In my experience …

All during my training and then throughout my medical practice, I met a
wide variety of physicians with different backgrounds and trained in
different specialties. It was not uncommon that during a discussion
related to the medical status of the patient, that a colleague would
refer to his or her experience in their field of expertise. The purpose of
mentioning their experience was clearly to express a unique type of
knowledge about medicine, something that you don’t get “from the books”.

I once heard a marvelous definition of experience. It went as follows:
experience is the growing level of confidence that a person has in doing
the wrong thing over and over again, as long as there are no serious
negative repercussions. In my own “experience”, I have seen doctors
justify treatments that were diametrically opposed even to the mainstream literature, all based on their personal anecdotal historical observations.

I remember as a junior resident doing rounds with one of the senior
professors in the surgical department. He would regularly regale us with his stories of medical care “in the trenches”. In the case of one patient, he flatly challenged the opinion of the infectious disease specialist, who wrote that the patient likely had a certain type of infection that required a specific aggressive treatment. The senior professor claimed that he would find the same bacteria by simply swabbing his own face (a means of capturing bacteria for testing), implying that the specialist had overcalled the case and thus, the patient did not need further treatment. I was flabbergasted and I commented to a friend but clearly in too loud a voice, that back when the professor was himself a resident, such patients tended to have their legs amputated (as no other options were readily available for severe limb infections). In other words, I basically challenged the value of my chief’s experience and opinion. I still completed my surgical portion of my residency [he didn’t kick me out], but I never forgot that interaction.

I came across an old study from 2005 which evaluated the relationship between clinical experience and the quality of healthcare. The simple question was if extensive experience was a positive or negative in terms of selecting the best care for patients. Please feel free to connect to the link above to read the entire study, but I will include here one of the final
conclusions, namely: “In summary, our results suggest that physicians with more experience may paradoxically be at risk for providing lower-quality care.”

Why would experience be a negative thing? Following this question, one
should now ask what is the best level of experience for a doctor. If a
doctor’s experience is five years post medical school, is that ideal and
better than someone with 20 years of experience?

One of the problems with medical school training is that there is to some
extent the false impression that the foundations of medicine do not
significantly change. For example, once you have learned the anatomy of
the human arm, this will not change during the course of one’s career.
Strictly speaking, a physician from 500 years ago could discuss issues of anatomy with a doctor living today. Contrarily, some fields in medicine
are so frequently updated that what is taught in first year medical school
may very well be found to be untrue by the end of the students’ four year
medical school training.

This basically explains why experience alone is truly ineffective at
supporting a valid and up-to-date medical opinion. It is simply impossible
for the vast majority of physicians to see enough patients with a broad
enough spectrum of disease, during their individual careers, in order to
keep abreast of the most recent literature on ideal management. Put
another way, if a doctor does not constantly read and does not make a daily effort to stay up-to-date in his or her medical knowledge, that doctor will quickly find themselves lagging in their knowledge.

So what are possible solutions? Should doctors never leave medical school? This is obviously impractical. What about emailing doctors up-to-date information and recommendations about medical care? This is actually a very common practice and falls under the definition of CME [continuing medical education]. By reading articles and summaries of new medical advancements, as well as attending various medical conferences on a regular basis, a physician can succeed in keeping his knowledge base timely. This does of course demand a significant investment in time, and in many cases, a doctor is not reimbursed for this extra time.

Another option takes a very different approach to this whole issue. An
electronic medical record can be designed to offer doctors suggestions and direct access to targeted medical information, such that the doctor always has access to the most up-to-date information. For example, imagine a doctor records the diagnosis of diverticulitis [an inflammation of the large bowel]. Then imagine that next to this diagnosis appears a small question mark that the doctor can click on. When clicked on, a pop-up appears with the most up-to-date information on diverticulitis. The doctor can scan through the information and even click on various portions of this pop-up to automatically insert up-to-date recommendations into the medical record [such as clicking on the recommended antibiotics to automatically record them and order them from the pharmacy]. The EMR would also email the same information to the doctor who could then refresh him or herself on this disease, but at their own leisure at home or later in the office. Such a system would require a set of physicians who are constantly scanning the literature in order to find significant changes in present protocols. Any changes would immediately be added to the pop-up. This type of targeted real-time educational material is in fact very effective. But as one sees, you still need a human physician on the backend to constantly be updating the information.

In comes Doctor Watson who has a photographic memory and an astonishing ability to link together various journal articles and even nonmedical publications, in order to find any connection that would enhance medical care. Doctor Watson is a computer system which is based on a newer type of artificial intelligence that allows Watson to understand huge libraries of written material and then to generate the correct answers to questions that include very subtle language. Watson proved itself by beating the previously crowned top two Jeopardy TV-game-show winners in a no holds barred real life competition. It really was astonishing and somewhat scary to watch.

In the course of the next 30 to 50 years, Doctor Watson’s capabilities will grow by a factor of a million to a billion times more than they are now. I don’t think anyone can legitimately predict what this will mean. Perhaps, with so much computer power behind it, Doctor Watson will manifest what is, for all intents and purposes, thought processes that are indistinguishable from its human creators. Thus Watson will be able to read, retain and apply all of medical knowledge available at any given point of time.

Technology such as Doctor Watson will effectively force the medical world to focus on evidence-based care. If there is even a single research paper on a particular disease, Doctor Watson will know about it and will be able to score it in terms of likelihood of being medically accurate. At the very least, this kind of information will be presented to the doctor who
will then be much less inclined to base care solely on personal experience. Of course, in cases where there is a vast amount of research on and evidence for the best treatment for a given disease, the computer may even block a physician from choosing a care plan that is without foundation in medical research. In summary, doctors will face intrusive technologies that effectively nullify their personal experience. But before anybody mourns the loss of this personal touch of their physicians, please realize that Doctor Watson will offer the most informed care, even if this is based on relatively little information. And when all is said and done, this is the best that the medical community can offer.

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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