pointed out: “Only in the fine print [do they] say ‘for entertainment purposes only.’ ” While this is true, these apps aren’t the real problem. There have always been and will always be alternative health products of dubious benefit that patients love. I’m quite sure randomized controlled trials don’t exist for apple cider vinegar cures, but it doesn’t seem to hurt their popularity, or us. Dr. Madara argued that we should be working to leverage, not eliminate, physicians. The real threat here is that we fail to appreciate and to meet our patients’ needs and wants.
We want to spend more time with our patients and believe that a deep doctor-patient relationship is a key factor in good medicine. But a profound connection with their doctor is not always what our modern patients want. The proliferation of $1.99 health apps is not the evidence here; rather, it is the proliferation of retail health clinics and virtual health. On-demand telephone and video appointments are exploding in popularity. This type of growth cannot be from slick sales pitches; rather, the growth stems from true patient demand.
We have throughout our history stayed close to our patients and adapted to their changing desires. In antiquity, we were spiritual; in the 18th and 19th centuries, we were personal (picture the family doctor arriving in horse and buggy to see the patient, pat the kids on the head, and do little more than listen). In the 20th century, we became scientific, accurate, and effective. Today, patients have added demands for us to be convenient, current, and affordable. For us to meet these changing requirements, we must add digital tools to our black bag. It is up to us to design and deploy them.
I disagree with Dr. Madara when he says that other industries have benefited from digital tools whereas medicine has not. Digital killed Borders and Blockbuster. Digital has saved radiology and rural medicine. Compelling and competing arguments are being made from many industries as to whether digital technology has either decreased or increased U.S. productivity. I am glad this speech has incited so much discussion in health care. We have a lot to talk about.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter.
In what might have been a lecture from the early 19th century, CEO of the American Medical Association James Madara gave a fire and brimstone address railing against snake oil hucksters, at the AMA annual meeting. The quacks he attacked, however, are of a 21st century kind: those peddling digital health wares.
Dr. Madara claimed, “Appearing in disguise … are other digital so-called advancements that don’t have an appropriate evidence base, or that just don’t work that well – or that actually impede care, confuse patients, and waste our time. From ineffective electronic health records, to an explosion of direct-to-consumer digital health products, to apps of mixed quality. This is the digital snake oil of the early 21st century.”
Dr. Madara listed telemedicine as an example of “positive” digital products, then spent the bulk of the speech admonishing health app and EMR vendors. “American physicians have become the most expensive data entry workforce on the face of the planet,” he said to resounding applause from his audience of AMA delegates. In what was most likely a reference to Dr. Eric Topol’s work, he criticized, without naming, a book for touting a future where patients order their own labs and treat their own diseases, an ostentatious prediction that Dr. Madara pointed out sells books but fails to resonate with real medicine. There are digital tools that “impede care, confuse patients, and waste our time,” he added. So, is Dr. Madara right? Is all digital medicine just snake oil?
Dr. Madara used his time on the dais to defend doctors and patients. His voice trembled and brow furrowed as he spoke; no doubt many of us feel the same frustration with the practice of medicine today. And digital tools are as fine a scapegoat as any. His snake oil analogy, however, is misleading. While no physician loves his or her EMR, and all physicians wish they could spend more time caring and less time typing, EMRs, unlike snake oil, are not without benefit. From a population health and patient safety perspective, they are as efficacious as any quality evidence-based medicine. The fact that EMRs have increased drudgery and decreased patient time for physicians is an undesirable, but predictable side effect – one that we ought to mitigate as we take a more active role in designing future versions.
As for the innumerate apps, wearables, and websites that promise more health than they deliver, Dr. Madara pointed out: “Only in the fine print [do they] say ‘for entertainment purposes only.’ ” While this is true, these apps aren’t the real problem. There have always been and will always be alternative health products of dubious benefit that patients love. I’m quite sure randomized controlled trials don’t exist for apple cider vinegar cures, but it doesn’t seem to hurt their popularity, or us. Dr. Madara argued that we should be working to leverage, not eliminate, physicians. The real threat here is that we fail to appreciate and to meet our patients’ needs and wants.
