rahul k. parikh's Open Salon Blog

Bedside Manner at the Apple Store Genius Bar

Wed, 30 Jun 2010 18:06:23 -0400

My life is wired by Steve Jobs and Apple. When I was a kid, my first computer was an Apple IIc, followed by Macintosh Plus for college. In residency, I used a Newton for a while to take notes on patients. I have a MacBook, an iPod (I’ve actually had 3 and my wife has had 2), an iPhone, iPhone 3gs; an iPhone 4 on order; an iPad, AirPort Express, an AirPort Extreme base station and accessories for all them (headphones, keyboards, mice—or is it mouses?, cases) scattered all over my house.

So when things go wrong, I don’t call the Geek Squad. I make an appointment at the Genius Bar. For those unfamiliar, this is a place in the Apple store where you can take your Apple product (along with your ignorance of its inner workings) to get technical help from Apple’s Top Gun computer experts.

In a sense, the Genius Bar staffers are sort of like doctors—like me—except the patient is a computer. In my world, a patient gets a stuffy nose, a fever, some stomach pain and they make an appointment. I talk to them, examine them, make a diagnosis, and prescribe something to make them better.

In their world, you iPad doesn’t turn on, you iPhone stops ringing or—as in my case—the SuperDrive on your Macbook stops burning DVDs can CDs—you make an appointment. They talk to you, examine your product, make a diagnosis, and send it off the shop to get it repaired if they can’t fix it.

Now as a doctor, I try to be conscientious of not just my clinical acumen, but my bedside manner. I want to be professional, but courteous and empathetic as well. In short, I strive to be patient-centric. After all, who pays my salary?

That’s where the parallel drastically ends between the Genius Bar and the doctor’s office. My experience with the Geniuses is that—like a talented but arrogant physician—they know exactly what they’re doing but have little to offer in the way of bedside manner—ie, customer service. Most of the time, I sit at the bar and find myself being talked at by a condescending 20-something who figures we ought to know as much about computers as he does (they usually are men, by the way). I keep being reminded of that 90’s mediocre medical thriller called Malice, which starred Alec Baldwin as a surgeon. The line to remember is when Baldwin was being questioned by a lawyer about a malpractice case.

Lawyer: “Doctor, do you have a God complex?”

Baldwin: “You ask me if I have a God complex? I am God!”

All of these parallels between my job and the Geniuses have been in the back of my mind for quite some time. But today, after my experience at the Apple Store, it really hit me. A couple of days prior, I made that appointment for the problem with my MacBook as I mentioned above. I made the appointment for 1245pm, during my lunch hour—the Walnut Creek Apple Store is just down the street from my office. I got caught up with some issue at work, and I hustled over. As I was walking up the Genius Bar to wait my turn, I was intercepted by an employee dressed in her blue t-shirt. Like a nurse intercepting a patient before they get to see the doctor.

“Sir, are you here for a Genius Bar appointment?”

“Yes.”

“What’s your name?” I told he as she looked it up on the computer.

“Sir you’re 6 minutes late, she declared looking at the screen. “They’ve cancelled your appointment,”

“6 minutes late? And you cancelled me? Really? I’m a doctor, and even we’re not that mean to our patients.”

“Yes,” she told me, “And there’s nothing we can do.” (that phrase has such gravity in medicine, by the way—I almost started laughing, except I was tired from walking over in near 90 degree heat)

Lesson learned the hard way: Don’t scorn the Geniuses.

I’m trying to think about how parents would react if I turned their kids away for being 6 minutes late. And what that would do to my professional reputation. There’s more than a little something about dismissing a customer for being 6 minutes that reeks of arrogance. Apple, with shares trading at over $200, has the largest market cap of any technology company in America—even its traditional nemesis Microsoft (is it me, or do most of the Geniuses act--and look--more like John “I’m a PC” Hodgeman instead of Justin “I’m a Mac” Long?).

I wonder, given some of what I’ve been reading about Steve Jobs, Apple vs. Adobe and their response to customers about the iPhone 4 reception problems, how high up the corporate ladder that arrogance goes.

