“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 eduction 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.
Leslie Kernisan, MD, MPH, has been practicing geriatrics since 2006, and is board-certified in Internal Medicine and in Geriatric Medicine. She blogs at GeriTech.
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Thanks for this comment, and for highlighting the important issue of communication.
I absolutely agree that communication failures are endemic in medicine, and that doctors in particular tend to be bad at reliably communicating with other healthcare providers.
I’ve often been impressed by how much more disciplined and thorough nurses and other providers are when it comes to documentation and communication.
Certainly a skill that tomorrow’s doctor will need!
I stumbled onto this article while researching a related matter and found it to be well-written and an enjoyable read. I found nothing I personally disagreed with but do wish you had written a few more sentences here and there on some of your thoughts as I was left wanting to read more – but maybe that was the intention!
Unlike many of today'[s medical professionals, I long for the “old days” where the general practitioner was more prominent in the medical world and made hospital calls on their patients. But time marches on and while I do miss those old doc’s, I also see the value in the Primary Care Team. As a wound nurse, I find the biggest problem with this concept is the “one hand not knowing what the other hand is doing” issue. Which brings me to the one thing I wish you had written more on – the PCP communication requirements. You touched on it in your paragraph on “Be able to coordinate and cooperate with other clinicians”.
I learned in the Marine Corps that “effective” communication saves lives and wins battles. As a nurse, one of the biggest problems I deal with is physicians not consulting with other team physicians/nursing on a patients care team. One doc tells the patient they will be in the hospital for at least a week. Two hours later another doc tells them they are going home tomorrow. Then a surgeon comes in and tells the patient they will be NPO that night for debridment the next morning. For this patient, effective communication, has not been achieved by the PCP. It isn’t that way with every patient of course but it happens…and leaves the patient wondering who is piloting their care.
Effective communication is paramount in every aspect of society. In the medical world, computers and paper charts are nice, but folks have to read ALL entries regarding patient care and not focus on only what that person has to say. When one PCP members doesn’t read or verbally communicate with another on a patient’s care, effective communication is lost and the chances of error rise sharply.
While I am not as articulate as the physicians and others who have responded to this blog, I hope you understand my thoughts .
Again, great article!
Rick Lawrence, LPN, BA, MBA-HC(Candidate)
MSgt., USMC/USAFR (RET)
Tomorrows Doctor will not be wearing a stethoscope around his/her neck.
Health is important for all people in world…. this is useful for all people
Health
Asking doctors to focus on the medically complex patients who need physician-level assistance and giving doctors smaller panels would indeed be one possibility. Even with the assistance of a primary care team, there are only so many medically active patients a physician can reasonably handle. (don’t ask me to define reasonably right now; that’s a post in of itself, as is panel size for that matter)
In general, if we primary care doctors want to stop the burnout, the madness, and the magical thinking of people around us, then we have to be very explicit about what it is we need to sustainably and effectively do the job we are being asked to do.
You can’t provide an aging population with compassionate & effective healthcare at sustainable cost without dramatically improving primary care for the Medicare population. That means adding resources to primary care (and reducing procedures and hospitalizations).
Devil of course is in the details.
Thanks for the reply.
Sounds like you’re saying, Yes, tomorrow’s doctor will have a smaller patient panel. That’s a great thought, but I sure don’t see any big movement in that direction (with an aging population and the ACA, all the movement seems to be in the opposite direction).
I’m physician who left conventional primary care due to burnout, so I take your concern very seriously.
The problem is not in asking physicians to do these more time-intensive activities; the problem is asking for this without giving them the time and support to reasonably handle this workload. The current approach of piling on yet more expectations is like magical thinking, and it’s failing.
How many patients each doc can care for will depend on how we define “care for” as well as the medical complexity of the patient, along with the patient’s (or family’s) communication requirements.
Working longer hours isn’t an option and won’t help us do our best work. I do think it’s pointless to ask any worker to work excessively as they just start to do progressively shoddier work.
Expecting tomorrow’s doctor to perform more time-dependent activities is a recipe for disaster: that’s the attitude that’s killed primary care, and has led to unprecedented levels of physician burnout. Your doctor of tomorrow will either have to care for many fewer patients or work much longer hours. Do you think either of those is realistic?
