A wide-open brainstorm: let’s list clinicians’ skills, beyond diagnosing

During a conversation with a friend last week I had a hare-brained thought – not rare, as friends know, but this one was thought-provoking. So, patients and providers and everyone else, let’s talk about this:

If diagnosis magically became automated – if some super-test could suddenly identify exactly what your condition is – what are the other skills that would keep clinicians employed?

I know it’s a long list because I’ve spent plenty of hours with providers, I love ‘em, and hardly EVER has it been for one of them to say “Dude, you’ve got X.”

So, patients: what skills do you appreciate, or do you wish you had more of?  And providers – can you help by listing the things you do?

For this exercise I don’t mean bureaucracy – filling out forms etc. I mean the stuff you were trained to do in medical school.

I’ll start with a few:

  • Knowing the treatment options
  • Prescribing, including leading us through the options
  • Caring (in all its forms).
  • Detecting when the robot’s diagnosis is wrong
  • Refining the diagnosis – subtypes, whatever
  • Follow-up / monitoring status

I know med school & nursing school included a lot more than that :) … please leave a comment to make the list grow.

(I hope it’s obvious that I have no covert agenda here – this all came up when someone said “Will IBM Watson do diagnosis?” and I said no, IBM will only let it dish up information, not “play doctor.” But it raised the question, what if diagnosis did have an automated perfect answer?)

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23 Responses to “A wide-open brainstorm: let’s list clinicians’ skills, beyond diagnosing”

  1. David States says:

    Communication. Communication. Communication. The most perfect diagnosis in the world usually does no good if the patient does not understand the diagnosis and the treatment. Yes, there are examples like acute appendicitis where a patient can be cured without understanding what happened, but even there, the patient needs to perform appropriate post op would care to avoid complications. For chronic diseases that are the majority of medicine, the patient has a huge role in treatment, and they need effective communications with their providers to fulfill that role. Some of this can occur second hand through PA and NP intermediaries, but the physician remains the authoritative coordinator.

    David States MD

    • > Communication. Communication. Communication.

      Yes yes yes! SO important, and SUCH a personal skill.

      I could write a book of anecdotes of the many subtle but artful ways @DrDannySands has communicated with me in our few years together. And BOY could I write a book about how my care team communicated with me when I was in hospital.

      (With a separate chapter for the conspicuous cases where others on various teams completely failed on me.)

    • @DrDatz says:

      Indeed. Agreed 100%.

  2. I imagine this day is not to far off in the future… Watson is already being tested in many clinical arenas.

    Physicians will be needed to be sure the data is properly identified and coach the patient through the process. Depending on how the computer’s data is spit out a physicians input will be necessary to guide the patient through the process and also serve as an interpreter of sorts due to the wide variation of health care literacy. Many many patients still require a significant amount of hand holding as they progress through “the process”.

    The physician’s role will most certainly evolve dramatically over the next 5+_ years. The medical education process had best take note of this and adapt to the changes coming to be sure the next generation of physicians are equipped to remain relevant in the environment they will soon enter.

    I still see the most important role(s) for the physician as a team member, walking the patient through the process, there to aid with data input, data interpretation, initiating a proper decision making process once the treatment variables are known, monitoring compliance and side effects, etc…

    Alas… as an orthopedist… I do not see Watson fixing your femur fracture.

  3. Cristin Lind says:

    My skills wish list, in no particular order:
    1. Belief that patient engagement is critical to outcomes and an understanding of the mechanisms of engagement.
    2. Ability to support shared decision making and teaching–at the very least, the ability to shine a spotlight on moments where decisions actually need to be made.
    3. Appreciation of the value of family-to-family, peer-to-peer, partner-to-partner relationships in health care.
    4. Able to connect me with community services and family-run organizations.
    5. Encourages self-differentiation for youth, gives lots of support for teaching health advocacy skills from a young age, like encouraging kids to check themselves in to their own appointments, fill out surveys, etc.

    I could go on!

  4. @DrDatz (Geralyn Datz) on Twitter said: Problem solving and listening. [Me: I'd love to flesh out "problem solving" some more, because there's a BIG variety of "problems" a clinician must face every day.]

    • @DrDatz says:

      Problem solving is HUGE. With my patients it ranges from teaching them how to adapt, overcome, delegate, and manage their disease state(s). It is discerning what is important and needed: empathic listening? Support? Triage? Referral? Involvement of family? Calling a spiritual leader, friend, family member on their behalf? Validating a patients perspective, being a sounding board, listening to and channeling outrage, anger, disgust, grief, sadness and normalizing the very common feeling of “WHY ME?!” I could go on for hours (and my patients could more so).

