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JOSEPH B. MARTIN

Digital doctoring

BY NOW, the stories are legion. Physicians at a California hospital rebel against a new computer system for ordering prescriptions and laboratory tests, forcing it to be shut down. In the Southeast, doctors at an acute care facility bypass the new computer system by seeking assignments on wards that have not been computerized. And in a suburban Boston hospital, the chief of surgery stalks into the CEO's office and, referring to a brand new medical computer system, demands, "Rip it out!"

Why are new technologies resisted by the very professionals they are designed to help, and why is there such aversion to systems designed to improve care, reduce medical errors, and lower medical costs?

The answer is training.

A generation ago, doctors were taught that they were all-knowing healers whose judgment was sacrosanct. But today, there's simply too much to know. With the overwhelming advancement of innovative drugs and procedures, doctoring has moved from an individual endeavor to a team effort, and it is technology that binds the team together.

For example, electronic medical records potentially enable any doctor anywhere to access the full profile of any patient anywhere. Equipment for monitoring hospital patients from a remote location requires only a single nurse or doctor to observe multiple patients at one time via a computer screen -- and to dispatch bedside care as needed. Computerized prescriptions replace illegible Rx scrawls that confound pharmacists and lead to dosage errors.

In general, these technologies let computers do what they do best -- collect and disseminate data -- while letting doctors do the doctoring.

The benefits, both fiscal and medical, are potentially vast. A study by the New England Healthcare Institute and the Massachusetts Technology Collaborative found that spending $210 million to install computer systems for ordering prescriptions electronically in all Massachusetts hospitals would reap savings of $275 million. As value added, the Computer Physician Order Entry system also reduces medication errors and lowers the length of hospital stays. Similar cost-benefit dynamics are at play with other medical technologies ranging from basic electronic records all the way to the remote monitoring of intensive care patients in "tele-ICUs."

But what to some is high-speed technology is simply a nuisance to others -- and here is where physician resistance comes in. Doctors resist new technologies because they are different, and learning how to use them is time-consuming. But more important , new technologies force us to change from the way we were taught to treat patients. From the beleaguered physician's view, technology amounts to a forced cultural revolution attacking their very training, and that is where medical schools can help.

Indeed, the revolution in medical technology is forcing a revolution in medical training as well. Medical school students are no strangers to tech, of course, being products of the digital age. But unlike the past, when medical training revolved around the independent and self-governing individual, today's medical training is, and must continue to be, increasingly geared to teamwork and technology.

"Key to this transformation is having physician training that emphasizes a new set of skills and knowledge," according to a report by the Medicare Payment Advisory Commission. The report recommends using a portion of the Medicare payments to hospitals to reward innovation in residency training.

Not surprisingly, everything is digital at today's med schools from on line physician manuals to bionic mannequins that allow students to practice clinical care on a simulated patient. But it is not just the technology they are trained to adapt to, but what the technology does to them -- monitoring and exposing them every step of the way.

Medical students are second-guessed by both colleagues and machines, and ultimately they learn to explain their thinking and to appreciate the fact that technology can help them to be better doctors.

Then there is the generation gap. Today's medical students are the "digital natives" who grew up showing their parents how to activate TiVo or fast forward the VCR. But it is the older generation of practicing physicians who are the source of resistance to the inevitable incursion of medical technology. How to bring them along?

When major new information technology systems are introduced into a hospital, among the keys to success are training and technical assistance for doctors, peer pressure and reverse-mentoring from younger, more receptive colleagues, and, if necessary, financial incentives to gain compliance.

Eventually, of course, physician resistance to technology will fade as the generations turn. Until then, it is important that the revolution continue, for technology benefits everyone -- by lowering costs and saving lives.

Dr. Joseph B. Martin is dean of Harvard School of Medicine and chairman of the New England Healthcare Institute.

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