Designing the Doctor of the Future

At the turn of the 20th century, we built a healthcare system on responding to acute, curative, episodic issues. This system saw the eradication of many diseases and the advent of vaccinations and new treatments. The model was truly developed to be a “sickcare system,” which was what we needed at the time, and saw huge successes.

Fast forward 100 years and Americans are sicker than ever — but with different illnesses. What’s more, there is finally a national consensus that our healthcare system is broken. With increasingly tragic consequences, the reactionary medical paradigm has not provided the preventive care or chronic illness management that our culture needs. Healthcare spending currently consumes 17 percent of our GDP and without a radical shift in thinking, this number may grow even higher.

Sadly, patients are not the only ones suffering. The status quo is breeding a morale crisis among our nation’s doctors. If you asked one of the many thousands of medical students who are just beginning their fall semester why they chose medicine, many of them would give you confused, anxious responses about the field they are entering. This does not bode well for the health of future generations.

Last Spring, we met at TEDMED, an annual “grand gathering” in Washington, DC where forward thinkers from all sectors explore the promise of technology and the potential of human achievement as it pertains to health and medicine. Here, we presented our respective positions. One of us, Ali, argued that new technologies will actively change our health behavior. Another, Sunny, argued that we needed systems thinking in public health, focusing on the causes of the causes. Yet another, Jacob, argued for stopping the “imaginectomies” and fostering creativity in medical training by rethinking selection criteria and curricula for entrance to medical school.

This led to conversations across the country — with trainees and senior leaders — with all trying to imagine (and reimagine) what would be different for this generation, the generation of millennials (and beyond). What are the expectations that we, and our patients, have about how we practice medicine in the 21st century?

The short answer is we don’t know yet — but the conversation has begun.

On Sept. 10, an intimate discussion was co-sponsored by the Institute for Healthcare Improvement (IHI) and the Young Professionals Chronic Disease Network in Boston on medical education in the 21st century. Here we began to define four questions:

1. What should be the image of the 21st century physician?

There is no doubt that health and medicine attract the most dynamic thinkers in the world, many of whom come with a love of science and art, a yearning to improve health and well-being and an appreciation for thinking differently. To us, the creative enterprise of imagining what could be is a central competency of the 21st century physician. It provides a new platform, value and principle that allows us to unlock gains in technology, in public health, in discovery and in mapping new connections to the full gamut of knowledge that can help help our species not just to survive, but to thrive. We think it should be someone who is, above all, creative, imaginative and compassionate.

2. What should be the new quality standards for training?

We think they should be the ability to work on a team (to put collective rather than individual interests first) and to always focus on the needs of the patient. We believe that protected time for exploring creative endeavours in medical school, graduate medical education and in practice, is essential for transforming our health. Taking a cue from Google’s successful policy, we recommend that medical schools create the space for students to spend at least 20 percent of their time exploring. And for those who doubt that we can spare 20 percent of the time during the medical school curriculum, we suggest that at least this much of the curriculum is now no longer worth committing to memory, in our new world defined by information at our finger tips.

3. What are the models?

The traditional classroom model where one professor lectures to a room of over 100 students is changing. We think that providing didactic lectures online would allow students to maintain focus on their core medical education while freeing up time to discuss relevant topics not always covered in their textbooks. Take, for example, longitudinal ‘concentrations’ such as the Yale System where there are no required exams, no mandatory courses, a pass-fail curriculum and a requirement for a thesis. At Duke, the second year of medical school focuses on core clinical competencies while the third and fourth years allow students to explore clinical investigations and complete elective rotations. We think these models begin to provide the requisite space for creativity.

4. What does the disruptive innovation look like?

With viral movements via Youtube, the ability for students to create their own content and mentor each other online, and new platforms like TEDMED, which challenge medical standards, we have a new way of sharing information — of creating a vision and executing it together. Students themselves could create curricular content — they could become each others’ teachers in partnership with physician educators.

