In their quests to become practicing physicians, medical students perform amazing feats of memorization to gain a rich understanding of the language and process of medicine. Despite their best efforts, misdiagnoses are still the top concern in the ECRI Institute’s 2018 report on health care quality and safety. In this age of ubiquitous digital information, why are medical decision errors commonplace? Poor training in using digital evidence to augment decision-making may be a key culprit.
The problem isn’t our capability to create technological tools to augment clinical decision-making. A number of these exist and are being used by physicians around the country. The problem is that these tools aren’t a routine part of the medical school curriculum, and medical students aren’t taught how to integrate them into clinical practice.
As technology advances, medical education has focused on the use of computers for simulation, but not on how they can be used in the exam room during the diagnostic process. This is like telling pilots to memorize routes and procedures, but never giving them the opportunity for training and evaluation in a cockpit to become familiar with the instruments and checklists that are used daily.
Most medical students learn within the first few days of medical school that to advance into the competitive specialties they must have great Step 1 board scores. As a result, the focus of medical students has become learning isolated facts for the test instead of putting facts together for the clinical decision-making process.
Tools such as clinical decision support systems have evolved tremendously. They now go beyond providing alerts and can assist physicians recognize patterns and aid in differential diagnosis. This growing market has advanced so much that by 2025, the global clinical decision support market will reach $10.8 billion. It’s time to embrace training with the professional instruments that are now available in clinical practices and that will be used more often in the future.
A woman in her mid-50s recently came to the University of Maryland Medical Center, where one of us (B.B.) works, with an unusual growth on one of her fingers. She had spent weeks trying to solve the problem at home on her own. After initially being evaluated by one of our residents, and then by a team of other doctors, no clear diagnosis emerged. As a team, we referenced a handheld clinical decision support tool in front of the patient and had a discussion about the possibilities, which ultimately led us to diagnose the growth as pyogenic granuloma (also known as lobular capillary hemangioma).
At the end of the visit, the patient appreciated being part of the process and the “thinking out loud” that went along with reviewing the possible diagnoses. Contrary to what some physicians believe, using decision support created patient trust. The opportunity to observe us through the diagnostic process getting assistance from technology instantaneously communicated to the patient that we were using tools to solve her problem.
Patients understand that doctors can’t memorize the corpus of medical knowledge. They expect us to have and to use tools that lead to better knowledge at the point of care. They also appreciate being included in the diagnostic thinking or conversation. It’s high time to put behind us the days of a physician going behind closed doors to find a diagnosis.
Embracing technological advancements in health care within medical education would set the stage for new physicians to understand how the doctor-patient relationship is evolving, while at the same time reducing the possibility of diagnostic errors.
A competency-based curriculum that integrates scientific and clinical education should remain the cornerstone of medical school. At the same time, educators must begin to model current strategies for acquiring information at the point of decision-making as students rotate with them. Purposeful, directed teaching in the use of clinical decision support tools and clinical problem-solving would help students gain an understanding of the field of medical informatics and, more importantly, bridge the gap to show practical applications that will help them improve the care they deliver.
By creating a space for students to thrive beyond standard memorization, educators can work simultaneously on analytical and logical competencies and the thinking skills required to use technology effectively to answer testing, diagnostic, and therapy questions.
Medical education is at a crossroads. Many of our educational leaders are rightly critical of the electronic health record and how it has diminished the physician-patient interaction. Point-of-care knowledge tools are different. Teaching to these tools, rather than to the memorization requirements of the Step 1 board examination process, is an important part of progress forward, as is modeling real-time information acquisition in front of patients.
Information technology has allowed pilots to move from open-cockpit biplanes to the complexities of 400-passenger jet aircraft. During this evolution in aviation, it is the avionics — the cockpit instrument technology that guides flight — that has made modern air travel safe and hugely successful.
Medicine has gone through a similar explosive growth in complexity during the same period, but doctors are still, for the most part, memorizing their routes and over-relying on intuition. Our students understand the need for modern information tools. They deserve nothing less than consistent training in those that define high quality, evidence-based modern medical practice.
Brian J. Browne, M.D., is chair of the Department of Emergency Medicine at the University of Maryland School of Medicine. Art Papier, M.D., is an associate professor of dermatology at the University of Rochester Medical Center and CEO of VisualDx, a clinical decision support tool that uses images to help physicians make better diagnoses.