Question Everything While You’re Learning – Peter Frishauf, Founder of Medscape

(Edited by the Guest for Clarity)

SHIV GAGLANI: Hi, I'm Shiv Gaglani. Today on Raise the Line, I'm delighted to be joined by my close friend and mentor and the Godfather of Osmosis, Peter Frishauf. Peter is a highly influential information and high-tech entrepreneur best known as the founder of Medscape, the most visited professional medical website in the world. He's currently an investor, board member, advisor, speaker, and leader in New York's vibrant startup culture in healthcare media and life sciences. We'll be touching on just a few of the dizzying number of organizations that Peter has either created, led, or been involved in within his long and successful career. I'm also looking forward to getting his perspective on COVID’s impact on our healthcare system. Thanks so much for being with us today, Peter.

PETER FRISHAUF: My pleasure, Shiv.

SHIV GAGLANI:  I obviously know a lot about you and your background, but for our audience, can you tell us a bit more about what got you started in journalism and then healthcare?

PETER FRISHAUF: I come from a long line of physicians, including my mother, grandfather, sister, aunts, uncles, and cousins. I grew up in a medical household. My father was an electrical engineer and patent attorney, so I had a few tech and engineering influences in my blood. Both my parents were World War II refugees who made it to the U.S. sponsored by Quakers. I was pre-med in the tumultuous, rebellious 1960s, and I dropped out of that track in favor of journalism. I was good at science and science writing and gravitated towards that, and stayed friends with peers who went on to become physicians. But the rebellious part of me and of some of my friends, that never left.

SHIV GAGLANI:  It feels like everyone knows you. You've introduced so many people to Osmosis including our board member, Mitch Rothschild, who's been very influential at Osmosis. So the thing you're most known for, in our community, is starting Medscape, which as I mentioned in the intro, is the most visited professional medical website in the world. Can you tell us a bit about the history of starting Medscape? And then anything else you want to mention about how it's grown since then?

PETER FRISHAUF: Well, I'll give you a short take. For a long-form, go to Medscape and read Medscape - The First 5 Years. It’s an article George Lundberg published on the site on its 10th year anniversary in 2005.

We started Medscape in at SCP Communications, which was a medical journal and medical education company that I started in 1982. SCP was the birthplace of Medscape. It's important because SCP innovated what we call “the electronic newsroom,” a radical concept in 1982. Back then, before many in our audience were even born, there were no PCs and Macs (yes, there was such a time). On a shoestring, we assembled a minicomputer system from parts. Everyone on staff -- from editors to salesforce to receptionist-- had a terminal on their desk. We were communicating on a single data set much like today, where a group of people might collaborate on Google Docs. But back then, most people all worked on typewriters, a great innovation from the early 20th century, and no one had any idea what anyone else was doing. 

The notion of collaboration was a foreign concept in publishing as well as elsewhere. We designed a workspace that, architecturally, was an open office. Today that's standard, but back then, that, too, was an innovation. So, it was no accident that SCP launched Medscape in 1995. Our peers in medical publishing from The New England Journal of Medicine to the McGraw-Hills and other academic STEM publishers such as Wiley and JAMA were basically asleep at the switch, We knew how to produce, assemble, publish and work together electronically. That's what gave SCP the edge launching Medscape in 1995. 

SHIV GAGLANI: Some of those early days of the innovations you led at Medscape -- with people like Vin Keane and others -- you've introduced me to have been very helpful for us at Osmosis. I know you all have looked at our processes for how we create, update, and edit our videos, so we've sort of been an extension of a lot of the things you innovated in the late 20th century. Medscape turned 25 this year, and obviously there's been a big celebration around that. How would you assess the role that Medscape plays today? I know it to be the largest online provider of continuing medical education. It's just one milestone, but what are the other things you'd like to describe in terms of the role Medscape plays?

PETER FRISHAUF: Well, I think what distinguishes Medscape from many, many other parts of what is still known as “the literature”, is that it is patient-care oriented. That's a bottom line for Medscape and for me and for sites like Osmosis l -- to help clinicians understand how to deliver better patient care, presenting clinical medicine skills in a way that is memorable and even fun is really what makes what we do so rewarding. Better patient care was also the goal of the first medical journal that I edited when I was 26 years old, a housestaff journal called Hospital Physician. We would do little charts, such as one explaining, “How to Diagnose by Smell”.  It covered what you should think of if your patient smells of shoe polish or almonds.

