Medical schools need to abandon the concept of medicine as art and begin training students to function in a rapidly evolving, team-oriented, science-based field.
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| Charles J. Shanley, M.D. | David Ellis |
The acceleration of biomedical understanding—and everything that follows in diagnosing and treating human illness—is now so rapid that by the time a student graduates from medical school, much of what he or she learned may be outdated or even irrelevant. The implication is that effective medical education reform requires much more than a superficial “nip and tuck” strategy; it needs an extreme makeover.
Modern science is team-oriented, technology-facilitated, informatics-supported and evidence-based. Modern medicine, like any other science-based profession, must adopt these practices and principles if it is to provide safe, effective and accessible care to an increasingly mobile society in the information age. For this reason, we expect that the art- or craft-based model of medical practice will trend inexorably toward a postmodern paradigm dominated by applied “medical” science.
We acknowledge that the modern practice of medicine is much more than applied science (at least not science in it purest form). But if medical schools are to prepare students for a 21st-century, science-based health care system, it is imperative that we challenge some of the assumptions underlying the traditional paradigm of medical practice as an art.
Medicine as Science
In his 2007 book, How Doctors Think, Jerome Groopman, M.D., embraces the traditional. “Medicine is still very much an art,” he writes. And that’s a problem because, as his Harvard colleagues Clayton Christensen et al. relate in their 2004 book Seeing What’s Next, “little by little, disease by disease, scientific advancements begin transforming the provision of care from an art to a science.”
No doubt both Groopman and Christensen are right to some extent. But both may soon seem out of date. “Little by little” does not reflect the rate of acceleration we are witnessing in medical science. The sequencing of the human genome alone has generated a tsunami of biological data and fresh understandings. It has also generated deeper mysteries, but nevertheless, our current science-based understanding of biological and disease processes has passed the tipping point and is fast rendering the art- or craft-based approach to medical practice obsolescent and untenable.
The classical physician was perhaps the epitome of humanity, compassion, dedication, learning, skill and judgment. This is not surprising if one considers that throughout much of recorded history the science underlying diagnostic and therapeutic medicine was at best rudimentary and incomplete. As a clinical reality, this knowledge gap supported the idealized model of the physician as artisan, guided by superior clinical intuition honed through empiricism and sound clinical judgment born of experience. Perhaps this is why the medical establishment in general and the mind-set of physicians in particular are not predisposed to challenge the romanticized image of the physician as altruistic healer.
Even so, as Martin Hutchinson has put it (“Busting modern medical myths,” BBC News Web site, April 4, 2007), while the public might be surprised at the low number of treatments backed by sound scientific evidence, doctors might be surprised that the number is so high. Frequently, even when new research clearly suggests that physicians should stop using a particular treatment, nothing changes. In other words, they know there is much to fix, and they know of available fixes—yet they seem reluctant to apply them.
This mind-set was exemplified by the leader of a 1,300-member independent physician association who said he considered electronic medical records to be “bad technology.” (See Gary Baldwin, “EMR Pushback,” HealthLeaders, Sept. 14, 2007.) Those 1,300 doctors use computers for practice management but continue to rely on paper charts for clinical documentation. “You have to realize that physicians have been trained four years in med school, then three to seven years in post-graduate training,” their leader said, somewhat inconsequentially, and while “they want to take care of patients,” they don’t want to become “specialists in creating medical records.” This mind-set dismisses abundant evidence that EMRs improve quality and enhance patient safety.
As Baldwin notes, doctors are simply “reluctant to introduce technology that upends old habits and threatens productivity.” It surely doesn’t help that medical school has inadequately prepared physicians even to understand the biostatistics in many research reports, according to recent reports in Journal of the American Medical Association and the Mayo Clinic Proceedings. How can they be expected to intelligently lever decision support and artificial intelligence, let alone the nuances of computational biology in postmodern medicine?
Many physicians, like Dr. Groopman, recognize that the complexities and uncertainties of medicine cause even the best to misdiagnose and mistreat patients. What they fail to recognize is that the growing complexities and uncertainties are increasingly amenable to well-developed scientific and technological solutions and in all likelihood, only to such scientific and technological solutions.
The postmodern physician will be less of an artisan and more of a scientist. Armed with a sound working knowledge of applied mathematics, informatics and statistics, the postmodern physician would never rely on the notoriously incomplete and unreliable (and often unavailable) paper-based medical records. None would want to pit his or her fallible experience, memory and cognitive skill against the EMR data-mining and decision-support tools able to handle extreme complexity and assist in diagnosis and evidence-based treatment.
