Being a doctor in the information age

If I didn’t have the experience of being a doctor and working in clinical medicine, I would imagine that being a doctor in the Information age would be quite easy. Afterall, almost everyone has been a Google doctor at least a few times by now and it seems that AI doctors are just around the corner. Having all that informational support on top of the background knowledge acquired at medical school - being a doctor should be a piece of cake. But is it? Are healthcare information systems really keeping pace with rapid technological advancements? 

 

A tale of two doctors and two phones

Back in 2011, I was an intern in University Medical Centre Ljubljana. To put it in the Information age perspective, this was roughly the time of Youtube’s, Facebook’s and Twitter’s biggest booms of widespread adoption. At that time, I owned a Nokia E52 phone, which was, according to most reviews at the time, an exceptional phone. Even though it had a physical keyboard (without a touchscreen), it was indeed classified as a smartphone. And a proper smartphone it was – it basically had everything one could want: Wi-Fi, camera, web browser, GPS, Gmail, YouTube and Office apps. Even better, its battery easily endured 3-4 days of moderate use.

However, in May of 2012, a few months before I started with my residency in rheumatology, I decided to replace my good old Nokia with a new phone: the Samsung Galaxy S3 - the freshest of the new generation of touchscreen smartphones. Even though it basically had the same core capabilities as the old Nokia, the experience, the swiftness and the charm of it all was on a completely different level. 

Nokia-Samsung
As I soon realized, the difference between the two phones was similar to the difference between an intern and a resident. One could expect an intern to write a draft of a patient report, to discuss the essentials of a patient's diagnosis and treatment plan but one shouldn’t expect an intern to manage a patient or even write a prescription on their own - as we wouldn’t expect the old Nokia to be our main camera or GPS guidance system. However, one does expect a resident to essentially guide the diagnostic and therapeutic process and to confidently manage patients with little to no oversight - and we all know by now that our touchscreen smartphones mostly replaced our cameras and the dedicated GPS guidance systems (to name just a couple of features that the modern smartphone has internalized).

As it turned out, the new smartphone would transform the way I did things, even in my professional life, in more ways that I could imagine. 

 

The development of medical information systems 2011–2023 – a personal viewpoint

Chapter 1 - Healthcare Information Systems 

First, let me quickly revisit the “.com” era of the Information age. At the break of the millennium, when I was still in high school, I took a course in computer programming. First year, the course was based on Visual Basic, a programming language that would let you draw objects like buttons, icons or text fields with a few clicks (you would still have to write the code to make it all work in the background though). The programs made with Visual Basic could look almost exactly like the state-of-the-art software of the time - Microsoft Office 97 or Windows 98. 

Fast forward to 2012, when I actually transitioned to being a real doctor. When I took the first glance at a hospital computer screen at the start of my residency, I was sure that I was looking at some doctor’s nostalgic Visual Basic afterschool project. As it turned out, it was indeed one of the main hospital information systems used by almost all medical departments of a relatively large tertiary hospital. The icons, the fonts, and the whole user interface closely resembled the elements that I used in that high school course more than 10 years prior. Worse still, almost all of the graphical features (small icons, mostly) were utterly unintuitive, sometimes even misleading. 

I have an eerie feeling that someone had made this core piece of healthcare software without even bothering to get any information from the end users - the doctors, the nurses. And, to add insult to injury, they didn’t seem to care enough (or lacked incentive) to make any meaningful updates to the user interface for at least 10 years. Accordingly, it’s not hard to imagine that most doctors considered this kind of informational “support” more of a nuisance than any kind of real support. Some doctors would use the software only for the mandatory “bureaucratic” tasks and actually write the patient documentation in an ordinary text editor (and then copy-paste it to the institutional software). Since the core platform was basically obsolete from its inception, no one in their right mind would expect any meaningful progress, much less a transition to a newer, more modern platform at that time.  

Unfortunately, the pessimists were right - and stayed mostly right even until 2023. Most aspects of the institutional “digital doctor experience” have basically stayed the same for the last decade, except maybe for the color update of the core user interface from gray-cyan-yellow to shades of something between blue and violet. That being said, there was the government-mandated transition from paper to electronic specialist referral forms and prescription forms, and the access to the national repository of electronic health records seems to have improved recently. Also, a large part of the screens that was filled with gray blankness ever since the computer monitors stopped being those big cube-shaped boxes was finally put to use in 2023 – but again, not in a way that would meaningfully benefit the doctors and the nurses using the software. 

