How Should We Train Medical Students for a Digital Future?

By guest contributor and TEDMED 2015 speaker Robert M. Wachter, MD

When I was a medical student about 30 years ago, I knew what a computer was, but the machines didn’t have any relevance to my professional life. When I started on the wards, all of my clinical notes were handwritten on pieces of paper stored in three-ring binders. We read paper journals, photocopied and handed out articles to our colleagues, and clipped out summaries of “keepers,” filing them in little recipe boxes for later review. To look at our x-rays, we trekked to the radiology department, since that was where the only copy of the film was stored. All of our laboratory results came back on flimsy carbon copy sheets of paper that were filed, in rough alphabetical order, on a rickety poker table outside the clinical laboratory.

In retrospect, it’s amazing that we didn’t kill more of our patients.

In the past five years, fueled by about $30 billion in federal incentive payments, medicine has finally become a digital industry. More than 90% of American hospitals now have electronic health records, as do the vast majority of physician offices. Decades after most other information-intensive industries switched from paper to silicon, in medicine, the x-rays, the three-ring binders, and the card tables have finally left the building.

Clearly, the world of today’s physicians will be vastly different from the world I entered in the early 1980s. Just as clearly, the training of future physicians must evolve for their work in a digital healthcare system. But how should it change?

Digital MedicineIn order to understand this, it’s important to make clear how digitization changes the nature of medical practice. The first issue is how one accesses medical knowledge. Online resources are now a click away, and more sophisticated electronic health records build in decision-support, which can do everything from reminding you that a patient is allergic to a certain antibiotic to guiding you to a well-vetted, evidence-based protocol for the management of a patient with a stroke.

On top of that, there’s the exploding field of analytics. The same technology that allows Amazon and Netflix to say, “Customers like you also liked…” will soon be applied to medical knowledge. Although your average physician won’t be performing big data analytics in the course of her workday, she will need to understand the results of such analytics, and be skilled at asking the big data experts (or the computers themselves, as the tools become more user-friendly) questions that can be answered effectively by existing data.

The role of patients will be transformed. As we’ve seen in other industries, computerization is The Great Democratizer. Patients will be far better informed through online resources, and will no longer be entirely dependent on the physician for expert knowledge. In certain cases, patients will also have access to apps and other tools that allow them to self-manage problems that used to require a physician visit. When they do need to see the doctor, many, perhaps most, of their visits will occur through telemedicine.

What does this mean for the training of future doctors? First, not all physicians will need to be experts in HTML. Clearly, some clinicians will want careers that blend informatics and medicine, and they should be encouraged to pursue this important work. And all students will need to understand the basics of how computers work in a medical context, but that is not the core issue.

Rather, the key change is that students will need to be trained to be leaders in improving systems of care, in working effectively in teams, in partnering with patients in new ways, and in using digital capabilities to enhance all of this work. While they will have less need than in the past to memorize everything in the textbook, it will be a mistake to say that they don’t really need to know very much since all the answers are a web search away. In many cases, it is the deep foundational knowledge that allows you to know when you need to learn more, or when the computer is giving you an answer that is inappropriate for a given patient’s situation. The physician of the future will still need to know quite a lot.

Probably the most important challenge will be one that gets even harder as the information technology gets better: balancing the technology with the humanity of medicine. We must train our future doctors – who will not know anything other than a digital environment – to concentrate on the real patient, not the digital incarnation of the patient, which Abraham Verghese calls the “iPatient”. With all of the data in the computer, this is easy to forget. But, as I wrote in The Digital Doctor, even when that wonderful day arrives when we have finally coaxed the machines into doing all the things we want them to do and none of the things we don’t, we will still be left with one human being seeking help at a time of great need and overwhelming anxiety. The relationship between a doctor and a patient does not feel transactional now, and I don’t think it will then. Rather, it will remain vital, scary, ethically charged, and deeply human.

