The Case for New Physician Literacies in the Digital Age

September 30, 2012

This is the rough narrative of a presentation delivered at Stanford’s Medicine X on September 30, 2012

I’m convinced I was born at just the right time in history.  I was trained as an analog physician but I’m a witness to medicine’s digital transformation.  It’s really a remarkable time to be in medicine.  And one of the key forces behind this transformation is information.  What I’d like to talk about is how information is changing  doctors and how we might begin to react.

The paper in mama’s bag

Not long ago I was treating a boy with ulcerative colitis who developed a complication of UC called sclerosing cholangitis.  This is a condition where there’s autoimmune activity against the duct structures leaving the liver.

During one of his clinic visits the mother brought with her a paper that had just been published on the use of a particular antibiotic for the treatment of sclerosing cholangitis.  It had been found to potentially stall the progression of the condition.  The paper had been under discussion on a patient network and she wanted to know if this was an option for her son.

I looked at the paper and immediately recognized that this was in the latest edition of a journal that happened to be sitting on my desk.  Mom had found the article before I had a chance to read it.

Those of you who read my blog, 33 charts, know that I’ve made a habit out of taking some of my everyday experiences and breaking them down as a means of illustrating how medicine is changing.  I’d like to use this brief encounter as a jumping off point.

Breakdown | Mom beats doc

What can we learn from this?

Physicians no longer control information.  While the idea of a patient bringing new research to her doctor isn’t a new phenomenon, in the broader historical context it’s huge.  For the better part of civilization our role as physician has centered around privileged access to information and knowledge.  But the web has created a type of disintermediation.  The face-to-face encounter with a physician is evolving as a more narrowly defined element in an individual’s quest to understand their condition and get better.  Access to information is the bedrock of the health 2.0 movement.

There’s too much to know.  There was once a time when physicians could get their hands around what they needed to know.  You’d go to the mailbox and pick up that 200 page journal and you were all set.  Not so much anymore.

And honestly, a part of me felt bad.  I’m a pediatric subspecialist – I’m supposed to be on top of this stuff.  But had I read that that paper, there would have been another patient with with a newly released paper.  There’s simply too much to know.

Information will find us.  While we used to be dependent upon search in order to get the information we need, information now finds us through our social networks just as this mother did.  And going forward, information will find us based on our context.  The right information will find us on our smart phones depending upon where we are, what we’re doing, or what clinic we happen to be in.  Social media visionary Shel Israel has suggested the last decade was about conversation, this coming decade will be about context.

We’re facing a crisis of medical knowledge

So this is what we’re up against.  We’re collecting more information and creating knowledge.  David Weinberger from the Berkman Center at Harvard Law School has suggested that information has become the problem rather than the solution and we’re experiencing a crisis of knowledge.  And beyond the volume of information that we now experience, it’s the speed, immediacy, and real-time flow of information that’s different.

Information is inextricably mixed with communication and sociality in a triple helix” — David Weinberger, Too Big to Know

So how have we traditionally dealt with this?  In the past, medicine exerted its old-style of authority by filtering information for us.  Weinberg suggests that knowledge has historically been about reducing access in order to make it more manageable.

  • Medical editors decided what studies we would see.
  • Librarians decided what goes on the shelf.
  • Since 1910, everything doctors needed to know has always fit into 2 preclinical years.
  • What patients knew was limited by what the doctor knew.

But something happened on the way to the clinic.  The Internet democratized information and eliminated the traditional filters that contained medical knowledge.  We suddenly were no longer limited by the space available on library shelves or the memory of a doctor.

But despite this revolution in information, we continue to think and work like doctors from 1957. We see ourselves in a 20th century construct.  And this will continue because medical students continue to learn in a system that assumes we can teach a doctor what they need to know instead of empowering them to access what they need to know.

Of course the availability of new technology to access and share information doesn’t mean that physicians will immediately begin to work and think differently.  Physicians in the 21st century will need new abilities in order to function in a digital environment.

Howard Rheingold in his book Net Smart tells us that 500 years ago the appearance of the printing press didn’t immediately drive the Protestant Reformation.  People first had to learn how to read.

“The interval between the technological advance of print and the social revolutions it triggered was required for literacy to spread”

So today we have the most remarkable technology emerging, but we’re creating doctors who don’t know how to read.

