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HIStalk Interviews Jay Parkinson MD MPH, House Call Doctor

November 5, 2007 Interviews 13 Comments

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Photo and site: Jay Parkinson, MD, MPH

I didn’t have much trouble tracking down Jay Parkinson. He’s ubiquitous for a guy whose medical practice is just a few weeks old. He’s been interviewed many times, has a blog, and apparently is coming soon to a TV near you, all because of his Medicine 2.0 – which is actually Medicine 1920s – making house calls, charging reasonable cash prices, and being available whenever his patients need him, all in the hip Williamsburg neighborhood of Brooklyn.

He insists that it’s not about the technology, which in his case is the PC tools everybody else uses (Google apps, e-mail, IM, etc.) He doesn’t even use an EMR system any more, having given it up because it didn’t meet his needs. So, the lessons to learn from Jay aren’t about use of cool technology, but more about practicing medicine the way he wants, addressing some of the challenges of the healthcare system along the way.

Tell me about your background and your practice.

I’m a 31-year old male. [laughs] I practice in New York City, mostly in Williamsburg and Brooklyn. I started the practice September 24 after two residencies, the first one in pediatrics at St. Vincent’s Hospital here in the West Village and the second one in preventive medicine at Johns Hopkins in Baltimore. Seems like it’s going pretty well for me.

Most people associate house calls with country doctors carrying little black bags, but you’re in New York City.

I still have my black bag that I carry. Just getting around the city is next to nothing. You take the subway, walk, or take the bus. In the near future, I’ll be buying a scooter so I can scoot around. Hopefully I can keep every house that I visit within a 15-minute travel time.

Describe a typical patient encounter.

It’s great because they submit all their information ahead of time, so I pretty much know what’s going on prior to the meeting. I know what to talk about, what points to hit, what things I can skip over that other physicians would concentrate on and waste time on. They spend 10-15 minutes giving me all their health information via an online form. It’s very streamlined, but I still spend about an hour and a half per visit, talking to them, having them show me their art work. It’s very laid back.

I’m not a very formal person. Everybody that I’ve seen has really enjoyed seeing their doctor rather than being in some sterile, foreign environment that everybody knows and loves as a doctor’s office.

What’s it like making house calls and what do you learn that an office-based doctor wouldn’t?

Somebody has asthma, maybe lives in a dirty warehouse loft, I can pick up the fact that it’s pretty friggin’ dusty or has mice. It just gives you a feeling for who somebody is. You can tell a lot by how they live, more from a mental health perspective. The United States is a pretty clean place so we don’t have a lot of sanitation issues or something, but it gives you a more full picture about the person.

What technology do you use to run your practice?

It’s very basic, freely available technology. I have a Macbook and an iPhone. IM programs, like ATM and iChat for the Mac. I just use regular e-mail, Gmail in fact, because it’s very powerful.

I use a website called Formspring for my online forms. It’s very simply drag and drop forms creation. Any form can be made in three minutes or so. It uses skip branch logic, so questions can appear or disappear based on responses to previous questions. I use that to get another diagnosis through a careful history, because an early question is a branch in the algorithm for proper history taking. I think it’s safer because doctors aren’t perfect and sometimes they forget to ask very important questions about something rare. If I can spend time asking these questions beforehand, I don’t have to be worried about always thinking about every little thing during my interview session with the patient.

I saw on the Web that you use the Life Record medical record system. Tell me how you chose it and how it works for you.

Actually, I have abandoned that, simply because it’s not very customizable and I thought it was going to be. So, I’ve abandoned that. But, I was fascinated by it because it has a lot of features that I think would be very valuable for a traditional office-based practice with multiple practitioners. Having access to records by iPhone on a Friday night at dinner is vital in some circumstances.

Now I use Apple’s version of Excel called Apple Numbers and have created templates for nearly every condition that I have. I can use them for a physical exam or generating an invoice. It’s really just using Apple’s iCal for scheduling synced to Gmail’s calendar. iCal and Gmail and iPhone are all updated at the same time in real time. It’s pretty basic stuff.

You’re an iPhone fan, I hear.

I love the iPhone. I think that’s amazing. Hopefully I will be able to put Apple’s Number files on my iPhone. I think they’re coming out in with developer’s kit for iPhone in February and I’ll be able to use my iPhone a little more intensely. I could only get to my records by iPhone with Life Record. He’s a great guy, the guy that developed it, and I’m sorry it isn’t specific for what I need.

