Adjunct Clinical Professor Medicine/Cardiology University of Arkansas for Medical Sciences and Clinical Professor Medicine St. Louis University Medical School USA.
Professor, Resident in Internal Medicine Dartmouth-Hitchcock Medical School, USA.
In the last half a century, unprecedented cardiovascular progress has occurred. With advances ranging from the human genome project to heart transplantation, cardiovascular medicine has seen tremendous growth throughout the spectrum of both basic research and clinical practice. At the current pace, more exciting advances such as prophylactic cardiovascular vaccines, genetic and stem cell treatments may soon be realised. Unfortunately, there are still serious infrastructural pitfalls in the coordination, communication and the delivery of medical care to patients. With prompt and effective digital communication, a well-coordinated and comprehensive medical care could be offered to patients. This approach would mitigate medical errors and duplication of medical testing and treatment saving lives and money. Furthermore, efficiency of care could be significantly improved.
Rapid transmission of patient information and treatment strategies are critical to optimal disease management. To assure consistent excellence of cardiovascular care, a well-informed team approach is needed. The team members need to believe in ongoing medical education. Unfortunately, antiquated medical education systems exist in many parts of the world.
Medical education at all levels must undergo a significant change. We cannot expect to demand excellence from our peers when we are not given the tools or any formal training on how to effectively teach them critical information needed to practice medicine.
Perhaps one of the reasons we failed to develop a consistent, evidence-based model of medical education is that we consider mastery of didactic knowledge as “adequate.” However, the rapid change of medical information makes this type of “memorisation-recall” focused education model increasingly futile as the growing fund of medical knowledge grossly outweighs any one individual’s ability to successfully recall it. Current guidelines for recertification and CME are consistent with this idea. Instead, we should focus on giving physicians the skills to enable them to seek out and integrate new medical data as needed. Furthermore, and perhaps more importantly, there is a large subset of knowledge that is neither formally taught nor found in medical textbooks. This is “experiential knowledge,” how to survive and thrive in the medical environment, how to anticipate problems, make tough medical decisions based on scanty data, etc. We sometimes refer to these as medical “pearls” of wisdom. Anyone who has made the transition from medical school to graduate medical training can attest to how important this type of information can be to successful patient care. Some of this knowledge can only be learned through experience, through trial and error; however, a significant portion is learned by emulating our peers and superiors. This knowledge is essential to the practice of efficacious medicine and is just as valuable as factual knowledge. While we have a plethora of electronic references that can provide easily synthesised factual information there are virtually no central clearing houses of this experiential, “how to practice” class of information. By leveraging the power of the internet and social networking, the creation of digital resources that enable physicians to share this type of information could prove to be a very powerful tool towards preparing physicians to practice more efficient and safe medicine.
With the prompt availability of recent developments and techniques via electronic media, prompt diagnosis and treatment of cardiovascular problems are expected in 2007. It is puzzling that the cardiovascular field has not fully utilised the power of networked technology and simulation to facilitate medical training as fully as other industries such as the aerospace industry. Practice simulations have long been shown to increase efficiency, decrease response time and improve decision making in various settings including ones that require urgent decision-making.
With physical distance no longer a limiting factor and intensive graphical and computing availability to the general public, the use of simulation software/hardware or other complex tasks such as surgery, ACLS, cardiac catheterisation, bronchoscopy, etc. could be simulated by teams of physicians working together connected via internet. This would enable practice and learning of new techniques as well as the ability to simulate problems and complications periprocedure or intraprocedure without any real world consequences to a patient.
For surgical procedures this would act as an additional, effective learning step placed between reviewing a text book one day, and expecting to perform in the OR during the procedure the next day. While several rudimentary simulation packages are currently in use, especially for endoscopic technique, CPR and central venous access, this technology has incredible room to grow before it reaches its full potential as a ubiquitous medical training tool.
Multidisciplinary education is also an underutilised methodology for medical education. Physicians spend a significant portion of their lives working along side other medical professionals whom they’ve never met, know nothing about, and are totally unfamiliar with in terms of the extent of their education. In light of this fact the physician workplace demands a seamless integration with nurses, clinical researchers, pharmacy etc. Working with or learning about ancillary medical staff, even briefly, during the process of medical education may increase long-term efficiency in the physician workplace. Medical schools are at the beginning stages of incorporating this type of interdisciplinary education, at least on a small scale. And, there are several examples of organised multidisciplinary cooperation within specific hospital environments i.e. intensive care units.
Another shifting pattern of practice is becoming evident with the development of growing demographics of the patients who utilise various public databases of medical information to learn about their illnesses. This presents a very challenging situation to physicians, as our role must evolve to educate and reconcile often inaccurate and incomplete medical information that is often gleaned from unreliable sources from the Internet.
Information can also flow the other direction, from doctor to patient as we have the potential to leverage technology in order to facilitate patient teaching; this information, in the form of interactive displays, distributable computer programs, or interactive simulations, can act as supplementary material to face-to-face doctor-patient discussion. This promises to keep doctor-patient encounters more informative for patients.
Top-notch healthcare will always critically depend upon an organised, efficient system of communication between physicians, ancillary medical professionals and patients. Unfortunately, the mostly outdated means of technology currently used by the healthcare industry; phone, fax, etc., results in a haphazard array of communication styles that are inadequate to handle the workload of a modern healthcare workplace. There is no centrally accessible database or platform for physicians in the United States to collaborate or communicate with each other let alone with their patients. This problem commonly manifests, with respect to doctor-patient interaction, with the “lost to follow up” phenomenon and has shown to result in non-trivial mortality and morbidity. Collaboration is not only essential to medical practice, it is in fact intrinsic to it.
