A catalytic opinion maker, Dr. Pho has received numerous accolades for his blog, which serves a communication medium for his own opinions and experiences, and also as an opinion distribution vehicle for physicians, healthcare professionals of all kinds, and patients.
At the same time, Dr. Pho practices internal medicine nearly full time at a private practice in southern New Hampshire. While many might look at Dr. Pho's work (and schedule) and assume he wears two distinctly different hats, he prefers to view the two undertakings as related to a singular pursuit: to connect with patients.
We had the opportunity to speak with Dr. Pho about how he balances his practice with his social media efforts, his feelings about social media's role in medicine, and the evolution of technology in healthcare.
What was your impetus to go from practicing into blogging?
I started practicing internal medicine about ten years ago. I trained at Boston University and my first job was in New Hampshire with the Nashua Medical Group. I'm still practicing in full time primary care. It was 2004 when I started my blog, KevinMD, and as you can imagine back then, blogging and social media was in its infancy, especially with regards to health care. I really wasn't sure where the blog would go or how long it would last, but I'd write a few articles giving my thoughts on the healthcare system and I'd comment on a few stories.
It wasn't until a few months after I started my blog, in the Fall of 2004, that Vioxx was recalled and I realized the power of social media. During that time, there seemed to be hourly headlines on Vioxx, and my patients would comment often and say “Dr. Pho, I'm on Vioxx, can it do any permanent damage? Are there any other medicines I can take?" With that, I decided to write a blog post on the issue.
The morning after the blog post, I walked into the exam room and the first thing the patient said to me was "Thank you, I read your blog post this morning and I was comforted by what you had to say. Now I realize there are other options for Vioxx."
I was stunned at how social media can be used to connect with patients. I think that's tremendously important because we now know that patients are going online more and more. Eight out of ten internet users are, according to Pew Internet Research, online looking for health information. I think it's important for doctors to go online with social media, blogs, Twitter and Facebook, and help guide these patients to better and more reputable health sites and resources.
If doctors aren't online, these patients will go to celebrities and other practitioners who may not have the patients' best interests at heart and physicians will eventually lose their authority online. I don't want that to happen and I think social media is a powerful way to connect with patients. That was really my impetus, and how I continue to run KevinMD. Not only to have my voice heard by patients, but also the voices of other doctors as well. Every day there's new health news that they read and want interpreted.
In a recent article you mentioned there was a 'lack of physicians' voices in the media.’ Is this tide shifting?
I think that's another great benefit of social media. Obviously we're in the midst of healthcare reform and one of the reasons I made that comment is because many of the health care reform decisions that are made, come from politicians. They're made by individuals who don't necessarily practice medicine, but are in academics, or public policy. I felt that we needed the voice of doctors, those who see patients every day in a primary care office. We need their voices to be heard because if they're not, these regulations and rules about how we should practice medicine are going to change significantly. If we don't have a voice, we don't have any influence on them.
On my blog, one of the goals I have is to talk about the difficulties that primary care doctors and other physicians face every day, whether it's bureaucracy, dealing with electronic health records, dealing with preauthorization…all the bureaucratic red tape that prevents us from giving out the best care we possibly could to our patients. I write editorials on my own site, and I invite other physicians to talk about what goes on behind the scenes. Hopefully the public can understand some of the difficulties that we face, because the harder it is to practice medicine, the more difficult it becomes to give patients the care they deserve.
I think social media has also given us the opportunity to speak on a larger stage. I have media entities who will read my own site and give me opportunities to write for USA Today and CNN.com and the New York Times. These mainstream media opportunities wouldn't have been available if it wasn't for my social media platforms.
To answer your question bluntly, yes. I think that social media gives doctors an important vehicle to get their voice heard and influence policy and influence how medicine is going to change. Without voices, decisions are going to be made without our input.
Do you have a good sense of who's following and reading your blog?
We did a survey a few years ago, asking who reads my blog. I'd characterize it as about 60-70% healthcare providers, mainly physicians, but also physician assistants, nurse practitioners, nurses who are on my site, and about 30-40% healthcare consumers. I think it is a good mix. It's tilted slightly towards healthcare providers, but whenever I ask physicians to write on my blog, I ask them not to use jargon. I think it's important for patients to understand what goes on behind the scenes. Writing in a plain language helps with that understanding.
What resistance do you see from physicians to start utilizing social media in their approach?
There are several points of resistance. Right now, whenever you hear about social media and healthcare, it's framed in a negative light. You read the newspaper and hear about a nurse or doctor who got fired because they posted pictures on Facebook or a doctor who got reprimanded because they talked about patients on Twitter and violated HIPAA.
