Sharing Insights from Elsevier’s New Clinician of the Future Global Report: Drs. Ian Chuang and Tate Erlinger

Shiv Gaglani: Hi, I'm Shiv Gaglani. Today, we're going to learn about an important new report on global healthcare addressing two questions that are constant themes on Raise the Line: what will healthcare look like in ten years and how can we prepare clinicians for that future? I'm delighted to welcome two colleagues from our parent company, Elsevier -- Dr. Tate Erlinger, Vice-President of Clinical Analytics, and Dr. Ian Chuang, Chief Medical Officer of Global Health -- to discuss the findings of Elsevier's just released Clinician of the Future Global Report. 

Elsevier and its partner, Ipsos, engaged nearly 3,000 clinicians from 111 countries to reveal current pain points, predictions for the future, and how the industry can build a roadmap to future-proof healthcare. I'm really looking forward to getting the details. So, Ian and Tate, thanks so much for taking the time to be with us today.

Dr. Ian Chuang: Thanks for letting us be here. 

Shiv: So, we always like to start by hearing in our guests' own words about their background and what got them to this point. So, Ian, let's start with you. What got you interested in medicine and how did you become the Chief Medical Officer at Elsevier?

Dr. Chuang: Thanks for this opportunity. So, my clinical background is in family medicine, and I've had the fortune of practicing in two different health care systems. I'm a graduate of the University of Toronto and practiced in Canada before getting recruited to the U.S. to continue my practice in primary care. It was really an interest in human biology at its center and then obviously the opportunity to be impactful and making the connections with individuals through their health and illness journey as a primary care physician.

Interestingly enough, I ended up transitioning to more of an informatics role because I had a passion for how do we improve the healthcare system as a process, and that requires data. When I was practicing it was just the beginning of digital information and digital health care transformation, so I had the privilege of getting involved in the early days of figuring this out... how do we transition to an electronic environment, and then what can we do with the data? 

So, in my role as Chief Medical Officer of Elsevier, it is really around communicating the experience and vision around the full potential of digital transformation; partnering and working with other healthcare leaders and organizations in their journey and in my contribution in that role from my experience; but then also taking advantage of the assets and the knowledge of Elsevier. 

Shiv: I’ve enjoyed seeing some of your posts on social media like LinkedIn...some of the articles you've written about the healthcare worker shortage, so seeing your involvement in Clinician of the Future was a good development. How about you, Tate? Let's get into your background and how you came to be the Vice President of Clinical Analytics. 

Dr. Tate Erlinger: Sure. I took a roundabout way through health care a little bit as well. I made the decision early to go into medicine for the simple reason of wanting to help people, wanting to contribute to the betterment of my community. It was that simple. I didn't really know anyone in medicine. None of my family was in medicine, but I went to medical school, started to really enjoy the experience and did a residency at the University of Chicago in internal medicine. 

There, I was exposed to two things that I did not know about really before. One is the world of clinical research, as opposed to laboratory research, and the other was these were the early internet days.  I joined in the year between my residency and fellowship and did a tech startup of sorts that still exists. After my residency, I went to Johns Hopkins and did a fellowship with them and a Master’s in Public Health and really studied clinical research and stayed on faculty there for about eight years or so. I was doing academic medicine about 80%, and 20% clinical, in Internal Medicine. 

I transitioned out of that, kind of like Ian, as the world became more digital. I just grew an interest in data, analytics, and healthcare informatics. These were things that didn't really exist for physicians, I would say, very much prior to the 2000s. So, I found myself in analytics positions for accountable care organizations, large health organizations, and building analytics and communicating those findings to healthcare leaders, to physician and nursing leadership. And that's what Elsevier was building. Elsevier was trying to expand their footprints in that arena, so I came to Elsevier. 

Shiv: It makes a lot of sense and this interview is coming a couple of weeks after we had one with the Head of Clinical Solutions at LexisNexis Health, your colleague Josh Schoeller. He spent a lot of time talking to us about the data sets that Elsevier has. So, it makes sense that you both would wind up here as well. 

So, the focus of this interview is the report. I'm curious about the big picture behind the Clinician of the Future Global Report. Why did Elsevier think it was needed, how did you go about conducting the study, and what are you hoping it leads to and accomplishes?

Dr. Chuang: So, I am actually participating in this podcast from HIMSS 2022. This is the closing day of the exhibition hall. The theme for this year is Reimagine Health. So, the Clinician of the Future Global Report really aligns to that, right? As we're coming out of COVID we're focusing on reimagined health and taking in all the learnings and experiences where the health system has been stressed globally, where the clinicians have been stressed, where the process of care and the patient experience has been turned upside down. 

