A few years ago I read a quote that said something like “people are the CEO of their health, and doctors are just consultants.” I believe that wholeheartedly. That concept is now front and center in Sherpaa. Our doctors have a plan for you, but you’re the one who needs to believe in it and make it happen. Today, Sherpaa launched a new version of our app that takes our app from just a messaging platform to a messaging platform + project management tool for patients complete with to-do’s and structured bots within cases to help you understand and approve your doctor’s plans for you.
Medical issues are problems to be solved. The vast majority of the problem is solved by patients implementing their doctor’s plan. Medical problems have structure to them. They have labs to be done, medications to take, referrals to specialists to go to, etc. Open-ended conversations between doctors and patients is the foundation for communicating the problem to be solved. But, structuring the problem and the solution with to-do’s, educational tidbits about the order, and the ability for patients to approve or deny orders creates clarity and efficiency.
When healthcare is communicated within the confines of an oral conversation in an exam room, people forget 85% of what their doctor says. How can we expect our patients to be “compliant” with our orders when we’re only 15% effective at communicating? Also, when we order something for our patients, we’re handing them an order and expecting them to do what we say without them fully understanding the order and its value to their health. When you give patients a say in every order to either approve the order or deny it like we did today with Sherpaa’s app, it allows patients to understand the value of the order and approve it or deny it. If they understand it, see its value and how it realistically fits into their lives, they can approve the order. But they can also deny it if they don’t believe it’ll work, it won’t fit into their lifestyle, or they can’t afford it. This enables our doctors to construct a new plan with the patient’s input that gets the patient on board to get their health in order. This is what we at Sherpaa call “compliance.” It puts the patient in the driver’s seat because the patient is the one that has to do all the work.
Patient complaints in healthcare often stem from the concept of time. It takes months to get an appointment with a renowned specialist. I spent two hours in the waiting room until I was finally called in to see my primary care doctor. Why is time so warped in healthcare?
Two main reasons. First, there is a supply and demand mismatch. There is a finite amount of “the best neurologist” that “everyone wants to see” so people schedule appointments for 3 months in advance. But if you want to see the young neurologist fresh out of residency, she’s available later this afternoon. You gotta wait for quality and experience.
Second, delivering services to patients with varying complexities and trying to fit each patient into the same 15 minute time slot means some appointments are inevitably going to go longer. Each patient’s problems can’t be solved by the same 15 minute widget of time being sold. When a patient who needs acute, more complex time-sucking care shows up, the rest of the day is shot. It’s just the nature of delivering a service to a population of folks with unknown requirements. And all it takes is one complex patient in the morning to throw off the entire day. Sometimes, even the Apple Genius Bar makes you wait because a few back to back complex broken MacBooks came before you. Primary care offices in the last 20 years or so have been experimenting with novel means of scheduling, called Open Access, but this hasn’t really taken off mostly because it’s just different than what’s always been done.
Of course all of this stems from healthcare paternalism. Doctors have been deified by our culture. They can sometimes work miracles. It’s been since day one, “doctor knows best” and the conversation around patients coming first has only recently begun. I obviously welcome this conversation and I’ve given my career to putting the patient first in healthcare delivery.
There’s recently been another conversation happening in healthcare about “on demand” healthcare. The concept of “on-demand” only works if the demander does not care who the supplier is and there is plenty of supply. If the demander cares who the supplier is, the demander will be subject to the supplier’s schedule. And when you are subject to the supplier’s schedule, it’s the waiting game all over again. You must wait for the doctor’s schedule to free up. Never mind that you have meetings and work to be done throughout the day. But now that healthcare can be delivered via on-demand video visits with doctors, we’re seeing patients are now being given the choice to choose their doctor and wait for them via video. Essentially, it’s a “video waiting room.” This assumes so many pain in the ass things:
Suppliers (doctors) have a dedicated period throughout their day devoted to only video visits
Doctors get paid the same amount for video visits vs. in-person visits. If not, they’ll skip time spent on the lesser paid visit.
Patients will accept the same concept as waiting for the cable guy to show up “anytime between 9am and 5pm tomorrow”
When the doctor is ready for the patient, patients will be immediately available to have a video chat with their doctor, in a private place in an era of open office spaces. This means they have to stop whatever they’re doing and find a private, secure place to have a medical conversation with their doctor about things that are often private and embarrassing and nothing you want your co-workers to overhear.
The concept of optimized time in healthcare is an elusive devil. For decades, doctors have been on their own schedules, patients be damned. But now, with the advent of “on-demand healthcare,” the assumption is doctor culture and their respect for time will change for a technology and a process that is by no means beloved, nor deemed safe or high quality, by either doctors or patients.
