Tuesday, May 13, 2008

Physician Stereotypes and the Failure of Health IT

As a result of my posting "Earthlings and Htraesians: The Parallel Worlds of Medicine and Healthcare IT", a discussion has started on the HISTalk blog. That discussion thread can be seen in the comments section here.

This posting from a PhD raised my eyebrows (emphases mine):

I have seen many people get hired into IT with degrees in everything from Zoology (really) to other non related fields. Their degree offers no value to the position or the job at hand. I think a physician is no more qualified to run IT than a CIO is qualified to perform brain surgery. I believe in a good mix of clinicians and technical experts makes the best combination on implementation teams. However, running an IT department is completely different than running a medical practice. Physicians who believe they can lead IT in healthcare are as misguided as CIOs who think they can design the perfect EMR. PS - I am a PhD in Information Science and do not presume to cross the line into medical practice.

"Physicians who believe they can lead IT in healthcare are as misguided as CIOs who think they can design the perfect EMR?"

That non-physicians cannot practice medicine (i.e., "CIO's not qualified to perform brain surgery") is axiomatic and irrelevant to the argument. However, to say a physician cannot practice something outside of medicine is a non sequitur (at best).

Has the writer spoken to each and every physician, once-physician, retired physician, physician informaticist, physician MBA, and every other physician on the planet, I ask part tongue in cheek and part dead seriously?

The CIO with medical credentials is as rare as hen's teeth, but as I have pointed out in the past, this is not a symmetrical affair. This is especially true in the culture of medicine, where when the opportunity arises, physicians seek additional education (e.g., in healthcare informatics).

What has led to such stereotypical thinking in our society where physicians are concerned? I find the phenomenon alarming, for I encounter it at least as frequently (if not more) than I did when I wrote this piece - a decade ago! - on stereotypes about physicians and IT.

Importantly, I believe this and related stereotypes about physicians are a driver and an enabler (either through genuine belief or through disingenuous opportunism) of much that ails medicine today through the interference of non-medical outsiders. The fundamental message is that physicians are children who cannot do anything more than medicine, and require "a village" of paternalistic non-medical outsiders to manage their affairs.

My response was as follows. I decided to offer specifics, although it is hard to reason people out of a position they arrived at irrationally:

It appears you just stereotyped physicians, who often have significant predoctoral and other experiences beyond medicine, especially those who’ve pursued graduate and postdoctoral training in informatics.

It it in part through such stereotyping, resulting in the exclusion or marginalization of needed cross-disciplinary domain expertise, that health IT runs into expensive, unnecessary difficulty, or fails.

However, you have not stereotyped CIO’s regarding inability to perform neurosurgery, unless that CIO has an MD and training and boards in neurosurgery.

I am a physician, practiced internal and occupational medicine, so I would appear to fall under your statement. My minor in college was computing, right up to IBM 370 assembler, and I began computing years before college via unfettered access to a hands-on DEC PDP-8/S and an HP-2000C timesharing system (1970-1974) and via a Heathkit H-8 I built in medical school for clinical-related experiments, 1978. Also built an infrared-sensing heart monitor in my elective in biomedical engineering at BU School of Medicine. I am also a Radio Amateur, licensed by the FCC at the highest (Extra) class after examination in electronics theory and radio laws.

That background is not entirely atypical for those in medicine who are interested in IT.

Please evaluate my other background items in my online bio, for example, and then tell me why doctors are “unqualified to run IT.” As an information scientist, it should be easy for you to locate that bio.

I await a response.

-- SS

Addendum - I received this response (the person's email address field indicating they are a fellow of HIMSS, the organization that certifies people as "Professionals in Healthcare Information and Management Systems" after a 100-question multiple choice exam):

Understand your comments. I meant to imply, but failed to say, physicians without IT training or CIOs without medical training.

Sorry for the confusion.

Here is a provocative question: was that a genuine clarification, or one done under duress of being challenged? (I believe my points -- in all of my writings including the ones that led to the HISTalk thread -- about the type of physicians best for HIT leadership roles have been extremely clear.)

I will, of course, assume the former as the motivation for the clarification. I replied,

You might add that in a follow up comment.

The problem has become one of stereotypes that are then used (either through genuine belief or disingenuous opportunism) for purposes that serve no one, including patients!

And in fact, the clarification was indeed soon added as a follow up comment by the poster.

