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

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. ●