Technology As The Tool, Not The Goal: Training Physicians In The Information Age.

Claire Topal examines the intersection between the ways technology, society and medical education are shifting, distilling a selection of modern challenges and opportunities for medical education in the 21st century and the physicians of the future.

Claire Topal, MA, AB highlights perspectives from six physicians at different stages of their careers; including retired physicians who still mentor students and doctors, physicians in the first years of practice and current residents.

How do we prepare physicians for the health and health care systems of the future? My answer to this question is based on interviews with physicians at different stages of their careers, including recently retired physicians who continue to mentor medical students and young doctors.

In discussing the ideal components of physician training in the 21st century, it has become clear that physicians, their training, and the practice of medicine are constantly evolving as technology advances. This evolution can progress more productively when education and training are updated to reflect the technology that is being implemented in medical practice. Adapting to and adopting new technology is not the problem, nor is it the goal or solution; medical education should leverage technology in order to reinforce the fundamental concepts of the art of medicine, to create practitioners who are prepared to practice in the 21st century.

Change is the Only Constant

Physician training and the practice of medicine are evolving as technology advances and demographics change. Numerous articles outline and suggest critical improvements and enhancements to medical education,1 for example, Frenk et al have emphasized the importance of adopting a competency-based curricula, promoting inter-disciplinary collaboration and using IT for information management.2 State-of-the-art assessments carry weight, creating a common reference point around which scholarship, policy and practice can coalesce.

One pediatrician interviewed used the term “clarion calls to action.” She noted in particular the 1999 Institute of Medicine (IOM) report on medical errors, which not only measured the number and cost of preventable deaths related to these errors annually, but also pushed the issue of patient safety to the top of the nation’s health care agenda.3 The report catalyzed the development of medical performance standards, an increase in error reporting, new integration of healthcare information technology and improved medical safety systems.

The Need for a New Training Model

Comprehensive, data-driven literature on physician training in the 21st century context is new and relatively sparse, compared to the volume of research that exists on medical conditions, treatments and complications themselves. The implementation of medical education and training, including measurement and analysis of the cost-effectiveness and efficiency of different training methods, is simply less studied and less often invested in, compared to the practice of medicine itself.

A seminal report that examines physician training in a rigorous way – including how to systematically implement specific training methods and evidence on what does and does not work in different contexts – could make an enormous impact on medical education. Such a report could influence how well doctors are able to navigate the constant flow of new technology to provide the most effective care. Additionally, an analysis of the current educational models could help physicians of the future be better prepared to navigate complex health systems in a way that reduces costs.

Health systems will reach a breaking point soon, when the number of people aged 65 and over surpass the number of young children. The current infrastructure simply cannot support these demographics. What if we could reduce stress on the system, lower costs and improve health outcomes by changing the way in which we train our medical professionals? What if, in doing so, we could train more people, more effectively, and increase access to better care? The path is complex and political, but the return could literally change the world.

Adopting and Adapting

Today, older physicians are performing complex procedures and surgeries that did not exist during their early training. Because medicine and physicians must adapt, the profession is a call to continuous learning. Additionally, today’s new young doctors have grown up in a high-tech world. The current residents with whom I spoke universally believed that today's students are savvy enough to navigate any new system with less effort than their predecessors. After all, learning new systems is a skill that they have acquired implicitly during their lifelong exposure to information technologies.

By contrast, the key issue for medical education in the 21st century will be how to train physicians to consider the broader social implications of new technologies, and to not fall victim to the allure of bright shiny objects. In other words, in the medical context, one priority should be to teach students to not accept that newer is always better.

All the physicians with whom I spoke highlighted what they see as a useful, but sometimes harmful, growing fascination with technology, especially in the medical sphere and among younger doctors who grew up in a digital world. Technology has certainly catalyzed watershed changes in medicine, (e.g., electronic medical records, home health monitoring systems), but as more innovation floods the field, at more accessible prices and with greater speed, medical educators must acknowledge and account for the fact that new technology is not necessarily better, even if it might make a practice or hospital more competitive or lucrative.

The physician’s ability to objectively evaluate technology will become increasingly important as patients are empowered enough to demand the latest technology without really understanding whether the latest is actually the greatest. While better-informed, technology-savvy patients often enhance medical practice, the flip side is that some patients know “just enough to be dangerous.” New technology may “do good”, it may “do nothing”, or it may “do harm”. Some of these options could incur enormous, unnecessary costs to people and systems. Unfortunately, health systems may provide skewed incentives for using or not using the latest tools and techniques.

