Why did you decide to begin your medical blog?

Well, I first began blogging because I noticed there was really so little information available to the public as to what a physician’s opinion might be on current medical news. I was really surprised at how it took off and offered me so many opportunities to share my opinion with colleagues and patients and to the general public. I wanted to fill this void, the seeming lack of a physician’s voice.

You’ve mentioned that other members of your practice read your blog. How does having a blog change the social or professional aspects of being a doctor?

My partners and all of my colleagues locally and even patients are aware of what I do, so professionally it has given me a lot of opportunities that I don’t think I would have had opportunities to write for large publications like The New York Times and USAToday, for instance. It has given me a connection with patients and made my patients more aware as they are able to find me on the internet by doing a Google search for me. I’m known as a doctor who is relatively technologically savvy and that appeals to a certain demographic.

What role do you envision the internet playing for the next generation of doctors?

I think the internet is going to be closely intertwined with what we do and I think it will be to every doctor’s benefit to have some internet presence. A growing number of patients are finding health care information online and it’s not only health information, they are researching their doctors and hospitals. From a marketing standpoint, it’s very important to be online. You want to have control over your name online – for instance you don’t want people to find your name and see a negative news article. For the current generation of medical students, things like Facebook are more second nature, so they will have an easy time embracing the internet as part of their practice. It’s the older generation that will have a harder time embracing these technologies.

What potential does social media hold for doctor to doctor communication?

I think there is a lot of opportunity. There are doctors on Twitter. You’ll see doctors who go to conferences and tweet updates. When a study is breaking they communicate via Twitter and get instant analysis and instant opinions on what is going on in breaking medical news. Part of the power of social media is the immediacy of the medium; these things can be discussed just as news is breaking. Previously you would have to wait for an article to be published in medical journals whereas now things can be discussed right as the news breaks. So yes, I think things like Facebook and Twitter offer a tremendous opportunity for doctors to collaborate with one another. You are seeing medical journals already on Facebook, The New England Journal of Medicine is on Facebook. You are seeing medical societies already on Twitter like The American Medical Association and The American College of Physician, and I think that will be a growing trend as the medium is so powerful and so attuned to collaboration.

There seems to be some resistance among physicians to technology. As someone who obviously reaps a tremendous benefit from technology, why do you think this resistance is there?

I’m not sure there is resistance to the actual technology. I think with the way our health system is structured, there is no incentive for doctors to embrace technology. Not a lot of health insurers pay doctors to spend the time to email and get on social networks so I don’t think there is resistance to it but I think the health system needs to provide incentives to get on these technologies. Doctors are busy enough. I am a primary care doctor and I and a lot of my colleagues see like 25 to 30 patients a day and you add on top of that social media and emailing patients, which is not reimbursed, and that doesn’t provide doctors with a lot of incentive. Health insurers should give that push as it provides doctors with a way to communicate with patients and patients themselves can benefit from the easy access they would have to medical professionals.

As an internist how do you find the time to maintain your blog and interact so much with social media?

It’s certainly a time commitment, and obviously I’m on one end of the spectrum. There is a tremendous benefit to participating in social media, but I also spend a lot of time on it. Personally, I do it after my family goes to sleep. I’m going to be honest and say it does take a certain time commitment, but I wouldn’t do it if I didn’t get a tremendous reward out of it.

As a primary care provider yourself you have particular insight as to the nation’s current crisis of internists. Given you expertise, how do you think we should address our shortage of primary care physicians?

That is a common issue on my blog and I think any foundation of health care reform needs to have a strong base of primary care. It comes down to two things: first, there is the disparity between salaries of primary care physicians and specialists. Currently most specialties have much higher salaries than primary care has. Second, there is the lifestyle difference. Primary care is inundated with a lot of bureaucracy that really interferes with the doctor patient relationship and when you take those together there is really not a lot of incentive for medical students and future doctors to go into primary care. The solution is twofold: we need to improve the practice environment and the lifestyle of the primary care doctor, remove the bureaucracy and any obstacle that impedes the doctor-patient relationship, and secondly we need to improve the disparity between what primary care doctors and specialists make. If you are a medical student, and the average student has $130,000 worth of loans when they graduate, you are going to see these issues and the choice for many is pretty clear. The Journal of the American Medical Association found a couple of years ago that only two percent of medical students plan to go into primary care/internal medicine. Take that number and extrapolate it to the future. We’re talking about things like universal health care and we need more primary care doctors so I think the shortage will become starker as we move forward.

