Physician-centered informatics

We've seen that physicians involved with patient care still do not have a way to get all the necessary and current information to them on demand. We have seen that not much has changed from the era when physicians tore out journal articles and placed them in a file cabinet, although the physical cabinet has been replaced by the computer. Even so, the task of getting the information to the physician is still hit-or-miss, and much depends on how motivated and computer-savvy the physician is. To help avoid the consequences of applying outdated therapy, health systems have attempted to ensure uniform and reasonably current therapy by instituting clinical decision support systems, which is a top-down approach, to "guide" the doctor to doing the right thing, as long as he/she uses the electronic medical record.

The problem, as I have highlighted, is that when physicians get updated, it must be parsed and filed for easy access when needed. I call this "source-prioritized" since the physician must stand ready to receive the flood of new information, whether or not there is a need for that particular data-item at that particular time. This is the paradigm for medical education at present. However, when faced with a new clinical problem, there is a need to get all that updated information at the point of need. This may be at varying intervals from the last time the physician attended to the electronic file cabinet, and the last time that new clinical data was received, which may be months in the past. For rare diseases, it may be years. The physician often resorts to PubMed and hopes that the clinical reports retrieved will be clinically relevant and helpful. This is "demand-prioritized" informatics, and the technology is primitive. As I can personally attest, it can be difficult to find and retrieve those meeting notes, where they discussed "practice-changing" data. Even so, many developments and breakthroughs come with controversy and provisos. Many times have I read articles that sounded like they were in the practice changing category, only to discuss these with experts who remained unconvinced, and recommended caution and restraint.

When generalist physicians have questions or problems, they call specialists. When specialists have questions or problems, they contact their sub-subspecialty peers. Often patients have to go to an outside institution for another opinion. There have been organizations, such as All4Cure, that help to establish the right connection for patients with specific disease. However, in the era of travel restrictions and energy inflation, traveling to another state, especially when weakened, can be impractical. And with the technology available, should not have to be absolutely necessary.

The focus of new healthcare startups has been mainly telehealth, data-mining for hospitals and insurance companies (and whomever wants the information, such as Big Tech), and to provide help with patient triage in the clinic. Some offer to use AI to help identify high-risk trajectories and assist the doctor in making predictions that could save lives down the line. While helpful, this does not address the problem mentioned above.

Being able to consult with a thought leader or at least a person more intimately familiar with a new medication or technology would be invaluable to a clinician. This luxury is not always available, but every physician can attest to the recommendation influence of hearing a thought leader's viewpoints as to a new treatment. In my own experience, the insights provided by a video review of PI3-Kinase inhibitors was extremely helpful in my decision to use the medication, and with which one to select. Many pharmaceutical companies are well aware of this, and the speaker programs often successfully persuade doctors to use a particular drug over the competition.

Some media companies have focused on capturing the opinions of thought leaders on video, and have already built a comprehensive library. One such company is Research to Practice. This company only focuses on a select group of the more common malignancies, however. Organization of the material is by conference or seminar, and there is no search function, so it would be difficult for a demand-prioritized query. Similarly, Targeted Oncology has a nice collection of videos as well, and cover a more comprehensive panel of malignancies. There is a search function here, which pulls up a list of videos. To be able to bookmark or easily set a link to these videos in one's knowledge management system would be wonderful. I am not aware of any way to automatically import a link to each video into software such as Zotero.

I would favor a Lexis-Nexis type of system, with a focus on medicine. Ideally, in this system, a physician could enter a clinical query and instantly pull up the latest information culled from practice guidelines, relevant conferences, warnings and precautions from the FDA, links to pharmaceutical databases if the query concerns the use of a medication, and relevant contextualized opinions previously captured on video. This is currently beyond the capabilities of any existing AI, and will likely require the ongoing input of humans. But these humans will need to be physicians, each knowledgeable in their respective fields. Who would devote themselves to this service? As it stands we don't have enough physicians in the workforce.

Physician thought leaders and enterprising junior staff, are instead devoting their time and energy to the development of clinical practice guidelines. So far, these guidelines have been written to be deployed by humans. But if the inputs are present in the electronic medical record, then it would be possible for software to recognize that a particular branch along a certain decision tree is pertinent to a patient's management, and should be considered. There would be the need for legal indemnities, of course, should the wrong pathway be implemented based on faulty input, but this is a matter for a different forum.

