Medical schools should usher disruptive transformation

In Clay Shirky’s engaging book Here Comes Everybody, he describes how professionals can be blindsided by disruptive competitors. It got me thinking about medicine.

Traditionally, new technologies reached medicine in a top-down direction. The invention of MRI, for example, was first introduced to hospital administrators and department chairs as a potential new diagnostic tool. Once accepted, others further down in the medical hierarchy gained exposure.

This technology wasn’t disruptive because it didn’t change the overall structure of the field. As before, patients still came to hospitals for sophisticated diagnostic work-ups, only now the hospital had a better, albeit more expensive, tool.

Many of today’s medical technologies are disruptive, which is different.

Take, for example, the iPhone app Skin of Mine. Take a picture of a suspicious mole and get either automated analysis about its likelihood of melanoma, or an online consultation with a dermatologist.

This invention is entirely unlike the MRI scenario. Instead of entering the field from the top down, it comes from the bottom up. Patients can walk into their doctor’s office with this invention already in their pocket, asking questions about a diagnosis made by their free mobile app, all without the department chair or hospital administration even knowing of its existence.

This changes the overall structure of the field: the patient has direct and cheap access to diagnostics, less need for an office visit, and more information in the patient’s hands.

A crucial question for medicine is how to respond to disruptive changes that come from the bottom up? My guess is that most clinicians, understandably, will not take kindly to innovations that reorganize their work flow. The nightmare of adopting a new EMR is trivial compared to the challenge of restructuring how and where a doctor sees patients. Nonetheless, I’m guessing this change will be inevitable as patients clamber for the cheap convenience of such disruptive technologies.

Personally, I think medical schools hold the key to ushering this bottom-up transformation. They can serve as the field-testing ground for disruptive innovations, training the near-future doctors as well as offering exposure to their more entrenched clinicians, but in a structured way that blunts the stress of disruption.

Aaron J. Stupple is a medical student who blogs at Adjacent Possible Medicine.

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  • needlesandpens

    The Bottom? I don’t consider myself “the bottom” of my medical care team. Maybe “the other side of the table” would be a better attribute for patients who are actively involved (as expected to be) in their own or their loved one’s  care ?

  • Aaron James Stupple

    Right, the “bottom” is an unfortunate characterization. I used the terminology of business-speak for the sake of clarity- I certainly don’t mean to cast anything but an encouraging and exciting light on the prospect of engaged patients. It’s the entire motivation for this post to begin with. Thanks for your input!

  • Anonymous

    As long as we are distracted by these (ultimately antiquated) hierarchical concepts we are missing the point of where health care needs to go…that we need to focus on the patient (and their health), not the system. Right now we just feed the system, and the patient usually falls by the wayside.

    • Aaron James Stupple

      Mike, I hear you, but I don’t think the hierarchies are a distraction- they exist. When you have a suspicious mole, you currently have no choice but to seek an expert, and you have to take time off from work and use a car to do it. It’s a very real hierarchy of medical knowledge. Sure, they’re inefficient, and patients get marginalized, I agree, but we can’t just talk these antiquated hierarchies away. We need a force that will actually disrupt these hierarchies, and we are obligated to do some work to bring it about soon, and yet as smoothly as possible.

      Thanks for commenting!

  • Anonymous

    I totally agree. Healthcare IT and mHealth technologies should be an integral part of med school. I describe this in my blog: You sound like someone who will be a leader. Congrats, Aaron.

    • Aaron James Stupple

      Thank you Dr. Scher. I hope you don’t mind if I use your phrase “the first wave of clinician experts in healthcare IT.” Here’s to them (us?).

      • Anonymous

        Not at all..I speak the truth.

  • Chris Boardman

    the user (patient) community is far ahead of the status quo. There is huge advantage in embracing disruptive technology. Further, we are not going backwards…ever. Communication and networking technology is here to stay.

    • Aaron James Stupple

      Right- we’re not going backwards! Thanks Chris!

  • Robert Bowman

    Medical schools are the key, but medical schools have failed to figure out where they and their products, physicians, are most likely to retain value. Science prowess and technologic advances will continue to result in more competitors than ever before. Clinician specific medical education focus and clinician specific care focus has been lost. Physicians are also failing in critical areas such as awareness of the needs of most Americans, communication skills, empathy, service orientation, and the ability to defer their own needs when conflicting with the needs of the patient or the nation.