Conversations like this must continue — not only at places like TEDMED or the IHI, but inside classrooms and teaching hospitals, between mentors and students, and between patients and physicians.

As we adopt a 21st century vision of where we are headed, we must adapt and adjust our training so that it meets the challenges facing the patients of tomorrow. Creativity — the spark behind imagining the structure of DNA, in vitro fertilization, the pacemaker — must be valued to unlock major health gains. It will be these new innovations and new models of healthcare and delivery that will continue to push medicine forward.

Even as physicians reimagine the practice of medicine, we must adhere to the same principles that we swore an oath to — to practice medicine ethically and honestly, and to serve humanity. And unless we, as healthcare professionals, take the time to do this reimagining, it will be done by those who have not taken the same oath, and whose approach to reimagining medicine is driven by other motivating factors.

We submit that the best source to imagine the new mental model is from within medical education and it must be accompanied by forward thinking changes in practice and delivery. We need to stop the “imaginectomies” and help, collectively, step by step, to make creativity, imagination and compassion the 21st century standards of medical education.

This century, your future and your health may just depend on it.

Share with us your vision of a 21st century doctor at www.tomorrowsdoctor.org.

Jacob Scott, MD is a research fellow at the H. Lee Moffitt Cancer Center and Oxford University Centre for Mathematical Biology. Sandeep Kishore is an MD/PhD student at Weill Cornell Medical College/Rockefeller University/Sloan Kettering Institute. Ali Ansary is a fourth year medical student at Rocky Vista University. All three are co-founders of Tomorrow’s Doctor.

20 replies »

  1. Thankyou very much to “JACOB SCOTT, MD, ALI ANSARY, & SANDEEP KISHORE” for writing such a informative article.

  2. You are aware that the new Obamacare health law mandates that NPs and PAs (midlevels) get paid the same amount as doctors, right?

    How are we going to save money if they get paid the same?

    Furthermore, why would I pay the same for a nurse when I can get a real doctor?

  3. Noticibly left out is the absent gorilla in the room. By 2025 there will be a shortage of over 100,000 primary care providers in the US. Why is that? Where are the doctors to provide this care? 2 reasons:
    1. The ROI in medicine is astoundany low unless you are fortunate to be in a very high paying specialty. Average med school debt is well over $200K. A primary care physician with amount of debt will sacrifice much to pay that off and have a hope of a normal life. Unless med school is mostly payed for as in all other western countries, this will continue to plague the field and the primary care specialties.

    2. Sensible immigration reform and training of foreign medical graduates to fill many of those primary care spots.

  4. Designing the doc of the future? Really?

    The doc of the present was not designed. The doc of today selected medicine based on her or his attraction to the profession at a point in time. Today it is a highly unattractive profession. You will select from a very weak applicant pool.

    The doc at the end of the century will be there in response to the factors that have always attracted people to medicine:

    1. Life of current (at the time) doctors: work satisfaction, status in community and society, income, control, direction of profession in terms of success, technology. Family encouragement.

    2. Interesting situations and experiences encountered during formative time.

    3. Perception of opportunity for personal prosperity and satisfaction in expected career timeframe.

    You cannot design a doctor. You can try to create an environment that attracts certain people. Right now the only people attracted are people who believe they can change ObamaCare once they are inside medicine.

    Take out all the government money chased by everyone, including patients, and then see what real medicine will look like.

    By the time the end of this century arrives, there will be no viable government funding of any personal benefits. Model that.

  5. The “BIG LIE” about the impact of organized medicine’s on health outcomes is finally becoming known. This is a fraud of monumental proportions and costs foisted upon a naive public. But the public is finally catching on!

    First and foremost physicians of tommorrow must deal with this dishonesty of their profession.

    see http://www.unnaturalcauses.org for what really impacts health outcomes

    Dr. Rick Lippin

  6. re #4: (I’m a first year med student) One of the biggest factors that could lead to real medical culture change is the impact med students can have on each other. In order for med students to have the confidence needed to elicit real change to the medical culture, more students need to be together and discussing important topics. Med schools, and the medical culture is a very isolating one. We need to allow students to have the freedom and the time to interact with each other, and develop their personal philosophies through dialoguing with each other. Spending tons of time in the library by ourselves ignoring everyone else is not doing the medical culture any good.