In my previous posts, I reviewed the nature of the problem that physicians face in trying to stay abreast of the massive amounts of information that grows daily and relentlessly. Many physicians have less free time to absorb the growing knowledge base, but have to have the latest information when they are confronted with a new patient. Fortunately most clinical problems are not quite so time-sensitive, but in my field of hematology and oncology, practice-changing updates occur more often than before. I reviewed that hospitals and insurance companies are aware of the need to have their employed physicians stay up to date, and therefore have implemented electronic medical records with Clinical Decision Support modules built-in.

Since the task of absorbing medical knowledge is still exceedingly challenging even for the dedicated physician, I mentioned that many physicians have their network of colleagues that they confer with to stay abreast. There are organizations (such as themednet.org consisting of physicians who make themselves available to weigh in on a clinical problem and provide commentary and advice. This is, in essence, an online tumor board. I have also seen smaller groups of physicians trying to do the same thing. I don't have information about the latency of this system, and would suspect that one should expect at least a few days between question submission and getting a response. Of course, if the response is too vague or in need of clarification and refinement, then another few days may be necessary before getting the desired helpful response. There are other online tumor boards, but these also suffer from the latency drawback.

As a physician would ideally like to be working with a contextual search engine that would give me focused and relevant results in real-time. Such a device doesn't exist, unfortunately, but it's not due to lack of effort.

Some physicians have used Twitter as a kind of online consult. The problem, of course, is that the Twitter format is limiting in terms of how much text you can post. So you have to be terse and concise, but that may hinder getting all the pertinent information across. Privacy should not be an issue as long as you don't post personal or identifying information. The information you get back is only going to be as good as who is subscribing to your Twitter feed and who reads it.

A few years ago, the University of Connecticutt sought to provide curated information about cancer mutations, compiling the latest in scientific research in genetics and molecular biology with the right treatments. The effort would be powered by human experts at the Jackson Laboratory and the Maine Cancer Genomics Initiative. I couldn't find information on who the "medical literature experts" were (physicians vs librarians) nor the current status of this effort. While intriguing, the ongoing reliance on human effort makes this initiative of uncertain benefit in the long-term.

A startup company Veeva.com had earlier sought to be a scientific information company, "centralizing global medical content" and developing a Veeva Vault MedComms, which would "deliver a single source of truth". The company has morphed into a clinical trials management company now.

In 2013, MD Anderson Cancer Center was involved in an ambitious project to create The Oncology Expert Advisor, which would provide advisory capability to help manage oncology care and connect patients to clinical trials. They used the IBM Watson engine to power this tool, one of the first efforts at using artificial intelligence. The promise was that Watson would absorb the information in the medical record and absorb the vast medical literature, and make treatment recommendations. Alas, the project proved to be too difficult, as Watson couldn't parse doctors' notes nor accurately digest patient histories. Physicians spent too much time on trying to make the technology work, and less time on patient care. Ultimately, the project was shut down in 2017. And recently, Watson Health itself was broken up and the pieces sold to a private equity company.

Another effort at using AI to help physicians in the clinic was the Babylon app, which used a chatbot approach to getting patient information into its system. The software had great promise but problems became evident after initial deployement, highlighting ongoing difficulty in replicating the human brain in the act of medical diagnosis and decision-making. The company also experienced difficulty with a data breach, which is always a potential threat when storing medical information. I would have been happy with just the medical diagnosis and treatment recommendation modules, but the app appears to be veering into the telehealth market, which is less of a technological hurdle to surmount.

Kurzweil's Singularity is fast approaching, but at this time, I can safely say that there is no artificially intelligent platform that threatens to replace the expert physician. There are too many cognitive process that cannot as yet be algorithmatized. While this is reassuring from a job security standpoint, at some point in the near future, physicians will need to have an assistive device, a cybernetic assistant if you will, to help with the clinical decision making. Even a task as containerized as assimilating the medical literature to a machine-parsable form is not simple. At present, the medical literature is mainly in human-readible form. Publishers may demand that new submissions to a medical journal conform to a new format, where authors provide specific machine codes (like ICD-10 codes) to help software better understand the substance of the article and how it relates to other information.

Clinical practice guidelines already exist to help human oncologists standardize treatment. These could be modified to help a cybernetic assistant traverse an algorithmic pathway to the appropriate endpoint, but there are many subtleties that must be taken into account that these guidelines are not designed to incorporate, such as a patient's personal factors, medical comorbidities, social situation, etc.

