I recently attended a meeting at the California state capital in which three prestigious speakers discussed how to improve healthcare quality through evidence-based medicine. I became increasingly agitated by a number of physicians in the room, whom after the talks, commented about how all or most physicians believe in and practice evidence-based medicine. They blamed insurance companies and others for any lack of high quality care. In response, I loudly voiced how astonished I was that we had all just heard strong scientific evidence that many physicians in the US do not practice scientific medicine, and that indeed there is a great deal of practice variation. I lamented that Paul Starr's book, “The Social Transformation of American Medicine” remains the story of 2009; many physicians desire autonomy in their practice, and this prevents any real chance of quality medical care. In my opinion, the most important component of health reform is to provide medical students (and practicing physicians) with an opportunity to choose an organizational “culture” that will allow them to really practice evidence-based medicine (EBM).
In this article, I will first briefly discuss important elements of medical culture relevant EBM. Next, I will argue the only specific types of medical organizations support EBM. Finally, I will discuss how Second Life could be used as a tool to help medical students understand that if they really want to practice EMB, they might have to sacrifice some autonomy and work within larger (or more social connected) medical organizations.
The Culture of EMB
Culture is composed of rules, ideas, procedures, or beliefs that influence behavior. Given this broad definition, almost all of human behavior is at some level guided by culture. Our personal beliefs are shaped by how people around us frame complex topics, and our behavior is often constrained by cultural rules and norms. Lets make the discussion more concrete by thinking about the cultural elements that embody the broad idea of EBM. First, most people know the cultural blueprint sometimes called the “scientific method.” This cultural pattern has evolved over thousands of years, and although the methods vary somewhat, the basic pattern is to identify a problem of interest, define some hypotheses, and then collect observations to make claims that hypotheses can be accepted or rejected. Second, once scientific studies have been debated and looked at together, knowledge can be generated. In medicine, clinical trails tend to be our favorite sources of information that can create prescriptions about how to treat patients. The next step is for physicians to consider using scientific knowledge when treating their patients. Here again, we need to think about cultural patterns. For example, what do physicians believe is quality clinical knowledge, and how will they access this information when they treat patients. Will they have the knowledge at the point of care (e.g., embedding in a clinical support system) or will they read medical journals in the evening and use the information the next day? Even more, are there rules or policies that clinical staff should meet to discuss scientific evidence? The list could go on and on. The point is to see that the culture of evidence based medicine is much more than scientific papers. What really matters is how (or if) information is used to improve the outcomes of patient care.
The Social Organization of EMB
As mentioned early in this blog, there is evidence that medical culture varies from place to place and from provider to provider. More specifically, the use of EBM among different medical groups, hospitals, and other types of medical organizations will vary as a result of the culture defining medical knowledge and how it should be used to improve patient care. A good way to think about this is to compare a large complex bureaucratic medical organization such as Kaiser with small independent practices. Large medical organizations such as Kaiser have people who operate in clearly defined and often specialized roles. For example, Kaiser employs research scientists in narrow fields, and very specific types of IT personal such as database experts and EMR systems designers. In contrast, independent practices with a few physicians and some support staff are forced to fulfill all the specialized duties themselves (if possible). Small groups are required to do their own library research, and install their own IT systems. Consultants can help, but this can also be challenging process. None of this should be surprising to anybody, but it is useful to remind ourselves about the benefits of large organizations; specialization of labor can lead to efficiencies and outcomes that small groups cannot easily accomplish.
I have been reading numerous scholarly publications by researchers such as Stephen Shortell (UC Berkeley Public Health), David Lawrence (former Kaiser CEO) and researchers from the Dartmouth medical school (Wennberg, Fisher). The consensus of this research is that US medical care is fragmented, inefficient, and often likely to produce too much or too little care. Other problems include having too many specialists in one area who fail to work as a team. But the common denominator of all this work is that the desire for physician autonomy keeps the system fragmented, and prevents the teamwork required for the practice of scientific or evidence-based medicine. In short, I will make a strong statement that I believe is supported by a large amount of scientific evidence from a variety of scientific disciplines; evidence-based medicine is extremely difficult to achieve among small independent physician practices that do not have real social connections with larger organizational entities.
Giving New Medical Students a Choice: Second Life as a Tool
I suspect that the majority of aspiring young physicians are drawn to the field to help people. Moreover, most see the value of science, and want to improve health outcomes using data, information, and knowledge effectively. Sadly, I think many American medical schools do not adhere to my statement about the importance of organizational elements to fulfill EBM. Thus, it is possible that medical students are given the false illusion that they can practice EBM as independent physicians. Of course, the reality is that a few talented and motivated physicians can pull it off. One of my health informatics classmates can do it I bet (Jonathan Ware). However, assuming that I am generally correct in what I have outlined above, would it be possible to use Second Life as a way to clearly illustrate my points? Once medical students had more information about the benefits of organized medicine, would this motivate more of them to work for such medical groups?
If I worked for a medical school, I would build multiple Second Life “islands” that represent the varying geography and human ecology of medicine. To make it evidence-based, I would employ ethnographic observers to spend time in a variety of medical settings. To start with, I might send teams to the Mayo Clinic and Northern California Kaiser to build examples of organized medicine. As a comparison, I would choose a few independent medical practices that have only a few physicians and small staff. Within Second Life it would be possible to build clinics that were similar to these real organizations, and then put in the importance “objects” such as record files, computers (with and with EMRs), and possibly some simple medical equipment. It might even be possible to embed examples of real EMRs systems such as Epic, so that the medical students would have a chance to actually try out a variety of IT systems. I suspect that it might be resource intensive, yet possible, to recreate the physical structures of medical organizations. However, how would it be possible to effectively demonstrate the subtle yet important cultural elements of these organizations?
To start, it might be possible to employ pre-medical undergraduate students to act as nurses, support staff, and patients within the Second Life environment. They could be trained to follow predefined scripts that embody the real procedures and subtle behaviors that were found in the ethnographic studies. For example, in the Kaiser setting, there would be multiple support staff that act in very defined roles. To address issues of procedure utilization, it might be neat to present the medical students with clinical situations that require difficult decisions about which treatments to select. In the Kaiser example, there would be a decision support system and some electronic guidelines that pop up as they enter data about the patient into the EMR. In contrast, there might be fewer of these IT structures in place for one of the independent practice settings. It might even be possible to re-create the daily clinical functions in paper-based system.
I have yet to become familiar enough with Second Life to fully evaluate if a virtual environment could provide enough human “context” to allow users to understand different cultures that exist among American medical groups. I suspect that the best way to fully understand other people is to travel and spend time with them within their organizations. However, the ultimate goal of this project might not be to fully give students an appreciation of the diverse ways of doing medicine, but give them the opportunity to think about what evidence-based medicine is, and how it can be truly achieved. Second Life might then provide enough interest to get students thinking about such diversity and make them curious enough to more fully explore their career options.
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