      Another pivotal issue is EDUCATION. Risks, benefits, and expectations about procedures, medications, therapies. Balancing the many sides of an intervention is a crucial duty of providers. Teaching patients how to understand, anticipate, and nurture in a positive way their course and prognosis. IDENTIFYING negative health habits, attitudes, obstacles to treatment, and achieving REALISTIC GOALS for patients is so life changing.

      Hope this is helpful and thanks for the stimulating discussion! Have to see a day full of patients so retweet away! Thanks for fighting the good fight.

      Warm regards,
      GD

      Wait, and didnt we just name a bunch more skills?

  5. Sara Kubik says:

    My skills lists would include skills necessary for those (few) medical providers who will stand up to lawyers in a court of law to testify on behalf of a patient.

    Too often, doctors will diagnose something but be unwilling to “get involved” in a legal sitatuation. Or doctors will not agree to be called in as expert witnesses.

    While there are many reasons why they choose this, it is most frustrating for the parents/caregivers of the patients to be on the receiving end of this type of care.

    Litigation and the legal arena are no fun to be a part of (for most, that is), yet having a doctor who will back up what they diagnose and state their medical opinions on the record is very important.

    So the skills that medical personnel also need are how to effectively do this in a legal setting.

  6. Fi McKenzie says:

    Listening at the early stages is key for me. Those that have not listened to me have occasionally misdiagnosed my problems. Those that listen, properly listen (not interpret and fit around their own first impressions), have got it right, which has meant the right treatment at the right time. For me this comes most from those that respect your expertise as the person living in your body.

    Observation is also important and is different from examination. I’ve recently been getting my ankle looked at and unsurprisingly lying me down on a couch and examining it (one consultant)didn’t have the same effect as observing me walk up and down a corridor (second consultant).

    Asking for the right diagnostic tests, appropriate to the concern raised by the patient, would be my third.

  7. Hi Dave,
    I think “diagnosing,” a term you include in this post title, along with “caring” may be the 2 most essential tasks of a physician. All good care depends on doing what it takes to accomplish those well.

  8. Cheri Baird says:

    After a work injury 14 months ago, I have been seeing different types of health care providers constantly. Of the many doctors I’ve seen, only one of them seemed to have my best interests at heart vs their own ego/agenda, agency rules or insurance mandates. The easy fix didn’t manifest & at times I’ve felt like a hot potato passed from office to office & treated by many in the most cursory & perfunctory manner.

    I’d like to start your list with some really basic items: simple kindness & courtesy; patience; listening skills; learn about the mind/body connection & it’s relationship to physical health; don’t mock patients for their self-care efforts & attempts to learn about their condition (we can be your greatest ally or foe just with our attitude towards our problems); empathy; behave like you actually have the time to be with the patient during their APPOINTMENT (ie time scheduled just for them); no cell phone interruptions by either party; learn about body language. If a provider won’t make eye contact with me, or sits across the exam room, arms & legs crossed looking down their nose at me, I already know a lot about them & am wishing I was someplace else. Don’t hire ancillary staff who dislike working with people or working in medicine; they will treat your patients badly.

    Take care of yourself so you don’t burn out. If you can, have a life outside medicine, in the end you’ll be a better doctor.

  9. e-Patient Dave says:

    Lots of good stuff in these replies … what I hear in some is a lot of hurt or complaints, which I’m sure is understandable given people’s experiences.

    I hear exactly the same complaints on doctors’ blogs about shortage of time; from what I hear, the gun for that issue points squarely at the forehead of the insurance industry. To use a crude metaphor, imagine if an oil change shop was ordered to get the job done in fewer and fewer minutes and get you out of there.

    I want to point out, though, that what I sought here is on a separate track from the shortfalls in care that people have experienced. I seek an inventory of what *skills* clinicians would need if diagnosis were not on the list.

    Many of the concern/hurt/complaint items in these comments would indeed map onto skills to be learned and practiced.

