Medicine's Great Disruption

"Disruptive innovation is competitive strategy for an age seized by terror."

- Jill Lepore, author of
"The Disruption Machine: What the Theory of Innovation Gets Wrong"

"What do you want me to do with all the stuff in this box?" my wife asked this weekend.

I looked inside and saw my former self: one of BNC and pin connectors, wires, a notebook with sin, cos, theta, and a host of other equations - a project I worked on but never grew - it came from a time of creativity and endless possibilities for me in medicine.  Engineering and computers were how I entered this field - the hope of solving problems, doing things a little better, safer, and maybe faster.  A chance to innovate and collaborate.  A chance to make a difference.

But the world of medicine has changed from one that promotes discovery and creativity to one that promotes productivity and the lock-step over the past several years.  See more.  Do more.  Don't sway.  Follow the guidelines.  Stay between the lines.  Want to try something new?  The message to doctors is loud and clear now: don't you dare!

Every month another set of guidelines and rubrics, as if the guidelines are how we want doctors to think, or rather, recite.  Medicine is rapidly becoming a staid world of group-think, as we are forced to use the latest "disruptive technology" to change our medical world.  Bit by endless meaningless bit.  The "value-added" ideas never end.  There is little ownership now.  Little personal investment.  Punch the clock.  Get 'er done.  Do what those grey suits say.

It's the era of the creative destruction of creativity. 

What kind of doctor we are breeding in medicine now?  The American Medical Association (AMA) and Accreditation Council of Graduate Medical Education (ACGME) want to shorten studies and push medical students through school based on competencies and "not based merely on a traditional time-based system."  Time with patients can no longer be trusted it seems.  In the place of time: competencies gained from simulators. Plastics superseding flesh. As though doctors should become technocrats that make a cameo appearance at the patient's bedside with their smart phone in hand.

Is the hurry-up push toward technology and Big Data really needed or what we're being sold?   Enter your note, doctor, click another box, you're being scored now.  Do as you're told.  What's that? A little software glitch?  Don't rock the boat.  Just work around it.  The fix will be here in September. We must do more with less.  Oh, and forget the staff, they're expensive. Hurry up.  Perfect data, remember?  Your pay depends on it.

Oh, and that idea you wanted to work on?  Sorry, no time or money.  Really doctor, we're on a time line. Could you move it along?  My kids have a play date.

The Disruption Machine is moving, alright.

But will we be better for it?

-Wes

When Regulators Pay for Peer-review

The ongoing controversy among US physicians over newly-implemented "Maintenance of Certification (MOC)" requirements created by the private organization, the American Board of Medical Specialties (ABMS) and its 24 subsidiary subspecialty boards has breached another ethical front: paying for peer-reviewed publications in support of their expensive and proprietary MOC process.

In the Fall of 2013, the ABMS single-handedly funded an entire supplement devoted to the MOC process in the Journal of Continuing Education in the Health Professions. This journal is published quarterly by the Alliance of Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on CME of the Association for Hospital Medical Education. Not surprisingly, the articles published were uniformly favorable about the MOC process despite evidence to the contrary. The American Medical Association (who also stands to benefit from the process politically) was quick to provide a free link to the full pdf of the supplement from its AMA Wire news bulletin.

Interestingly, the literature review of the MOC process performed by Lipner et al. (page S20 of the supplement) admitted the limitations of their review:

"First, we did not consider certification by other entities other than ABMS boards; these results may not generalize to other certification bodies. Second, we did not use a formal system to judge the quality of the methodology used in the studies. Third, a meta-analysis to compared effect sizes across different data types was not done; designs were extremely diverse, and it may not be possible with the information available."

Given these limitations, the "value" of the MOC process, based on the data, is totally subjective. Despite these glaring limitations, the article concludes:

The main goal of certification is physician accountability to the public (editor: note that the "patient" and "doctor" are not mentioned). We have shown that a substantial body of evidence supports the value of certification and MOC in meeting that goal but the evidence is not unequivocal. In response, the ABMS have begun to enhance their programs to be more authentic and relevant to practice while maintaining their rigor and continuing to study the program's validity."

If the way the ABMS "enhances" the value of its proprietary MOC process is to pay for peer-reviewed publications that ignore the serious limitations mentioned by the authors themselves, then those directly impacted by the MOC process (like myself) have an obligation to question the validity and ethics of the ABMS's self-promotional practice.

I welcome the ABMS's response regarding their practice of paying for publications in support of the MOC process in the comment section of this blog.

-Wes

Are Print Medical Journals Dead?

This morning in the Chicago Tribune's business section appeared an article entitled "Just What the Doctor Ordered" that included an interview with Dr. Howard Bauchner, the new editor for the Journal of the American Medical Association (JAMA). He plans to pursue a strategy of "intelligent innovation" for the journal:

...looking for ways to get information to doctors and consumers through several new platforms, such as social media, video and other forms. "If you look at TED or Big Think, they have been experimenting with video clips," Bauchner said. "I could imagine having some of our authors do video clips where they speak about the meaning of their research for eight or 10 minutes, and then that's easily linked to a smart phone."

He also wants shorter on-line version of articles that condense the topic to 500 words from the typical 2,500- to 3,0000-word articles not too dissimilar, I suppose, to the abstract.

Which leads to the inevitable end result: print medical journals are on life support. Like Borders Book Stores, print journals will no longer be archived in neat little rows in doctor's offices any longer - it simply is not how we get our information anymore. Dr. Bauchner, to his credit, acknowledges this.

But what he also fails to acknowledge is the business model that must keep pace with today's internet. Doctors have a myriad of choices as to where they can turn to get their information and unless the content itself is really compelling there will be too many other sources of feel-good information-crack out there that will catch doctors' eyes. Doctors will not pay for their content since there is no precedent to doing so, so the journal will have to rely on advertising revenue to fund their publications, much like the rest of the internet. Doctors and the public have already grown weary of the endless public relations "research" forwarded to our smartphones and the JAMA content will become just one more such source to cast a wary eye. How they manage to remove themselves from industry bias of "free content" provided to doctors will be JAMA's greatest hurdle.

But there's one other important challenge the journal will encounter in keeping their physician readers: their name. It will be next to impossible for the Journal to escape that fact that they are associated with the American Medical Association, since the odds of a rebranding of the name after 128 years is unlikely. Ultimately, how the next few years shape up for doctors might have more impact on the journal's physician readership than the content they deliver.

-Wes

Sermo and the AMA

Peter Turner over at Opensource.Association has some interesting thoughts on Sermo and its relationships with the American Medical Association.

My point is why does the AMA need them to create an environment where “people come together, have their voices heard, and send messages out?” In fact, advocacy is not the main purpose of Sermo which is to sell aggregated information to institutional clients of Sermo....
Would you trust this model?

Doctors are paid for posting and even given Amazon gift cards to join. One student doctor said he was getting between $40-100 per month as a result of his postings. Clients (those in the lower half of the Sermo business model diagram below) pay a subscription fee and in return can post questions to the Sermo community. If doctors vote on one of these postings, they may be financially rewarded for “your astute observations.”

And I especially like the part that explains that full access to JAMA and the Archives journals are free on Sermo, but AMA members must pay for them.

-Wes