Leadership Exchange: Engaging the Millennial Doctor
In partnership with inVentiv Health, MM&M corralled one — Weill Cornell fellow Sona Shah — to ask her about everything from her frustrations with the existing pharma marketing model to her willingness to receive texts from patients. How does she feel about the educational resources at her disposal? Would she open her door to a pharma rep?
The answers to these and other pressing questions can be found within this edited transcript of a nearly two-hour-long discussion.
Larry Dobrow (senior editor, MM&M): We might as well start on the broadest note possible. How different an animal is the millennial doctor?
Ezra Ernst (CEO, Physician's Weekly): It's only fair that we should start with the millennial doctor herself.
Sona Shah, MD (endocrine fellow, Weill Cornell Medical Center): I'll do the honors. One of the huge things about our generation is that we live in a connected world and we've been taught to be innovative in our thinking. A lot of our learning occurs via advancement through technology — social media and digital spaces that prior generations didn't have access to or, really, the pressures to learn from. We rely on these spaces to improve health literacy for our patients, as well as improve communication with patients.
We also have access to a huge network of other physicians, so we're constantly collaborating with other doctors and learning from other people. It's a team-oriented approach. Because of this, our generation has become very efficient in how we work and learn. In our inpatient setting, in our offices, and even in our outpatient settings, everything is connected through the EMR. All of our appointments are made through platforms like ZocDoc.
So everything is seamless. And a lot of management, especially in diabetes, has become team-oriented, which is different than what it used to be like for the baby boomer generation. Those things are new to our generation and they're exciting.
Jeanine O'Kane (president, inVentiv Health PR Group U.S., pictured): Do you think technology is also changing the nature of the interaction with patients in terms of how you're giving and receiving information and how they expect to get and receive it?
Shah: I think so. Our generation is under a lot of time constraints. We see tons of patients and, because of that, I often think the patient–physician relationship is sort of compromised. When I see patients in the office, I'm sitting behind a computer, I'm typing my notes, and I'm talking to them at the same time.
So I do think that technology has impacted how we interact with patients, but at the same time I don't know if there's a way around it.
Lucy Rose (president, Lucy Rose and Associates): There was a landmark study done by the University of North Carolina in 2012, so it's already a little bit old. But it lists a lot of the characteristics of millennials versus those of previous generations. They look at the concepts of teamwork and collaboration and note how you guys love to work together in different ways.
O'Kane: If you become a doctor, regardless of whether you're a millennial, there's at least some desire to serve and protect the health of others. So that's a shared value. All the other dynamics that are happening now, around teams and collaboration, are probably related to the other millennial characteristics, like perhaps the importance of work–life balance. Millennial doctors today are sort of creating an environment that matches up with those characteristics and values.
[To Shah:] I think first you're a doctor and second you're a doctor who is a millennial who comes with those characteristics and values. Is that fair to say?
Shah: I think it is. What's different for our generation is that shift toward patient-centricity. I think patients used to enlist a lot more trust in their physicians and confided in them almost 100%. Millennial physicians approach the concept of patient-centricity as trying to understand what the true voice of patients is, what their needs are, what their experiences are.
Rose: Which is interesting because physicians aren't hanging shingles as individual doctors but come together in group practices, which relates to the connectedness technology-wise because you can connect them in different ways. It puts a whole different spin on these concepts we've been talking about, because you have a multidisciplinary team all around you.
Shah: Exactly. Something like 50% of physicians are working in hospital-based settings or in large group settings. No one really goes into solo practice anymore.
Part of the appeal of that is that there is shared cost, but also it's that you have your colleagues there and you can run ideas off them. It's more of a team-oriented, collaborative approach, which is something that's new to our generation.
Ernst (pictured): There are systemic shifts happening outside the physician's control that have had major impact. There was an article in The New York Times recently that said physicians are prescribing more opioids because they have to get a high satisfaction rating from their patients. There's a lot of pressure on the physician to make the patient happy.
One other systemic thing I find fascinating is that the millennial generation has not dealt with the pharmaceutical industrial complex in the same way that previous generations dealt with it.
Dobrow: You make them sound like the Death Star.
Ernst: Before 2005 it was a different world. There were junkets and trips and things like that. I don't know any millennial physicians who are used to that. What they're used to is a patient saying, “I saw this commercial, I'm very interested in this product, it can help.” There's this consumerism of patients who are now advocates for themselves and have the same technology you have. It's the “WebMDification” of the patient, who comes in with a ream of paper and tells you how best to treat him or her.
Stacy Wallace (sales rep/clinical specialist, Genentech): The collaboration definitely does involve the patient. The patient is part of his or her own health. I'm sure for physicians that could be good or bad. There's a lot of information out there that patients may not understand or that may be incorrect.
