Why I quit medicine
gautams.posterous.com
gautams.posterous.com
What we have instead is a very well intentioned individual that is getting out of medicine because they want to run a startup. And that's fine. Maybe getting jealous because they see it as a path to riches and have been reading about to many outliers. Or maybe wanting to change the world.
But the job that he does is known as a "hospitalist" in this country. (Essentially Internal Medicine but not office practice).
http://www.hospitalmedicine.org/
My wife is one, and practices in a very modern hospital system. I've asked her many times about "the handoff (signout)" from the first time we were dating. Because it seemed outdated to me that when we were at dinner (and she was on call) she had to scribble down notes about sometimes 20 patients over the phone). But apparently the verbal interaction is important as well between two doctors and can't easily be summarized in writing. And I've overheard plenty of handoffs and can attest to the interactions between doctors and the nuance that can't be expressed in writing. (I even said why can't the other doctor just record something that you can listen to and a million other ideas and she shot all of them down very easily as not being practical. And she had every reason to support an idea like that if she thought it would make me money..)
Getting things done is difficult, and yes, they are very closed minded and it's hard to get change.
But drawing a comparison with "Considering I can talk to my smartphone and tell it to send a message to my dad or remind me to water the plants when I get home" doesn't take into account that whatever system is setup and accessed needs to be rock solid, dependable and can't fail in many degrees above your typical startup offering.
So this is a great ambitious idea that he has undertaken and I wish him well. But my guess is that he will have to partner with a health system in order to get adoption of this idea and work out the kinks and prove the concept.
You're right about how important face-to-face interaction is. That is not going to be replaced any time soon - nor should it be. But for the purpose of handover, you still need a written summary of all the patients on a ward that people can refer to. As I mentioned in the post, it would be useful to see who wrote what about each patient - so that you know who to talk to for further information. Having a handover application won't replace the morning handover meeting or a person-person handover - but it will definitely make that process less painful, more accountable and much more efficient.
(P.S. if I was jealous of the so called riches of being an entrepreneur - I would have focussed my energies on my medical career and right now I'd be driving my A5 from work rather than sleeping on a friend's couch thousands of miles from home :) I don't think anybody who takes this path should be under any illusion. Most start-ups fail and it's not an easy path. That said, I do love a lot of what building a company involves...)
Bottom line: here in the US of A, your average doc (most certainly NOT an outlier) is making between $150k and $350k. Put that in your VC-backed pipe and smoke it.
(Debt? Between $150k-$200k for 4 years of med school. Post med school training, in the form of residency and fellowship, runs anywhere from 3-12 years and pays around the $50k mark. Basically, nobody went broke by becoming a doctor.)
Which means, of course, that the outliers can do very well. I have a friend who's Dad is an oral surgeon in the Eastern Shore of MD (what might be considered the "boonies" by some). He clears about $750k/year for a 35 hour work week. llimllib's wife above is probably around the $250k mark in the ER/ICU. If that ain't coin...
Anybody who thinks that somebody left medicine for the money knows very little about medicine.
Medicine is still an extremely reliable way to become everyday rich, if not outrageously so. It beats the pants off of corporate jobs, and it beats law on average (though law outliers tend to beat medicine outliers). It loses out to investment banking, but the lifestyle is far superior.
A smart person can do a lot worse than medicine.
You're low on your med school debt estimate, remember that loans don't just need to cover tuition, but living expenses too. Furthermore, many of her fellow not-yet-attendings are sitting on undergraduate college debt that has been deferred until they become attendings.
Nonetheless! Your overall point is totally valid. I've out-earned her for the past 6 years, but she'll even it out in about 2-3 years as an attending, and doctors frequently work well into their sixties.
(Also: Baltimore represent!)
In medicine's favor I will say that the median income is probably higher, the median social status is much higher, you have a much better chance of directly making a positive impact on many people's lives, and you work in a field with a more balanced gender ratio.
