‘We need to put the high touch back in medicine’

Modern Healthcare - - Q & A -

Dr. Lloyd Mi­nor Since De­cem­ber 2012, has served as dean of the Stan­ford Univer­sity School of Medicine, part of an aca­demic med­i­cal cen­ter that in­cludes Stan­ford Health Care, Stan­ford Chil­dren’s Health and Lu­cile Packard Chil­dren’s Hos­pi­tal Stan­ford. The med­i­cal school has to­tal fac­ulty of more than 1,900 and an en­roll­ment of nearly 500. As­sis­tant Man­ag­ing Ed­i­tor David May re­cently talked with Mi­nor about trends in train­ing the next gen­er­a­tion of physi­cians, part­ner­ships with lo­cal tech gi­ants, in­clud­ing the Ap­ple Heart Study, and what Stan­ford Medicine is do­ing to ad­dress physi­cian burnout. The fol­low­ing is an edited tran­script.

Mod­ern Health­care: What are some of the es­sen­tial changes you be­lieve need to be made in the way young doc­tors are be­ing trained to­day?

Dr. Lloyd Mi­nor: The way we prac­tice medicine to­day, the way we teach doc­tors in train­ing, they know that med­i­cal prac­tice is go­ing to change, even over the course of the next five years, and in par­tic­u­lar over the next decade or decade plus. So, it’s im­por­tant for physi­cians now more than ever to be life­long learn­ers. And we can try to do that in a num­ber of ways. One is by help­ing physi­cians in train­ing to in­ter­act mean­ing­fully with tech­nol­ogy. The other is to make sure that we’re bring­ing tech­nol­ogy into med­i­cal prac­tice in a timely way, and that as we bring tech­nol­ogy in, we’re train­ing physi­cians how to max­i­mally use it.

While there’s still a core of knowl­edge and skills that every physi­cian should be trained in, we also need to rec­og­nize that the di­ver­sity of physi­cian in­ter­ests and of prac­tice in­ter­ests are grow­ing with time. We need physi­cians to­day who are data sci­en­tists. We need physi­cians who can in­ter­act in a mean­ing­ful way with com­puter sci­en­tists, with en­gi­neers to bring tech­nolo­gies di­rectly into med­i­cal prac­tice a lot faster than they have in the past.

The one-size-fits-all med­i­cal cur­ricu­lum, it never re­ally did fit all, but it par­tic­u­larly doesn’t fit all to­day.

MH: You men­tioned tech­nol­ogy. Are there ad­van­tages in that area given Stan­ford’s lo­ca­tion in Sil­i­con Val­ley?

Mi­nor: Ab­so­lutely. I think our lo­ca­tion is a great as­set as we can build on part­ner­ships and col­lab­o­ra­tions. The ma­jor tech firms to­day are very much in­ter­ested in health and health­care. It’s cer­tainly be­com­ing an area of con­sumer fo­cus.

One thing that still con­cerns me a lot is get­ting med­i­cal records from one physi­cian or one health­care de­liv­ery sys­tem to an­other. It’s a com­plex and com­pli­cated process. We still have pa­tients who cart around their records burned onto a CD or carry around a packet of pa­per records, or use the fax ma­chine.

There’s a tremen­dous op­por­tu­nity to have tech­nol­ogy, in a con­struc­tive way, dis­rupt health and health­care de­liv­ery. I view these dig­i­tal ad­vances as be­ing in two cat­e­gories, sep­a­rate but closely re­lated. One is a cat­e­gory of con­sumer-fac­ing dig­i­tal de­vices and tech­nolo­gies, so this gets to the Ap­ple Heart Study. It gets to all the wear­ables that are avail­able to­day. The sec­ond area is be­ing able to mine and use an­a­lyt­ics on this vast trea­sure trove of data that ex­ists there, to re­ally ex­tract in­for­ma­tion.

MH: Can you talk a lit­tle about the Ap­ple Heart Study?

Mi­nor: The Ap­ple Heart Study of­fi­cially rolled out in Novem­ber. This lever­ages the power of con­sumer­fac­ing tech­nolo­gies. The study will en­roll hun­dreds of thou­sands of pa­tients in order to de­tect what we be­lieve is the most com­mon ar­rhyth­mia, atrial fib­ril­la­tion. It’s in­ter­est­ing be­cause al­though atrial fib­ril­la­tion is the most com­mon heart ar­rhyth­mia, we re­ally don’t know what the true in­ci­dence and preva­lence of a-fib is. The rea­son we don’t know that is that it can be in­ter­mit­tent. We may get some phys­i­cal symp­toms and signs, but to re­ally know that we’re in or we’re out of a-fib has not been some­thing we could know in the past.

So, work­ing with Ap­ple, the heart study uses the sen­sor in Ap­ple Watch, which now is the most com­monly used heart rate mon­i­tor in the world. We use that in­for­ma­tion from the heart rate, cou­pled

with in­for­ma­tion about ac­tiv­ity level, to draw an in­fer­ence about whether or not some­one does or doesn’t have atrial fib­ril­la­tion.

If the app picks up that there’s a sus­pi­cion, then peo­ple who are en­rolled in the study get a mes­sage that gives them the op­por­tu­nity to speak to some­one about what has been found from mon­i­tor­ing their heart rate and their ac­tiv­ity.

“The one-size-fits-all med­i­cal cur­ricu­lum, it never re­ally did fit all, but it par­tic­u­larly doesn’t fit all to­day.”

MH: What’s your opin­ion on the use of ar­ti­fi­cial in­tel­li­gence and big data? Are we over­promis­ing on any of this?

Mi­nor: I don’t think so. Of course the over-promising comes down to how specifics are com­mu­ni­cated, but I think the prospects for AI are enor­mous.

