[This post was first published on The Health Care Blog on 3/8/13, titled “What Will Tomorrow’s Doctor Look Like?“
“What does the 21st Century Physician look like?”
Lisa Fields (@PracticalWisdom) cc’ed me on a tweet about this; it’s the featured question at www.tomorrowsdoctor.org, an organization founded by three young professionals who spoke at TEDMED last year.
I’ll admit that the question on the face of it struck me as a bit
absurd, especially when juxtaposed with the term “tomorrow’s doctor.”
Tomorrow’s doctor needs to be doing a much better job of dealing with
today’s medical challenges, because they will all be still here
tomorrow. (Duh!) And the day after tomorrow.
(As for the 21st century in general, given the speed at which things
are changing around us, seems hard to predict what we’ll be doing by
2050. I think it’s likely that we’ll still end up needing to take care
of elderly people with physical and cognitive limitations but I
sincerely hope medication management won’t still be a big problem. That I
do expect technology to solve.)
After looking at the related Huffington Post piece,
however, I realized that this trio really seems to be thinking about
how medical education should be changed and improved. In which case, I
kind of think they should change their organization’s name to “Next
Decade’s Doctor,” but I can see how that perhaps might not sound catchy
enough.
Linguistic choices aside, there’s an
important issue here, and it keeps coming to mind as I follow the trends
in healthcare innovation:
How far ahead should we look as we try to apply creative energy to solve important problems?
I say let’s be careful about how far ahead we look. After all, there is more than enough to keep us busy today, and tomorrow.
For instance, I take care of complex patients now, and I know that
there will be people very much like my patients around for the next
20-30 years, if not for longer. This is part of why I don’t have much
patience for the tendency of the innovators to emphasize “prevention”
and a nifty tech future in which technology changes behavior so that
people don’t develop all these pesky chronic illnesses which
characterize the “sickcare system.”
It’s not that prevention isn’t important, or that we couldn’t face a radically different healthcare landscape in 20 years.
Rather, it’s that it slightly kills me that so much of this
creativity and intelligence and innovation keeps leapfrogging over the
very important — and very interesting — problems facing healthcare’s
power users, and these are problems that we need to solve by TOMORROW.
Or the day after. Or maybe the year after, but really, if they don’t get
meaningfully addressed within the next several years, we are going to
have even worse problems than we have now.
And yes, a key subset of those problems that need solving is how to
equip physicians to step up to the challenges at hand. (All clinicians
need equipping, but because of their historic status and role in
healthcare, the case of physicians requires special attention.)
So let’s think about it: what do we need doctors to be able to do by tomorrow?
What Tomorrow’s Doctor Should Be Able To Do
I’m going to talk literally about tomorrow, in that these are all
things that ideally docs would be able to do today. Here’s how I would
start my list:
• Be comfortable with the e-patients.
This means being comfortable with patients who are engaged, equipped,
and empowered, often because they are accessing resources outside the
traditional healthcare system (i.e. online patient communities, journal
articles, etc). Not all patients are e-patients, but many are and we
should expect this to become much more common. Patients will also
increasingly be reading their notes, a la OpenNotes.
o In practical terms, this means docs should be
comfortable with patients who ask a lot of questions, and should be
prepared to explain their recommendations. Unfortunately, many docs are
not so comfortable with this, in part because it’s a cultural shift in
the clinician-patient relationship, and in part because of systemic
hindrances, like visit times that are way too short to address
everything that should be addressed.
• Engage in shared decision-making.
Rather than just tell patients what to do (or what we think they should
do), we should really be engaging patients and families in working out a
plan. This means we need to be able to present options, counsel
patients on the expected benefits and risks, solicit input from patients
regarding preferences and values, and otherwise effectively collaborate
in how we move forward with patients’ health.
o In practical terms, this means doctors need get better
at presenting expected benefits and risks (technology could help make
the data easier to have at hand), and doctors need the communication
skills to have these conversations with patients.
o Some would even say that many doctors need a complete attitude
adjustment, and I suppose this is true. Still, more constructive to
focus on a few key skills that we can ask doctors to work on.
• Be able to coordinate and cooperate with other clinicians. The
days in which a single doc was PCP and followed patients into the
hospital are gone, even though some heroic clinicians still manage to
provide this continuity of care. Medicine now requires doctors to work
effectively with many other clinicians (not to mention the teams which
are becoming increasingly common with primary care offices).
o In practice, this means that docs need to:
– Document so that other people can figure out how to follow-up and synergize. This is a big change for many docs.