Empowering physicians to both evaluate the effectiveness of new tools and understand the implications of their costs will be ever more important for medical education in the litigious United States. Exacerbating the evaluation process is the fact that many insurance and health systems make the cost structure opaque; if the procedure is “covered,” patients do not always realize they just cost the health system thousands of dollars. Driven by the fear of lawsuits, physicians are sometimes incentivized to prioritize meeting patient desires over meeting medical needs in the most efficient and effective way possible, which are not always in sync.

Addressing the above tension (i.e. sorting out technology benefits vs. costs, and patient wishes vs. patient needs) is mainly the job of policy-makers and hospital administrators, but providers are on the front line. Doctors need to understand the financial (and other) implications of their decisions, even when inefficiently structured systems do not always allow them to practice evidence-based medicine.

Assuming that the United States medical system is chartered to train physicians to provide the most effective care, in a way that does not unnecessarily strain systems that are already financially “under water,” medical education should address the issues of technology’s benefits and costs, vs. patient needs. Physicians deserve some separation from the financial bottom line, so that the health bottom line can be front and center, but awareness of costs will be more important as strain on systems grows. Educating medical students regarding how to find out about medical costs and make efficient decisions, that still maximize outcomes and safety for the patient, should be a critical aspect of today’s and the future’s medical education.

Demographic Changes

A recently retired emergency room (ER) doctor painted a disquieting picture of the implications of demographic shifts for physicians. Half the patients admitted to his ER were over 60, an average in keeping with ERs nationally, and increasingly, internationally. This means that “every ER doc becomes an expert in geriatrics.” This unintentional geriatric specialization is not isolated to ER doctors, either: as the over age 60 global population has increased, due to the “baby boom” generation (born from 1946-1964), a greater percentage of patients in all specialties will be old, frail, and in need of more care and services. Complicating this shift is the widespread rise of non-communicable diseases, impacting both affluent and developing societies and adding fuel to the long-burning infectious-disease fire. How do physicians care for growing populations of patients whose goals move from preventing death and disease to simply delaying disability and dementia? Medical educators in the 21st century must prepare physicians for 21st century demographics.

Along with prioritizing geriatrics, 21st century physicians must also care for young people in a new context, attempting to prevent adverse childhood experiences and damaging behaviors that may negatively impact the life trajectory and multiply complications later in life. Technological innovation positions medical educators beautifully to shift health care from a focus on acute care to a focus on prevention.

Technology as the Tool, not the Goal

Demographics are shifting, and technology is continuously evolving. What stays the same? According to all the doctors I interviewed, many common components of the current practice of medicine will endure and grow throughout the century ahead. Three stood out:

The key question becomes how medical education can leverage technology to facilitate the tried and true elements of the art of medicine.

History & Physical

A sample case study might go as follows: An elderly man enters the ER complaining of dizziness and stomach pain. The staff perform a basic physical and help him complete a comprehensive questionnaire. When the doctor on call comes into the room, he notices that the patient is still wearing pants. When the patient removes them, the doctor notices a cellulitis and stasis changes on one of the patient’s legs, an indication of congestive heart failure and vascular problems. The findings on the leg are the tip-off, and without a thorough history and physical, they might have been missed. The patient has had no idea his “leg sore” was related to his other symptoms.

“This kind of situation has borne out time and time again,” reflected the ER doctor later. “People try to reduce history-taking [communicating with the patient],” he continued “because it is uncomfortable, and time- and anxiety-producing for everyone. We all have a subconscious tendency to minimize it, but it is important.”

In the future, one-on-one time between the patient and doctor may shrink, so how can technology help doctors and patients benefit from the necessary history and physical? In certain situations, technology can save medical staff significant time and increase the accuracy of getting certain vital signs (for example, through sensors on gowns and in rooms). Medical education could leverage simulation technology to train physicians to ensure that no stone is left unturned (or no pants left on) once the technologies that will ostensibly make everything more streamlined have taken their turn. Simulation could reward questions that gather more data, even if doctors do not have time to look over every limb or cannot physically be in the same room as the patient. In emphasizing the importance of the history and physical exam, medical educators can take advantage of new tools that help physicians reach age-old goals in spite of increasing time or distance constraints.

Healthcare needs good leaders, and clinicians need training and support to develop good leadership and management skills. They don't just spontaneously develop on their own.

Paperwork & Documentation

United States physicians universally lament their paperwork burden that the practice of modern medicine requires, and which seems to consume more of their time even as the electronic recording of information becomes more advanced. Despite scribes and administrative help, “the user interfaces are poor, and systems don’t talk to each other. It’s horrible,” one doctor, who has been in practice for ten years, said, summarizing the sentiment of most of my other interviewees. “It’s silly to have the highest-paid employees spending hours every day entering data,” another pointed out. Nevertheless, all of the doctors and residents with whom I spoke appreciated the value of the information and the medical record itself.

