Going Independent Doesn't Mean Going It Alone. Dr. Basil Kahwash on Fixing Referrals and Building Physician Networks

... a patient who was referred to me by her primary care physician, and she came in and told me that she wanted to be tested because her PCP thought she might be allergic to an MRI, the MRI machine. And that story just did not land with... I was like, that can't possibly be right. But in her case, I had her PCP's name. So I looked up the PCP's name, called her number, left my phone with the nurse at the front desk and gave her my cell phone number. And within 15 minutes, while the patient was still in the room, the PCP called me and we were able to identify that, oh, actually this was a case where there was concern about allergy to the CT contrast, not the MRI. And so relying on the patient to be the middleman to communicate that information comes with some downsides also, which is that sometimes you're playing telephone and the information doesn't get communicated properly. Every time I've told that story, people are amazed that I was able to get ahold of the PCP that quickly.

Thanks for having me on the show, Graham, and thank you for the introduction.

Yeah. Well, I was drawn to the field probably a little bit later in the game than some other people. I think these days, a lot of medical students know what they're going to specialize in and subspecialize in. And my story's a little bit different than that because I went into internal medicine after residency because I wanted to leave as many doors open as possible. A lot of it was my own personal experience growing up with asthma, especially exercise-induced asthma, and later being diagnosed with a condition called eosinophilic esophagitis, EOE. That, and then I saw that it was this really fascinating specialty where the immune system was really core to it. And when I looked at everything that was happening and a lot of progress in medicine, I was like, wow, immunology is really front and center and taking center stage and taking off. So that's what drew me to the specialty first and foremost. And you're right, it's not one of those specialties that people think about a lot in medicine because we're not as visible in the hospital, for instance, or visible during people's training. And now I give lectures sometimes to medical students and residents, and one of my lectures is an introduction to allergic disease and introduction to allergy because I know that's not something that's being covered comprehensively a lot of the time in medical education.

Yeah. And for that reason, I think we need to sharpen our communication and we need to position ourselves well to attract those kinds of referrals. And I know we're going to talk about referrals later on, but I think that that's one of those things where, as a subspecialist, you have to highlight what it is that you can offer to the patients that another person might not be able to. And exactly what you just said right there, is that ability to deliver the important communication when it comes to controlling a chronic disease like asthma.

Yeah, not a small decision at all. And I mean, for me it was more when I graduated from my fellowship, I had a few different ideas. One was stay in academics, which is what I had been used to. I think everybody who trains in an academic medical center is more comfortable in an academic setting. They don't really know what private practice is like behind the curtain.

Yeah. And you read papers from academic docs and you're starstruck by some of what you're seeing, and in some cases, people that you're meeting, et cetera. So academics has a lot of appeal, and especially if you're the kind of person who's intellectually curious, you like to do some research, maybe you like to do some teaching. I think that will attract a lot of people to academics. I told myself in the beginning, I want five years in academics at least, and then I'll reevaluate, am I going to do something else afterwards or am I going to stay and be a dedicated academic? But I thought five years was reasonable. I ended up getting four at Vanderbilt just because I was presented with the right opportunity at the right time. I think my situation may have been a little bit unique because it was a downhill transition, if you want to think of it that way, to private practice from academics because it was a group that I had rotated with in fellowship.

Yeah, I did my fellowship here at Ohio State and I had rotated with that group when I was a fellow for a month. And so I got to see not only what's private practice like behind the scenes, I got to see also, okay, this is a group that practices good medicine. This is a place where I would fit in. I already know a lot of the people here. I have my extended family in town. So my situation, it wasn't just like, okay, I'm at a juncture right now, and do I have to put in a lot of activation energy to leave academic medicine and go into private practice? For me, it was more like, wow, I have this really amazing opportunity, and it's going to be really, really hard for me to pass it up because I don't know when it's going to present itself again.

Absolutely. And you touched on a great point, which is that you don't have to compromise on the quality of the care and the evidence-based medicine that you're delivering just because you're not part of the academic medical center. Yeah, of course you're cut off from some of the innovation and the frontline cutting edge advances that are happening in your specialty by not being in academics, but that doesn't mean that you cease being a good doctor, so to speak. And it doesn't mean that you can't find ways to keep up.