You mentioned universal health care. As a physician, what is your perspective on the current bill for health care reform?

I think the bottom line is that the status quo is not acceptable. Currently we have close to 50 million Americans who are uninsured and health care costs account for almost 20% of gross domestic product. If nothing is done then those problems will worsen as time goes on and will really bring the American economy to its knees. So something needs to be done; the question is ‘how to do it.’ I’m going to stay a political, but we need to find a way to cover more Americans and control health care costs, but underlying that would be increasing the number of primary care doctors. If we cover everybody, and we have more patients, then we need more primary care doctors. There is going to be more pressure in the future to look for primary care doctors and, I’ve said this before, what is the point of having insurance if you can’t find a primary care doctor to see you? The bottom line is we need to find more doctors to take care of people and that is definitely a bipartisan problem.

You’ve mentioned a few times the problem of soaring health care costs so , on this topic, what do you think is the biggest culprit in terms of wasteful medical spending?

There is a lot of medical waste that goes on. Many doctors don’t have electronic medical records and often because of that tests get duplicated. Also the way a lot of doctors are compensated is a problem as most doctors are compensated on a fee for service basis and that encourages more doctors to prescribe more tests because that is, frankly, how most doctors get paid. Research at Dartmouth has found that, because of this financial incentive, there is a wide disparity in our country as to how much doctors spend. I think secondly we have this problem of so called defensive medicine which is practiced to avoid the threat of malpractice lawsuit. Currently our malpractice system is very uneven as to how it punishes doctors and compensates patients and because of how uneven and unpredictable the system is doctors have another incentive to order more tests to prevent the threat of a malpractice lawsuit. I could certainly go on but if you were to name two of the biggest culprits it would be the way doctors are compensated and the way they to practice to avoid a lawsuit.

How do you avoid the trap of defensive medicine in your own practice?

The best way is to communicate with patients. You always have to be more open and discuss all of the options. Multiple studies have shown that doctors who have better relationships with patients and who have open lines of communication get sued less. The problem is we operate in a system where time with patients is not valued. Doctors are always encouraged to see as many patients as they can and there is really a conveyor belt mentality as to the way the system encourages doctors to practice. So the best way to reduce malpractice lawsuits would be to first off explain every medical decision you make and explain the risks and benefits and come up with shared decisions. And secondly, if a mistake is made, open the lines of communication with the patient, apologize to them, and explain what happened. Studies have shown that doctors who offer a sincere apology to patients get sued less.

There is currently a move in health care toward digital medical records to which there seems to be some resistance among physicians. Why do you think this is?

I think the idea of digital medical records is good and the ideal would be for the entire country to be running on the same digital medical record system, similar to what the Veterans Admiistration uses for their system. The problem with digital medical records right now is there are so many competing systems and they all can’t talk to one another. If I had a patient who was admitted to the hospital now under their system and then that patient saw me for follow-up and I use a different system there is no way for my electronic system to communicate with the hospital’s system so it’s very fragmented and the fact that they can’t talk to each other is a big problem. If I had my ideal, a very simple idea would to have all of the systems equipped to communicate with each other so tests aren’t repeated. The other thing is a lot of the interfaces aren’t up to standard. If you look at Google and Facebook the interfaces that they use are very intuitive and easy to use. A lot of interfaces of the current generation of digital records are somewhat archaic and make it difficult for the doctors. Doctors are already pressed for time so if you encourage them to use a tool which doesn’t improve their lifestyle or practice environment there will be obvious resistance. I think the first thing these digital medical records have to do is prove themselves as tools that make doctor’s lives easier, and right now that is not the case.

What role do you think Comparative Effectiveness Research should play in a physician’s practice and do you think a physician will accept redefined principals?

