June 27, 2019

Tech and the Renaissance of Clinical Practice

This article was adapted from remarks I gave June 7, 2019 at Harvard Medical School’s reunion as part of a panel on physician burnout.

It can be hard to feel sorry for doctors, who are consistently listed among the best-paid professionals in the United States. It’s also true, however, that there’s a genuine crisis of physician burnout. Rates of depression and even suicides among doctors have reached alarming levels and show no signs of abating. By one report around 44% of physicians report feeling burned out, with the rate close to 50% among family medicine and internal medicine doctors. Up to 15% of doctors in the same survey said they had contemplated or attempted suicide.

Aside from the direct burden on physicians themselves, this crisis has real implications for patients and the public. Particularly in specialties with higher burnout rates, like family and internal medicine, physicians are leaving the workforce and/or limiting their hours of patient care. Medical students are also avoiding these specialities in favor of those with better lifestyles such as dermatology and plastic surgery. 

Moments of crisis create opportunity for breakthroughs.

By one projection, there will be a shortage of approximately 44,000 primary care physicians (PCPs) by the year 2035; another study showed that even in a city known for healthcare like Boston, people wait more than 100 days on average to see a new family doctor. Finally, the perception that they are providing low quality care has been shown to be an important driver of physician burnout. 

It's time for a breakthrough

Moments of crisis create opportunity for breakthroughs. It’s time to radically re-structure physician work in the context of technological innovation. Doing so can restore joy, while dramatically improving productivity, by allowing us to focus on the small proportion of our current practice that truly adds value.

Technology in other industries has made the workforce more productive and highly skilled. In medicine, the first wave of digitization has had the opposite effect, forcing physicians and nurses to become data entry clerks and contributing to our widespread malaise. While findings have been mixed, there is some evidence that EHRs actually decrease the number of visits that doctors are able to do. And “too many bureaucratic tasks (e.g. charting, paperwork)” and “increasing computerization of practice (EHRs)” were reported as two of the top three drivers of burnout.

Some innovations are further fragmenting care

Onto these bleak shores has crashed successive waves of care delivery innovation that seem discordant with the values, art and science of clinical practice we learned in medical school. We were taught the sanctity of the physician/patient relationship and centrality of a thorough history and physical, followed by a disciplined, evidence-based approach to diagnosing and managing disease. Yet, many new service models move medicine further in the direction of episodic, transactional encounters with different providers, prioritizing convenience over continuity, efficiency over thoroughness, and automation over human judgement and action. 

Over the last decade, for example, we’ve seen the market entrance of first in-person, and then virtual, urgent care services, often staffed by non-physicians, that provide convenient, episodic, transactional care for routine conditions. Newer tech-enabled services, like Roman or NURX, are perhaps even more dystopic from the perspective of our treasured values, marketing on-demand erectile dysfunction treatment and contraception respectively directly to consumers. Finally, in disciplines from pathology to radiology to dermatology, we are seeing artificial intelligence encroach on work previously done only by highly-trained physicians.

...it’s possible that this period of disruption by new technologies and service delivery innovations presages a renaissance in clinical practice.

There's a better way

The confluence of these factors and the enormous pressure to reduce costs and eliminate waste promises a period of rapid and profound change in clinical practice. Taking this picture in, a clinical traditionalist would have good reason to despair. From a different perspective, however, it’s possible that this period of disruption by new technologies and service delivery innovations presages a renaissance in clinical practice. 

To appreciate the possibility of this renaissance requires accepting a number of realities about our present, past and future circumstances:

1. If physicians don’t get much more productive, the economics won’t work

Physician labor is a major driver of the unit cost of healthcare. Assuming that physicians wish to continue making salaries on par with other highly-paid professionals and executives, at the same time that we have to find ways to slow the growth in medical spending relative to overall economic growth, we will need to dramatically improve their labor productivity. This means that physicians will need to participate in the care of far greater numbers of patients over time. (This in the context of physicians already experiencing productivity pressure as a major driver of burnout.)

2. Unprecedented breakthroughs in biomedical discovery necessitate unprecedented changes in medical practice 

The past several decades have witnessed an explosion of biomedical discovery without precedent in human history. Even if it were ever the case in the past that the safest, highest quality approach to delivering medical care was to rely on an individual’s ability to hold and apply the full body of medical knowledge in their head, that is certainly no longer the case.

3. Professionalism compels us to embrace innovation

Our profession has always embraced biomedical technological innovation that demonstrably improved our ability to prevent, diagnose and treat disease. I believe professionalism compels us to also embrace technological advances that improve the safety, reliability and efficiency of care delivery, even if this involves profound changes in our role in delivering care.

4. The access crisis disproportionately affects the least fortunate

The extensively documented disparities in healthcare access along lines of race, socio-economic status and geographic location will be exacerbated by the worsening crisis in primary care access. There is no way to extend healthcare access to the billions of global citizens who currently lack it, thereby compromising global security and exacerbating migrant crises, without exponentially increasing physician productivity.

5. Standardization and substitution are inevitable and we should embrace them

In the ambulatory setting, a large percentage of the work we do on a daily basis is routine and algorithmic. Some activities in this category include medical history taking, diagnostic work-ups and treatment of common conditions, both acute and chronic. These are the aspects of our work that will inevitably be replaced by technology and/or lower skilled, less-expensive members of the workforce.

6. Let’s not lose what’s truly valuable

Of all the different ways in which physicians have traditionally participated in patient care, the ones that add the greatest value and are hardest to replace are complex decision making and compassionate interactions with patients and their families at critical moments in their lives. When given sufficient time to participate in and be present for these activities, they are also the aspects of clinical medicine that bring doctors the greatest degree of fulfillment.

We can and should relinquish the many aspects of our current work that could be done just as well or better by technology and non-physicians.

This will be the golden age for clinical practice

Taken together, these realities suggest the possibility of a renaissance in clinical practice coincident with disruptive, tech-forward innovations in the delivery of care. We can and should relinquish the many aspects of our current work that could be done just as well or better by technology and non-physicians. Radically changing the structure of our daily work and interactions with patients and other healthcare providers will unlock the potential for intelligent technologies to make the care we provide much higher quality, safer and user-friendly. This is the only way to unblock the massive efficiency gains we need to see to make healthcare affordable for all.

This will inevitably happen whether we embrace and contribute to the change or consider ourselves victims of it. In so doing, we stand to gain the opportunity to spend a far greater proportion of our time and energy on those aspects of clinical work that contribute the greatest value to our patients and their families and bring us the most joy and fulfillment. And we can align our own professional satisfaction with the goal of ensuring that all people can access great healthcare by the year 2030.

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