One of the key problems facing educators in medicine today is how to train future doctors in medical decision making in an emerging era of electronic decisions support in EHR (electronic health record).
Let’s look at the transition that is occurring.
In the traditional model of care the doctor is presented with diagnostic and management problems by a patient. The doctor gathers information to make this decision. The doctor does this by history taking, physical examination and selection of tests that will aid him/her in the decision making process. In some, perhaps many circumstances the doctor will need to seek additional decision aids. These decision aids were originally hard copy textbooks, journals and guidelines but now are accessed online. The decision making process combines automatic responses learning through repeated observation and practice and critical reasoning hopefully informed by the best available evidence.
In the new model of care the history and examination are entered into the EHR. The EHR can then act as an iterative decision aid. It may suggest an order set of tests based on the history and examination. When these results are available it may in turn suggest treatment pathways or modification to treatments e.g. in guiding antibiotic dosing based on renal function derived from blood results. The EHR becomes a 3rd party in the decision making. To add to the complexity the patient may be more engaged than ever before. The patient may have contributed their history electronically and be armed with a list of differential diagnoses and treatment options derived from research conducted on the internet.
In the new model of care the processed leading to the decision are apportioned differently. The formulation of initial impressions may be supplanted by algorithms. Electronic decision support may provide some advantages in terms of standardization of practice leading to quality and safety improvements. Equally so, for a long time, the algorithms will not be artificial intelligence. The role of the medical practitioner must become one of knowing when following the algorithms is appropriate and when the system needs to be overruled. The doctor, or nurse, needs to be able to justify this and also explain to the patient why they are bypassing the system. Indeed, the role of the medical practitioner, more than ever before, moves from being the source of truth to being the filterer of options and the explainer of decisions. Practitioners will need to be able to promote health literacy in their patients in order to allow them to use the information they have found on the internet.
When I originally started thinking about these problems I thought simplistically of the doctor as a knowledge managed collating the necessary data needed to make medical decisions. In the EHR-enabled environment this would appear, at face value, to become easier. In reality the role is greater than collector it is one of curator. The curator must work with their environment, the EHR, and use both system 1 and system 2 (see Thinking, Fast and Slow by Daniel Kahneman) to make decisions. Currently, physicians who have trained in the traditional methods may actually frown upon use of electronic decision support but they may be better equipped to use it than the doctors of the future. If the doctors of the future are trained in an environment of instant decision support they may fail to gain the clinical experience necessary to recognise when the algorithms are inappropriate. The doctors of the future may be buttressed by electronic decision support but might have less capacity to deal with more complex problems and decisions simply by virtue of not having at one point sweated on the easy stuff. Their medical system 1 may not have grown enough to allow the best use of system 2.
Frank Davidoff compares physicians to musicians declaring that “clinical practice is above all a matter of performance” (Ann Intern Med. 2011;154(6):426-429). If this is the case then the training doctors of the future will need to spend at least some of their time ‘unplugged’ from the eletronic decision support in order to hone the skills needed to perform medicine at the highest level. Trying to establish the right balance will be the challenge for the medical educators of the future.