We want to spend more time with our patients and believe that a deep doctor-patient relationship is a key factor in good medicine. But a profound connection with their doctor is not always what our modern patients want. The proliferation of $1.99 health apps is not the evidence here; rather, it is the proliferation of retail health clinics and virtual health. On-demand telephone and video appointments are exploding in popularity. This type of growth cannot be from slick sales pitches; rather, the growth stems from true patient demand.
We have throughout our history stayed close to our patients and adapted to their changing desires. In antiquity, we were spiritual; in the 18th and 19th centuries, we were personal (picture the family doctor arriving in horse and buggy to see the patient, pat the kids on the head, and do little more than listen). In the 20th century, we became scientific, accurate, and effective. Today, patients have added demands for us to be convenient, current, and affordable. For us to meet these changing requirements, we must add digital tools to our black bag. It is up to us to design and deploy them.
I disagree with Dr. Madara when he says that other industries have benefited from digital tools whereas medicine has not. Digital killed Borders and Blockbuster. Digital has saved radiology and rural medicine. Compelling and competing arguments are being made from many industries as to whether digital technology has either decreased or increased U.S. productivity. I am glad this speech has incited so much discussion in health care. We have a lot to talk about.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter.
Driverless health care
Health care is changing. For some, this is cause for celebration: A safer, convenient, more efficient system is upon us. For others, the end is nigh: impossibly demanding patients, crushing bureaucracy, and a once sacred relationship desecrated by invasive technology.
The ascent of digital health technologies is an important driver of health care change, yet its impact is still indeterminate. Any technology that empowers patients as well as physicians will improve patients’ health outcomes. Or so it might seem. The truth is more nuanced: Some services will improve outcomes, others won’t. Fitting Fitbits into our current system is like inserting the wrong key into a lock: It might go in, but it doesn’t open anything. Fortunately, some keys are opening doors to better care – doors that that we’ve never entered – but finding the right ones is laborious. Dr. Joe Kvedar is here to help.
As a physician leader who straddles the gap between physician-centered and consumer-centered health care, Dr. Kvedar has spent his career leveraging technology to improve care delivery for both. In his new book, “The Internet of Healthy Things,” he shares what he has learned. He uses numerous examples from his experience as a physician and pioneer in digital health care with Partners HealthCare, Boston, delving deeply into the business of health care and the behavioral habits of patients.
As he notes, Partners was “prescient” in the health care landscape, introducing video conferencing in the 1990s, second opinions on the Internet in 2001, and texting as a tool for health messaging in 2008. He asks now: “What are the connected health devices and applications that our clinicians will be using in 5-10 years?” Then he uses his acumen and research to answer his own question. The ensuing chapters are more prescriptive than predictive, however. None of us knows where health care will be in 10 years, but we should think about where it ought to be.
Whether you chart on an Apple Watch or on paper, this discussion is important to you. Physicians are key players in determining where and how medicine is practiced, and we need to understand relevant risks and benefits to make the right decisions.
Confusing the matter is that desired outcomes are not absolute but relative. It depends on the frame of reference. Patients measure outcomes with service, payers with cost, and we physicians with quality. Which measurement is correct? How can we know if a remote monitoring device is worthwhile if we can’t agree on what it delivers? Is it simply sending home “the sicker even quicker?” Does a Big Pharma beyond-the-pill app really only increase consumption of the costliest medications or create more affordable alternatives?
Technologies that increase access to services such as live chat, messaging, and monitoring may be preferred by patients, but physicians see them as piling on to backbreaking loads. More artificial intelligence is needed to enable these services without requiring physician work. We need driverless health care.
Keeping patients involved has a whole other set of requirements. The tools must be easy, the information personal, the data actionable, and its use Candy-Crush-Saga addictive. This is no small feat, but there is hope.
Partner’s Text 2 Move program, which Dr. Kvedar describes as the “gold standard of what learning about your consumer means,” showed that highly personalized, targeted text messages could have a significant impact on patients’ behavior and health. It is just this type of technology that many are relentlessly pursuing to deliver care more effectively.