    There is little or no indication that medical education leaders will return to the basic skills and characteristics needed – even when medical students are beginning to understand that clinician focus is more and more essential. Those that have experienced the care of true physicians have the beginning of a great physician and hopefully training will not derail them.

    Without a solid clinician foundation established from the first week of the first year of training, no manner of technology will fix the problems facing physicians, including the problem of those that will displace them.

    If Flexner was somehow returned to reevaluate medical education, he would be appalled at the lack of education dedicated to developing clinicians. Where technology improved this focus, he might be supportive. Where the technologies distract or where the other duties of “faculty” distract, he would call for reform. And he would also call once again for a substantial reduction of the numbers trained for any number of reasons including improvements in the quality of physicians and medical education.

  • Brian Curry

     I think you may need to reevaluate your premises. Technology such as Skin of Mine isn’t necessarily disruptive in that it endangers the entrenched hierarchy of medicine, and I think you do your future peers a disservice by characterizing resistance to such innovations as due to that disruption.

    Consider, for example, the possibility that Skin of Mine isn’t actually all that good (haven’t used it, can’t comment on it). Perhaps it has such low sensitivity and specificity that it really just isn’t a particularly useful innovation. Say what you will about the allure of so-called “bottom-up” innovations, but so far they haven’t proven terribly useful yet. It’s easy to envision an ideal scenario where a patient uses the product, and is then armed with the appropriate questions to ask his/her PCP, but what about the other side of the coin? Is there a risk that a patient is mistakenly reassured, and so FAILS to bring it up with his/her PCP? What if the app mistakenly indicates a need for concern, and the PCP has a different opinion?

    In fact, the disclaimer on the terms of use site for Skin of Mine effectively say that the app is for entertainment purposes only, most likely because the makers of the app recognize the potential for untoward consequences with an online consultation scheme that has no standardized way of ensuring image quality, or any realistic, practical ability to perform a follow-up.

    In its current form, this is merely an intriguing idea, not a major step forward. Not yet, anyway. Does that mean it is doomed to fail? Not at all; as I said, it’s intriguing. But it ain’t ready for prime time.

    Moreover, why in the name of all that is holy should medical schools (which are already just barely able to condense the curriculum into the standard 4 years as it is) devote precious time to such technologies, considering that the vast majority of them will likely be flashes in the pan?

    • Aaron James Stupple

      Dr.(?) Curry- I agree with you here, especially your last paragraph. Skin of Mine is certainly not ready for prime time.

      My point is that patients don’t know this, and they will seek apps that appear to short circuit the traditional hierarchy of medicine if they can avoid taking time off from work to get their problems fixed. App makers know this, and hopefully their products aren’t crap, but there obviously will be some that are.

      Regardless, rough waters lie ahead- how should we deal? I think that med schools should try to figure out how to incoporate these developments, learn how to assess them for being crappy or not, and marry that process with app makers while simultaneously using the med students to expose the clinical faculty to these breakthroughs.

      Agreed, it’s fanciful, but I think worth considering. I totally agree with the challenges indicated in your last paragraph.

      Thank you for reading and offering your insight.

  • Aaron James Stupple

    Dr. Bowman, I appreciate your comments. I’m going to pass along your blog post to our curriculum redesign team. In brief, it is my humble opinion that the newer tech tools will take a lot of the technical duties out of Dr.’s hands and free them up to do more of the human duties (subtle use of a tablet and incorporation of apps for chronic disease, say, to enable longer office visits that focus on the patients’ needs.)

    Thanks for commenting!

  • MiddleGateMed

    In my humble opinion believe Mr. Curry may have strayed from the primary point of the article.  Indeed, individual technologies may be found wanting because, among other things, they lack the the specificity or sensitivity to be truly useful. However, if I read the article correctly, it is simply a call to recognize that a large part of the future of medicine may very well be in these bottom-up disruptive technologies as opposed to the top down hierarchical technologies of old.  

