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What’s It Like to be a Doximity Community Fellow — COVID-19 Notwithstanding?

Doximity (https://www.doximity.com) is the largest online community of healthcare professionals in the United States. It offers curated medical news, HIPAA-compliant on-demand video calls with patients, case collaboration, the opportunity to publish articles as essays or opinion pieces (“Op-Meds”), messaging, and other capabilities. Launched in 2011, Doximity claims to have over 1 million members in its network, including more than 70% of United States physicians, 45% of all nurse practitioners and physician assistants, and 90% of United States fourth-year medical students.

I was a Doximity Community Fellow from July 1, 2019 to June 30, 2020. I was selected through a competitive process based on my background, ideas related to online medical content, and writing samples. My position was remote; there were no set hours — “put in as many or as little hours as you want,” I was told — and I was promised a small stipend and company stock options after my one-year term ended.

· My primary responsibilities were threefold:

1. Ensuring members’ responses to Op-Meds contained balanced and diverse opinions on clinical topics.

2. Promoting civility in medicine by tracking members’ comments for appropriate content; and

3. Fostering a positive environment that promotes the exchange of information and ideas for everyone in the Doximity community.

· My “deliverables” consisted of the following:

1. Reviewing comments to Op-Meds, especially those with the most traffic, “liking” thoughtful comments that brought value to the discussion, and citing “bad” comments (more on that below).

2. Steering conversations that veered off-course to a more productive and collegial direction rather than an uncontrolled rant; and

3. Advising Doximity staff each month about trending topics, including quoting directly from members delivering particularly unique or insightful views.

The Doximity Community

My experience as a Community Fellow was enjoyable and enlightening. My finger was on the pulse of American medicine throughout the year. I was exposed to various schools of thought espoused by physicians, pharmacists, advanced level practitioners, and medical trainees. My position kept me on the cutting-edge of new developments impacting practice.

Doximity members are concerned and critical about the state of medicine — especially the corporatization of practice and erosion of the doctor-patient relationship — so they welcome Doximity’s “clinician first” mentality, which embraces their needs and aspires “to build simple, easy-to-use tools to solve complex problems.”

Doximity reaches doctors in all specialties. Family and Internal Medicine, Pediatrics, OB-GYN, Psychiatry, and Surgical specialties are especially well represented. I’d say there were a subset of physicians who spent significant time responding to Op-Meds on Doximity and could be considered regular commenters. Most physicians “played nice,” but there were occasional personal attacks, and fortunately the community-at-large was quick to notice and respond to the offender, often chiding the responsible member.

Insults were sometimes hurled at people’s politics, and the community seemed to be equally divided between liberal and conservative views. I was considerate of diverse viewpoints and only “reported” a few members for what I considered grossly inappropriate or abusive content or language, e.g., vulgarity, profanity, obscenity, SHOUTING, and highly discriminatory remarks based on race, ethnicity, religion, gender, or medical specialty.

General Dysphoria

The predominant pre-COVID-19 theme that emerged in Op-Meds was angst and unrest among physicians. There was a general dysphoria among many community members, and it manifested through their comments to essays on burnout, electronic medical records, payment and payers, and loss of autonomy associated with employment, as opposed to practicing independently. But there was also a strong sense of optimism among those who had managed to find their way through the healthcare system, whether it be in a niche or concierge practice or some other alternative to the daily grind.

Of course, there were myriad topics other than burnout discussed in Op-Meds. Chief among them were medical errors, gender and racial barriers to medical training, issues unique to trainees and international medical graduates, the perceived injustice of peer review and prior authorization requirements, and the influence of social media in medicine. Here are some representative comments from the community taken from their responses to selected Op-Meds over the year:

· “As a primary care physician, I am now pursuing an MBA. I plan on leaving clinical medicine as the stress level and abuse from all sides is so not worth my health and sanity.”

· “The first thing I experienced after retiring was the joy and serenity of sleeping through the night. [It] actually felt ‘weird’ at first since I kept anticipating ‘something’ to happen. The public has NO CONCEPT of what frequent call can do to your physical and mental health, family life, love for your profession, etc.”

· “I am glad to be self-employed. True, in a sense, every patient is my ‘boss,’ but I have substantial control of my work environment, who my patients are, and my work-life balance.”

· “One of our first days of medical school, one of the faculty physicians told us, ‘some day you will do something or make a decision that will lead to someone’s death. It may be a mistake, but it is much more likely that it will be the absolute best decision that you could make at the time. But nonetheless, someone will die because of the decision you made.’ It was one of the most important things I was ever told during my training.”