  10. Elias Kassir says:

    I’m just an undergraduate so I’m afraid I can’t comment with a terribly well-informed opinion, but it seems to me like such a huge part of a physician’s job (particularly one who interacts with patients frequently) is finding out what’s wrong with a patient. Whether that’s sitting face to face with a patient and getting them to tell you enough information for you to figure out what’s wrong with them, or reading test results after ordering some type of imaging scan (and even then, usually a specialist will interpret the image), or whatever else is necessary to diagnose a patient. It seems like only a small portion of the effort a physician has to put into their work actually involves figuring out the treatment, since I imagine that’s fairly straightforward once you have a diagnosis.

    Given that, I’m not sure you would actually need a fully trained physician to determine what the treatment needs to be once a diagnosis has been found, unless it’s a particularly rare problem. I also can’t imagine that you would need a fully trained physician to interpret the results for the patients, just because I wouldn’t think you’d need someone with all that training to interpret the results, someone else could do it (a nurse maybe? Just shooting in the dark here.) And although this is outside of the scenario presented, I’d imagine a diagnosis machine that could give you a perfect diagnosis would also be able to break down the results in an easy-to-understand manner.

    Although there are very specific things that this diagnosis machine could not even begin to replace of course, like doing surgery, as others on here have mentioned.

  11. Khoi Trinh says:

    A doctor can do something a machine can never do: he can listen to a patient’s story, interpret it with his medical knowledge, and parse out the important information. The doctor can understand each individual patient’s personal situation and act appropriately. A lot of information that a patient may provide the physician in their personal narratives will not be easily convertible to a format that machines or programs can use. A doctor will always be needed to be the bridge between the patient and any “super-test” that could be invented. Even if the “super-test” can diagnose the patient accurately without any input from the doctor or the patient, someone must still interpret and explain the diagnosis to the patient. The doctor must also explain the various treatment options to the patient, and then help the patient decide on which option is most preferable for the patient’s personal situation. For instance, some patients can afford to be more risky with their treatment plans if they have fewer external obligations that depend on them. A single parent on the other hand may not be able to afford to undergo such a risky procedure if it would leave him or her incapable of fulfilling other obligations. A machine or program cannot fully understand the patient’s situation, and the patient will be unable to fully appreciate the risks and benefits of each possible treatment option. The doctor is the bridge that can synthesize both the “super-test”’s diagnosis and treatment plans with the patient’s desires and requirements.

  12. Nichole Taylor says:

    I am also just an undergraduate and have thus far (thankfully) not had the need for too many visits to the doctor, but I still appreciate the importance of communication. Surely this theoretical automated diagnosis machine could not draw out the information crucial to understanding what exactly happened and how it could be prevented in the future.
    Any “super-test” could still not get a thorough patient history, which is as important for diagnosis as it is for providing a good course of treatment. I don’t think that the diagnostic machine could at all replace this function, because this requires connecting to and earning the trust of patients. I do agree that perhaps the machine could provide a possibly quite specified based off the information inputting into the machine about the patient (assuming it includes things like sex, weight, age, etc.). However, unless you know that patient X is a single parent with 3 kids in elementary school and works overtime every day you will not know that the 1-time treatment is much more feasible for patient X than the daily dose.
    Another function of the doctor is ensuring that patients continue to get regular checkups/exams. Although not every doctor plays this role, it is important for patients to understand the importance of these exams.
    I think it will be interesting to see how the role of the doctor evolves with the automation of some of the functions of doctors. I wonder if perhaps the cosmetic and psychiatric roles of doctors will expand more, as these issues are not solved by the simple diagnosis and treatment. With the job of diagnosing eliminated, it seems that there could be a polarization of future doctors, with some following the surgical route and some pursuing more empathetic engaging of the patient.

  13. April Velasquez says:

    I’m going to have to agree about communication and caring being the top aspects of a physician. It wouldn’t sit right with a lot of patients to have a computer spit out a diagnosis and then you’re done with the machine. It’s very impersonal and it has the feeling that doctors are too busy to give some of their time to talk directly to the patient, even if they will probably see them for treatment options. It makes it harder to trust a computer that calculates the input from the patient and gives a diagnosis a minute later, especially if a collection of symptoms could mean multiple things. How would the computer differentiate which diagnosis to give? Also, if the diagnosis were wrong, what would be the consequences then? The patient would never want to use the computer again.
    Turning into a different direction, this could change how patients view hospitals and how they are portrayed in media as well. Would medical TV shows be changed to accommodate this new technology or would we continue to have shows like House when all he does is diagnose, even though it wouldn’t be as prevalent anymore? He would be out of a job. His life would change due to the supercomputer. It could change the patients’ view of science also. Computers aren’t science. This could take away some of the legitimacy of the medical field in people’s minds. On the other hand people might see it as a faster way to have doctor’s appointments and may be more willing to engage in appropriate, timely checkups as needed.
    This machine could be a good thing or bad thing for patients. It just depends on how the physicians respond to not being needed for diagnoses.

