Urologists share how digital ideas became reality

Identifying unmet needs in both medical school and clinical practice, urologists Alexander Kutikov, MD, associate professor of urologic oncology at Fox Chase Cancer Center, Philadelphia, and Todd M. Morgan, MD, assistant professor of urology at the University of Michigan, Ann Arbor, created UrologyMatch.com, an online resource for medical students, and drawMD (Visible Health, Inc.), a suite of iPad apps to help physicians explain anatomy, conditions, and procedures to patients. In this interview, Dr. Kutikov and Dr. Morgan discuss the impetus behind these endeavors and how they benefit physicians and patients. They were interviewed by Urology Times Editorial Consultant Philip M. Hanno, MD, MPH, professor of urology at the University of Pennsylvania, Philadelphia.

What was the impetus behind UrologyMatch?

Dr. Morgan: Alex and I went to medical school at Harvard together, and we were going through the match process in 2002-2003 and just could not believe that there wasn’t more information out there. We asked friends who had gone through the match and got bits and pieces of information, but we kept wondering why there wasn’t a place we could go to talk with other applicants and get information from individuals who had gone through the match before. So as we went through the match process, we started taking notes and asking other urologists and program directors: What is this about? How do we maximize knowledge gained?

A lot of us have ideas, but very few of us are able to actualize them and put them into practice. How did you proceed once you had the basic concept?

Dr. Kutikov: Just like any other project, you have to break it up into parts. The first part of the UrologyMatch.com venture was to create a guide for medical students. The site started out by offering a very simple, step-by-step recipe on how to become a urologist: what steps you need to take in the first few years of medical school, what rotations you need to do, how you engage potential advisers, and how to succeed in the process. It was a bit of an afterthought to create a “bulletin board” discussion forum where people could interact with each other.

We put up the site at the end of our fourth year in medical school, a few weeks before I got married. I remember logging into my e-mail on my honeymoon and seeing an e-mail from Todd saying, “Check out the website; it’s taking off.”

We really filled a niche that people were looking for. Immediately, there was a tremendous amount of conversation that was happening through this very basic platform that we established.

Where did the expertise in programming come from? Did one of you have that, or did you look for someone to help?

Dr. Morgan: Amazingly, neither of us had it. One of our housemates at the time had done some programming before and lent some help. But really, Alex just jumped right in and figured this out. The initial site definitely looked more elementary than the site we have today, but it was clean and simple and absolutely got the job done.

How did the financing come about?

Dr. Kutikov: Initially, it was really a bootstrap kind of effort. The cost for starting the website was very low-about $10 a month for server space and to obtain a domain name. As we started expanding the site, we needed a sponsor to champion it and to allow us to create content and pay for server space as the traffic grew. We really need to thank Boston Scientific, who saw the value early on in offering this kind of content to students, and they’ve supported us for many years now. That’s kept the “lights on” for UrologyMatch.com and has allowed the urology community to benefit from the site.

So you were able to commercialize this idea and get financial returns from it?

Dr. Kutikov: Yes, we’ve had sponsors, but I would say the vast majority of anything that we receive from them, we put right back in, whether it’s UrologyMatch.com or drawMD.

Dr. Morgan: The key is being able to evolve the site. It started out as a very directed site geared toward the match process and engaging applicants on the discussion board community. In order to expand it and evolve it, we’ve had to put the majority of the sponsorship money back into the site and hire outside developers to grow not just the appearance of the site but also how users interact with it.

How does the website help the medical student?

Dr. Kutikov: The way I look at it, one of the key values that UrologyMatch.com provides is a community for medical students who are trying to decide whether urology is right for them. I think it sets urology apart from a lot of other specialties in that it makes us appear to be not only very organized but also shows that the field of urology has a tremendous esprit de corps. By offering such a resource for medical students, I would like to think that it helps us attract the cream of the crop to our specialty.