“We’re in a period where the cutting edge of change has moved from the technology to the literacies made possible by the technology”

So what are literacies?

Literacy was once characterized by the ability to read and write.  But in modern vernacular, literacies may be viewed as the broad skill sets needed to function.  Rheingold tells us, “Literacy is skill plus social competency.

Physician literacies have traditionally been founded in an analog world.  Most are centered on silo’d workflows.  As doctors we needed to know how to find information in books and libraries.  Handling paper medical records brought its own skill sets.

While there are many that this group could identify, I thought I would share a few critical literacies for the digital physician:

1.  Network Awareness/Collaboration

Like it or not, we’re no longer alone in this, both in learning and treating.  We need to learn to see ourselves as part of a broader network of collective knowledge.

2.  Input management

Human attention is now the most valuable commodity and balancing information input may represent the greatest challenge of this medical generation.  Clay Shirky has suggested that we’re not facing a problem of too much information, but rather filter failure.

Doctors need to understand their filters and participate in their formation.  Human filtering represents one way to do that.  This is how I use Twitter: I hire a few hundred people to bring me the best information available.  More and more my life is about finding the right signal.

3.  Creation/Translation

I’ve always wondered what it would be like if we could harness the practical knowledge and wisdom of doctors:  Clinical wisdom, procedural pearls, solutions, opinions, unusual patterns, unique cases, hard-learned lessons, and even simple stories.

What if this knowledge could take the form of video, audio, images, or boluses of curated content packaged, tagged and archived so that it’s retrievable by patients and students of the next generation.  That would be remarkable.

What we know and understand should be seen as a gift.  And how we create, translate, and share that for common good using new media should be seen as a literacy.

Is there a moral obligation to create?  I’ve been suggesting for some time that physicians have a moral obligation to create.  But I’m starting to question that.  But when we look at the hierarchy of physician involvement, you see that most doctors watch, some talk, a few curate and the smallest number create.  The real money in leveraging physician power may be in participation through conversation and curation.  Curation can be seen as a type of literacy.

4.  Mindfulness

In a world of distracting digital tools and immediately available information, we have to learn to balance technology with attention to patients.  Medical mindfulness represents a new literacy that must be taught and practiced.  Medical mindfulness requires intent.  And despite how much information or networked knowledge exists, what matters is how we connect it to that single human encounter.  What matters is that between me and that mother, we find the right information that helps both of us make the best decision.  The ultimate interface is human-to-human.

This list of literacies can be discussed, adapted and built.  The point is to begin a conversation.

Medicine’s culture of permission

The common denominator for many of these new literacies is involvement and contribution.  Going forward, the conversion of information into knowledge can only happen in a culture of participation.  Our ability to make change is dependent on our participation.

Instead we are trained in a culture of permission.  Most of us believe that someone else will decide which ideas are worthy of discussion.  Every idea or the creation of an idea is something that needs some kind of validation.  We’re a profession of information isolation.

Information is extending who we are

Machines have already extended and even replaced what we can do with our hands, our eyes and our ears.  Intelligent networks will extend what we do with our minds. Information and how it’s accessed represents an example of our entrée into a new era of posthuman medicine.  We need to begin to think about where we fit into the bigger picture of a knowledge network.

I have to finish with this quote from media visionary, Marshall McLuhan.  What’s more remarkable than the fact that he so clearly envisioned the internet is the fact that he did it in the early 60′s.

In this electric age we see ourselves being translated more and more into the form of information, moving toward the technological extension of consciousness.  — Marshall McLuhan, Understanding Media, 1964

Information will redefine us.  The way we view it, hear about it, access it, store and organize it. How we react to it as a profession will determine where we go.

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{ 12 comments }

Kathy Nieder MD September 30, 2012 at 5:43 pm

Thanks for a good summary of the problems AND solutions to the “Medical Information Age”. Twitter is an amazing tool in helping me to see the broader picture in Social Media both with patients and other physicians as well as bringing my attention to resources I’d never know were available otherwise. But the filter problem is real and difficult. It’s hard to stop watching the feed, you might miss something. Fortunately the really good stuff tends to keep coming around.

