As I am currently working on revamping a Curriculum to Train Physicians, I am discouraged by our overwhelming Physician Ego. We as physicians can not let go of ourselves to serve others in a way we would like to be served. We must accept ourselves, our patients and the system in which we survive, but without contentment. I hear from collegeaues, "How can we teach students to take histories when they do not have the basics". If communicating, active listening, acceptance of the patient, non bias approaches, self reflection, understanding the transferences and countertransferences are not basics in which we thrive, then we have missed the opportunity to train a techinician to become a physician. Physicians need to be the role models in this every changing environment of medical education, we need to stay in the role as physician(teacher). With all the different curricula's and methods of teaching, has anyone found the best way to educate a physician. How can we measure the medical student (outcome) prior to residency? We definitely need a revolution and not evolution! How many revolutons are successful? And not every revolution is good for all concerned, especially the ones on the front lines.

This is a great 'summer reading list'. One of the most important aspects of revolutionizing healthcare, especially with respect to connected health is connecting with the generations of providers that are in training. We have not had good luck in this pursuit at Harvard Medical School because the curriculum is full of other pursuits that are more traditional in nature. I"d recommend this reading list to medical school administrators across the country.

I have added an additional 5 books to complete the reading list. Thanks to Drs. Detar and Kvedar for comments so far.

Genomic Medicine: Articles from the New England Journal of Medicine by Elias Zerhouni , Alan E. Guttmacher , Francis S. Collins , Jeffrey M. Drazen

The issue: Genomics will likely completely change the face of clinical practice over the next 15 years. Great physicians will be distinguished from average largely on their integration of genomics into their practice. Are we sufficiently educating physicians to practice “personalized medicine”, and preparing them for the culture shock as their superior genomic knowledge meets current clinical practice?

The advances in genomics come so quickly, that clinicians must accustom themselves to stay very current with the literature. This introduction from the NEJM is as valuable for it’s content, as for the message that clinicians should habituate themselves to staying very current with the literature, especially in this rapidly changing and pivotal area.

Overcoming the Five Dysfunctions of a Team – Patrick Lencioni

The issue: Effective clinical practice is now much less dependent on individual effort than teamwork. Yet medical education still emphasizes the complete primacy of the physician and provides little formal training in the dynamics of good teamwork.

This classic provides a simple analysis of how teams become dysfunctional and what to do about it. The physician of the future will not be just a team captain, she will be required to manage teams effectively and overcome breakdowns to produce better outcomes for patients.

Small is the New Big – Seth Godin

The issue: 70 % of internet users search for healthcare information on line in any given year, and the utility of the internet in healthcare delivery is growing rapidly. Physicians need a deep understanding of the new economy and why the internet is becoming so powerful as a social networking device, since health is largely about connection to self and others.

Seth Godin provides a quirky and highly original take on business in the new economy. In the process, he provides a window on how individuals and organizations will succeed in a world governed by new rules. His observations are indispensable to future leaders who will need to be conversant in everything from viral marketing to blogs to help their organizations succeed.

Wholeness and the Implicate Order – David Bohm

The issue: The mind-body problem has taken on new relevance with recent research demonstrating the extreme plasticity of the brain, and clinical observations of the role of placebo and belief in clinical outcomes. Physicians would benefit from a more sophisticated view of the philosophy of mind.

This classic by a Nobel Prize winning physicist and friend of Einstein, argues that all points in the universe contain all others. The surprising implications may help solve the otherwise inexplicable phenomenon of the mind’s ability to synthesize simultaneous data presented to different areas of the outer cerebral cortex into a unified “consciousness” without evidence of interconnecting neuronal tracks. Accustoming physicians to think deeply about paradoxes like these opens them up to understanding patients (and their contradictions better), and helps create a constructive curiosity and sense of awe for the brain and the mind.

The Collected Poems of Robert Frost

The issue: Increasingly, narrative medicine is being recognized as a means of encouraging and growing the natural humanity in young physicians.

These poems are deceptively simple, dealing with universal themes with an uncanny sense of rhythm that communicates much more than the surface words. They are great training for physicians who need to learn to read all aspects of a patient’s communication, both verbal and non-verbal. One of my favorites, and a wonderful place to end, is Frost’s wry comment on revolutions. (I thank Jim Bramson, a teammate at Revolution for introducing me to this poem). In it, Frost cautions us not to take ourselves too seriously, and to make certain that we temper the change we advocate with good sense, so as not to end up back where we started.

A SEMI-REVOLUTION
By Robert Frost

I advocate a semi-revolution.
The trouble with a total revolution
(Ask any reputable Rosicrucian)
Is that it brings the same class up on top.
Yes, revolutions are only the salves,
But they're one thing that should be done by halves.

Medical Education can easily be revolutionized with existing technologies. There are a few issues that remain/need to be ironed out. I see a few movements in the field of holistic medicine, some growing interest in 'introspective approaches' to mental health etc...., introspective approaches that are being made observable by third parties through various sensor and imaging technologies etc... I heard that a paper documenting the mental health of monks in a reputable laboratory run by Davidson (Wisconsin), Paul Elkman(Berkeley) for e.g. is the 5 most downloaded paper in history. There are also other domains which are not getting revolutionized when it appears that things should really be trivially easy. Let's look at distance education technologies and simulation technologies for example. I can talk about those because these are my field of interest. I had a chance to discuss those with Joseph when I was at the last ATA. While I am fond of philosophical abstractions, I also think there are practical things that can be done here and now, and the only stumbling block at this time for revolutionizing medical education through distance learning and simulation technologies is mainly cultural. For example the target audience for this forum, one would have hoped, to be coming more from practitioners, clinicians, nurses and less from the management end of things. I think there is a lot of effort to be done there. Inspite of the wealth of telecommunication and web2.0 technologies, it is really discouraging to see the outstanding intra communication problems between people in the field.

