I’m a doctor who co-founded Figure 1, the medical app known as “Instagram for doctors”. We now have 1 million healthcare professionals. AMA!

What sort of patient consent issues do you face with photo sharing?

Consent is a real issue, and it's a big deal in health care. We make it easy for people to get consent from patients (or their surrogates) by including a built-in consent form. Consent rules vary from jurisdiction to jurisdiction and workplace to workplace, so healthcare professionals need to be aware of the specific policies that apply to them.

So is this more of a wikipedia w/ photos kind of thing, or more like examples of case studies? How does HIPAA play into this?

It's more like the latter - healthcare professionals take pictures of real cases they see and share them. People share cases to teach, to learn, and to discuss. As for HIPAA, the law governs the way that we're supposed to treat Protected Health Information - info like your name, birthday, and any other bits of information that might identify you. The images on Figure 1 have all these types of information stripped away, so all the images are de-identified, and safe to share.

so is it like, if you're taking a picture of a hysterectomy, in the description would you use #hysterectomy so other healthcare professionals will find it? kinda funny when you look at it that way, but i can see the usefulness.

Definitely weird to see medical conditions with a hashtag the first time. But you get used to it. #ErsipelothrixRhusiopathiae

Sorry I'm late here, I just found about about this.

My question to this would be: Isn't some identifying information sometimes important for the case, for example age?

Personally I have looked into anonymization only briefly as part of an idea I had about sharing personal health records.

Believe it or not, age is not an identifier, unless the person's age is 90 or above. The way Figure 1 posters handle this problem is by simply saying the patient is 90 or older. (90+, >89, etc). Truthfully, it matters most what age bracket the patient is in, but their exact age is almost never important.

Those HIPAA identifiers are things that are unique to you - your SSN, your insurance number, your IP address, your phone number, etc. That info isn't really important to addressing the medical aspects of a case.

Hello, thanks for stopping by. Do you have any plans to have a "problems" section? I work as an engineer in medical devices and one thing that I feel there isn't enough of is cross talk between physicians and engineers/scientists. It would be a very cool feature if physicians could post cases from disease states that they feel have insufficient treatment options for so that engineers can design new devices.

WOW that idea blows me away. I suppose the next thing after the steps you mention here is to somehow engage the bioengineering community. Not impossible, but a new learning curve, for sure. I'm going to mention that idea around, and if it gets traction, I'll get in touch to dig deeper with you.

With the current pipeline, this isn't an idea we could build NOW, but something I can see building SOON.

What is your favourite lizard?

First things first, the Lizard - obviously it's the Gila Monster. 2 reasons: 1. MONSTER. 2. The toxic, venomous saliva of the GM was actually used to make a diabetes drug. The substance is called Glucagon-like peptide, in case you were wondering.

In the category of "unlikeliest places we've found medicine from" like the Gila Monster what is your favorite?

Top places to find medicine:

• MONSTERS (see above)
• Frogs (curare-derived paralytics for surgery)
• Mold (Penicillin)

• Salmon sperm

Right - for calcitonin!

This is the first time I've heard of the app and I've just downloaded it. I wonder what the vetting process is for cases. Is it only unusual cases that you post or do you include regular ones for doctors just starting out as well?

THANKS! We have an amazing moderation team that works around the clock, looking at each case that gets submitted. If an image doesn't meet our educational standard, or contains a violation of our community guidelines, it doesn't get posted.

It's both types of cases that get posted. I post cases to demonstrate a particular finding ("teachable moment"), or of cases where the presentation was unusual or striking.

What's the most difficult case you've had that you wish you had figure 1 for before you made it?

Great Q. When I was in residency, we looked after a young woman who visited the Amazon (the place, not the website) and stepped on a nest of poisonous caterpillars. She came home and within a few days, she developed bruising on her legs. When she came to the emergency department, we found a lot of abnormal lab values - particularly with her body's ability to form blood clots. She started to develop respiratory and kidney failure over the next week, and it wasn't until she was on life support that we found out there is an antidote for the caterpillar venom. By the time we had access to that antidote, unfortunately it was too late and this young woman passed away. It was awful.

