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Simon Carlile and Ann Jervie Sefton
The information age, combining rapidly developing information technology and massive growth in biomedical and clinical data, is placing special demands on healthcare workers. Further, radical changes in access to information in our society are affecting the doctor-patient relationship. These changes necessitate a new approach to primary and continuing medical education. A number of imperatives for medical education are identified and some practical changes to a medical curriculum are described.
MJA 1998; 168: 340-343 Introduction -
The information age -
Management of healthcare -
Information technology and medical institutions -
Information technology in general practice -
The changing patient-doctor relationship -
Information technology and medical education -
The direction of curriculum change -
References -
Authors' details
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©MJA1998
Introduction |
More than two decades ago Alvin Toffler wrote prophetically about the
need to recognise and manage the dramatic changes that he foresaw in
our society.1 That change is
certainly upon us and, as predicted by Toffler, is being driven by a
multitude of technological and economic developments. In
particular, the rapid development and popularisation of the
Internet and the World Wide Web (WWW) have profoundly changed the
accessibility of information for medical practitioners and their
patients. Moreover, rapid developments in the basic and clinical
sciences and in diagnostic and therapeutic technologies place their
own particular pressures on medical practitioners. Now, more than
ever before, we need to be equipped with the mental attitude and
intellectual tools to deal with and to exploit such changes.
Primary and continuing medical education needs to play a principal role in this process. Education needs a fundamental change of focus from simply delivering content to developing the ability to manage these changes. "Learning to learn" and "learning for life" should be a major guiding influence in curriculum development.2,3 In this article we examine the "information age" and explore its implications for medical education and future practice. |
The information age |
The fusion of computing and communications is considered the
defining characteristic of the information age. For medicine, such
changes need to be examined in the context of the explosion of relevant
information from the basic and clinical sciences.
The Internet and the World Wide Web One principal effect of the WWW has been to shift the emphasis from institutions (public or private) to individuals as publishers of information. It has been argued that, as the users of this technology increase in number and degree of sophistication, this so-called "democratisation" of information will change many of our social institutions. For instance, the political process will undoubtedly be affected by the increased availability of government documents, court rulings, and an increased variety of political commentary (see the website at http://www2.eff.org/pub/Activism/). Similarly, the nature of education will change with the increased availability of on-line courses from a global range of institutions, together with appearance of just-in-time training (allowing selection of training programs when they are needed). This impact is likely to be greatest for institutions that rely on controlling particular types of information to maintain authority. In medicine, the doctor-patient relationship is likely to be affected by the increased availability to patients of medical information. Information technology and the information explosion in biomedical
science For medicine, the information explosion brings with it an increase in treatment options, accompanied by an increase in the possible treatment combinations and possible interactions. While dissemination and use of such information remains a problem, information technology (IT) is providing partial solutions. For example:
The development of such tools begins to address the problem of evaluating the ever-increasing volume of data. However, simply deploying technology for accessing this information is an inadequate response. Doctors need to become independent in their capacities to review and select the most valid and relevant information quickly and efficiently, and medical educators must address this need. |
Management of healthcare |
A recent Commonwealth Scientific and Industrial Research
Organisation report indicates that the cost of healthcare has risen
steadily from 5% of gross domestic product in 1960 to almost 9% today.13 This report is based on
Australian and United Kingdom foresight studies which indicate that
appropriate deployment of IT will play a role in containing health
costs, principally through improving the mechanisms of collection,
analysis and sharing of relevant data. As a result, investment in IT by
health authorities is almost certain to increase in an effort to gain
efficiencies and cost savings in the healthcare sector.
Information technologies are already having a major impact on areas such as medical imaging and pathology. Image manipulation, remote consultation and patient records are increasingly managed by means of various forms of IT.11,14 While the interfaces to these systems are generally relatively straightforward, the current lack of standards is unhelpful, requiring an unnecessarily high level of sophistication for users to be able to generalise across systems. The development of an electronic patient record, which has been the focus of considerable effort both in Australia and internationally,15 will provide the basis for considerable improvements in standards for data access and manipulation.16 The development of standards for both electronic patient records and the interfaces that allow manipulation of these data should be driven by the data-handling needs of clinical users so that appropriate strategies are used. Data-access methods that are unnecessarily complex and user-unfriendly lead to a loss of user confidence and resistance to their use. Further, training -- informed by and designed for the healthcare workers using these systems -- is necessary. Such an approach will be an essential ingredient in the acceptance and success of such systems. |
Information technology and medical institutions |
In the medium term it is likely that hospitals will be equipped with
bedside workstations, which would use a consistent user interface
and provide the following kinds of data:
Such technology is already in place today in the neonatal intensive care unit at the New Children's Hospital at Westmead (Sydney, New South Wales).17 This is seen by many as a pilot project for applying these kinds of technologies throughout that hospital. Accordingly, the New Children's Hospital also has a state-of-the-art IT infrastructure, a computer on every desk with universal e-mail access, and a film-less radiology department. Electronic mail and messaging are used heavily by most hospital staff. Without even looking over the technological horizon, a number of straightforward estimates can be made regarding the kinds of technologies very likely to be deployed within the next five years. The clinical environment of the near future, based on extant technology, will include:
These are all systems that are currently in development or beginning to be trialled in different work environments. |
Information technology in general practice |
Among studies of the current and projected use of IT by general
practitioners,18 many have
been aimed at identifying areas where significant value or
functionality could be added to the activities of a general practice
using desktop systems and the Internet. Services identified
included:
Many of these kinds of services are already available from providers such as the MIMS medical network or Internet service providers such as Mediserve (NSW, Australia), Health Communication Network Ltd (Australia) or Health Net (Australia). These systems exploit rapidly evolving technologies centred on the WWW as the principal means of delivery. The only certainty about these technologies is that their character and role will change dramatically over the short to medium term. However, as they are currently being exposed to the most stringent form of market testing -- that by relatively unsophisticated users -- their evolution will result in increasingly intuitive and transparent interfaces. |
The changing patient-doctor relationship |
The WWW is shaping up to be the world's greatest repository of rapidly
accessible information, although this is uncatalogued in any
conventional way. To date, the major search engines have indexed
every word on more than 30 million Web pages. However, as yet there are
no agreed protocols for renewal and evaluation of the information on
the WWW, although there are a number of guidelines available (eg,
http://www.science.widener.edu/~withers/inform.html), and the
WWW consortium which sets internationally agreed standards has a
number of working parties exam ining these issues (see
http://www.w3.org/TandS/ and http://www.w3.org/PICS/). The
number and type of websites is increasing exponentially (see the
Box), and, although many sites contain information of little
educational worth,19-21
there are also many very useful sites.
