Jay Parkinson recently wrote a post responding to a question raised by Atul Gawande: Can technology be a change agent for health care? Jay’s answer focused on the generational tech divide in medicine today. One quote:
“Many of the most influential doctors practicing medicine today have an antagonistic relationship with computers. Change will only come in a massive way when the under-40 generation takes control.”
I tweeted his post, followed by a link to an essay I wrote about my grandmother, who grasped the potential of the Web immediately — at age 85 — and was a daily internet user until she died, more than a decade later. She is an example of someone who defied generational generalizations, to say the least.
Lots of people responded to my tweets, including:
@SusannahFox @jayparkinson agree. electronic banking transformed our relationship with money – immediacy and trust are required.
— Dovetail Care (@DovetailCare) November 10, 2013
Leadership not tech alone -> RT @SusannahFox: Agree or disagree, but read @jayparkinson on tech + health care http://t.co/2C7ZjpwofK
— davisliumd (@davisliumd) November 10, 2013
@SusannahFox @kevinmd @jayparkinson Agree but many, not all baby boomers in healthcare struggle w/HIT some are the pioneers
— Lauren Wiseman (@yzman) November 10, 2013
@aliciacollin @EdBennett @SusannahFox @jayparkinson nice post. But IT-SoMe-med-Ed not just the province of the young.
— Karen Price (@brookmanknight) November 11, 2013
@SusannahFox Diverse on Twitter, but twitter not representative of colleagues in “real life” @jayparkinson
— Linda Pourmassina,MD (@LindaP_MD) November 11, 2013
@LindaP_MD @SusannahFox @jayparkinson I beg to disagree and wow this is stereotypying everyone over ? 50.
— Mary Verrilli (@mv) November 11, 2013
@LindaP_MD @SusannahFox I don’t it’s divided along age lines that crisply. I’m 54 & a #hcsm devotee. Not all millennial docs see the value
— Robert S. Miller, MD (@rsm2800) November 11, 2013
Let’s talk about this. My contribution will be data, in addition to the anecdote about my outlier grandmother.
Manhattan Research finds that tablets are “mainstream” among physicians in the U.S. but use of technology in medical settings varies widely across the globe. Note: Manhattan surveys nurse practitioners, pharmacists, and other clinicians but I couldn’t find a comparable set of studies with basic usage/adoption stats. If you have a link, please share it in the comments.
Looking at the Pew Research Center’s data on the U.S. population, we do see a generational divide when it comes to internet and gadget use, but it isn’t at the 40-year-old mark, as Jay suggests, and is often erased when looking only at college educated adults (which includes clinicians, of course).
Health care is a special case and I have sought to illuminate a fair question asked by busy clinicians: How do we know that social media is important to health care?
What other sources of data can we bring to this discussion? What other variables would you include when diagnosing our current health care system’s tech challenges? How would you answer the question: Can technology be a change agent for health care?
I would argue that the technological divide isn’t as neat as pre-computer/Boomer gen vs post-digital/gen x/y/z, but that there are actually progressive levels of technology (dis)comfort, with each newer generation challenging the comfort levels and norms of the previous.
For example: I was born towards the tail end of Gen X, in Silicon Valley. I grew up with a Mac SE in my bedroom. I had high-speed internet access in my college dorm room. I would absolutely say that I’m comfortable with digital technology, as are the majority of my generational peers and colleagues. We’re all about maximizing utilization, usefulness and inter connectivity of EHRs. We have tablets, and smartphones, and we online bank and online shop, and we use Facebook to stay in semi-constant contact with friends and family.
But the next wave of the digital revolution, with social media and the expectation of living one’s life publicly and online, and this blurring of lines between private and public identities, I think might be the next generational divide. Obviously, there are adopters of SM in every generation, but my impression is that your average 20-something is more likely to have an active twitter account than your average 30-something.