* The job is boring
* The pay is average for a smart person
* The doctor spends a ton of time interacting with people that have sub-average critical thinking ability
These three things are something that one cannot admit in writing, but are all true. Some people just don't have personalities that can survive being a hospitalist. One way to cope is to have hobbies outside of work. Children are a particularly popular route. The author doesn't seem to be going down that path, so I think the startup world is a great way to escape a dead end job.
http://www.ncbi.nlm.nih.gov/pubmed/21773849
Your contention that hospitalists actually hate their jobs and lie on surveys is implausible.
Medicine is lots of things, but it's never boring, especially in hospitals which are mad, mad places. Sure hospital work is not for everyone, but that isn't because it 'sucks'.
"The job is boring"
A hospitalist deals with more difficult cases than an internist in a office based practice.
"The pay is average for a smart person"
Are you factoring in job security? And since when does "smart" equate to pay? There are tons of well educated "smart" people (who trained to be lawyers) who are unemployed or working menial jobs.
"The doctor spends a ton of time interacting with people that have sub-average critical thinking ability"
Are you referring to patients, nurses or? What do you think the entrepreneur running the local business interacts with? At least Physicians have other physicians as co-workers. Try running your own typical small business and see who you end up interacting with.
"One way to cope is to have hobbies outside of work. Children are a particularly popular route. "
Cope with what? Did it occur to you that there are people that like this job? (This is not a comment on what my wife feels by the way I'll leave that out of this discussion..)
You attacked his motives for quitting, and I think you were right, but there are also motives for quitting that can't be written publicly (unless you are willing to go Greg Smith).
A doctor can't write "I am dealing with a fatty with an asshole family and mismanaged diabetes thus now has renal failure and I have to deal with this shit" in a blog. It is a reason to quit being a hospitalist, but not something a person can blog. You can also quit Goldman because your co-workers call clients muppets. Some people love it, some people hate it. I am just not surprised.
Total upvote for that one! Yes that is true.
"AMA" patients are quite common and frustrating. I've heard the same or similar. And of course mentally ill patients as well. I'm actually amazed at the stories I hear about families and how they treat doctors (especially woman and minorities as opposed to tall white male physicians).
I can fully understand how frustrations with the job can cause discontent. But I think that viewing the success of others (as has been pointed out by a few others here) definitely magnifies that discontent.
It takes many many years of study to become a doctor. It seems strange to me that (given they run into the "fatty patient" in other phases and should certainly know of that prior to completing training, residency etc. or even going into medicine) you wouldn't think that would be a reason for them to bail. Although yes it is possible.
1) She consistently asserts that handoffs are the most difficult and error-prone part of the job. They take up a large chunk of her time. Further, with work hour restrictions only getting stricter, the number of handoffs is only going up.
2) While face-to-face interaction is indeed crucial, surely there are improvements to be made! Let the doctors give crucial information face-to-face, secure in the knowledge that basic patient information is stored in a trustworthy system, and you should see less errors.
> they are very closed minded and it's hard to get change.
Obviously this is a huge obstacle! But even by your own argument, there are surely ways to improve, and an ex-doctor is the ideal candidate to figure out how to do so.
I didn't say that.
I gave three possibilities:
1) "getting out of medicine because they want to run a startup."
2) "Maybe getting jealous because they see it as a path to riches and have been reading about to many outliers."
3) "Or maybe wanting to change the world."
I referred to "financial reasons" in only 1 case. And even in that case I used the word "maybe".
That's hardly "thinking this guy is getting into startups for financial reasons".
I didn't say improvements needed to be made. In fact if you re-read what I said you will see I questioned the issues with handoffs.
Thinking about this more, its actually a bit scary if I do create something and he is able to get them to use it as I could be opening myself up to a lot of liability. I figure, as a doctor, he should be aware of all this but not 100% sure how up on this he actually is, maybe I should get him to sign something having him take full ownership and responsibility of the software
It will break, in horrible and unknown ways, and even if it didn't if the company supporting it got wind that you used a different version of IE, or heaven forbid Firefox, that's probably enough to deny support. It's probably not even ancient software, they might have purchased it in the last couple of years. Medical software has to be the absolute worst made software on the planet.
