This piece, “How to Improve Medical Practice (Hint: It's not with Lectures)”, appeared on page 30 of the Spring 2023 issue of Chicago Life Magazine.
Well-educated doctors are absolutely critical but not nearly sufficient to achieve excellent patient care. It takes an empowered team, supported by carefully designed, smoothly functioning systems, to consistently deliver the best medicine has to offer.
It can be viewed using this link: Chicago Life Magazine - How to Improve Medical Practice
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It doesn’t need saying that delivering the most up-to-date medical care ought to be the mission of every single person involved in healthcare. Facilitating that goal was my objective as Director of Continuing Education (CME) for a hospital in Colorado. I wanted to educate practicing physicians so they could serve their patients ever-more-effectively. Not long after taking the post I realized that my job description actually came down to putting on conferences. I was expected to mount educational events for the medical staff. Period.
I did my CME director job enthusiastically, organizing varied and interesting conferences once or twice a week, generally well attended, especially if we offered lunch; all the while knowing, based on endless hours of college and medical school lectures, that no matter how eloquent the presenter nor how many lovely slides they projected, passive listening is a terrible way to learn. The education literature bears that out. One definition of lecture is, “an event whereby the notes of a presenter are transferred to the notes of their audience without passing through the head of either.”
So how then do we get doctors to improve their practice? That’s where the field of implementation science comes in. It was barely on the horizon back in the day when I was a CME guy. Implementation science is about systems.
Principle number one of practice improvement is to depend as little as possible on doctors’ memory. Though our memory may be an order of magnitude or two beyond the mean (after all, we did get into medical school), physicians are still just plain old human beings with finite brain storage capacity. There is simply no way--by lecture, reading, audio file, subliminal audiotapes or operant conditioning--to cram into the limited space inside their skull all the information a physician needs to practice, let alone to make the facts accessible the moment they are needed.
That’s where electronic information systems and their near infinite storage capacity come in. Today the smartphone I carry in my pocket gives me instant accesses everywhere to UpToDate, an authoritative, well-indexed, continuously updated five gigabyte medical database authored by 7100 experts. I don’t know how I used to do without it.
Step one, then, is to greatly extend doctors’ brainpower by giving them ubiquitous access to good medical information. A journal article published in 1983 found that, of 11 immediate care-related questions about diagnosis or therapy generated in the course of a day of practice, the average doctor answered just 3 of them. I’d love to see if a similar study done today would show some improvement.
Step two is to provide the physician with complete patient data, via an electronic medical record (EMR), that is easily paired with the medical literature they now have at their fingertips. Making sense of it all takes understanding and judgment, traits humans have and machines don’t. However, a well-designed information system can greatly enhance human judgement. EMRs still have a long way to go to realize their potential to enhance clinical practice.
Computers don’t just “remember” unimaginably large amounts of stuff, they can sift it, checking data against protocols that may remind the doctor about tests to be ordered, diagnoses to be considered, immunizations to be administered, and give early warning when a patient is about to go south. (There is a real hazard here, though. Too many reminders can induce “alarm fatigue,” an all-too-common occurrence where the clinician just ignores or turns off the system in order to escape frequent interruptions for trivial or erroneous concerns.)
So far we’ve talked only about enhancing physician practice. But that’s not nearly enough. It is simply impossible for a doctor--no matter how smart, how well educated and how well plugged into data and information--to do the best job for patients all by themself. It takes a team.
I’ll illustrate this point with the example of outpatient management of diabetes. Every patient with the disease, just for starters ought to have their blood sugar, glycohemoglobin, cholesterol and kidney function checked regularly and results followed up. They tend to require frequent adjustment of their blood sugar medications. Many take drugs to lower cholesterol and to control blood pressure. They need lots of education and ongoing support about diet, foot care and a myriad of other self-maintenance items. Annual retinal exams are a must. They must have the same immunizations as everybody else, only more so. This is just a partial list. Get the idea? It’s an overwhelming amount of stuff for a practitioner to keep track of and perform.
Before computers we had flowsheets with lists of things to do and check. Paper reminders made it more likely that patients would get what they needed than if it all relied on the doctor remembering what to do. Automating reminders and patient callbacks has helped a great deal. But what is really needed is teams that explicitly divide and coordinate the labor among the scheduler, medical assistant, nurse, record keeper, lab tech, patient educator, and finally, the physician. (In a small practice the same person may fulfill multiple roles.) A well designed electronic information system provides the essential documentation and communication among the players to make this happen.
That’s how you really improve practice and ultimately patient outcomes. You start by bringing together clinicians, support staff, technologists and administrators to brainstorm and implement solutions. You no longer leave it up to technologists, administrators, or doctors working in isolation.
So what is a CME director to do these days? First, truly define themself as a practice improvement professional. Second, if they still want to put on conferences, design events where people can exchange ideas freely, across disciplines and professions. The goal is to get them taking to and trusting each other, not to cram more stuff into their heads. Let the information systems do the cramming. Leave humans to do what we do best, which is relating to other human beings and solving problems, not to remembering things we’ve heard in lectures.