I could visualize an Osmosis video doing that today. Or what do you do if you're in a city hospital, and you find a roach has crawled in an incubator and into the ear of your preemie? There’s not a lot of information or teaching from the texts or the literature about this kind of clinical situation.We preented little illustrated tidbits called “Here's How I Do It,” which would show you how to remove that roach and not hurt your little newborn.

Medscape is patient-care oriented. They talk about patient care issues, both in clinical medicine, and in terms of social impact, in terms of policies. They do those things very, well. From the top of the organization, from the editorial organization, people like Eric Topol and George Lundberg -- who I'm proud to say is still there after I was able to lure him to Medscape in the 1990s after he was fired from JAMA. Medscape helps clinicians deliver better patient care in a way that is very significant. The New England Journal has been around since 1812 and Medscape just since 1995. But many more millions of clinicians and clinicians-in-training get information from Medscape. It's accessible to people for free all over the world. That's really important, too. Medscape very much leveled the playing field for lots of people delivering patient care, much as Osmosis does today with a different take, but there are many similarities.

SHIV GAGLANI: Absolutely. We've learned a lot from Medscape, not only from you and then your successors there, but we also do partnerships. We've often published our student blogs on their Medscape med students section, and then they also, occasionally or I think on a weekly basis, publish an Osmosis video on Medscape. We have a very thriving partnership with them, and we'd like to thank you for that.

Switching gears to another company you helped found, Crossix, which uses a proprietary technology to perform analytics on healthcare data.  Can you tell us the story behind that, and what contribution do you think Crossix has been making to the industry?

PETER FRISHAUF: Well, the entrepreneur behind Crossix is a friend of mine, Asaf Evenhaim, who I worked with at Medscape for a bit. He had this idea that privacy-safe measurement and analytics was something extremely important for healthcare research and consumer messaging. 

For example, the usual model of running television ads for lung cancer treatments seen by massive audiences and not targeted at all to people who might have lung cancer or need therapy. It’s a huge waste of money, and an annoyance. Instead, you want to reach people who might be candidates for using your product. That's hard to do in healthcare where privacy is an issue because you can't identify somebody personally. But there are ways of doing it very much like exit polling is able to target groups of people with common interests.  

So Asaf came up with a technology, which was patented, to help entities -- payors, pharma companies, other researchers -- reach people who are interested in a message. We worked with a HIPAA attorney to make sure that the Crossix technology was following both the letter and the spirit of privacy protection, and it turned out that it was. I helped Crossix raise financing and joined as board chairman. I stayed in that role until the company was sold to Veeva Systems last year. Asaf and the key management of Crossix remain at the company. They're all doing great.

SHIV GAGLANI: That was great timing. Obviously, by the end of 2019 and now 2020, the world has completely shifted. Switching gears now to COVID, you're as well-informed on COVID as anyone I know, and obviously have a pretty broad perspective on healthcare. You've been a constant source of information for both Rishi Desai, our Chief Medical Officer, and me and the entire Osmosis team. What do you think the most significant lasting impacts of COVID will be on the healthcare system here in the U.S.?

PETER FRISHAUF: Well, you're generous with flattery but I don't know as much as other people you know. Certainly not as much as Osmosis medical director Rishi!

On COVID, I think it comes back to a focus on what matters in terms of delivering better patient care, and many, many of these are policy logistics issues that we have screwed up terribly in the U.S. and wound up hurting clinicians and patients. The lack of personal protective equipment on clinicians -- there's just absolutely no excuse for that. That's not a scientific issue, but it really shows how broken much of our delivery system is. A friend of mine,  Violeta Michel Pantaleon,was a Medscape intern in the late 1990s – and now a healthcare hero -- . She works as a nurse at the Indian Health Service in New Mexico. She told me the other day that she has been told to clean the gloves issued to her six times before a change, because they are so short of PPE.. There's just no excuse for that kind of thing. That absolutely has to be fixed. And you know what? Clinicians who blow the whistle on this need to be protected, too. We need a whistle-blower protection act for those working in healthcare, who find themselves or their patients in dangerous, situations . There's just no excuse for this. It shouldn't be tolerated, and we have to fix it.