Yeah. I'm one of them.

Yeah, almost two. Almost two years in.

Well, I did my homework about what would be expected. I mean, I talked to the people in the group and I talked to other people that were in community practice. In fact, I even talked to some folks who had been, like me, in academics, including a good mentor of mine who was nine years as the chair of allergy and immunology at an academic center before he went into private practice. And you learn from other people's experiences, you can hear those stories and mentally prepare yourself for what you're getting yourself into. So I knew that I would be seeing a higher caseload, more patients during the day. That's obviously going to be true if you go into community practice. I knew that in general, those cases were not going to be, for the most part, quite as complicated as what you're seeing in an academic center or a tertiary referral center.

Exactly. Yeah. More bread and butter, I mean, which makes sense. You're frontline facing the community. And I knew being at a place like Vanderbilt where I was before, a lot of my referrals were actually from other allergists who were like, "Hey, this is a really complicated case. They need an academic medical center." So that's understandable. And so I mean, that's something that you can see coming. I knew also that there's a lot of freedom in practice, perhaps more so than in an academic center because you have your team that is with you pretty much the whole time and you're in your own shop. So you can run things the way that you want to, not according to an institutional policy. So pros and cons about all of those things, but I didn't realize quite until I got into it how siloed independent practice is. And I mean, I could give some examples of that, but I would say that one of the huge advantages of being at a place like Vanderbilt was when I had a case that was complex and that needed multiple specialists or the specialists and the primary care physician to put their heads together, it was really, really easy to get ahold of the collaborating physician. I mean, you just find their .edu email address as the last resort, and you could just send them an email and say, "Hey, I've been trying to get ahold of you. Can we talk about this?" And 99% of the time they're going to respond. Or you send them an Epic direct message and they'll respond. Or you just send them your note directly in the system, which they can then pull up. But I think one aspect of independent practice that I didn't realize is that you just have your electronic medical record that belongs to your practice and you could see your notes and your colleagues' notes that are in your practice, but everything else has to either be scanned in or you just don't have access to it at all. And I think another thing that took me by surprise was that patients didn't really realize that. They still thought that, "Oh, can't you pull up Dr. So and-so from gastroenterology? Can't you just pull up their note and see what they said?" And I was like, "No, I really can't."

Right. Yeah. Yeah, yeah, yeah. You obviously know going into independent practice that you're going to be in your own independent institution, not part of something bigger, but you don't fully appreciate the ramifications of that until you're in it.

All of the above. I do my best not to repeat labs. And sometimes just last week I had a patient who I ordered several labs and she told me that she had had labs drawn, but I didn't have any of those labs from the place where she had them drawn. I didn't have the results. So I wrote down the labs on a piece of paper and I said, "These are the labs I want you to have. Once I get the results that you've already had obtained, then I'll call you and I'll tell you which ones to scratch off." So I documented that. And I ended up getting her results, and some of them were labs that I had planned to order. So I told her, "Okay, you don't have to get this and this drawn, but go get these other labs drawn." You have to be invested to make that happen. It's time-consuming. All of these things are inefficient processes. And oftentimes I think a lot of people will repeat labs, repeat studies, or will make assumptions based on information that they don't have that perhaps are not exactly accurate. One of the more, I would say, not widely recognized uses of MyChart, for instance, is patients will use MyChart to show their doctor their results. You know what I mean? So the patient will come to me and say, "Here's what I've had done already," and then just pull up their MyChart from another doctor and allow me to just scroll through their phone and look at what their lab results are. And I think that people don't realize that... A lot of people just don't appreciate that that's something that's also happening in terms of finding shortcuts and ways for doctors to exchange information with each other.

Yeah. And it's using the patient as a middleman, which is also less than ideal.

Until somebody builds a better way to exchange that information, that's what we have right now a lot of the time. I mean, there are other ways of getting that information, but it's the fastest, it's the easiest. And if the patient consents to it, in some ways they know that that's going to save them plenty of time and plenty of effort on the doctor's part. So they're like, "Sure, why not? You can take a look."