If I had Figure 1 then, I wonder if we might have known that vital piece of information earlier and her life may have been saved.

Wow, that's really interesting. I don't think it even occurred to me that a caterpillar could be that dangerous.

I love the crowdsourcing aspect of this, would have made House a very boring show.

If you watch it with your friends who are all nerds like me, it's not that fun either. Imagine 6 type-A keeners all trying to out-explain each other as to why something on TV was wrong.

How do you feel about non doctors using the app as a way to view gore pictures for shock value?

How do you see the app expanding in the future, will it stay as a niche service among doctors, or be social medias answer to web md?

Are there any safe guards in place if some one sues for doctor patient confidentiality being broken?

3 QUESTIONS!?!? I said ask me anything, not EVERYTHING, amirite?

Question 1: Generally disappointed. Try to keep in mind that these are pictures of real patients. Nearly all of our members are health care professionals/students who use the app to teach, learn, or help others improve patient care.

Question 2: The current plan is to stay focused on the needs of healthcare professionals, and we're planning to launch something new in a few weeks - HIPAA-compliant direct messaging.

Question 3: It's a professional responsibility. That means that each doctor is responsible for how they treat patient information. As for Figure 1, we moderate all the images manually to ensure that patient privacy remains protected.

Regarding messaging, will you be using Direct? I could see this app being tied into an HIE or ACO being quite useful.

I don't think I know what Direct is. We have built our own messaging platform, so maybe that answers your question? LMK.

Any plans on doing this for other medical professionals (like dentistry)?

Actually, there are categories on Figure 1 for Dentists and dentistry specialties too. (So, yes).

I'll be the one --- why isn't "Instagram for doctors" your favourite nickname?

Essentially, we're a mission-driven company. I want to empower the world's healthcare professionals to connect, cooperate, and collaborate - it's not a simple thing to diagnose and treat sick people, and I don't want to be reductionistic about it.

That moniker is catchy, and it gets a point across, but not the most important point.

From WIRED:

Instagram is what most people use when they need a distraction from work. Figure 1 lets health professionals—not just doctors—immerse themselves in the stuff. Figure 1 is educational, engaging, and privacy-obsessed. I’d probably describe Figure 1 as a Pinterest-inspired version of Epernicus mixed with Doximity and a dash of Diaspora. But if you’re at a party, I guess “Instagram for Doctors” works fine.

The idea that Figure1 is not a distraction is very interesting. I think most apps are designed to distract people in a way that makes it easy to make mistakes, but possible to achieve success. Instagram is not just a distraction from work in my opinion, it's a distraction from all social responsibilities. If you make a social mistake on Instagram (like sending your ex an eggplant emoji because you're horny, or making a rude comment on a friend's photo because you're bitter/angry) it's not as dire as making a social mistake at work (like flirting with a coworker because you're horny, or making a rude comment to a client because you're bitter/angry). On the other hand, you can really use Instagram as a tool to create a social identity. For example, you can sell yourself as a photographer, philosopher, radical feminist, muscle-bound twink, etc.

My point/question is...

In what ways would you say Figure1 is a distraction from healthcare and in what ways is it a tool that enhances healthcare? In other words, what mistakes are you allowed to make in Figure1 that would be relatively inconsequential in your career (whether in publishing, practice, or any other part of your life that you consider career-oriented)?

edit: wording

SUPER thoughtful question. Let me start by saying something annoying: any virtue can become a vice when applied incorrectly. Using Figure 1 when you're supposed to be doing important documentation/reviewing charts/doing CPR is problematic, distracting, and potentially harmful. Using Figure 1 to solve problems and answer questions ​is something that can​ bring you information that ​may​ save your patient's life. It's a 2-sides-of-the-same-coin type of thing.

Your second is a bit different than the first, and it's maybe even a more important question: Is it OK to be wrong if you're trying to help someone? That's a really complicated question. The most practical answer is that this same process occurs in real life too. Happy to dig deeper if anyone would like.

Awesome, sounds like a great platform. My question -- do you ever get grossed out by the human body? Or have you lost the capacity for disgust?