It will take great discipline and all the professionalism we can muster to remember, in a healthcare world now bathed in digital data, that we are taking care of human beings. The iPatient can be useful as a way of representing a set of facts and problems, and big data can help us analyze them and better appreciate our choices. But ultimately, only the real patient counts, and only the real patient is worthy of our full attention.

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Bob Wachter, digital medicine expertIn his TEDMED 2015 talk, renowned UCSF internist, author and patient advocate Robert M. Wachter shares his struggle to balance patient empowerment with patient safety in our digital age.

The future of infusing art into anatomy

Achilles_anatomy

Greek street artist, Achilles, used the rooms of an abandoned building to create a spatial journey through layers of a human head, from the skull to the face.

By guest contributor and TEDMED speaker Vanessa Ruiz

Eaton-Houdon Écorché by Scott Eaton

Eaton-Houdon Écorché by Scott Eaton

When we talk about the future of medical illustration and learning anatomy, it’s often tied to advances in technology. What advances in technology will allow students to learn anatomy faster, allow them to memorize terms more efficiently, or provide better methods for them to interact with anatomy without actually touching a cadaver? But if you look at all of the resulting technologies, such as 3D anatomy apps, augmented reality organs, or virtual reality cadavers, the foundation still lies within an established ideal of anatomical representation. We’ve simply moved the same anatomical imagery from a textbook page to a screen. But instead of trying to change the medium by which we learn to technology, why not change the mindset of the approach to an artistic one, to engage a broader audience? Why shouldn’t the public, rather than just medical professionals, have access to learning anatomy?

Nearly 10 years ago it was difficult to find many artists featuring anatomy as a subject in their artwork. And I’m not referring to “the figure” as it is studied in art. I’m talking about the muscles, skeleton and viscera— what lies beneath the skin. Today the acceptance of anatomical art in pop culture is palpable. It’s pulsing in the trends of film, street art, advertising, interior design, and even fashion. A quick web search for “anatomical heart necklace” yields an overwhelming amount of resulting iterations. What is fascinating is that this anatomical art movement has risen exponentially alongside the rather stagnant practice of anatomy education. With all of the advances in medicine, the time and resources allocated to teach anatomy to medical students is diminishing. This is why students often turn to technology such as anatomy apps to supplement their learning.

Danny Quirk paints the musculature of the forearm on Anna Folckomer of Immaculate Dissection

Danny Quirk paints the musculature of the forearm on Anna Folckomer of Immaculate Dissection

But, as the boundary between science and art blurs, it is no longer sufficient to talk about either on their own. We need to see how each informs the other. This crossover between medical illustration, art, and anatomy learning is beginning to take place. We’ve gone beyond the “Anatomy Coloring Book.”

The dramatic anatomical body paintings by medical artist Danny Quirk, of Immaculate Dissection, are now used to teach anatomy to anyone from physical therapists to athletic trainers to bodywork practitioners; the technique has been so popular that it’s been replicated in anatomy classes around the world.

Sculpting anatomy by hand from the skeleton outward has become a means for not only artists to learn anatomy, but for medical students as well. This is where the distinction between viewing a body in 3D versus tangibly building a body becomes clear; building by hand requires spatial knowledge and memory– tying doing with learning instead of looking and memorizing.

The truest delivery of anatomy to the public takes the form of street art. A growing number of artists are vibrantly broadcasting anatomy on the streets in a vast array of styles. Street artists are pushing their work to be site specific and interactive.

heArtbeats by Lanoc

heArtbeats by Lanoc

Imagine the immersive experience of learning anatomy by walking through rooms of an abandoned building. As dynamic as Achilles‘ warehouse anatomy above, this piece by Croatian street artist Lanoc shows an anatomical heart pumping blood through industrial air ducts. It is site-specific street art, pulsing with life.

Austrian street artist, Nychos, is famous for his explosive views of anatomy. He recently started a series of anatomical charts using his edgy, hard metal style.

