November 24, 2014

#2 The Secret, Gruesome Internet For Doctors

by Reply All

Background show artwork for Reply All

An app called Figure One wants to be Instagram, but for doctors. Why would doctors need their own Instagram? Because no normal person would want to see the gruesome photos which doctors post, fave, and comment on. We spy on the secret medical internet, and talk to a resident who actually belongs there. 

The Facts: Our theme song is by the mysterious Breakmaster Cylinder. 

 The special ad music was written and performed by Build Buildings.

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PJ Vogt: Hello, I'm PJ Vogt, and from Gimlet Media this is Reply All, a show about the internet. This week’s episode is super gross and disturbing. I have 98 apps on my phone and this week we’re talking about the only one I am I’m terrified of. That app is called Figure One, and it’s billed as instagram but for doctors. That means it’s a place where, if you’re a doctor at work and you see something that is really disturbing like a particularly unusual kind of gunshot wound, Figure One will let you take a picture of it, post it online and have other doctors comment and favorite it. Your first question about this app is probably how can this be legal? And, actually, it’s entirely legal. The app forces the doctor to actually get consent from the patient that they’re photographing. There’s a built in screen where the patient has to have the entire app explained to them and then sign their approval with their finger. And the app includes a bunch of rules about how the pictures must be taken in a way that preserves the patients’ anonymity. One of those rules is that you can’t show someone’s face, really. Which means that as you scroll through the app -- which does look remarkably like Instagram -- you just get close-ups of the broken parts of bodies. Cuts, breaks, rashes. For most of the reporting of this story I was relying on other people’s description of the app because body stuff is the stuff that most squicks me out. But this week, I have finally decided to open it, because, you know, journalism. And I decided to make my-cohost Alex Goldman open it too, because frankly he’s spent a lot more time on the gross, gory sites of the internet -- 4chan, 8chan, Rotten dot com. Place where people develop the kind of armor that lets them look at stuff like this without retching.

ALEX GOLDMAN: Bring it on.

PJ: I just want you to scroll through and have the experience that I saw and tell me what you think.

ALEX: Alright. We’re beginning with...a brain scan of someone who’s been shot.

PJ: I couldn’t figure out that that was a brain scan.

ALEX: Kinda hard to see. “Hip fracture with femoral head ball path specimen after arthroplasty.”

PJ: See, I was already having problems with the hip thing.

ALEX: I mean there like a gruesome thing, but it’s, again, really hard to figure out what it was.

PJ: Can you describe the gruesome thing?

ALEX: It looks like if you opened a tennis ball and there was just viscera inside it.

PJ: Yeah, that’s a really good description.

ALEX: It’s pretty gross. “Any idea what this is: patient family is unable to give us any ideas.” And it’s a chest x-ray with what looks like a USB key stuck in it.

PJ: That caught my eye, too. And then, actually, one person says it’s a USB key and then, like, 3 people identify it by name brand in the comments.

ALEX: So is it someone who swallowed a USB key?

PJ: I think so...I think it’s probably a kid, right?

ALEX: No idea. 8 wisdom teeth…

PJ: Keep going.

ALEX: Yeah…

PJ: Right now would you say it’s just kinda boring?

ALEX: So far, it’s a lot of, like, cat scans and x-rays, so it doesn’t have all the goo, you know what I mean?

PJ: You’ll get to the goo.

ALEX: Let’s see...more x-rays...oh! I take it back. I take it back. I just scrolled up to the one that’s doing it for me.

PJ: What is it?

ALEX: “Male diabetic patient that was asleep at his home and woke up to his toe being chewed off by a rat.”

PJ: [gasps]

ALEX: “The patient did not feel it at first so the rat got most of the big toe.” I’m gonna go to comments and then I’m done. Ugh...I loaded it and I got the picture again.

PJ: Describe the picture to me.

ALEX: It looks like a looks like a foot that has congealed into one gigantic, bloody toe, basically.

PJ: I think I have to look at this. Like because we’re doing this, I think I have to look at this.

