Joshua Liao


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Doctor 医生 | Researcher 研究者 | Writer 作者 | Editor 编辑



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Beyond Silver Bullets in Medical Innovation

In my early days as a medical student, the promise of electronic health records (EHRs) was all the rage. In some circles, it was all some researchers, IT leaders, and clinicians could talk about. These enthusiastic conversations touted EHRs as a way to improve clinical decision support, centralize patient information, reduce administrative costs, and share information across health systems (among other reasons). Some saw this new technology as the silver bullet that could help fix health care.

(image from Medtech Boston

In the years since, the medical community has matured in its understanding of what EHRs can and can’t do. Now that we are pursuing a fuller spectrum of solutions and endpoints – including more business intelligence and patient empowerment – we are faced with a challenging, but worthy, effort.

In this effort, we have to forge forward thoughtfully, careful not to excitedly place our hope in the newest, slickest innovation that claims to improve care (particularly since all of them seem to). Instead, we should utilize the lessons we have learned thus far from EHRs and soberly assess each new innovation. Only then can we remain objective among the myriad of new technologies marketed to improve health, separating real solutions from the promises of new, would-be silver bullets.

Grading Residents on their Clinical Performance

As healthcare organizations address issues of inconsistent quality, high rates of harm, and rapidly rising costs, there has been growing interest in how residents physicians - medical school graduates but still doctors in training - contribute to these problems.

Reviewing and acting on performance-related data is an essential competency, but training programs have traditionally not provided housestaff with reliable information about the quality of their clinical performance. Implementation is complicated in a number of ways, but the effort is still crucial.

Several solutions can help educators address this issue, including being transparent about how data will be used, and gaining broad leadership support. My full thoughts here via an article with UCSF’s Bob Wachter.

Better, Not Broken

Empathy is a crucial element to good care and improved patient outcomes.

This isn’t exactly surprising. Within the medical community, and particularly among educators, there has long been an explicit appreciation for humanism and compassion. There has also been a tacit understanding of its importance to doctoring: Empathy is the core quality that every medical applicant tries to convey, the one that admissions committees attempt to identify in candidates.

If the data are to be believed, however, medical education doesn’t always promote empathy, despite all of the recognition of its importance. Reports show that medical students lose measures of empathy as they transition from classroom teaching to clinical clerkships, and other data showing that students can quickly acclimate to unprofessional clinical cultures and behaviors without even recognizing them as such. Reports and anecdotal evidence suggest that this process is likely to continue, or even accelerate, in residency training. Between what we are teaching through explicit didactics and the “hidden curriculum,” the collective messages we transmit to learners in everyday words, actions and behaviors, we may be losing our grip on a sacred professional value and significant gains in our patients’ health outcomes, due to a lack of empathy.

How can we find a better way forward? My thoughts here

Providing Comfort in Chaos is a Kind of Work-Life Balance

In residency, new physicians must learn to appropriately address and handle acute sickness.

In situations involving catastrophic disease (e.g., in intensive care settings), this often requires them to absorb measures of emotion associated with illness while shielding themselves from its full weight. Balanced steadiness in the face of severe illness is crucial—a core competency in its own right—because remaining calm and collected in crisis is often as important to decision making as clinical acumen. Thankfully, most residents learn to find steadiness and focus amid chaos.

This steadiness, however, must also be thoughtfully directed. It is clearly helpful for young physicians who frequently spend long hours dealing with the sickest patients with the most complex medical and social problems. But increased exposure can also ingrain steadiness to the point where it progresses insidiously into something perceived as detachment, particularly by patients on the receiving end of bad news or poor prognoses.

This issue - the cynicism and emotional insulation that can prevent illness from meaningfully moving and affecting residents as people - is something that has concerned medical educators for some time now. Finding balance can be difficult.

Full version of my recent thoughts on the attendant challenges.

Speaking Up About the Hidden Curriculum

There is a curriculum that is at work in medicine that goes beyond the formalized teaching that students receive in the classroom. This “hidden curriculum”—the collection of implicit messages about professional values and practices that are transmitted through everyday words, habits, and interactions—powerfully shapes the attitudes and behaviors of learners, for both better or worse.

While the hidden curriculum can transmit positive messages (e.g. professionalism, humanism, etc), it can unfortunately also create dynamics in which team members, especially those lower in the medical hierarchy (students, trainees), are afraid to speak up about their concerns. In such situations, the hidden curriculum threatens patient safety as well as clinical learning.

This is an important issue within medical education, as well as patient safety. My recent article about this issue here, in Health Affairs.

