This generation of doctors has permanently lost their physician brains

Since the earliest days of medical school, I learned fast to bring my computer wherever I went.  Not only did my laptop function as my personal entertainment center through the dullest parts of lectures, but it also proved to be a source of instantaneous and infinite medical knowledge via the click of a mouse.  Four years later and here I am, one hand on the shoulder of patients whilst listening to their afflictions with the other hand already reaching for my iPhone, ready to pull up necessary gaps of my medical knowledge.

Is this proper way to train as a physician?  Surely I’m not the only doctor to sneak out of the patient room like a cheating lover to softly glance at a guideline on UpToDate or straight up ogle a dosing regimen on Epocrates.  Yet, this is how many of us Gen Y physicians survived medical school and how many of us will continue to claw our way through residency and beyond.

It’s a fact.  Your doctors today do not know everything about your health.  But we sure as hell have perfected the art of finding out exactly what we need to provide the right kind of care for you.  So the question remains: are the new physicians of the world the adventurers of medical knowledge, paving paths through the vast and ever-widening available online literature?  Or are we the lazy college grads living in our mothers’ basements, completely functional yet totally okay with someone else doing all the housework?

To infinity and beyond

Every time I am on the phone talking shop with the real Dr. Secemsky (my father), he never hesitates to counter my complaints about residency with unsolicited anecdotes of what it was like during his training.  Back in those days (years? decades?) the only websites around were in unswept cellars and children’s books about Charlotte.  (And yes, they had to walk three miles in the snow to work!) In all honesty, medical training back then sounded awful, not only because of the long hours, but also because of the lack of available medical resources to rely on during their daily grind.   In the 1970s and 80s, students and physicians alike had to trek to the nearest library between patient visits in order to find a relevant journal article or dig up treatment guidelines for uncommon conditions.  Now that there are more computers in hospitals than there are patients, all one needs to do is take a few steps to the nearest terminal and, through a variety of popular medical search engines, find answers to most any clinical questions.

PubMed, created in 1996, was one of the first big players in the field of online medical resources.  It functions as a subscription medical database that provides full access to most life sciences and biomedical journal articles dating back over two decades.  Thankfully, the creation of this trove of online knowledge obliterated the painful activity of searching through countless paperback journals for the right issue and specific study.  Another behemoth, UpToDate,took things a step further by becoming the largest online evidence-based medical textbook.  Written by physicians and covering almost every angle of clinical medicine, it quickly replaced the 30-pound textbooks that even I (gasp) had to lug around the hospital like a baby in a sling.  Can’t wait to tell my kids about that one.

Not only has medical literature become ever more accessible to physicians today, but it is also becoming much more individually tailored to their specific needs.  Take Docphinfor example: created last year by a resident from UPenn, it functions as a free online platform for physicians to share and discuss research from hundreds of specialty-specific journals.

Losing the physician’s brain

So what’s the problem, the reader might ask?  In today’s world, where the efficiency of a physician is more important than ever (think of the estimated 30 million more insured Americans flooding clinics and hospitals around the country in the next few years), one might say that online medical resources are the silver lining to our otherwise stormy healthcare system.  However, critics of such large and readily available online databases are right to question the effects that these sources of medical knowledge are having on physicians’ ability to critically think on their own.

One of the first phrases that I’ve readily picked up as a new resident is “forgetting your intern brain.”  This essentially involves an intern misplacing his notes in a nursing station, only to become completely useless as a physician until said notes were recovered.  I can’t tell you how many times I’ve lost my intern brain, only that it’s a shock that I still have the capacity to write this opinion piece.  In a similar vein, one might rightfully question if newly trained doctors are as dependent on online resources.

What if the Internet shuts down in our hospitals?  Are physicians today prepared to calculate the fractional excretion of sodium without their medical calculator app or recall the recommendations of landmark articles without stepping out to do a quick online search?  In fear of respecting my father in public, his generation of physicians was certainly more readily equipped to do such mental math.  This is simply due to the fact that medical resources were scarcer and less efficient back then, prompting a greater need to commit such knowledge to long-term memory.  Thus it is more than probable that physicians today, not excluding myself, may be too dependent on online medical resources, to the point where it hinders our potential to become more autonomously knowledgeable as practitioners.  It just might be that this generation of new doctors has permanently lost our physician brains.

Take home point

Online medical resources are certainly not the next fad in healthcare.  They are likely to become a permanent fixture in the way we as doctors practice medicine.  Therefore, it is the responsibility of practicing physicians in every generation to not only learn how to navigate these online tools but also to spend enough time absorbing as much of this vast medical knowledge as possible in order to be able to critically think on their own.  Although easier said than done, it’s better for the patient to have their doctor’s brain inside the exam room than left at the computer.