ALEX: Alright, hold on just a second. Are you ready?

PJ: Yup...OHH!!!

ALEX: [laughs]’s pretty gross.


JOHN HERRMAN: I’ve been on the internet for my entire conscious life, more or less, and in that time I have seen many things I regret seeing, but my top 100 list of things I regret seeing is now populated, I’d say, half by things I’ve seen on Figure One.

PJ: The reason we originally found out about this app was because John Herrmann, who heads the website The All, wrote a piece about it. John said that the part of Figure One that really gets to him isn’t the pictures, it’s the comments beneath them, left by other doctors.

JOHN: When you see a doctor talking about, like, a finger that’s been punctured by a nail and making a joke about how the patient nailed it and then punctuating that joke with “lol,” it’s just...I wouldn’t say it’s wrong, it’s just so strange to see it.

PJ: Right.

JOHN: I caught myself feeling strange about this and then immediately thought, like, “Of course this is how doctors talk. This is how I would talk. This is how anyone who faces anything like this would talk.” There will be lol’s and lmao’s and rofl’s and things like that...These are like the conversations that doctors would be having in a breakroom when they assume no one else was there. The combination of tone and subject matter is something that I’ve never seen anywhere a civilian, I guess.

PJ: What do you most wish you could unsee of the things you’ve seen on it?

JOHN: Uh...for some reason, it’s the late stage skin cancers. Those are pretty common, I guess you would say, trope on here because it’ll be someone who came in with an undiagnosed melanoma and, clearly this person doesn’t have long left, you’re just seeing a cropped image of, like, a lower back with this...fatal growth on it. And then there’s no sense that you’re watching someone, or that you’re eavesdropping on this conversation about someone who has any sort of chance.

PJ: Alright, so we’ve established that Figure One is a place where, if for some reason if you want to, you can get a doctor’s view of the world. But what about the people that Figure One is actually made for? Doctors, nurses, other medical professionals. I mean, a) did anyone ask doctors if they needed their own Instagram? And also, like if they’re using it, how are they using it? Is it actually what it bills itself as, which is a useful medical tool? We’ll find that out after the break. We will also find out how to talk to your husband about your exciting day at work when you spend that day at work chopping a corpse’s penis off. Stick around, I promise you’ve already heard the grossest part.


PJ: Thank you for coming back to Reply All. So I talked to John Herrman, and for the next week the thing he said that just stuck in my head was something that he just tossed off casually: this idea that Figure One made him feel like a civilian. Overhearing doctors is like overhearing soldiers because you’re listening to a group of people who are acquainted with death regularly and you’re listening to them as someone who just isn’t. And that’s why, as much as an app can be traumatic, Figure One is traumatic because you’re getting a proxy experience of something you don’t have the training or the context to process. That was my highfalutin, podcast journalist theory anyway. So I decided to test it.

[PHONE RECORDING] Healthcare Hamilton automated attendant service...

PJ: I called my friend Lauren who is a first year resident in an emergency room. So, the first thing I learned was that, yes, Lauren and her friends do use Figure One. It’s really popular, particularly among med students, and when I told her that John had used it and that he’d found it unsettling, she could not fathom that at all.

LAUREN: Worst, grossest things he’s seen are like horrible images from the internet? Really?

PJ: Yeah.

LAUREN: Oh...weird. Most of it’s not like gawk-worthy, I don’t think. But maybe I’m...maybe I’ve lost more empathy than I thought. I don’t know.

PJ: Lauren said, for her, Figure One was not a useful educational tool. That, actually, she was using it like John was using it: as a thing on her phone to look at when she’d gotten bored of looking at all the other things on her phone.

LAUREN: I mean, I look at it in kind of the same way that I look at Instagram. I’m not like, “I’m going to sit down and do some studying by looking at Figure One.” I’ll be like “I’m bored,” and it feels more like a useful waste of time to look at something that is at least tangentially related to medicine.

