While most of us fail to see it, but doctors are changing.  We’re changing as a result of the social and technological innovation.  In 2050 what we do and how we do it will be very different from what we did at the turn of the century.   We’re evolving from analog to digital. I think it’s important to consider the ‘digital physician’ as a concept worthy of attention.  The training and support of this emerging prototype has to meet its different needs and workflows. Perhaps the criteria by which we choose medical students should take into consideration the anticipated skill sets and demands of this next generation.  And we need hard information about the digital physician and her habits.

Here are some differences between the digital and analog physician:

The digital physician

1. Information consumption is web-based
2. Rarely uses a pen.  Care and correspondence is conducted through an EMR.
3. Socially connected.  Comfortable with real time dialog at least on a peer-to-peer level.  Recognizes the inevitable role of synchronous digital dialog between doctor and patient.
4. E-patient centric.  Recognizes the sovereignty of the patient and recognizes their access to information as a critical asset to care.
5. Mobile dependent.  Sees the ability to provide patient care as dependent upon a smart phone or tablet.
6. Uses digital tools to control inputs.  Has web-based mechanisms in place to help curate information and other inputs from various sources.

The analog physician

1. Consumes information through paper books and journals.  Often overheard saying curious things like, “I like the smell of paper” or “I’ve gotta be able to hold it.”
2. Still use paper charts.  While she may interface with computers, her care is coordinated and facilitate via the manual exchange of ink on pulp.  Illegible prescriptions are seen as a badge of honor.
3. Has little to no social presence.  Either doesn’t understand the value of engagement or is driven by fear.  Sees no obligation to participate in social dialog or content creation.
4. Physician centric.  Sees physician as the core provider of information.  Care delivery centered as much on the needs and demands of the physician as the patient.
5. Smart phone has no real role in her provision of care.  Even the simplest point of care queries are done through dog-eared manuals kicking around the work area.  May be overheard lamenting AT&T’s discontinued support the Motorola StarTac.
6. Core inputs are snail mail box and email.  Can be heard giggling, “If it’s not in my ‘in box’ I’ll never see it.”

This transition is happening to very slowly and most of us remain analog doctors in a digital world.  But that won’t last.  The natives are arriving.  In July I met my first intern who had never worked in a paper chart. Are you digital or analog?  What else defines the digital physician?

 

Can we teach empathy to the next generation of physicians?  The University of South Florida Health thinks so and they’re putting it on the line this week with the launch of the SELECT program, a new curriculum intended to “put empathy, communication and creativity back into doctoring.”

The SELECT (Scholarly Excellence. Leadership Experiences. Collaborative Training.) program will offer 19 select students unique training in leadership development as well as the scholarly tools needed to become physician leaders and catalysts for change. During their first week on campus, instead of the old-style medical school tradition of heading to the gross anatomy lab, SELECT students are immersed in leadership training centered in empathy and other core principles of patient-centered care.

The hope is that this program will prepare the next generation of departmental chairmen, CMOs and physician thought leaders through more intense, non-traditional preparation.

Students will spend two years studying at USF Health, followed by two years of clinical training at USF Health’s partner in SELECT, the Lehigh Valley Health Network in Allentown, PA, to complete their MD degree.  Lehigh Valley was chosen for its unique culture that supports the vision of the SELECT program.

The selection of the students for this program is interesting.  USF Health worked with the Teleos Leadership Institute to utilize an in-depth interview process to assess emotional intelligence.  Founded by two best-selling authors and scholars from the Wharton School of Finance at the University of Pennsylvania, Teleos focuses on finding how leaders can improve organizational outcomes through emotionally resonant leadership.

(Perhaps we should screen all medical school applicants this way.)

While it will be interesting to see where this goes, it wasn’t exactly clear how the program plans to prepare its future docs for health 2.0.  Recognition of the exploding role of diagnostic and predictive technology in clinical care, evolving communication platforms, self-quantification and the realities of the empowered patient represent glaring elements that will define our next generation of providers.

Yet in a medical education system mired in the last century I think that any effort to move the chains forward should be recognized.  I suspect that over the coming generation as technology pulls us further from our patients we’ll find ourselves exploring the unique value that we bring to our patients.  And empathy is always a good place to start.

