What Steve Jobs and iPhone 4 Antennagate can Teach Doctors and Patients

First, I am a big admirer of Apple CEO Steve Jobs for his thoughtful 2005 Stanford commencement speech, his clarity of vision, and his superb skills as a leader. Fortune magazine named him CEO of the decade after turning around the company he founded from near bankruptcy in the late 1990s to becoming the most valued company today. Though I have great respect for him, I haven't bought an Apple product, ever, until this year.

So I watched with great interest his press conference regarding Antennagate which has consumed technology news with regards to the design of the new iPhone 4 and its new antenna design. Apparently this makes the smartphone vulnerable to dropping phone calls when held a certain way, known as the death grip. If one simply avoided holding the phone that one explicit way, the phone otherwise worked fine. As a result, 22 days after the latest iPhone was available to the public, Jobs and Apple were instead addressing an issue which dwarfed their latest product launch.

Doctors and patients can learn plenty by watching Jobs approach to the problem because the situation he and his team were tackling is similar to what a doctor addresses daily in the office.

• Perception is reality regardless of the truth.
• Hard data is important to have candid conversation. Specifically the right data.
  
• Sometimes emotions are so overwhelming that something needs to be done. This can be good or bad.
• People who advocate certain positions have inherent biases, which can make their argument far from objective, hence the need for hard data and expertise to interpret.

With all of the negative press, Jobs figured that a reasonable person might figure that about 50 percent of iPhone users would complain of dropped calls or that a significant number would return them. The hard data from Apple shows that only 0.55 percent of calls to their customer service center were in regards to phone call reception and that 1.7 percent of iPhone 4s have been turned. This return rate was far lower than the 6 percent observed last year during the iPhone 3GS launch.

Although Jobs noted that there were plenty of opinions about the possible reasons and solutions for the problem, the press conference was convened nearly three weeks after launch because Apple engineers needed time to understand the issue fully. As revolutionary as the iPhone 4 is, the very small technical issue which affected a very small number of users became a firestorm. Jobs announced free cases to all iPhone 4 users which seems to mitigate the problem even though the vast majority of users have no problems. He reiterated that new owners unhappy with the phone could return it for a full refund within 30 days. In the end, Jobs reflected that he and the people at Apple work extremely hard to keep their users happy.

Doctors address these issues daily which come up in conversations with patients. This could be in regards to the risk and benefits of immunizations, the need for antibiotics for possible Lyme disease exposure, or many other concerns where a person can psych himself. The internet can be powerful in arming patients with plenty of information, but fails to provide them experience or medical expertise or the objectivity needed to make a good thoughtful decision. (A good reason why doctors shouldn't take care of their own family members).

With the ongoing economic crisis, many patients are presenting with chest pain. Some are convinced that they have heart disease and won't accept anything less than a heart stress test or other imaging even if based on their symptoms, initial testing (basic labs, chest xray, and EKG), and risk factors (age, gender, smoking status) that the hard data clearly points a problem elsewhere.

At that moment, sometimes doctors are unable to talk a person down from their emotional ledge need to do something to address a patient's piece of mind. This could be a referral to a cardiologist or a basic treadmill test.

Hopefully that resolves the issue, but at what cost? Was it the right thing to do?

If the treadmill is a false positive, this will require a further work-up which may include an invasive cardiac catheterization. Although rare, patients can die from the procedure. Doing a test in a highly unlikely patient would be considered very questionable by many doctors. Will an individual doctor be confident enough to stop the process based mainly on emotion and perception when hard clinical data points in another direction? Is it possible that the tyranny of the short office visit and the need to do something perpetuate the problem and result in further testing?

In this case, all of this was done for stress? Was all of the additional testing and increased risk of harm needed to demonstrate a normal heart?

As Jobs and Apple know, an issue can be blown out of proportion and emotions can run high when perception distorts reality. Free cases are an easy fix.

When it comes to medical care, sometimes the easy fix may require doctors being calm, listening, and spending time to understand a person's concern. Does keeping patients happy and healthy sometimes mean saying no and providing rational thoughtful care?

For patients it means not believing everything they read or hear from friends, family, or the internet (or even other doctors and healthcare providers who only know pieces of information but not the entire story). With increasing financial responsibility through higher deductibles and copays (consumer driven healthcare), will patients listen to doctors who can help make the right decision with their clinical expertise or rely on the information gathered by the internet and demand testing believing that is the right thing to do?

Based on my experience, it doesn't look good. It's getting harder to talk some patients off their ledge.

We could certainly use Jobs and his leadership team in healthcare or least his presentation skills. When asked during Q&A, Jobs and his team pulled out their iPhone 4s - all without an external case.

And yes, my phone works perfectly fine.

Favorite Websites of Doctors

I'm increasingly learning more about healthcare through important physician writers like Atul Gawande, Bob Wachter, as well as Pauline Chen. In Dr. Chen's most recent NY Times article, she highlights favorite website of doctors. It's an excellent list that all patients should reference.

In a time when patients can access quickly a vast amount of information using the internet (especially Google), it is vitally important that they have a list of trustworthy resources which are worth the time, particularly since some information on the internet is frankly wrong and preys on people's false hopes.

The experts quoted in the article note that there are real differences among healthcare providers (doctors, hospitals, insurers) in providing great care beyond the bedside manner. In other words, healthcare providers like other goods and services we purchase are not all the same with some far better than others.

With the economic and financial crisis we are all facing, it is important that as we select doctors, insurers, and hospitals that we research which ones provide us the best value and service in keeping us healthy and well.

I would only add another excellent website, particularly when researching the best health insurance plan is at www.ncqa.org, the National Committee for Quality Assurance. NCQA is a not-for-profit organization that rates health insurance plans on how well they keep people healthy and those who have problems like diabetes, asthma, heart disease that they get the most up-to-date care.

It also has under the Report Cards section the Physician Recognition Program. These are doctors who have voluntarily submitted their patient charts to NCQA on various conditions like diabetes, heart disease, to name and few, and have shown that they consistently provide the level of care recommended by expert committees of the American Heart Association and the American Diabetes Association. Research consistently shows that we only get the recommended preventive care only about half the time in this country. If you are spending a lot for healthcare, shouldn't you get the doctors who consistently provide the highest quality of care?

Can't Trust Everything You Read on the Internet

A sad but interesting phenomenon we've all noticed in the internet age. People assume whether it is an email chain from Bill Gates and Microsoft a financial payoff only if we forward the email or other offers which are too good to be true that if it is on the internet it must be true.

Take the example of an Oregon homeowner, Robert Salisbury, who discovered strangers taking his belongings after someone but an ad on Craigslist that he had abandoned his home. Mr. Salisbury had no such intention.

• "I informed them I was the owner, but they refused to give the stuff back," Salisbury said. "They showed me the Craigslist printout and told me they had the right to do what they did."
• The trespassers, armed with printouts of the ad, tried to brush him off. "They honestly thought that because it appeared on the Internet it was true," Salisbury said. "It boggles the mind."

It recalls articles written about how patients use the internet to research their symptoms and ask their doctors if they suffer from a particular ailment. The challenge for many doctors is that often people don't have the experience or knowledge of whether a particular description truly fits their situation. Many doctors can empathize with this predicament as during medical school we had just enough information but not enough perspective to think we had every single neurologic, dermatologic, and infectious disease, we happened to be studying at the time.

The problem many doctors encounter is that patients simply don't believe what we tell them, because if it is on the internet, it must be true!

From the NY Times - Visits to Doctors Who Are Not in, Ever
From Time magazine - When the Patient Is a Googler