The Future Of Medicine Is A Problem and An Opportunity For Young Doctors

Creating Opportunity In Your Future Medical Career.

The world of medicine that the next generation of physicians will be inheriting from their predecessors is the most advanced, complex and dysfunctional in the history of humankind. As future physician begin to take the wheel of a health care system that is at times revolutionary and at times in complete disarray, we must realize a few important facts.

• We will become the leaders of a heath care system that will have new pressures and demands placed on doctors at an unprecedented rate.

• We will enter a world with a global aging patient population. This is happening at a rate unseen by any previous generation of physicians and this rate will only continue to increase.\

• We are entering a more centralized medical care system. This centralization will take place at both the patient-physician and physician-hospital level.

• The economics of modern medicine demand increased specialization among doctors and this will continue to progress as biomedical advances progress. 

These simple facts about our modern health care system present a laundry list of problems and opportunities for young doctors. It also places us in a position to suffer or thrive more than any group of doctors in medical history.

This means one thing, the traditional approach will not work....

The level of specialization, rapidly changing knowledge, outside pressures in today's medical practice has evolved beyond the current medical education models which are still largely build on the 100 year old Flexner Report. Thus, the length of study, focus, and framework are build around principles of medical education have not kept up with the pace of modern medical practice. In fact, there are some leaders in medical education that are and have been calling for a complete overhaul of the US medical education system.

In an interview for the University of Virginia Magazine Dr.Randolph Canterbury, the medical school’s senior associate dean for education said this,

It’s become pretty clear in the last couple of decades that this is probably not the best way to learn something as complex as medicine. The idea that physicians ought to learn the facts of all these various disciplines—anatomy, physiology, biochemistry and so forth—to the depth that we once thought they should doesn’t make much sense. About half of all medical knowledge becomes obsolete every five years. Every 15 years, the world’s body of scientific literature doubles. The pace of change has only accelerated. The half-life of what I learned in medical school was much longer than what it is today.

There will need to be huge changes to every level of the medical system and medical school is not exception. I feel that student doctors who realize medical school cannot, and will not teach them everything they need to make in the future are best in the position for success.

Working hard to learn the skills taught in medical school is imporant but when you consider that most of what you learn will be outdated in 5-10 years, it makes you look at your grades differently.

Yes, getting good board scores and having a nice class rank are important, but the will not be important past residency.

Doctors will no longer expect to graduate and have a killer practice handed to them on a platter. Skills like networking, leadership, managment, and creativity are all vital if you want to separate yourself from the crowd once you become a doctor and they are all completely impossible to teach in a lecture hall.

Medschool Is Tough, But Your Brain Is Up To The Challenge

Your Brain By The Numbers

At times medschool makes you feel like your head is going to explode if you try to fit one more obscure fact into your cranium. Well, here is some proof that it's possible. Here are some crazy statistics about the most complex and least understood organ in our body.

I know all you wanted to see it some more numbers and facts about the body.

Don't worry, there's no test for this....

Study Motivation From The Greatest Speech Ever Made

A three minute reminder of why medical school is worth it

At times medical school can become stressful and monotonous, especially during second year. Spending your days with piles of material to get through before eat, sleep, and do it all again the next day. Breaking up the day with a quick run garnished with a bit of inspiration is just what you need to make the pre-test push. So if you beginning to feel the pressure of an upcoming exam or just need a little pick-up, look no more.

My Advice?

1. Watch This Video

2. Go For A 15 minute run

3. Come back and crush your least favorite subject.

4. Repeat PRN

A Transcription of The Greatest Speech Ever Made by Charlie Chapman

I’m sorry but I don’t want to be an Emperor – that’s not my business – I don’t want to rule or conquer anyone. I should like to help everyone if possible...

Jew, gentile, black man, white. We all want to help one another, human beings are like that. We all want to live by each other’s happiness, not by each other’s misery. We don’t want to hate and despise one another. In this world there is room for everyone and the earth is rich and can provide for everyone. The way of life can be free and beautiful.

But we have lost the way.

