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.

Four Thought Leaders Shaping the Future of Health Care

By guest contributor and TEDMED 2015 speaker Thomas H. Lee, MD

For years now, experts have said health care should move “from volume to value,” and the good news is that it’s finally happening. Even within the past few months, the pace of change has accelerated. More and more payments to providers are tied to quality and efficiency, and increasing amounts of data on their performance are being published online.
Empathy suffering health careIn my TEDMED talk, I spoke about how the reduction of suffering was becoming the focus for health care. Today, many health care providers are starting to compete on how well they meet patients’ needs.
As this competition increases, health care providers can look to four key thought leaders whose work influences my own every day: Michael Porter, Leemore Dafny, Ronald Burt, and Nicholas Christakis. Individually and collectively, their contributions provide clarity on what we need to do in health care, why we need to do it, and how to get it done.
Over the last few decades, Michael Porter of Harvard Business School has defined the meaning of strategy for business in general. His work on health care clarifies why an overarching strategic goal is important for every organization, and why that goal should be to create value for patients. He and his colleagues have described how multidisciplinary teams should look, and what kind of information and incentives those teams need to drive improvement.
If Porter’s work describes the “recipe” for what we need to serve in health care, Leemore Dafny helps us understand the heat that is necessary to start things cooking. She is the Harvard economist who has studied payer and provider consolidation and shown how it leads to weaker competition and higher prices. I have long been leery of thinking about health care as a marketplace, concerned about unintended consequences if patients have to act like consumers and make tradeoffs in quality and price. But Dafny and her colleagues are persuasive when they argue that competition in a value-driven market has greater potential to drive improvements in quality and efficiency than the alternatives – and that providers like me should embrace competition and learn to trust market forces.
Porter and Dafny’s work tell us what we have to do, and why we have to do it. But how do we get that work done? Part of the answer is to strive for the creation of social capital.
For the last several years, I have given a book to virtually every new close colleague: Brokerage and Closure: An Introduction to Social Capital by University of Chicago sociologist Ronald Burt. We all know about financial capital (the funds that enable organizations to do things they otherwise could not do), and about human capital (hiring good people). Social capital is about how those people work together. If they are reliable in their coordination, the organization can make leaps in quality and efficiency. Burt provides a clear and useful structure for learning (increasing variation in what is done by brokering ideas) and then converging on best practices (closure).
Then there is the challenge of how do we make collaboration and compassion the norm in health care. Financial incentives cannot get the job done. That is why I think so often of Nicholas Christakis, the Yale social network scientist who has shown how epidemics of values and emotions can spread from person to person. While the work of Porter, Dafny, and Burt define the big picture, Christakis characterizes the nature of the work that needs to be done on the ground.
There are, of course, many more colleagues whose work I respect and learn from, but these four constitute a “package” that I think can accelerate the transition to a new and better health care system.
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TEDMED Speaker Tom Lee, on addressing patient suffering in health careIn his TEDMED talk, quality care pioneer and Chief Medical Officer of Press Ganey, Tom Lee reveals his passionate quest to define empathy as a business asset and patient suffering as an outcome.