Medical care delivery depends upon the combined efforts and analysis of multiple medical specialities; it would not be unreasonable to see the development of an internet based solutions to foster this collaboration by networking physicians; giving them a consistent and unified platform to communicate and share data. An internet based network that connects physicians opens doors to a staggering number of possibilities for teaching physicians and patients, collaboration, consultation, research and healthcare delivery. The ability to remotely view diagnostic data, in radiology for example, are changing the system of healthcare delivery within that field. We can expect to see similar changes to other medical specialties where diagnostic data can be acquired and sent for analysis at remote locations via the internet (i.e. echocardiography, cardiac catheterisation, CT angiograms, EKG, EEG, colonoscopy, etc.).
Tele-medicine could easily be integrated into such a platform. Although current tele-medicine initiatives are being used to showcase specific procedures or to treat underserved areas in fields such as radiology and dermatology, these tools are still relatively in their infancy, the future holds tremendous potential for these platforms to evolve for real time healthcare delivery and teaching. Imagine surgeons at several different locations working together on a case using robotic surgical technology, or, routine on-demand video conferencing and consultation from an underserved clinic to medical specialists at larger academic centres.
As such a system grows, it could potentially foster patient-doctor, as well as doctor-doctor communication. One powerful result would be the ability to facilitate patient triage by enabling the acquisition of vital data or hemodynamic parameters from home for a patient with a pacemaker or special monitoring device, possibly given to patients with advanced illness, thereby helping to decide whether they will require hospital admission or an adjustment of their medication. This technology exists in very early phases; patient’s can already have their pacemakers interrogated over the phone.
Several studies have examined the use of internet based monitoring for children with asthma. The hardware necessary for this type of monitoring is in development, “smart” clothing, apparel containing embedded sensors that can measure vital signs and transmit them to a remote site has already reached the marketplace. With respect to electronic networking, precedents already exist outside the medical field in the form of various “social networking sites” which currently serve not only entertainment purposes but also to foster important communication between contacts as well as facilitating the formation of new contacts. The medical community could readily adapt this existing technology to at least create the initial version of a physician network, thereby bringing social networking to physicians. At the time of this writing several companies are bringing such networks to market. For example, in a given geographic area of practice, all the participating healthcare professionals can sign in to a secure medical intranet.
The patients in the system are provided with modern tools to appropriately communicate with their healthcare. All the relevant information of these patients including history and physical examination as well as laboratory information should automatically be sent to that intranet and the concerned healthcare professionals should be able access this through a secure site on their hand held digital device and laptop. If they desire, healthcare providers may be alerted through their hand held or their digital beepers.
Sick patients admitted to cardiac ICU may be fitted with sensor laden health vests so that cardiac ultrasound, ECG, oxygen saturation and hemodynamic information could be transmitted to the nurses station or other monitoring stations via wireless (Wi-FI, blue tooth etc) technology. This information could be fed into a pre-programmed computer (a computer programmed with protocols, diagnostic and therapeutic information gleaned on line through world’s latest literature). This computer would have artificial intelligence and together with the information provided as described above, will come up promptly with the most appropriate care plan for the patient and this plan could be further altered by the patient’s physician as deemed necessary.
With the development of comprehensive medical records, there is no doubt that they will become the dominant platform for medical documentation and communication in the future. Current systems, however, can vary in their power and ability to facilitate efficiency in the workplace. In the near future, we can expect continuing refinements to these systems that actually result in time savings, reduced redundancy of documentation and improved patient care.
A great deal of research has been performed over the least 20 years detailing the magnitude of medical errors in the United States. As physician-patient load, clinical responsibility and patient expectations of physician performance continue to increase, medical errors will continue to be a topic at the forefront of any conversation. In depth analyses of these adverse medical events always reveal a very complex sequence of events that eventually lead to a bad outcome. Clearly, current attitudes toward medical adverse events must change; a focus on systems-based thinking and analysis of events that lead to medical errors could result in the streamlining of complex medical systems, increased usability of current medical technology by improving human-machine interaction, and finding new roles for technology to act as decision support and fail safes within the medical environment. The potential to take “humans out of the loop” for data gathering and pharmaceutical drug delivery has the potential to reduce human error in these areas that could directly result in a significant decrease in patient harm. For example, some electronic medical record systems and decision support systems already warn practitioners of potential adverse drug combinations or wrong doses.
We currently know that the efficacy of different medications depends upon an individuals metabolic polymorphisms as determined by his/her genes. In some cases, whole drug classes work better within certain ethnic populations for e.g., calcium channel blockers and African Americans with hypertension. The ability to custom-tailor specific drugs to patients with specific metabolic patterns could greatly increase the efficacy of our treatment regimes. Future decision support systems could utilise this data by recommending the most efficacious and appropriate class of medicine for a specific patient.
The recurring theme of advances and new paradigms within the context of medical communication and education, as well as diagnostic and therapeutic clinical medicine, is the efficacious use of technology. Effective healthcare delivery and prompt medical decision-making depend upon an ever-increasing burden of both objective and subjective patient data.
Traditionally, the burden of collecting this data has fallen primarily upon physicians. However, with efficient use of information technology to collect and collate data such as history and physical examination lab data, results of studies, and by using non-invasive monitoring, remote monitoring, and decision support tools, we can free our time to focus on problem solving and analysis, rather than information collection, thereby potentially increasing our diagnostic and therapeutic acumen. For this to occur, however, requires a fundamental shift in our attitudes toward the role of technology in medicine. We must assuage fears of technology replacing the human touch, physician experience, or the ability to diagnose and form therapeutic plans for patients. This evolving role of technology in decision support and information collection areas of medicine will represent one of the greatest paradigm shifts in the medicine.