So, sadly, not much progress has been seen on the side of institutional healthcare information systems. Surely, you say, the official, government-financed national drug database must have kept its pace at least somewhat better with the whole digital revolution?

 

Chapter 2 - Drug Data

In 2011, when an average doctor wanted to prescribe a drug that hasn’t yet fully settled at the bottom of their brain, they would most commonly use their faithful desktop assistant – the paperback version of the drug registry (yes, something very similar to a phonebook, if you can remember those). Were the doctors able to access the crucial information needed to prescribe a certain drug? Let’s see: the book included all the drugs (that were registered before the specific edition of the book went into print); it also included all the possible dosings (as long as the patient didn’t have any special circumstances, like chronic kidney disease). Search feature? Yes, kind of: the whole book was organized alphabetically, by registered drug names. Updates? Of course, two options: once yearly (if one bothered to buy a new book) or “customized” (if one made the effort to make the updates with a pencil).

However, some doctors were more advanced than that and could use an online version of the drug registry that was made available in the first decade of the new millennium. It was a rudimentary webpage that basically included all the text from the book. Most web browsers also had a text search feature built-in at the time, so a digitally advanced doctor could find what they wanted a bit quicker - as long as they were able to find an unoccupied computer or had a proper smartphone with a decent mobile data plan (institutional Wi-Fi wasn’t really a thing yet). An added bonus was that the updates were probably a bit more frequent than once yearly.

To be fair, a new version of the official national drug registry, this time called the Central Drug Database, was released in 2012. It was a pretty capable tool - at least for someone who bothered to learn exactly how to use it. In all honesty, the user interface was far from optimized for daily use in the clinic and the data most relevant for practicing physicians was hidden behind an inconspicuous link to a full-text SmPC document, buried under a mountain of clinically less relevant text. Did a version optimized for mobile screens exist? Not really, and it still doesn’t. Worse still, the user interface of this official source of drug information has stayed basically the same for more than a decade now. Fortunately for most doctors (and their patients!), someone else took care of making access to crucial, clinically useful drug data more user-friendly.

It might sound like I’m exaggerating, but even the first version of the Mediately app, then called Drug Registry, was a life-saver for a fresh doctor in 2012. Let me explain. Most of the young doctors, fresh from the university, are full of theoretical knowledge. They seem to know all there is to know about the pathophysiology of diseases, mechanisms of drug action, etc. However, perhaps not surprisingly, they soon find out that clinical practice differs quite a lot from theory. One can know all there is to know about pathophysiology of a certain disease but if they don’t know how to treat the disease in practice, they can’t do much good for the patient. Similarly, one can know all there is to know about the mechanism of action of a certain drug, but if they don’t know the exact indications, the exact dosing and, crucially, the registered name of the drug (to name just a few pieces of essential information), all that theoretical knowledge is worth very little when taking care of a real patient. And then, every so often, a brand new drug comes along that wasn’t even mentioned in the big old books.

But even after more than 10 years of experience in clinical medicine, the digital app remains a crucial companion for every doctor I know. Even the old-school doctors, some of them seemingly reluctant to rely on digital technology, found out that decades of experience can’t compete with a constantly updated digital knowledge base that includes comprehensive drug data, disease classification systems, practical medical algorithms, and much more, all packed in a user-friendly digital format. It is no hyperbole to say that the Mediately app has become a part of the doctor’s toolkit as essential as the stethoscope.

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Conclusion

Being a doctor, even in the digital age, is exceedingly demanding. Some would argue that the advancements in diagnostics and therapy have made things easier for the doctors. But this is true only if we assume that the state-of-the-art has stayed on the same level for the last decades.

If anything, the endless possibilities that have led to improved patient outcomes have also made many aspects of medicine extremely complicated. The volume of data that needs to be processed by a doctor’s brain and the number of decisions that need to be made are rising exponentially, with a similar rise in standards of care and public expectations.

This means that even now, but especially in the times to come, no doctor can afford to miss out on the digital aspects of medicine. 

 

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