I think the whole idea is that we don't have an easy way in independent practices to communicate with one another seamlessly. People have invented all kinds of ways to try and bridge those gaps, including having the patient carry their chart around on a USB drive, things like that that are also, again, put the burden on the patient. But what people haven't really done is create information super highways between independent practices out in the community. I think one of the impetuses behind the letter is that we deliver better quality of care when we can collaborate and when we can team up and when we can really understand what the other person is thinking, when we can understand why they sent the patient to us, what the point of the referral was, what their background logic was in managing the case, and what exactly it is they're looking for, and when we can follow up with them directly and communicate with them and coordinate, I think all of those things make healthcare better. And I felt like when I first joined independent practice, that was one of the things that I really, really missed about being at a major medical center or an academic medical center is that there is that culture where it was not uncommon for me at Vanderbilt to have case conferences with two or three other specialists where we would jump on a Zoom call together. Granted, we had the time built into our schedules to do this, but we could jump on a Zoom call together for 20 minutes and just talk about, okay, what does allergy think of the case? What does infectious disease think? What does dermatology think? What does the primary care doctor think? Et cetera. And that does not really happen in community practice because the incentive structure for that to happen, one, doesn't exist, and two, the ability to form that type of a collaborative network, even if all parties wanted it to happen, it's just not seamless and not easy. So I think the whole idea behind writing the letter was, okay, we're stuck using fax machines to send each other paper charts and each other's notes. We're stuck having to either track down each other's cell phone numbers from somebody or calling the front office or asking nicely to speak to the doctor who referred the patient in order to be able to communicate directly with each other. Wouldn't it be nice if we built an online community, an online village, just like we have in so many other spheres of our lives, for this type of a purpose and for patient care rather than having to spend all of this effort and all of this time and our staff's time and our limited amount of mental bandwidth during the day on trying to quarterback and organize and coordinate care for a patient? Why can't we just do that relatively easily and put all those pieces together so that we can go back to taking care of patients? Which the whole mission of off-call is to restore the joy of medicine, as you said in the start of the podcast. So I think that aligns very, very well with the mission there.

Mm-hmm. And from ENT.

Yeah. When we send and when we receive, I didn't fully appreciate how central the fax machine still is to that process. And that was one thing where maybe it was because it was all happening behind the scenes, but I think largely speaking, what happens in a back office is that that person is still printing, and still largely faxing. But when you're in an independent practice, you're seeing that happen right in front of your eyes. I didn't fully appreciate that when I'm sending a referral to another office, I have to write everything down or I have to enter it in the system and have my nurse print it and then fax it. Additionally, I didn't realize that there wasn't a directory of specialists that I could refer to or that wasn't easily found. I had to ask my colleagues, "Okay, who are you referring to? How do I get their number? How do I get ahold of them?" And a lot of it was I would ask somebody and they would say, "Oh yeah, this is the doctor's name," or "I'll write it down for you." But then I would still have to go online, Google them, find their office's fax number, and trust that that was an up-to-date fax number and that that referral was going to go to where it needed to go and be received, and have them contact the patient in a timely manner and in a way that met the needs of what we were looking for there. And so you're trusting... You're at the mercy of the fax machine essentially, more or less.

Sure.

Yeah. The problem is right now, a lot of the referrals I get are just basically like the patient intake sheet or the patient data form, and then at the bottom it'll be a diagnosis code, and that's all it is. It'll say, "Diagnosis: allergic rhinitis." Or, "Diagnosis: cough." And that's all you're getting from the referring physician. I think even if you just had a tiny bit more context, you don't even need to make the referring doctor write out a whole paragraph of, "Oh, this is what I'm looking for, this is why I'm sending you the patient." But just attaching their notes, their thought process, some background about the patient, all of that goes a long way right by itself, but we don't have a seamless way of exchanging that.

Hereditary angioedema or something like that.