Meanwhile your ability to do everything else breaks through shear attrition.
Among the relevant regulations, the big ones are HIPAA and HITECH:
http://en.wikipedia.org/wiki/Health_Insurance_Portability_an...
http://www.hhs.gov/ocr/privacy/hipaa/administrative/enforcem...
A big point that I remember was that a HIPAA breach was up to 1.5 million dollars in fines.
"A maximum penalty amount of $1.5 million for all violations of an identical provision"
This is one of the markets where BigCos can and should make a difference (and loads of cash in the process, but well, that's what regulations get).
On the flip side, HITECH introduced up to 20 billion dollars in incentives for adopting Electronic Health Records (EHRs), so maybe the millions in compliance are worth it for some startup :)
I got some interesting data from here ("Opportunities and Challenges of Cloud Computing to Improve Health Care Services"):
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222190/
and some information by CompTIA’s Third Annual Healthcare IT Insights and Opportunities study.
http://www.comptia.org/news/11-11-16/Healthcare_Practices_Em...
Talking != doing.
Government contracting really is a different world.
You check out SBIR grants - http://en.wikipedia.org/wiki/Small_Business_Innovation_Resea...
I'm curious -- how does this work? I.e. what kinds of organizations contract her for what kinds of tasks / duration? I would have thought that research was inherently un-estimatable.
I wish it were different.
Seriously? A shared Word document? With no audit trail of who wrote what? And that is an improvement over the state of the art? It sounds like Wordpress has far more robust data management (and probably security) than what he just described.
As a doctor who can code, I'm sure the OP will be in a great position to make real change. He knows the regulatory stuff to get past, what rules can be bent, who the movers/shakers are to get stuff moved. Likely just bringing some very basic CMS/ERP functionality to medical records management in a hospital would be huge.
Good point. I'd also add that it's difficult to automate the process of scanning millions of hospitals for crumpled pieces of paper, whereas scanning blocks of millions of IP addresses for vulnerable smartphones is something any reasonably competent script-kiddie can do.
The whole taking notes, jotting down patient information. It seems antiquated, but it's really a hard problem to "fix" - if it really needs fixing. These are not medical records he's talking about, but personal notes on each patient and todos you carry around with you during your shift.
Paper/pen in taking these notes is faster than computer/tablet input. I've tried it. In several different forms. There's a lot of shorthand doctors develop that help out. Arrows, diagrams, etc...
Still seems a small part of the bigger picture, which is electronic medical record keeping.
Regardless, good luck with your venture!
If you don't mind my asking, why did you quit?
Additionally, hospitals require doctors to put in diagnosis / treatment notes into EMRs which is usually done by transcribing service that the doctors can call or by sitting at a computer and typing it out. Although this process is worse than doing it over a mobile client, healthcare IT is not in the dark ages as people would have you believe.
I think this article should be a cautionary tale about socializing health care.
- locking: only one person able to change the record - auditing: keeping records of who read what, when, and where they did it - signing: any additions are cryptographically signed and timestamped - sharing: many clinicians need to be able to access the data across a wide range of hospital networks.
The UK NHS spent £11bn on a system which was late or didn't appear.
(http://www.bbc.co.uk/news/uk-15014288)
About 10,000 people in England die each year because a clinician makes a mistake with the meds. While that risk is very low (because there are a huge number of patients taking a huge number of meds) it'd be nice if something simple could be done to reduce that number.
I'm in medical school currently and the emphasis on locking down patient data is one of the most frustrating things to see. I'm convinced that it's a policy that everyone knows has little benefit and yet pushes for ethical brownie points. What's to be gained from freeing up the data far, far exceeds what could potentially be lost.
Even freeing up anonymized patient data seems to be met with opposition. Imagine the data analysis that can be done on millions and millions of patient cases and the clinical/treatment models that can emerge as a result.
