What If You Don't Have a Hunch? - Dr. Joe Habboushe, Co-founder & CEO of MDCalc


Providers who have treated hundreds of patients with the same problem can develop a "gut sense" of how to proceed. But a new disease like COVID-19 does not allow for such hunches. Dr. Joe Habboushe knows that first hand, having worked on the frontlines in New York City ERs during the worst of the crisis. That's where "decision-support" tools like MDCalc come into play, providing all of the credible available guidance at the fingertips of clinicians. MDCalc, which Habboushe co-founded and leads, is also an instant reference for established diseases and conditions, and the majority of U.S. physicians have come to rely on it to make the best possible decisions and reduce unnecessary care. Check out this episode to find out how that happened, what we can learn from other countries about handling pandemics and how medical training should be changed from this 7th-generation physician.





SHIV GAGLANI: Hi. I'm Shiv Gaglani. Today, on Raise the Line, I'm happy to be joined by Dr. Joe Habboushe, the CEO and co-founder of MDCalc, which through its smartphone app and website, is a leading provider of medical calculators and other tools to help doctors make clinical decisions. MDCalc is used by millions of medical professionals globally, including more than 65% of the U.S. physicians. 

Joe is also the creator and editor in chief of EMRA’s pocket guide series The basics of Emergency Medicine and an emergency physician and associate professor at NYU Langone and Bellevue Medical Centers in New York City. We were introduced by one of our mutual friends and connections, an emergency physician named Dr. Jason Theobald. Thank you, Jason, for doing so. Joe, thanks for being with us today.

DR. JOE HABBOUSHE: Thanks so much. It's really great to be here with you.

SHIV GAGLANI: My first question is, beyond the intro I gave, can you tell us about how you actually got interested in a career in medicine and what it's been like working during these last few months as an ER doctor in New York City during COVID?

DR. JOE HABBOUSHE: Yes, for sure. I come from a long line of physicians. My family's from the Middle East originally. My parents met in medical school, in Iraq, in the 1960s. My mother was a female doctor in the 1960s in Iraq. Can you imagine? She and her sisters are all physicians, pretty incredible women. She's a sixth-generation physician. That makes me, my sister, and some cousins, the seventh-generation physicians. It’s pretty wild. 

I grew up in one of these medical immigrant families and love medicine. I was actually a science nerd. Even more than medicine, I was a math and physics guy in high school and actually majored in that in college. This all will come together into MDCalc in a second. You could tell that I love math. The other thing that I love to do that felt so at odds with medicine, which I love, was I wanted to be an entrepreneur, and I only said entrepreneur because I just wanted to fix bigger picture problems.

To me, it was fun to figure out ‘here's a big, new potential way to approach how we're doing something’ that maybe there'll be some benefit from it, how to creatively find a solution and work your way through those issues in a way that wasn't laid out for you. I love that concept, so I started sort of doing leadership roles in high school and college.

I knew I wanted to do something like that, and it felt so at odds with what so many folks in this audience are going through now, this medical path, where there's a lot of hoops, you jump through. They say, “Jump!” You say, “How high?” I did that for a long time before becoming a physician. 

Eventually, I was able to combine it. It took some time for sure, but I really feel so blessed that, in my career, I can see patients medically. I can take that medical knowledge, combine it with the math, for MDCalc, medical calculators, and it's all entrepreneurial.

SHIV GAGLANI: Totally. It is super impressive to be able to combine those interests. I've talked to a lot of people who are interested in the MD/MBA pathway. I was on it myself. Immigrant family. I’m still on leave for medical school, and they're probably listening, waiting for me to go back. I got my MBA. 

How did you decide to do emergency medicine? Can you tell us a bit about, again, the last few months in New York City during COVID, and then we'll dive deeper into how COVID has affected MDCalc as well?

DR. JOE HABBOUSHE: When I was in medical school, there wasn't much besides emergency medicine that drew me in. Frankly, I didn't like that many paths in medical school. It felt like so much of medicine was siloed into very specific specialties, and I liked the idea of being able to see a lot of variety of types of cases, of types of people. What felt like being a doctor to me was being presented with a new problem and having to figure out, while talking to and touching a patient, how to solve that problem for them. 

In the emergency department, we see more undifferentiated chief complaints than anyone else. We are the modern diagnosticians in medicine, and it has that variety of cases and variety of types of people. At NYU, I could have an indigent patient with the CEO of a Fortune 500 company right next to each other, and I'd be able to take care of them. So the variety is incredible, and then it also gives us this flexibility to work on other projects. 

When I'm not working a shift, I have time. My medical knowledge is broad, and that's also helpful for MDCalc.

