How Big Pharma Listens in on Doctor Networks

What might you overhear if you got 100,000 doctors together in one virtual room? You could find out if you had access to the social network Sermo. It's just one of a growing cadre of sites designed for the nation's practicing physicians. Here, doctors from across the country can consult each other about the ordinary and the weird (or "zebras" in the lingo). There are queries about treatments for everything from plantar warts to photographs of mystifying rashes and even questions about an unfortunate fellow with postorgasmic nausea.

It's not surprising that the chance to confer with other practitioners from around the country is increasingly popular among doctors. Today most of them work in small outpatient practices, missing out on the old-school social networking they used to find through weekly grand rounds, curbsides in hospital corridors and coffee refills in the physician's lounge. About 15 percent of practicing American doctors have signed on to Sermo since it launched in fall 2006. Its major competitor, Medscape Physician Connect, a part of WebMD, entered the ring a year ago. Both sites boast thousands of new registrations each month.

These sites may be free for doctors, but they are not nonprofits. Sermo makes money by selling access to doctor talk, mostly to Big Pharma. Lately the data has become so rich that the financial industry has taken interest. Bloomberg inked a deal with Sermo this fall that allows Bloomberg subscribers to see comments by Sermo members related to particular companies and products. WebMD similarly gives its paying clients tools like a trend graph reminiscent of Google Trends, which tracks keywords hot on the lips of its physicians. With a few clicks, WebMD's clients can deconstruct the clinical chatter via detailed demographic profiles, zooming in on threads by practice years, specialty, geographic area and so on.

Purchasing access is a no-brainer for drug marketers. The branded pens and free steak dinners ended when the voluntary PhRMA Code on Interactions with Healthcare Professionals went into effect this year. "These people who are on here are very aggressive and high-prescribing physicians, which makes them very valuable to the pharma community," says Erika Fishman, director of research at Manhattan Research, which studies the health-care market. Fishman's report "Physician Social Networking and the New Online Opinion Leaders" surveyed 1,832 doctors and found that most plan to sign on if they have not already.

Daniel Palestrant, Sermo's CEO, acknowledges the inherent dilemmas with sites like his: "I had a lot of concern about how many problems and challenges we would have," like protecting patient confidentiality. To his delight, Palestrant discovered that "physicians self-police incredibly well," even online. With more than 100,000 members, Sermo says only three of been banned for inappropriate behavior.

Early on in the development of his business model, Palestrant asked Arthur Caplan, chair of the medical-ethics department at the University of Pennsylvania, for input on the site's procedures. Caplan worried that not all doctors would understand that the site operates as a kind of a one-way mirror with doctors chatting on one side, and industry analysts studying their behavior on the other. He suggested that physicians be notified "on the Web site in big type, in a prominent place," and indeed, Sermo displays its "information arbitrage" model on a page called "How We Make Money."

But there are other questions as yet unanswered: is Sermo obligated to notify regulators if a doctor says she's using yak's milk to treat cancer or nine times the approved dose of a drug? What if comments are pertinent to a malpractice case? Both Sermo and WebMD say they zealously protect physician anonymity from all third parties. Ultimately Caplan withheld his endorsement. "It's a new arena of ethics for sure. It made me nervous enough that we backed away," he says. "I'm not going to yell about you," Caplan diplomatically assured the company. Meanwhile, Palestrant acknowledges that after the initial overture, Sermo never did call on Caplan's services: "After a year or two we've mostly allowed that relationship to lapse ... so I wouldn't call it an active relationship at this point."

These networks may be funded by today's industry players, but they don't necessarily support the status quo. Last January a Brooklyn, N.Y., internist named Sean Khozin began a post declaring, "It's now clear to most people that the current healthcare system is unsustainable." His message spawned a work group of over 1,000 physicians who collectively wrote a letter to the American people, which they later posted publicly, explaining how the insurance industry and defensive medicine assaults their autonomy, endangering patient health and crippling the country with unnecessary expenses. Khozin says we can simply follow the money to find health-care waste, citing Princeton economist Uwe Reinhardt's calculation that physicians take home less than 10 percent of health-care dollars. Two months ago that initial online work group became a registered nonprofit called Doctors Unite.

According to Khozin, the online grass-roots collaboration that spawned Doctors Unite is the first example of "a new channel of communication that represents the collective voice of physicians." Khozin believes the American Medical Association has become too entangled with tangential interests. (The AMA doesn't have its own social network, but it does work with Sermo.) "The focus has to be on the patient and their engagement with their health-care provider because that's where it all happens really. The focus has been totally diluted."

As president of Doctors Unite, Khozin now has the ear of White House health-policy advisers, having initiated talks with both sides during the campaign. No word on whether he'll loan them his Sermo account. Otherwise, they'd be well advised to inquire about a government discount. There may be no better way to understand health care today than listening to the frank online exchanges already happening between thousands of men and women on the front lines.

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