Medicine right now is an old, stiff wooden board bending under the weight of technological innovation. Something's going to snap and I'm looking forward to see it happen.
I really support what you're doing, and if you want design help, my email is in my profile. Best of luck!
Unfortunately, statistically, "anonymous patient data" is an oxymoron. Any useful amount of patient data contain enough information to deanonymize it to a great extent, and in conjunction with other data often fully deanonymize.
http://33bits.org/2010/06/21/myths-and-fallacies-of-personal...
Is this meant hyperbolic? Confidentiality is probably one of the most important parts of a doctor-patient-relationship. Even "statistical" information about people's health/illnesses should in my opinion only be used after prior written consent.
The potential amount of damage to reputation, social life or life (depending on circumstances) of leaked/stolen medical records/patient data redeem every effort to keep them as closely guarded as possible, in my opinion.
The state published a set of anonymized data on patient care stays associated with workman's comp.
The company wrote code to correlate data from these scrubbed records (age, sex, treatment dates) with data it had, to identify the patients.
These days, much of healthcare business is oriented around data flows -- pharmaceutical dispensing machines which double as patient-data-and-dosing information capture devices. The drugs vendor is willing to sell the drugs at or near cost simply to capture the datastream and sell it back to the pharmaceutical companies.
There's very, very good reason to view EMR with strong suspicion.
As to the OP, there's still a room to improve existing software technologies. And there is still a lack of consensus about best ways for improving handoff processes: http://www.ingentaconnect.com/content/jcaho/jcjqs/2010/00000...
Large scale analysis of (anonymous) patient information will lead to many breakthroughs. Hopefully, one day we will get there.
(http://www.badscience.net/2011/03/when-ethics-committees-kil...)
Passing along patient information is a tricky subject due to HIPAA-compliancy. Most patient information is transmitted via fax machines and doctors are alerted of incidents through pagers, often carrying multiple. This technology is archaic and considering 75% of US physicians own some sort of Apple product there has to be change. In particular, physicians need better forms of communication that saves them time.
I'm hoping this changes as it will impact us all. It isn't going to happen overnight but with more and more physicians pushing for change in this area, one can only hope it happens sooner. If you're interested in what my company does, check out our website at https://www.doximity.com and our blog http://blog.doximity.com/ talks about similar problems.
Sivakumar is right in that there aren't many doctors who can also code. While he may not get to feel the joy of directly improving patients lives, this goal of his seems far more important to the well-being of everyone.
White collar does not mean that you are in a research field and pushing the limits of knowledge, from what I understand it has long had an entirely different meaning. Personally, I feel that white collar / blue collar are very outdated terms. I often feel that a software developer is somewhat of a modern blue collar worker as its a creative trade and very different from a "white collar" job such as a sales or marketing job.
But I still feel that software development is a creative field whereas most of medicine is reactive. All fields are based upon past knowledge so the use of APIs seems irrelevant since they are just tools used to create.
The criterion to differentiate between creative and non-creative fields seems to be whether multiple "correct" answers exist. Obviously in programming the solutions to problems vary in terms of algorithms,implementations, etc. On the other hand, medical diagnosis is either correct or incorrect. Even prescribing treatments seems to be more of "do X with A factors, do Y in the presence of B factors" rather than an individualized, creative approach.
However, sometimes--probably most of the time--the patient's presentation is so unclear (e.g. "I just feel weird. . . ."), there are so many variables to juggle in your head at once (twenty different lab values, the way the liver feels, the imaging findings, the color of the patient's sclera, the smell of their breath, their mood) that things become far too complex for any flowchart. These are the times when you need creativity, "book smarts" and perhaps above all, "emotional intelligence" to be a good doctor. There are plenty of doctors lacking one or more of these elements, and they just aren't very good at the job.