  14. Hannah says:

    From my experience, medicine is a far cry from just a technical science. It is also a social science based heavily on human interactions. This has been the case with medicine for all of its history; from the time of doctor’s going on house visits to see their patients. Doctors are there to care for patients in more ways than one. Not only are they responsible for treating any physical ailments, but also they need to make the patient feel cared for in terms of being understood, appreciated, and important. As one of my friends has said, “I like going to the doctor. He listens to my stories and makes me feel important.”
    Doctors are there to listen to their patients. To understand the full story and from this piece together a diagnosis and treatment plan that will fit the individual’s health status and lifestyle. For this reason it will always be impossible to replace doctors with machines. A diagnosis comes from more than just a list of symptoms. Doctors have to listen to the patient’s whole story, collect a family history and bring it all together to get a full diagnosis. Even the smallest detail a patient says could be the key to making the correct diagnosis or determining how they are treated. A machine is not able to look at all the factors as specifically and weigh their importance the way a doctor is trained to. Even if the “super-test” can make the diagnosis it cannot treat the patient. It cannot administer medicines, track the patient, ask the patient how he/she is feeling, perform surgeries, or a hoard of other jobs that will remain with the physician. While it is necessary for technology to adapt and improve as the medical field advances, and physicians need to learn and advance with technology, this does not mean it will ever be appropriate to entirely replace physicians with technology.

  15. Seja Abudiab says:

    When it comes to discussions such as these, I feel that it’s important to realize that what clinicians provide beyond diagnosing is what is actually essential to preventing medicine from slipping into this postmodern world where everything exists within the realm of technology. I believe that doctors play a significant role simply in their physical interactions with patients – the actual physical contact, the interpersonal dimension, the healing nature, and the caring for a patient who is ill.
    In a class reading, it was proposed that the “experience of living in a fleshly body that can be injured, can feel pain, can become ill or die is something that simulation cannot supersede or replace with virtual experience.” This idea embodies the distinguishing element that prevents medicine from being entirely virtual and consumed by technology. It is essentially our humanity that prevents us from neglecting the significance that is the doctor-patient relationship. We are not computers or software programs and, for that reason, treating a patient goes beyond some algorithms that form a diagnosis. The patient is an entire body and must be addressed as such.
    In response to the question at hand, I feel that physicians are skilled in dealing with patients and have the ability to address the patient’s physical, emotional and mental needs that distinguishes clinicians as not simply diagnosticians, but as healers.
    I also agree with Dr. Datz’ response that the ability for the doctors to not only speak at, but speak with a patient, is important in diagnosing and educating the patient. In this era of participatory medicine, clinicians are able to engage the patient in a two-way line of communication and educate the patient about proactive health-related measures so that the patient is no longer in the passenger seat, but is navigating the course of their own health.

  16. Felix Yang says:

    Over time, it appears the doctor-patient dynamic has shifted significantly from one where the doctor is in a position of authority over the patient to a present day relationship based on equality between the caregiver and patient. The idea of an all-knowing and omnipotent doctor, the “hero” who can diagnose and cure any health problem, is most likely long eradicated from the minds of the educated public (however, this image is still used among many types of media). Many patients today have taken a more active role in their own healthcare through various forms of social media and technology such as this very website.
    A theoretical “Watson-esque” super-computer that can flawlessly spit out correct diagnoses renders a crucial component of the doctor’s job somewhat useless. As I read through the previous posts, there seems to be a reoccurring theme among the required or desired “skills” of the doctor in the age of this hypothetical future. It seems that as patients become more educated and aware of the vast resources at their fingertips, a lot of the previous posters demand some form of recognition from their doctors as partners in the management of their health. Rather than the doctor being the sole solution to their health problems, patients are now more willing to get involved. Doctors also seem to be encouraging this trend as well.
    Over time, it appears the doctor-patient dynamic has shifted significantly from one where the doctor is in a position of authority over the patient to a present day relationship based on equality between the caregiver and patient. The idea of an all-knowing and omnipotent doctor, the “hero” who can diagnose and cure any health problem, is most likely long eradicated from the minds of the educated public (however, this image is still used among many types of media). Many patients today have taken a more active role in their own healthcare through various forms of social media and technology such as this very website.
    A theoretical “Watson-esque” super-computer that can flawlessly spit out correct diagnoses renders a crucial component of the doctor’s job somewhat useless. As I read through the previous posts, there seems to be a reoccurring theme among the required or desired “skills” of the doctor in the age of this hypothetical future. It seems that as patients become more educated and aware of the vast resources at their fingertips, a lot of the previous posters demand some form of recognition from their doctors as partners in the management of their health. Rather than the doctor being the sole solution to their health problems, patients are now more willing to get involved. Doctors also seem to be encouraging this trend as well.
    The enormity of today’s health issues such as heart disease and diabetes can best be safeguarded through preventative methods and healthy lifestyle choices rather than a singular form of treatment or medication. Thus the doctor can merely give guidance on the best options and it is on the patient’s part to ensure his own healthcare to prevent future visits. With advancements in technology occurring on a daily basis and the rising role of patients in healthcare, the skill set of the clinician must change to one that emphasizes many of the attributes listed above: communication, support, education, and most importantly the forging of a peer-to-peer relationship between doctor and patient.