It’s a good idea. I do believe that doctors should practice based on the best available evidence. If you look at some studies based on Medicare spending, different parts of the country spend a different amount of healthcare dollars because of the variation of care nationwide. If you look at a heart attack patient in Miami, FL the cost and amount of medicine that patient will receive is different from say Minneapolis, MN. So if you had doctors practice according to the same evidence based set of guidelines that will help out in the variation. The problems you have are because comparative effectiveness reduces medicine down to so called cook-book medicine and doesn’t take into account the individual component of a single patient. It really depersonalizes medicine and that is one of the problems. If you base comparative effectiveness on studies that cannot encompass every patient you encounter. So I think it’s good, but there needs to be flexibility for individual cases. If you could address those concerns, you are going to find more doctors accept comparative effectiveness, because that is the problem: it doesn’t allow for individual treatment decisions that may occur outside the set of guidelines.

What do you think of the recent proposed guidelines in mammography and the media backlash?

You are referring to the task force recommendation that doctors discuss whether a mammogram would be suitable for women ages 40 to 50. Of course there is a lot of controversy on that so I think the problem is communicating with the public. There is a pervading belief among the public that more testing is better and that goes for cancer screening. People think that if you get a mammogram early and get them every year that naturally leads to better care, and that’s not necessarily the case. There is a downside to cancer screening. There are a lot of benign diseases that can get detected, which sometimes leads to a further invasive test like a biopsy. I think communicating the idea that more cancer screening isn’t necessarily better is a difficult idea to communicate. I think the task force just publicized their recommendations without any surrounding nuances and so I think they were partially responsible for the controversy. In terms of what I think, it has to be a shared decision between the doctor and patient. When I have a healthy woman in my practice who is 40, I discuss cancer screening. I certainly discuss the risks and benefits of mammogram and we come to a decision between myself and my patient. The decision could be to go ahead and do a mammogram and it could be to not. I think, bottom line, it has to be a decision between the doctor and patient and it is up to the doctor to really explain the risks and benefits of going ahead and doing a mammogram.

What experience have you had in your 6 years of almost continuous blog activity that really stands out?

I didn’t expect it to be as big as it is and I am certainly gratified that people are as interested as they are. It’s certainly given me opportunities that I wouldn’t have had otherwise, opportunities like writing for publication such as The New York Times, being a regular columnist for USAToday, appearing on The CBS Evening News and being invited to speak and talking to you for instance, I think it’s really been enlightening and I think it has forced me to think about issues on a deeper level. In all social media you get continuous feedback, you get posts to the blog, you get conversation on twitter so whenever I write something I get instantaneous feedback on what I think. This has allowed me to see other views and whether they agree with me or not, it’s allowed me to really think deeper on a lot of issues.

Do you think that having this connection via social media has made you a better physician?

Absolutely. When I talk to patients, even on a superficial level, it makes a difference. When patients come in with an article they’ve read earlier that day chances are I’ve already read it just because of the sheer amount of reading I do. And secondly on controversial issues like mammograms or drug recall, I’m able to get an instant opinion of a variety of medical viewpoints so it’s really beneficial to me. When patients come to me with these issues I’m able to present to them a more informed opinion.

What advice would you have for other health care professionals who are interested in sharing information in the way that you have done?

I think first off I would say ‘go for it’. I feel very strongly that medical professionals need to be online, not only to help their practice out, but also because patients need guidance as to what medical information is reputable online and it’s really our responsibility to get online and be that source of reputable medical information. That said, there are certain pitfalls that I want everyone to avoid: first off, patient privacy has to remain paramount. It’s very easy on Twitter and Facebook, for instance, to accidentally disclose patient information, and with the strict privacy rules of HIPPA any medical professional needs to be cognitive off that. Secondly, I wouldn’t give any medical advice online. [Internet cases] are still relatively new, especially in terms of the malpractice field and so I wouldn’t give any personal medical information online. But if you keep those two things in mind, there shouldn’t be any reason why any medical professional shouldn’t embrace the internet. I think it can help not only their practice but also their patients as well.