· “The advent of the [electronic health record] has, and will continue to be, an unmitigated disaster which consistently degrades the quality of communication between practitioners while simultaneously benefiting the insurance companies in their ongoing quest to reap more profit instead of authorizing requested care.”

· “The oath you take as a physician is between you and the patient. Not an oath with the insurance company, or your state’s medical board, the hospital administration, or an attending. I carry a copy of the oath on my cell phone.”

· “As a long-time Doximity reader and author of two Doximity articles, I was dismayed to see the racist and sexist rant of [this doctor]. Her blind accusations against an entire race (‘white’) and sex (‘male’) were disgusting, nakedly offensive, and unworthy of your platform.”

· A doctor is like any other job… it’s a job. It pays the bills and your lifestyle. It does not define you as a person. If you don’t have a passion for your job (any job), you are going to hate it and want to quit eventually. No job is always going to be a beautiful garden every day. It’s the passion for the job that keeps you going on those bad days.”

· “When a middle-aged man with coronary artery disease having chest pain, tells me he can’t be admitted because he has to put food on his children’s plate, we are doing something incredibly wrong.”

· “What is contributing to the stress is not the time we spend with the patient applying our knowledge to help them, it is the stupid bureaucracy of mindless government regulation, payment (or nonpayment) systems, time-consuming [information] systems and hospital systems who are in an arms race for ambulatory patient revenue.”

· “My college advisor said ‘I don’t think I would want to be treated by you’ after I told him I wanted to be a doctor. Well, 30 years of practicing medicine, two board certifications and a faculty appointment to an American med school later, I happily retired never having to treat this ‘counselor’.”

· “It may be hard for some of our colleagues to fathom that due process may not be afforded to every physician who faces accusations by the establishment.”

· “I recall the old medical school teaching: there are only 2 reasons why people come to the doctor…pain and fear.”

· “A simple and effective solution to the entire problem [the decreasing numbers of private practitioners] is getting the government the heck out of our healthcare. They have no moral nor constitutional mandate to be involved.”

· “I resent the term [provider] and feel instant antipathy for those who use it.”

· “Humiliation and ridicule are not effective teaching tools…the most effective way to teach is by example.”

No More Business as Usual

Business as usual on Doximity changed dramatically once the coronavirus pandemic struck the United States. A COVID-19 “quick link” was established in March (2020) to provide community members daily updates on the latest news, research, clinician perspectives, and best practices related to the pandemic. Doximity also provided members guidance and resources to promote their well-being and help them adapt their practices in the face of the crisis.

By the time May (2020) rolled around, Op-Meds were almost exclusively COVID-19-related. Here is a sample of topics:

The immediate impact of the coronavirus — apart from its striking morbidity and mortality — was a decrease in patients visiting emergency rooms and doctors’ offices. Much needed healthcare was deferred or never occurred; telemedicine visits barely made a dent in the huge decline in office visits. The financial strain on hospitals and practices from unreimbursed or limited-reimbursement care, plus decreased elective care, highlights that many health systems operate on razor-thin margins and their sustainability is not guaranteed.

The Royal College of Physicians predicted nearly half of physicians in the United Kingdom will be working under capacity for at least a year, in part because it takes extra time for infection prevention and control measures to be implemented. In contrast, in the United States, it has been necessary to augment the supply of healthcare workers in states hit the hardest by COVID-19. Licensure requirements have been waived for some physicians practicing across state lines — notably, without any deleterious effect on the provision of health care.

The Doximity community deemed managing mental health disorders in providers and patients during and after the pandemic one of the most significant challenges to recovery. Social-distancing measures and the pervasive climate of anxiety and isolation have been especially damaging to individuals’ well-being. Indeed, several healthcare professionals working on the front-lines worldwide completed suicide due to the stress and hopelessness of the situation, including their own fear of exposure to the virus.

Delivering on Its Mission

In retrospect, Doximity delivered on its mission of fostering the exchange of medical information and viewpoints, and I felt privileged to help ensure a balanced and diverse agenda on various topics of importance to medical practice today. I even contributed a few Op-Meds of my own, and I should note they were reviewed by the editorial team and were not a slam-dunk for publication. I was grateful for the opportunity to participate in the Doximity community both as a Fellow and author of articles.

If you are interested in becoming a Doximity Community Fellow you must be a Doximity member. You should be a leader in your field, forward-thinking and enthusiastic about the practice of medicine, yet with a critical eye. The ideal Fellow will be a dedicated writer, researcher, or educator interested in engaging with Doximity members and collaborating with Doximity staff.

Do you enjoy sharing your stories and insights with peers, pushing your creative boundaries, and possibly creating new types of content? If so, a Doximity fellowship may be just what the doctor ordered.

Physician, author, speaker, wellness advocate

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