All of this is fixed when doctor-patient communication happens asynchronously, like email or texting. Patients can communicate when convenient and this enables more thoughtful conversations. Removing the expectation that healthcare conversations need to be in real time creates an efficiency orders of magnitude higher than today’s exam room or video conversations.
Imagine popping a cipro for your UTI, sitting down in the lazy boy and watching some tv, and as you got up to grab some Cinnamon Toast Crunch, your achilles tendon snapped. Ooof.
Once a drug is approved by the FDA and makes it to market, it is deemed safe and there’s no passive, simple way for the FDA to collect ongoing data about side effects or adverse outcomes. It truly depends on doctors, nurses, and patients to actively report what they think are bad things to the FDA. Once a drug has been approved, the FDA thinks it has done its job and it’s now up to the prescribers and users to alert that a drug is proving to be unsafe.
As a preventive medicine resident in 2006, I worked at Public Citizen. At the time, their healthcare group was an 8-member team and they were the only group in America acting as a full-time consumer watchdog group on the pharmaceutical industry. This blew my mind. For the entire US of A.
I was the main author on a petition to the FDA requesting that the FDA mandate a black box warning on all fluoroquinolones, a class of antibiotics including the popular drug, Cipro. Most drugs have a laundry list of side effects they are mandated to list. If one side effect is more severe than others, it’s included as “black box,” a design element intended to draw more attention to the particular serious side effect. Fluoroquinolones were causing healthy people’s tendons to rupture sometimes hours after taking the medication. That’s no good. Public Citizen saw an increase in reports of these tendon ruptures associated with this class of antibiotics and tasked me with writing the petition to the FDA. We were successful and a black box warning about tendon rupture was required on all of these antibiotics in this class in 2008.
Fast forward 8 years, and the FDA issued a new alert last week announcing to patients that the risks of this class of medication outweigh the benefits when another class of medications is available. Change for the better happens in healthcare. And you can make it happen. It’s a long, drawn out procedure involving multiple people, persistence, and passion. But this is what makes healthcare people so great. Healthcare changemakers are the most passionate, patient, driven, and resilient people. They’re in it for the long haul. I’m proud to consider myself one.
P.S. I wrote another petition in 2007 to ban third generation oral contraceptives, one of the most popular class of oral contraceptives because they carry double the risk of blood clots. Last year, a friend of mine died from a blood clot while taking a third generation oral contraceptive.
Imagine sitting with an author of a novel that has 15 chapters. She tells you to pick her book up and read chapter 4 and then put it down. It’s such an awkward place to start, but the chapter was interesting and you want to know more. So you start peppering her with questions about the first 3 chapters. After 6 or 7 minutes, time’s up. You don’t have all day. It’s time to move on to the next author.
This is what it’s like being a doctor trying to understand the stories patients tell us about their health issues. Health issues are stories that evolve over time. They follow the classic story structure and have a beginning, middle, resolution, and, ideally, an end. An exam room visit is a small snippet in a much larger story. The best doctors are professional investigators who know the highest yield questions to ask about the earlier chapters. But the best doctors can’t predict the future. Once the “author” leaves, doctors again have to skip chapters and catch up in sometime in the future after the story has evolved for the better or worse. That is, if the author comes back.
This is the problem with 12-minute buckets of episodic care whether that care happens in the office or via video. Asking all the right questions that cover all bases in real time. Responding with accurate, thoughtful answers. And then having no easy way to share more simple and complex details as the story evolves. It’s as if the doctor-patient relationship is a 15 chapter novel where the doctor only gets to read Chapter 4 and Chapter 9.
This weekend, the WSJ reported on a recent study that analyzed the accuracy of today’s typical doctor-patient video visit:
“The services failed to ask simple, relevant questions of patients about their symptoms, leading them to repeatedly miss important diagnoses,” said Jack Resneck, a dermatologist with the University of California, San Francisco, and lead author of the study, published online in JAMA Dermatology on Sunday.
Ateev Mehrotra, an associate professor of health-care policy at Harvard Medical School who wasn’t involved with the current study, said it “identifies a number of egregious quality issues that raise significant concern.”
Since 2007, when I started the world’s first internet-driven house call practice, I’ve been an outspoken critic of the healthcare transactional visit in both physical, and most recently, virtual settings. In response to what I saw as a serious issue with quality in both physical and virtual doctor-patient transactions, I designed a process, found in Sherpaa, that solves the following issues:
Doctors don’t always ask appropriate breadth of questions about the immediate situation
Doctors don’t always ask the appropriate breadth of questions about the patient’s past medical history
Patients don’t have time to thoughtfully answer questions
Doctors don’t have time to educate and explain the value and risks of their treatment options
Patients can’t send quick or more lengthy updates to their doctors about their evolving stories
Doctors don’t always ask appropriate breadth of questions about the immediate situation.