Definitely I get grossed out sometimes, but it's not by the types of things you might expect. Blood and other fluids don't really affect me, but I still feel lightheaded when I see needles disappear into someone's joint.

How did you go about creating the app? Do you have a tech background? Will it be monetized - and if so, what kind of advertisements would you approve?

The creation of the app was a partnership with my 2 co-founders, Richard Penner and Greg Levey. Richard is the developer among us, and he built the prototype and a large part of the first version of the app. Now we have a whole team of developers, who are excellent, by the way. I don't have a background in CS, but have always been a tech enthusiast.

We are VC-backed, so that means we will find a way to monetize. I want to make sure that anything we do adds value to the community. Sorry if that's vague, but we're still figuring it out.

Thanks for responding. So I tried joining, and it says it'll take a few weeks for my ID to be verified. Overall I look forward to using it!

That's great! You can use it right away, and hopefully verification can happen quickly. Actually, if you DM me your UN, I can ask the team to do it today.

Which case has received the most attention on the platform?

Any plans of turning the best and most interesting cases into a book like this one?

It's hard to identify the best case, but we did assemble the best 100 into a blog post that we put out this week. Unfortunately, no books are currently planned. My current favorite case is one that I posted of a massively dilated colon in a patient who had an emergency operation outside the OR.

How did you come to an idea to create Figure 1?

And, what's your favourite specialty, in terms of medicine, in professional life and on Figure 1? :D.

Thank you for making such an awesome app for medical professionals and everyone interested in medical sciences, plus greetings from "bevacizumab" on Figure 1!

Firstly, happy cakeday. Secondly, intensive care is my favorite specialty - it's the one I chose to specialize in, after all. Also, it's one where you really get to see cases from many other specialties. Other favs include infectious diseases, hematology, and toxicology. Hi back to Avastin!

I always ask this of those in medicine: which medical show or movie gets it the most right?

If not medicine, what do you think you'd be doing?

What kind of music do you like?

What's something you had to remove from Figure 1 you can talk about?

The show that gets medicine the most correct, IMO, is scrubs. Obviously not the fantasy sequences, but they really captured the strangeness, the loneliness, and the teamwork.

If not medicine...something sciencey for sure.

I like music that blends more than one genre, and things are a little strange. Here's a recent fave.

As for removals, we take down selfies sometimes. Docs and nurses occasionally post pics of their own medical conditions - often just to share something interesting - but we don't permit that because of the privacy implications.

How do you see the business model for the app working out?

vide supra.

SharePractice, Sermo, Doximia, QuantiaMD... What makes you different from your competitors?

I'll highlight just two important ones for now and I hope it helps.

Figure 1 was built as a mobile-first product. That means the entire service was designed for you to use on your phone (or tablet, I suppose). The app wasn't an afterthought or an add-on. We employ best practices for building a world class product, and our team is staying current with mobile trends.

Our content is images+captions+comments. That's all. We've tried our best to stay true to this style because it's proven to be interesting to our users. It's simple to use because it does one super-important thing: share medical cases for discussion among healthcare professionals.

With the proliferation of cameras and recording devices found in all manner of electronics, many hospitals, and the physician groups they contract, are implementing policies against capturing or transmitting pictures or information on any non-approved device.

How do you see this trend impacting Figure 1's ability to continue to grow its database?

It's true that some hospitals prohibit the use of mobile phone cameras, and it's really important to me that healthcare professionals follow the policies of their institutions. That said, there is so much to be gained simply by joining the conversation. In fact, I might be so bold as to suggest that there's often more value in the discussion on Figure 1 than the image itself. Consider: The smallest, most active group of users are the posters, the next sizeably larger group are the commentors, and there are plenty of lurkers too. Users can be any of these things and still gain (and contribute) tremendous value.

Also, I must say, it hasn't hurt our growth much ;)

Any chance you'll expand this to include veterinary stuff? Some of that could be very interesting.

I definitely agree about the interestingness of vet cases. Right now we're focused only on humans, so no vet plans at the moment.

Hi Dr. Nick Landy! Very interesting concept you have created. What impact do you see this platform having on the advancement of medical care, both locally and around the world?