The implications for medicine are that this is an information resource that is accessible by an increasing number of patients, and in many cases is being contributed to by patients. A keyword search on "HIV" using the AltaVista search engine provides pointers to about 300 000 pages of information on the WWW. Self-help and support groups for an increasingly large range of diseases and disorders provide complex indexes and WWW navigation trails to these information sources. In addition, local medical groups are increasingly looking to provide their patients with relevant information and pointers to the best information available internationally, and clinicians and hospitals are publishing on the WWW to provide local information and advice. It is important to recognise that patients will increasingly turn to such sites for medical and other information over the next few years. Patients are likely to become more medically literate and, as a consequence, there will need to be a shift in the doctor-patient relationship that focuses on sharing resources and negotiating treatments.22 Practitioners will need not only to review and evaluate relevant sites regularly, but also to offer advice on locating accurate and up-to-date information. Patient access to information on best practice will also have important implications for the centralised management of healthcare. For example, treatments that are favoured for their cost effectiveness may not always correspond with what a patient sees as his or her own most effective treatment.23 |
Information technology and medical education |
The combined pressures of the information explosion,
administrative and fiscal pressures towards digital management and
advances in diagnostic and therapeutic technologies all require a
reasonable level of IT sophistication from medical practitioners
and other healthcare workers.
Information technologies are slowly being integrated into secondary and tertiary education.24,25 However, the way in which these technologies are generally being deployed in medical education needs to be radically overhauled. More often than not computers, computer-based education and informatics are offered as ancillary courses or additional learning resources. To be effective, it is essential that this training be integrated deeply into the medical curricula.26 Effective training must exploit the information and procedural models that are currently used and most likely to be used in future medical practice. Further, as a generation in computing terms has shrunk to around 18 months for both hardware and major systems developments, there is a need to emphasise generic computing skills rather than specific packages and interfaces. A recent survey of the directors of clinical training in teaching hospitals in Sydney indicates that the level of IT competency among interns and residents is generally low.27 Exacerbated by a lack of interface standards, such doctors are reported to have difficulty with generalising across different hospital systems to access the information they need in their clinical practice.27 In the area of fellowship training and in continuing medical education, IT competency is also important, as it provides access to a range of flexible teaching and learning options such as self-pacing, customisation and self-evaluation that are, in general, not being exploited at this level. These are very important messages for those who educate our doctors. The pedagogy needs to change significantly to enable tomorrow's doctors to manage and exploit the technological change necessary to cope with the information management demands that will come from their profession and their patients. There is no simple technological solution. The necessary change involves alterations in the way educators and practitioners incorporate information into their practice. Educators need to focus on the processes of learning and on reinforcing the natural curiosity that underpins an attitude of "learning for life".3,28 Doctors need to be able continually to evaluate new information that informs clinical practice in the context of evidence-based medicine.8,29 This capacity requires a range of intellectual and technical tools together with a flexibility of approach that has not been apparent in many mainstream medical curricula. For instance, there is generally a stark contrast between the didactic educational model in the preclinical years and the problem-solving required in the course of normal medical practice. This is being addressed by curricula developed at the Newcastle Medical School and now at the three graduate medical schools (Flinders, Queensland and Sydney).2,3,30 |
The direction of curriculum change |
It is clear that IT needs to be an integral part of the medical
curriculum, and that the way it is taught needs to reflect the ways
students will use these same technologies when they graduate. Such an
approach is currently being implemented at the University of Sydney,31 where students are taught
to make clinical decisions on the basis of a critical appraisal of the
best evidence readily available. Students use computers to access
information and learning resources (text, images, websites etc),
communicate by electronic mail and electronic forums, consult
databases, use word processors and presentation tools for preparing
written work, and analyse data using spreadsheets. Translated to
clinical practice, ready access to relevant and current data enables
informed decision-making, which ensures quality care and can
contribute to minimising the costs of that care.
Medical education also needs to prepare students for changes in the doctor-patient relationship. Placing appropriate emphasis on personal and professional development helps students develop skills in evaluating the quality of information and in communicating their conclusions to increasingly literate patients. |
References |
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Reprints: Dr S Carlile, Department of Physiology, F13,
University of Sydney, NSW 2006.
E-mail: simonc AT
physiol.usyd.edu.au
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