So what should Apple do? Maybe take a page from my own health care group. After patients come to see me, a random group of them get a survey asking them about the quality of their visit. We take these survey results seriously: twice a year I get a report card with my performance and part of my compensation is tied to it. Docs who aren't performing get help. I think it's helped quite a bit to make our doctors patient-centric because service and quality are high priorities.

The irony of it all—I’ll be back there Friday (on time!) to get my MacBook checked. What else is an adoring Apple user supposed to do?

Jenny McCarthy vs. Jenny McCarthy

Tue, 30 Mar 2010 09:03:11 -0400

It can be hard to keep track of your own opinions. Just ask Jenny McCarthy, who can't quite seem to keep her rhetoric about autism and vaccines straight, often in the span of one interview!

On the concept of vaccines

"I think vaccines are one of the greatest things ever invented."

From Cookie, 2009

"She has backed off of her most heated rhetoric saying she is now not against all vaccines...."

From Time, 2010

On the other hand:

"Time magazine's article on the autism debate reports that the experts are certain "vaccines don't cause autism; they don't injure children; they are the pillar of modern public health." I say, "that's a lie and we're sick of it."

From Huffington Post, 2010 (after the 2010 Time piece)

Later in the same essay

"Almost all kids get vaccines -- injected toxins -- very early in life."

On whether she is "anti-vaccine"

People have the misconception that we want to eliminate vaccines. Please understand that we are not an antivaccine group.

-From Time, 2009

But, then, in the same interview:

I do believe sadly it's going to take some diseases coming back to realize that we need to change and develop vaccines that are safe. If the vaccine companies are not listening to us, it's their f___ing fault that the diseases are coming back. They're making a product that's s___.

On the false choice between infections and autism

"If you give us a safe vaccine, we'll use it. It shouldn't be polio versus autism."

-From Time, 2009

But measles is ok?

"If you ask a parent of an autistic child if they want the measles or the autism, we stand in line for the f___ing measles."

(that quote, again, is from the same 2009 Time interview)

On the tone of her rhetoric

"For all her bravado, Mccarthy prefers to cast herself as a voice of moderation. she claims her goal is to move the debate toward what she sees as the middle..."

-From Time, 2010

On the other hand, see above! but also,

"We get that [vaccines are] saving lives, but the increase is ridiculous, you guys. Look, it's plain and simple. It's bull (EXPLETIVE DELETED).

-From Larry King Live, 2008

"During appearances on Oprah, 20/20, Good Morning America, Larry King Live and other televsion shows, she decried what she claimed was a vast and profitable conspiracy to vaccinate children, which she said was responsible for the great upsurge in autism diagnoses...she glibly and with irate dismissal of the scientific evidence accused pediatricians of poisoning children and then witholding treatments that could save them."

-From Time, 2010

Huffington Post Health Watch: HuffPo Gets it Right?

Sun, 28 Mar 2010 14:03:48 -0400

Did April Fools' Day come early at the Huffington Post?

I couldn't help but ask myself that when I came across some Tweets about a post on it called "Is Jenny McCarthy Afraid of the Truth About Autism?" The essay is by a journalist from Iceland named Iris Erlingsdottir, who is the mother of two children with autism. Her post is a direct response to a March 10th essay by McCarthy about vaccines and autism, and offers the view from what I believe is a silent but large group of parents with autistic children who don't buy the notion that vaccines cause it.

The Post, as many Salon readers know, is woo central. Its most famous quackery is about vaccines and autism, and it is home to anti-vaccine folks like McCarthy, David Kirby, Kim Stagliano, and others. But there are many other snakeoil salesmen slithering around there as well. Most recently, Salon's Thomas Rodgers debunked a claim made by one doctor that MSG was a health hazard worse than alcohol or tobacco.

Given its illustrious anti-scientific lineage, it really took me by surprise when I saw Erlingsdottir's essay there, which begins with a personal story from 1975, when her then 20-month old cousin woke up unable to walk, and gradually developed severe neurological problems:

"The following day, the left side of her sweet little face had become strangely contorted, and she was completely unable to move her left arm or leg. Terrified, her mother took her to the hospital where the family spent the next five weeks in agony and fear until doctors finally discovered what ailed the child. Little Kristín had mumps, which in the 1960s before vaccination was available (in Iceland not until 1989), infected millions of children every year. The virus usually causes a chipmunk face and fever, but occasionally it penetrates the brain and spinal cord linings, causing seizures, meningitis, paralysis, and in some cases, death."