Thanks for the Q. Essentially the goal here is to increase the ease with which healthcare professionals can exchange information. As you might know, healthcare is not an industry with a great track record for efficiency. If you are a healthcare professional, it's probably pretty great to say to your patient, "I'm not sure, but let me ask a million other doctors & nurses and get back to you in 5 minutes."

Do you think this creates a potential for liability issues as far as diagnoses go?

I don't want to oversimplify the diagnostic process. Figure 1 is another tool in the massive toolbox of a physician - like textbooks, other online resources, or asking a colleague IRL. In the end, the MD is the one who makes the dx.

Hi, not a doctor... But I got a question... So yeah! You say that the MD is the one that must give the final diagnosed, and your app is another tool to use to get to the answer of health problem... If you find a doctor who already had a similar problem, that mean that you can get in contact and work together to find the better way to treated? That would really be helpful and a conversation around that diagnostic is better than reading texts to read hundreds of papers and give a real a healthy solution for the problem (I'm engineer and sometimes you have to study a lot to understand a problem and is very hard to find colleagues with the same problem) (English is not my first language)

I think your mental model here is right - here's this doctor with a problem, they think they know what the diagnosis is, and they have Figure 1 on their phone. What can they do with it? First, they can upload an image and ask the community to weigh in. Second, they can page a specialist on Figure 1 and ask a question (if they know what specialty they need). Third, they can search the app for images related to their patient's condition.

The first option I mention, uploading an image for discussion, is what you're referring to, and it's absolutely a more efficient way of problem solving than fruitlessly reading long textbooks in vain hope.

Do you have a team that audit and filters the images that are posted? How does that process work?

Also, are you hiring?!? Informatics/ ER nurse here :)

Thanks for the Q. If you want to inquire, shoot an email to [email protected].

As for the images, we have a moderation team that reviews each image before it's posted. They're looking to ensure that privacy remains protected, and also that the images comply with our community guidelines: it's posted for educational benefit, and the patients are respected. The guidelines are on our website (and in the app).

Hello Dr. Landy,

Let me first say that Figure 1 seems like a really cool, innovative, and streamlined way for doctors to share ideas and information.

But, I was just wondering, do doctors ever troll each other on Figure 1?

Awesome UN.

Thanks for the nice comments. We've been lucky to see almost no trolling. Healthcare is a professional environment, and generally the community is supportive.

Hey! Gorgeous logos and great name!

Are the pictures posted to the app still legally owned by the professional? Can they use the image afterward in a paper, presentation etc or do they become the property of Figure 1?

Thanks, and I'm glad you like my name. I'll tell my folks.

The images remain property of the user who uploaded the image (provided they own it to begin with). Figure 1 has a worldwide royalty-free license to use the images, but the OP can do whatever they want with the image outside of Figure 1.

As a startup co-founder AND practicing physician -- what's your work/life balance like? What do you like to do in your free time?

Well, I don't sleep that much, but I do try to spend time with my family and friends when I can. Some days I wake up at the hospital and go right to the startup. When I get home, I relax by making ice cream, playing with my custom-made puppets, or watching Ghostbusters.

Tell me more of these puppets

All my favorites are hand puppets, though I do have a few marionettes as well. What makes these ones special is they're customized versions of my family members. TBH, one puppet that I have never been able to find online, but want so, so, so, so badly is an inspector puppet - with a trench coat, magnifying glass, etc. If you know anything, help a guy out please! (I haven't looked into r/puppets, so maybe I'll do that when I'm done here)

I'm so glad I spotted this post just downloaded the app and I'm in love with it already.

I suppose I must ask a question. What's your favorite sandwich?

Crusty sourdough bread, grilled chicken thighs with a molasses+garlic bbq sauce, Sriracha mayo, fresh tomato, avocado, and grainy mustard.

brb making a sandwich

Aren't Prior Authorizations just the worst?

I know, right? (I don't really. I'm Canadian.)

Question: You created an app which shares visual information, what is your perspective on medical illustration and its role in communication?

Anecdote:

Just a massive personal thank you. About 2 years ago, I decided to change my career.

I'm working full time, taking classes and will be applying to grad school for biomedical visualization/medical illustration. Your app has helped me immensely.