Dr. Kvedar devotes significant attention to the patient/consumer experience in a thoughtful, complex manner. Rather than elevate or denigrate the rise of the engaged patient, he examines this phenomenon through several lenses, addressing equally the concerns of practicing physicians and health care entrepreneurs. Nearly 20 years ago, Regina Herzlinger of Harvard Business School, Boston, predicted the rise of health care consumerism. Retail clinics, direct-to-consumer services, and the “Yelpification” of health care are signals that we’ve arrived.
It’s tough to make predictions, especially about the future, Yogi Berra warned us. The book’s mention of Theranos, the failing pinprick blood lab company founded by celebrity Stanford student Elizabeth Holmes, is an example of how risky it is to place bets on where we are headed and how quickly we will get there. DIY at-home labs are further off than they appeared, and that is the hazard of any such books: it is difficult to see more than what’s just in front of us.
Ultimately, Dr. Kvedar’s message is as realistic as it is optimistic: “The same information that could help drive healthcare costs down can be used to create highly individualized programs that will help people stay healthier and happier.” But we should resist the urge to ask “Are we there yet?” No. We’ve a ways to go.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Health care is changing. For some, this is cause for celebration: A safer, convenient, more efficient system is upon us. For others, the end is nigh: impossibly demanding patients, crushing bureaucracy, and a once sacred relationship desecrated by invasive technology.
The ascent of digital health technologies is an important driver of health care change, yet its impact is still indeterminate. Any technology that empowers patients as well as physicians will improve patients’ health outcomes. Or so it might seem. The truth is more nuanced: Some services will improve outcomes, others won’t. Fitting Fitbits into our current system is like inserting the wrong key into a lock: It might go in, but it doesn’t open anything. Fortunately, some keys are opening doors to better care – doors that that we’ve never entered – but finding the right ones is laborious. Dr. Joe Kvedar is here to help.
As a physician leader who straddles the gap between physician-centered and consumer-centered health care, Dr. Kvedar has spent his career leveraging technology to improve care delivery for both. In his new book, “The Internet of Healthy Things,” he shares what he has learned. He uses numerous examples from his experience as a physician and pioneer in digital health care with Partners HealthCare, Boston, delving deeply into the business of health care and the behavioral habits of patients.
As he notes, Partners was “prescient” in the health care landscape, introducing video conferencing in the 1990s, second opinions on the Internet in 2001, and texting as a tool for health messaging in 2008. He asks now: “What are the connected health devices and applications that our clinicians will be using in 5-10 years?” Then he uses his acumen and research to answer his own question. The ensuing chapters are more prescriptive than predictive, however. None of us knows where health care will be in 10 years, but we should think about where it ought to be.
Whether you chart on an Apple Watch or on paper, this discussion is important to you. Physicians are key players in determining where and how medicine is practiced, and we need to understand relevant risks and benefits to make the right decisions.
Confusing the matter is that desired outcomes are not absolute but relative. It depends on the frame of reference. Patients measure outcomes with service, payers with cost, and we physicians with quality. Which measurement is correct? How can we know if a remote monitoring device is worthwhile if we can’t agree on what it delivers? Is it simply sending home “the sicker even quicker?” Does a Big Pharma beyond-the-pill app really only increase consumption of the costliest medications or create more affordable alternatives?
Technologies that increase access to services such as live chat, messaging, and monitoring may be preferred by patients, but physicians see them as piling on to backbreaking loads. More artificial intelligence is needed to enable these services without requiring physician work. We need driverless health care.
Keeping patients involved has a whole other set of requirements. The tools must be easy, the information personal, the data actionable, and its use Candy-Crush-Saga addictive. This is no small feat, but there is hope.
Partner’s Text 2 Move program, which Dr. Kvedar describes as the “gold standard of what learning about your consumer means,” showed that highly personalized, targeted text messages could have a significant impact on patients’ behavior and health. It is just this type of technology that many are relentlessly pursuing to deliver care more effectively.
Dr. Kvedar devotes significant attention to the patient/consumer experience in a thoughtful, complex manner. Rather than elevate or denigrate the rise of the engaged patient, he examines this phenomenon through several lenses, addressing equally the concerns of practicing physicians and health care entrepreneurs. Nearly 20 years ago, Regina Herzlinger of Harvard Business School, Boston, predicted the rise of health care consumerism. Retail clinics, direct-to-consumer services, and the “Yelpification” of health care are signals that we’ve arrived.