We wrote up a manuscript several years ago, which was published in the Journal of Surgical Education (2009; 66:212-5), where we documented that over 40% of UrologyMatch.com users reported that the website not only helped with their decision to pursue urology as a career, but also influenced critical decision making during the process. So the site certainly gives people a forum to obtain information and to exchange information with others. Residents and attendings frequently come back to the site to provide advice. Also, we have a guide for “Moms”-this helps students explain their career choice to their loved ones!

Dr. Morgan: Alex and I love being urologists, and we love carrying the flag for urology as much as we can. A primary reason that we both went into academic urology was to help attract the next generation of urologists. Nothing is more gratifying for us than when residents come up to us and say, “I knew nothing about urology. I thought it was strange, different. Then I started going through your site, learning what urology is, seeing the conversations on the discussion board, and urologists seemed very welcoming and open and interesting. That’s what made me start thinking about going into urology.”

How do you police the website? If someone wanted to destroy a program, it seems like they could have quite a big influence.

Dr. Morgan: We have a number of individuals who help us monitor the discussion board. Our interest is in promoting urology. We want the discussion board to be an open community, an open forum for honest discussion. Slander of individuals and programs is not something we allow on the site.

Dr. Kutikov: Negative comments have been posted over the years, but those are isolated incidents that were brought to our attention and removed from the website. I can probably count on one hand how many times that’s come up. People realize that this is a forum to exchange information and ideas and not to slander programs or individuals in any way.

Dr. Morgan: It’s also important to point out that most users understand the nature of discussions on any discussion board these days. They can be extremely helpful, but some comments need to be taken with a grain salt.

Do you have data on the site’s traffic?

Dr. Morgan: The website gets well over a million hits a year. It has about 20,000 unique visitors a month. That increases during match season, so during September, October, and January, the site’s traffic goes through the roof.

Dr. Kutikov: We’ve really worked on building more content in order to continue to engage residents as they go through the residency process after the match. We have a job guide, a financial guide, and a fellowship guide. There are content offerings now that are beyond the match that bring people back to the website.

The site contains a urology atlas that discusses basic principles of anatomy and genitourinary pathology. For instance, if in the operating room, one needs to know laser settings, the website allows one to look up those settings at the point of care both for upper and lower tract disease. A very comprehensive bladder cancer corner is also available on the site.

Is this idea easily adaptable to other specialties, and are you working on this?

Dr. Morgan: Yes, it’s adaptable. But being urologists, our interest has been in pursuing urology. There are so many varied interests within urology that branching out is something we haven’t really had the interest or time to explore.

Dr. Kutikov: You have to avoid what Todd calls “scope drift;” you’ve got to keep it focused. We target sophisticated users. If we put up, say, an anesthesiology site, I don’t think it would have a lot of face validity behind it and it wouldn’t gain traction. You have to know your audience, and we know urologists best.

Does this have any international applications?

Dr. Morgan: There’s a huge community of international urologists who utilize the site, particularly those looking for information on how to get into programs, how to do fellowships, and which fellowships have a strong history of educating foreign graduates.

I’m also thinking about foreign training programs; are there efforts to get those on the site?

Dr. Kutikov: As the social media revolution has taken off, UrologyMatch.com has actively participated in that transition. In fact, we recently received the BJU International Social Media Award 2013 for social media engagement. The more we engage users from around the world in social media, the more aware they are of the experience of young American urologists. But to answer your questions, we haven’t really delved into understanding nuances of the process of becoming a urologist in other countries; the logistics just vary so widely.

Let’s turn to drawMD. How was this idea born, and how did you proceed once you had the idea?

Dr. Kutikov: The idea was very simple. When Todd and I entered practice, we began to experience first-hand the limited amount of time during which the exchange of information between the provider and the patient takes place. And we thought the mechanisms for how this happens are really outdated. In a short visit, you’re trying to educate the patient about very complex anatomy and physiology and postoperative care, and we found we were drawing images on the exam table roll-off paper, tearing them off, and giving them to the patient. iPads were just being announced, and while on a conference call with our developers about UrologyMatch.com we asked, “Could you develop an application for the iPad?”