[To Shah:] Your predecessors are resistant to a lot of this change. They had their own practices and now they're told they have to change to EMRs in New York State. Their scripts are now only electronic. They're not used to going in an exam room with a laptop and pecking away while they're seeing their patients. They tell me, “I wouldn't even be a doctor now. I would never do this.” Especially the internal medicine people — they feel they need to see 20 or 30 patients an hour because they have to meet a quota.
Shah: There are still a lot of challenges. There's all the Medicare coding and documentation regulations and utilization measurements. There are endless pressures and a focus on writing notes and malpractice and so much else that has really detracted from patient care. Even though it might seem like practicing medicine now is easier, there are certain external pressures that have made it pretty difficult.
O'Kane: And returning to your earlier point, that probably has driven the emphasis on collaboration and teamwork.
Rose: And then there's the business of medicine, which medical schools never bothered to teach until recently. But because of all the complicated issues, they've started to understand the importance of adding that as part of the normal curriculum.
Ernst: The most trafficked area in our sites, in our print publication, on Twitter, on Facebook, everywhere, is business-of-medicine questions. How do I set up my practice? How do I navigate an ACO? How do I deal with Meaningful Use 2 and 3?
Ten years ago, at Medscape, the largest CME course was palliative care. It's like, “I know how to do the medicine, but how do I navigate the other pieces?
Peter Kirk (CEO, Sermo), pictured: Adding to what everyone is saying, it's not just an age group thing. It is the context we find ourselves in, and that is one of being a digital native. We did some quick polling of millennial doctors prior to coming to this meeting and what's so interesting is that only 15% say they use consumer social networks like Facebook and Twitter to interact with patients. They're digital natives, but with patients it's very much “that is my private life.”
Shah: We were just talking about that. We don't really use social at all.
Kirk: It's too much exposure.
Shah: Patient confidentiality and HIPAA have steered us away from that. But we do use physician networks, such sites as LinkedIn, Doximity, and Sermo.
Dobrow: Which leads us into a question about consumer and professional networks. Is there any one site or tool you find most useful? Is there anything that makes your job easier or even more fun?
Shah: Doximity and Sermo, absolutely. Both of them have been helpful in terms of doing prior authorizations. You can email and text through some of the applications, which are HIPAA-secured. Some of them give you research alerts and some of them even provide referral networks.
Kirk: But most people just put them all in one bucket. Just as we use Twitter, LinkedIn, Instagram, and Facebook differently, it's the same thing with professional social networks. Doximity is much more akin to LinkedIn. Figure 1 is much more akin to Instagram.
Ernst: What about news sources? My father was a pulmonologist in the Bronx and he'd just sit there and look at journals.
[To Shah:] Where are you now?
Shah: I think the same. We're still using PubMed for some journal articles. There's one mobile app that I was recently introduced to called Journal Club, which is pretty much PubMed but in a digital form. We're still using Epocrates. Up to Date is huge. And we're still using actual journals.
O'Kane: Here's a question: What will happen to the medical meeting? Will that exist only virtually?
Shah: Maybe down the road. Right now we're still going to all these meetings in person. Virtual meetings? I don't know.
O'Kane: That's a business venture waiting to happen.
Rose: How about this: If you could wave your wand and create whatever you wanted, is there a way you'd like to have information packaged? How do you determine what to look at?
Shah: The Journal Club app I mentioned — it summarizes the latest literature in a more concise format. You don't need to read the entire article to get a sense of what it's about.
O'Kane: It's probably how that information can get to you, with all of these other things going on.
Kirk: In the millennial poll we did, 95% said they learn from medical journals and 75% from their peers and 50% from medical education and CME. Pharma reps only came in at 28%.
Ernst: The reason we're having a resurgence is there are no more pharma reps.
Wallace: I'm a dying breed. That's the problem. We can't get in.
Shah: There are two schools of thought on how we view pharma reps. Some think information about drugs and technology from a pharmaceutical rep is very biased and they want to avoid all interaction. Then there are people like myself who think that some of the information is helpful.
It's helpful to learn about new products and new technology and also have direct input, which we otherwise wouldn't have. With information from reps, we just have to be a little bit more cognizant about making prescribing decisions based on it.
Ernst: It must be hard given how much influence DTC ads have on patients. They're coming in and asking about a specific brand, not about a class of products. It's difficult for physicians to answer those pointed questions about a brand without talking to an expert, like a rep, about it.
Now, whether that means doctors are going to prescribe it, that's a completely different question, but they need to at least learn about the brand. This goes back to the systemic shift that we've been talking about, how millennial patients also differ from older patients. They're very willing to say, “I don't care what you recommend. This is what I want.”
Shah (pictured): Exactly. Which is why it's helpful in that sort of setting to have some sort of background. We're under so much pressure to see patients that we don't have a lot of time to read up on everything that's new in the industry. We do have to be a little bit aware of where the information's coming from and how the data is being pulled, but I don't think we need to avoid all engagement with pharma.
Dobrow [to Shah]: Patients coming in with brand requests, patients coming in with a huge roll of questions. How does that affect the way you go about your job? Is the so-called empowered health consumer a good thing from where you sit?
