Can a Doctor Memorize it All?

If you are “old,” as in you did not have a computer or smartphone in high school, you might question your doctor’s ability if they research a diagnosis or look up medical knowledge during the office visit. Just 25 years ago, physicians were thought to be omniscient. The idea that they would need help in their thinking or open a medical book in front of the patient did not support the image doctors had of themselves, or that the patients had of them. 

If you are under 40, it is difficult to understand why your doctor is not using a computer to help diagnose or decide tests and treatment during the office visit. Patients who search the Internet before and after their doctor visit wonder why their doctor is missing details that the patient read on a free physician medical portal. If some diagnoses are made on clinical symptoms and physical exam clues alone, it seems to many people that physicians might leverage information immediately, during the clinical interaction. Yet research shows that 45% of clinical care questions originating during the patient visit are not pursued and are not answered by the doctor. It is evident to patients that doctors do not perform consistently in terms of information retrieval.

Of course, most doctors are using computers every day, some almost every minute, to record patient information in the electronic health record (EHR). Beyond record keeping and ordering, however, computer-based information – eg, to guide diagnosis, testing and therapy – is rarely used. Patients are trying to understand why many of their physicians are only using computers to document the visit rather than assisting with knowledge and thinking.

The real transition we are living through in medicine is not from paper-based records to EHRs, it is from memory-based practice to guided, more reliable assisted thinking. Just like pilots use their cockpit instruments to help inform their decisions about altitude, direction, and speed based on the particular circumstances of each flight, medical knowledge tools encourage physicians to consider relevant alternative diagnoses as they work, as well as more appropriate tests and therapies customized to the patient. Yet in medicine, many physicians still “fly by the seat of the pants.” If doctors ran the airline industry, it would be as if some commercial pilots used cockpit instruments, while the others were fine just memorizing the route.

Even at the most progressive institutions, many gray-haired physicians and physician educators mistakenly believe the computer is replacing thinking, lamenting the loss of the “good old days” and interpreting the use of computers to guide care as “cookbook” medicine. These doctors do not understand that the quest for an excellent patient history and physical exam is not subsumed by using knowledge tools; in fact, excellent clinical exam and thinking skills are required to use these new tools. Ironically, operating from memory alone and simply leveraging the most common and most serious diagnoses in the office today really is “cookbook medicine,” whereas using computers to expand the diagnostic process and to acquire information as they work actually requires the doctor to think and consider more. 

Ultimately, knowledge software known as clinical decision support will be universally used by physicians. At our academic medical centers, medical students and residents are leading the way using medical knowledge applications consistently. Not surprisingly, students are teaching their teachers about new apps and how to use them, and many professors enthusiastically embrace this reversal of roles. Medical education will move from closed book multiple choice exams to training and testing in the use of the knowledge tools that the students will continue to use once they are in practice. New models of care delivery will include the patient answering symptom-based questionnaires contextualized to their unique medical history from home, on their smartphone, or in the office waiting room.

Our current fee-for-service financing of medicine encourages speed, not quality, and it has driven physicians away from thinking and delivering the best possible care. The Institute of Medicine in its landmark September 2015 report, Improving Diagnosis in Healthcare, encourages policy makers to focus on improving diagnosis. A key recommendation is to encourage best practices in diagnostic decision support. The point is that cost savings and saved lives will flow from encouraging clinical diagnostic accuracy during each and every of the 1 billion outpatient visits in the United States each year. Improving Diagnosis in Healthcare highlights the causes, scope, and harm of diagnostic errors in US healthcare. The report states that “It is likely that most of us will experience at least one diagnostic error in our lifetime, sometimes with devastating consequences.” Now that is something to think about.

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