What does the 21st century physician look like? 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. 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. 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. 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). 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. 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. 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. 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). 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. Source