    • Felix Yang says:

      Ignore that last post as it has some repeated passages:

      Over time, it appears the doctor-patient dynamic has shifted significantly from one where the doctor is in a position of authority over the patient to a present day relationship based on equality between the caregiver and patient. The idea of an all-knowing and omnipotent doctor, the “hero” who can diagnose and cure any health problem, is most likely long eradicated from the minds of the educated public (however, this image is still used among many types of media). Many patients today have taken a more active role in their own healthcare through various forms of social media and technology such as this very website.
      A theoretical “Watson-esque” super-computer that can flawlessly spit out correct diagnoses renders a crucial component of the doctor’s job somewhat useless. As I read through the previous posts, there seems to be a reoccurring theme among the required or desired “skills” of the doctor in the age of this hypothetical future. It seems that as patients become more educated and aware of the vast resources at their fingertips, a lot of the previous posters demand some form of recognition from their doctors as partners in the management of their health. Rather than the doctor being the sole solution to their health problems, patients are now more willing to get involved. Doctors also seem to be encouraging this trend as well.
      The enormity of today’s health issues such as heart disease and diabetes can best be safeguarded through preventative methods and healthy lifestyle choices rather than a singular form of treatment or medication. Thus the doctor can merely give guidance on the best options and it is on the patient’s part to ensure his own healthcare to prevent future visits. With advancements in technology occurring on a daily basis and the rising role of patients in healthcare, the skill set of the clinician must change to one that emphasizes many of the attributes listed above: communication, support, education, and most importantly the forging of a peer-to-peer relationship between doctor and patient.

  17. Peter Cabeceiras says:

    A machine could not account for the idiosyncrasies of the patient, not to mention perform any surgical procedures. In an era of postmodernism, a transition to personalized medicine cannot be accomplished through standardized automated machinery. It requires the interpretation of a well experienced professional who knows what information can be used to tailor a treatment for the patient that is as individualized as the disease.

    The machine providing a general diagnosis and treatment is a harsh oversimplification of what the ideal doctor could accomplish. A physician can show the patient how much they care by making eye contact and asking considerate and pertinent questions during their discussion. The personable doctor can make the patient feel comfortable; this may help the patient describe their problem more clearly, and it may encourage the patient to expand on their lay expertise. The doctor can also take into account all the visual, emotional and psychological cues of the patient that could guide them to a more comprehensive form of diagnosis.

    Doctors can transcend the generic diagnosis which is all too often coupled with a prescription. Physicians, unlike diagnosing machines, can use their experience and knowledge of the patient to find the mechanisms and patterns that comprise the disease. They have to give a name for what the patient’s problem is, but ultimately the explanation for why they have it, and the plan for amelioration are more significant. In the end, the patient wants to meet with a familiar physician who can see the many perspectives of their problem. http://www.webmd.com/news/20080310/what-do-patients-want-from-doctors. Medicine requires much more than the diagnosis.

  18. Meddik says:

    I chat regularly with bloggers diagnosed with chronic conditions and a complaint I hear time and time again is that doctors do not prepare patients for the social and emotional consequences of illness. Doctors cannot double as psychologists, but they should be prepared to engage in these conversations with patients – or at the very least, direct patients to the appropriate channels for seeking care.

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