I just joined Twitter recently myself, and I asked friends, colleagues, coworkers – are you on Twitter? Do you have a publicly accessible online presence? And I couldn’t find a single 30-something (or above) in my real-life world that said yes. These are all people who use the internet every day, but I think that for many of my generation, there’s this perceived line between utilizing technology for one’s personal needs vs. choosing to put yourself publicly and openly online.
Just a few thoughts from a digital native but SM novice…
Susannah Fox says
Thanks, LB! I agree that we need to bring in cultural attitudes about tech use, not just adoption patterns. A majority of clinicians have tablets…but what do they *do* with them? (For example.)
For those following this conversation, Richard Lum had so much to say that he took to his own blog to respond:
Joe McCarthy says
One area the Computer-Supported Cooperative Work (CSCW) community focuses on is healthcare. There was a workshop at CSCW 2010 on CSCW Research in Healthcare: Past, Present and Future that may provide some useful data (there is a link to accepted papers on the homepage).
Personally, I believe it is not just a technology and/or age issue but a mindset issue. I’ve encountered a number of MDs who are very authoritative in their interactions with patients. I believe new technologies – especially those with a significant social component – can be seen as a challenge to authority.
I’m fascinated by some of the scenarios depicted in videos of IBM Watson. If the system ever moves out of the prototype / demonstration phase, it will be interesting to see how receptive physicians are to employing it in their interactions with patients.
Susannah Fox says
I like your “mindset” frame, which is less challenging to people than “ego” (but is related, wouldn’t you agree?).
I also like the idea of bringing in other disciplines, such as the CSCW community.
I reconnected recently with a close friend from college who is a hepatologist. He was trying to understand what I do, exactly, and how it fit in with his worldview. After listening for a few minutes, he tried to describe what I do back to me and ended up describing the field of Human-Computer Interaction. Sort of, not really, but close, I said.
Your comment and that conversation reminded me that I need to do some more reading in those fields. If anyone has suggestions for relevant readings, please post them. Here’s what I found, when I searched:
IOM report: Health Care Comes Home: The Human Factors
Duke Center for Health Informatics
And of course:
AMIA: American Medical Informatics Association
Sue Woods says
Fabulous topic, Susannah, and nice to see it in the New Yorker.
As a primary care doc, faculty to residents, and informatics evangelist – it’s important to think about (a) health professionals using technology as part of their work and (b) embracing patients and caregivers using technology as part of the patients’ work — their life! Of course, these two overlap but the latter is more about their mindset (supporting Joe’s comment here).
Jay Parkinson is not fully off the mark believing that we’ll have easier adoption and better usage with a younger generation, when it comes to technology as part of the workflow. An implicit factor, not addressed enough, is that the technology has to bring value and be relatively easy to use. At least, not make it harder to do the same thing without it. So, the degree to which a clinician uses technology *routinely* in their own lives is probably the greatest predictor of adoption in healthcare. Among a highly educated group, age may offer the greatest contribution.
The second issue, embracing patient-facing health IT, is another story altogether. It means: recognizing that the internet, digital tools and social media provide a valuable service to patients; that digital tools for patients/caregivers can improve communication, enhance patient knowledge and self-care; and most importantly, that patient contribution and participation in their health and their care can improve experience and outcomes. This is not about technology, it’s about how a health professional lives and breathes “the role of the patient”.
If there’s data out there on characteristics of clinicians related to their belief about patient/caregiver role, I’d love to see it.
My observations are that there is a divide, but it doesn’t seem to pattern itself on gender, or age, or comfort with technology. Last year I implemented secure patient email with over 40 internal medicine residents. With blocks of 10 residents during an educational session, I first asked how they feel about patients using the internet. Thinking that these young, online natives wouldn’t have any issues – I was surprised (4 times!). Yet, I watched the Red Sea part….people lined up on two sides. Those who felt “it makes the visit longer” and “I have to un-do everything they read online”, with those who understood the evidence – that these patients, by and large, were already engaged and that the interactions were easier, not harder.