Besides having an AI assistant, are there other ways to help physicians get educated? Yes, I believe so, but at this time, these options are at a rudimentary stage. I will discuss this in my next essay.

Consider a physician at the point of interaction with a patient. After taking the history and performing the physical examination, and ordering the necessary lab tests and imaging studies, the physician might be ready to recommend treatment. There are many factors that go into his/her decision-making, and although I will discuss more of these later, for this discussion I will focus on how the physician feels confident in recommending the optimal therapy, based not only on individual factors pertinent to the patient, but drawing upon the knowledge base built up after many hours of learning the basics and dedicated inculcation of new advances. These are part of the decision-making that goes into formulating a treatment plan.

How physicians stay updated on latest developments is likely personal style. Those involved in research or who are narrowly specialized generally keep abreast of the latest developments by reading specialty journals in a focused manner. Specialists also often serve as a referee for specialty journals, reviewing submitted manuscripts for publication (since they often review and summarize the field of concern). They also attend focused research meetings, which offer the opportunity to interact with peers, and sometimes learn the scuttlebutt of what successes have been seen in some researcher’s lab, which

For the general clinician, absorbed in patient care, journal reading is the best way of learning of latest developments. This is, of course, easier said than done. With a busy clinic schedule, with time taken up by navigating through the electronic record system (which, at least in the system I used, was plagued with updates which mainly served to re-arrange the interface that one grew familiar with, forcing the physician to develop new workflows and keystroke patterns until the next update). Then there’s family time, and time to just rest and recharge. Trying to find dedicated time to “enter the zone” and study journals is very challenging.

There have been some efforts to lower the barrier to resistance to this effort, such as to email physicians the table of contents of a journal, in order to make it easy to click and browse articles. However, not all journals provide this service, and I’ve found that locating all of the the desired emails when it’s time to study is not always easy.

My journal newspaper

I have found it easier to browse a “newspaper” instead. In my field of hematology and medical oncology, I have compiled a newspaper containing assembled links from all the journals that I typically browse to stay abreast. It has been much easier to read all the latest articles this way. You can check it out at

https://heme-onc.news.

Using a reference manager is key

Being able to peruse the journal contents is only half the task. One needs to be able to store these in a retrievable manner, akin to the file cabinets that were used in bygone times. It is vital to have a system that allows for organized and quick retrieval of reference material. Some have maintained a system of PDF files in a folder, but this requires finding the link to the PDF, downloading the file, and storing it in the appropriate folder. To save time and accomplish this task more efficiently, I have recommended to residents the use of a good reference manager. I have found Zotero system to be easy to use and conveninent. One can install a browser extension that when clicked, can download the article and save it in the appropriate folder for later retrieval. This system does require a reasonably affordable cost in storage, however, but it is definitely worth the investment.

But having a digital file cabinet of references does not alone guarantee that a patient is going to get the latest and proper treatment from his/her physician. I will discuss more of this in my next posting.

In my last two postings, I described how a physician’s task to stay up to date with medical knowledge in the field has increased in difficulty over the years, as the body of literature from which to cull the necessary knowledge has increased tremendously. I then described how physicians performed this necessary duty — initially by filing curated articles ripped from print journals, then later digital subscriptions and publications, attending tumor boards, meetings and selected seminars, keeping up with accreditations, and consulting with local experts. Even so, this methodology is hit-and-miss, and many discoveries and practice-changing developments could easily be missed. Academicians, who often have a lighter patient care load, are better suited to attend meetings and have more time for reading than the community physician, who is often saddled with an increasing amount of administrative paperwork and the extra time needed to deal with electronic medical records.

Hospitals, insurance companies, medical group administrators have long been aware that a doctor’s grasp of current developments is not always reliably comprehensive. However, these healthcare organizations know that better treatments often lead to better outcomes that improve survival, and better patient outcomes are what healthcare systems would prefer to tout to consumers selecting personal healthcare options.

Practice guidelines

One approach has been to develop clinical practice guidelines. In my field of oncology, the National Comprehensive Cancer Network (NCCN) has developed an extensive set of algorithmic guidelines that have proven to be a great resource to medical oncologists, especially to those who are relatively inexperienced, need a refresher, or are practicing in an environment with no easy access to expert consultants. Unlike the textbooks of yore, these algorithms more explicitly direct the oncologist to consider options that might be proferred by an expert consultant.

