The Networking Doctor

The Oxford dictionary defines networking as a system of trying to meet and talk to other people who may be useful to you in your work.

Doctors have always been part of formal and informal networks through which they make patient referrals, take clinical decisions and update themselves on the latest treatment protocols. Even that Whatsapp group of your medical college batchmates is an informal network of doctors. Networking also caters to the continuing need of building one’s professional reputation and impulsive needs like jobs, medicolegal consultations and medical device purchases.

Doctors, as history tells us, can never work alone. Solving healthcare issues like antibiotic resistance, rising healthcare costs, public sanitation and last mile delivery is like killing the ten headed Ravana. Individual doctors and the medical community as a whole cannot hope to overcome the sheer complexity of such evolving villains by themselves. After all, even Shri Ram had to network with Hanuman to kill Ravana.

When Dr. Sidney Farber. a pathologist working to find a cure for childhood leukemia networked with Mary Lasker, a socialite, the war on cancer took a huge stride forward.

Most doctors network wrong. It’s not their fault. Our education system values data absorption and regurgitation more than the art of blending knowledge with empathy and synergy for the cost-effective welfare of a fellow human being. Also between the long study hours in medical colleges and the longer night shifts at hospitals, doctors spend most of their adult life surrounded by either books or fellow doctors. A generic doctor’s exposure to other professionals/fields of work remains very limited.

So in a world where physician burnout claims more lives than Thanos himself, building strategic partnerships or developing interpersonal skills that are helpful to create that ultimate Healthcare Avengers team remains a high effort/low return proposition for the majority of doctors who are either running after that glamorous Radiology PG seat or trying to make a high return on those 5+ years of medical education. 

Those who end up trying their luck at this ‘highly experimental’ protocol learn through trial and error. Some born with that networking gene are successful. But most fail and end up wasting years attending medical conferences and updates hoping for that elusive impactful meeting of a lifetime.

Digital Networking

Networking sites for doctors have been here for a while. Sermo, PlexusMD, Doximity and Curofy are well known names in this domain. Sites like Incision Academy for surgeons, Orthomind for Orthopedicians and MomMD for doctor-mothers are catering to very specific niches.

The most important function of such sites is real-time medical crowdsourcing. Breaking geographical and accessibility barriers, doctors are now consulting each other over difficult cases to improve patient outcomes. The beauty of this is the creation of digital repositories of treatment workflows. Over time efficient search and sort tools can bring up anecdotal cases to assist medical decision making.

Other digital networking applications:

  • Sharing medical updates.
  • Discussions.
  • Sharing practice management ideas.
  • Actualizing issues that faces the profession as a whole and taking a stand for it when necessary.
  • Partnerships with patient advocacy groups, NGOs & non profits.
  • Extension to student communities for knowledge sharing.

The only real concern with digital networking is that it might distract you from your actual work. It’s another way to bring your work home with you, and this could further contribute to physician burnout.

The Economics of Networking

Does the way doctors network affect healthcare costs for patients?

A research paper by James Whisler, Kumar Kanisan & Jesus Leal Trujillo published by Deloitte in 2019 studied physician network dynamics using Medicare Fee for Service claims filed in three US states. They identified six conditions with relatively predictable care and treatment patterns — cerebrovascular disease, chronic obstructive pulmonary disease, coronary artery disease, fracture/dislocation of the hip/femoral head, hypertension (essential) and spinal/back disorders. By retracing patient referrals, they mapped out the structure of physician networks providing care to patients with these conditions and measured the relationship between network characteristics and average spending per episode.

Deloitte’s analysis of these network dynamics in Medicare shows that where physician relationships are tightest, spending for certain health conditions is lower. For instance, an increase in the physician centrality (a measure from network science that captures the degree of coordination between disparate parts of the network) decreases average episode of care cost for hip fracture by almost 15 percent (or US$2,000) and for coronary artery disease by 26 percent (or US$1,050).

This has immense applications in healthcare plans like Ayushman Bharat Yojana and Ex- servicemen Contributory Health Scheme (ECHS). Claims data can be used to identify high and low performing networks and all the physicians who are part of that network. For example, one can find a specific cardiologist whose costs are lower compared to others in that cardiologist’s network. This information can be shared with doctors and patients to encourage them to change their care patterns and referrals or for validation of their efforts in this direction.