What I kept thinking about was how the ROLE MODELS – the faculty – us! – were falling down and not working hard to make the parted Red Sea get back together again.
I posted recently about how patients and caregivers need to help us shape our medical curriculum. http://www.sharedhealthdata.com/2013/10/31/great-idea-patients-and-caregivers-helping-shape-curriculum/
We can’t wait, as Jay said, for generations of older clinicians to go away. Plus, time likely won’t be enough for us to get there.
Bryan Vartabedian says
Interesting discussion, Susannah. For what it’s worth, our study of social adoption by MDs found that years since graduation (proxy for age) had no bearing on adoption. This has been my own experience working with college students right through to docs near retirement.
Youthful hipsters fancy themselves as having a corner on the market.
Susannah Fox says
It’s worth a lot!
A quote from the study’s conclusion:
“The main factors influencing a physician’s usage of social media to share medical knowledge with other physicians were perceived ease of use and usefulness. Respondents who had positive attitudes toward the use of social media were more likely to use social media and to share medical information with other physicians through social media. Neither age nor gender had a significant impact on adoption or usage of social media.”
Your study speaks to Sue’s first point, I think, but I wonder if anyone has data or insights to share about her second question. If not, I wonder how we might gather it. A benchmark of clinicians’ current attitudes toward patient engagement could be verrrrrry useful.
Robert S. Miller, MD says
Great ideas all, and appreciate Susannah’s facilitating this conversation. I’m speaking here as a baby boomer physician who had my “a-ha” moment about 3-4 years ago when in the process of trying to understand social media channels on behalf of my professional medical society (to figure out if this should be a benefit of membership) I discovered the unbelievable networking power of the Twitterverse and the exposure to this diverse personal learning network that it afforded me. So my take on the generational issue raised by Jay Parkinson and extended in these threads, based on my own experience, is that those of us who aren’t digital natives can still easily be drawn in to social media and embrace it if we view it like any other disruptive force in our professional lives, be that email, genomic medicine, or Medicare reform (should that ever occur). If it helps me – fill in the blank – see more patients, do better science, become a more effective educator, etc. – then I’ll make it work for me on my terms, as long as someone doesn’t force me to do it. But I think here’s the rub for many physicians these days – their prime exposure to health IT is the misery that is today’s electronic health records. Using today’s EHRs have made so many of my colleagues bitter, cynical, frustrated, you name it – about physician autonomy, the demise of private practice, the dang gubmint interfering with my livelihood, etc. that they can’t see technology as anything more than something else to slow them down and add to their administrative burden and overhead. (Not saying I buy this argument; I’m one of the few enthusiasts, see http://am.asco.org/seeing-beyond-skepticism-frustration-ehrs-finding-meaning-meaningful-use). But I think it’s very challenging for the average doc who didn’t grow up with texting or Facebook to see the value in this world of hashtags, apps, and a public presence, when for them technology in healthcare is clicking boxes for meaningful use and cursing the darkness.
You asked what should the research questions be to tease out the true impact of age. Going back to the McGowan/Vartabedian paper above (Disclaimer: I was a co-author but @BrianSMcgowan and @Doctor_V were the really brains behind the work), the paper suggests that physicians may use social media in one of three ways – to treat patients and deliver medical care (probably not a good idea); to educate groups of patients (e.g., @seattlemamadoc); and to network and share content with other health care professionals. So I would like to know:
1. If you take #1 off the table because of privacy and HIPAA, does that make it more comfortable for physicians to use SM?
2. Are those physicians who see their mission to provide public health messaging (#2 above) also using SM to network and share with each other? Or do some do #3 almost exclusively and ignore #2 as not their mission?
3. If you could create a thought exercise where physicians were meaningfully reimbursed for time spent on patient care whether or not connected to a visit, would that lead to trickle than a flow than a torrent of physicians interacting and sharing with patients and each other more freely? If it’s not about the money?