Greed has poisoned men’s souls – has barricaded the world with hate; has goose-stepped us into misery and bloodshed. We have developed speed but we have shut ourselves in: machinery that gives abundance has left us in want. Our knowledge has made us cynical, our cleverness hard and unkind.

We think too much and feel too little: More than machinery we need humanity;

More than cleverness we need kindness and gentleness.

Without these qualities, life will be violent and all will be lost. The aeroplane and the radio have brought us closer together. The very nature of these inventions cries out for the goodness in men, cries out for universal brotherhood for the unity of us all. Even now my voice is reaching millions throughout the world, millions of despairing men, women and little children, victims of a system that makes men torture and imprison innocent people.

To those who can hear me I say “Do not despair”. The misery that is now upon us is but the passing of greed, the bitterness of men who fear the way of human progress: the hate of men will pass and dictators die and the power they took from the people, will return to the people and so long as men die [now] liberty will never perish…

Soldiers – don’t give yourselves to brutes, men who despise you and enslave you – who regiment your lives, tell you what to do, what to think and what to feel, who drill you, diet you, treat you as cattle, as cannon fodder.

Don’t give yourselves to these unnatural men, machine men, with machine minds and machine hearts. You are not machines.

You are not cattle.

You are men.

You have the love of humanity in your hearts.

You don’t hate – only the unloved hate. Only the unloved and the unnatural.

Soldiers – don’t fight for slavery, fight for liberty.

In the seventeenth chapter of Saint Luke it is written ” the kingdom of God is within man ” – not one man, nor a group of men – but in all men – in you, the people. You the people have the power, the power to create machines, the power to create happiness. You the people have the power to make life free and beautiful, to make this life a wonderful adventure.

Then in the name of democracy let’s use that power – let us all unite. Let us fight for a new world, a decent world that will give men a chance to work, that will give you the future and old age and security. By the promise of these things, brutes have risen to power, but they lie. They do not fulfil their promise, they never will.

Dictators free themselves but they enslave the people. Now let us fight to fulfil that promise.

Let us fight to free the world, to do away with national barriers, do away with greed, with hate and intolerance.

Let us fight for a world of reason, a world where science and progress will lead to all men’s happiness.

Soldiers – in the name of democracy, let us all unite!

5 Must Watch TED Talks For Any Medical Visionary

Visionary people face the same problems everyone else faces; but rather than get paralyzed by their problems, visionaries immediately commit themselves to finding a solution.    -Bill Hybels

Ok, I'm sure you are all familar with TED.com, basically it's is like crack for those who thrive on big ideas. I must admit, TED is a bit of an addiction for me. So if you have a bit of extra time this weekend; here is my must watch list for anyone who wants to do big things with their medical career.

1. The Wireless Future of Medicine

Eric Topol says we'll soon use our smartphones to monitor our vital signs and chronic conditions. At TEDMED, he highlights several of the most important wireless devices in medicine's future -- all helping to keep more of us out of hospital beds.

Eric Topol is a leading cardiologist who has embraced the study of genomics and the latest advances in technology to treat chronic disease.

2. Medicine's future? There's An App for That

Daniel Kraft offers a fast-paced look at the next few years of innovations in medicine, powered by new tools, tests and apps that bring diagnostic information right to the patient's bedside.

Daniel Kraft is a physician-scientist, inventor and innovator. He chairs the FutureMed program at Singularity University, exploring the impact and potential of rapidly developing technologies as applied to health and medicine.

3. Robert Fischell on Medical Inventing

Accepting his 2005 TED Prize, inventor Robert Fischell makes three wishes: redesigning a portable device that treats migraines, finding new cures for clinical depression and reforming the medical malpractice system.

Robert Fischell invented the rechargeable pacemaker, the implantable insulin pump, and devices that warn of epileptic seizures and heart attacks. Yet it's not just his inventive genius that makes him fascinating, but his determination to make the world a better place.

4. How Do We Heal Medicine?

Our medical systems are broken. Doctors are capable of extraordinary (and expensive) treatments, but they are losing their core focus: actually treating people. Doctor and writer Atul Gawande suggests we take a step back and look at new ways to do medicine -- with fewer cowboys and more pit crews.