COVID is such a mixed bag because in many areas, we've done such an excellent job in being resourceful and innovative. We’ve seen great innovation and resourcefulness by clinicians, and fast publishing and peer review. The development, approval manufacturing and distributionof a vaccine is a tribute to how quickly we can change if we put our minds to it.

In other areas -- the lack of testing, the stupidity of both the CDC putting out tests which were faulty initially, and now the FDA not being Johnny-on-the-Spot in terms of approving rapid, inexpensive home testing, is a big, big issue. There are so many best practices around the world which point to better ways be they in Taiwan and South Korea, and many other countries that have far fewer resources than we do, Vietnam being just one example. Those things that are wrong need to be fixed. Those things that are right need to be celebrated and promoted. We need to take a close, careful look at what's working and what isn't. Let's eliminate what isn’t and get on to dealing with this in a far better way.

Of course, we have massive, massive equity issues, in the Navajo Nation, where my friend is working and in Black and Brown communities. These are all huge issues that we have to deal with. It's not that the Navajo or Black or Brown people are genetically disposed to being more vulnerable to COVID. It's that we send them to lousy schools. We feed them a crappy diet. We don't teach them about diet and exercise, so of course, they grow up with chronic diseases. They're more vulnerable. They're more obese. There's no reason for that. Our best athletes are from these populations. They know how to take care of themselves. They're not sick. This is not genetic destiny. This is a social destiny, and we need to do a lot better in terms of fixing that because whatever we do in healthcare, teaching the consumer about diet and exercise, in the end, is going to do much more to improve patient care than tweaking our intubation techniques or making a better ventilator.

SHIV GAGLANI: I couldn't agree more. Two points on that that I would like to share. One is that the vaccines are being rolled out as we're doing this podcast, and I've never seen so much discussion around equity and equity of distribution of the vaccine. Clearly, maybe because of the George Floyd incident and all the racial reckoning we've seen this year, that's been from and center. On your point about educating the public and getting them the resources they need to be healthier...we call this podcast “Raise the Line” because it’s about how to improve access and capacity of the healthcare system, the nurse shortages, the PPE shortage, as you mentioned. 

However, one really important point, and one reason medical publishing is so important and medical information, which you've dedicated your career to, is that we wouldn't need as much healthcare and healthcare professionals if we were able to pass the baton in a meaningful way to the consumers and the patients. If they flattened the curve, we wouldn't have to raise the line as much. That's not their fault. It's just the fault of the systems that you've talked about, the inequitable access to good quality food or exercise and those kinds of things, so I just wanted to riff on two of those points you had mentioned.

PETER FRISHAUF: 100 percent. You know what? One of the greatest innovations that I'm proudest of with Medscape is that from day one, it was open to everybody, consumer or clinician. In 1995, this was an absolutely radical concept, and a lot of physicians and academicians hated the notion. “You're going to let patients have access to the same information there their doctors have?” It’s one of the great things about us. Medscape started that way, and to this day, it's open to everyone. Another great innovation is Wikipedia, and Osmosis’ collaboration with Wikipedia is another wonderful thing that I'm very proud of Osmosis for doing. 

In fact, in addition to Vin and Amin Azzam of Osmosis, who brilliantly innovated with his medical students at UC Berkeley to teach them to become digital citizens and edit the medical content pages on Wikipedia, the medical information on Wikipedia is at a very high standard. Teaching medical students how to edit Wikipedia articles is a trend which has now been picked up by dozens of health sciences universities and pharmacy schools around the world, from Israel to Australia and many places in between. 

