As I walked through the critical care area of the emergency department, one of the residents asked me to verify her ultrasound reading before she placed a central line in the internal jugular vein of a woman with sepsis from an infected kidney stone. Because her supervising faculty member was busy with another patient, I looked at the screen and agreed that she had accurately identified the jugular vein. She was about to place the catheter when I asked her why the patient needed the central line.
“It’s part of the protocol for sepsis,” she said. “The central line will allow the doctors in the ICU to treat hypotension, if it develops, with medications we could not give through the peripheral IV,” she added.
“But she may not need those medicines,” I said. “Is her blood pressure okay, now?”
“Yes, but it’s part of the protocol, and the ICU wants it.”
I nodded. This was not my patient and I did not want to intrude, but I was concerned that we might be performing an unnecessary and potentially dangerous procedure without considering the risks and benefits. The patient did not seem confused or unstable. She was talking normally, asking appropriate questions. Recent published research on the treatment of sepsis had been less enthusiastic about the use of a central line as part of the treatment protocol. I asked the resident to hold off for a moment and walked away to discuss the procedure with the other attending.
“Oh, the ICU wanted us to place the line before we send her up,” said the other attending. “I agree the patient might not need it, but they feel more comfortable with the central in and are really getting swamped. And Julie, our resident, is really slick at them. She’ll get it in two minutes.” And so we proceeded to place the central line. The patient went off to the ICU after receiving antibiotics, she received a stent for her obstructed kidney stone, the sepsis resolved, and she did well. The central line remained in place for the next three days without any complications.
Most people would consider the case a success, but as I reviewed the literature about the need for central lines in sepsis,1–3 I became concerned because the recent literature no longer supports the routine placement of the central line. Even with the use of ultrasound for the line placement, there are risks of complications from insertion, such as bleeding of the vein or nearby carotid artery, and puncture of the lung.
I could remember other similar procedures that had been adopted and later been abandoned after questions about their safety and usefulness were raised, such as the use of the Swan-Ganz catheter. Recently, Thakkar and Desai4 described the history of the Swan-Ganz catheter, which was another type of central line that was inserted further into the heart and pulmonary artery for measurement of cardiac output and to assess and treat heart failure. I remember learning how to insert these catheters and convincing patients of the benefits of the device for their treatment. Eventually, as more studies were done, the dangers of the device, such as pulmonary infarction, were recognized and the benefits were questioned, and it was largely abandoned. However, for many years, the catheters were used by doctors who may have unwittingly harmed patients. In the assessment of the problems with the catheter, Evans et al5 noted that in addition to problems associated with the insertion, maintenance, and manipulation of the catheter, “inappropriate clinical decisions and/or inaccurate hemodynamic data may well constitute a greater risk to the patient than all the other pulmonary-artery-catheter-related complications.”
These comments about a particular health technology are an example of the need for education about the proper use of such technology and the assessment of health technology in the real world, including the educational needs of those likely to use the technology. If those who are most likely to use a technology cannot use it safely and effectively, its value will be diminished even if it offers advantages in some circumstances.
As I thought about how technology influences health professions education and health care delivery, I realized that there are three somewhat different areas to consider:
- The first area is the assessment of health technology using evidence-based methods and considering economic and other social effects. Examples of technologies currently mentioned frequently in the medical literature are electronic health records, robotic surgery, machine learning, artificial intelligence, and telemedicine. Medical students, residents, and practicing physicians need to know how to evaluate new technologies and make good decisions about when to use them.
- The second area involves the adoption of new technologies that can affect health professions education, such as distance learning using the Internet, simulation for procedural training, and using video for student and resident selection.
- The third area involves the use of education in the implementation of technology related to patient care—such as the use of ultrasound to improve safety in performing procedures—which is not always considered in the category of education because it is applied education. Patient safety and quality improvement experts are particularly interested in this area of education.
Because physicians, nurses, and other health professionals have considerable latitude in the introduction of new or replacement technologies into the clinical and learning environments, I believe our education community must have an organized approach to all aspects of technology assessment in the health care environment. With that in mind, I focus the rest of this editorial on the assessment-of-technology skills needed by our education community.
Technology has been defined as the use of tools or machines to solve problems. Goodman6 described technology as “the practical application of knowledge,” and health technology as “the practical application of knowledge to improve or maintain individual and population health.” He included drugs, biological devices, procedures, programs, support systems, and managerial systems in his definition of health technology. Goodman defined health technology assessment as the “systematic evaluation of the properties, effects, or other impacts” of health technology to affect decision making at the individual patient level; at the health care provider level; or at regional, national, or international levels.
Evidence-based medicine provides many of the skills needed to assess a technology. However, the funding for studies that will provide best evidence is often lacking. Even when there is evidence from randomized trials and systematic reviews, the information may not be sufficient for the purposes of a health technology assessment because, according to the Institute of Medicine,7 such an assessment should also include assessment of “safety, efficacy, feasibility, and indications for use, cost, and cost effectiveness, as well as social, economic, and ethical consequences whether intended or unintended.” Most evidence-based reviews focus on fewer areas than those suggested by the Institute of Medicine, leaving many unanswered questions. There are also biases that can affect decisions about new technologies. Ioannidis8 has noted in his critique of evidence-based medicine that
clinicians are under tremendous market pressure. Most discussions in department meetings are about money. One can sense the pressure to deliver services, to capture the largest market share (a synonym for “patients”), to satisfy customers (synonyms for “humans”), to get high satisfaction scores, to charge more, to perform more procedures, and to tick off more items on charge forms.