I've been able to completely change my illustration and have found endless material to translate and study through your app.

thank you!

Illustration can often be as informative, or more informative, than photographs - take Frank Netter's anatomy illustrations, for example. Whenever I'm demonstrating anatomy to my patients, I always draw a representative illustration, never a photo.

When should premedical/medical students begin to use this application? What do you hope students use Figure 1 for? Is it useful for studying and boards?

I've seen students recommend it to their peers in aid of studying for various levels of board examination, and I do think it's great for that. It's most useful for people who work in the field of healthcare, which includes medical students. Also, some of the discussions are quite technical, which can be frustrating if your vocabulary is undeveloped.

Do you expect to be bought out by a tech company? It seems a large trove of medical imagery could be quite valuable it these days of machine learning.

No, we don't have any plans like that.

So if I have a condition that has stumped my medical team for awhile now, I should ask them if they've heard of Figure 1 and have them check it out?

That's not a bad idea. Let me know what they say.

Hello Dr. Landy, I love Figure 1 and have been following you guy for a while now. I have learnt so much following doctors and physicians (penguinophile is my favourite) and I am not even a medical professional. I am a product designer but have a keen interest in medtech. Could you throw some light on how the product team is structured at Figure 1? Who are the designers working on the mobile/web product? Considering how busy doctors get how did the growth team manage to market the product and get a million health care practitioners to start using the product. Thank you!

Thanks for the nice words about Figure 1!

The product team is still a small group led by the founders. We work closely with the growth team (Phil) and our designers (Mike and Jess), whose UX work is a thing of beauty.

My favorite way that we spread the word about Figure 1 is our med student ambassador program. Students who love Figure 1 serve as a liaison between Figure 1 and their classes, and we provide incentives for them to spread the word.

Hi, Dr. Landy. I'm a big fan of Figure 1 and the innovation it brings to a very silo'd healthcare community (especially in Canada). What tips do you have for small startups in the medical space to make that leap into the mainstream market?

Make your product really, really good. Users know when they're touching a high quality piece of software.

Inspire delight in your users. If they love you, they'll tell people - word of mouth is everything to us at Figure 1.

Is it possible to set for example tags to only see pictures regarding trauma surgery or brain surgery? If not, is this planned for the feature?

What's your thought on cooperations with pharma or medical engineering industry?

There's two ways to do what you're trying to do: either you can search for keywords, like #neurosurgery, which is a reasonably popular tag, or you can look in the categories (e.g. Neurosurgery).

As for industry: Remember that at the non-marketing level, these companies are solving hard medical problems. It would make sense for the people who practice medicine to be in direct contact with the engineers who design solutions for medicine. There's obviously a layer of economics that I haven't mentioned, but that's the core of my thinking at the moment.

I am an MD who initially downloaded the app excited for what was advertised, but was quickly disappointed to find the comments section filled with nursing students giving unqualified opinions. If this app is in fact for doctors, then why do you allow the unqualified to contribute?

Edit: This is exactly what I am talking about, "I have your app! I heard about it a year ago from Reddit (it was the picture of the bloody bronchial tree.) I'm in a healthcare field, public health. But I don't get a little tag next to my name, even though there seems to be a category for public health. Med students and nursing students get theirs, why not me?"

That sounds like an irritating experience - I'm sorry that happened. This question represents a problem of balance between student and teacher. The most important thing that Figure 1 can do is spread medical knowledge to people and places where it's needed. Permitting students to openly ask questions and practice their clinical acumen is one part of how we deliver value.

I hope that helps.

Wjat is it like being a doctor? 

Generally, it's good. Hard sometimes, especially during emotional moments for patients and their families. Overall, it's an incredibly rewarding job.

Are you planning on having computer matching, or making the database available for machine learning? It'd be interesting to be able to take a photo of a condition and have an algorithm come back with the 10 top possibilities and tests to distinguish between them, then be able to make further suggestions based on the results of the tests.

Yeah, I'd love to do this. There's the problem, and then there's the problem behind the problem.

The problem is that you need a lot of images. That's okay though. We have a lot of images.