Glad to know this has resonated with some readers, and thank you all for these thought-provoking comments!
Vineet, interesting to think of when reverse-mentoring is likely to work and when it’s not. In 2001 when I was a third year med student, I remember outraging my attending when I pointed out that pharma advertising influenced prescribing, but that view has now become much more mainstream. My own guess is that QI and adopting tech are more amenable to reverse-mentoring than is making more gut-level shifts in how we see ourselves (there to treat patients or to partner with them?) or our practices (meant to stay the same forever, or often improve?).
Great post! I like how they made the title more appealing. “Tomorrow’s doctor”. Tomorrow’s doctor would be a much better doctor compared today. Why? Since they have dealt with problems and mistakes now, which they can correct tomorrow to become a much better doctor that we all need that can help people save lives.
Great post! One thing to consider is that in order for practicing physicians to become doctors of tomorrow,they need time. Time to engage with e-patients, communicate with other providers, time for training etc. The system needs to change to support this time. I would also highlight that cementing these practices in current medical trainees is the best chance of success. One additional benefit is that they can engage in ‘reverse mentoring’ to teach the older generation of doctors – this has already happened with QI efforts for example and health IT where residents often teach the faculty the tracks for using the EMR.
Sorry to disappoint you all but the doctors of tomorrow will be mid levels. Medical doctors will be doing research or concierge care, and life expectancy will be spiraling downward, because the government is investing in HIT devices that do not work and are doing further damage to medical care rather than the care of those in need.
First rate thoughts, Dr. Kernisan. Thank you very much.
I would add that doctors, tomorrow (at the latest), need to seize the day. They need to realize that whatever happens to the future of healthcare will be decided, directly or indirectly, by physicians. If we remain in our silos and refuse to take the sort of aggressive steps outlined in your blog, medicine will continue to languish because someone else (i.e. pharma, Wall Street, insurance companies, gov’t…) will make the decisions. On the other hand if we accept that the best way to take care of the patient sitting in our examine room is to make certain that the entire health system functions, and if we decide that physicians are the ones most likely to make that happen, then the future can be bright.
Medicine will remain the most exciting, challanging and satisfying career a person can choose. Tomorrow’s doctor is tech savy, a compassionate communicator, a fluid recreator, a micro/macro educator and most of all knows that change is something she makes happen, not that happens to her.
Thanks again for a thoughtful piece,
jcs
Thanks, Dr. Kernisan. Your commentary on this topic is very complementary to mine:
http://informaticsprofessor.blogspot.com/2013/01/what-do-twenty-first-century-healthcare.html
Bill Hersh
Thank you for the reference to the Farm Bill – it has seemed to me that perhaps the best thing we can do to improve health care is to pay more more attention to the Dept of Ag and the EPA than the Dept of HHS. Stop the subsidies to Big Ag/GMO tech and give them to small local organic operations, use the precautionary principle in approving what chemicals are allowed in our environment. There seem to be more and more indications that that the reason for the diseases that are now killing us is what we are ingesting/inhaling.
I do not think this a digression at all, because it gets right at the heart of what today’s docs need to do to prepare for tomorrow – and that, IMO, includes becoming active in politics – many of the changes that need to be made to improve healthcare need to be made in the halls of Congress .. We need, IMO, to change the national dialogue on what being “healthy” means and how we get there and docs need to lend their “prestige” to that effort …
Lots of great observations here – LOVED this line
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
Excellent distinction – docs are going to be able/need to be able to do both
As a health care professional for nearly 35 years and a stage IV prostate cancer patient navigating a broken system, you have provided important words of wisdome here. Kudos for a well thought out and provocative piece.
Another blog post where I agree with you 100% on everything you said. The frustrated health IT innovator in me especially loves your skepticism of the current fad of whiz-bang prevention apps, when what we really need is better software to help clinicians practice good medicine and help our patients make informed decisions. Rather than prevention-focused apps, I would much rather see dramatic reform of the Farm Bill, which would be more effective prevention than any app ever will be. Alas, I digress. Great stuff!