 

It’s the age of medical disconnect.

The disconnect describes the emotional and intellectual detachment that physicians feel from their patients and patients from their doctors.  This disconnect is the result of a confluence of factors, some from within the profession itself, others are more broadly social and economic.

To understand the disconnect you need look no further than your neighbor or your parents.  Dissatisfaction is evolving as the norm.  Patients feel increasingly marginalized in their experiences with physicians.  Shrinking length of visits, indifferent attitudes, poorly coordinated evaluations, difficulty obtaining test results, an institutional feel to the patient experience, and the overall sense of not feeling at all important.

The truth is that many of us are really not aware of the disconnect. Most of us have been born into a system of dysfunctional provider relationships and we know nothing else.  As physicians we’ve been trained to be detached.  As patients we’ve been conditioned to live happily detached.

Of course there are plenty of physicians who defy the trend to be removed from their patients.  And we hear about them but more in the context of an anomaly.  It’s as if people are shocked when a physician makes a remarkable connection.  It’s newsworthy.  This is indicative of the disconnect.

As a physician I have had the experience of seeing health care at the cusp of two generations.  I’ve watched it unfold.  I’ve watched the dialog in the ‘social space’.  This is vernacular for the web based spots where people gather to talk about their diseases, doctors, and dissatisfaction.  They’re taking matters into their own hands.  I’ve listened.  I have participated, but as much out of selfish curiosity as anything else.

Doctors and patients are in the process of radical redefinition.  While most of us don’t see it, our roles in the next generation will be unrecognizable to what we understand today.  Most of us have our noses to the ground just looking to survive another day.  But if you step away from the canvas a bigger picture begins to emerge.

It’s an amazing time to be in medicine.  I consider it a gift to witness the disconnect.

 

This post from Kelly Young on Howard Luks’ blog asks when patients cross the line with respect to their own advocacy.  It’s worth a peek.

The question of boundaries between doctor and patient is interesting.  All of my patients are empowered in some way.  The extent and level of that empowerment is personal.  On our own there are few lines and little with respect to boundaries.  We have effectively unlimited access to information and resources.  And how far we go to look after ourselves and our kids has few limits.

But when we enter into a relationship with a provider, we’re no longer alone.  It’s unreasonable for a provider to tell a patient exactly how it will be.  It’s unreasonable for a patient to tell a provider exactly how it will be.  Every great doctor-patient relationship is unique and lines that define that partnership need to be identified.  In this context both providers and patients can cross a line that makes the relationship ineffective.  And in this case the other party needs to decide whether the relationship works.

In our working relationships with patients we need to draw lines that define our role.  Good fences, after all, make good neighbors.

 

I evaluated a 7-year-old girl with abdominal pain last week.  When I entered the room I noticed that she was wearing a High School Musical t-shirt.

That’s, of course, where I started.

During the first couple of minutes in the room she learned that I have a daughter about her age, I’ve seen High School Musical at least a dozen times, and I know most of the songs by heart (I even hummed a few bars).  The discussion segued into dialog with the parents about the Disney Channel.  They learned about my disdain for its irreverent characters.

None of this was calculated.  It’s just the two-minute drill that transpires during the early stages of a relationship.  It’s a critical first step in establishing trust.  The relationship between a provider and patient is, in many ways, just like any other relationship.

Perhaps most importantly our brief repartee told the child that I understand her.  It told the family about my values with respect to parent-child relationships.  It reflected that I understand how very important a t-shirt can be to a 7-year-old girl.  All critical first steps for helping to facilitate an open dialog.

A good doctor, like a great salesman, understands that making the connection is a critical first step in the ultimate goal of closing.

 

This week I lost one of my patients, Cooper. He was a feisty 4-year-old with mitochondrial depletion syndrome.  I began looking after him as an infant when he wouldn’t stop screaming.  I saw him through surgeries, diagnostic rabbit trails, and ultimately helped with the painful decision to undergo small bowel transplantation.  Inexplicable symptoms and strange complications defined his short life.  While he spent his final days in considerable pain, his lucid moments were spent throwing marshmallows at his siblings.  It sort of encapsulates who he was.  Great spirit.