The goal has been to “continuously” update these guidelines, and in practice, they are updated “at least annually” although an important development could trigger an interim meeting. Changes are approved by a committee and then the guideline is updated. But it is possible that a practicing physician might not be made aware of late breaking developments for varying durations, possibly weeks to months, for example, if he or she unaware of changes made to the guidelines. What shall we do about doctors not checking guidelines regularly?

Clinical Decision Support systems

Recognizing that creating a nice reference tool is of little value if it is not used, another effort has been made in parallel with the deployment of guidelines. Rather than rely on the physician to read and follow the guidelines, what if the guidelines are put in front of their faces whenever the physician tries to order a treatment? What if the treatment that has been recognized as the most suitable, is promoted as the best option, when the physician is ready to place the order for a treatment? Brilliant, isn’t it? This is guaranteed to capture the attention of the ordering physician at the time of decision-making, to make sure that the right therapy is at least considered. This approach has been referred to as “clinical decision support”. No more dependence on doctors to educate themselves! The system will step in and educate the physician as to what to do. Physicians may be given the option to decline the suggestion, and enact the original decision, but the reason for the departure from the orthodoxy generally must be given in order to proceed to completion. The goal is to encourage physicians to modify their practice in accordance with what is considered standard therapy, and this is often done by utilizing the electronic medical record platform and “computerized physican order entry”, known as CPOE.

This approach has the backing of HealthIT.gov and at least one widely-used electronic medical record (EMR) system has implemented this. In the oncology world, the company behind many clinical journals, and which calls itself an information and analytics company, has a tool called ClinicalPath, which offers an algorithmic approach to cancer care similar to that of the NCCN guidelines, but which can be integrated into an EMR. While this will help guide an oncologist to select a treatment from a set of “reasonable” options, the implementations that I have had experience with have been similar to having to take the extra time to feed an automaton with pertinent clinical data, then having the algorithm present the treatment options to consider. If you agree, then you are done, but if you disagree, you ust state the reason behind your objection, and provide references and then detail the alternate regimen you recommend. This process needs to be repeated for every single patient who is getting treatment that day, and as you might imagine, get very time consuming. Proponents of CPS point to studies that suggest that these systems improve patient care and save lives. However, clinical decision support systems have not always been viewed with enthusiasm by physicians. Some of the reasons include interruption of workflow, and time consumption. Some have voiced low confidence with the recommendations presented and the evidence behind them. Some complain about the suboptimal implementation, with inadequate detail of the data input into the system, leading to simplistic and inappropriate recommendations. Some have said that the system is fraught with annoying and repetitive “advisories” that are sometimes irrelevant and are viewed as simply disruptive. CDS systems have been known to contribute to physician fatigue and burnout. Once implemented, there may be little effort taken to evaluate the effectiveness of the system, nor mechanisms to allow physicians to provide helpful feedback. These systems are very expensive, and once purchased and installed, it is highly unlikely that an organization will reverse course.

Yes, CDS systems are not going away, and substantial investments have been made to implement these systems already. The proponents of the concept have sold the idea to major healthcare systems, who see the benefit not only of providing evidence-based information to the employed physician, but also offers the ability to audit each physician. One can see which doctor ordered a treatment, and how that compares with peers, what the objections were, and even how much a treatment is costing the system.

Maintaining these systems, and keeping them current with latest evidence-based data requires an ongoing subscription investment as well. Committees of physicians will need to commit to the necessary update meetings to refine the guidelines on which the recommendations provided by the CDS will be based. Many aspects of medicine are not cookie-cutter straightforward and there are many clinical situations that do not lend themselves to rote algorithmic implementation. There is still the need for understanding the finer points of the studies cited behind the recommendation, and the nuances of the patient for which the treatent is being considered.

While CDS-directed systems have advantages (especially to the auditors, administrators and tech companies), it doesn’t address the fact that physicians are still not reliably being educated. For a while, it might feel that these systems get in the way of practicing medicine, and make the physician feel that he/she is reduced to just being an implementer of a committee’s decision. It takes more time and effort to deviate from recommended protocols, so the temptation may be to just “go with the flow” every single time. The physician may feel that his/her knowledge base is not as valued as before, but instead, he/she just needs to trust the software. I personally feel that this system is not what I envisioned medical practice would be like. I think that there is still a role for the informed, educated and insightful physician, willing to make bold and reasoned decisions.