When it comes to technology, you seem to be a geek, but you deal with artists and are one heck of a photographer. Where do you fall on the geek-doctor-artist continuum?

I’m definitely fairly geeky, I guess. I really like technology and gadgets. Right after the iPhone came out, I wasn’t going to wait in line forever down in Baltimore. I’m all things Apple. I did the iPod first day it was announced years ago. I designed my own website and can do programming. I don’t know CSS or anything like that. I’m not trained in any technology, I just kind of figured it out on my own.

You charge $200 a house call. Do patients find that competitive and can you make a decent living at that price?

Sure. Look, I have no overhead whatsoever. If I charge $200 a visit, $195 of that is straight profit. I think that’s a pretty good living. If I see eight patients a day, that’s $1600. Without having staff, an office, billers … it becomes a very easily doable practice. I definitely designed the business model looking at that. The concept of doing the housecall was a way to open a practice without putting $300,000 upfront. I started this whole thing for less than $1,500.

Would your med school classmates think this is weird, or are they looking for more satisfying practice models too?

Everybody that I’ve trained with has been extremely supportive. I just got done with an interview for the London Times. Obviously there’s something interesting about what I’m doing since now I’m making international news.

What I’ve created, not to toot my own horn, is pretty ingenious. It’s a Band-Aid to a gaping wound in a lot of ways, the fiasco that is the American healthcare system. 50 million people without health insurance – there are a lot of voices behind what I’m trying to do. I’m doing a good job, I guess, getting the word out about the plight of the uninsured and also seeing patients at the same time.

A few people have mentioned security and privacy issues because of the technology I use, but because I don’t deal with insurance companies and don’t submit any patient health information online to insurance companies or Medicare or Medicaid, I don’t have to follow HIPAA regulations. I’m considered a country doctor, which is kind of interesting.

On your website, you talk about how you search the market to find the lowest fees for specialists and other medical services you can’t provide directly. How do you do that and what interesting stuff have you found as a result?

It will blow your mind what I found out. I graduated residency June 30th. Since then, between June 30 and September 24, there’s a good three months where that was what I was doing, finding accurate contact info for physicians in New York City and calling them up and asking what they charge, putting the information into a database. A mammogram ranges from $175 to $750, both of them amazing facilities, but nobody’s regulating healthcare prices.

Also, there’s widespread belief in the healthcare industry that they shouldn’t be competing for cash-paying patients because there’s so few of them. 50 million isn’t that few at all, but there’s no free market in the healthcare industry. The vast number of people have health insurance and doctors aren’t competing for their business at all. Its so funny, when I tell radiologists or pharmacists or anyone who stands to benefit from me referring my cash-paying customers to, it’s laughable how they kiss my ass to try to get my business.

The ultimate goal here is to create more transparency in the healthcare pricing scheme. I’m trying to create that transparency on my own because the healthcare industry won’t do it because they profit from that.

How would you compare what you do with the retail clinics that are springing up everywhere?

Most of the time, it’s simply a profit-driven marketing scheme. I’m personalized service. You call me up, I go to your home, physically examine you, follow up by IM or e-mail or text messaging. I get to know you as a person. I’m not remotely competing with retail clinics at all. People who go there want something different than I provide.

From your viewpoint, what’s the most wrong and most right about the US healthcare system?

It depends on who we’re talking about. Older people and very poor people, there’s absolutely nothing wrong with it whatsoever. For people who have insurance, there’s not much wrong. People who don’t have insurance because they’re young and healthy and priced out of paying an average $10,000 here in New York for an HMO, there’s a lot wrong. It really just depends on who you’re talking about. It’s hard to generalize that way.

My patients are people who are concerned about having or not having health insurance. New York State has policies that ensures that everyone pays the same for health insurance. That’s great for sick and old people, but young people can’t justify spending $9,500 when they only make $45,000. That to me is a significant problem for the uninsured in New York State. It’s a great solution if you’re old and sick.

You just started this practice and here you are, four or five weeks later, you’re in newspapers and on TV. You mentioned in an interview that you’re getting unbelievable offers to do TV and books. What’s coming your way?

You name it, I’ve gotten it. It’s pretty insane. Keep your eye out, probably next fall, for a TV series from a producer of movies that the whole world has seen, She’s getting back into an original series. I’m starting to write with her in a week and we’re going to start developing a TV series together, not a reality series. The major networks are interested in this concept. We’re developing it so it appeals to everybody, but it deals with the healthcare issues that are afflicting America. That’s in the works.