Brian J. Secemsky is an internal medicine resident who blogs at The Huffington Post.  He can be reached on Twitter @BrianSecemskyMD.

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  • MBMD

    I’m sorry but I don’t not understand how providing my patient with the most up to date evidenced based medicine is “clawing my way” through medicine. I thought I was providing my patient with the safest, most reliable medical therapy available without relying on my outdated medical brain that is prone to the human error of believing what was the best treatment 15 years ago is still the best treatment today despite numerous studies showing otherwise. Your entire article suggests that this is a bad thing – but its not, this is the best thing for our patients and they matter a lot more than your ego when facing “older” physicians who think we are too dependent on technology and should rely on the faulty mechanisms of the past.

    • RJones

      I’m a patient not a doctor. I definitely think young physicians are too dependent on looking up information online. It’s a little like having an open book test … and yes, sharp minds can quickly find the correct answer, but it is no substitute for actual knowlege and thinking.

  • dcsmedicallibrarian

    Brian, allow me to make a few comments about what you have said, from my perspective as a medical librarian.

    I’d like to to set the record straight about PubMed. It is NOT a subscription database — anyone can use it, at no cost. PubMed includes the MEDLINE database, which has been around since 1964, and now contains records back to 1950, and is the grandmother/grandfather of all medical literature databases. I wonder how many lives have been saved or bettered because of its free availability throughout the world.
    Depending solely on electronic resources does raise the risk that if there is no power, one loses access to all that knowledge. It’s certainly a good idea to have some backup print resources available for such an eventuality, and as someone with an interest in disaster planning, I recommend just that. But there is simply so much information out there that no one can remember it all, and being able to access it electronically makes it accessible pretty much any time and anywhere.
    Having access to all this online information, either directly, or with some help from your friendly local medical librarian, does not mean you should not know how to think critically about how this information relates to any given patient. Hopefully medical school and your residency program have given you the critical thinking skills you need to do just that.
    And I think your practice as a physician, over time, will cement much of the day-to-day information you need in your brain, with the added option of accessing the things you don’t know immediately through one or more of the electronic resources that are out there to supplement your working knowledge.

  • avianburner

    I completely agree with MBMD. These days there is no excuse to not do something “right” when you have the ability to look up EBM guidelines on your phone right outside of the room. I’m sure our patients would prefer this over guessing, or as the previous commenter said using the same treatment from 15 years ago because that’s what your mentor did.

    And for the record, uptodate is a great resource, but not evidence based. They will have evidence basis for basic things, but for controversies it is still expert opinion. I use it as “a little better than emedicine” to get a great survey of a disease and ddx

  • http://www.facebook.com/people/Patricia-Kelly/56303697 Patricia Kelly

    Up to Date needs to be free for providers, sponsored by the NIH, IOM or like medical body, peer reviewed on an ongoing basis by select committees of providers, and linked to the (eventual evolvedl) standard of care EHR so that instant updates and checks can be automatically accessed at the point of care. After certain diagnostic or therapeutic codes have been entered, links will/should be provided for any recent updates (recalls, warnings, new clinical guidelines, etc.) You would not have to step out of the room and use your smartphone, and the patient would be assured and could be reassured that the latest information was at least available for review before they left the office
    . And it would not be that difficult, or even expensive.

  • karen3

    I’ll chime in with agreement with both of you. Residents with “brains” need to keep in mind, however, that most of these resources are available to modestly enterprising patients. So, if you start quoting x, and the patient scrubbed up on the article the night before the appointment, you’re going to be caught red-handed. There are serious errors in both up-to-date and wikipedia for my condition, I know what they say and I can recognize a cribbing intern at 50 paces. And I get surly when I have to get approval for something from someone who knows less than me and who doesn’t bother to put as much effort into my care as I do.

    To me as a patient, what I really value is the doctor who goes beyond up-to-date, knows where its weak, understands why something may or may not apply to me. I look for a doctor who understands rather than recites.

    • RJones

      Good response Karen.

  • http://www.facebook.com/laura.mitchell.3781 Laura Mitchell

    I think technology, in general, is great. And while computer generated algorithms and decisions trees are helpful, the patient still relies on the human judgment of the health care provider. My biggest concern is that these algorithms are not being used to guide treatment, but that they ARE the treatment. It’s great to have access to all sorts of information, but what do you do if, for some reason, this access is limited or cut off? For example, to pay off your student loans, you agree to go to the south Pacific (one of the OBs I worked with did a year in Truk to reduce his student loan obligation), and internet access is wonky at best? By all means, incorporate technology into medical and nursing education as an adjunct, but do not view it as a substitute for that education. BTW, I remember when the first online access to PubMed, etc. was called “The Grateful Med.”