SHIV GAGLANI: That makes a lot of sense. Most entrepreneurial doctors I've met are mostly in emergency medicine for the reasons you stated. 

Emergency physicians being the front line workers got a lot of attention during the pandemic over these last few months. Before the show, we talked a bit about how your life changed in the heart of NYC. Can you talk a bit more about what you've seen over the past few months?

DR. JOE HABBOUSHE: It's been a whirlwind for sure. You learn, in medical school and along this path, what you're supposed to do during pandemics or during war scenarios, but it's nothing we actually have done and been trained at in more than just a theoretical way. Suddenly this pandemic was coming in, this disease, which we really didn't know much about at all...how it would act and how many patients would get it, and every day more and more patients were getting it.

Every night after a shift, I'd come home and discuss different aspects that were getting discovered about this disease. It was an insanely intimidating process because we didn't know how bad it would get, and we were just forward predicting in our minds when we would run out of space, when we were going to run out of ventilators, things that, again, you prepare for it, but you've never actually had to face, including whether or not we would get sick. You start hearing all these reports that young people get sick or often it’s healthcare workers. “Are we going to run out of PPE?” That was a big issue for a while. “Am I wearing the PPE in the right way?” And no, one's perfect with these things. You start touching things. It's really hard to be 100%.

We now know a lot more, so it's easy to be calm about it, but it was emotionally something I was not prepared for. I should say in some ways we were prepared for it because that's what we're supposed to do in emergency medicine, but it was an intimidating and thrilling thing to face for sure.

SHIV GAGLANI: Totally. That's where we came up with the concept of Raising the Line, because everyone talks about flatten the curve, which is how do we avoid overwhelming the healthcare system, but then the other half of it is how do we increase healthcare capacity. So PPE, as you mentioned, ventilators, the number of people who are trained to make these appointments, telemedicine and so on.

I think MDCalc, as well as some of the other things you talk about regarding evidence-based medicine, probably play into that. Can you talk a bit more about what you've learned from this crisis, and what are some lessons you think that we should all take away as far as how we can increase healthcare capacity?

DR. JOE HABBOUSHE: I think our healthcare system in the U.S. is not designed for increasing healthcare capacity during an emergency. We are a for-profit system that is broken up across a bunch of different institutions. Hospitals typically try to operate at 65% or higher utilization. That's not a system you want, if suddenly everyone's going to be sick with a disease or if there's some terrorism or biological warfare, et cetera, and a lot of people get sick and we need to really expand quickly. 

There are some systems around the world where things are done better. For example, in Israel, they think a lot about disaster preparedness. I used to be part of a disaster preparedness medical society that's international and based in Israel. After the hurricanes that hit New York a few years ago, I was very involved with that. During the Ebola response, I was involved with that, so I did a bunch of disaster preparedness and was involved in this conference.  

You learn that some countries, where things are more centralized, they can be a lot smarter. In Israel, they have the emergency departments across the country look and feel similar, and clinicians will spend a little time in hospitals that they're not usually working in, so when the need arises, there are a bunch of physicians that have done a shift in many locations.

Because everything's in the same place, you're not a useless new physician, not knowing how to use the computer, not knowing who to talk to and not knowing all the logistics of the hospital, which is stuff we ran into, for sure, during the hurricanes, and then, of course, during COVD. 

My hope is that we're going to learn a lesson from what we were not prepared for and prepare better, so we have a whole bunch of ICU beds that we quickly turned on, a bunch of extra ventilators and a system to get clinicians shifted between institutions, maybe between specialties too. It's another thing we were trying to do. It was done very imperfectly, but we did what we could at the time.

SHIV GAGLANI: I'm based here in Salt Lake City, and I know the Intermountain Healthcare system sent a bunch of physicians over and other health care professionals to New York. Hopefully, that'll accelerate the ability for clinicians to go practice in another state because this was a forcing function, a catalyst for change. 

DR. JOE HABBOUSHE: Exactly. Right. 

SHIV GAGLANI: Another catalyst for change is obviously telehealth. A lot more people have been exposed to telehealth. They realized it's not as bad as they thought it would be. 

I think MDCalc can fall into a category of clinical decision support. What effect has COVID had on MDCalc and can you just tell the audience about exactly what type of calculators you have and just describe the product as a whole.

DR. JOE HABBOUSHE: Yes, for sure. MDCalc is a 15-year-old medical reference product. In medical school and in residency, you learn about what we generally call medical calculators or clinical decision tools. These are famous things. We didn't create any of them. They were created in medicine, published in the peer-reviewed literature, and often are the standards of how to treat patients. 

Some of them are true calculators. You have a numerical input and a numerical output. For example, you have a deranged value, and you have to correct for it. But often there are clinical rules with discrete inputs that help you make an important decision for the patient. 