How might we better integrate health technology assessment into health professions education? The acquisition, analysis, and assessment of the literature about new technologies is a good starting point in spite of the limitations that will occur with new technologies. Our students and faculty need to be encouraged to question new technologies and the strength of the evidence that supports them. Mytton et al9 describe five safety questions that should be considered as part of the decisions to adopt a new technology:
Are there safety concerns? Is it safe under experimental conditions? Is it safe under real-world conditions? Can we apply it safely here? How should we apply it safely here?
Even when there is adequate evidence of efficacy of a health technology, its implementation in actual care delivery settings may yield different results due to differences in the training of medical staff, differences in patient selection, or differences in the care environment. There may also be concerns related to cost, ethical, or social considerations that have not been considered in the development of the new technology. The inclusion of health technology assessment into evidence-based medicine courses for medical students and residents would be a relatively simple way to provide an initial exposure to this important topic.
As mentioned earlier, there are a number of technologies that are often introduced into medical education. Yet it is only after substantial experience that data are collected and analyzed to provide an assessment of these new educational technologies. The analyses of technologies such as Internet-based learning,10,11 simulation,12 and telemedicine13 through the review of published literature are often plagued by lack of well-designed studies, leaving many questions about the effectiveness of the new technologies. While technological innovations applied to education do not carry the same risks to students that a Swan-Ganz catheter in the pulmonary artery might create for patients, ineffective learning technologies can lead to wasted time, poorly trained students, and transmission of inaccurate information.
In this issue, Hanson and Eva14 raise such concerns about the introduction of technology into the medical school and residency selection process. They identify the situational judgment test and the standardized video interview (SVI) as two examples where a computer has been interposed between an applicant and an assessor with unknown consequences. They ask,
Are we letting advances in technology and convenient access exert too much influence on how and why we conduct the admissions process without adequate consideration of the loss of human contact and other unintended consequences?
Bird et al15 describe initial results from two studies of the SVI. They note that the purpose of the new technology is to provide information about residency applicants’ professionalism attitudes and communication abilities to inform program directors’ decisions about which applicants to invite for in-person interviews. Such information had been difficult to identify in standard residency application materials. They conclude that the SVI could broaden the pool of applicants who were chosen for interviews and contribute to holistic admissions. However, whether the SVI is actually providing valid information about professionalism and communication skills is not clear, and further research is needed. Until that occurs, the results obtained from this new technology should be used cautiously.
As I noted earlier, technology has been used for some time to provide online education. In this issue, Chen et al16 describe how to develop curricula for online learning using a six-step process: problem identification and general needs assessment; targeted needs assessment; goals and objectives; educational strategies; implementation; and evaluation and feedback. They provide advice for different online approaches, including a blended curriculum of online and face-to-face interaction between students and instructors, an instructor-led and fully online curriculum, self-paced modules, and massive open online courses (MOOCs), which are large-scale interactive curricula open to all with Internet access.
Chen et al16 note that online learning provides unique opportunities such as access to a geographically and temporally dispersed population of learners and the availability of data about performance. These authors also offer advice about how to overcome curricular challenges in developing online curricula using the six steps.
Another challenge of shifting an in-person curriculum to an online one is resistance from faculty, who may be unfamiliar with the methods of online learning. Mayowski et al17 present a Last Page graphic that uses diffusion-of-innovation theory to provide an approach to encourage and support faculty to teach online. The authors focus on the use of communications channels and illustrate how faculty can observe each other, try out new technology together, and share their experiences as they venture into this new area of teaching.
Finally, another area where technology and education have a critical partnership is in the use of education to facilitate the effective use of technology. Leggott et al18 have described how anesthesiologists switched from general anesthesia to the use of ultrasound-guided peripheral nerve blocks for orthopedic surgery. Education was critical for the anesthesiologists to attain the skill level needed to demonstrate that they could perform the procedure competently, which then persuaded the orthopedic staff to accept the innovation. Education of the residents in the procedure facilitated the spread of the innovation and the technology throughout the health system and improved the quality of care for the patients. Pronovost et al19 have also described the use of education as part of improving the insertion and management of central lines to reduce infections. The education involved physicians, nurses, other staff, and all phases of the central line process and resulted in improvements in education and in patient care outcomes.
I have described three ways in which technology and education can be synergistic: education about health technology assessment to help with decisions about technology adoption and use, understanding and using technology to improve educational processes, and education that is linked to the effective implementation of technology. The overriding message for all three applications of technology in health and education should be one of cooperation and joint enterprise. However, there is one other important message about technology and education to consider. Li et al20 in this issue caution that
[m]edical schools must teach students cutting-edge medicine without losing sight of the human aspects of medicine. Curricula should focus on two core areas: improving human judgment and delivering patient-centered care.
They emphasize the importance of training a health workforce that understands health technology and uses it to free up time to provide human contact and advocacy for patients and communities.
I believe that in our zeal to use new technologies in health care, we must not lose sight of the importance of the healing relationships between health professionals and those suffering with illness. Our challenge will be to understand the limits of our technology and to support those critical relationships and cultivate human healing relationships as technology becomes more and more widespread.
David P. Sklar, MD
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