4. And finally to go back to the EHR issue and my mini-hypothesis that this is what poisons the well, what would physician attitudes be toward technology if their EHRs worked as well as their iPads and if their online transactions were as seamless as booking a flight or buying something on Amazon? I betcha more would be commenting on this thread!
Justin Smith says
One thing that I think we are still learning and in need of is translation back to patients. How do we take the physician interest in social media, etc and move it back to something relative to patients? I am fairly active on twitter along with many other pediatricians but a big percentage of my followers are pediatricians and other health care-type people.
The overwhelming majority of health-care is still done in a face-to-face setting and I feel it will continue to be so for a while to come. So, how does what I do in the on-line world actually benefit my patients? Do they actually see what I do online as having benefit for them? My guess is that to answer that question, I’ll ultimately have to do something that translates back to them in a more personal setting or use a personal interaction and back it up with social media.
If you look at the top ranked blogs, podcasts, etc, you’ll commonly find blogs about how to do blogging/social media etc to be the most popular. I worry sometimes that the same is true for medical bloggers, etc that we’re the most popular amongst ourselves at this point. I know this isn’t completely true, but there is at least some shred of truth to it and something that we need to focus on for the future.
How do we do this? I think going back to our more “seasoned” colleagues and borrowing some of their marketing skills will be critical to finalize this loop. Some of them might care less about social media but they know how to market themselves and stay relevant and this a big piece of what social media is about now. I believe engaging them and borrowing their strategies while making them relevant in a new digital age is critical. In doing so, you might find that you bring someone who didn’t have interest into the fold with you as well. We could use people with more experience who have seen health care change over decades actively involved in the social media world.
I’d love to know if there is a correlation between patience adherence or even general positive impressions of the doc/patient relationship and the prevalence of social media use. I believe that docs who engage with patients outside of the traditional clinical space are showing their willingness to collaborate and learn things together. If there was data to show some sort of relationship between SoMe doc usage and patient involvement/adherence/compliance whatever, more clinicians might be willing to embrace the idea, regardless of age, seeing the value of its use.
Susannah Fox says
Clinicians’ participation in social media is one thing, their engagement with patient data in the clinical setting (enhanced by tools like OpenNotes, etc) are another.
I wonder if we need (or if someone has created) a taxonomy of tech tools in health care, along the lines of what Daniel Solove created for the concept of “privacy” in the law. He found that there are 12 distinct meanings — anonymity, security, identity…
His article (and then book) is the ultimate “You keep using that word. I do not think it means what you think it means” for that field, changing the conversation forever for those in the know.
Check out some of Solove’s work:
A Taxonomy of Privacy
Fred Trotter has written about patient data in a similar way here. I think defining our terms will help us to navigate this conversation and map out future studies.
Thanks for developing this conversation, Susannah.
Yes, there are many docs who are ‘boomers’ who still have their assistants print out their email to read and make cryptic notes on, for return to that assistant with instructions to send the email replies. But there ARE boomer-docs, myself included, who are passionate advocates of technology for optimizing patient care. As EHR platforms continue to evolve, some are incorporating HIPAA-compliant texting and email service between patients and their care team, incorporating those communications into the health record. Despite my own technophilia, I do agree with Atul that the generation of email-printers-for-reply-by-assistant will need to be replaced by the tech-competent before medicine catches up to the general population with regard to using various social media to improve healthcare. It WILL happen, though, and for the benefit of us all. Studies tell us that patients who are “connected” with their care team – through SMS and email – are healthier: Of course they are! They are connected, empowered, involved in their healthcare, and they are more compliant with their treatment regimens. As a result, there is a rapidly-growing population of blogging docs who use their platform to counter-balance the healthcare MIS-information that pervades the digital world. MIS-information that exists to drive pay-for-click revenue, and to sell products. Those of us in healthcare – physicians, nurses, hospitals – have an obligation to our patient communities to provide accurate healthcare information. I already have a sense of the benefits of blogging for my own practice and patient relationships, but I look forward to pending data on the benefits of incorporating these social media into the EHRs. Not to mention the potential for personalized healthcare recommendations that should evolve from the analysis of ‘big data’ that accumulates in these EHRs.