In the next posting, I will discuss some efforts made to help guide physicians into making decisions for their patients.

Further reading:
https://www.nature.com/articles/s41746-020-0221-y

https://healthitanalytics.com/features/understanding-the-basics-of-clinical-decision-support-systems

https://ehrintelligence.com/news/top-clinical-decision-support-system-cdss-companies-by-ambulatory-inpatient

The past twenty years has seen incredible changes in how people work, much of it driven by computers and the advances in computational firepower and miniaturization, and medicine is no exception. However, it is a well-known trope that physicians tend to lag behind in adoption of newer technologies. For example, we still use an acoustic stethoscope during bedside rounds and in the clinic — technology just slightly modified from the 19th century. And the way physicians get educated about new developments in their field hasn’t changed much either.

Good ol’ printed journals

Physicians receive new information through reading journals as before. In bygone years, it was not unusual to see stacks of unread journals piled up in a corner, waiting for that free weekend or moment, when there will be time to start whittling away at the pile. I am not aware of any study that analyzed how diligently physicians attended to this task. There have been services set up to help physicians at least be aware of developments by sending them a list of the table of contents by email, so that at least they could glance at the titles of the current issue. This would often entail a subscription, however, and it wasn’t clear that it was worth subscribing just to get an email periodically, when you weren’t really in need of access to the journal itself (since it was often availale freely in the hospital library). There were subscription services, where someone would curate a list of key articles in various journals and this would be sent to you (I contributed to one such publication). Of course, this meant you had to trust the editors to make sure you weren’t missing out on the important developments, and delegating this task to someone else never felt right with me.

Meetings

Attending key national meetings was often a priority, especially for academicians who presented their research. But if you were in a group practice or a hospital-employed physician, these meetings were cumbersome to arrange, expensive, took time away from work, and were only once a year. It was not always possible to attend these meetings if you could not arrange coverage for your absence. Annual meetings are not frequent enough for a physician to rely on to be considered up-to-date. Oh sure, you could go to multiple events, but that gets really expensive. Many physicians took to attending evening meetings, hosted by pharmaceutical companies. These were fun to attend, but you couldn’t be certain that you were getting an unbiased education that was not designed to steer your practice pattern a certain way. One of the benefits of the recent pandemic has been the greater access to online participation in conferences, but even so, there is a limit to how many of these conferences a physician can devote time to.

Before I leave the topic of meetings, I would like to point out that how a physician views himself/herself determines the meetings that he/she will attend. The general physician (or even the generic specialist) will go to larger, broad-interest conferences. While the more specialized specialist will go to more focused meetings, such as those that might deal with lung cancer alone, or in immune checkpoint inhibitor therapy, or in clinical applications of genomics. There are other meetings that are of interest to specialized specialists (like those that only deal with breast oncology) where discussions are focused on what questions should be answered in future clinical trials. These can be insightful gatherings as those at the forefronts may discuss what has been working and what hasn’t; what looks like a hot development that hasn’t yet been published. Insights from these meetings can shape what will be the focus of clinical investigation in the near future, and might provide options for novel treatment that most other oncologists might not yet be aware.

Identifying your trusted “local experts”

After reading the above, it is quite clear that not all physicians are equally “on top” with the latest information. And how could we? There is way too much to know. One of the areas where this became starkly apparent was the way that patients with COVID-19 were treated. How an afflicted patient was treated for this novel condition depended on the local hospital. Community hospitals often transferred their sickest patients to hospitals in the major centers where there was centralized expertise. The local infectious disease specialist was often the designated COVID-19 authority, and that person was tasked with staying abreast on the latest treatment recommendations. But although the CDC provided guidelines and suggestions for management, those who followed the Twitter feeds of certain physician groups were aware that there were doctors who were incorporating novel therapies based on models and shared clinical observations that were not formally disseminated to physicians at large. It was up to the local physician to look for the latest information and put that into practice.