Roughly 90% of obtaining an accurate diagnosis stems from taking a proper, detailed history. The questions doctors ask are designed to rule potential diagnoses in or out. However, within in-person conversations, conversations can meander, both doctors and patients can get side-tracked, and it’s nearly impossible to follow a checklist to ensure you’ve covered all bases. Over the past 4 years, the Sherpaa clinical team has built roughly 250 protocols for asking the proper breadth of questions for the presenting symptoms. We have ~7,000 questions in our backend nested below a symptom, like neck pain. When a patient presents with neck pain, our doctors respond with the same 28 questions that all patients with neck pain are asked. This is the definition of checklist-driven history taking to rule out serious issues, but also give our doctors the information they need to understand which rabbit hole they should head down.
Doctors don’t always ask the appropriate breadth of questions about the patient’s past medical history.
The patient’s past medical history is only relevant if it’s up to the minute accurate. Immediately after submitting their case, as patients are already engaged and waiting for our doctors to respond, we either ask them targeted questions about their medical history or play their previously reported answers back to them to ensure it’s still accurate. We do this with a new bot we debuted a few weeks ago that’s found within our app. His name is Sherpee.
Patients don’t have time to thoughtfully answer questions.
If you’re in an exam room and a doctor is throwing question after question at you interrupting you a few seconds into your response, it’s stressful and intimidating. It’s better to get a series of questions with big free text boxes that you can answer thoughtfully without stressing or feeling that you haven’t been listened to. This is why we’ve designed Sherpaa’s question and answer process in this way. It allows patients to tell their story in their own words and on their own time and terms. It also allows them to communicate potentially embarrassing issues without having to look someone in the eyes. The quality of Sherpaa’s history-taking process is unprecedented in healthcare and we are still the only place in healthcare where the entire history of the story is written in the patient’s own words and on their own time and term.
Doctors don’t have time to educate and explain the value and risks of their treatment options.
Sherpaa’s definition of compliance is “does the patient truly understand the value of an affordable, realistic treatment plan that fits into their lives?” The rest of healthcare defines compliance as “did the patient take the medication prescribed to them?” This assumes the patient properly understands the value of the intervention. If people don’t understand the value, you can’t expect them to engage with the plan. That’s why Sherpaa built ~250 treatment protocols for our 250 most popular diagnoses. Each protocol contains a description of what the issue is with links out to the best articles or videos that best describe the issue at hand. For each medication we prescribe, we link out to Iodine to ensure the patient understands the pros and cons of the medication our doctors want to prescribe for them. And then we do something unprecedented in healthcare. When our doctors want the patient to take a medication, we send the patient a request to approve or deny the prescription. If a patient approves the medication, they choose their pharmacy, which triggers the e-prescription. If a patient denies the prescription, they give a reason like “this is too expensive” or “I’ve tried this before and it didn’t work.” The goal here is to create a realistic treatment plan the patient understands and believes in.
Patients can’t send quick or more lengthy updates to their doctors about their evolving stories.
Health issues can take turns for the better, but also for the worse. Today, exam rooms or scheduled video visit are the only avenue patients have to provide updates. This creates a barrier for good communication. Some updates are quick and simple and others are diatribes. But the smallest update can drastically change the story. Updates need to be as simple as logging into an app and communicating the issue within the case. Barriers to updates are unsafe leading to low quality outcomes.
And that’s the big issue highlighted by this new study on traditional, transactional video visits with doctors. These kinds of visits are poor quality, unsafe, siloed and irresponsible. And that fundamentally stems from the core design of the video service. It takes what’s already a terrible means of communication, the exam room, and makes it worse via video. They are designed to perpetuate the problems of the exam room visit except video visits can’t order tests to confirm diagnoses nor follow up with the patient to ensure their story is evolving positively. Today’s video transaction visits are siloed without the ability for video doctors to communicate and coordinate care with local specialists and facilities. And it is irresponsible to use physicians to treat pink eye, when we need all the primary care physicians we can get to actually do real primary care that moves the needle on our nation’s health.
Needless to say I’m very anti-video visit. Mostly because it’s a shitty way to deliver care. Transactional video visits are fundamentally flawed by their design and I hope more studies can be done to prove they are low quality and unsafe. But I’m not a complainer. I’m an observer and a doer. I identify weaknesses and inefficiencies and build something better that addresses my complaints. Hence, Sherpaa. We welcome an opportunity to work with any independent entity interested in studying Sherpaa’s process of delivering high-quality, checklist-driven care that facilitates doctor-patient communication about the issue quickly and effectively throughout the entire story from beginning to end.