Independent of the circumstances, a child’s death is always brutally difficult to process.  It’s counterintuitive.  And facing Cooper’s parents for the first time after his passing was strangely difficult for me.  When he was alive I always had a plan.  Every sign, symptom, and problem had a systematic approach.  But when faced with the most inconceivable process, I found myself awkwardly at odds with how to handle the dialog.  In a hospital my calculated clinical role has a way of sheltering me from a parent’s reality.  At a funeral it’s different.

Patients like Cooper offer the most unusual landscape for thinking.  They force us to look at what we’ve done and more importantly what we failed to do. At Cooper’s memorial service yesterday, Father Gerald Sevick‘s quote of Isaiah 11:16 was timely for me: And a child will lead them.  These children teach us.  And when you look at these experiences in just the right way, they represent a unique gift.

Disney interviewed me in 2007 in a feature piece on colic.  Pictured above with his mother Sarah, Coop was one of our models.

 

How comfortable are we with uncertainty?  I struggle with this question every day.  I treat children with abdominal pain.  Some of these children suffer with crohns disease, eosinophilic esophagitis, and other serious problems.  Some children struggle with abdominal pain from anxiety or social concerns.  I see all kinds.

But kids are tricky and sometimes I can’t pinpoint the problem.  Trudging forward with more testing is often the simplest option since it involves little thinking.  And some parents perceive endless testing as ‘thorough.’

The question ultimately becomes:  When do we stop?  Once we’ve taken a sensible first approach to a child’s problem and judged that the likelihood of serious pathology is slim, when and how do we suggest that we wait before going any further?  This requires the most sensitive negotiation.  It’s about finding a way to make a family comfortable despite the absence of absolute certainty.  This is easier said than done.  Parents can unintentionally advocate for themselves and their worries by insisting on the full court press.  Alternatively they may refuse invasive studies when absolutely indicated.

All of this is for good reason: You can’t be objective with your own kids.

Pediatrics is tricky business and managing parental uncertainty is perhaps my biggest preoccupation.  As I’ve suggested before, sometimes convincing a family to do less represents the most challenging approach.

Image: iStockPhoto

 

This week a reporter cornered me on the issue of professional behavior in the social space.  How is it defined?  I didn’t have an answer.  But it’s something that I think about.

Perhaps there isn’t much to think about.  As a ‘representative’ of my hospital and a physician to the children in my community, how I behave in public isn’t any different than a decade ago.  Social media is just another public space.  Sometimes it’s easy to forget that we’re in public.  When I’m wrapped up in a Twitter thread it’s easy to forget that the world is watching.  But the solution is simple: always remember that the world is watching.

On Twitter I think and behave as I do in public:  Very much myself but considerate of those around me.  I always think about how I might be perceived.

Here’s a better question, online or off:  What is professional behavior?  I have a pediatrician friend who, along with the rest of his staff, wears polo shirts and khaki shorts in the summer.  The kids love it.  One of my buttoned-down colleagues suggested that this type of dress is ‘unprofessional.’  Or take a handful of physicians and ask them to review a year of 33 charts posts and my Twitter feed.  I can assure you that some will identify elements that they find ‘unprofessional.’  I believe I keep things above board.

This is all so subjective.

The reporter was also interested in how I separate my professional and personal identities in the online space.  I’m not sure the two can be properly divided.  The line is increasingly smudged.  I try to keep Facebook as something of a personal space.  I think it was Charlene Li who suggested that she only friends people she knows well enough to have over for dinner.  That’s evolving as my rule as well.  But independent of how I define ‘well enough,’ Facebook is still a public space.  My comments and photos can be copied to just about anywhere.

Social media has not forced the need for new standards of physician conduct.  We just need to be smarter than we were before.  Everyone’s watching.

 

Recently I spent some time watching videos of surgeon David Samadi and the Da Vinci robotic operating sytem.  I began thinking about doctors and automation.

I wondered what part of me will be replaced by  artificial intelligence?  I suspect that much of what I do will be done more efficiently by machine.