I got a book offer on Monday, so I’ll be writing a book about the healthcare industry using examples from my life and practice. The London Times was today. I’ll be doing a big talk show soon and Steven Colbert on November 12. It’s kind of insane. They’re all coming to me. I don’t have a PR person. I’m doing everything myself. I haven’t put out a single press release.

Is is scary that people want you to comment on an industry that you’re brand new to?

No, not at all. Sure, I don’t have experience in private practice dealing with insurance companies, but I’ve worked and talked about the healthcare system for years, getting my master’s in public health. I worked with Sidney Wolfe in Public Citizen’s Health Research, Ralph Nader’s consumer watchdog group in DC. I’ve worked at the Maryland state department of health level. I worked with National Association of Firefighters as their medical consultant. I’ve done a lot.

I’m not like a normal doctor who finished a residency and sees patients. I intensely studied the healthcare system and figured out its strengths and deficiencies. I spent the last three months at Hopkins on quality of patient care, studying quality in the American healthcare system. Doing Six Sigma and Lean Kaizen in various departments in Johns Hopkins, trying to figure out where the patient problems lie, problems with reimbursement and unsafe practices that lead to poor outcomes. I’m not worried about being a spokesperson.

Do you think you’ll keep practicing with all these offers?

I wouldn’t mind doing part-time for both. One thing I don’t want to be is part of the industry. I’ve got plenty of offers to join companies and form alliances, but then you become part of the problem, like most doctors. The practice of medicine is very conservative and appeals to a conservative type of person. They don’t really teach you to think outside the box. They try to prohibit you from thinking outside the box.

A lot of people are getting hung up on the “doctor who makes house calls.” Really, there’s no difference in seeing a patient in their homes instead of in the office. I don’t have a laboratory, so I can’t do rapid strep tests. It’s a little difficult to do male urethral swabs, stuff like that. Female exams, I just don’t do, but I refer to someone.

There’s really no difference between a house call environment and an office environment. I draw blood as I need it and a car comes up and picks it up outside my apartment door each night. To me, it was just a business model to start a practice on the cheap. People are also hung up on the technology, but it’s the stuff that everybody uses in every other industry in America. It’s just not being used to communicate with doctors.

Most doctors don’t even want to get patient e-mails.

Congress just passed a 10% Medicare reduction on to physicians yesterday. The only way doctors are making money these days is volume. If you see 30 patients a day, at 6:00 you go to your computer and there’s 30 e-mails, God, I can’t charge for these just yet. Why would I entertain the possibility of receiving e-mails from my patients? I understand why doctors are averse to that.

The way I treat patients, I can see six to eight patients a day, and as I’m traveling, I can answer e-mails. I’ll receive forms in my e-mail from patients who want to see me in the next hour if I’m not busy. With an iPhone and a Macbook, its ridiculously easy to keep track of everything.

You obviously love New York.

I’m a big fan. It’s the center of human culture. Everything is right here. If you want to go see this really obscure movie, it’s playing down the street. If you want to see this amazing photography by the best photographer in world of all time, it’s coming to town next week.

A woman was visiting me from Ireland and said something that describes New York as a summary. She said, “The one thing I love about New York is that the answer to every question is yes. It might cost some money, but the answer is yes.” She asked if I’d been to Ireland and I said no. She said the answer to every question in Ireland is either no or maybe.

The architecture and infrastructure here is just awesome. You don’t have to have a car.

Will you stay there or go Hollywood? You could leave your practice after one month and be in the public eye constantly if you wanted, doing stuff that people only dream of.

I’m not to going to go Hollywood, at least not yet. It seems that way, doesn’t it? We’ll see what happens. If I can start some sort of system … I have ideas and I have people backing me to create something along these lines that can benefit more than the 1,000 patients I can see here.

You could easily be rich and famous.

You should see my apartment right now. [laughs] It doesn’t look like I’m rich and famous just yet. But It’s New York, where the answer to every question is yes. The opportunities for me are endless, I think.

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Currently there are "13 comments" on this Article:

  1. Cough, cough. Um, Dr. Parkinson, I am in desparate need of a house call.

    Mr. H told me he had interviewed you. If I had known you were so adorable I would have insisted he fly me to NYC to handle the interview myself.

  2. Brilliant interview from a bright and entrepreneurial man. It is refreshing to see someone really question the assumptions and make a bold change that helps people.

    Jay – you have a product there in your forms. I’d recommend either open sourcing it, developing it as a product, or selling the concept.

