Stay on track until I tell you to completely change direction

I want to thank Judy Siegel, the health news reporter from the Jerusalem Post for sending me a link to the following article “Your doctor is arriving now” by Jennifer Van Grove, in the San Diego Union-Tribune from Feb 3, 2016.

This article describes a new company, called Heal, that is focused on recreating the house-call, albeit with the backup of today’s technologies. To quote:

Heal is meant to be a viable alternative for scenarios when scheduling a doctor’s visit feels impossible, but a trip to the ER is definitely not the best option. The app, which the co-founders hope turns into an acceptable stand-in for primary care, can also come in handy for oft put-off preventive care or flu shots.

With Heal, doctors are available for on-demand attention daily between 8 a.m. and 8 p.m. The company is also in-network with a couple of insurance providers, including Anthem Blue Cross of California and Blue Shield of California, meaning the in-home convenience could cost no more than your standard co-pay. Otherwise, Heal charges a fixed cost of $99 per visit

I responded to Judy in an email, and I wish to share the email’s contents here. Thank you for your attention.

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Dear Judy,

Once again, thank you so much for sending me an excellent article that raises a whole range of issues. And once again, I find myself referring to Dr. David Applebaum, who understood these concept 30 years ago, well before the world was ready for it. Delivering a solution that answers people’s needs for health care, between the family physician and the emergency room, is the raison d’être for David’s concepts of health care. David’s initial work in delivering blood thinners to heart attack patients, already in the ambulance before even reaching the hospital, changed the entire world’s approach to heart disease.

David understood that the classic delivery of care was insufficient. Given time, which both he and his daughter were denied, he would have had all of these modern ideas and more. David shared with me ideas for technologies that I kept telling him were still years, if not decades, away. It was even near the end of my time in TEREM that I was still implementing ideas that he raised. And I was on the verge of starting a whole new phase of technology for TEREM that would have further implemented more of his ideas. But I left.

When TEREM was young and the only clinic we were running was Romema (situated at the entrance to Jerusalem), our quality of care was very high. The clinic was staffed by senior physicians from various backgrounds and truth be told, we were not as yet receiving complicated patients. Waiting times tended to be shorter, although post-Shabbat periods were still very busy, and waiting times did become significant. The point is that on a small scale, it is always possible to deliver a quality that becomes very difficult to deliver as scale increases.

I always use a simple mathematical formula to explain the issue of scale in medical delivery. The top 10% of doctors is numerically 10% of all the doctors. So, if there are 1000 doctors in the country, the top 10% is 100 in number. If you start any service, that ends up demanding 101 or more doctors, then you start to draw from the group of doctors who are not top 10%. It is possible to compensate for this by training the second-tier doctors up to a higher level. The primary way I compensated for this was via my software. So if a doctor would forget to do a basic test, the software would remind him or her to do it. Making consultation, with a remote senior physician, a single click affair, dramatically increased such consultations. As such, junior doctors had immediate access to seniors and thus learned “on the job” and became more proficient at their work.

By the time I left TEREM, it was possible to see X-rays, ultrasounds, photographs, the entire patient history and of course a digital record of the patient’s present stay in TEREM. With all of this information, it was much easier to render an accurate consultation.

I was also still waiting for tablets of the size of an A4 piece of paper to drop below $100. At this magic number, it would have been cost-efficient to give such tablets to all of the staff and finally implement a concept I have had for 20 years, for digitalyzing the “hand written” patient chart. The last thing I would have implemented would have been the present day breakthroughs in automated X-ray reading. This is something that I directly contributed to, and the potential is nothing short of game changing.

The model for home visits described in the newspaper article sounds wonderful. BUT you have to find the doctors, you have to be able to pay them enough, you have to trust them, they have to be able to safely go to where the patient is, and you have to be ready to deal with any medical legal issues that come up. All of what I’ve just said is exactly why it is so hard to expand these models beyond relatively small geographical areas.

The future of the home visit is, not surprisingly, technology-based. We are on the verge of seeing a breakthrough in home-based intelligent robots. These robots will be driven by an AI that does not yet exist (but will, in the next 5 to 10 years), and these robots will be equipped with all of the devices I have already mentioned, including many more. Please remember that the future of wearables is as implantables, smart clothing and buildings, and of course the AI to put all the information together into a clear, concise and clinically relevant package.

The patient who is at home, with baseline congestive heart failure, will be constantly monitored for any change in his or her status. Even before the patient realizes that there is a problem, this home-based monitoring system will alert a medical overseer who will decide whether a home visit, clinic visit or hospital visit is necessary. In other words, home visits by a physical doctor is a beautiful idea which presently does have a market, but will fade away over the next decade due to these critical and life-saving robotic and AI technologies.

This entire medical field is so dynamic that startup companies have to plan for obsolescence almost from day one. If a startup in this field is successful, they constantly have to be thinking how to “pivot”, i.e. drastically change focus, as soon as the winds start blowing in a different direction. Even Microsoft has drastically pivoted in the last couple of years. One of the reasons why I personally find it so hard to believe that Apple is the most financially successful company in the world is because they really don’t pivot. And I am not the only one who is expecting that anything short of a dramatic new technology will leave Apple in a very vulnerable position in the years to come. But of course, any prediction I have had about Apple has been wrong, so I wouldn’t put much credence in what I have just said.

If the new generation of doctors finally accepts their role as service providers rather than as G-d’s disciples on this planet, then startups like this one will have a much greater chance of success. The entire old school of medical thought is so outdated, it almost begs an archaeologist to document it. The younger generation is faced with a very difficult task of learning from older doctors who just don’t get it, while introducing and implementing on their own, all of the new technologies that are coming our way. Once the medical students of today have become the professors of tomorrow, then the exponential improvements in medicine will truly take off.

Another thing that future doctors will have to internalize is that making the salaries that they do already puts them at the highest end of the middle class. Doctors who will still have the fantasy of becoming super wealthy via their medical practice will either face disappointment or have to retrain as Beverly Hills plastic surgeons.

My viewpoints are still considered quite radical when shared with fellow physicians of my age, i.e. in their late 50s and 60s, and includes those physicians who are already contemplating retirement. They smile at me when I talk, and still manage to say that what I describe is a fantasy. Despite the fact that much of what I have said has become a reality, they still laugh. I guess their brains are simply not plastic enough to internalize such grand changes in their worlds. In my case, I guess my wild imagination finally paid off.

Thanks for listening.

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.