It’s tough to make predictions, especially about the future, Yogi Berra warned us. The book’s mention of Theranos, the failing pinprick blood lab company founded by celebrity Stanford student Elizabeth Holmes, is an example of how risky it is to place bets on where we are headed and how quickly we will get there. DIY at-home labs are further off than they appeared, and that is the hazard of any such books: it is difficult to see more than what’s just in front of us.
Ultimately, Dr. Kvedar’s message is as realistic as it is optimistic: “The same information that could help drive healthcare costs down can be used to create highly individualized programs that will help people stay healthier and happier.” But we should resist the urge to ask “Are we there yet?” No. We’ve a ways to go.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Health care is changing. For some, this is cause for celebration: A safer, convenient, more efficient system is upon us. For others, the end is nigh: impossibly demanding patients, crushing bureaucracy, and a once sacred relationship desecrated by invasive technology.
The ascent of digital health technologies is an important driver of health care change, yet its impact is still indeterminate. Any technology that empowers patients as well as physicians will improve patients’ health outcomes. Or so it might seem. The truth is more nuanced: Some services will improve outcomes, others won’t. Fitting Fitbits into our current system is like inserting the wrong key into a lock: It might go in, but it doesn’t open anything. Fortunately, some keys are opening doors to better care – doors that that we’ve never entered – but finding the right ones is laborious. Dr. Joe Kvedar is here to help.
As a physician leader who straddles the gap between physician-centered and consumer-centered health care, Dr. Kvedar has spent his career leveraging technology to improve care delivery for both. In his new book, “The Internet of Healthy Things,” he shares what he has learned. He uses numerous examples from his experience as a physician and pioneer in digital health care with Partners HealthCare, Boston, delving deeply into the business of health care and the behavioral habits of patients.
As he notes, Partners was “prescient” in the health care landscape, introducing video conferencing in the 1990s, second opinions on the Internet in 2001, and texting as a tool for health messaging in 2008. He asks now: “What are the connected health devices and applications that our clinicians will be using in 5-10 years?” Then he uses his acumen and research to answer his own question. The ensuing chapters are more prescriptive than predictive, however. None of us knows where health care will be in 10 years, but we should think about where it ought to be.
Whether you chart on an Apple Watch or on paper, this discussion is important to you. Physicians are key players in determining where and how medicine is practiced, and we need to understand relevant risks and benefits to make the right decisions.
Confusing the matter is that desired outcomes are not absolute but relative. It depends on the frame of reference. Patients measure outcomes with service, payers with cost, and we physicians with quality. Which measurement is correct? How can we know if a remote monitoring device is worthwhile if we can’t agree on what it delivers? Is it simply sending home “the sicker even quicker?” Does a Big Pharma beyond-the-pill app really only increase consumption of the costliest medications or create more affordable alternatives?
Technologies that increase access to services such as live chat, messaging, and monitoring may be preferred by patients, but physicians see them as piling on to backbreaking loads. More artificial intelligence is needed to enable these services without requiring physician work. We need driverless health care.
Keeping patients involved has a whole other set of requirements. The tools must be easy, the information personal, the data actionable, and its use Candy-Crush-Saga addictive. This is no small feat, but there is hope.
Partner’s Text 2 Move program, which Dr. Kvedar describes as the “gold standard of what learning about your consumer means,” showed that highly personalized, targeted text messages could have a significant impact on patients’ behavior and health. It is just this type of technology that many are relentlessly pursuing to deliver care more effectively.
Dr. Kvedar devotes significant attention to the patient/consumer experience in a thoughtful, complex manner. Rather than elevate or denigrate the rise of the engaged patient, he examines this phenomenon through several lenses, addressing equally the concerns of practicing physicians and health care entrepreneurs. Nearly 20 years ago, Regina Herzlinger of Harvard Business School, Boston, predicted the rise of health care consumerism. Retail clinics, direct-to-consumer services, and the “Yelpification” of health care are signals that we’ve arrived.