    Also, podcasting or blogging about your practice would be a great way to spread the word to medical students to consider the alternative form of practice.

    Best wishes Jay

  3. More PHR please. More doubt and negativity concerning Personal Health Records (PHR) as successful, it looks as though PHR is coming home on the coat tails of EHR.

    The good people at HL7 are ready to vote on The PHR functional model. Don’t want to make too much comment about inevitable PHR because it only appears to incite readers but take a look at your own risk: http://www.hl7.org/ehr/

  4. He’s also a big fan of physician dispensing – aka, filling prescriptions “on the spot” via a supply of pre-packaged prescription medications. Talk about convenience! (Yes, the service is safe, and no, he doesn’t dispense every prescription … just the most common generics.)

    I love his blog. Very down to earth guy.

  5. Great interview, and really an excellent example of a healthcare entrepreneur. It’s too bad there’s such a need for this type of service as our system fails so many people. I was initially wondering how one would keep up one’s interest and intellectual stimulation in a model like this, since the medical part of the practice must become very routine very quickly, and is probably dwarfed by the counseling side, but the range of other activities that have sprung off from teh practice is very impressive.

  6. “”A few people have mentioned security and privacy issues because of the technology I use, but because I don’t deal with insurance companies and don’t submit any patient health information online to insurance companies or Medicare or Medicaid, I don’t have to follow HIPAA regulations. I’m considered a country doctor, which is kind of interesting.””

    Yikes… Eventhough you’re not dealing with insurance, you are still identified as a “covered entity” under HIPAA and required to abide by the privacy and security rules. You mention your tool set includes Gmail, IM, forms, etc. all of which fall short of the HIPAA required level of security/encryption to protect the PHI being exchanged. Why do you feel you don’t have to follow HIPAA regulations? That statement really concerns me… I assume med school would have reinforced compliance in each class before sending you out on the street (pun intended).

  7. 1 word…cherry picking. just a concierge practice for the worried well. not even close to a national solution for healthcare crisis in this country. one year from now he will be doing something else, and no one will recognize his name or game. but i’m not bitter…

    /30 year combat veteran (ED/Hospitalist)

  8. ID Thief…

    As a matter of fact, I am not a covered entity under federal HIPAA laws. The definition of a covered entity under HIPAA is very, very specific and the federal government has a flow chart to determine if you are a covered entity. It can be found here:

    http://www.cms.hhs.gov/HIPAAGenInfo/Downloads/CoveredEntitycharts.pdf

    I still have to abide by NY state privacy laws where HIPAA regulations do not preempt them. NY state does have privacy laws as well (most of which are preempted by federal HIPAA laws). NY State has a very informative (albeit a little confusing) webpage devoted to what state laws apply and where federal HIPAA laws apply. HIPAA solely regulates those individuals who transmit private health information to another entity such as insurance companies, research institutions, etc.) The proof of me not breaking any privacy laws in NY State is found here:

    http://www.nyhealth.gov/nysdoh/hipaa/hipaa_preemption_charts.htm

    Thank you for your concern.

    DZA MD…You are absolutely correct. Young people don’t need doctors. They never get sick! Just because the demographic I’m treating doesn’t need to see the doctor as much as 30 year combat veterans, they still see a doctor on average about 3 times a year. It’s just the nature of life sir. No demographic is immune to needing a doctor. Some simply need it more than others. If you think that the only point to being a physician is to prolong the lives of the elderly who use the healthcare system to it’s capacity, then I don’t even know why I’m addressing this issue with you. I’d also appreciate it if you could tell me how my practice is a concierge practice. You must not have read up on the real issues of my practice. It’s not the house calls nor the technology. It’s much more about taking care of my patients ensuring they don’t get screwed by the Industry that profits from keeping cash paying customers in the dark…and that’s an industry you, as a veteran physician, helped create. I wish there were more physicians who were fighting for more transparency in healthcare prices back when you were my age. If so, 50 million people across America might not be in such a bad situation.

  9. Jay-

    I must apologize for the terse and cranky nature of my comment. Up all night with critically ill patients does that to me. And ad hominen attacks are simply unacceptable, and it is valid to reply in kind. So let us start fresh.