-- SS

Addendum: another post appeared, anonymously, focusing on straw arguments, an apparent belief in some sort of symmetry between IT and medical education, a belief that "changes" in IT (largely new programming languages and faster networking and other toys that can be mastered by those already fluent in IT in a short time) outpace those in medicine, that the "hire to the month's technology version du jour" strategy is alive and well in IT, etc. There is real evidence that the cultural divide between IT and the community it purportedly serves - medicine - will not be bridged anytime soon:

From "Preston":

This was a very thought provoking post. After I cooled down a bit I could certainly appreciate your views as true taken from a certain perspective.

Let’s shift that perspective a bit. Consider the nature of the two disciplines with regard to formal education. As a field of study, medical practitioners have the advantage of hundreds of years of collegiate tradition and lexicon with some fundamental concepts so well ingrained into the profession that most TV viewers can rattle them off with ease…breakdowns of anatomy, diagnoses, methodologies, pedagogical structures like “rounds” etc…all substantially similar over decades or hundreds of years.

A key difference in the IT realm is the shear pace of change within the mind-space. Obviously, technological advances in medicine cause rapid change, but I would suggest to you that the speed and scope of changes in IT far outpace and outreach those in medicine.

Changes in IT are evolutionary - scope and speed, mainly - and in fact from the perspective of EMR's is glacially slow. It's been advances in biomedical informatics that have been revolutionary towards creating effective (potentially) clinical IT. In the realm of awareness of sociotechnical (social, organizational, "people") issues in IT projects, the pace of change in IT can perhaps be measured, but the progress would measured in microns - ed.]

Here is a hypothetical example: A computer scientist who achieved doctoral-level credentials at a college in the late 1970s would have worked primarily in an environment of mainframe computing, focused on centralized data processing using procedural programming languages or machine-level code.

Jump forward to 2008 and the credential that that computer scientist received would provide little practical knowledge pertinent to the implementation of small-scale distributed (or web-based) applications using modular or service-oriented concepts...

[that is, assuming they were Americans, were asleep against a tree like Rip Van Winkle, and had a learning disability keeping them at their 1970s level of knowledge, therefore requiring the hiring of foreign nationals - ed.]

... I would further suggest that the limited value of formal education that we often purport is due to the fluidity of change in the area of concern.

["limited value of formal education"- "a degree doesn't get you anything"- how different this ideology is compared to medicine - ed.]

My IT training was accomplished through self-study. I have a music education degree and a Master of Healthcare Administration and I serve as an IT director for a health plan. I also have a professional certification in information security and I will no-doubt continue to seek further education as I go. However, consider this: My education included an alphabet soup of languages/skills that I don’t use anymore in my daily work. You are going to have a hard time convincing dedicated IT professionals that their lack of a rigid educational achievement indicates that they are not viable contributors because the pace of change thwarts all such efforts.

[A classic strawman argument. My point is that a lack of biomedical education and experience put IT personnel outside their core competencies in healthcare IT leadership roles, not that they are "not viable contributors" to health IT because they lack "rigid educational achievement" (whatever 'rigid' means) - ed.]

I value the input of my medical staff and our business directors for the value that they bring (oddly enough, it hadn’t occurred to me to question or even examine their credentials) and I hope that they judge my value primarily on the basis of their interactions with me and the results that we achieve together.

I value "my" medical staff? For the "value they bring" -- in a healthcare setting, no less? Those phrases alone are revealing about the paternalistic and patronizing attitudes at the heart of the IT-medicine cultural divide.

Such ossified views are also characteristic of what I've described as a power inversion in healthcare such that control by its enablers (clinicians) has been usurped by its facilitators (non-clinicians such as IT personnel) to the point that the latter feel they are absolutely entitled to the leadership role.

In effect, the worst aspects of the IT culture are being inflicted upon the medical profession, and due to their relatively good nature and political naiveté, medical professionals are sitting ducks.

This really must change.

-- SS


Nick said...

I've always had the view that the CIO should be removed from the day to day operations of an EMR. Their job is strategic, and it's best to leave that to someone who does the EMR and knows the system.

A CMIO should be the point person between the physicians and the IT group, ideally with a core group of physicians acting as an advisory group to the CMIO.

The only way that an EMR implementation will be successful is if physicians design workflows. If you cut out the physicians, you're screwing yourselves and ultimately, the patients.

InformaticsMD said...

I go a step further.

Pharma partitions IT into business IT and research IT. Names vary, but the idea is that the two are different and require different types of leadership. Both may report to a CIO, but there is a lot of independence tactically and strategically.

I see physician informatics experts as leading health IT, not just acting as advisors.

-- SS