Davis Liu, MD says
Though I appreciate Jay’s comments, technology is a tool and alone won’t change health care. We know outside of health care, technology is used by a variety of people of different ages. The difficulty in adoption within health care can’t simply be due to a generational issue. This is too simplistic of a conclusion. Instead might it be due to the circumstances many doctors find themselves today? Many are in one to three doctor group practices without significant resources that an academic medical center or very large multispecialty medical group has – like a Mayo or Cleveland Clinic – to adopt technology. Might the reason for discrepancy be the nature of the fragmentation in health care? There are no large national organizations in health care at the same scale of airlines or financial services where technology is used widely and consistently by tens of thousands of people daily. Might it be these circumstances that exist be the reasons that doctors and health care (particularly the delivery system aspect) did not adopt technology widely as other industries?
Without the leadership skills to lead change, those in the under 40 generation may find changing the existing system is not quite as easy as it sounds. Many under 40 have opted out of the current system because they (we) are fortunate enough to live in a time precisely where tools are available now where people are build things, be heard, get funded more quickly and more cheaply than a generation ago. Had they simply been born 10 years earlier, they would not have been able to do so. Creating and leading a start-up is different than changing an existing organization from inside out. If we use a “technology” example like Peter Pronovost’s 5 step checklist to decrease central line infections, we learn that despite its simplicity and stunning success to eliminate central line infections, adoption is variable among hospitals across the country. How much simpler could it be? http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=all
It wasn’t clear in the past, but it now appears even Gawande is increasingly aware of this issue. It isn’t just checklists, workflows (ala Cheesecake Factory) that will make health care better. It is more than that. It is likely that whatever technology or tools we have available that they may change the world. That might, however, not be enough. To get the level of consistency, high reliability, and adoption needed across entire industries like health are we need scale, organizational structure and leadership. http://www.newyorker.com/reporting/2013/07/29/130729fa_fact_gawande?currentPage=all
Hence my tweet – Leadership not tech alone…
Susannah Fox says
Thank you! Your tweet was intriguing — one of those tiny strings of words which are clearly attached to a mountain of thinking. I’m grateful that you took the time to explain.
Susannah Fox says
Another reader who had so much to say he took to his own blog:
Things I love about Josh:
1) He uses footnotes, even in short blog posts.
2) In trying to figure out which generation he’s in, he shows the fallacy of the categories. Which totally makes him GenX [ducking for cover]
Richard Lum says
The issue of what are the most important drivers of change of course shows up everywhere. Here, from a completely different field, is another post that anticipates generational change being a key driver: “Millennials and Why Nations Fail”
Art Jones says
I believe this FORBES article says it all:
Excerpt: All of us need to adopt a Millennial mindset, regardless of when we were born. Why? In order to thrive in the workplace of the future we need to be agile, digitally literate, use the latest social technologies and above all, be open to people of all cultures, since our workforce of the future will be increasingly multi-cultural, age diverse and global.
(Jeanne Meister, the author is officially a Baby Boomer, acts like Generation X, but secretly wants to be a Millennial. Her 24year-old daughter took the quiz and scored “78” 6 points below her Baby Boomer MOM, who scored ”84” without any tattoos or body piercings.)
Susannah Fox says
If anyone else wants to take the Millenial test, here’s a link:
(Note: I work at the Pew Research Center, which developed the test.)
Greg Matthews says
This is a fascinating discussion, and it’s nice that we’re introducing a bit more data (and scientific approach) than the usual “old people don’t use computers” argument. As one small data point to add to the mix, my company is tracking many thousands of doctors who use twitter. While we don’t have data for every physician that allows us to triangulate their age, we do for a statistically valid set. And get ready for this: Their average “years in practice” is 20. It’s not the youngsters that are leading docs to think differently about their role in the system & the ways they communicate – or at least it isn’t ONLY them.