We’ve had peo­ple here, col­lab­o­ra­tions that in­volved the Stan­ford fac­ulty and oth­ers, in ar­eas, for ex­am­ple us­ing in­frared light sources and video cam­eras in order to de­tect when some­one has fallen. Peo­ple who are in as­sisted liv­ing, first of all, they need to be able to man­age their lives as in­de­pen­dently as they can, but also you can’t have a per­son in the room with them 24/7, but how do you know if they’ve fallen, for ex­am­ple? Well, that can be de­tected by mon­i­tor­ing mo­tion, and the al­go­rithms are ac­tu­ally very good at know­ing when a per­son has fallen and then alert­ing a nurse or a rel­a­tive that there may be a prob­lem.

These are things that are not that far from be­ing im­ple­mented. We’re also see­ing al­go­rithms be­ing de­vel­oped for care de­liv­ery, to know what the very best care is based upon anal­y­sis of a large amount of data from pa­tients with sim­i­lar dis­eases and un­der­ly­ing fac­tors. This gets to the in­di­vid­u­al­iza­tion and per­son­al­iza­tion of health­care de­liv­ery.

MH: What about pre­ci­sion medicine? It’s al­ready chang­ing can­cer care. Where are we headed in the near term?

Mi­nor: Can­cer care is cer­tainly one in­cred­i­bly im­por­tant area. The more we learn about the ge­net­ics of can­cer, the more we’re able to tai­lor treat­ment based on the cel­lu­lar molec­u­lar ge­netic char­ac­ter­is­tics of the tu­mor and the in­di­vid­ual. So that will move for­ward for sure. I’m also very ex­cited about ap­ply­ing those same en­ablers of ge­nomics, big data science, ap­ply­ing those in a pre­dic­tive and pre­ven­tive way. The no­tion is that each of us has a cer­tain set of bi­o­log­i­cal de­ter­mi­nants for our propen­sity to de­velop dis­ease. We don’t fully un­der­stand those. We un­der­stand some to­day, with for ex­am­ple, the BRCA genes, but we’re gath­er­ing new knowl­edge all the time.

The idea would be that through a va­ri­ety of meta­bolic tests, and also look­ing in de­tail at our ge­netic makeup, that for each of us, we would know our rel­a­tive risk of cer­tain dis­eases, and then be­cause of the rev­o­lu­tion that’s oc­cur­ring in ad­vanced di­ag­nos­tics, for each of us there would be a spe­cific pre­ven­tive reg­i­men.

MH: Switch­ing gears, one of the is­sues we’ve been writ­ing about is clin­i­cian burnout. How is that en­ter­ing dis­cus­sions at the med school level?

Mi­nor: It’s a huge area of fo­cus for us. We were the first aca­demic med­i­cal cen­ter to cre­ate the po­si­tion of chief well­ness of­fi­cer, and Dr. Tait Shanafelt joined us this past Septem­ber. He had been at the Mayo Clinic, and I think is rec­og­nized as one of the thought lead­ers in the causes of physi­cian burnout, and of even greater im­por­tance, pre­vent­ing physi­cian burnout.

It’s very con­cern­ing to me that from a va­ri­ety of dif­fer­ent stud­ies, 50% of physi­cians that prac­tice in Amer­ica to­day are burnt out by a va­ri­ety of dif­fer­ent cri­te­ria. There’s not a sin­gle uni­tary cause for that, but there are sev­eral strongly as­so­ci­ated causes. One of those, at the top of al­most ev­ery­one’s list, is the elec­tronic health record.

So, we will be spon­sor­ing a na­tional con­fer­ence here on June 4 with lead­ers from the in­dus­try, from the EHR sec­tor, as well as from the pol­icy world, to fo­cus on how we could im­prove the EHR so that it be­comes an op­por­tu­nity to im­prove the ef­fi­ciency of prac­tice, rather than a bur­den.

MH: What are some of the other drivers and so­lu­tions?

Mi­nor: Well, re­turn­ing to the joy of the prac­tice of medicine. Let me tell you about a study that Tait and his col­leagues did when he was at the Mayo Clinic. Of course, Mayo is a large clin­i­cal en­deavor. They took a group of clin­i­cal ser­vice lines and they said to the lead­ers of these ser­vice lines, “We want you to work with the fac­ulty that are re­port­ing to you, and for each one of them we want you to iden­tify what they en­joy most about their work. So, for an on­col­o­gist, it might be see­ing pa­tients with a par­tic­u­lar type of can­cer. But we want you to work with each fac­ulty member to iden­tify that as­pect of their work that they en­joy the most, and then we want you to make sure that 20% of their time is devoted to that.” They did that in one group.

Then in an­other group, a con­trol group, they con­tin­ued to prac­tice and or­ga­nize their prac­tices in the same way so there’s no in­ter­ven­tion. Then they looked over time at in­di­ca­tors of burnout among the two groups. And in the group for whom 20% of their time had been al­lo­cated to some­thing in their work life that they re­ally en­joyed, there was much less burnout and they were more pro­duc­tive. They were do­ing more clin­i­cal ac­tiv­ity and were more ef­fec­tive than the non­in­ter­ven­tion group.

Tech­nol­ogy and medicine for the past 20 years has re­ally served more of­ten than not as a bar­rier to the physi­cian-pa­tient, provider-pa­tient in­ter­ac­tion. Think about the num­ber of doc­tors to­day who the mo­ment you walk in to start see­ing them as a pa­tient, they’re typ­ing into the elec­tronic health record. That’s sep­a­rat­ing the pa­tient from the provider. We need to put the high touch back in medicine. That still is, I think, a ma­jor driver of why peo­ple choose to be­come physi­cians, and we need to en­able the high touch by the high tech. ●

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