Moving Family Medicine Forward by Embracing Disruption

Many recent conversations in the advancing world of health care delivery have integrated the term "Disruption". At first glance, this is perhaps quite jarring and counter-intuitive to the mind of the forward or progressive thinker. It is ever the more uncomfortable to the medical mind that is trained to carry on in the face of adversity, through exhaustion, and despite resistance. Paradigmatically, the medical world has recently been presented with progress and innovation through abrupt disruption of the modern model.

Much of the context and logistics have been borrowed from the business community, and the Harvard Business school's teaching on "Disruptive Innovation". To bring matters close to home, Clayton Christensen translated the idea directly to the medical community in 2008 with "The Innovator's Prescription - A Disruptive Solution for Health Care". The premise is that for health care to truly move forward, we cannot accept a gradual or trajectory change - we need to replace a broken system.

I think the book is brilliant, and students and physicians alike should at least look at an executive summary, such as this or this. I hope that this would be an appropriate forum to offer considerations as to how the family physician can successfully embrace such "Disruptive Innovation" for the future of health care.

The proposed solution includes discarding the current fee for health care service model, supplementing precision intervention with individualized-care, and facilitating patient-patient coalescence and interaction. Interestingly, a key for Christensen is the expansion of the primary care workforce - but his recommendations promote an increase in mid-level providers. Further, he hints at diminishing the scope of practice of the primary care physician. If there ever was a time for family physicians to wake up, take a deep swig of coffee, and prepare to be leaders riding the wave of change - it is now. Following, are my considerations, tailored to thoughts on how family physicians can integrate into a disruptive discussion.

1) Embrace technological change
Let me be frank - the days of the omniscient and omnipresent family doctor are past. We cannot argue this, because our patients now posses more information in the palm of their hands then we collectively engage during the duration of our training. This is great news! This change empowers us into the role of patient facilitator. We no longer need reside in a world of regurgitator of information - rather we can be an intuitive examiner that arrives on the scene to decipher information and make recommendations. 

In the greater conversation on "disruption" in medicine, this term of "intuition" keeps coming up.  It is a direct outgrowth of advances in technology that allow medicine to become ever more "precise", or "cook-book", if you like. As precision improves, skill, education, and experience become less requisite.  This is simply because we know that if we do X, we can almost certainly guarantee Y.  In contrast to this precision-focus is intuitive medicine; though the two do often work in concert.  Family physicians must continue to position themselves within the world as intuitive investigator - utilizing a unique skill-set that transcends technology and testing.

The next step is not limited to the acceptance of technological advancement - in effect the buying of new computers and electronic medical records.  Rather, it is taking these devices and their near limitless application and allowing the frame-shift to adaptively respond practice and expectation for the next generation of family physicians.

2) Be a "Patient Specialist"
The goals of disruptive change for medicine assume that increasing specialization will necessarily move the profession towards ever increasing division of responsibilities.  We have come quite a long way, already, in the past twenty years in this direction - and some would suggest we need to go further.  I think we must accept this as an inevitable consequence; one that springs from the aforementioned technological complexities thrown into a tornado of rapid turnover in evidence based medicine and treatment preferences. 

Framing family physicians as patient specialists removes the burden of the current trend towards super-specialization and subdividing care.

I suppose this can best be imagined as the focus of the lens one chooses to look at patients for whom they care.  Many physicians deftly employ the magnifying glass, or even a microscope, to analyze the minute and detailed aspect of a patient's condition.  I would like to consider that family physicians know how to pick up a microscope, when needed, but choose to look at the world with the naked eye.  Standing back, from this perspective, the whole patient comes into focus, and the examination extends to family, friends, community, and the long-range, big picture.

The perspective of diabetes, for example, is very different when viewed from that of practice, community, or population health as a whole, then when examining a renogram or even an individual nephron.  The instigating factors, barriers, complications, and burdens can look quite different, depending upon where one is standing.

Change, in any form, necessitates the overcoming of barriers. Altering habits, embracing new information and patterns, and investing time are challenging enough - then we add a price tag to the equation. I believe that much of medicine is based upon expectations - those that we have of ourselves and those that our patients hold. Choosing to ignore or slow play technology, we let our patients down and we cast an antiquated shadow on our practice. We should look to embrace the value of infinite access to information, the internet, and social networking - and allow these to transform both scope and practice. Proactivity, in this regard, is the best medicine - even if some see it as the toughest to swallow.

Newsflash: Medical Students Assist in Medical Care at Teaching Facilities

About a week and a half ago, The Dallas Morning News published an unfortunate case of medical mismanagement, mainly dealing with a lack of oversight from attending physicians over residents and medical students.

"Even students – who have yet to graduate from medical school – provide key care, sometimes without direct supervision....
...(the) surgical consent form had warned that (the patient) could face 'blood vessel or nerve injury' complications. It also noted that students might be involved in (their) 'surgery and surgical care'."

They also released a spin-off article stating that ethicists generally feel that patients around the country are not made aware of medical student involvement in their care.

Many hospital patients don't know who's caring for them at any given moment, said Dr. Lisa Soleymani Lehmann, a Harvard Medical School assistant professor who runs the Center for Bioethics at Brigham and Women's Hospital. Many don't distinguish between residents, who are degreed doctors getting paid, on-the-job training, and students, who are unlicensed and still in medical school.

"There's a tremendous amount of confusion," Lehmann said.

She has surveyed about 200 Boston-area patients who underwent operations in which students participated. Half of the patients didn't even realize that medical students had been in the operating room, she said.

Lehmann said many hospitals' consent forms have improved in recent years and now tell patients that medical students will be "involved" in their care. But patients "don't know what that means," and many don't even read the forms, she added.

Over the past week and a half, I have had an internal struggle about what to write about this event. The specifics of this case are quite tragic and should never happen anywhere. At first I was rather annoyed that the author of the original article happened to release the spin-off right away while generalizing all medical students and implying a general lack of communication around the country. Could the author use such an unfortunate case as a stepping block to create generalized anxiety throughout the nation?

As previously mentioned in my burnout blog post, our medical education is already compromised by a feeling of uneasiness from our attending physicians with their practice of defensive medicine. If we place further restriction on our medical training because of a select number of medical mismanagement cases, will we continue our travel down the slippery slope and overall loss of educational opportunities? Will intern year be the new 3rd and 4th year of medical school? (not to mention the possibility of increasing the number of years of residency!?)

Take a look at AMA Opinion 8.087 - Medical Student Involvement in Patient Care. It basically states that medical students need to be identified and patients need to be disclosed as to how the students will be involved in their care, whether it is in the community health center taking an H&P or simply "driving the camera" in surgery.

After taking some time to settle down and think about my own medical training experiences, I have realized that there are definitely ways to improve communication with all members of the team towards patients.

From attending physicians to medical students, it is quite helpful to know the extent of our involvement, especially in surgery. This is not an easy task, as some attending physicians may provide student opportunities during procedures on the fly at their own discretion. Again, this is a difficult task as there is always a first time for doing something and assessing ability is impossible unless the task actually occurs in real-time.

When is it appropriate to drill a pin into a broken bone? How do we know when a student is ready to suture? Are students more prepared to advance their skills on the last rotation of 4th year or as a resident during the first week of internship?

From attending physicians, residents, and medical students, we all need to communicate better towards patients in regards to our role in patient care. Consent forms that are vague and do not provide specific detail are not adequate for patient satisfaction or overall patient safety. We need to identify ourselves to our patients and not just disclose the side effects of medication or the risk of infection and bleeding, but each of our roles in providing safe and effective care.