Yeah. Well, I'll do one better. I've got two examples. I've got one for a referral that didn't go so well or a situation where the outcome was not ideal, and I've got another one where we actually had a fantastic outcome. So the first referral was, this was a case that we actually presented recently at a national meeting. It was a pregnant woman with hyperemesis gravidarum. Now that's not something I'm ever going to manage, but the patient was referred to me because she was having what seemed to be an allergic reaction or an intolerance to the medication, the Ondansetron that she was using to try and control her hyperemesis gravidarum. And we did, in the end, diagnose her with a pretty rare type of a drug allergy to that Ondansetron medication that she was getting to control her vomiting. Now the hard part was tracking down the OB/GYN who sent me the referral, because of course, this was coming from an OB/GYN who I didn't know. I was fairly new to practice here in Columbus, and I didn't have any contact information from her other than her office. So I had to have my staff call and leave my cell phone number at her office's voicemail. And by the time she got around to calling me back, it was three or four days later, and who knows what could have happened during that time. I can't make a recommendation for hyperemesis gravidarum as far as what's an alternative that the patient can use to treat this condition seeing as the initial first line drug is something that she has a serious allergy to. So that quick correspondence and that ability to communicate and that we're stuck using landline phones and fax machines that are really going to slow us down, especially when time is of the essence, that, to me, highlights the urgency and the need for the type of the technology that you and I wrote about in our manifesto. And I think the really positive case is about a patient who was referred to me by her primary care physician and she came in and told me that she wanted to be tested because her PCP thought she might be allergic to an MRI, the MRI machine. And that story just did not land with... I was like, "That can't possibly be right." But in her case, I had her PCP's name, so I looked up the PCP's name, called her number, left my phone with the nurse at the front desk and gave her my cell phone number. And within 15 minutes, while the patient was still in the room, the PCP called me and we were able to identify that, oh, actually this was a case where there was concern about allergy to the CT contrast, not the MRI. And so relying on the patient to be the middleman to communicate that information comes with some downsides also, which is that sometimes you're playing telephone and the information doesn't get communicated properly. And it took really, every time I've told that story, people are amazed that I was able to get ahold of the PCP that quickly, but a lot of things have to align for that to happen. But I think we can recreate that bright spot using some technology. We have the tools to be able to do it and tools that we're building right now so that that doesn't become such a rarity.

The other point I made to you guys when I was advising about this product very early on is that these communities are, to a large extent, already forming online, but where are they forming? They're forming within specialties, right? I mean, you can go to Facebook groups of emergency physicians and there's a Facebook group, a very robust one, of private practice allergists and immunologists, and the types of things that they exchange back and forth are they'll share case stories or ask people's opinions about treatment or ask who's using this new type of treatment that's out there. But they'll often ask, "Okay, my patient is moving to Wichita, Kansas. Who do we know out there that I could send the patient to?" But what I noticed is that what doesn't exist is, within cities or within communities, Facebook groups of physicians saying, "Okay, I have a patient who needs to see this type of specialist." Let's say I have a patient and I need them to see a toxicologist. I don't know any toxicologist here in town. I don't have a reference list of toxicologists, and I wouldn't know where to find one, and those communities for some reason just have not formed organically. It's not just about improving the quality of referrals, it's about allowing there to be a back and forth exchange within a geographic location that's going to enhance collaboration, and enhance the patient care and patient outcomes by the end.

We're making it work based on the old technology to some degree, but I think people, when they see that we're using electronic medical records, they assume a lot of patients that electronic means digitized or electronic means that it is up to date with the way the rest of the electronic-

... system and the internet... Yeah. And the internet works in 2026. But I think what they don't realize is that, yeah, we created these electronic medical record systems, but they are just an analog or an electronic way of storing analog information. And we're still working on ways to build out the digitized aspects of that. I think we're going to get there, and I think that for instance, our tool, our goal in the end is for it to have some EMR integration so that you can easily transmit that information from an EMR system to another EMR system. But right now, all of the EMRs, unless you're in a huge medical center, the EMR systems themselves don't often communicate with one another, and they're basically just electronic storehouses for what's otherwise analog information. I mean, as a clinical informaticist, would you agree with that characterization?

Yeah. I mean, it would look much different than today. And I think we'd see improvement in patient outcomes that we can't even predict because I think when you combine the human aspect of it and people wanting to do the best they can for their patient by being frustrated by the way that the system works right now, and how complicated their patients are by and large, with the assist and the aid coming from the technology side of things, once those things are able to be merged together and synchronized well in still a way that maintains the patient's privacy, I think you're just going to see multiples on multiples of downstream positive consequences result from that.