– Read other people’s notes, and incorporate into their own activity.
Also a big change for some docs. For instance, when I was at the VA, I
noticed that many specialists were not reading my primary care notes,
even though they were easily available.
– Appreciate that other clinicians, including non-docs, have an important role to play in the patient’s care.
• Be comfortable with continuous quality improvement (CQI) and PDSA cycles.
Many doctors are far too used to their practices remaining fairly
static, barring the introduction of new drugs here and there. In fact,
not only do we need to improve things, but we should really expect that a
regular part of our work will be reviewing and improving our personal
practice.
o Doctors should be familiar with such on-the-ground quality improvement techniques such CQI and plan-do-study-act. Of course, we need to develop better measures and we’ll need capable guidance on PDSA cycles,
but in general, all practicing physicians should be familiar with the
basic methods by which we can review our practice and improve it.o Doctors should be used to constructively participating in these
activities on a regular basis. Having tried to herd physicians into
doing this, I’d say it should really be a weekly activity.
• Be comfortable learning new ways of practice.
There is learning to tweak and improve what you’re already doing (see
above), and then there is learning a whole different approach or method
of doing your work (like learning to do your work with an EHR, or no
longer having to fit work within face-to-face visits, or adapting to
team-based primary care). Medicine is changing, and even though I really
don’t know what it will look like in 10-20 years, clearly we docs must
be prepared and willing to rethink how we apply our knowledge and skills
in the service of helping people with their health.
o Periodic changes in the way we practice should be expected. Just as the kitchen staff at the Cheesecake Factory (read Atul Gawande’s New Yorker piece
if you haven’t yet) expects to learn to make several new dishes twice a
year, doctors should expect to change the way the practice regularly
(though hopefully not every six months).
o On the other hand, someone will have to invest time and resources in
these upgrades (it’s a seven week process for the Cheesecake
factory)…the current climate in which we expect docs to update on the
fly because it’s better for society and patients — and because we’re
throwing some incentive money at them — is really not realistic.
• Be comfortable with well-designed technology. Not
only do we all need to be able to type, but we’ll need to all be fairly
comfortable using technology, because more and more of it will be
involved in healthcare.
We could of course come up with more key competencies, and also the
skills needed to be proficient in the above, but I’ll stop there for
now.
Incidentally, although I think we need the skills above tomorrow, I also suspect they’ll all be useful in 2050.
The medical education effort we really need
The truth is that although we certainly should revise and improve the
medical school curriculum, the people who are most in need of a medical
education effort are our estimated 950,000 practicing physicians.
Why? Because many of them are expected to continue practicing for
decades, because their actions currently drive much of what isn’t
working well in medicine (although heaven knows much of that is the
crazy system around us), and because we really can’t make healthcare
better without changing what physicians do and how they feel about it.
Furthermore, although the effort to change medical school education
is laudable, medical students are profoundly influenced and shaped by
what is modeled by the practicing physicians around them.
How can we help practicing physicians develop these new skills and behaviors?
I haven’t yet seen any large scale proposals that seem viable,
although I’m sure we could learn a lot from Kaiser and other larger
organizations that have experience shaping physician behavior. Certainly
a little CME credit or incentive money won’t cut it, but what will? If
you have ideas, I’d love to hear them. (I myself am very interested in
tapping physicians’ intrinsic motivation, but am not sure how one would
operationalize into a large-scale change effort; change is hard!)
Summing it up
Tomorrow’s doctors need to have the skills to deal with today’s most
pressing healthcare problems, because today’s problems — including
helping people with multiple chronic diseases — are not going away any
time soon.
Specific skills that we all need to develop ASAP as physicians
include becoming comfortable with e-patients, with shared
decision-making, with continuously reviewing and revising our practices,
with using technology, and with meaningfully collaborating with other
clinicians (and with patients and families). We also need to prepare
ourselves to periodically substantially revise the way we deploy our
skills in the service of the healthcare system.
The highest priority for this education effort should be today’s
practicing physicians, rather than the medical trainees. Although
medical trainees also need to prepare for the healthcare system of
tomorrow, it’s the actions of today’s practicing doctors that exert
incredible influence on the healthcare system, and powerfully influence
medical students.