    Yes, young people do get sick. Usually from self-limited illnesses that their mothers could once handle. The demographic you serve has a mortality rate of between 2 and 10% of that of the general population and a fraction of a percent of the highest risk population (the elderly). While I share your dismay with the over treatment of the old and dying (personally, I share Ex-Colorado Governor Richard Lamm’s point of view that the frail dying elderly actually have a moral “duty” to die, which is why he is an ex-governor), few if any, of your patients are seriously ill. And when you walk into your first hot leuk, DKA, HIV w an OI, or septic cirrhotic GI bleeder, please let me know how you plan on handling it…a 911 call would seem your only real option and yet a very cost effective and safe disposition from your perspective, no? and then you simply walk on to your next “case”. Of course, now that patient is in my world. And yes, I did create the current insurance company/ greedy clinician brinkmanship fee-for service arms race, but I so rarely get credit. You are too perceptive and kind. ( BTW- I have been on salary my entire career).

    In regards to concierge practice…I just glanced at your (very eye candyish) web site. Just exactly what is NOT concierge about it? Cash only, and if one is actually ill, a list of other doctors (pick me!) to go to. Buena suerte persona enferma!

    And, you may as well know, I was bucking the system before your were a blastocyte, beginning with a medical school Grand Rounds Expose on the morally bancrupt policies of the AMA, to open forums on the medical-industrial complex, getting black balled for calling out physician executives, to one of the most famous hacks in medical lore (http://picasaweb.google.com/mike.dematteo/Funny/photo#5130812848713903442).
    (FTR-I am not actually admitting to being mike dematteo md (( I wish!)), but he was kind enough to host my stuff)

    So, lighten up. And hurry up and diagnose those sniffles and rashes before they go away!

  10. Dr. DZA,
    I have one word for you: sour grapes. I have been in health care for almost 20 years. Lest you think I am some obsequious sycophant trying to curry the favor of the latest flavor of the month, I am under no delusion about what is happening here. I realize that this gentleman could just as likely appear in an underwear ad as in a picture with a stethoscope around his neck. I am not so naive as to think that if Dr. Jay looked like (oh I don’t know, how about photo # 17 from the link you supplied?) then this story would probably not be spreading so quickly.
    Additionally, I also know that it helps to have someone who does not seem to shy away from the media spotlight as the poster boy. In fact, I have read interviews with Dr. Parkinson on several websites which were unique interviews and not reprints. One can’t help but think, how does one make time for house calls with all the interviews, book deals, and TV projects seemingly taking up so much time?
    Still, with all of that said, I greatly admire Dr. Parkinson because, regardless of the messenger or the means of communicating it, the message is an important one. Just because the practice of medicine has turned you into a bitter gerontophobic physician, it doesn’t mean that Dr. Parkinson’s demographic is to be discounted. Obviously, the good doctor can comment for himself, but it would seem that the folks that he treats are those, primarily, without insurance. Secondarily, these individuals just happen to be the demographic that you seem to loathe. You point out that he does not “treat” sick people, but refers them to other doctors. Well, as an ED doc, don’t you think the argument could be made that you have made a career out of sending patients to “a list of other doctors” (pay ME!)?
    Lastly, you may look back fondly at some of your earlier “fraternity pranks” in regard to your rebellious, radical days of yore. The sad truth is that your “statement” (if there is one) is on a public access site in the form of cutout letters glued to a white piece of paper. Dr. Parkinson’s message, on the other hand, can be found, among other places, on the London Times website which, I have heard, is a fairly respectable publication. Could it be that this man has accomplished more in 6 months than you have in an entire career?

  11. Sour grapes? Would explain the acrid tongue. Sharp work, Osler.

    For the sake of civility let me end offer this. Many before Jay, including myself, have toyed with concepts of uncluttered practice models and the holy grail that is the high touch/high tech boundary. Elusive, it is. So, give it a go, Jay, and good luck. In the end clinical ennui will probably get you, if fame does not. Otherwise I shall be hushed and chastened if Dr Parkinson is still doing this even 2 years from now. In the meantime, let us all be careful about bashing those boots on the ground who work against the machine from the inside, day in and day out. The modern hospital setting is the most complicated human working environment on earth and will not come into order easily, if ever. If it were otherwise, M$ or Google would have done it already.

    BTW- I love this website. Thanks Mr H and keep up the good fight.

    DZA MD

    “I am not young enough to know everything.”

    -Oscar Wilde

  12. reading through the comments chain, I had to smile at the fact that Jay is ‘still doing this’ (disrupting healthcare for a better patient experience) 7 yrs later despite those who voiced otherwise (see above). I never had a doubt. thanks for always being an inspiration in medicine and design, Jay and I hope sherpaa spreads like wildfire.







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