MEDICAL EDUCATION IN, AND FOR, AN XPONENTIALLY HANGING ORLD E C W CCME, Winnipeg, CANADA, April 30, 2017 My background • A former teacher at all levels • A former consultant at the Boston Consulting Group • A thinker about k-12 and tech (7 books, 100s of articles and essays) • Coiner of the term “Digital Native” What I try to do • See new perspectives • Spot trends early • Generate original ideas • Find solutions Key Caveats • I’m from the U.S. • I’m not a physician But… • I have a strong background & interest in science • I know a lot about technology and K-12 • I do research • I have original ideas The most diverse nation on earth? Only 35 M, but a leader What you do is Incredibly important Medical schools in world: 1,935 Pop. (M) # Med Schools 1,388 China 130 1,343 India 219 326 USA 147 Canada: 17 schools Indonesia 32 264 Brazil 84 211 4 in top 50 (top 4%) 197 Pakistan 34 192 Nigeria 22 12 in top 250 (top 13%) 165 Bangladesh 96 143 Russia 60 130 Mexico 40 My 4 escapes from death Ruptured appendix (age 3) Torsion of Testicle (age 13) Prostate Cancer (age 51) Type II Diabetes (age 55) “The Epley Maneuver” used to treat benign paroxysmal positional vertigo (BPPV) of the posterior or anterior canals. BUT NOW… You are in the center of enormous change We all live in a world evolving incredibly rapidly, and… No matter how fast, or how much, you think the world is changing, it is, in fact, changing faster, and more. AND… No matter how much you think we know, we are still only at the beginning Known part of universe (w/o dark matter/energy) 10% Cells in our body that are “human” (w/o dark DNA in biome) 5% Known amount about the brain 3% We live in “exponential times” “It’s humbling” “Acquire …above all, the grace of humility.” Sir William Osler (1849-1919) Let me cut right to the chase The medical world is on the cusp of really, really big changes The state-of-the-art in medicine Is rapidly evolving— Forces of change are transforming education and health for both individuals and the system. Dermot Kelleher, MD Dean, Faculty of Medicine The University of British Columbia There will be “radical transformations” in medicine in coming decades Jeffrey Flier, MD Former Dean Harvard Medical School “Half of what we teach you during four years of medical school is going to turn out to be wrong or irrelevant by the time you graduate.” Edward Hundert Dean for Medical Education Harvard Medical School “The content of medicine will be turned on its head, because so much of what we don’t understand about diseases will be revealed ... It is a completely different medicine than we understand today” — Larry Smarr, PhD UCSD & Calit 2 The preventive medicine of the 21st century is going to identify the earliest disease transitions and reverse them. Leroy Hood, MD President and co-founder, Institute for Systems Biology So we are clearly at the start of a huge transformation… …yet we still have many places —and will continue to have many places— WITHOUT state-of-the-art • Data • Knowledge • Equipment • Facilities • Practices • etc Much of Our Current Medicine is: Conservative and slow changing Hierarchical A lot more “data free” than many think Full of people with “strongly-held opinions” Research has documented the phenomenon of decreasing quality of clinical performance with increasing years in practice: The more years of practice experience a physician has, the more out-of-date his or her practice patterns may be. Student Perspective: “We are not on the cutting edge” “The way they learned is what they expect of us.” Medical students GIVEN THAT Current medicine Future medicine Is our well-established Is exponentially different, system but still a few years off AND We need to serve the old world as we move to the new ISSUE HOW DO WE TRAIN DOCTORS • For our current medical practice AND • For the practice of the future? A USEFUL TOOL? Peter Hinssen’s “DAY AFTER TOMORROW” FRAMEWORK WHAT WE EMPHASIZE NOW TRADITION TODAY DAY AFTER TOMORROW TOMORROW Source: Peter Hinssen WHERE THE VALUE IS: DAY AFTER TOMOR- TOMORROW ROW TODAY TRADITION Source: Peter Hinssen Healthcare is going to the day after tomorrow faster than ever before. --Peter Hinssen WHAT WE TYPICALLY DO IN REFORMS TRADITION TODAY DAY AFTER TOMORROW TOMORROW Source: Peter Hinssen WHAT WE NEED TO DO TRADITION TODAY DAY AFTER TOMORROW TOMORROW Source: Peter Hinssen We need to simultaneously prepare: “The doctor “The doctor of today of the day and after tomorrow” tomorrow” We need to simultaneously teach: Current Future (Exponential) Medicine Medicine Why? “…the next generation of patients will demand this.” Oncologists working with Watson (per Ginni Rometty, CEO, IBM) How? DAY AFTER TOMORROW MEDICINE TECHNOLOGY is becoming exponentially more powerful We can now collect, store and analyze orders-of-magnitude more data Everything becoming information-based SCIENCE is exponentially changing (tool-driven revolution) We are beginning to understand: • Flows and interactions • Patterns • Systems BIOMEDICAL SCIENCE is exponentially changing New data, New devices, New tools Quantified self, scientific wellness, data