Tag: Training

What’s Up, Docs


Here’s how I’ll know when we’re serious about reforming the U.S. healthcare system: we’ll no longer have both M.D.s and D.O.s.

Now, I’m not saying that this change alone will bring about a new and better healthcare system; I’m just saying that until such change, our healthcare system will remain too rooted in the past, not focused enough on the science, and – most importantly – not really about patients’ best interests.

Let me make it clear from the outset that I have no dog in this hunt.  I’ve had physicians who have been M.D.s and others who have been D.O.s, and I have no indication that there have been any differences in the care due to those training differences. That’s sort of the point: if there are no meaningful differences, why have both?  

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Should We Send Docs to Tech School?

Tech Skool

An article in Information Week caught my eye recently . It reviews a new program offered by Texas A&M with support from Dell to help medical students and other healthcare professionals “come to terms with  the ways technology is changing their jobs”. The article, Doctors Can Go Back to Tech School, says Texas A&M will launch its new health technology academy later this year as part of its continuing medical education program.

Now, don’t get me wrong. I’m all for education and career improvement. I’m just not sure that the best way to improve Health IT is to get more physicians trained in IT so they can, as the article suggests, move into IT roles. How about giving full time clinicians who have an interest in improving Health IT some extra support and time so they can help those who work in IT better understand what clinicians need to do their jobs efficiently and safely? How about just a little paid time away from the daily treadmill of patient care to educate IT about the nuances of medicine and clinical workflow? I believe understanding that would do more to help IT deliver better solutions.

Over the course of my career, I’ve been many things. First and foremost, I am a physician. Only a true clinician understands how clinicians think and work. For many years, I continued to practice even when it no longer made a whole lot of sense with regards to my income or available time. I was a biology major in college. I went to medical school and did a residency in family medicine. I never had any formal training in either business or technology. I learned the ropes by doing. It was often trial by fire. I’ve had my share of success as well as a few failures along the way. When I advanced into the role of a hospital CIO and CMIO, it wasn’t because I knew tech. When my then CEO asked me to step into the CIO role, I’ll never forget what he said to me. He said, “I want to put a civilian in charge of the military”, meaning a doctor in charge of a department that existed to serve clinicians and their patients but had become a renegade army running out of control and way over budget.

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Moments of Failure

There was a night when I was in training that all the decisions, disasters and chaos, which are the practice of medicine, caught up to me.  In those dark hours, I felt practically despondent.  What I had seen left me in tears and overwhelmed by the tasks in front of me.

At that moment a wise attending physician took a moment to sit with me.  Rather than tell me how wonderful a doctor I might someday become or brush away my errors, he validated my feelings.  He said the best doctors cared, worked hard and sacrificed. However, that the basic driving force is fear and guilt.  Fear for the mistakes you might make. Guilt for the mistakes you already had.  How I handled those feelings would determine how good a doctor I became.

I have reflected on those words over the years and tried to use that sage advice to learn and grow.  Focused properly, guilt gives one the incentive to re-evaluate patient care that has not been ideal.  It drives the study and the dissection of past decisions.  Nonetheless, excessive guilt can cause a doctor to avoid completely certain types of cases and refuse even the discussion of those medical issues.

Fear of error drives compulsive and exact care.  It helps doctors study and constantly improve.   Taken too far it can result in over testing, avoidance and over treatment.  The art of medicine requires the practitioner to open his heart to criticism and be strong enough to build from failure.

Some years ago, I saw a patient who had leukemia.  I concluded that the patient’s low blood count was because of this blood cancer.  This was correct.   I missed that in addition to the leukemia she was bleeding from a stomach ulcer.  By the time another doctor spotted the ulcer, the patient was sicker than she might have been, had I made that diagnosis earlier.

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Tweaking Medical Education to Leverage EHRs

Tweaking Medical Education to Leverage EHRs



Author’s Note:The purpose of this 5-part series is to make the case for implementing a widespread, systematic approach to HIT education in medical schools and continuing medical education programs for physicians. Previous posts reviewed challenges posed by the HIT Deluge and the Impact of EHRs on Medical Education.

EHRs have begun an inevitable march into the lives of all physicians. The US government has established an ambitious plan for their deployment, and providers seem both eager to comply and anxious to avoid financial penalties associated with not doing so.

But as described in Part II of this series, EHRs can have deleterious effects on the education of medical students and residents. These include disrupting interactive sessions involving educators and trainees and complicating patient-physician communication.

Jay Morrow and Alison Dobbie of Texas Southwestern Medical Center argue that much of this negative impact derives from a mistaken perception that EHRs are a health care delivery method rather than a medium through which physicians deliver care. It follows from this argument that the quality-improving, cost-reducing benefits of EHRs can only be realized if multiple systems and user-based factors are aligned to optimize utilization of the new medium.

Medical educators can begin the alignment process by developing answers these 3 questions:

When Should EHR Education Begin?
Arguably, the process should begin as early as possible. Since the 1970s, medical curricula have included non-science oriented courses such as “Introduction to the Patient,” “Communication Skills” and the like. These courses present ideal opportunities to introduce the new medium.

Students in such courses should be taught to navigate through and use basic EHR functions such as order entry, lab look-up, messaging and charting. Ideally, this exposure should occur outside the clinical setting so trainees can focus on mastering the EHR interface itself. At this time, it should be possible to identify those in need of extra help with keyboard skills, and to provide assistance as necessary.

Keyboarding skills should not be assumed, even for the current generation of physician-trainees. In a 2007 focus group of first-year students at Texas Southwestern for example, 62% of the participants expressed concerns about such skills, and many claimed to have better texting than typing abilities.

If students master keyboarding and EHR navigation skills before starting their clinical rotations, they can focus the latter time on traditional learning exercises, such as clinical reasoning, diagnosis, acquiring medical procedure skills and interacting with ancillary caregivers and patients.

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