Yeah, I mean, I think Columbus is a fast growing city. It's one of the fastest growing cities in the US. Has been for a long time. So I think that that by itself, the fact that it's a young families... It's an attractive city for a lot of young families, and that there's this big professional community here now, I think that makes it a really exciting place to be an independent physician. I think the culture here is also, I mean, people associate Columbus with huge institutions like Ohio State University or like a Nationwide Children's Hospital, which is one of the larger children's hospitals in the country. But even outside of that, I think that there's always been this very strong culture of independent practices here in Columbus. And I don't know where that originates from specifically, but it exists. When I first started practicing here, I quickly realized that, oh yeah, there's basically any specialty in the world, you can find it here as an independent practice, by and large. Not every single one, but quite a lot of them. And so I think that the richness of that culture makes it an easy and relatively seamless place to practice as an independent physician compared to other places. There is a legacy of independent physician communities also. So there are groups like the Columbus Medical Association, things like that, which are comprised of both independent and practicing physicians that are part of larger health systems. And I know that, to some extent, those communities frayed during COVID, and maybe they lost a lot of that community aspect, but there are still enough people that remember what it was like before that are trying to restore a lot of those bonds that I think that that also lends itself well to being a city where something like an independent practice connection tool is a great place to test it out. You don't always want to test your products, your new tech products in places like New York or in the Bay Area of California because you're trying to prove a concept that is going to be widely applicable. And we know that a city like New York, DC, San Francisco, I know a lot of tech innovation happens there and a lot of new concepts in tech are proven there. But when you're talking about something like healthcare, which you know is going to have application everywhere across the country from small towns to medium-sized cities to huge metropolises, I think that the right testing ground for that is a medium-sized city. And it also gets people excited because it's like, wow, we're the testing site for this. We are not often the kinds of place where new health tech innovation has its birthplace, but it gives people a lot to look forward to when you're trusting that kind of a community to be the group that's going to test something out for the first time.

Yeah, I mean, I think what gets me most excited is that, I think, where we're at right now, independent to some extent means isolated. So you're in private practice, you have this referral black hole. So you're sending off referrals to people who maybe you know them, maybe you don't, to try and take care of your patients and send you back their recommendations. You're getting referrals from also a community of physicians, some of whom you know, others, you're not sure how you're going to track them down or have a conversation with them if you need to. And we have this administrative drag of the fax machine, which is really the rate limiting step for a lot of what we can do and how we can communicate with our colleagues. I think what gets me excited is this idea that we're going to hopefully create a network of independent physicians that will restore a lot of autonomy and make independent practice much easier and much more seamless. And I think that a lot of what we're seeing right now, a lot of the attractiveness of working for a large major medical center, and there are pros and cons. There always will be pros and cons to working for a large major medical center, but I think a lot of the attractiveness of it is that you don't have to worry about things like that. You don't have to worry about where your collaborators are going to come from. You know that you're going to be part of this big community and that there's a safety net associated with that to catch you if you slip up, if you miss something. I think a lot of people are intimidated by going into independent practice because that safety net doesn't exist. But if we can create a web of independent practices and have that web be very seamlessly and digitally interconnected, you've essentially recreated that aspect of a major medical center while still allowing each specialist or each primary care physician to maintain total autonomy over how they practice within their own institution and within their own practice. So that's the part that makes me the most excited. And not that we're trying to compete with necessarily the major medical centers, but that we are creating an alternative for and an alternative practice setting for people who do want to practice independently and still want to practice collaborative and high quality and evidence-based medicine.

I think what winning looks like is that the doctor no longer has to track down referrals, no longer has to spend so much of what... No longer has to dedicate so much of their time to coordinating care and overcoming the friction of sending and receiving referrals and collaborating with other physicians, that that just becomes something that fades into the background, and we can devote more of our attention to good clinical care and building relationships with our patients.

You can certainly find me on LinkedIn. I am friends with this guy, Graham Walker, MD on LinkedIn, so if you just search my name. There's not that many people with my name, so I think that's probably the easiest place to find me. Always happy to connect there and always happy to continue the conversation.

Definitely.

Thank you so much for having me on.