flows, -omes - Systems approach being applied to everything Getting closer to understanding underlying mechanisms of disease and wellness What we KNOW is exponentially changing Huge Shifts in Perspective Huge Shifts in Information Deep Shifts in Understanding Of disease and wellness Genomics Humans Transcriptomics Proteomics are a Metabolomics Co-species Epigenomics Phenomics Exposomics What we can MEASURE, STORE and SEE is exponentially changing Sensors Storage “Insidables” Dense dynamic data clouds Dashboards WHAT WE CAN DO is exponentially changing Predict Prevent Personalize The VISION of MEDICINE is exponentially changing It’s NOT just the digitization of existing medicine, but A NEW DIGITAL WAY The VISION of MEDICINE is exponentially changing “a completely new digital care delivery system … unfettered by the analog framework of our past.” — Stefan Bini, MD The VISION of MEDICINE is exponentially changing “a better process that does not look like the current process of medical care.” Isaac “Zak” Kohane, MD Head, Biomedical Informatics Harvard Medical School The VISION of MEDICINE is exponentially changing “Multidisciplinary, with computational experts, genetic experts, clinicians working in a team to create qualitative – or quantum – differences in care.” Isaac “Zak” Kohane, MD Head, Biomedical Informatics Harvard Medical School But wait… There’s more! The MEDICAL CARE PARADIGM is exponentially changing From individuals: Patient MD Care To teams: Medical Family Friends Care Team Technology Payer MD Patient CARE Other Health Hospital Professionals Employer Industry Profound Shifts in Medicine Individual Team Capturing little Capturing everything Unusual cases highlighted/studied All cases available Private data Shared data Educated Guessing Precision Reactive Proactive Populations Individuals Averaged Personalized Disease Wellness and disease Data & monitoring Intermittent Data and monitoring continuous All in person Much remote Acute case treatment Early Prevention & Reversal Long lab to bedside time Quick lab to bedside time Treating proximate causes/symptoms Treating Deep Underlying Causes 55 percent wrong treatments Very few wrong treatments By hand By machine Profound Shifts in Doctoring Autonomous Team “Shut up” Patient whisperer/coach Strong opinions tightly held Strong opinions weakly held Med school as event Med school as process Educated Guessing Precision Reactive Proactive Populations Individuals Averaged Personalized Disease Wellness and disease Data & monitoring Intermittent Data and monitoring continuous All in person Much remote Acute case treatment Early Prevention & Reversal Long lab to bedside time Quick lab to bedside time Treating proximate causes/symptoms Treating Deep Underlying Causes 55 percent wrong treatments Very few wrong treatments ”Art” and “Craft” Information driven By hand By machine Individual diagnoser and treater Executor of consensus strategy Solver of clinical problems Finder of clinical problems Applied scientist Patient coach to wellness Care giver Relator Center Periphery NOW WITH… MEDICAL INFORMATICS GOALS 1. To create an information commons of heterogeneous data that will be useful to researchers, doctors and patients 2. To improve diagnoses and treatments, e.g. improved automated diagnosis systems to Generate new models of diagnosis. remove subjectivity of clinical interactions. 3. To reimagining the clinical encounter, with just-in-time data and decision support 4. To connect all the –omes 5. To train doctors to ask relevant questions Medical students need to be just as adept in advanced computing and data analysis as in biology and patient care. Chirag J Patel, PhD Assistant Professor Department of Biomedical Informatics Harvard Medical School INFORMATICS POP QUIZ (JUST ONE QUESTION) “If a test to detect a disease whose prevalence is one in a thousand has a false positive rate of 5 percent, what is the chance that a person found to have a positive result actually has the disease?” 2 percent The test will yield 50 false positives in a population of 1,000, but only one patient will actually be ill—so a positive test result would mean that a patient has only about a 2 percent chance (1: 51) of having the disease. More than three-quarters of the respondents in the study got this wrong. The most common answer was 95 percent. AND… It’s all getting faster — exponentially Knowledge discovery Drug discovery Knowledge acquisition (Watson) Genome Sequencing Time to test (cont’s monitoring) Clinical Trials Time to tools/improvements Diagnosis Time to reach patient (telemedicine) Doctor Access Time to cure Lab to Bedside Speed of collaboration (J. Mattison) Time to Recovery Medical school? (3 yrs) And there’s even more! People are Changing too! There are lots more of them! They’re increasingly digital natives, with new attitudes, new relationships to tech, & different expectations Digital Natives: Kids who want to be doctors • Different experiences • Different relations to technology • Different expectations about doctoring Digital Natives: Medical Students “I grew up hands-on & instantaneous.