The Art of Medicine – Shifting the Paradigm

“Any intelligent fool can make things bigger and more complex. It takes genius and a lot of courage to move in opposite direction.” – Albert Einstein

The problem with many is not that they’re ignorant, it’s just that they know so much that isn’t so and haven’t experienced a new and better way of working.

For many years, I was like a prisoner. Blindfolded. Restrained. Blindly following the prevailing dogma of how a physician should act, what a physician should carry and how a physician should study. In time, I have had a breakthrough. An epiphany. It has become clear to me that one of our the greatest hindrances is that of uninspired knowledge, that of an approach solidly grounded in a pre-data driven era. An approach with a basis in pride.

Pride is a weapon. Pride pushes people in a direction, to act for good or to act for self-interest. Who would not feel good when prompted on rounds by an off-the-wall question to be able to respond correctly? It serves self-esteem. It serves ego. It serves pride. However, we must not forget that pride can also push us in the wrong direction. For every 10 things known, there are likely a dozen or more other things not known and in that fact lies the humility that must remain at all times with even the best physicians.

Today, it seems to me fortunate that my life has allowed me to have such early interactions with science, such interest in the applications of technology and such forward-centric views on society. Time after time, in study and in work, I was always struck with the same question when seeing how something was done: is this really the best way? The more I thought about each situation, the more my question began to transform itself into more questions: Is there a better way? Can we define a best way? How do we persuade and drive to change?

For those of you who haven’t heard about some of the exciting developments on the cutting edge of health care, let me introduce you to the field of mobile medicine, or mHealth. mHealth is still in its early stages, but developing rapidly. In the presence of smartphones, health care may soon become more “citizen-centered” meaning that treatments can be tailored to individual patients, who can then access health information, consult with physicians, and manage their own prevention through a range of smartphone apps. However, real future growth will be in physician-centered apps for the iPad, iPhone and Droid devices. Currently, these include data entry, reference, and decision aids (see Part 1 and Part 2 of my medical software review for some examples). Some apps even aid in remote care — doctors can send photos to a consulting center and receive treatment advice, while others guide doctors through protocol.

As an example, Phoenix’s Mayo Clinic is one of the few hospitals currently wired for mHealth. Current estimates are that only one or two percent of hospitals are wired for mHealth. The Mayo Clinic has even released a couple of its own iPhone apps, and experts note that some doctors and patients use pill reminders and residents use medical reference apps. There are even direct implications for telemedicine — basically, practicing medicine through video chats — with devices such as the iPad and the new, high resolution iPhone 4.

So where does this leave us? We are left with two possible outcomes: American medical education will either embrace technology-integration from day 1 or it will fall needlessly behind the rest of the world as developed countries learn to develop, implement and integrate mHealth. We need great vision, leadership determined to transform our approach into something special, something uniquely our own, something truly world class for which America will be admired and to which the rest of the world will aspire.

Now is the time we must cease our outdated ways of thinking. We must have the courage to abandon past practices and embrace a new dawn in ideas and a new paradigm in judgment, including the real-time integration of electronic reference into daily practice and training. The problem with many is not that they’re ignorant, it’s just that they know so much that isn’t so and haven’t experienced a new and better way of working.

For those that doubt my vision, let me relate a story. Just recently, I experienced this problem first-hand. I was in a discussion with a physician who confused one heart condition with another. The details are not important, but I was asked several questions to which I responded correctly yet I was told I was wrong. Had quick electronic reference been an acceptable practice, I could have easily shown my colleague that I was in fact correct. In this discussion, minor in the grand scheme of things, the only likely casualty was a continued misunderstanding of treatment. On the floors, however, the casualty could have been a person’s life.

I will also relate a second story, this time as a demonstration of the inefficiency of conventional thinking. Recently, I was sitting in a conference room with a number of doctors who were discussing clinical cases. The question arose, “What are the components of Ranson’s criteria?” Think about this carefully. The question was not “When do you use Ranson’s criteria?” or “What are the drawbacks of Ranson’s criteria?” but rather what are the components of it. The question led to a short discussion with people throwing out values and saying “I think it’s this…”. Before the meeting’s leader could even reiterate the question, I already had the criteria on display on my device along with the mortality statistics. This is the type of mindless trivia from which we must free ourselves. The indications for use and the drawbacks of use are certainly worthwhile knowledge but the actual calculation and memorization of the criteria’s specifics and statistics, which are likely to change over time, are best left to that which works most efficiently: technology. All the while during this discussion, I could not help but marvel at how far we likely still have to go to raise consciousness and to raise the state of our ideas.

In addition to raising the level of our consciousness and ideas, we must also raise our level of ability. Overwhelming evidence shows that the most effective prevention and treatment for chronic diseases such as heart disease and diabetes is what we eat, how much we exercise, how we handle stress, and our social connections. These factors are often referred to collectively as “lifestyle medicine.” Lifestyle medicine is not just about preventing chronic diseases but also about treating them. It is often more effective and less expensive than relying exclusively on drugs and surgery. Far too often we focus on treating the symptoms like hypertension or high cholesterol and not the cause of those symptoms, much to the detriment of our patients and our nation.

Our focus must be to shift medicine away from drug and surgery-driven reimbursement and toward total management wherein physicians are rewarded for and thus given incentive to provide total care. Combine this with data-driven ideas and mHealth and we have the recipe for continual, sustained improvement in our population and the lowering of healthcare-related costs on a national scale.

If I am wrong, I will cease my practices and adhere to the prevailing dogma.

But I am not wrong.

I am absolutely convinced that I am correct, that I have managed to see past current practices to the dawning of a new era and the synthesis of a new way of thinking. We need but let new ideas shape the field to approach medicine in a more intelligent and comprehensive manner.

To pursue anything less will be a disservice to our profession and to our patients.

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