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.