So physicians often discuss cases with one another, and many physicians have their network of trusted experts to keep them informed when they have questions. This can be a curbside phone call or a formal referral for a second opinion. Patients often request second opinions as well, sometimes just to get reassurance of a proposed treatment plan, but sometimes to get another opinion because of special factors in a case where the right answer is not so clear. When one has exhausted all clinical management options, it can be helpful to get the insight from someone who regularly attends the focused subspecialty conferences, not only to possibly glean new insights into treatment options from a person who attends the latest meetings, but to get make sure that a clinical detail did not get missed. In oncology, cases can get presented to a tumor conference, and many physicians feel that this provides some support for an action plan. However the conference is as good as the attendees.

How well does this work?

All right, I’ve covered many (undoubtedly not all) of the ways that physicians get information to stay up to date in their field. It should be apparent that this process is somewhat hit-or-miss, and is largely guided by the physician. Different physicians have their own system, but once he or she leaves training, there is no systematized method of updating one’s knowledge base. This may be one of medicine’s glaring weaknesses.

Physicians are tested periodically by national medical boards, and these organizations strive to keep physicians current on the latest treatment. The American Board of Medical Specialties used to just certify physicians every 10 years, but recognizing that this is not frequent enough, now have programs where you can maintain your certification with testing every 2 years. Many physicians embark on a flurry of review and cramming before the exam, but it’s not clear that this promotes information retention.

So far, there has been no solid effort made (that I’m aware) to help physicians address this important deficiency. However, organizations such as hospitals and insurance companies have recognized that it does not serve their clientele when physicians on their panel don’t seem up to date, and select treatments that are wildly disparate from their colleagues, are expensive or outdated. So what is being done to rein in these maverick doctors?

I’ll discuss this in my next posting.

The “rip and tear” days

Back in the 1980s, when owning a personal computer was still mostly the domain of nerds and techies, most physicians depended on printed medical journals. Since it was impractial and unnecessarily expensive to subscribe to them all, it was not unusual to mainly get the official journal of medical societies delivered to the office. The rest were available at the hospital library, of course. Some doctors would rip and tear out key articles from their personal subscriptions, and file them in the office file cabinet for handy reference. As a resident and subspecialty fellow, I would often be handed these to copy and read.

In the early days, physicians would often request that the hospital librarian do a literature search for them, and send back a list of suggested articles. Then the physician would select a few articles for the librarian to retrieve, and then the article would get back to the physician in a day or two, depending on how long it took to locate another library that carried the publication. When personal computers became more mainstream, the more computer-savvy physicians would learn the PUBMED syntax and try their hands at doing medical literature searches themselves. One still had to ask the medical librarian to retrieve the articles, however. Supplemental education would take place at medical conferences and evening meetings that pharmaceutical companies would sponsor. I remember being told by one of my instructors that he didn’t need to attend conferences because he was able to read everything he needed to know in the journals her subscribed to. Good times…

The Information Boom

In my own subspecialty field, which is hematology and medical oncology, there’s a lot to have to keep up with. The specialty of hematology covers diseases of the blood, such as iron metabolism, coagulation (both excessive clotting problems and inadequate clotting leading to excessive bleeding and bruising), hematopoiesis (which basically covers growth of red blood cells, platelets, each subtype of white blood cell), and malignancies of the blood system (such as leukemia). Medical oncology covers cancers of solid organs, like those of the lung, pancreas and colon, etc). Although surgical oncology and radiation oncology are separate disciplines, the medical oncologist has to keep up enough to know how advances in those disciplines will affect the medical management of cancer. We need to stay current with the latest medical therapy, such as the indications of all the newly approved drugs, as well as their pharmacology. What has made this more challenging are the advances in genetics and molecular and cell biology, which has relevance to diagnosis and disease classification, but also has impacted therapy. Advances in computational technology has accelerated progress incredibly in the past few decades, and this had made my field incredibly interesting and rewarding, as so much progress has been made in understanding cancer and hematopoiesis.

I’ve sensed that the amount of information that a competent hematologist/oncologist has to absorb and master has increased since the rip-and-tear era, and my instincts were confirmed. Using the number of articles registered in PubMed in the National Library of Medicine, it is clear that there are more articles published since the 1970s.

And look at how much the cancer literature has increased in the past few decades:

This is especially notable if one focuses just on the literature dealing with the cancer at the level of genetics, protein (genomics, proteomics, metagenomics, etc — now just lumped together as “omics”)

How is the modern physician expected to stay reasonably up to date with all of this? We’ll continue this discussion in my next posting.