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Forever Young

Is the current crop of new doctors as competent as their elders - or are they more prepared for future challenges?
Doctors perform a liver transplant, April 7, 2003 (file photo: Flash90)
Doctors perform a liver transplant, April 7, 2003 (file photo: Flash90)

Almost every day, I read a series of blogs, some of which regularly express opinions that are very contrary to mine. I think it is very important to be open to new ideas, and to be regularly exposed to people who fundamentally disagree with you. This forces a person to sharpen their arguments and to be extra careful when making any (unsubstantiated) claims.

This blog post is based on the following article called “What can be said about the Generation Y physician?” I have included below, a number of excerpts from this article, and below these excerpts are my comments on the topic, as I posted them as a response to the article.

  • “it is more or less impossible for a medical trainee to digest and retain all that there is to know about their field of interest.”
  • “No longer are we asked to become databases of medical knowledge as much as proficient navigators of an ever-expanding wave of medical discovery.”
  • “equally imperative to our training is learning when and how to use online resources in real-time clinical decision-making – a skill-set relatively unique to our generation.”
  • “Medical education has seen major changes over the last decade. Current resident physicians have their schedules closely monitored and their time-off strictly mandated, leading to shorter shifts and greater frequency of and reliance on the “handoff”: a task that occurs at a shift change when one physician hands over patient care responsibilities to another.”

My response:
It should be clear to everyone that no non- augmented human can initially learn and/or retain all of medical knowledge. This was actually true even 30 years ago when I was a medical student. But clearly today, there is no way to truly know the literature without having IBM Watson scan it for you.

One key problem that the present medical professors are comfortably ignoring is that they are totally inappropriate to be the teachers of the present generation of young doctors. Until recently, medicine was mostly primitive and still limited enough in span, such that a doctor from 300 years ago could have managed just fine 150 years ago. But a surgeon trained 30 years ago, could not exit a time machine and start practicing in a present day OR. He or she would have to be retrained, not only in endoscopic surgery, but also in diagnostics.

Most of the previous generation of physicians, who are most of the professors of today, lack the basic concept of switching between in-human-memory information [i.e. in the doctor’s brain] and ex-cerebro medical information that comes from one’s smart phone, linked to the Internet, linked to remote databases/data analytics/remote consultants and the like. A simple example of this point is multiple senior physicians who literally laughed in my face when I told them of how I used my cell phone for remote review of x-rays. While I never claimed to be a radiologist nor that the quality of the images I was looking at, on my phone’s screen, was sufficiently high to do a primary read, I only encountered a handful of cases [from many thousands], where I felt the need to look at the film on a large screen at full DICOM quality.

Can you really get into a discussion of how best to use Medscape as a medical student, while doing rounds with a physician who is over 50? Is it even appropriate for a medical student to try and remember a medical fact, without double checking it immediately? The professors of today don’t have an answer for that..

The professors of today also cannot assure anyone that their own specialty will not undergo major changes in a few years. Let’s say a medical student or young resident is doing a rotation through radiology. I would personally be very surprised if humans are still reading imaging studies in 30 years from now. By then, I would truly hope that computerized reading would be well-established, after having been proved in multiple studies to be even better than human radiologists’ interpretations. So, how can a present day radiologist advise a student? What will radiology be like in 20 to 30 years? For that matter, what will surgery or any other medical specialty be like in 20 to 30 years?

It is far more likely that physicians of the near future will be working as overseers of staffs of other healthcare providers. I personally believe it is much more likely that nurse practitioners and physician assistants will provide more and more care, with physicians playing the role of quality assurance directors and consultants. Is present-day medical school preparing doctors for this experience? As far as I know, it is not.

The author of the blog post that I’m commenting on, mentions the issue of the “handoff”. The real issue is continuity of care. While there are definitely handoffs during a hospital stay, one of the most critical handoffs happens when the patient is discharged home. This is recognized as a critical point in the recovery of the patient, and it is also recognized today as a serious point of failure for far too many patients. The answer to both in-house and in-community handoffs is to have a personal health record that follows patients everywhere. That personal health record has to have sufficient “smarts” to make sure that the human physicians  do not forget to transfer a medication order, or to make sure that follow-up appointments are ordered.

Linking up the hospital events to the community physician, was not even on the radar when I was training. As a young resident, it was my job to write up the discharge summary of many patients, and this ultimately was the only document that the patient took to their family doctor. That is of course assuming that the patient went to the family doctor after the admission, and that the family doctor really took the time to review the discharge note [assuming it was legible].

Without getting into details, it’s clear to everyone that the old way of doing things failed miserably. So  any young doctor who mimics their predecessors is doing patients a great disservice. And this also has to be recognized by the medical establishment. Doctors have to be trained in a totally different way in how to manage continuity of information and care.

Doctors of today complain that they have effectively no say in the direction that medicine is taking. The only real way to deal with this is to garner the skills to become policymakers. In addition to studying medicine, a physician should have the option to do post graduate training in policy, health economics, health management and so on. I personally believe that only in this way, will doctors continue to have a significant say in how medicine is practiced. Is there any physician who trained 30 years ago, who can advise young doctors about such a path?

I recently worked with a brilliant young physician who did her postgraduate training in medical informatics. Her hands-on clinical training was limited. Is this a bad thing? Or, do we need many more like her in order to make sure that future EMRs are appropriately geared towards the clinical needs of physicians.

The world is changing day by day. And young physicians really have no one to consult with, to help them choose their best path. In fact, following the example of their predecessors and superiors, could hinder young doctors from making the best choices. At the very least, the medical establishment must admit that everyone in the medical world is in uncharted waters. Professors and students alike need to start working together in a very different way than before. Only then is there a chance to gain from the experience of the professors while taking full advantage of present day technologies and reality.

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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