Simon Sikorski MD October 1, 2012 at 5:52 am

Great post Bryan. If more doctors focused on the need for creation of content we’d have more need for filtering, there would be more discussions, and more observations. Right now companies put together content and get doctors to be the “curators.”

With physician blogs doctors can have an immense impact on the general population as well as profitability of their practice. There’s an article about it on Physicians Practice Blog – http://bit.ly/QEpvDn

Lois Wingerson October 1, 2012 at 11:57 am

Dr. Vartabedian, I continually find your comments energizing and enlightening. We in medical “publishing” are also moving from the permission culture to the filtering business. We’re indebted to you for so eloquently describing why it is in the interest of physicians to embrace new and unfamiliar ways of sharing information.

Camilo Erazo October 1, 2012 at 1:24 pm

Very insightful as always, Bryan. I will use some of these ideas and examples in an upcoming presentation about virtual communities of practice for Primary Health Care in Chile. Reading this post made me think about the “eHealth literacy” concept (http://www.jmir.org/2006/2/e9/). Do you think it would be also useful to talk about the different type of skills or ‘literacies’ that primary care doctors will need to develop to become effective digital physicians?

Gary Levin MD October 1, 2012 at 4:47 pm

Born just a bit too early, since I retired from clinical practice two years ago The upside is that I can devote just about full time to engagement in social media and consult with practicing physicians to build their online presence, advise about new mobile apps, health inormation technology and also dedicate myself to both patient advocacy and physician advocacy to help build this important bridge.

I am planning a Google Hangout On Air. The video conference will host 10 conferees, and it can be broadcast on YouTube as well as archived. I would very much like to have you on board. I can send you the list of other invitees if you are interested.

As usual Bryan, we seem to hit on the same subjects almost simultaneously.
twitter @glevin1 G+ Gary Levin FB/gmlevin http://healthtrain.blogspot.com

Dr_som October 1, 2012 at 6:43 pm

If physicians are increasingly part of a team who has culpability for medical errors? Where does the responsibility of doctor end and patient/parent begin? For poor accessibility, availability, long waits, delayed diagnosis or treatment? All doctors make mistakes: http://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that.html

Farid A October 2, 2012 at 11:37 am

Dr. Vartabedian, you bring up some great points regarding the logistical issues the medical community is beginning to encounter here in the digital age. What I find particularly interesting is the struggle to harness a thorough understanding of new information that is continuously being made.

As a pre-medical student, I encounter fellow students who do not seem to understand the connection between knowing medical knowledge and practicing medicine. They appear to believe that being a great doctor relies only on their mastery of the medical information. In this new era of inter-connected networks filled with easy-to-access medical information, memorizing information is becoming more and more obsolete. The concept of completely understanding one’s specialty in modern medicine is becoming unfeasible as the rate of new information and knowledge being produced is astronomical. As you say, there is just too much to know. This is in addition to the availability of medical knowledge to everyone, not just doctors. The knowledge gap between doctors and patients, though still significant, has shrunk dramatically. Because of this, the role of medical mindfulness in clinical practice is multiplying.

A doctor’s skill should not be judged solely on the depth of their knowledge, but their ability to interact with patients to achieve the best possible outcome. Practicing medicine depends on fostering a relationship of understanding with patients, and a main aspect of this is involving patients in their own diagnosis. Physicians must hone their ability to translate a patient’s subjective story related to their condition into a medical diagnosis. They must be able to focus in on key aspects of narratives while filtering out unnecessary information.

In order for awareness of narrative medicine to grow, there needs to be a grass-roots campaign starting in medical schools. Up and coming doctors need to be taught to practice medicine in the digital age and no longer be trained as analog physicians. Students must understand the ever-evolving dynamic between technology, social media, and medicine while understanding how both patients’ and doctors’ roles are changing due to these factors in clinical settings. This is a wide-spread cultural change in medicine that will take many years to implement, but it appears as if we are on the right track with the insight of doctors like yourself and those who commented above me.

Julian Hinson October 2, 2012 at 1:53 pm

I just wanted to – re-affirm how correct you are – as a former Emergency medical scribe and current medical student – the disparity between our education and practice (when it comes to things digital) is painfully visible.

Jay Hochman October 3, 2012 at 10:21 am

Great post. I enjoy your blog entries. You look at some areas that have been very tangential to my practice previously and make a good case for better alignment. I think with the advance of information physicians will be needed to help interpret this massive information and act as medical travel guides.