Surgeon by day and public health journalist by night, Atul Gawande explores how doctors can dramatically improve their practice using something as simple as a checklist.

5. Where Good Ideas Come From

People often credit their ideas to individual "Eureka!" moments. But Steven Johnson shows how history tells a different story. His fascinating tour takes us from the "liquid networks" of London's coffee houses to Charles Darwin's long, slow hunch to today's high-velocity web.

Steven Berlin Johnson is the best-selling author of six books on the intersection of science, technology and personal experience. His forthcoming book examines "Where Good Ideas Come From."

Becoming A Rockstar Doctor: Part 2

Make Great Decisions in the Blink of An Eye

Imagine you are in a minor car accident or fall on a mountain bike. You are roughed up a bit with bumps and bruises but seem to be alright. Suddenly, you cannot catch your breath. This quickly gets worse and your friends are beginning to panic. They call 911 and by the time you arrive at the Emergency Department things are looking pretty dicey, in fact, you lose conciseness and begin de-saturating rapidly. Your friends are now freaking out, there is a frenzy of commotion all around. As you are wheeled into the hospital, nurses and EMTs furiously work to start IV lines and ready the crash cart. 

Then, through the blizzard of activity walks a figure with a calm and collected but focused look. There is a moment of contemplation and suddenly a large needle appears out of nowhere and is slammed into your chest. This is followed by a loud hissing sound and your breathing begins to slow and stabilize. The pressure in you chest subsides as does the tension in the room. 

Blink: The Power of Thinking Without Thinking

Blink is a fascinating look at the psychology and science of snap judgment and rapid decision making. This book is well suited for any future physician or surgeon, as our training is largely about producing doctors with great clinical discernment, and sometimes this is required in an instant.

Great Doctors Become Experts at "Thin-Slicing"

You may have already experienced the phenomena personally. Last time you took a test came across a question that you where unsure about but just felt the answer was D. Another classic is walking out of a test and feeling like you failed because you felt like you where guessing on every single question, then it turns out you did fine. As we progress in medical school we may get to experience this on wards as well. No doubt you have seen an attending instantly and effortlessly produce a diagnosis that was not even on your radar. This is because they have become experts at something called thin-slicing.

The Nuts and Bolts of Thin-slicing

The term Thin-slicing is used in psychology and philosophy to describe a person's ability to instantly make important and complex decisions based on very narrow experience or "thin slices". In Blink, Gladwell gives many examples of this phenomenon. One is about a firefighter in Cleveland who responded to a routine call with his men. They arrived to find a kitchen behind a one-story house was quickly becoming engulfed in flames.

After breaking down the door, the firefighters began dousing the fire with water. Strangely, the fire did not stop. The fire lieutenant recalls suddenly thinking to himself, "There's something wrong here," immediately he ordered his men out of the room. Moments later, the floor where they had just standing collapsed. When asked how he knew to get out, the fire lieutenant had no idea. He just had this "feeling" and thought it was ESP or a premonition.

What actually happened?

The fire was not in the kitchen but in the basement and if he had not been able to make this split second call, the results could have been disastrous. In fact, taking time to reassess and make a more informed decision could have proven fatal for the group.

Gaining A Magic Mind: Harnessing the Power of Thin-slicing

Some critics of Blink make the point that one should not minimize critical thinking and not discount it's importance in these blink-like judgments. In reality, it seems doctors do this on a spectrum. Critical thinking has a huge role in the way doctors decide how to solve the difficult problems encountered on a day to day basis. However we are looking at how to develop a "good gut" and gaining the ability to decide on an action in a split second or when our tests and exams do not offer the answer. These type of calls certainly make up a minority in the practice of medicine but they are often under pressured and difficult conditions.

There are some problems that are not solve by systematic and deliberate thinking to come to an answer. Here is a great example from the book.

A man and his son are in a serious car accident. The father is killed, and the son is rushed to the emergency room. Upon arrival the doctor looks at the child and gasps, "This child is my son!" Who is the doctor?