Shah: Patients constantly challenge us. They're constantly bringing in information that they read on the Internet or on social media, which is obviously something that prior generations of physicians didn't see. It's hard to practice, especially with the limited time we have, when patients constantly demand certain things. As we were saying earlier, patients want what they want, especially millennials. That makes the job a little tricky. But it's been that way the entire time since I started practicing medicine. It's something I've gotten used to. I didn't experience it the other way around, you know?
It can be a good thing. Patients are now constantly reading up about their diseases and how to manage them and how to change their lifestyles. There's a lot more accountability. It helps us practice medicine when patients participate in their care.
O'Kane: I was wondering if there was a behavior change on the part of the patient. Are they actually making changes or is it just the thirst for information? Meanwhile, people are living longer and there are more patients who deal with chronic disease.
If you're a millennial doctor with this group of older patients who have chronic conditions, but also this other group of younger patients, how do you tackle that dynamic? How do you deal with that spectrum of patients coming with different attitudes about their role and what they want and need from you?
Shah: Well, in general, millennial patients aren't going to their primary care doctors as much, myself probably included.
Ezra Ernst: You're indestructible at that age.
Shah: But when they do they look for a holistic approach. They want not just advice on healthcare, but on nutrition and organic foods and exercise. It's more of a lifestyle approach than it is for the older generation with chronic disease, which is more targeted.
O'Kane: You said earlier that you were surprised about the challenges that you get from patients. Does that mean the older patient is more traditional in terms of listening to what the doctor says and taking that course of action?
Shah: I think so. The millennial generation is better in that they're using technology to communicate with us, whereas the older generation doesn't do that. For them, it's all about face time. It's the millennials who are using the patient portals.
Ernst: Are they really using them?
Shah: Yes, especially at Cornell. Patients are always on the patient portal texting and emailing. I mean, even in my clinic I sometimes give out my phone number or email so that patients can text or email me.
Rose: That you get such a limited time with them in the office has something to do with that. What did we used to call it in the old days — “doorknob consults,” because on the way out they'd say, “One more thing, doc …” With the portals, patients can go back home, they can digest what they heard, and then ask that follow-up question that maybe didn't occur to them during the visit.
O'Kane [to Shah]: Is it overwhelming?
Shah: It is, especially with diabetic patients emailing their glucose logs every week. But it's a team-oriented approach. There are NPs and PAs to help. There are nurses to call patients back.
Ernst [to Shah]: Can you specifically talk about what millennials are using the portals for? Is it just communication with you or are they looking at education materials and patient handouts?
Shah: For the most part they're looking at labs and communicating.
Ernst: They're interpreting lab results?
Shah: That's the downside of it. They have access to all their labs and then a number will be flagged if it's abnormal and then they'll panic because they don't know how to interpret it. Then they'll email us frantically for an explanation and about why no one has called them back. It's great that patients can access their labs, but it adds more work for us.
Dobrow: How about patient responsibility? Do you expect patients to report to you about how they're doing in terms of informing you enough but not too much? What are your expectations?
Shah: We can't have expectations on an initial visit. We have to expect that they don't know anything. In terms of follow-up, I do expect patients to have some accountability for their care, as all chronic diseases require attention on a day-to-day basis. We're constantly hovering over them to manage these things.
Rose (pictured) [to Shah]: How do your patients sift through all of the available information? If you were to Google “diabetes treatment,” you might get 20 million hits. How do you help your patients help themselves?
Shah: It's a huge problem. Regardless of what we tell them, they're constantly googling things. There's really no good way for them to sift through that information and know what's valid and what isn't.
Dobrow [to Shah]: Is there anything that pharma can do to make your life easier in this regard?
Shah: A really important part of our job is patient education and pharma does do some of that. But if there were a way that pharma could look at all the specialized information out there and translate it into a more easily understood resource or platform for patients, that would be incredibly useful. We don't always have time to educate patients on everything.
Wallace: But everything has to go through legal. I might be talking about a particular disease state, but then I can't pull out a branded piece to speak about a product. The doctor says to me, “What do you have?” I say, “I can't tell you, doctor. I have to come back another day to do that.”
Rose: Pharma does have some really good information about disease states and some really nice sites out there about treatment. So the question becomes: Is there a way pharma can provide even better information packaged in a way that you think would be more helpful? Yes, there are ways to work around regulatory and legal things.
Wallace: We also have nurses that work with my team who can go in and speak directly to patients. We know doctors don't have time, especially for a rare disease that's very complicated. They don't have the hour that, at a bare minimum, it's going to take.
Shah: This is all news to me. I didn't know a lot of this information is out there. So if there's a way that that could be advertised.
Wallace: It's tricky. You're so busy and these patients are very sick. But they have to get counseled. We have 24-hour hot lines. We can't go to a patient's house, but we can meet at a third-party location.