The Human Skeleton Anatomy Sheet by Nychos

Imagine seeing this in a doctor’s office: The Human Skeleton Anatomy Sheet by Nychos

While the public is embracing anatomical art, there are many medical professionals that still see medicine and art as two separate subjects. A radiologist approached me after my TEDMED talk and excitedly told me that she creates art from X-rays. When I asked her to see it she said that she never shares it because she doesn’t think it is special or it might be looked down upon by her peers. I encourage artistic expression in medical professionals because it is natural and deeply tied to medicine.

It can be argued that there are only so many ways to represent anatomy, but I counter that by all the astounding ways that artists are able to portray anatomy in their work. Artists have broken anatomy out of the confines of the medical world and are now beginning to reintroduce it back in with a whole new approach and style. The future of medical illustration doesn’t depend solely on advances in technology; it begs to be pushed further by artists. I feel compelled to showcase and catalog contemporary anatomical art, as well as promote the artists and medical illustrators that are pushing the boundaries of anatomical visualization. Because one day, they will be part of the history that leads to something greater– when the public will fully appreciate and understand its own anatomy.


Watch anatomical artist and curator Vanessa Ruiz’s TEDMED talk, in which she shares how she fulfilled her dream to take anatomy to the streets, and make medical illustration– and the resulting public knowledge of the human body– intersect with contemporary art. Check out her website, streetanatomy.com, which showcases human anatomy in art, design and pop culture.

Meet Dr. Pamela Wible, physicians’ guardian angel

In this interview, TEDMED’s Dr. Nassim Assefi and founder of the Ideal Medical Care movement Dr. Pamela Wible discuss physician suicide, sexism in medical school, and how to escape “assembly-line medicine.” You can watch Pamela’s TEDMED 2015 talk, “Why doctors kill themselves,” here.

Pamela Wible

Nassim: You’re one of the few physicians I know who’s been outspoken about physician suicide, open about her own history of depression while in medical practice, and proactive in addressing medical student and physician mental health. How did you become such an activist?

Pamela: I’m an activist and community organizer at heart. I was born into a family of physicians, activists, and entertainers. My grandfather started the motion picture workers union in Philadelphia. I’m related to Curly, Moe, and Shemp of the Three Stooges. It’s in my blood to be joyful, comedic, and lighthearted, but also to speak up for the oppressed and victimized. I’m a born healer and problem solver—whether it’s a patient with an ingrown toenail, a doctor with PTSD, or a suicidal health system. I’m curious, relentless, and very vocal about injustice. Yet without action, words fall flat. Action is what excites me most.

Nassim: You’re a somewhat controversial figure in such a conservative profession. You wear glitter, throw Pap parties, and even deliver balloons and homemade soup to your patients during house calls. Is this quirkiness and whimsy an intentional strategy to spread joy and love in your medical practice or just an extension of who you are? Have you ever received pushback from a mistrusting patient or colleague?

Pamela: My personality and my glitter are not strategic. I’m just being me. I find that when I am free to be myself, my patients feel free to be themselves. Authenticity is therapeutic for us all. Authenticity is also sorely lacking in health care, much to the detriment of physicians and patients. Medicine has too many starched white coats and not enough color, soul, and feeling. My patients are relieved and even thrilled to meet a “real” doctor who is a “real person.” Once (in response to an article I wrote for a medical journal) I did receive a letter from a male clinic manager who claimed my appearance was unprofessional. I recited his letter and responded to his concerns in my TEDx talk, “How to get naked with your doctor.”

A surprise birthday party physical at Pamela's clinic.

A surprise birthday party physical at Pamela’s clinic.

Nassim: You’re a pioneer of the Ideal Medical Care movement, have written a book about it, and offer courses and retreats to help doctors escape “assembly-line medicine.” Can you give me the nitty-gritty on ideal medical clinics?   

Pamela: I’m simply practicing medicine the way my dad used to practice as a neighborhood doctor back in the 1950s (though I’m pretty sure he didn’t throw Pap parties for his ladies). Like my dad, I have no staff and I’ve never turned anyone away for lack of money. My dad and I genuinely love people, and I’m sure patients can feel the love.