Of course this puzzle relies on insight, not a math equation, to come to the answer you need to mentally leap past your unconscious assumption that all doctors are men. Then the answer is clear...this is the boy's mother.

Blink does offer suggestions for those who want to take rapid cognition seriously.

The Value of Insight

There are times when insight is clearly the best way to solve the problem. As future doctors we must find the balance between deliberate and instinctive thinking when it comes to treating patients. Much of our training stresses the deliberate thinking process and tends to down play the role of insight thinking. This is why it is important for doctors to realize the value of insight and learn to improve this skill. 

There is Structure to the Madness

Blink gives examples of fast paced sports like basket ball or imporv comics to show how the participants are rapidly making complex decisions and instantaneously reacting to their surroundings. What allows them to do this? Learning the structure of the game, knowing each person's role and practicing this as a team.

We see this played out in the hospital. If you notice the contrast between a code run in the ICU and one run on a basic floor you will see this principle in action. In an ICU setting the nurses, respiratory therapists, physicians have practice and can execute, and even improvise as needed, with relative ease. However this is not the case everywhere and things can get a out of hand much quicker with a group of people who have not trained together.

Becoming an Expert

Once you become an expert in something, it becomes much easier to deconstruct this type of rapid thinking. Experts can look behind the curtain of spontaneous unconscious thought and decode what lies behind what appers to be a snap judgement.

That takes us back to our scenario at the beginning, the calm doctor can take one look at you almost breathless and in a matter of seconds have the confidence to stick a huge needle into your chest. To to most people this may seem like a moment of awe and clarvoiance. But once you learn to take one look at a patient and see brusing on the chest (possible broken ribs), trachypnea, desaturations on pulse oximetry, and tracheal deviation the answer instantly leaps into your head, tension pneumothorax! A few seconds is all it takes, and nothing else is needed but a nice big needle.

Becoming A Rockstar Doctor: Part 1

Why Malcolm Gladwell Should Be Required Reading For Medical School

The tidal wave of information thrown at you during medical school can be a challenge to manage and the idea of adding more books to the list may make you want to vomit. But before you do, take a moment to hear me out. 

Besides having a ton of respect for his feral afro, I believe that Malcolm Gladwell is one of the best authors for taking abstract, ill-defined phenomena and clarifying it with surgical precision. His work is some of the most researched writing you will see outside of a PubMed search and that resonates well with evidence based minds.

Throughout our medical training we are taught to question and continually seek to uncover the truth. Gladwell takes that same approach to the subject of success, human decision making, and epidemics with the books Outliers, Blink, and The Tipping Point. I can strongly recommend getting a copy of these books. His insights will give you the tools you need to stand out from the crowd, and make you re- evaluate the way you see your own medical training.

I know you may be busy, even bordering on overwhelmed, right now so I have distilled some of the vital principles into a nice little summary; until you have a chance to take a breath and get the full experience.

Outliers: The Story of Success

At the outset, most would-be doctors become obsessed with outliers, in many ways we all need to be outliers to continue in our career and as we progress this becomes increasingly difficult to achieve.

Opportunity for Quality Learning:

If you where to play hockey in Canada the month of your birth is a major factor that contributes to your success. Outliers explains that the boys who have the earliest birthdays are older at each level of junior hockey. This makes them a little stronger and faster than there peers. Which means they get chosen for the best teams, they get the best coaching, and have the most opportunities for high quality practice.

The point here is not to find out what month is the best month for Rockstar Physicians to be born. It’s the idea that the players selected early are given the best opportunities for learning, practice, and competition. The question then becomes how can I put myself in the path of those types of opportunities in my career.

Understanding the importance of quality learning means that to become an outlier we must be proactive in our medical education.

I do not consider my self an especially impressive outlier but here are three ways I have learned from people who stand out in school and life.

Clarify Your Purpose

What kind of legacy do you want to leave as a doctor, as a person? What do you care about? What would you work on if you had 20 million dollars in a trust fund? These are good questions to help clarify your purpose. The answer, "I just want to be a doctor and help people" is too vague. The more clear you are the better.