Think on the lines of high patient rated and cost effective medical practices in a particular geography being connected digitally. Think about doctors running these practices being so connected to each other that Dr. A knows not to send a child with a broken arm to Dr. B because Dr. B is getting his Xray machine repaired. Think about the peace of mind that we can get knowing that we have made the referral to a dependable highly rated colleague at a cost that the patient can afford. Think cloud connected multi tier healthcare for patient referrals.

Sounds like a startup.

Ars longa, vita brevis.

(The art of medicine is long, life is short.)

Hippocrates

Veganism & Vitamin B12 Supplementation

The Economist declared 2019 “the year of the vegan“. Globally, more people are adopting the vegan lifestyle today than ever before. Vegan restaurants are opening up in every geography. Supermarkets are improving their selection of vegan processed food. Don’t be surprised if a plant-based meat shop opens up next to your neighborhood KFC.

The reason for going vegan may be health related, after all, there is documented evidence linking reduction or exclusion of animal foods to lower risk of lifestyle diseases. Or the reasons may be ethical and environmental. In the latter case, knowledge about the nutritional aspects of such a choice might be lacking. Although well-planned vegan diets are considered appropriate for all stages of life, including infancy and pregnancy, it requires food fortified with Vitamin B12, Vitamin D, Calcium and certain useful Fatty Acids which are naturally deficient in plant based diets. 

Vitamin B12, also called Cobalamin, is a water soluble vitamin important for making DNA, myelin sheaths (structural component of a nerve cell), neurotransmitters and matured blood cells. Recommended Daily Intake (RDI) of Vit B12 for adults and pregnant women is 2.4 and 2.6 micrograms respectively. A common misconception among vegetarians is that the presence of dairy products and eggs in their diet is enough to take care of their Vit B12 requirements. It’s body stores lasts for several years and its deficiency develops slowly. However, the combination of malabsorption and inadequate dietary intake will hasten its deficiency. The only substantial source is animal meat. The prevalence of vitamin B12 deficiency (<200 pg/ml) is at least 47% in Indian population. If B12 levels of 200 – 300 pg/ml are considered as borderline deficient, then up to 74% of the Indian population would be potentially deficient.

Clinical manifestations of Vit B12 deficiency can be broadly divided into neuropsychiatric (like myelosis, cognitive disorders, depression and dementia) and hematological (like megaloblastic anemia). Neurological symptoms are the first to appear. Typically a new patient comes with complains of pins and needles sensation in the foot sole and along the legs. The diagnosis is based on clinical symptoms and blood investigations, but no gold standard test exists at present.

At risk population for Vit B12 deficiency:

  • Vegan/Vegetarian diet.
  • Elderly (Age > 51 years).
  • Pregnant women, lactating mothers and their infants.
  • Patients who have had weight loss surgery.
  • Patients taking proton pump inhibitors (PPIs) like Pantoprazole (popular among the elderly as Gas ki Dawai a.k.a. Medication for Dyspepsia) or diabetics taking Metformin.
  • Patients with Gastrointestinal conditions.

Prevention:

  • Diet – Inclusion of more dairy products and eggs in a vegetarian diet. Shiitake mushroom is an excellent source as well. As mentioned above, a vegan/vegetarian diet alone isn’t enough to meet daily requirements.
  • Food Fortification – Food fortified with Vit B12, like nutritional yeast flakes and breakfast cereals. But considering the magnitude of deficiency in the general population wheat flour fortification is being looked at with great interest. Presently, there aren’t enough intervention trials on the effect of different fortification levels of flour in different populations. But this will be a huge opportunity for wheat flour companies in India going forward if they can do what Tatas did with Tata Salt Plus to combat nutritional iron deficiency in India.
  • Oral supplementation – Vit B12 pills are available over the counter in varying doses. A standard multivitamin delivers 6 micrograms of Vit B12, more than enough to cover the average body’s daily needs. But some studies have shown that using multivitamins can be inefficient and counterproductive for the supplementation of Vit B12 as Vit C and copper in such pills can form inactive by-products with Vit B12.