Then I thought about last week’s post on how I structure a patient visit.  The process of data collection – hypothesis – data collection – repeat.  Can this be performed by a machine?  Of course, and probably quite well.

The hang-up is with the relational part of what I do.  Understanding a parent’s hidden agenda, watching a child’s face during the abdominal exam, observing the non-verbal dialog between a mom and daughter during the history, hearing their experience and, most importantly, processing all of it in a way that fixes a child or helps a mother better understand her child.  Perhaps the most important issue that I negotiate with parents: what level of uncertainty can we live with?  How far will we go with the technology we have?

Heady stuff.  Especially for a robot.

But I bring a chauvinistic, human bias to all this.  None of us understand the ultimate capacity of artificial intelligence.  A lot of what I do can be replaced.  But not all of it.

 

If you visit my clinic, I follow a structured process during the the encounter.  It’s fairly traditional but has some hidden twists that I think are worth thinking about.

Introduction (provider directed).  During the first few minutes I try to connect and find some type of common ground with the child and parents.  Basic, human stuff.

Landscape of the encounter (provider directed).  I always outline the course of the visit.  Kids want to know what’s going to happen – it puts them at ease.  Parents like hearing that their problem is going to be handled systematically.  I discuss the sequence of history, exam and discussion at the whiteboard.  I remind the parents that I’ll be typing at my EMR during my history and that I will likely have periods where my eye contact is with the screen.

Why are you here (patient directed).  This is a subjective element of the history where the family leads off.  They share why they’re here.  For families accustomed to only 5 minutes with a doctor there can be a tendency to ‘dump’ their history.  A pressured, rapid-fire summary of their story.  If I hear this happening or once I feel they’ve shared the core reason for the visit I’ll ask permission to lead into some specific questions about their complaint.  For patients unclear as to what to say and how much to say, this suggestion is typically taken with relief.  The burden of properly packaging a story can be significant for a nervous mom.

History (provider directed).  I take a fairly focused approach to this part of the visit.  This is where I learn the where, when, why, how of the complaint.  For a child with abdominal pain I may ask as many as 50 questions.  With each answer I create hypotheses that I test with follow-up questions.  This gives me the critical information I need to help understand their problem.  In my line of work, this is where the money’s at.  I finish by asking ‘That was alot of questions…Is there anything that I failed to ask you about that I need to know?”

The patient’s opinion (patient directed).  After I feel like I’ve collected the required objective information I turn the mike over to the family by asking an open-ended question that help me understand their thoughts about the problem.  Depending on the case, I might ask what they understand about what’s happening.  I ask their opinion of the problem – their hypothesis.  Sometimes it’s helpful to find out what worries the parents most.  These questions offer powerful information regarding the patient’s perspective.  It can reveal what’s been called ‘the hidden agenda.’  This dialog usually happens naturally as I’m washing my hands and starting the physical.

Physical Exam (provider directed).  This the touchy feely part that speaks for itself.

Assessment and plan (mutually directed).  I start at the whiteboard with a concise bullet list of key symptoms followed by a discussion of potential issues that could be behind the child’s problem.  I recommend a course of action and we discuss.  A lot of what I do and when I do it is subject to negotiation with a family.

As you can see, I think of two ‘modes’ of direction during the course of the visit:  1) my collection of objective information and 2) the patient’s subjective perspective on their issue.  Both are important and offer balanced control.  But when I’m collecting my information I do it in a methodical, focused way.  When the family is opening up to something it’s their time.  I like to keep the two compartmentalized.  It’s my process.

It’s important that we teach the next generation to think critically about their time with patients.  What I see are young physicians who fail to conduct interviews but rather follow the flow of a patient encounter in a disorganized, meandering way.  “I couldn’t get a word in,” I hear.  “The mother wouldn’t stop talking.”  They seem hesitant to assert themselves.  This leads to an inefficient use of time for both the patient and the provider.

While we fantasize that time is an unlimited resource when it comes to a patient’s needs, reality dictates that time is a resource that must be allocated.

A medical interview needs leadership.  It needs a conductor.