The problem behind the problem is that you need a lot of metadata. We have lots of that too, but it's in the form of comments and discussion. That's the perfect metadata for a brain, but not for a machine. We're learning how to transition between the two, and it's super interesting and exciting - if we nail that, we'll be laughing.

Given the amount of on-the-spot photos which come from smartphones, and the advantages of a large medical database of data such as Figure 1, would you be interested in seeing the development of a cheap smartphone attachment which performed a range of basic, fast medical tests (or at least took records)?

I'm thinking something which gets pressed to the skin for a second or two, plus a range of initial diagnostic / image analysis software to assess/markup general photos. Maybe a lab-on-a-chip for blood tests? Essentially, something that even a person with zero medical knowledge could use in an emergency, and which medical personnel could be trained to use the more advanced functions of.

That would be amazing, revolutionary, and industry changing. I am aware a small number of companies trying to crack this problem. In fact, there is a $10 million prize up for grabs for the first team to build a real life medical "tricorder", which is the Star Trek name for a device similar to what you've described. None of the candidates are smartphone-based, as far I'm aware.

A recently-troubled company that is taking a different road to (probably) that same goal is Theranos. They make blood testing machines that use a fraction of blood compared to the usual machines.

big fan of what you guys are doing! on behalf of the world, thank you.

what i want to know is what's the weirdest/most interesting/unexplained condition you've seen on Figure1? ever encountered any real-life x-men?

You're welcome.

We recently cross-posted a case from the UK. The BBC reported on a mysterious condition of a young woman who would intermittently bleed from her eyes and ears. Still no diagnosis, as far as I know, but the case is definitely a head-scratcher.

As for X-men, sadly no. But we did get to see Ant-Man.

How many regenerations will it be until you are the curator who looks just like an older version of the 4th Doctor?

EDIT: I just read the first four words of the title, sorry.

Not being a time lord myself, it's hard to know.

Thank you for doing this AMA! Your responses have been very interesting!

I am currently working on my Bachelor Thesis where I am writing a communications strategy for a small start-up that is developing an app for patients with a psychological condition.

What communications/PR/marketing measures did you implement? Did you let everything grow slowly and simply tried to spread the word as much as possible? OR Did you use the help of PR/marketing professionals? Through which channels did you reach out to other medical experts?

The first employee we hired was a communications coordinator - she did everything: made our website, set up our social media channels, and told blogs and news outlets about our story. The most important thing is articulating the purpose of your company and the unique value of your product in a simple accessible way. Once you nail that, all other tactics flow from there. It's good to take advantage of online channels because they're efficient. But it's also good to know when to leave the online world behind and meet people in person.

Can you explain why so many surgeons and to a lesser extent doctors are such incorrigible assholes? Please note I'm not assuming anything negative about you or even surgeons and doctors. But I work with them and they're collectively disappointing segment of society. For every one that truly inspire me there are 20 megalomaniacs. g

Firstly, I'm sorry that you've had such underwhelming experiences. That makes me want to overcompensate by being extra nice :D

I think some doctors develop a bad attitude through modelling. It stems from how our teachers acted when they taught us. Generally, docs don't get a lot of feedback about their behavior (unless it's really, really bad), so there's no feedback loop to help them correct it.

I have your app! I heard about it a year ago from Reddit (it was the picture of the bloody bronchial tree.) I'm in a healthcare field, public health. But I don't get a little tag next to my name, even though there seems to be a category for public health. Med students and nursing students get theirs, why not me?

I suspect one of two things might be happening:

• You are using a custom specialty, not the built-in ones (those tags are only supported for built-in specialties.
• You might not be verified. Verification gives you a bit of flair and mentions your specialty too.

Do patients get to opt out of this?

Absolutely - consent for photographs is 100% up to the patient or their decision-maker (if the patient is incapacitated).

[deleted]

Umm, I think you might be in the wrong AMA...but seriously, folks, your genitals are about 1% of the body's surface area and if the images are proportional to the human body, then it should be about 1% of our cases. (I've never thought to check that out though.)

Where are my free headphones?

Good question. If we promised you free headphones and you didn't receive them, contact us at [email protected] - we'll make it right.

What do you think of Dragon?

I'm ambivalent.