It’s important to remember that asking these questions is an important first step. You may not have all the answers right away and the answers may change over time, but the process is important. As you become more clear on your purpose you can increase your focus and place effort into areas of you life that will give you the highest yield.

Seek A Mentor

Good coaching is vital to success. Once you know where you are going it’s much easier to evaluate the type of people who can help you along your way. Asking for advice and help can be difficult, especially in the world of medicine. Many times people hesitate because they think “that doctor is super busy and will never get back to me or will think I am unworthy of their time.”

Yes, both of these things may happen but don’t sweat it, just move on to someone else. However you may be surprised at who will be willing to help you along the way.

Commit To One Small Action Everyday

The road to becoming a doctor is long and it’s easy to feel like you are stuck unable to do anything about some big goal you have in your life because you have no time, no money, and should spend every waking moment trying to care about oxidative deamination in the urea cycle or the blood supply above and below the pectinate line.

Even in the face of all these constrains, commit to one small daily action the brings you closer to that goal. Do you want to start a business, do a super sweet fellowship, or run a marathon? Don’t wait, begin working on that goal in a small way today.

Focused Practice

One of the most striking themes in Outliers is the emphasis on practice. Gladwell shows us why the 10,000 hour rule is important to remember for any would-be outlier. The idea is simple, it takes roughly 10,000 hours, or about 10 years, of focused (the more focused the better) practice to become great at something. He uses examples like Bill Gates, the Beatles, Mozart, and chess grandmasters to make his argument for this 10,000 hour rule.

What does this mean for training physicians and surgeons?

If you do some quick math and estimate the typical resident works 300 days per year (accounting for days off and vacation time). That is about 43 weeks per year and, at 80 hours per week, this means they would reach the 10,000 hour mark in almost exactly 3 years. It’s interesting that this correlates well with the amount of time spent in most of the non-surgical specialties.

But why do the surgeons need five, six, or, in some cases, 8 years? The the answer is focused practice. Gladwell calls it 10,000 hours of “hard practice.” For a surgical resident to reach 10,000 hours of hands-on operating experience it takes much longer. In many institutions the surgical intern and even junior resident spends much of their time outside the operating room and even when the do get to gown up for the OR they often have limited time where they are running the show.

Of course there are good reasons for this, patient safety foremost among them, however this does not mean that we cannot learn from the 10,000 hour rule. Remember just being busy at the hospital does not automatically mean you are becoming a better physician or surgeon. It is important to look for ways to find focused practice and wring the most out of each patient encounter.

This may also mean we need to re-evaluate how we train residents to increase the amount of focused practice they get during training. With arguments surrounding resident work hours, length of training, and the need for increased specialization constantly on the rise, a new look at how residents can reach the 10,000 hour mark as efficiently and safely as possible is important.

Here we have fascinating proof of Thomas Edison’s famous quote:

Genius is one percent inspiration and ninety-nine percent perspiration.

Genius Is Not Everything

Entering the world of medicine means you are stepping into a community filled with brilliant people. We can all think of those people in medical school who had seemly infinite mental horsepower. In some ways we are all in awe of this, we admire it and are, at the same time, a little jealous. But is this the right way to think?

According to Outliers, no.

The book makes a compelling case that genius cannot be soul predictors of success.

Exhibit A: Christopher Langen

Reported to have an IQ of somewhere between 195 and 210 and dubbed by many as the smartest person in America. He is a self taught expert in mathematics, physics, philosophy, Latin and Greek. He got a perfect score on the SAT, even though he took a nap during the test. But he has spent much of his life working as cowboy, construction worker, and a bouncer and has failed to reach his full potential due to his poor social skills and lack of emotional intelligence. (More on this guy at wikipedia)

But Gladwell goes on further, stating that a person's emotional intelligence and likability are often overlooked as measures that many outliers possess.

This idea is especially important to future doctors because our current training system does not reward people with emotional intelligence or likability, only mental prowess. However as attending physicians we are expected to be leaders, managers, and work as part of a team. We have all seen many examples of intelligent doctors who cannot function well as physicians for that reason.