We thought that kidney stones would be the “lowest hanging fruit;” the idea was to be able to show patients what their stone looks like and its size. You can shrink the stone image and expand it and put it in the right anatomic location; show what a stent is; and show what a nephrostomy tube is. A picture is worth a thousand words, and without an image, explaining a ureteral stent to a patient is actually extremely complex. You really have to draw it all out, because otherwise most people envision a ureteral stent to be very short, like a cardiac stent.

Again, the lesson here is to find a champion. All these ventures cost money and you have to be able to finance them. You have to find somebody who believes in you and your idea. Boston Scientific was the industry sponsor for this. We came to them and said, “We want to build this; can you give us a little seed money?” Those guys really stepped up and gave us some seed money and we put the Urology drawMD app into the iPad App Store.

Was urology the first application for this type of program, or did this start in another area?

Dr. Morgan: It started in urology. That’s what we know. The idea was simple: to use the app to show patients what it means to have a kidney stone or bladder tumor or whatever brings them to the urologist’s office. The content is the key-what are the images that we need, what structural layout do we need in order to educate our patients, and what can we send them home with that they can reflect on and make sure they really understand and remember what was discussed during the visit. Starting with what we know helped tremendously.

Had this been done in other specialties before?

Dr. Kutikov: In order for this to work, you have to be an expert in a particular specialty. For instance, Todd and I had no idea what an ENT would need for a conversation with a patient. We engaged some consultants who know the ENT space and said, “When you sit down with a patient with a head and neck tumor, where do you start, what anatomy do you need to show?” It was a similar situation with orthopods and other specialists, who explained that there were certain anatomic images of pathology that needed to be simplified.

Engaging these consultants has really made the venture a success. Other folks who have entered this space after us offer pre-made images that you can doodle on, but that doesn’t work. It has to be a conversation; it has to be a pre-determined process on how you counsel a patient with regards to pathology or a disease process.

What other specialties is drawMD available for now?

Dr. Morgan: It’s available for anesthesia and critical care, cardiology, ENT, female pelvic surgery, OB/GYN, ophthalmology, orthopedics, pediatrics, thoracic surgery, transplant surgery, general surgery, and vascular surgery.

Dr. Kutikov: The general surgery drawMD app is actually our biggest app. Sitting in front of the patient explaining the complexity of bowel diversions with just a few clicks on the iPad makes the process so simple that that app is incredibly popular.

I recently spoke to a urology program chair who said he uses drawMD all the time in his office. How do you use it in your office?

Dr. Kutikov: The drawMD app lowers barriers. It lets me transmit information faster and better to my patients. It gets me out of the room faster, and the patient has a much clearer understanding of the plan. This solves a big issue for the clinician. I use it in the office. I think it lends itself incredibly well to prostatectomy. In no time at all, you can explain the whole prostatectomy with the patient sitting there soaking in every detail.

I practice in Philadelphia, where it is a relatively saturated market for urologic oncology, and I see second and third opinions all the time. I frequently have patients tell me, “You explained this to me better than anybody has ever explained it to me in the past.”

Another example of the app’s usefulness is for cystectomy. Cystectomy counseling requires a great deal of information transfer: extirpative details, neobladders versus Indiana pouches versus ileal conduits, showing patients the stents and the drains that they’re going to wake up with. With drawMD, it just takes a few minutes to walk the patient through all the complexity. It really simplifies and facilitates the conversation.

Dr. Morgan: It’s amazing how often we hear patients say, “I’ve had this problem for 3 years and this is the first time I understand what’s going on.” That’s a beautiful thing; that’s what we’re going for. It’s so hard to communicate what we know and what we think to patients, especially when you’re talking to patients about surgery.

I read an online review of the general surgery drawMD app, part of which said, “While most of the illustrations I saw were generally accurate, as a trained medical illustrator, I would disagree that the illustrations are beautiful. This is my chief complaint about this app. It reminds me of student medical illustrations-better than a non-artist could produce, but not professional quality.” Are there any plans to improve the quality of the illustrations?