It’s tough to make predictions, especially about the future, Yogi Berra warned us. The book’s mention of Theranos, the failing pinprick blood lab company founded by celebrity Stanford student Elizabeth Holmes, is an example of how risky it is to place bets on where we are headed and how quickly we will get there. DIY at-home labs are further off than they appeared, and that is the hazard of any such books: it is difficult to see more than what’s just in front of us.
Ultimately, Dr. Kvedar’s message is as realistic as it is optimistic: “The same information that could help drive healthcare costs down can be used to create highly individualized programs that will help people stay healthier and happier.” But we should resist the urge to ask “Are we there yet?” No. We’ve a ways to go.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
How to be a better negotiator
One of the most valuable things I learned in business school was how to be a better negotiator. Negotiation skills are helpful not only for job contracts, but also for many areas of life. Negotiating with your vendors, employees, health plans, and even spouse or children can be a fruitful experience. Indeed, using good negotiation techniques with your patients can help you optimize the best care with the best service whether in person or virtually.
The three principles I want you to understand are:
1. Negotiate on interests, not positions.
2. Frame or be framed.
3. Win/Win is not only possible; it is the most likely outcome of good negotiating.
Let’s use an example to illustrate each of these: If a patient comes to you asking for Vicodin (hydrocodone and acetaminophen) because you froze actinic keratoses, your first instinct might be to think this patient is a drug seeker and that he is not going to be satisfied unless you give in to his demand. You are a conscientious doctor and never prescribe narcotics for liquid nitrogen treatments. Here, you’ve just locked into a position, and there is no opportunity for negotiation. Instead, take a different approach – consider interests, not positions.
Positions are what you’ve decided. Interests, in contrast, are the reasons why you came to that decision. Think about both your interests and your patient’s interests. The patient wants something to block pain. You want to provide appropriate, safe care. In this instance, ask him why he wants Vicodin; probe about issues that might underlie his request. Keep asking until you feel you understand his interests. This is critical to good negotiation. Then think about your interests. You don’t want your patient to be in pain, and you don’t want to feed a patient’s dependency problem or risk your license for inappropriate drug dispensing.
Second, frame the problem (as you see it) or risk being framed by your patient. Your patient might see you as uncaring and unwilling to help him. You can change this by reframing yourself as the doctor who actually does care. For example, you might say, “I’m concerned about you. Taking Vicodin for this is not normal, and this drug is notorious for leading people into drug dependency. I don’t want to expose you to that risk.” Here, you have taken control of the frame and presented yourself as concerned rather than uncaring.
Third, in almost every negotiation there is an opportunity to expand the pie. That is, each party can offer something that was not in the original discussion but would benefit both. In this instance, you might offer to give the patient samples of a topical treatment for actinic keratoses. The patient, sensing your genuine concern, might offer to bring his mother to you for skin cancer treatment as she, too, is particularly sensitive to pain.
Of course, not all negotiations end in agreement. Sometimes your best option is to reject the request. If your patient is unwilling to compromise, then your best course of action might be to not treat him at all. Before doing so, remember that you will often have a better outcome if you try to reach agreement and that using sound negotiating practice will be a significant advantage. (Please, just don’t tell my wife about this column.)
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter. Write to him at [email protected].
One of the most valuable things I learned in business school was how to be a better negotiator. Negotiation skills are helpful not only for job contracts, but also for many areas of life. Negotiating with your vendors, employees, health plans, and even spouse or children can be a fruitful experience. Indeed, using good negotiation techniques with your patients can help you optimize the best care with the best service whether in person or virtually.
The three principles I want you to understand are:
1. Negotiate on interests, not positions.
2. Frame or be framed.
3. Win/Win is not only possible; it is the most likely outcome of good negotiating.
Let’s use an example to illustrate each of these: If a patient comes to you asking for Vicodin (hydrocodone and acetaminophen) because you froze actinic keratoses, your first instinct might be to think this patient is a drug seeker and that he is not going to be satisfied unless you give in to his demand. You are a conscientious doctor and never prescribe narcotics for liquid nitrogen treatments. Here, you’ve just locked into a position, and there is no opportunity for negotiation. Instead, take a different approach – consider interests, not positions.