Good to hear from an actual physician though. Do you think that your initial disappointment is a unique response or do most med students go through it? I ask because everyone I know who is getting accepted to med school has wanted to be a doctor since high school. I assume that makes med students get tunnel-vision when deciding their career choices and have an idealized, incorrect view of the field. (I figure most future doctors just get over this pretty quickly by finding different, but equally important reasons to be in the field.)
In college, I was drawn to the humanities and to computer science more than to biology, but I stuck with it. I was a willing victim of the rather unhealthy obsession with "getting in" that most pre-meds develop. Medical school, at least at first, was a rude awakening. It was not intellectually challenging (other than by virtue of the sheer volume of material), it was rote, the hours sucked, the and the culture was unpleasant.
It was not until a couple of years into my residency that I started to really appreciate more of the nuances, and to enjoy practicing medicine. As it stands today, I love what I do. I help people in a tangible way, I make a good living, I am respected and valued by my community, and at as I described above, my creative and intellectual muscles get a daily workout. However, I don't do any busting into ORs and, sadly, I don't drive a BMW.
1. Befriend and work with a mentor who happens to be high up in the IT department in a health system.
2. Create some kick-ass app
3. Open-source it(use the open-source version as a way for IT people in other health systems to use your work)
4. Have your mentor implement that software in their health system as a pilot project.
5. Befriend other IT directors and try to sell to them.
6. Befriend other medical software providers and try to license to them.
7. Make hay while the sun shines.
http://patientsafesolutions.com
Using a iPod Touch and a proprietary jacket, patients can be monitored and transferred to the next shift of nurses through an intuitive App. Its really quite amazing.
But it's become apparent to policy makers that Medicare is getting more and more expensive, and some type of change is going to have be initiated. With private health insurance, it's the same picture. Costs are going up and more of these costs are being shifted to the insured (patients). Deductibles have gone up tremendously, and the days of the $5-$10 co-pay are almost gone.
The solution, in both cases although perhaps implemented in different ways, is going to have require the patient/insured to be responsible for paying for themselves directly. On the surface, it seems like a bad thing, but in the longer run it's a good thing. It brings into play what healthcare has been lacking - market forces. Almost all other industries have market forces in play, but not so much in healthcare. Go to a great surgeon, or go to an average one, they get paid the same. Why? It shouldn't be that way.
But once people have to pay more out of their own pocket, they are going to be far more careful about who they see. The level of service provided is going to matter. Ease of access is going to matter. Outcomes are going to matter. How about a refund if certain things don't turn out as promised?
And that's where there is going to be tremendous opportunities for startups. To provide technology for patients, and for doctors, hospitals, etc to provide a better level of service. All parties involved will be actively looking for these tools at some point.
Granted there are some regulatory hurdles, and HIPAA was really a poorly thought out piece of legislation, but as the startup community grows, there will be tools made available to navigate these hurdles as well.
But, as a doctor, changing careers and creating a startup, especially one on the other side of the planet, seems an extreme reaction with extreme risk. Why not go private or even change geographies but remain a doctor while working on this problem on the side?
I say this because, given how well compensated doctors can be, as well as clear and progressive career paths and the strong vocational aspect, the opportunity cost of this change is enormous!
TL;DR. Are there other more significant issues involved?
To do this would take about 6 clicks and due to the slow system about 40 seconds I figured out. There would commonly be a queue in the morning to use this computer.
I made a simple script on a pen drive that allowed me to print my bloods for patients I had on a list of 'my patients'
i got a slap on the wrist :(
But you know what's worse? Dying because the doctor misses a vital piece of information which can't be found in disorganized paper notes, or a bureaucratically designed medical information system (which set the hospital back roughly the cost of a new life-saving machine).
So it's not always a choice between privacy and death. In fact I'd hazard a guess that this is the case the majority of the time.
As an entrepeneur, you'll have to deal with clogged sinks, office rentals, legal filings, and lots of other hassles similar to carrying around a piece of paper.
I bet he also believes he can make some money too, but I don't fault him for omitting that. Surely that goes without saying.