Educating consumers with trusted information on an open platform -- and these include Medscape, Wikipedia, and Osmosis -- is critical to improving healthcare for everyone. Teaching kids in school what constitutes good healthcare, what constitutes a good diet, why it is such a tragic mistake to be addicted to junk food and poor food, how to deal with that using your brain, using resources to change government policy so we're not subsidizing crappy food, and that a pound of broccoli is never, ever more expensive than a pound of meat, which it is in today's agricultural ecosystem. Those are all things that we have to change that are going to make a much bigger difference in healthcare than anything we do in clinical medicine, as important as that is. Because we want to take care of the sick, but even more important we want to keep people healthy and to the extent that we can prevent sickness, we can do a lot better.

SHIV GAGLANI: Definitely. I couldn't agree more. Again, Amin and Vin, because you mentioned both of them, are the reason we got connected. If you remember, Vin sent you Osmosis early on, and Amin also mentioned Osmosis. I think those two references to Osmosis had us get connected on LinkedIn, and the rest has been history, as they say. I know we're coming up on time, so I have two other questions for you. The first is, as you know, Osmosis has many, many students and early career health professionals in our audience. What's your advice to them about meeting the challenges of the COVID-19pandemic and approaching their career in healthcare?

PETER FRISHAUF: Well, I would say they should question everything while they keep learning and do their very best to improve patient care. If they think there is a better way of doing something, they should investigate that. If it turns out that they're right, they should go ahead and do that. As I said, I grew up in the rebellious 1960s. We wouldn't have an NP and a PA profession or the specialty of Emergency Medicine if it wasn't for the rebellious people in the 1960s. Now NPs and PAs deliver more primary care than physicians. In the 1960s and early 1970s being an emergency room doctor was looked down upon. Now it's a specialty that is a prime resource for the delivery of primary care and a very respected, important, critical specialty. The people involved who were the pioneers of the PA profession, the NP profession, emergency medicine as a specialty knew there was a better way to deliver patient care that could help tens of millions of people.

For clinicians in training, share everything. Your ideas might be stupid. They might be brilliant. If they're brilliant, you owe it to the universe of people out there to test out your ideas and push on them a bit and see what proves out.

Finally, I would say I have a lot of skepticism for many academics. Now, there are a lot of academics who care dearly about good patient care, and I love them, but I don't love the ones who aren't really focused on better patient care -  the “publish or perish crowd” and the “impact factor crowd.”  Another early Medscape staffer, Ivan Oransky, publishes Retraction Watch, and every day keeps academic medicine and academic journals accountable. “Publish or perish” and the tenure system are not basically in the public interest. To clinicians in training, keep a skeptical eye out for those practices which aren't really promoting the public interest, that aren't helping patient care. And keep learning from sites like Osmosis that really do help. That's my advice.

SHIV GAGLANI: That's awesome advice. Thanks for sharing that, Peter. Is there anything else that you'd like our audience to know about you or your career or anything else that we haven't covered?

PETER FRISHAUF:  I guess I’m going to end with a recommendation. Fire up your Netflix account and watch The Trial of the Chicago 7, the Sorkin movie, with Sasha Baron Cohen playing Abby Hoffman, one of the brilliant bipolar people of the 1960s.  One of my heroes who tragically died due to his bipolar disease in a suicide. There's a lot to learn from that era. Remember that the next time you work alongside a PA or an NP, if you are a physician, or if you are an NP or PA, that era has a lot to do with where you came from. It was ideas like that which really did have their roots in the time when I was a young adult in the 1960s and 1970s. And we can learn a lot from that history.

SHIV GAGLANI: Actually, I love that movie as well. Sasha Baron Cohen was fantastic. Actually, I did not know the NP and PA history came from that period. It makes you wonder in this 2020s period, what careers in the next 20, 30, 40 years will be as essential as NPS and PAs are. Is it health coaches or what we're doing at Osmosis with nursing assistants? We're trying to train them up in a dramatic fashion.

Peter, it's always such a pleasure to talk to you. I'd really like to thank you not only for taking the time to be on the podcast with us today but more importantly, for all the work that you've done dating from way before Osmosis days to raise the line and flatten the curve and improve medical literacy for hundreds of millions of people, maybe even billions of people, worldwide. Thanks for all you do. 

PETER FRISHAUF: It’s my pleasure. Thank you, Shiv. And thank you for all you do.

SHIV GAGLANI: Well, with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show, and remember to do your part to flatten the curve and raise the line since we're all in this together. Take care.