Erlingsdottir then delves into the modern anti-vaccination movement:

"Measles have now become endemic in the UK as a result of the decline in vaccine coverage, 14 years after the disease had practically vanished. In Dublin in 1999, the year after Andrew Wakefield's 'trial-lawyer funded, an incompetent, and quite likely scientifically fradulent paper' more than 100 children were hospitalized with measles."

Then Erlingsdottir turns her criticism to McCarthy. Many readers already know that McCarthy--like other anti-vaccine folks--weaves together anger, fear and anecdote into a conspiracy theory that pediatricians and others are out to harm children. Erlingsdottir, however, won't have any of it. "McCarthy's logic...is a snakepit of neurotic aberrations, conspiracy theories, childish outbursts ("that's a lie and we're sick of it"), profanities ("it's their [vaccine companies] fucking fault"; "bullshit"; "it's [vaccine] a shit product"), and outright lies: "our own government clearly acknowledges that vaccines cause brain damages in certain vulnerable kids", which it does not at all"

Erlingsdottir then debunks McCarthy's "proof" that vaccines cause autism, including the following:

"McCarthy claims that 'other countries give their kids one-third as many shots as we do,' but a comparison of European and US vaccination schedules reveal that they are largely identical; with some countries even out-vaccining the evil USA."

Finally, and to my delight, she takes a hard look at McCarthy's motivations, and that of other anti-vaccinationists, for keeping this debate alive:

"I'll venture that McCarthy has no less a financial stake in the vaccine wars than Big Pharma and the evil "diagnosticians and pediatricians." There is a lot of money to be made in snake oil pitching and crockpottery -- long known lucrative side industries for aging celebrities -- as she knows from personal experience selling books and the false cures on her website where her sponsors peddle hyperbaric chambers and useless supplements-- in the US, a $24 billion industry annually -- to desperate parents of autistic children. When you have a whole industry -- books, TV appearances, supplements, merchandise -- and the adulation of religiously devoted followers riding on your theory, the stakes are high. Having to admit you're wrong is intolerable. (How's McCarthy's "quantum prayer wheel" working for your kid's autism?) It is much easier to simply reject the truth, which as we know, the vaccine denialists don't care about; it is irrelevant to them. Their attitude is that of Lord Molson: "I will look at any additional evidence to confirm the opinion to which I have already come."

The other refreshing point about this post (at least so far) is the number of positive responses it has generated. The usual modus operandi of HuffPo readers is to hurl insults at anybody who writes to the safety and importance of vaccines. But here, there is a fair group of responses thanking and defending the author.

Perhaps it's a sign that the Post's readership is growing beyond its angry, conspiracy-minded, and anti-scientific base. But I won't so far as to declare the it cured of that constituency anytime soon. On the other hand, the responses are more likely an aberration, with the comments supporting Erlingsdottir those of people who are not regular readers. Like me, they were probably tipped off by Twitter or other alerts to directing them to it, and dived into the normally crazy comments section to help.

www.rahulkparikh.com

www.twitter.com/docrkp

Huffington Post Health Watch: Dr. Dean Ornish's Infomercial

Sun, 8 Nov 2009 09:11:11 -0500

Dr. Dean Ornish seems to be getting too much inspiration from other Huffington Post Living Section bloggers, who appear on the site when they need to promote themselves and their friends.

In what can be described as nothing other than an informercial, Ornish, the Post's Medical Editor, posted "Sharecare Builds a Web 3.0 Bridge to Better Health." In it, Ornish basically talks up a venture that he seems to believe is a cutting edge idea: a website that offers health advice and information to patients.

You can read the ad if you have the stomach for such blatant press self-promotion. Basically, Ornish describes joining forces with the likes of Oprah's Dr. Oz and Deepak Chopra to provide expert advice. In addition:

"Sharecare will include many points of view from people who have similar interests, concerns, and experiences. Peer to peer social networking functions will allow users to talk with one another about common issues, problems and successes within the context of expert content. Being able to communicate directly with others who have gone through the experience of illness not only gives different perspectives but also provides a level of compassion, empathy, intimacy, and shared strength that is itself healing."