For instance, a four-year-old falls and hits their head. Fifteen years ago, all those four-year-olds would get CAT scans in the ER, essentially. A very small percentage of them would have a bleed that you would do something about, and all of the other ones would be exposed to radiation. That's not good for kids and the cost, et cetera, so a group of smart clinicians created the PECARN rule, which is a bunch of pediatric emergency physicians, tens of thousands of patients in several different studies, to come up with a rule that says, “If you meet XYZ criteria, you're safe, you don't need to get a CAT scan.” That is a very patient-centered rule. 

If you meet these other criteria, you can watch them for six hours and decide. Otherwise, get a CAT scan. That's one of 560 plus clinical rules on MDCalc across almost every specialty in medicine. Physicians know about these rules. It's hard to memorize them, so they need to look them up. Because we were the first movers and because we respected the medicine and academics about it so well, we became the first hit when you Google searched almost any of these. 

Now we're the standard app for that as well. We are also the standard EHR integration because most medical centers in the country would like to integrate these kinds of tools into their EHR. And because we are the gold standard place where they come to, then they've all asked us to create this product that they can integrate into, which we've done, and we actually work with the folks who created the rule. So Dr. Phil Wells from the Wells Score, he writes for us. All the folks who are doing the academics and literature and creation of these tools will often write for us. That’s MDCalc as a whole.

Now, during COVID, we stopped what we were doing and said, “What can we do to help during this crisis?” Our team said, “Anything, any idea is a good idea right now.” Now, as far as the tools go, COVID is ripe for clinical decision tools, because it's an area where most clinicians do not have a good gestalt. You get a good gestalt and hunch on how to take care of patients when you've seen hundreds of them, but most of us haven't seen hundreds of them so you can't rely on what feels right quote-unquote.

Number two is that there's a huge variability in how doctors are taking care of these patients. Another place where it's great to have a clinical decision tool. Number three is we were fearful that we would have to face a lot of research allocation questions. Those are those terrible scenarios where we're out of ventilators, and you have to pick who gets that last ventilator, who gets the last ECMO machine, who gets that last ICU bed. 

There's a whole bunch of clinical rules that already exist in medicine where we are the main place doctors go for those rules around those questions. Most of the criteria that are put forward by medical societies or governments will include some type of clinical rule. We were thrust into the middle of this conversation and did our best to build a COVID resource center with the tools that existed. None of them is COVID-specific because COVID didn't exist before. 

Now we're seeing many of these academic folks trying to create COVID tools, and there are dozens of them out there, but we're very selective in which ones we will add into our resource center because once it's on MDCalc, people are going to really trust it and believe it.

SHIV GAGLANI: That's fascinating. I knew a bit about that, but that's really interesting how you've just described all the rules that are required to treat these COVID patients because this is going to be with us for a while. 

It's certainly not as bad here in Utah as it was in New York, but there's a lot of physicians seeing these for the first time, so being able to go to the trusted resource makes a lot of sense. Do you have any patient-facing content as well, or is it all physicians? Can you describe who the users of MDCalc are?

DR. JOE HABBOUSHE: In general, MDCalc is used by physicians and other clinicians who take care of patients. We don't create patient-facing calculators. There are a few projects we're working on that somehow help the conversation between the physician and the patient. 

For example, when you explain --  my example earlier, the PECARN rule --  now you have to explain to the mother of that four-year-old why you don’t want to order a CAT scan for them. They're worried that they need that CAT scan. They are worried about their kid, and they want to do what's best for the kid, so learning how to have that proper conversation...that is such a key aspect of why sometimes great clinical rules that are really helpful for patients don't get followed because either the physician doesn't know how to trust the results, or they don't know how to communicate those results.

There are a bunch of academics who literally study the conversation between the physician and the patient or patient's family. We call these “decision aids” or sometimes “shared decision-making tools” where you're discussing with them the pros and cons. 

Sometimes there are icon arrays that try to express visual risk so it's easier to understand. These tools are studied in academic literature. We've worked with some of the experts to create these tools, to create some data products on MDCalc to help with that. That's an area of potential new products for us that are hopefully helpful at the bedside.

SHIV GAGLANI: That's great. I actually didn't know that you guys were exploring that. We partnered with the Council of Medical Specialty Societies and created a video on shared decision making. 

Clearly, there are a lot of areas like palliative medicine or informed consent or risk management that require much more shared decision making also to drive behavior change.

DR. JOE HABBOUSHE: That’s great.

SHIV GAGLANI: Yes. That's something we should click on.

DR. JOE HABBOUSHE: Yes, for sure. And obviously, only a subset of them overlap with medical calculators, but when they do, we're just the natural place to exist.