Nadia Ismail October 4, 2012 at 9:09 pm

This was an extremely insightful article and a clear realization of the amount of access that the public has to recent scientific research. You are right; in this day in age, it’s completely unrealistic to try to restrict access to the vast amount of knowledge available to the general public. However, I do believe that some patients and their families need guidance with accurately interpreting the information they find. People should take advantage of the vast resources on the web to learn more about medicine, but should be wary of falsified or exaggerated information. While it is true that many patients have begun to take a more active role in managing their healthcare, some are still at the point where they are not quite sure how to handle the information influx. Current (and future) doctors need to acknowledge that patients have access to this information and need to ensure that the quality of the knowledge and understanding gained from these sources is valid.

As Dr. Sikorski writes above, it is doctors that need to try to be the ones involved in this spread of knowledge. Medical professionals need to help move along the spread of accurate knowledge and can do so through participation via social media. Doctors cannot all assume that someone else will bring a new idea to light; in that viscous cycle, nothing gets done. By playing an active role in social media, as you and many other doctors do, physicians can dispel rumors and increase understanding of medicine among the lay public. The issue is the filtering, rather than the availability of information. It’s extremely helpful to use social networking sites such as Twitter and Facebook to help with this filtering; I, for one, am definitely more likely to read an article linked on a social media site because I feel as though it has been considered somewhat legitimate if one of my friends or followers has recommended it.

But as you mentioned, ultimately it’s the one-on-one personal interaction with a patient that affects everything else. There are those who have an unsurpassed ability to memorize and learn, and there are those who are able to gracefully navigate social media, but if one isn’t able to efficiently communicate with patients face to face, then all other talents are irrelevant. Medicine is about striving to make a human connection with others through healing; this is impossible if doctors and patients can’t even have a conversation. If patients don’t feel comfortable with their doctors, then communication breaks down and patients choose to pursue their own knowledge without guidance.

Peter Cabeceiras October 4, 2012 at 11:52 pm

When you described the “disintermediation” of medical information exchange I thought of my experiences shadowing doctors. I saw residents doing quick internet searches on specific medically-related information. After they searched, they usually ended up getting the information from Wikipedia. I was surprised that medical professionals get some of their facts from the same place I use to look up trivial information. Everyone knows that you don’t need to be “privileged” to read or create the information in Wikipedia. It seems like your blog entry offers strategies to eradicate common problems like this. So, if doctors are to use technology and social networking to upgrade how they obtain necessary and competent sources of information, this leads to the question: what can the patient do?
Since medical information has been “democratized”, or opened to the public, doctors could encourage their patient’s to do some research as well; this way the patient may find useful information (like the mom mentioned in your blog), or they will be better informed and prepared for their upcoming treatment/visit. I’m sure every doctor (who works with patients who are awake) would agree that they have come across a patient whom they wished could more acutely describe their problem. Motivating patients to do their “homework” will create a more stimulating doctor-patient encounter/conversation that will ultimately be more beneficial to the patient.
Doctors who are more technologically “literate” could use the internet to have even more of a presence with their individual patients. Don’t get me wrong; I’m not suggesting that physicians check up on their patients via wall post. Doctors could give their patients the links to reputable websites that they think would be in the patient’s best interest to explore. Maybe the physician could use their iPad or tablet to show the patient pictures or a video clip to help describe something to them. Since the ownership of smart phones in on the rise, the doctor could show a patient how to track their heart rate, or glucose levels with their smart phone. I have even seen a few patients going above and beyond by quantifying their every last action and physiological function with apps and other devices – http://www.latimes.com/entertainment/news/la-ca-lifelogging-20120603,0,4239215.story. When doctors adopt the roles of “digital physician” and social networker, they will be able to harness the power of technology, which will dramatically help physicians and their patients to obtain reliable information.

Alastair Somerville October 15, 2012 at 4:07 am

Coming from the direction of user-driven care, this article is really interesting.

I was writing about need to find a balance between professional, clinical needs and user privacy and control over the weekend. Draft is here on Dropbox. http://db.tt/DplxsObI

I am interested in how it will be our devices that help triangulate the information problem for all

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