A recent study done by Dr. Andrew Klein a transplant surgeon at Cedars-Sinai Medical Center, Los Angeles, CA. Shows that surgeons who are rude to the operating room staff actually have worse outcomes.

Dr. Klein commented that, "in an increasingly rude society where it is rare for a stranger to give up a bus seat to a senior citizen and expletives have become all-too common in daily conversation, the lack of civility has degraded all aspects of life, even the surgical suite...Operating rooms are social environments where everyone must work together for the patients' benefit. When a surgeon, who is in the position of power, is rude and belittlies the rest of the staff, it affects everything."

Shit Med Students Say, An Interview With The Creators

Left to Right - Emily, Alessa, Annie

Emily Silverman, Alessa Colaianni, and Annie van Beuningen are members of the Johns Hopkins School of Medicine class of 2014. They are also the creative genius behind the viral video "Shit Med Students Say" and are the reason I now ask all my patients if they have bombastic diarrhea.

They where nice enough to take some time out and answer some questions about surving med school with a sense of humor.

 _________________________________________________________________________________

I thought Hopkins was a place for serious students, the who's who of serious gunners, how are you guys so funny and laid back?

EMILY: I don’t know about gunners. But we are nerds. For instance, I’ve had no trouble finding classmates who share my love for Ocarina of Time and Battlestar Galactica.

ALESSA: Oh, that thing about Hopkins being the who's who of gunners is a total myth. Ha ha ha (dismissive/uncomfortable laugh). Now if you'll excuse us, we have to go print out decoy notes with mistakes on them to throw our classmates off our knowledge trail. Right after we cure cancer in our secret labs.

ANNIE: Because the gunners here are great fodder for comedy.

How did you guys get the idea for the movie?

EMILY: When “Shit Girls Say” came out, it just seemed like a given.

ALESSA: We all loved "Shit Girls Say" and Em texted me during class suggesting that we make one for med students. We spent the rest of the class writing a script via text message.

ANNIE: We're bad med students and do things like watch every rendition of "Shit Girls Say" on YouTube rather than study the ins and outs of pseduopseudohyperaldosteronism.

How do you guys find time for this type of hobby in medical school?

EMILY: Before starting med school, I promised myself I would find a way to keep my creative side alive. Making videos is a fun way to do that, especially when you have hilarious friends like Annie and Alessa.

ALESSA: It keeps me sane. You can spend every second of your time studying during med school and still not feel like you're learning enough, and eventually you get to the point where you don't feel like a person anymore. That's not healthy. For me, it's been important to cultivate my non-medical interests as a way of staying human.

ANNIE: Studying all the time is just not feasible for me. I get to a point where I'm no longer productive or actually remembering what I'm trying to learn. Keeping up with other hobbies is a great way to break up the studying routine.

What are your medical interests?

EMILY: The only rotation I’ve done so far is pediatrics, and I loved it. But who knows. One thing I know for sure is I want to be involved in medical education. We’ve had such excellent teaching here at Hopkins, and I want to be a part of it someday.

ALESSA: I have no idea. I like everything.

ANNIE: I change my mind all the time. Right now I'm still at the point where everything is interesting to me.

Any plans for future projects?

EMILY: I’m sure we’ll make something again when inspiration strikes. As for the long term, I’d love to incorporate the arts into my career somehow. If anyone has any bright ideas, let me know!

ALESSA: Nothing in the works right now, but if you ever need someone to do voice-acting or weird accents, please call me. I’m not kidding.

Now that you finished your first two years in Medicine what do you wish you would have known before you began?

ALESSA: Turns out all those viral structures I ignored during pre-clinicals are super- important for Step 1… womp womp…

EMILY: Take notes on your laptop! Then, when it’s time to study for boards, you can Ctrl + F all the stuff you’re confused about. Brings back memories. Plus you’ll have the notes forever. ANNIE Pay attention to the acid/base disorder lectures during renal - lots of people actually have these. And CHF. Learn about CHF.