PJ: If you were putting it on the credibility scale with like Yahoo answers at the dumbest end of it and, like, I don’t know, Mayo Clinic website at the highest end, like where would it fall?

LAUREN: Somewhere along the middle of the spectrum. Like, it’s more knowledgeable idiots posting nonsense, sort of.

PJ: [laughs]

LAUREN: And there are like other websites out there that do a similar thing but, like, with less educational images. Like, it’ll be like “oh! Look at this abdominal series of someone who has, like, a beer bottle stuck up their butt.”

PJ: So there’s like a whole doctors-gawking-at-patients internet?

LAUREN: Oh, god, yeah.

PJ: Really?

LAUREN: Yeah. I try not to...I’m not trying to sound like a good person--I try not to engage in it. It’s...I don’t know, kind of mean-spirited. But, yeah, there’s tons of that stuff.

PJ: Wait, so what are the other places?

LAUREN: Lots of like, random, message-board-y I don’t know of any apps that do the same thing, but there’s subreddits where people post like for an object in rectum, kind of stuff.

PJ: Lauren’s not the kind of person to surf the beer bottle in rectum doctor internet, but when her and I talk about her work, those are actually the kind of stories she tells me: silly, quick anecdotes. Like the time when she was working in an Israeli hospital and, using her not so great Hebrew, tried to ask a patient to lean forward so she could listen to his heart, instead asked him to lean forward so she could try to fuck him. She tells me those stories not because she’s a cold, unfeeling person--she’s the opposite--she tells me those stories because they’re funny and they’re the part of her day that she can tell me about. And I kind of know in the back of my head that actually there’s this other thing going on, a thing that Figure One shows.

LAUREN: You probably don’t look at people’s wounds all day in your job or like, you probably don’t see people’s genetalia regularly at your work and like the questions I am compelled to ask people as part of my job, is very personal stuff.

PJ: Like what kind of stuff?

LAUREN: Do you have gonorrhea? Are you sure you don’t have gonorrhea? Do you for sure not have gonorrhea? Can we test you for gonorrhea? Or like...when you had blood in your stool was it only on the outside or was it like mixed in with the stool, was there any mucus? Was it diarrhea? How many times? Questions that I wouldn’t be thrilled to answer if somebody asked me them.

PJ: And are those the kinds of things that if I said “how was today?” you would say “I can’t believe how much blood this guy had in his stool”?

LAUREN: Yeah and like, I guess that’s not an example of something I find exciting but like, I don’t know, like if there’s a really interesting way that somebody died, I guess just even saying that makes me recognize what the difference is because to most people there’s not an interesting way to die and I recognize, for sure, that it’s sad that someone has died but there may be something that is clinically or, like, physiologically interesting about it and same with the trauma, right, like, you don’t really care that someone’s foot was only held on by their Achilles tendon, like you don’t really want to know more about that, probably. Like, the fact of these things happening are more commonplace and so there’s less processing time, I guess, involved. It’s not like “oh my god, first of all I totally need to unpack, this and tell you somebody’s foot fell off!” You just say, they had a partial amputation of their foot and no one would be like “wait, what?!” You know?

PJ: Yeah. Do you have like a specific memory of talking to someone you were close to who wasn’t a doctor and just sort of realizing half-way through the story that this was not going to work?

LAUREN: Yeah, I feel like pretty much every time I talk to Dave about anything that happens at work…

PJ: Dave’s Lauren’s husband.

LAUREN: I remember Dave was particularly horrified in med school when we were doing dissections and we only had one male cadaver and we were dissecting the external genetalia and I was the one who removed the male cadaver’s penis.

PJ: Uh huh.

LAUREN: I feel like I hear it in your voice that you’re terrified by that also…

PJ: [laughs]

LAUREN: But yeah, I think that was definitely something that stuck with Dave and he wished it wouldn’t.

