What happens to doctors who think outside the box?

Upon finishing my second residency at Hopkins in Baltimore in September of 2007, I moved back to Williamsburg to start a new kind of practice:

  1. Patients would visit my website
  2. See my Google calendar
  3. Choose a time and input their symptoms
  4. My iphone would alert me
  5. I would make a house call
  6. They’d pay me via paypal
  7. We’d follow up by email, IM, videochat, or in person

It was simple, elegant, and affordable for me to start. But most importantly, it just made sense given how we all communicate and do business today. Starting a new practice was obviously challenging for me having never done so before, but my patients loved the experience– I was an accessible, affordable doctor in their neighborhood who communicated just like them.

I was coming off a $15,000 resident salary (“because it’s a privilege to do your residency at Hopkins”). It cost only about $1500 to get started– I designed my website and created the technology to power my mobile practice. I didn’t need an office or staff. Everything was run by me, my iPhone, and my MacBook Pro. My overhead was about 10%, compared to a regular doctor who spends about 65-70% of their practice revenue on overhead. I was profitable after just a few days. The 7 million hits on my website in the first month obviously helped get the word out about my new practice (thank you internet!).

Then, about six months later I got an official letter from the New York State Office of Professional Conduct. Obviously, that was unsettling. It essentially said that someone had made a complaint about my practice and my use of the internet. They wanted all of my records about the eight patients I prescribed narcotics for in my practice– I prescribed one time prescriptions for Tylenol #3 for eight patients treating their acute pain for various conditions. The state wanted a serious offense they could charge me with, hence why they singled out the narcotics. I pulled up my records on my MacBook for all eight patients and made them into a pdf and sent them off to the state proving that I’d seen the patients in person, established a doctor-patient relationship, followed standard medical treatment guidelines, and kept the records to prove it.

With all my press, someone didn’t like me. I knew I had plenty of haters given the heated debate in the medical blogs and news stories about my practice. I need to point out that I never once received any criticism from patients or the general public. The only criticism I’ve ever received came from within the medical community. So someone, somewhere called the state and complained…and given the online discussion I can only assume the complaint was made by a doctor. You see, anyone, anywhere, can call the state anonymously and report any doctor they want. The state then takes action by sending a startling letter to that doctor asking for records. You are then asked to produce those records and appear in front of their board with or without your lawyer at your expense (lawyer’s fees and lost revenue from time not practicing…thousands of dollars).

The state was looking to see if I was prescribing narcotics to strangers I’ve never met using the internet to do so.

Obviously, I wasn’t. That surely wasn’t what my practice was about. My practice was about being an old-fashioned neighborhood doctor using today’s technology to provide care to the uninsured in my neighborhood who lived close enough to me to walk or ride my bike. I looked at internet communication as augmenting the real-life relationship I had with my patients. That was my dream, and that was my reality.

Of course, random people from all over the world would email or IM me asking for medical advice or prescriptions and I had a standard reply “I’m sorry but I only give medical advice or prescriptions to those I’ve already met in person and established a doctor-patient relationship with.” Then I blocked that person.

My practice was about bringing back the personal relationship I felt was lacking in today’s version of medical care.

After about three months, the state got back to me asking me to come in and talk to them along with my lawyer. They had reviewed my records.

I arrived. They asked me questions for about half an hour. My lawyer answered some. I answered some. They saw that all of my records were complete, I was acting according to standard guidelines, and that all of my patients were people I’ve established a real life relationship with. It was obvious to them that I’d done nothing wrong.

Then the board members lightened up and asked me about my practice. Both of them were in their late 60’s. They whipped out their iPhones and told me how their grandkids were teaching them to text and how the internet has a real potential to change healthcare. Then they started complaining about the current state of medicine and the death of the doctor-patient relationship. They loved my practice and congratulated me on being innovative.

As of today, I haven’t seen a patient in over three years. This tale was just one minor reason why I stopped practicing.

A doctor’s practice is his/her livelihood. If a doctor can’t practice medicine, the 9 years of training and $260,000 they spent on medical school goes to waste. Receiving a letter threatening this livelihood is terrifying. Also, doctors are essentially guilty until proven innocent and must spend time and thousands of dollars on proving this when someone, anyone, anywhere can pick up a phone and ask for an investigation.

Medical education and residency is pretty militaristic. You fall in line or you’re out. Trust me, I’ve been there. If you are an “outside the box” thinker, this doesn’t last long in medical school or residency. The egos of your superiors are too threatened. This is an important fact. Doctors have such a preoccupation with being right, they can’t tolerate being wrong. This is of course needed because who wants to go to a doctor known for being wrong all the time? Questioning the status quo is threatening. 

Combine this with the fact that most doctors, upon graduating residency, are late 20s or early 30s starting to settle down, marry, and/or have kids. It’s not a lifestyle conducive to the uncertainty of doing something innovative.

Doctors fall in line with the system they’re given. Don’t question it because you, your family, your finances, and the profession will suffer. That’s why innovations like my practice are so few and far between.

Technology won’t solve complex human politics and culture. Real change won’t happen until our medical institutions and the American public want change to happen.

The first step is realizing that our current medical culture doesn’t foster innovation and creativity. In fact, at almost every level, it actively and legally stifles innovation.