The Doctor That Never Sleeps

What if you could text a doctor with a medical question at any time of day and get a quick, thoughtful response? No more haphazard Googling (swollen feet allergies; tick stuck in ear access to brain?). No more sifting through random message boards. No more WebMD algorithms suggesting that a vague stomachache might be the first sign of a terminal skin disorder.

As a patient, I’d say that sounds great. As a doctor, I’d say that sounds at best unsustainable, and at worst disastrous. The average primary-care physician has about 2,300 patients. He or she would never sleep. But Ron Gutman, a Silicon Valley entrepreneur, would say that’s a business opportunity. Since he founded HealthTap four years ago, the Web site has grown into an interactive community of more than 60,000 licensed U.S. physicians, who answer user questions for free. More than 10 million people visit the site every month. Now the company has added a service called Prime, whereby a subscriber can talk immediately with a licensed doctor by phone, tablet, or computer; using voice, text, or video; at any time of day or night; as many times as he or she might like; in sickness and in health, for better or for worse. For this, a person pays $99 a month.

Is this a vanity service for wealthy hypochondriacs, or a harbinger of a coming revolution in health-care delivery? Possibly both. If some basic needs were addressed remotely, doctors could focus on more dire cases during their busy office hours. Patients could ask simple questions without needing to take an afternoon off work for an office visit. As of last year, only 12 percent of Americans had ever texted or e-mailed with a doctor, according to a survey conducted for The Atlantic. But about a third of people under 30 were open to having their primary communication with their doctors be online.

HealthTap is not, at least for now, trying to take over for anyone’s doctor. It is instead trying to supplement standard primary care. Specifically, it is trying to sell you on the idea of not ever having to wait for health-care advice. Upon hearing the story of an untimely fall from a horse or seeing a photo of a child’s post-water-park rash, the doctor on call might tell you to sit tight, or make an appointment to see someone in person, or run to the ER.

Doctors on HealthTap are paid for the time they spend conducting one-on-one consultations with patients, but they aren’t paid for answering questions submitted by anonymous users via the Web site. Why do they do it? “I think doctors are great people, in general,” Gutman told me. Being a doctor, I found that explanation reassuring. But physicians also participate in HealthTap for reasons not unlike the ones that motivate restaurants to post professional photos on Yelp and the CIA to join Twitter: they want to gain credibility and construct the dreaded but increasingly necessary online presence. Online presence is mentioned nowhere in the Hippocratic oath. But it can, Gutman says, help doctors “build a name and get speaking engagements, or just advance their careers.”

One doctor with an enviable online presence is Keegan Duchicela. HealthTap’s doctor-rating system gives him five out of five stars; he is also ranked first among HealthTap doctors nationwide for his knowledge of “insurance” and third for “abscessed tooth.” His profile boasts that his answers have been corroborated by other doctors 5,803 times, that patients have given him “thanks” 12,555 times, and that he has saved 25 users’ lives. (Whenever a doctor answers a question via the service, a pop-up box asks the patient whether the answer helped him, made him feel good, or saved his life. The number of “lives saved” by a given doctor indicates the number of people who checked that box. By this curious logic, HealthTap figures that its doctors have collectively saved 16,336 lives.)

On the basis of all this information, if you were in search of a family-medicine physician in Northern California, you might well seek out Duchicela, who practices in the Bay Area and teaches doctors-in-training at a Stanford-affiliated residency program. Especially in the tech-obsessed South Bay, Duchicela says, if a doctor doesn’t have an online presence, “patients think, Are you still using leeches?”

In keeping with his enthusiasm for new doctoring platforms, he was among the first to jump on board when Prime launched. When he can spare the time, he picks up a shift, during which he generally hears from a handful of patients. He can log in from anywhere, has to do almost none of the bureaucratic paperwork that burns physicians out, and gets to meet and help interesting people in that predictable, finite, and instantly gratifying way that typifies Internet interactions.