PJ: The same way people as soldiers if they killed anybody, I know intellectually that when you’re at work sometimes people die, I bet the number of people who I think you’ve seen die is crazy low compared to the amount of people you’ve seen die. And I don’t think that’s just ‘cause I don’t know hospitals, I think that’s just ‘cause my brain starts shouting when I get close to that. Like I would say like less than ten and I bet it’s not less than ten.

LAUREN: Yeah, no. I don’t know, I think that...that there is some degree of, sort have to disengage a little bit, you know, you can’t feel everyone’s pain as though they were your own, or else you wouldn’t get through the day. I remember the first time I saw like a code…

PJ: Wait, a code? What’s a code? A code is a CPR?

LAUREN: Like a resuscitation, CPR. Like a code blue is when somebody found them unresponsive, typically and if they’re in actually cardiac arrest they’ll do CPR.

PJ: Yeah

LAUREN: and I remember the first time I saw that as a med student...It was like super traumatic, I recognized intellectually that like what people were doing, like to save someone’s life, but it’s not gentle. It’s not like it looks on TV.

PJ: What’s it like?

LAUREN: Violent. You break ribs and you break people’s sternum and people always make jokes about how bad TV CPR is.

PJ: Like the TV CPR is too gentle?

LAUREN: Oh, yeah. Nobody would ever come back from that.

PJ: Did the person die?

LAUREN: Yeah. And, I think, that was even the weirdest part was that everyone was just like “okay, we run this for a long time, does anybody else have any other ideas?” and everybody was like “nope” and then they stop. There’s sort of this juxtaposition between this really violent thing that you intellectually know is a good thing and that’s what you should be doing if that’s what the person wants and all of that stuff and then just like, oh we’re done. And everyone that I’ve talked to, the first time they saw CPR they felt the same way

PJ: But gradually, people who actually work in medicine learn to do what Lauren learned to do: they learned how to feel enough that they’re still human but not to feel so much that they’re overwhelmed and they can’t help their patients. They develop a way of talking about the world as they see it and they mostly keep that language secret from the rest of us, because we won’t understand it and we don’t want to understand it. And then Figure One stumbles into the whole thing. I asked Lauren if it bothered her to imagine civilians like me or John looking into her world.

LAUREN: I never really considered that. But I never considered that it would be interesting to anyone other than people who look at images like that all day long.

PJ: When we were talking on the phone a few weeks ago and I was asking you if, like, learning medicine was like being a soldier that you felt like you end up in this place where you’re experiencing a world that you can’t totally explain to people on the other side of it, and then talking to John I felt like he was like looking through a window at this world and like totally being traumatized by it.


PJ: You’re just like “yeah, this is the world.”

LAUREN: Yeah and I think maybe, I don’t have a great sense, anymore of what it’s like to not see it the way that I see it. I can’t remember what I was doing, it was somewhere in one of the senior residents was draining like a perianal abscess or was something that, like, understandably, some anxiety on the side of the patient.

PJ: What’s a perianal abscess?

LAUREN: It’s when you have an abscess like right around your anus.

PJ: Oh.

LAUREN: Yeah, you have to drain them. But what the resident said was he was like “You know what, I know that this is the anxiety provoking you, but this is just what we do at work.”

PJ: The writer Paul Ford once said that the thing about social networks was that they gave you a different kind of story. On like a book or a movie, where you get three acts--beginning, middle and end--a lot of times the internet just gives you the middle of someone’s life. And it gives you that middle over and over again. Figure One is that in the purest sense: a picture from someone’s day in the office and we fill in what comes after, whether we’re equipped to do that or not. The Friday before this episode went up, I got a text from Lauren that was unlike any she’d ever sent me. She said she just wanted to let me know that she was really excited for work that day, she was going to get to see an organ harvesting. Ick.


PJ VOGT: Reply All is Alex Goldman, Lina Misitzis, Kaitlin Roberts, Alex Blumberg, and Matt Lieber. Our theme song is by the Mysterious Breakmaster Cylinder. If you want more Reply All, go to our website You can also follow us on Twitter, Instagram, I think on Facebook, too. Thanks for listening and we’ll see you next Wednesday.