It's been said in this blog, multiple times, that tomorrow's medical progress is built on today's data. Breakthroughs in treatment of disease can only be achieved by capturing data in an efficient manner to best gauge the effectiveness of a course of action. Similarly, tomorrow's great physicians are built on the lessons of today - what we teach those medical students and residents will carry forward into how those future doctors administer care. This can be seen today speaking with physicians who were once students themselves. When working with these doctors, they often talk about what they were taught when documenting procedures or when performing surgeries - the lessons have been so instilled that many decades later they are still in use. This is why it's important to identify not only the best practices for physicians to adopt, but also to figure out the best way to get them adopted very early in the medical career. If facilities - training hospitals, medical schools, residency programs - can have these optimal methods thoroughly ingrained in their students, then that will translate into better performances when they are practicing medicine. Two recent papers have identified two different best practices that could be adopted in medical education programs - clinical decision support and synoptic reporting.
Both are methods for documenting occurrences and events in providing treatment to patients, and both are widely in use by various practicing physicians in different departments. The benefits for clinical decision support are so well known it's even expected to be included in meaningful use rulings for the EHR portion of the Affordable Healthcare Act. This blog - and others - have talked at length about the various ways that synoptic reporting can help establish uniformity of responses to improve billing, research and other processes. However, in these posts, the authors outline and underline the fact that such standardized and structured information can be of great use to medical students and surgical residents revealing not just how to document matters but also constituting a guideline on what to do and what to pay attention to in these procedures.
In 'Clinical Decision Support for Medical Students' by Jesse M. Ehrenfield MD MPH, Brian Drohan PhD, and Kevin S. Hughes MD the authors define the term 'clinical decision support' before discussing the ways it can improve medical students' learning experience. The authors approach the issue by looking at the need for embracing 'evidence-based medicine' - processes based on results from scientific method - as opposed to 'memory-based medicine' - which is to say relying on a person's own memory to remember a whole host of medical information that could be pertinent to the particular case at hand. Evidence-based medicine relies on (and promotes) the establishment and adoption of standards of care while also capturing the most pertinent information in a structured format that can be used later. Not only does this improve the care provided to patients, but it has financial benefits as well. As the authors write:
The Rand Corporation estimates that “30 percent of medical costs are avoidable if evidence-based medicine is consistently practiced by providers all of the time.” This translates to a potential annual savings $660 billion.
And thus we get to the authors believing that clinical decision support is the best solution for embracing evidence-based medicine while simultaneously acting as a teaching tool for medical students. They define "clinical decision support" as
the use of computer software to apply knowledge bases, guidelines and algorithms to patient data in order to identify the best course of action, and then present that result to the clinician in a way that helps the clinician understand why that is the best course of action
Software designed to lead people to taking the best course of action sounds like the perfect educational tool when it's laid out that way. Branching logic and various calculations can easily show medical students the different outcomes based on the different information they enter. This allows students to understand the variables that will require different treatments - by changing one number or clicking a different selection, they see a new diagnosis or a new requirement for providing care. It's an easily demonstrative tool that will encourages faster comprehension by showing the elements that must come together in order to arrive at a particular diagnosis or treatment plan.
In order for the clinical decision support tool to work for healthcare providers (not just students), it relies on entering data into discrete fields. Only with this structured data can algorithms and knowledge bases be enacted to help form decisions and plans of action. Similarly, synoptic reporting relies on entering in specified responses in their respective fields. This creates and promotes a standard of reporting, where physicians must ensure that certain sections are completed so that data can be collected uniformly. These standards also serve as a way to encourage completeness of reports and as a guideline for surgical residents, according to this study. The study ("The Computerized Synoptic Operative Report: A Novel Tool in Surgical Residency Education" by Illa Gur, MD; Daniel Gur, BTech; and James A. Recabaren, MD) reveals that using a standardized report for operative reporting not only encourages residents to focus on what truly matters in the surgery (what they are reporting on), but it also forces the residents to pay more attention in order to fill out these mandatory fields.
Unstructured operative reports - the kind produced by "memory-based medicine" with dictation and transcription - has no required elements and pretty much allows surgeons to speak at length about whatever they like. Many reports have more information about the emotional state of the patient prior to the procedure than clinical findings that may be of use in the future. Sure, the patient was "pleasant" but how large was the tumor you removed? How clean were the margins you left behind? Synoptic surgical reporting doesn't allow for that information to come at the detriment of critical clinical data. There will always be free text spaces to fill out those sidenotes and tangents if wanted, but the crucial fields are very apparent and emphasized. This emphasis sends a message to surgical residents that they need to report on this, so they need to be aware of it in surgery. And if that's the habit that's formed in residency, then it will carry forward when they are practicing surgeons at another facility - where they will train their residents how to report correctly, thus creating a cycle of improved reporting and enhanced data capture.
A physician once told me "as surgeons, we're trained to be storytellers. We're meant to set the scene of what we're doing. But that doesn't cut it anymore." Training is crucial in so many ways to medical students and residents - not the least of which is the habits they pick up during their training periods. Doing important work to provide care to the people who need it, all while working grueling hours and constantly learning new procedures, terms, and diagnoses. Technology exists today to help those learning make better informed decisions and focus on what truly matters most. It requires a change of approach by entering in structured data - but for those just starting out, this isn't a change at all. This will merely become "the way it is" and not a sea change in documentation. Their learning is improved by being better informed with strong guideposts on what to do; the care they administer is improved by this information and by being more attentive to the most crucial elements; and the information they enter is more complete and accessible by multiple other programs, physicians, and researchers for the benefit of countless patients. Tomorrow's care is built on today's data, and tomorrow's physicians are built on today's education - why wouldn't we want them to have every advantage possible?