I wanted to experience a HealthTap consultation from a patient’s perspective, so I waited for something to happen to me. The editor of this magazine suggested I get myself punched in the face. I turned that over in my mind. Luckily, my throat started to feel scratchy. The next morning, it was legitimately sore. Jackpot.

“Would you like to speak with a doctor?,” HealthTap prompted. Yes. “Is this an emergency?” No. Next, the site allotted me 150 characters to explain my problem: “Sore throat for two days, getting worse, no other symptoms.”

Within 30 seconds, I was in the virtual presence of Dr. Vicken Poochikian. He was bespectacled and white-haired, sitting in front of a painting in what may have been his home or office. He wore a sweater over his collared shirt, and a white coat over that. He must have been someplace colder than where I was.

Pleasantries were brief.

“Are your bowels doing okay?” he asked. Doctors are trained to ask these all-encompassing questions as part of a traditional examination, even if the patient clearly states that he has no other symptoms.

“Yes.”

“Do you have coughing?”

“No.”

And so on, until Poochikian was satisfied that I indeed had no other symptoms. I inquired about antibiotics (knowing that they weren’t yet medically warranted); he said it was too soon. I was ready to shine a flashlight in my mouth and lean over my computer’s camera, but I wasn’t asked to do so. He suggested that I stay hydrated, take it easy, and call back in a couple of days if I wasn’t feeling better. Immediately after we disconnected, he documented our encounter for a record that will follow me through future HealthTap visits. His notes were to the point, in sharp contrast to the tedious documentation required in most electronic-medical-record systems. His account of my exam, in its entirety, read: “Common cold symptoms. On video he didn’t really look sick or in any distress.”

This cursory exam is emblematic of a larger trend in medicine: physical examination has become less central to diagnosis than it once was. To some extent, this is because of increased reliance on tests and imaging. Doctors are less and less concerned with honing their stethoscope skills, because echocardiograms are readily available. Tapping on a sore stomach tells a doctor something, but rarely as much as a CT scan does. And to some extent, this change has been a matter of necessity. The average medical appointment now allows a doctor little time to interrogate or thoroughly examine a person, or really get to know him.

That may also be the most significant limitation of a service like HealthTap Prime. Under the current model, doctors don’t see patients on an ongoing basis. As a result, a patient is inevitably getting advice from a doctor who, because she hasn’t seen what he looks like when he’s not sick, can’t tell whether he really “looks sick”—a gut valuation that remains crucial to effective primary care.

Yet, with the American Association of Medical Colleges projecting a national shortage of more than 90,000 doctors by 2020—especially in rural areas—there simply may not be enough doctors to provide this kind of ongoing care. Telemedicine could play a crucial role in addressing basic needs, particularly in settings where long-term relationships don’t come into play, like emergency rooms. Already, to take one example, a company called Avera Health makes physicians in cities available via video to hospitals in small towns, where they are remotely helping to staff emergency rooms overnight. (They work in concert with people who are on-site. So, for instance, a nurse might perform hands-on work at the direction of an onscreen doctor until a local doctor can arrive.)

For his part, Duchicela hopes that HealthTap and similar platforms will allow for continuous doctor-patient relationships in the future. He already brings up e-mail etiquette when teaching his medical residents, and he imagines their training evolving to include instruction in telemedicine—say, how to evaluate a mole via smartphone. He also hopes to one day use video service to supplement care for his regular patients. He might initially treat someone in person, but answer follow-up questions and give reassurance via the camera on his phone.

And really, providing peace of mind may be the most important thing any doctor does. “It’s kind of funny: we’re most anxious when we’re not feeling well; we need immediate gratification more than any other time,” Ron Gutman told me. “The only place we’re expected to have a waiting room anywhere, outside of the DMV, is the doctor’s office. We’re trained, as health-care consumers, that we need to be patient. It’s not a coincidence that we are called patients.”

It is a coincidence, actually. I looked it up. Patient (the noun) comes from the Latin for “one who suffers.” But he might be on to something.