ANNOUNCEMENT: You Have 90 Days to Become a Doctor

Well, that’s not quite right! Becoming a real, practicing doctor would take a bit longer and gobs more memorization! Not to mention a license to practice.

At Dalhousie University in Halifax Nova Scotia, Dr. David Zitner teaches a 3-month course for Health Informatics students on being a physician. This course imbues students with a deep understanding of what being a doctor is about, how one functions in the healthcare system and the crucial ideas necessary to diagnose and treat medical problems. David has been teaching this course for many years and numerous students have had the chance to experience it.

I first got to work with David about 20 years ago when we collaborated, together with Dr. Bob Bernstein, on the definition of Health Informatics competencies (See: Pointing the Way: Competencies and Curricula in Health Informatics at http://www. nihi.ca/nihi/ir/Pointing%20the%20Way%20MASTER%20Document%20 Version%201%20Final.pdf.)

As it turned out, we worked well together and had a great time producing what others have said was an important contribution. I admit, however, that I called it one of the most boring books ever written – that’s just the nature of the attempt to incorporate actionable detail.

Over the last five years, David has been working on a book that incorporates what he teaches at Dalhousie and extends it quite a bit. About two years ago, David invited me to join him in writing this book. I must admit that the project has been one of the most interesting of my career. In particular, I have deeply enjoyed our conversations as we attempt to understand and lucidly reveal the nature of health care and both explain ideas and disambiguate them from common perceptions. We are hoping to complete this Magnum Opus in the new year, but wanted to share with everyone some of the key things we have learned along the way.

Health Care as a Background for a Competent HI Professional

I think most people recognize that Health Infomaticians ideally would have a professional healthcare background of some kind, such as by being doctors, nurses or allied professionals (many, in fact, are). These healthcare professionals could become knowledgeable in informatics-related disciplines like computer science, information science, the social sciences and so on. It has long been recognized that, at the very least, fairly deep healthcare knowledge is a crucial pillar of Health Informatics, being an essential area of competency. However, what do non-clinicians really need to know about health care? In our work on Health Informatics competencies, we did not detail the health care-related competencies to the degree necessary for someone to undertake a formal self-directed program in that area.

As we were writing our new book, we recognized that there are crucial areas, which, lacking, would severely restrict a person’s ability to be an effective Health Informatician or health services administrator. We believe that everyone with informatics, management, or governance responsibilities for health care should understand the key ideas that are the basis of clinical medicine. Herein, we will touch on these crucial areas.

Crucial Specific Competencies

The starting point is a deep and detailed knowledge of the nature of the healthcare system and all its components, with their functions
and the major issues related to them. For example, the professional Health Informatician must know about hospitals, medical and surgical clinics, office practices, allied health facilities staffed by Kinesiologists, Occupational Therapists, Nurses and so on and the myriad variants of these facilities. The professional also needs to understand how patients access these facilities, why they do so, and what these facilities can do for patients, along with the problems the agencies face. Knowledge of how these facilities interact and co-ordinate, how continuity of care is maintained, what they do and the effects they can have (or don’t have) are all important.

Then there are the professionals who work in these facilities: physicians, nurses, all the different allied professionals, technicians and technologists, biomedical engineers and so on. The Health Informatician needs to understand the nature of the work and responsibilities of each of these healthcare professionals, what they do for patients, the limitations they have, their effects and the problems they confront.

I think it is clear, even at this point, why it would be easier for a healthcare professional to enter the HI field. Healthcare professionals would know all this stuff either through training or through direct experience.

Sticking with the non-healthcare expert, however, the next level of depth is the understanding of what, in specific, each type of professional does. This includes both their physical activities, like examining patients and administering treatment. However, it also includes their cognitive functions: what they think about, how they think, what kind of decisions they make and how they do that, as well as what knowledge and information resources they need. Of course, these clinical professionals also need to be able to create memorabilia that other care providers can share. Therefore, HI Professionals need to have knowledge of the kinds of records care providers keep, the content and structure of those records, their vocabularies, as well as the issues that arise in record-keeping, such as the use of diagnostic terminology and classifications of disease.

But, it doesn’t stop there! In order to really function as a Health Infomaticians, one must deeply understand the nature of the information that is captured from patients and from other sources, how that is used, and how it is recorded.

This information is both deep and wide. There are many kinds of information and the information has incredible depth. For example, the Professional Informatician needs to know concepts that physicians use to make decisions. These include things like the sources and nature of formal evidence, quantitative information on the Numbers Needed to Treat (NNT) and Numbers Needed to Harm (NNH), measures of how many people benefit from an intervention versus suffer harm from it. It also means that one must get an understanding about where physicians are going with their thinking process and how they make diagnoses and treatment decisions.

HI Professionals need to know that the ultimate destination of the clinician is the determination of the actual cause of whatever problems the patient has. Luckily, these causes are divided up into 10 to 20 what are called ‘etiologies’, the roots of disease, like infection, or environmental toxins, or injury. To be really capable, the Health Informatician needs to be able to follow the reasoning pathway from what are often multiple, common symptoms or signs a patient exhibits, through the results of various investigations, down to where the problems originate and then back up from there to what the physician can do to ameliorate the problems or even possibly cure them.

There’s also the need to know the interdependencies of care providers on each other: the general physician on the specialist, the specialist on other specialists, all of those on support professionals, and so on.

Understanding Public Health sort of puts a cap on all of the clinical aspects of health care, as this area looks over the entire population, the extant and emergent diseases, and their spread and control. Similarly, there are agencies that look over all of the data produced by the care system, measure the system’s performance and make judgments about its efficiency and effectiveness…or they should do so.

That’s Not All – Not by a Long Shot

There is, of course, a great deal more. This is only a 50,000-foot view. We must not forget mental problems. Not only must there be knowledge of physiological health and sickness, but also of mental health. This is an area that is quite challenging, because things like fundamental causes are often unknown or difficult to pin down and may be unknowable. Treating without clear knowledge of a cause is like shooting without a target!

For all illness, an understanding of the details of the examination of the patient, the use of diagnostic testing (with all its issues and potential errors), the types and nature of medications and nonmedical interventions – like maintaining fitness – are all important. And, there is the magic of the ‘laying on of hands’, the placebo and nocebo effects, and the discernment of the wisdom regarding intervening medically versus applying the ‘tincture of time’.

I guess we should apologize for brevity and all the things we have not mentioned!

Beyond Health Informaticians

When we started working on our tome, we focused it on Health Infomaticians. However, it didn’t take long before we realized that it would be valuable to everyone, including every type of patient who is exposed to health care. It became clear that knowing about health care to the degree we explored, would enable anyone to become engaged in his or her care and foster participation and engagement. So, our conclusion has become that what is crucial for the health Informatician also turns out to be crucial for virtually everyone. If we can accomplish that, health care itself will become a team sport – something we participate in rather than have inflicted on ourselves.

Although this overview is very cursory, our hope is that we all get the key ideas. That most crucial of these being that the ultimate success of a Health Informatician depends being deeply informed about health care. We think it’s also clear that the successful participation of patients in their care depends on exactly the same thing!

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