  7. Dear Jacob Scott, MD, Ali Ansary, & Sundeep Kishore, What do we do while waiting for the changes? Any way to speed up the system change?

  8. Great article folks. I enjoyed it

    We need to design the doctor of the future based on the needs of healthcare delivery. Your’e absolutely right, medical school needs to be re-tooled to help get to that future. Medical school shouldn’t be about memorizing the healthcare database. It should be about how to use tools to most effectively take advantage of hundreds of years of work and discovery that have been contributed to the healthcare database.

    Moreover, the medical education process needs to be re thought. We need more mid levels and fewer MDs to help reduce the cost curve. The fact of the matter is that medicine lives by the 80-20 rule – 80% of patients are relatively easy to diagnose and treat. 20%, perhaps even less, are not. You just dont’ need someone with 9 years of medical training to diagnose most issues. What we need instead are those with 3 years of medical training that understand what they don’t know, and can refer patients accordingly.

  9. There is a CONFLICT of interest in MEDICINE, from academia to corporate medicine. We ALL need to acknowledge that fact before we can transform ourselves. As Primary care physicians, enundated with regulations, resulting to overwhelming paper work, and the need for “efficiency”= seeing more cases to justify our 6 figure income and 7 year income of our employers, we had NO TIME to be involve with policies.

    The conscious or unconscious lack of introduction or elimination in our curriculum of past medical leaders history, may facilitate these ignorance as well. As a result we, the grass roots, the ones in battle called the lowly PRIMARY care MD’s, became uninvolved with health care policies. Instead, clueless, theoretical MD administrators or executives and MPH’s create these recommendation. Worst promoting watered down programs both in Medicine and paramedical fields.

    The CDC mentioned that chronic illnesses cost the country 75% of the health care cost – http://www.cdc.gov/chronicdisease/resources/publications/AAG/chronic.htm
    Reconciling CDC with the world economic council of 2011 http://www.weforum.org/news/non-communicable-diseases-cost-47-trillion-2030-new-study-released-today, one can easily see why developed countries can go bankrupt..

    The system have to address PREVENTION OF EXPRESSION of these diseases rather than TREATMENT. We emphasize these issues in our practice and I developed a graph on the PILLARS of health and account my patients for their lifestyle choices. I have yet to meet a resident or a medical student since 1998 that can discuss about the details of exercise, yet most can discuss how to TREAT CVD, DIABETES etc. PRIMARY care means PRIMARY PREVENTION. Let us examine ourselves from within and accept that primary care’s current model is to be part of the “VERTICAL SYSTEM”, essentially PIMPS for the now so called MEDICAL INDUSTRY and PHARMA. Feel free young forward thinkers, if indeed redesign of primary care is something truly you want to start NOW. My letters were largely ignored in most training programs.

  10. I hire residents. I do all of the recruiting for my group. I can tell you what I need in someone I hire. They need competency in their specialty. It cannot just be memorized. Within their first month they will run into a problem they have not seen before. That will happen all of the time. They need to figure it out. I cant hold your hand for more than a few months.

    They need integrity. Quality matters, and you have to make sure you keep current. You have to work fast, an economic reality, but still do the right thing. Makes for tough calls sometimes. They need stamina. Long hours are part of the job, and a lot of it is really boring. If you need to be off by 5 everyday, go get another job. They need people skills. (You are correct that teamwork matters)

    It would be great if you have writing skills, and dont write like a doctor. Learn what your nurses are doing. Learn to listen to, and be available for, the good ones. That goes for techs also. Good bladder control is a plus. Stay healthy. You will be working with a group. If you are sick a lot, you will get dumped.

    Finally, no whining. Solve problems, dont just complain. Looks like you have a start, even if it is a bit touchy-feely.