No amount of empirical experience, cognitive prowess nor hard-won clinical judgment will tell the postmodern physician that the patient has a mutant BRCA gene: This diagnosis requires a genetic assay and a permanent record of the results in the EMR. For all intents and purposes, effective postmodern medicine simply cannot be retained “between the ears” and practiced by “hunch and intuition.” In the postmodern clinical reality, the practice of medicine and the delivery of medical care is an applied science.
Physician as Steward
Clearly, a science-based clinical reality is not conducive to the traditional model of the physician as artisan. On the contrary, a postmodern health care delivery system calls for a new paradigm for medical practice centered on the physician as steward.
In the preface to his classic 20th-century treatise, Metabolic Care of the Surgical Patient, the visionary philosopher-surgeon-scientist Francis D. Moore, M.D., wrote that “The fundamental act of medical care is assumption of responsibility” and that “The surgeon [physician] employs any effective means available to serve the patient best.” This timeless principle of medicine as a stewardship for the welfare of the patient is not only entirely consistent with knowledge acceleration but also with another postmodern reality that such a stewardship can and must be shared with other caregivers and with the patient.
To use the metaphor of a symphony orchestra, we see the role of the postmodern physician shifting from that of the soloist to that of the conductor. Physicians will need to accept this responsibility and to provide this broader leadership effectively in a science-based reality that abhors the silo-driven and “soloist” culture that has dominated the image of the physician and of premodern medical practice. On the contrary, postmodern physician-scientists must embrace a new reality and a new culture of medical practice dominated by increasingly empowered and highly sophisticated interdisciplinary teams that include the patient.
The Challenge
The challenge to medical education is to facilitate and promote this transition even as it accelerates, retaining the character traits of the responsible steward (integrity, altruism, dedication, compassion and commitment) and employing the arts of the premodern physician-artisan in the absence of anything better—but discarding them without hesitation in favor of validated science and tested technology.
Preparing medical students during a rapid transition of medicine is not easy. As former U.S. Secretary of Education Richard Riley has said in relation to education generally, we are currently preparing students for jobs that don’t yet exist, using technologies that haven’t yet been invented, in order to solve problems we don’t even know are problems yet. We might say the same of medical education in particular.
While some conscientious physicians will take it upon themselves to keep up to date with advances in medicine as a science, the fundamental stewardship of medical educators is “to change the next generation of medical practitioners,” as Paul Glasziou, director of the Oxford University Centre for Evidence Based Medicine, put it in the BBC article mentioned above.
A medical school remade with an intense, interdisciplinary focus on science and technology would have a curriculum that emphasizes postmodern medicine and computational biology. Its professors will likely include mathematicians and philosophers, and its infrastructure will be populated with supercomputers and advanced simulation technologies. Upon graduation, the postmodern physician’s little black bag will be stuffed with a postmodern armamentarium of gene chips, portable scanners and PDA access to Internet-based diagnostic and treatment decision-support tools.
Where to Start?
Twenty-first-century medical reality will witness an accelerated evolution of applied medical science in a “provision of care” reality that is increasingly patient-centered, team-oriented, technology-facilitated, informatics-supported, quality-driven and evidence-based. The postmodern physician-scientist-steward will provide the necessary leadership for the safe and effective functioning of these interdisciplinary teams. These principles are not at all inconsistent with the directives of the 2003 IOM Report Health Professions Education: A Bridge to Quality. But compared with the “nip and tuck” reality of medical education today, they imply the need for an extreme makeover.
Prerequisite to undergoing an extreme makeover is an understanding of the acceleration in medicine and a recognition that we are past the tipping point from medicine as art to medicine as science. As part of the makeover, medical schools must build a flexible and dynamic infrastructure, flexible and dynamic interdisciplinary (not just multidisciplinary) faculty, and flexible and dynamic curricula. They must wholeheartedly embrace and teach the simulation, telemedicine and other technologies their students will encounter as interns and residents. Health policy-makers and funders should support them in these efforts.
Above all, they must focus on where medicine will be tomorrow, not where it was yesterday.
Charles J. Shanley, M.D., is a vascular surgeon and intensivist who serves as senior vice president and chair of surgical services at William Beaumont Hospital in Royal Oak, Mich. Dr. Shanley is also executive director of the Applebaum Surgical Learning Center, a state-of-the-art simulation facility, at Beaumont.
David Ellis is corporate director of planning and future studies at the Detroit Medical Center and publisher of Health Futures Digest, a monthly online discursive digest of news and commentary on long-range, leading-edge technological innovations and their consequences and implications for health care policy and practice. Mr. Ellis is also a regular contributor to H&HN OnLine.
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