I see 6 to 8 patients per half day for 30-60 minute visits. I document on an electronic medical record that I created myself on my Apple laptop. I accept insurance and submit claims in 1-2 minutes after each visit through a free online clearinghouse. I roll out the red carpet for every patient, whether millionaire or homeless. It’s VIP without the fee. By cutting out the middlemen, I decreased my overhead from 74% at my favorite assembly-line job to nearly 10%, leaving me with 90% of the revenue I generate. Physicians who practice this way can exceed their previous full-time salaries working a fraction of the hours. However, most doctors enjoy their newfound freedom and autonomy more than money. No amount of money can compensate for a miserable life and most doctors today seem pretty miserable.

Meanwhile, I’m happy. My patients are happy. I feel like I’m on vacation 24/7. I rarely get after-hours calls. Plus, I’ve never sent anyone to collections in 11+ years. This feels like the only viable way to practice medicine.

Best of all, our clinic was designed by my patients. I held town hall meetings and invited my entire community to design their ideal medical clinic. I collected 100 pages of written testimony, adopted 90% of citizen feedback, and we opened one month later with no outside funding.

What Pamela calls the "reverse white coat ceremony" physicians' retreat.

What Pamela calls the “reverse white coat ceremony” physicians’ retreat.

Nassim: Your mother, Dr. Judith Wible, is a psychiatrist and has a scholarship for visionary female medical students in her name. Did she play a role in your activism? 

Pamela: Yes. My mom is an activist and leader in the women’s rights movement. During my childhood she took me in my stroller to women’s liberation marches, bra burnings, and all of that. She and I went to the same medical school too, and what she went through was much worse than what I had to deal with due to out-of-control sexism and harassment.

Nassim: You’ve had some major success lately. A new book, Physician Suicide Letters Answered, that was #1 on Amazon for Medicine for a month after release, a new house bill in Missouri that addresses depression and suicide in medical schools, and you’re being featured in an upcoming documentary, Do No Harm, by an award-winning filmmaker, Robyn Symon. Are you optimistic that all this attention will translate into more compassionate medical education and practice for the students and doctors?

Pamela: I’m a perpetual optimist. All these successes couldn’t have happened without public and professional support and a willingness to finally address medical student and physician suicide. It is a defining moment for us all.

Nassim: So, what’ s next for you?

Pamela: I’ve been sent on some Michael Moore-style missions through hospitals with secret film crews for the documentary. That’s really fun! I’d love to dig deeper into investigative journalism.

A Lesson With NextGenU: Q&A with Erica Frank

At TEDMED 2014, founder of NextGenU Erica Frank shared her revolutionary prescription for ending the global shortage of physicians. We reached out to Erica to learn more about her ideas and aspirations.

EricaFrankYoutubeThumb

Why does your talk matter today? What impact do you hope it will have?

We are poised for huge scaleup, with NextGenU.org being in essence the first and still only free university.  We are at a point where we have users in 128 countries. Our collaborators include government agencies from the US to Sudan, and our funders span from Grand Challenges and WHO to the Macy Foundation and NATO. We just received a $16 million endowment from the Annenberg Physician Training Program in Addiction Medicine, and we are here to stay.  But, we want more people taking advantage of our trainings, and we hope that this talk will help with that – more health scientists and providers in training and practice coming to the site, and getting credit for free.

Is there anything you wish you had included in your talk?

In 2014, we focused on Graduate Medical Education.  We began our first residency program, Family Medicine, now with the first 200 of the 60,000 residents we have agreed to co-train in the next decade with the Sudanese government and the University of Gezira. Our next two residencies will be in Preventive Medicine and Occupational/Environmental Medicine; we plan to pilot these at Pacific NW University (in Washington state), Stanford (California), U of the Incarnate Word (Texas), and USFQ (Quito, Ecuador).  We are developing these with the American College of Preventive Medicine, Association of Prevention Teaching and Research, European Society of Lifestyle Medicine, Harvard Institute of Lifestyle Medicine, MedVid.io and others to create the first globally-available residencies.

