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?
In 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.
In 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.