Dr. Morgan: I love that review because it highlights the importance of really understanding the nature of a patient-doctor visit, and I don’t think this reviewer has a great handle on that. There are a lot of apps out there that have gorgeous 3-dimensional images, but they are unbelievably meaningless when you show them to a patient. What we sought to do is to create simple drawings that patients can look at and quickly understand the anatomy, as opposed to being distracted by the most beautiful 3-dimensional images they’ve ever seen. Our apps are directed toward helping the patient understand complex medical problems and their treatments and not be distracted by what we consider to be “eye candy.”

As more and more medical schools use tablets for training medical students, how do you perceive this will impact the drawMD endeavor?

Dr. Morgan: Tablets are the future of medicine. Sitting at a desktop computer with your back to the patient, typing in notes and orders, and talking to the patient behind you doesn’t make any sense and runs totally counter to what we all know about establishing good patient-doctor rapport. Since virtually all documentation and ordering is now electronic, these are going to have to evolve to be tablet based, which can be done while you sit shoulder-to-shoulder, next to the patient. The iPad is a amazing tool that, from our standpoint, can be used to help explain things to patients so they can make educated medical decisions. But there are other great applications for medical students, particularly with respect to textbooks, study materials, and other educational applications for students. Without question, iPads are being used in medical school and they’ll continue to be used in clinical practice, so we are working hard to continue to improve our platform as we reach more clinicians and patients.

Dr. Kutikov: One of the leaders in this endeavor has been UC Irvine with their iMedEd initiative-they preload drawMD on every iPad they issue to medical students. We also have had nurses tell us they use it to explain things to patients that the docs don’t have time to explain.

Is this available in languages besides English?

Dr. Morgan: We’ve talked about it. Several urologists from other countries have asked us about the availability of the app in their language. But one of the great things about it is that it’s image driven; it’s not language driven.

Dr. Kutikov: We were highlighted in the New York Times in an article discussing which apps to preload on your iPad when you travel in the event of a medical emergency. We were highlighted because drawMD transcends language; you can explain to a physician in Asia where your cardiac stents are, what your coronary pathology is.

What advice would you give to a urologist who has an innovative idea of their own?

Dr. Kutikov: Align yourself with a talented technology team that believes in and is willing to dedicate time to your idea. Don’t expect results overnight. These projects often take years to blossom. Also, Todd and I are always open to discuss ideas with folks and point them in the right direction.

You both have extremely busy and stressful full-time occupations as urologic oncologists in academic settings. How do you find the time for your outside business operations?

Dr. Morgan: Time is tough to come by. We look for spots, like phone conversations when we’re driving home from work. That’s our typical time to talk. We have late-night conference calls with our team. When it’s something that you love and something that you’re really driven to do, you find the time to make it work.

The other thing that you do is get help. We have a fantastic development team for UrologyMatch.com, and we have a fantastic development team for drawMD. John Cox, the CEO of Visible Health, which is our parent company for drawMD, runs everything on a day-to-day basis. He manages the team, is tasked with building and pushing us forward, and is doing an amazing job.

Dr. Kutikov: I believe in the concept that if you want something done, get the busiest guy to do it. The momentum is there.

Are you working on any other endeavors?

Dr. Kutikov: We’ve been working with some medical students, and one thing that’s really lacking is good test preparation software. So we’re launching a venture called “Qjitsu.” The name comes from jiu-jitsu, where the weaker opponent can beat the stronger opponent leveraging proper techniques. This is going to be a crowdsource resource for students to first train for USMLE exams but maybe down the road to train for other exams as well.  The platform was recently rolled out at a West Coast medical school and we are looking to beta-test it at other universities. More information about the venture can be found at www.slideshare.net/secret/9ztN7qHN7bkmOA.

How can readers access your programs?

Dr. Morgan: UrologyMatch can be found at www.urologymatch.com, and drawMD can be downloaded at the Apple App Store. Readers can also find more information at www.visiblehealth.com.UT

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