Figure 1 helps doctors, puts the rest of us off our lunch

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jesusWhen Andrew Kesselman has some down time during the day, he scrolls through what might be the world’s weirdest social network: Figure 1, the Instagram for doctors.

Instagram for doctors is exactly what it sounds like. A stream of photos of various injuries and medical images and cat scans and infections and broken bones and tissue, taken by doctors, on a mobile app feed. It almost sounds like some kind of sick Dexter themed way to pass the time. But for the doctors, it’s actually a useful and more fun way to learn about new pathologies and cases from other medical professionals.

Figure 1 just celebrated its one year anniversary and announced that is has signed up 12 percent of all US medical students.

It works exactly the way Instagram does, with added consent forms. Doctors have their patients sign away the rights to their images, whether limb, head, skin, X-rays, internal organs. Figure 1 comes with its own version of Instagram filters, but in this case its anonymizing filters to blur any identifying patient appearance. The user can add information about the condition and hit post, and it shows up in the streams of anyone following that doctor. Users can comment on each others’ posts, carrying on discussions about the epidemiology background on the disease, possible treatment, and notable symptoms to look for.

As an almost-doctor wrapping up his medical residency, Kesselman heard about Figure 1 from fellow med students. “For me it was initially the shock value of the app that drew me to it,” Kesselman says. “Originally there were a lot of pathology photos I hadn’t seen before that were posted.” 

In fact, there’s plenty of pathology photos still on there today. When I downloaded the app, I was treated immediately to a feed of gross, scary looking afflictions from an open pus-filled sore with mucus coming out of it to a giant tumor-like lesion on a young boy’s lip.

After being sucked in by the pathology photos, Kesselman stayed for the radiology shots — his specialty. “Based on what population you treat you might see different conditions,” Kesselman says. “It’s nice to see things that for me are rare but for other people might not be rare.”

The clinching deal that turned him into a Figure 1 fan came when he saw a patient with a unique congenital facial deformity. He wouldn’t have arrived at the diagnosis nearly as quickly if he hadn’t seen a similar case on Figure 1 the night before.“I would have had to seek out a more senior radiologist or look in text based documents,” Kesselman says. “It would have been a longer process.”

At this point, he says he goes on it ten to thirty minutes a day, scrolling during downtime the way the rest of us might waste brain time on Instagram.

Figure 1 raises the question of what role social media can play in industries you might not think of it mattering. Social media is, at heart, about connectivity between people. It can help professionals engage more with current developments, share knowledge more quickly, stay up to date, and feel emotionally invested in the work.

Although doctors could get the information they need from textbooks, social media is the dose of sugar to help the spoonful of medicine go down. “It makes it a lot more fun to view these cases,” Kesslemen says. “When you can make it more social and interactive it makes it easier to digest the information and remember it.”

Figure 1 isn’t the only social media for doctors out there. Doximity is the “Facebook for doctors” where medical professionals have full profiles with their information and can securely communicate with each other, HIPAA-compliant, about other patients’ conditions. In the case of Doximity, the technology can even be life-saving. As we’ve covered, one Doximity doctor was able to get information about an epileptic emergency room patient’s conditions when she came in undergoing a cardiac arrest much faster through the e-fax system. It saved him fifteen to thirty minutes of vital time.

Figure 1 is less about such instant communication and more about ongoing education. “I don’t think directly it would be life saving,” Kasselmen says. “But it’s starting to grow now where it’s allowing people to keep up to date on things that are changing in medicine.”

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That Medicare doctors’ payment database shows how screwed the US health care system is

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rich-doctor-pennybagsOn Wednesday the authorities released the detailed information on how much Medicare pays out to physicians around the nation. And there’s been a lot of commentary on how amazing it is that some handful of doctors are earning tens of millions of dollars out of the system. It was also quickly noted that the top earning doctor, gaining over $ 20 million in one year from Medicaid, was currently being prosecuted for trying to rip the system off. So that’s OK then, the Feds are already onto this.

However, it’s all becoming a bit more complex as more information comes out about what has been going on. The first and most obvious point to make is that this doctor, Solomon Melgen, didn’t actually “earn” $ 21 million from Medicare at all. That’s what he was paid. And Medicare payments include the costs of the treatment as well as the payment for the labour of the doctor administrating it.

The secret becomes a little more obvious when you think that Melgen is an opthalmologist and that he’s practicing in South Florida. Where, rumour has it at least, there are quite a lot of old people. Add in a little more: one of the most expensive treatments (other than weird cancer ones applicable in small numbers) to come to market in recent years is the use of Lucentis for wet macular degeneration. $ 2,000 a pop, a course of treatment is in the $ 50k to $ 60k range. And yes, wet macular degeneration is a common enough disease that leads to blindness in the elderly.

So, one way of reading the story is simply that the right sort of doctor in the right sort of part of the country to have a patient base needing this new and expensive treatment gets paid a lot by Medicare. So what?

Except we come to another point of this story, which is that Lucentis and Avastin (a treatment for colon cancer) are in fact the same drug. Except that Avastin hasn’t been tested on wet macular degeneration and Lucentis has. Oh, and that Avastin can be had for $ 50 a pop. Yes, they’re both made by the same company, Genentech, and a doctor can use Avastin if they wish to: off-label uses are entirely legal. But the doctor gets to decide which drugs his patient gets and that’s probably how we want that government funded health care system to work. The doctors’ compensation is 6% or so of the drug bill with a minimum fee so one can see why one drug might be preferred over another. But obviously in this case it was entirely for purely medical reasons.

So we’ve got a bit of dodginess around the patent and marketing status of the two drugs. But here’s where the story gets really bizarre. For what is it that Melgen is being prosecuted for? If he’s just giving and expensive drug to patients who need it, as he’s allowed to prescribe, what’s the problem?

This:

According to the audit, the FDA-approved labeling for Lucentis stated that physicians should use one vial of the drug for each patient, at a cost of about $ 2,000. Each vial contained four doses, but the labeling stated that physicians should use only one dose for each patient and discard the excess amount, the audit said.

In 2007 and 2008, Melgen typically used each vial to treat four patients and billed Medicare for $ 8,000, according to the audit. He continued that practice through June of last year.

Well, that’s very naughty of him… wait, what?

The regulatory bureaucracy itself is insisting that 75% of the doses of one of the country’s most expensive drugs must be thrown away?

I’m not a fan of the US health care system the way it was and I’m not a fan of the way it is now either. But there are times when I think the Carthaginian solution is needed: raze it to the ground, sell the population into bondage and plough the land with salt then start again. Then I calm down a bit and think only that radical reform will do: which has to start with the admission that the FDA is at least a part of the current problem.

[illustration by Brad Jonas for Pando]

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