The educational system will span from expert-created competencies, through learning resources and activities, multiple choice and mentor, peer, and self assessments, to recommending Continuing Medical Education based on trainees’ patients’ outcomes, observed through electronic medical records.  It will be unprecedented in the scope of the span throughout a practitioner’s career, and with a community of practice of trainees who have learned to interact globally and meaningfully.

What action items do you want your viewers to take?

Come take a course and get credit for free, or create a globally available course with us!

What legacy do you want to leave?

There is now free accredited education available globally – this could solve so very many problems for so many people.

A Surgeon’s Touch: Q&A with Carla Pugh

Carla Pugh spent her childhood tinkering with appliances and electrical outlets. Quite fittingly, she spoke in TEDMED 2014’s “Play Is Not a Waste of Time” session. Now a surgeon and the Clinical Director of University of Wisconsin’s Health Clinical Simulation Program, Carla shared why haptic skills training matters so much in medicine. Eager to learn more about what she sees for the future of medical education, we reached out to her for a Q&A session.

Carla on the TEDMED 2014 stage. [Photo credit: Jerod Harris, TEDMED].

Carla on the TEDMED 2014 stage. [Photo credit: Jerod Harris, TEDMED].

What impact do you hope your talk will have?

I want to spark a serious conversation about need for elite, high-end, mastery training in the healthcare profession. Healthcare is at a critical juncture where there are huge opportunities for major information exchanges that can empower physicians and patients. Both patients and physicians will benefit from clinical skills performance data. For example, what if we all knew which haptic techniques place physicians at risk of conducting poor clinical examinations?

Outside the measurement of haptic skills, are there other gaps that you believe exist in medical education?

I think the future of medical education is about the global improvement of all skills. The soft skills – like interpersonal communications, and the promotion of tolerance – are definitely the most difficult to achieve. As educators, I think there are gaps in knowing how to be the best teachers we can be, and understanding the limitations of observational learning. When my students walk away from watching a video, I have no idea who’s learned what and who hasn’t. Traditional learning hasn’t fully recognized that, and still hasn’t made strategic efforts to change. Watching videos is helpful because it does give students a certain level of instruction, but at some point it’s important to have that team conversation where you face your colleagues. Also, if you are doing a procedure, at some point you have to pick up an instrument and use it. Videos and observation can only get you so far. Applied learning doesn’t take place until action happens.

Could you paint us a picture of your dream patient simulation lab?

Integration is key. Our whole education system isn’t where it could be; I still dream of something that’s full service. The dream simulation lab would have a central facility, where people come to train and discuss a wide variety of clinical skills. It wouldn’t only be about haptics – it would include communication across professions, and improving patients’ communication with their healthcare providers. Beyond that, it would also be a place where patients could come to learn important techniques – like how to give themselves a shot, take care of a wound, or think of creative ways to remember to take their medication. We would educate using broad, hands-on heuristic techniques.

Standard measurement of a physician’s skill is through the board exam. If you were designing the board exam for surgeons, using all of your haptic technology, what would it be like?

The way that the board exam is administered is highly centralized – we have to go to a board designated location to get tested. Ideally, there would be maintenance of professional certifications, where doctors are given relevant lifelong learning opportunities that are ongoing and well integrated into their daily clinical practice. This is something that the board is working on.

I would like to see decentralized opportunities where doctors are able to practice clinically relevant scenarios.   As doctors, we need to maximize our use of local social capital. For example, I have a few experts working down the hall from me, but I don’t have access to their knowledge, their haptic and communication skills for example. We need more information sharing, and the opportunity for shared practice. I want to compare their performance to my performance, and the ability to choose a training paradigm that directly matches the mastery level that I want to achieve. It’s about mastery, not skills – when we talk about skills, we tend to think of them in terms of “you either have them or you don’t.” Mastery is about constantly improving and working towards better performance. That’s what we should focus on.

Are there any actions items you want your viewers to take?

Make sure to read my research article about using sensor technology to assess clinical skills, which will be published in the New England Journal of Medicine on February 19!