Happiness is Love. Full Stop.

For over three decades, George Vaillant directed a study out of Harvard, one of the longest running longitudinal studies about human development ever.

Recently, in summarizing the interesting trends and findings from the study, he had this to say in conclusion:

“The seventy-five years and twenty million dollars expended on the Grant Study points … to a straightforward five-word conclusion: ‘Happiness is love. Full stop.’ ”

A more in-depth review of the findings here at the Atlantic.

Anatomy, Physiology, and Policy: Teaching Medical Students About Healthcare Costs

It’s probably not a surprise to many people anymore, but healthcare costs are high and quality of care is sometimes low.

If last year’s government shutdown reinforced anything about our healthcare system, it’s that everyone is more concerned than ever about its price tag. The exorbitant costs of U.S. healthcare have been well documented and widely publicized. Partisan views and individual opinions aside, almost all can agree that change is needed to make healthcare more affordable.

As many are also realizing, however, cost cannot be the only consideration. It is also crucial to emphasize the need to provide high quality care and favorable patient outcomes.

Promoting value — care that is high quality and low cost — will require multiple interventions, many of which are already underway: insurance reform, changes to physician reimbursement, strategic mergers and acquisitions, transparency and shared decision-making with patients, and increased efficiency.

My full article at Boston NPR Cognoscenti here.

Waiting Room Music

The waiting rooms in most hospitals are viewed, perhaps appropriately, as cacophonies of noise and busyness. People shuffle through, and monitors, doors, passing healthcare workers all contribute to what most people in most situations perceive as a warble, disordered mess.

But I’ve sometimes wondered if - for those whose emotions hang in the balance sitting there in the waiting room - a kind of music or melody can arise from the chaos. I wonder if the fathers, mothers, sons, spouses, friends, or relatives of a sick patient are more attuned to what’s at stake in that space, and the drama that’s unfolding there. In the end, I wonder if and how their pain or anxiety causes them to engage the waiting room in a way that’s completely distinct from how I do as a physician. 

The product of these thoughts? My new poem out this month in the Journal of Medical Humanities.  The first few lines below.

The noise bleeds
As I wait, thick ink
Composing my wifes words Into familiar melodies
Inside my chest.

The Reason for Medical Innovation

For those of us in and around the medical community, innovation is upon us. Adoption of practices from other high-risk and service industries, along with the data being gathered under the ‘big data’ movement, is fundamentally changing the way we are delivering care to patients. Both redesign and innovation promise to change medicine as we know it.

While these are great developments, however, innovation can sometimes lack ‘clinical punch.’ Well-intentioned projects, devices, and apps don’t always equal useful ones, and new innovation that works in labs doesn’t always work in clinics or hospital floors. 

Through a column call The Point of Care, I hope to explore this issue more. Ultimately, I hope to emerge from all of this with knowledge that helps me and my readers apply innovation to healthcare effectively, and highlights the ultimate point of the care we offer: better health for our patients.

A fuller introduction to my column

Who Others Say We Are, in Life and in Death

On Thanksgiving this week, I had a wonderful dinner with loved ones. We went around the table sharing the things we were most grateful for over the last year, and I mentioned how thankful I was that most of my family and loved ones were alive, more or less healthy and living vibrant lives.

That sentiment can sound cheesy, or trite: “thankful that everyone is healthy.” But as with most things like that, it was true before it was trite. And for someone like me - whose job requires repeated engagement with death and loss; whose daily charge is to help people and their families broker meaning amid suffering; and whose personal mandate is to do all of this without becoming numb or losing sensitivity towards it  - the message has always hit home. And never more than at Thanksgiving.

The sentiment also reminds me that whether in life or death, in health or illness, our memories and legacies rest with our loved ones. In some ways, the best parts of us arise less from who we say we are, and more from who our loved ones say we are. It is a great gift to have people around us to share their appreciation and remind us of our roles in their lives.

The all-too-obvious reason we shouldn’t take this for granted is that not everyone has it. There are some who aren’t able to gather with loved ones, others who don’t have loved ones to gather with. In my first year as a doctor, I encountered such a lady - a kind, gracious elderly woman with severe disease, and sadly no living family to weather it with her. I had the privilege of taking care of her in her final days, and of writing about my experience with her as she passed from life to death.

That the account of our time together was published this Thanksgiving week in the Lancet is a great coincidence, but also an outstanding blessing. It has further reminded me of something I hope all of you will also remember over these few days: that life, and the loved ones who fill it, is precious, and worthy to be affirmed - deliberately and decisively - through our words and our actions.

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