Flipping the Doctor’s Office

Jul 18, 2013, 10:42 AM, Posted by Thomas Goetz

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Consider the doctor’s office: the sanctum of care in American medicine, where a patient enters with a need—a question, or an ailment, or a concern—and leaves with an answer, a diagnosis, or a treatment. That room, with its emblematic atmosphere of exam table and tiny sink and bottles of antiseptic, is in many ways the engine of our health care system, the locus of all our collective knowledge and all our collective resources. It’s where health care happens.

But in a less sentimental light, the doctor’s office doesn’t seem so exalted. Yes, it remains the essential hub for clinical care. But what occurs in that room isn’t exactly ideal, or state-of-the-art. The doctor-patient encounter is fraught with tension, asymmetrical information, and flat-out incomprehension. It is a high-cost, high-resource encounter with surprisingly limited value and limited returns. It is too cursory to be exhaustive (the infamous fifteen-minute median office visit), too infrequent to create an honest relationship (one or two times a year visits at best), and too anonymous to be personal (the average primary care doc has more than 2,300 patients).

At best, it offers a rare personal connection between doctor and patient. At worst, it is theater. The doctor pretends she remembers the patient, and that she has actually had the time to read the patient’s chart in full; the patient pretends that he hasn’t spent hours on the Internet trying to diagnose himsef, half-admitting what he’s really doing day to day, and pretending he won’t second-guess the doctor’s orders the moment he gets back to a computer.

As woeful as that sounds, we know that there’s real value here. This encounter can be meaningful; it should and must be meaningful. The doctor is a necessary interface to medicine, and his office is a source of care, expertise, and trust. The patient is eager and receptive to learning, primed for guidance and direction. Pragmatically, the doctor’s visit is a powerful part of modern medicine. The problem is that we are not optimizing this resource; we have not reconsidered and re-evaluated how we might exploit the visit to its full advantage.

So how can we improve this situation? How can we fix this thing?

This might be one more nebulous problem left unarticulated, except for the inspiration of Sal Khan, founder of Khan Academy. Earlier this year, Sal visited the Robert Wood Johnson Foundation, and explained the premise and power of Khan Academy. By putting simple, clear explanations of academic subjects in online videos. Khan Academy has “flipped the classroom,” by reversing the normal flow of instruction. In a “flipped” classroom, the lectures happen at home, in video form, and the homework gets done in the classroom, where the teacher can give individual attention to individual students. This flipped classroom maximizes the teacher-student encounter and puts the teacher’s expertise to its best effect.

But that’s only one of two flips Sal has done. In the second flip, the fixed and variable conditions are reversed. Traditionally, the progress of instruction is fixed: The coursework moves ahead on the teacher’s schedule, and at year’s end, the entire class—or at least those who’ve fulfilled minimum requirements—graduates. The variable is the proficiency of each student. Some have mastered the material, some glean parts but not all, and some are left behind. In Sal Khan’s vision, these are reversed. Each student should reach a high level of proficiency with all the material, but should proceed at his or her own pace, not the teacher’s.

Together, these two flips represent a significant reimagining of the student-teacher experience in the classroom. Suddenly, the classroom becomes a hub in a broader network of resources and information, and the teacher’s expertise is reasserted, treated less as a commodity and more as a precious resource.

Sal Khan inspired us, and the similarities between the classroom and the doctor’s office were obvious: Why not “flip the clinic” the way Sal has flipped the classroom? Later that day, I was talking with Anne Weiss, team director of RWJF’s Quality/Equality team. What, we wondered, would a flipped doctor’s office look like? What would a new sort of doctor-patient encounter involve? Is video content required? What are the resources, and the players, beyond the doctor (nurses, nurse practitioners, other staff) and on the patient’s side (family, co-workers)? And how could you bring this new approach to both care providers and patients alike?

As with any good idea, it turns out many people are already working on these notions. In New Jersey, the Camden Coalition of Healthcare Providers has aligned to change the way they deliver primary care, leveraging data from across the coalition to coordinate resources and improve the efficiency of care. At the brand new The Betty Irene Moore School of Nursing at UC Davis in California, the faculty is rethinking the role of the nurse in care delivery, training a new generation in informatics, resource management, and interdisciplinary innovation. And HealthLoop, a San Francisco-based startup, is addressing the episodic nature of clinical medicine by turning follow-up—the essential but often overlooked post-visit status check—into a feedback loop, engaging the whole physician practice (doctors, nurses, support staff) in the end-to-end needs of patients.

These are all inspiring projects. We’re hoping that we can learn from each of them, and start fostering a community of change. For the next few months, part of my mission as the Foundation’s Entrepreneur in Residence involves working with an amazing team of program officers and gathering string on where innovation is happening. We want to capture and consolidate it, with the goal of creating a robust resource for all physicians, their practices, and their patients, to improve the most potent resource in medicine. The end result, we hope, will be a toolkit for flipping the clinic, offering a specific source for new ideas, better tools and best practices. An important part of this project is to engage the broader community of stakeholders—patients of all kinds, providers at all levels, and experts of every niche—to share their ideas and feedback.

Right now, flipping the clinic is just an idea (for one thing: should we call it “flipping the doctor’s office,” which is more explicit, or “flipping the clinic,” which is more catchy?). In a few months, we hope to propose a new framework for administering effective health care for all Americans, and others worldwide, with the goal of improving understanding, efficiency, and outcomes.

In the meantime, please offer your ideas and reactions below, or send them to me at TGoetz AT RWJF.org . We can’t wait to get this started.

Read a Pioneering Ideas blog post by Khan Academy medical fellow and Pioneer grantee, Rishi Desai, MD, MPH, in which he shares his thoughts on how Khan Academy's approach to learning can help transform the patient experience