Positions are what you’ve decided. Interests, in contrast, are the reasons why you came to that decision. Think about both your interests and your patient’s interests. The patient wants something to block pain. You want to provide appropriate, safe care. In this instance, ask him why he wants Vicodin; probe about issues that might underlie his request. Keep asking until you feel you understand his interests. This is critical to good negotiation. Then think about your interests. You don’t want your patient to be in pain, and you don’t want to feed a patient’s dependency problem or risk your license for inappropriate drug dispensing.
Second, frame the problem (as you see it) or risk being framed by your patient. Your patient might see you as uncaring and unwilling to help him. You can change this by reframing yourself as the doctor who actually does care. For example, you might say, “I’m concerned about you. Taking Vicodin for this is not normal, and this drug is notorious for leading people into drug dependency. I don’t want to expose you to that risk.” Here, you have taken control of the frame and presented yourself as concerned rather than uncaring.
Third, in almost every negotiation there is an opportunity to expand the pie. That is, each party can offer something that was not in the original discussion but would benefit both. In this instance, you might offer to give the patient samples of a topical treatment for actinic keratoses. The patient, sensing your genuine concern, might offer to bring his mother to you for skin cancer treatment as she, too, is particularly sensitive to pain.
Of course, not all negotiations end in agreement. Sometimes your best option is to reject the request. If your patient is unwilling to compromise, then your best course of action might be to not treat him at all. Before doing so, remember that you will often have a better outcome if you try to reach agreement and that using sound negotiating practice will be a significant advantage. (Please, just don’t tell my wife about this column.)
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter. Write to him at [email protected].
One of the most valuable things I learned in business school was how to be a better negotiator. Negotiation skills are helpful not only for job contracts, but also for many areas of life. Negotiating with your vendors, employees, health plans, and even spouse or children can be a fruitful experience. Indeed, using good negotiation techniques with your patients can help you optimize the best care with the best service whether in person or virtually.
The three principles I want you to understand are:
1. Negotiate on interests, not positions.
2. Frame or be framed.
3. Win/Win is not only possible; it is the most likely outcome of good negotiating.
Let’s use an example to illustrate each of these: If a patient comes to you asking for Vicodin (hydrocodone and acetaminophen) because you froze actinic keratoses, your first instinct might be to think this patient is a drug seeker and that he is not going to be satisfied unless you give in to his demand. You are a conscientious doctor and never prescribe narcotics for liquid nitrogen treatments. Here, you’ve just locked into a position, and there is no opportunity for negotiation. Instead, take a different approach – consider interests, not positions.
Positions are what you’ve decided. Interests, in contrast, are the reasons why you came to that decision. Think about both your interests and your patient’s interests. The patient wants something to block pain. You want to provide appropriate, safe care. In this instance, ask him why he wants Vicodin; probe about issues that might underlie his request. Keep asking until you feel you understand his interests. This is critical to good negotiation. Then think about your interests. You don’t want your patient to be in pain, and you don’t want to feed a patient’s dependency problem or risk your license for inappropriate drug dispensing.
Second, frame the problem (as you see it) or risk being framed by your patient. Your patient might see you as uncaring and unwilling to help him. You can change this by reframing yourself as the doctor who actually does care. For example, you might say, “I’m concerned about you. Taking Vicodin for this is not normal, and this drug is notorious for leading people into drug dependency. I don’t want to expose you to that risk.” Here, you have taken control of the frame and presented yourself as concerned rather than uncaring.
Third, in almost every negotiation there is an opportunity to expand the pie. That is, each party can offer something that was not in the original discussion but would benefit both. In this instance, you might offer to give the patient samples of a topical treatment for actinic keratoses. The patient, sensing your genuine concern, might offer to bring his mother to you for skin cancer treatment as she, too, is particularly sensitive to pain.
Of course, not all negotiations end in agreement. Sometimes your best option is to reject the request. If your patient is unwilling to compromise, then your best course of action might be to not treat him at all. Before doing so, remember that you will often have a better outcome if you try to reach agreement and that using sound negotiating practice will be a significant advantage. (Please, just don’t tell my wife about this column.)
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter. Write to him at [email protected].