SHIV GAGLANI: One innovative thing you all released recently, and that was from a conversation you had with a mutual friend ours, Bunny Ellerin, is the Ad Grants program, and Osmosis has been fortunate to be part of the MDCalc Ad Grants. Do you mind just talking a bit about how that came to be, and what your goals are with that?

DR. JOE HABBOUSHE: Yes, for sure. When we took a pause and said, “What can we add to MDCalc as a mission-based team that's focused on helping the COVID crisis? What can we do?” Then we looked at all types of ideas across everything we do and came up with a few other ways we can support others who are taken care of by the COVID crisis. 

One of those is through our Ad Grants program. So MDCalc has ads. That's how we support our team. We know there are so many great organizations out there that are doing what they can do to help the COVID crisis in their unique ways that could benefit by getting in front of more physicians. 

Again, we're used by two-thirds of U.S. physicians - and those numbers are old. It's probably more than this two-thirds of the U.S. physicians on a weekly basis, so we’re very broadly used across medicine. So we started this Ad Grants program, pretty similar to the Google Grants Ad Grants program, where organizations who are doing their part in COVID crisis can apply. We were impressed by it. We were flooded with applications, actually. It's really impressive.

We worked with Bunny Ellerin with the New York City Healthcare Business Leaders who helped promote this concept. They're helping us choose the organizations. I am happy to say Osmosis was the second organization chosen, and we are setting up to have your ads on MDCalc now.

SHIV GAGLANI: Yes, super exciting. We've gotten to know more of the team. It’s been great, and there's a lot of natural fits, I think. I know we're coming up on time, so just two more questions for you. 

One is, do you have any advice for people who are considering careers or early on in their careers in healthcare at this point, as an entrepreneur, someone who's treated COVID patients, all the things that are going on in the world?

DR. JOE HABBOUSHE: I would say I love medicine. I love clinical medicine. I love seeing patients. I love the interaction. I love that I get to learn every day, and I did not love it when I was a medical student. I was looking at potentially not practicing medicine. I think it's very difficult to see beyond these many years of training to get to the point where you can actually see patients.

As much as possible, I'd like to encourage folks not to just look a couple of years into the future, which is really difficult for someone in their twenties who is starting down this path who just wants to get exposure to what it's like actually to see patients at the end of that path. 

I eventually did do that. I'm very glad I took the path I did. There were a couple of forks in the road where I could have not practiced medicine, and I'm really glad that I did.

SHIV GAGLANI: Great advice. Hopefully, we can also make that path a little less burdensome, whether that's reducing debt or streamlining it because like you, I did not enjoy a lot of medical school in terms of the ‘death by PowerPoint’ concept, all the lectures and the lack of autonomy that comes with it.

DR. JOE HABBOUSHE: Fifty years ago, the average number of years someone would train before practicing as an attending was less, and we keep on tacking on more years. It used to be that some docs would just do an internship and practice, then people would do a three-year residency. Now you have people doing six, seven years, and then get all these extra fellowships, et cetera. They're taking a year off to do research. It makes sense to streamline it. If we want to become hyper-specialized, let's find creative ways to look through the whole system and make it more useful and more based on not memorizing, but on functional knowledge, because 50 years ago, it was about memorization. We don't need to teach memorization anymore, which I think you guys are really great at approaching that problem.

SHIV GAGLANI: Totally. It's funny. You mentioned the length of training. I used to give a presentation to the American Board of Medical Specialties, ACME, and the CME group. I've given this presentation where one of my first questions to the audience was, what's the average age of a graduating resident? It's in the low to mid-thirties. It's gone up every year, as you've said.

Then I would pop up a slide showing that for the history of humanity, the median life expectancy was 29, so you would die before you finished a residency, for most of the history of humanity. We're trying to figure out ways to streamline it and make it more effective, make education a little more efficient. 

DR. JOE HABBOUSHE: Osmosis is great at that. 

SHIV GAGLANI: Thank you.

DR. JOE HABBOUSHE: Thank you for what you've done.

SHIV GAGLANI: My last question is, do you have any other comments or thoughts that you'd like to leave for this audience?

DR. JOE HABBOUSHE: Wow. I just want to say thank you for what you all are doing. You're dedicating yourself to the most honorable profession in my view, in the world, which is figuring out how to best take care of people and patients, and keeping your eye on that. 

Everything you do needs to be patient-centered. When you make a clinical decision, when you make decisions going forward, don't allow your judging to be clouded by other aspects. All aspects should be, “What is best for this patient?” 

SHIV GAGLANI: Great advice at the end. Joe, thanks so much for taking the time to be with us today. 

DR. JOE HABBOUSHE: Thanks so much for having me. I really enjoyed it. 

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