Abraham Lincoln famously said: “This country, with its institutions, belongs to the people who inhabit it. Whenever they shall grow weary of the existing government, they can exercise their constitutional rights of amending it, or exercise their revolutionary right to overthrow it.”

The very fact that we are discussing the latter rather than the former “right” indicates the desperate state that some aspects of healthcare finds itself in.

Prior to taking up arms for revolutionizing healthcare it is essential to emphasise the need for “revolutionizing the person”. Let us go back to 1968 and to the scene of another revolution. Reportedly, during the French student revolt of May 1968 there was a poignant graffiti which read, “The revolution must take place in men before it can be manifest in things.” In the long term it would be futile to propose solutions knowing full well that the “soldiers” responsible for delivering it lack the humanity and humility that could make the most bitter pill taste as sweet as honey. I believe it was Mother Teresa who said: “The biggest disease today is not leprosy or tuberculosis, but rather the feeling of being unwanted.” The psychology of the interaction between the physician and the patient can be as important if not more important than the clinical care that the patient receives.

Yes, education (not only for the healthcare professionals but also the general public) is one of the main foundation blocks of an ideal healthcare system. Back in 2002 while looking at some diabetes statistics I was shocked to find out that of the 17 million Americans affected by diabetes one in three did not even know it. It transpired that even those who were aware of their condition were not receiving proper care - for example 52% reported that their healthcare provider NEVER discussed lowering blood pressure or lowering cholesterol (45%).

But it would be a mistake to prepare a highly trained and educated group of revolutionaries for a journey without ensuring that proper infrastructure, systems and vehicles are put at their disposal. There is no point in sending the most highly trained deep sea divers to the Sahara desert. Show them the Ocean…

“Nothing is particularly hard if you divide it into small jobs” – Henry Ford. The significant healthcare problems we are faced with are solvable. Furthermore, in my humble view, we currently have more technology than we need to address the issue. We are beginning to see what I refer to as Tribal Revolutionary Leaders. Leaders concentrating on specific aspects of healthcare. The trick now is to evolve this so that we can encompass all the relevant aspects of healthcare. In a strange way it looks as if the answer lies partly in revolution and partly in evolution. This echos Robert Frost’s telling poem (see Jeff Gruen’s article above).

In conclusion, the problems associated with healthcare are not specific to the U.S. This is an issue with true international dimensions. And right here lies a most interesting opportunity. A truly international business opportunity with the potential of enviable return to the investors and delivery of a cost-effective patient-centred, caring, quality healthcare made possible mainly through economies of scale and innovative solutions, technologies and business models of a nature not available until recently.

Jeff Gruen started his fascinating and thought provoking column by quoting Einstein. It would only be appropriate to end by quoting this genius once again: “In the middle of difficulty lies opportunity”.

Sepe Sehati

I would add the following:

Amusing Ourselves to Death: public discourse in the age of entertainment and Technopoly, both by the late Prof. Neil Postman;

Medical students need to understand that we live in an age of entertainment and big business and celebrities. All of this talk about senstizing medical students to patients real inner selves and real needs is just so much talk. The reality is that doctors have become cogs in the assembly line of medical care that is run by Harvard MBAs and other business types. See Dr. Richard Reece's self published book: The Corporate Transformation of American Medicine. Medicine is big business. The $2 trillion U.S. health care economy is ripe pickings for business types or "bidnessmen" as they are called down here in the provinces of South Texas. Medical students are attracted to medicine because they want to help people. Few enter the profession merely for the purpose of making money. But they will soon find that their professors, often beholden to Big Pharma and not wanting to rock the managed care boat, don't tell them what is really going on in the actual practice of medicine. I once asked Harry Schwartz, long time New York Times editorial writer,why doctors in HMOs couldn't take good care of their patients. He boomed in an answer that caused other diners in the Barbizon Hotel dining room to turn their heads, " Because they won't let them!" By that he meant that the MBA types who run HMOs and insurance companies set the rules that govern how doctors get paid. and no, it's not doctor ignorance and greed, that justifies managed care and the business takeover of medicine. It's big money that controls congress and the courts and prevents things like ERISA reform that would allow patients and their honest, conscientious doctors to resist the unchecked ability of business types to define what is medically necessary care.

Lest you think I am not committed to a scientific examination of outcomes, I helped develop the Duke Cardiovascular Databank that will celebrate its 40th anniversay this September. This is the largest cardiovascular databank in the world that allows doctors to track acutal outcomes in all patients with coronary artery disease who have been treated at Duke Medical Center since the 1970's. This project was long ago defunded by the insurance industry and government and the Robert Wood Johnson Foundation ( clinical scholars program )as being too expensive. That means it was business persons, not doctors, who didn't want to pay for a rigorous look at outcomes so doctors could tell their patients how other patients just like them in terms of prognostic variables did with interventions such as bypass surgery vs. medical treatment. Medical students need an accurate view of history and need to know that the busines community and thier bought off political enablers in national and state legislative bodies have constructed a health care system over the last 40 years that is not friendly to doctors or patients. Postman's two books will allow them to understand the real process of political discourse.

For the business community and for medical students, I have this advice: you can't get the doctors without also getting the patients.

Brant S Mittler MD JD
San Antonio, Texas