One South African physician noted that physicians in his home country do not have the same documentation burden as exists in the U.S., due to his country’s relatively less litigious society. In his own experience: “our medical staff in South Africa tend to write the bare minimum, leaving a lot to be desired; if anything, we ought to be paying more attention to being particular about more detailed and accurate records.”

The records have value, but the documentation burden will endure everywhere and increase in some places. Despite the amazing software that underlies the electronic medical records (EMR), their user interfaces, data-visualization tools, and coding are often less than intuitive and can detract from the patient-doctor interaction. For example, one pediatrician noted that a skill she had not anticipated needing was the ability to type data into an electronic record while simultaneously maintaining eye contact and a connection with a patient. Another physician pointed out how much she would like the EMR to be a tool during the patient-doctor visit, by pulling graphs and charts that would immediately and elegantly show the patient trends or consequences of certain behaviors over time, for example. While those capabilities exist in some forms in some EMR systems, I found universal agreement around the hope that they would grow.

While cumbersome, learning the systems is just part of being a physician, although it seems to be easier for younger doctors to quickly adapt to new EMR systems. While medical students do not necessarily need to learn specific EMR systems, they could certainly benefit from an added emphasis on the value of these systems and how they impact the relationship with patients. Medical education could prepare physicians to leverage the data-visualization tools these records are continuing to develop, and get students excited about how to use them to communicate more effectively with patients and incentivize healthier behaviors. If the ultimate goal of interoperability is achieved, amazing things will be possible.

Leaders & Thinkers

Patients may be making more health care decisions than they have in the past, and the roles of nurse practitioners and physician’s assistants are becoming more and more recognized. Most doctors that I interviewed believe that the role of the physicians as leaders and thinkers will endure, and arguably become more important in years to come. Given this prediction, medical education should, 1) leverage technology for increased leadership training, and 2) acknowledge the gravity of the responsibility of leadership and empower the physicians of the future to take advantage of technology to make them better leaders.

All the physicians with whom I spoke wished they had had more (or any) training in leadership and management during medical school and residency. While medical education cannot be responsible for ensuring that all physicians can operate well-managed businesses, it can place more emphasis on leadership training and inter-disciplinary communication. Simulation can serve as a valuable tool, not just for applications like surgical simulation, but also for less-well-known training applications such as preparing physicians to anticipate different management scenarios and test responses.

Additionally, there are all sorts of things that computers may do better and more consistently than people. However, rather than compete against computers or worry about whether or not computers will replace physicians, medical education should train doctors to use technology to process more information faster, in order to free them up to evaluate findings, extrapolate and compare health and cost implications, and to approach their leadership and decision-making with care and thought. For example, some smart phone Apps can reduce stress and increase accuracy by cross-checking the indications and precise calculations of medications in emergency circumstances against large databases of data. Others calculate appropriate dosage amounts and drug interactions.4 Physicians still need solid stores of information in their heads to be able to make good decisions when diagnosing and treating, but medical education can help the physicians of the future understand how to leverage evolving digital tools to be better information managers as the volume and complexity of medical knowledge continues to expand.

Conclusion

While policymakers and business people are the primary decision-makers for how health care systems are structured, shouldn’t physicians, nurse practitioners, PAs and other medical practitioners at least have some input? For doctors to join in this discussion, they must have fluency in numerous business concepts (including economics, finance, policy, public health, business and psychology). According to the pediatrician with whom I spoke, “If physicians can’t at least converse in these languages, then non-health people will be making all the decisions about health, and the role of physicians within it. Physicians need to be at the table.”

About the Author

Claire Topal, MA, AB is Senior Advisor for International Health at The National Bureau of Asian Research (NBR), Senior Research Consultant at the Center for Sustainable Health within Arizona State University's Biodesign Institute, and Principal of Red Tomato Consulting, LLC. She has worked in global health and the non-profit sector for 10 years, serving international and domestic organizations and overseeing health research, strategic communications, and high-level, cross-sector forums engaging the U.S., Asia, Europe, and Africa. From 2005-2012 Claire was Managing Director for the Pacific Health Summit and Vice President of International Health for NBR, serving as Director of NBR's Center for Health and Aging between 2009-2012. Previously, Claire taught in China and worked with the Associated Press and Louvre Museum in France. She holds an AB from Cornell University and an MA from the Fletcher School of Law and Diplomacy.

References

1. Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. NEJM. 2006; 355: 1339-44.
2. Frenk J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010; 376(9756): 1923-58.
3. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999.
4. Coovadia A. Appsolutely! Does a paediatrician really need a smart phone? Arab Health. 2013; 2: 44-6.