What I try to do when talking to media publications is to reframe social media in a positive light. I mentioned earlier about connecting with patients online, and helping to clear up misconceptions on the web, but a couple other positive things we need to enforce would be how social media can improve patient satisfaction. I think patient satisfaction is growing increasingly important and more and more of an influence in terms of how hospitals are paid.
There's research from YouGov illustrating that 51% of patients believe that a hospital having a strong social media presence is considered 'cutting edge' and that 57%, all things being equal, would choose a hospital that they had a social media connection with. I think it's tremendously important to show some of the positives when it comes to social media. Showing how patients are expecting their medical institutions to have some type of presence there.
The second thing is that doctors are busy. They don't have a lot of time. I see 20-25 patients a day in my primary care office and I'm sure the last thing that many doctors want after a long day is to write a blog post or go on Facebook and Twitter. Again, showing how social media can benefit doctors is critical.
One of the ways I'm trying to push that benefit is through online reputation, because more patients are not only going online looking for health information, but they're also going online to research their doctors. They Google doctors, they Google medical practices and I think that doctors who don't have a strong social media presence are going to be defined by these online rating sites like RateMDs and Healthgrades. We don't have a lot of control over that information.
One example of positive social media is just having a simple profile on LinkedIn. It takes 15 minutes to do, and an MD who has one would rank high when their name is Googled. I think that particular point resonates with a lot of doctors. They don't have to use social media to the extent that I do; just getting a presence, getting comfortable online and encouraging doctors to go at their own pace. It's something that all doctors can do.
Social media needs to be framed in a way that makes it useful and acceptable to busy doctors today. I think those are the two main points of resistance when it comes to doctors. If we can frame turn social media to turn it from a burden into something more positive, we can overcome those.
These third party SEO sites that compare healthcare and vitals are somewhat impersonal and the doctors have little control over them. That must be a source of frustration getting doctors to engage with these.
Absolutely. I always say the easiest way to go about this is for doctors to get profiles on Twitter, Facebook and Linked In. To make sure the first 5 or 6 results in your Google results page is something that you can control. Incidentally I'm coming out with a book in February, “Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices.” It is a comprehensive guide to manage your online reputation.
What other technological advances do you forecast in medicine?
I think that point of care apps are going to make a stronger presence. Doctors are all using smartphones now and more of them are using apps in the exam room. I know I do. I have an iPad mini and when I bring it into the exam room I can use an app like Epocrates, if a patient asks about side effects from a certain medication or interactions with another drug. With the app, I can give them that information right away. There are various medical calculators that I use on my tablet, where I calculate things like framing risks and I can do that instantly with mobile technology.
On the other end, patients are adopting smartphones and mobile apps at an increasing rate when it comes to their health. They're coming in with more information than ever because they have health apps that can measure everything. They can measure sugar levels and blood pressure. They can take diaries of what they eat. They can keep a headache diary.
Since patients are coming to us with so much more information, it's up to us as healthcare professionals to analyze that and find the best way to integrate that information into a patient care plan. We're not quite there yet, because we're dealing with so much information and how we can analyze it and incorporate that into our daily schedule, but I think the future is tremendously exciting. The proliferation of smartphones, apps and mobile tablets is just going to make things that much more exciting.
What's the app that you really would love to have at the point of care that you don't have today? Any you've thought "I wish someone would make this," or "I wish this app had this feature?"
A lot of electronic medical records don't really have great utility from a mobile device. It would be good if I could use an EMR system that divorces itself from a laptop and completely makes it easier to enter information on a tablet like an iPad.
What is your take on the Pharma apps? Are these apps that you or your patients use?
I'll be honest, I haven't used any Pharma-specific apps, so I can't really speak specifically on that. Whenever I talk to Pharma, they always ask me about how we can use mobile apps to connect doctors with patients. I think that Pharma can join with doctors in a useful way by encouraging patient compliance, because if you look at the statistics, less than 50% of patients are taking medications they're supposed to. If Pharma can do outreach, that can help me as a primary care doctor to connect with patients and to make sure that they're taking their medications appropriately. That will be a win-win on both sides. If there's a way they could do that on a mobile platform, whether it's a text message or some other way they can connect on a smartphone, it would be a great idea that'd help me as a physician as well.
What are your thoughts on where telemedicine is taking us? Do you foresee a time when doctors will be able to perform a routine patient visit over the internet?