Of course, Ornish doesn't exactly describe what he means by "web 3.0." Does he mean social networking and support groups? That's web 1.0-2.0. Revolution Health, founded by former AOL head Steve Case, has been at it for years now.

It's not clear how anybody--whether it be readers, other HuffPo editors, or those who pay for legitimate advertising on the site--can find Ornish's post credible or newsworthy. If anybody at the Post took their journalistic responsibilities seriously, or cared about the information they were peddling to patients looking for serious health answers, then Ornish would probably have been reprimanded for abusing his authority the minute he posted this.

"No one has a monopoly on truth," Ornish ads.

Indeed. So here's the truth for Arianna and company: Ornish's post is a vacuous-self-congratulatory-cliche-littered-plug, one that promotes a venture based on a recycled idea.

The only thing missing is where to mail your check (or does "web 3.0" use PayPal?)

Medical Malpractice Revisited on NPR

Wed, 4 Nov 2009 23:11:56 -0500

I appeared on NPR's Talk of the Nation last Monday to discuss my Salon article on medical malpractice reform. To no surprise, I was on hot seat in the virtual doctor's lounge, as physicians called in with their concerns--and gripes--about my point of view that tort reform will not solve America's health care problems.

I have a few thoughts about the interview, especially about those who called in. First, all three were doctors, and reflected on cases from their experience and point of view.

But medical malpractice is a patients' rights issue as well. The discussion may have been more provocative had we heard from someone who had been injured due to physician negligence. Then, we may have seen how hard it can be to seek redress. Here in California, for example, we have one of the oldest laws capping malpractice payouts at $250,000. The figure hasn't changed since the mid-1970s when the caps were enacted, despite the obvious rise in inflation and the cost of living. That often leaves an injured victim with very little recourse because the cost of fighting for compensation exceeds the payout. So while caps may prevent frivolous suits, they also make it harder for a patient to hold a doctor accountable. For an example of this, listen to my story at the end of the NPR segment or read it here.

Second is the issue of defensive medicine. The callers, and most other doctors, argue they practice defensive medicine to prevent being sued. Consider the comments by one particular caller:

"I think doctors are afraid of being sued, whether they're going to be sued for $20 or $2 million. But the question is, are these cases going to be tried by a jury of inner city people who sympathize more with patients than with the doctors, or are these cases going to be tried in front of professionals who understand the cases?

I think, you know, any data that you have, I completely - I can't possibly think applies to my practice or my husband's practice or what I'm seeing. Every doctor, every day, practices defensive medicine. There's no doubt about it. And I think it's ridiculous that it's not more of an issue in the health care litigation - or health care legislation that's before Congress right now. It should be..."

Let's look at the caller's main points: One, defensive medicine is practiced every day by doctors. Two, that tort reform should be a big part of health care reform due to the impact of defensive medicine on costs.

No doubt we practice defensive medicine. The question is whether tort reform is the cure for it and therefore, a key to lowering health care costs.

The short answer is no. You can look at my references in the Salon article, but let's take another example. I practice in Walnut Creek, Ca, and the caller who made the comments above practices in Baltimore, Md. As I said we have malpractice caps here, as does Maryland. If you believe the caller is right, then health care spending should be lower in both areas where we practice.

But take look at health care spending in both areas, as measured the by the Dartmouth Atlas of Healthcare. What you'll see is that both my county (Contra Costa) in Northern California and Baltimore have very high health care costs (darker green on the map). There are certainly many other factors that account for costs in both areas, to be sure. But there is no effect of caps in curbing spending seems in either area.

That leads to my last point--we doctors don't practice defensive medicine just to protect ourselves from lawsuits. If we did, then the caps would have done the trick.

That means that are a whole host of other reasons we play defense, ones that tort reformers never mention, and ones that have nothing to do with fear of litigation. One of those reasons is profit: in fee-for-service medicine, more tests and referrals mean more revenue for you and your specialist colleagues down the street. Another reason is time pressure: many times, doctors don't have the time to sit down with their patients and get a good history of their illness. Ordering tests saves time and allows us to move onto the next patient. Finally, there's customer service: many of us believe that our patients want more, and so to please them, we prescribe and refer more. Tort reform won't impact any of these reasons for playing defense.