    Furthermore, it appeared that the intent was to state that we would be well served to train future physicians to evaluate and decide whether to accept such technologies as they are brought to them from the bottom-up rather than the current approach which is to resist and attempt to plug them into a top-down (“you must participate in a long term, prospective, randomized, double blind study…that is likely funded by the very pharmaceutical/medical technology company with a vested interest in the outcome”) paradigm. Case in point:  During my clinical career, I went through three EMR installations.  Each time, the younger generation of physicians seemed better able to understand the relative merits of the EMR, and thus, they were better able to roll with the inevitable frustrations of the installation (Please…no agism comments here…this was simply an observation).  This is hardly a true “bottom-up” approach, but it did speak to the merit of one generation of physicians being relatively more open to a new technology than the previous one.Were one to apply training to this observation (i.e.: “How to incorporate/analyze disruptive technologies in your practice”), the outcomes could be rather pleasant in terms of public health, and physician mental health outcomes.

    • Aaron James Stupple

      MiddleGateMed- yes, indeed. Regardless of how well I’ve conveyed it in writing, you are in fact describing my intent quite nicely. Thank you!

    • Brian Curry

      Oh, certainly. I mean, I keep getting amazed every time I take my phone out of my pocket, to think that this phone is hands-down more powerful than the full-sized computer I had on my desk not even 10 years ago. The potential for innovation, for streamlining, for ushering in the dawning of a new health care era exceeds the ability of my feeble imagination to conceive.

      But I envision a problem with crowd-sourcing medical innovation, in that it would be extraordinarily difficult to ensure that QUALITY of care does not vary inversely with CONVENIENCE. And I think it is of utmost importance to consider this. It doesn’t necessarily mean that there is no value to so-called “bottom-up” innovation, and I didn’t mean to imply that I believed that. I do, however, believe that integrating such innovation into our current system must be done VERY cautiously, without irrational exuberance. Any drop in quality or safety will be measured in human lives (and/or quality thereof).

      So I suppose my position is one of cautious optimism. The possibilities are certainly intriguing (and, dare I say, exciting?), and I will be interested to see how these things progress.

      I stand by my criticism, however, that medical schools are probably not the place for field-testing these innovations. Keep in mind, however, that my opinion is affected, at least in part, by the fact that I’m currently slogging my way through my second year.

      • Aaron James Stupple

        Gotcha. I have precisely the same concerns about quality and convenience, and the need for caution. In fact, that’s why I’m suggesting that medical schools should be involved- specifically to target this issue of quality and caution, yet married with the innovative and idealistic spirit of the younger, more digitally savvy in the field.

  • Anonymous

    Nice stuff, Aaron.  I’m on board with the idea of medical transformation coming bottom up but I have concerns that the current system won’t embrace this kind of change.  I suspect that innovation will come from the fringe driven, as you suggest, by the consumer.  Contrast this with the way things happened in the 20th century.  Everything arose from academia.
    I suspect that schools will not usher changes from outside but will adopt from a position of not having any choice.  

    • Aaron James Stupple

      Doctor V- I agree, schools probably won’t. I just think they SHOULD. And maybe, if an adventurous school went for it, as a little pilot project, then maybe it would catch on, if only a tiny bit…. Predicting the future is so hard.

    • Brian Curry

      I always get a little bit uncomfortable when people start referring to patients as consumers. This may be the wrong forum to discuss this (and if so, I apologize), but I would be curious to know why people choose that word: Is it A) to reflect a greater sense of empowerment among patients (which I view as a very good thing), or B) a belief that health care truly ought to move toward a customer-service mindset? Because I can get behind the former (and then I would probably see the merit in your comment), but the latter, not so much.

      • Aaron James Stupple

        When I call or email Zappos or Apple customer service and I get an immediate response to my concerns, I actually feel that these companies care about and for me, regardless of their true motivations. I imagine that if patients can’t get that kind of support from their doctor over the phone or via email, they may feel not cared for, again regardless of their physician’s true motivation.

        Personally, I agree that using the word consumer is tricky, and I like your breakdown a lot. But I think we’re doing patients a disservice if we ignore the successes that private industry has achieved in customer service and treat patients as wholly other than consumers.

  • Jonathan Marcus

    I’m a family doctor in Toronto.

    Of course we need to make mastering use of info technology part of medical education but I think the most important place to emphasize the ‘bottom up’ approach is in the actual doctor-patient relationship.  And this does not occur in medical school but in our offices… and hopefully in the future in any modern communication tools we use with patients.
    We need to get doctors thinking the way Aaron describes…. probably best with young physicians who are more likely to be open-minded.

    This needs to trickle down from patients and physicians to medical schools, not start in medical schools, which are already higher up on the hierarchy chain.

    Bottom line is this all starts with a patient and a doctor engaging each other and saying ‘how can we make this better?’

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