The answer is yes – but eventually. I think there are a lot of these health 2.0 companies that come up with these great ideas and great technology but I think that health policy hasn't quite caught up with that. Despite what you hear about the Affordable Care Act, most healthcare in the United States today is still driven by the office visit. It's driven by volume and by bringing patients in. Anything outside of that, like a telephone call or a web visit or even texting or connecting over social media…it isn't paid for. Whatever's not paid for, the adoption is going to be significantly slower.
Now with the Affordable Care Act, you're going to be having more of these accountable care organizations, larger integrated systems, and there's going to be less of an emphasis on doctors getting paid per episode, per visit and I think there's going to be a decreased emphasis on volume. Once that happens, you're going to see more of these mobile solutions taking effect. Where you don't necessarily need to bring patients into the office to manage their medications or their blood pressure or diabetes and it can be done remotely. Until that happens – and I would estimate that we're talking 5-10 years from now – I think the adoption of these mobile technologies, and not bringing patients into the office is going to be pretty slow.
To answer your question though, eventually that's going to be the norm, because there is a good portion of what a primary care doctor does that doesn't need to be seen face to face and the only thing preventing us from doing so is the way most doctors are getting paid.
Is that a function of coding and billing? That the Government hasn't provided codes for that kind of a visit yet?
It's a function of the payers, be it Medicare or private health insurance, that just don't pay for these type of visits. There's a minority that do, a lot of pilot projects that will pay for web visits and telephone encounters, but that's certainly not the majority. If you want to increase adoption, it has to be through Medicare. Medicare is the biggest payer right now, and wherever Medicare goes, private insurance follows. If you want to rapidly increase adoption, Medicare would have to pay for these technologies, and once they do, I'm sure that will really speed up adoption.
What are your feelings on healthcare reform legislation? Is something that will be beneficial to doctors and patients in the long run?
I get asked about healthcare reform from lots of people and I think that politically I'm pretty moderate. I've always been of the belief that the problems facing our healthcare system are too big for any one political party to solve. I think that we do need ideas from both ends of the spectrum, whether it's putting more of a burden on consumers or increasing the insured population, I think we need ideas from both ends.
With the Affordable Care Act specifically, I always frame it as "it's better than nothing." If the status quo goes on, obviously healthcare costs are going to consume almost 20% of our GDP. The Affordable Care Act is essentially a stop gap to that. Even though the Right paints it as something pretty progressive, it's actually a pretty moderate proposal. Its origins actually came from the right wing think tank Heritage Group back in the early 80s. I've talked to progressives, and they say "it's not single-payer, we hate it!" and I talk to Tea-Party members who say that "It's socialism!" If you have both ends of the political spectrum hating it, then you pretty much know it's in the middle.
What other functions, besides connecting with patients, does your blog allow you to do?
I think it's important to highlight some of the difficulties that we as physicians face every day. It's important to put patients in our shoes. So the patient waiting 45 minutes to an hour in the waiting room has to realize that doctors aren't in the back twiddling their thumbs or playing games. There are legitimate reasons that they have to wait, whether it's patient over scheduling, phone calls that we have to do, pre-authorization, etcetera. It's important that patients understand that.
At the end of this year, there's the sustainable growth rate, and if the Government doesn't rate one year patch I think that Medicare reimbursement rates are going to go down 20-30%. There's a misconception in this country that doctors are rich and that all we care about is money. They don't realize that many independent practices depend on this money, so if the sustainable growth rate and the Medicare cuts go through as they're scheduled, a lot of these practices are going to find it very difficult to meet their payroll and to pay for malpractice insurance. Like any business, if you lose 30% of your revenues, it's very difficult to be viable. I think there's a lot of things that patients just don't understand as far as what physicians go through.
Conversely I think it's useful because doctors don't know what patients go through as well. I have patients who also blog on my site and tell how difficult it is to navigate our medical system from their end. I get lots of comments from doctors to tell me how enlightened they are, hearing from patients on my site. I think having these two voices sharing their opinions and stories so openly is a definite benefit of social media and my blog in particular.
It brings both doctors and patients onto the same metaphorical page.
Definitely. I think everyone's goal is to improve patient care. That's what doctors want. They want the best for patients. Sometimes doctors get blamed and painted as part of the problem and I think we need to be part of the solution. There was a Gallup survey in 2010 where they asked the country who they trusted most when it came to healthcare, giving the options of the President, Congress, Policy experts and Doctors. It was actually physicians who came first in the poll as the most trusted. Patients are still listening to us, so it's important to get our voices heard, and in the end our goals are similar. Doctors and patients want better care. Sometimes I think that common goal gets lost.