The Clinician of the Future Global Report is a timely report that basically starts to answer some key questions and provide insights about, in this reimagined health world, what would the role of clinicians need to look like to be effective, caring, empathetic clinicians in treating, assessing and providing care for the population that we serve recognizing that there are all these factors to be considered as we go into a more digital ecosystem? 

It's really getting that feedback from those on the front line with a broad global perspective of what it takes, what are the barriers and opportunities, and what do we collectively, across all the stakeholders -- from the frontline clinicians to healthcare leaders, even educators and institutions -- need to do to achieve the full potential of this future vision of a truly digital transformed healthcare ecosystem delivering on the full potential that we know that we can achieve?

Shiv: Obviously, you reached quite a few clinicians in this report. Over 3,000 across 111 countries. So, it's pretty comprehensive and I'm very curious to know what the overlaps are across the countries. But before we go into some of the key findings, Tate, was there anything you wanted to add to that general big picture of the report and what you're hoping it accomplishes?

Dr. Erlinger: I think Ian summarized it well. I would just add that a lot of the findings of this report have been emerging for some time in healthcare. There has been evidence of this from other surveys -- maybe not as global in nature -- but many of the findings here have been echoed, or at least there were warning signs of this, in previous data. I think what this report does is shows what's happening during the pandemic itself, but also, allows it to shift the conversation a little bit from problems to solutions.

Shiv: So, going into key findings and potential solutions…one of the areas of emphasis in the report is providers needing support developing health technology skills, and I know that's one of your areas of expertise, Ian. I think it was 69 percent of clinicians surveyed believe the widespread use of digital health technologies will be a challenging burden on responsibilities if they aren't appropriately supported. And about 38 percent believe health care training and education is needed to stay up to date on these areas in digital health and telehealth and those aspects of healthcare delivery now. 

So, I may have already given some of those facts that you were going to share, but what are some of the key findings that you'd like to add to that in terms of that segment?

Dr. Chuang: I think the importance of this is the global perspective, and there are some nuances in the data and the responses that contextualize to how the health care system looks and where they are in that journey to digitalization and digital transformation. So, the good part is, collectively, universally, there was the belief in the benefit that is possible while recognizing what you've called out, which is that we may have put the technology too far ahead. We may have sort of thrown technology at the problem, not realizing that a healthcare system is complex. There's people, culture, and process in addition to tools and technology that have to align as we transition and pivot and transform. 

So, without some of the backend requirements to develop these skills, the clinical acumen is now inclusive of data analytics, right? It used to be, we joked, "garbage in garbage out" in terms of the data use and access, but now with ever-increasing large datasets, you also have to be skilled at data processing, being discerning of good data versus bad, and how do weed through all that volume of data. Those are skills that we've learned on the job, but we may have to consider baking them into the whole educational system. 

We develop clinical acumen by how we look at research studies, how we process that and apply judgment to good evidence, medium evidence, low evidence in terms of quality. I think we need to do the same with data that gets presented to us -- at the point-of-care even -- and that's a skill set and it needs the same discipline and rigor as we have with clinical knowledge and biology and things that are part of the curriculum now.

I think we're still working in an old paradigm, but we're also working in a new paradigm, and the two have to better align. 

Dr. Erlinger: What I would say is physicians are just like anyone else out there in terms of their use of technology. They all have a smartphone, laptops, etcetera. The idea that somehow physicians are less tech-savvy than the average person I think is incorrect. The difference is that technology is now inserting itself into a relationship, and there are good things and bad things about that. 

The good things are that care can be more standardized. Certain documentation aspects that are critical for accurate analytics are much easier with EHRs. Information moves faster. More than one person can look at the chart at a time. Back in the paper days, you had to wait for somebody to finish with the chart. 

However, things are more complicated with this as well. It's like putting a computer in front of somebody and saying, "Have a conversation with somebody in 15 minutes, but you have to type while you're doing it and we want you to evaluate the strength of that relationship afterward." Well, it's not just the computer that's changed, it's the time in the room. The throughput of patients through clinical offices has increased and now you're inserting technology in front of them and in between two people who are trying to have a conversation.

And so, it can be disruptive. In part, that's reflected in some of the data around impacts to empathy. Although I sort of look at that as being impactful to the relationship itself. It is just hard to do all three things at once and feel like you're having someone's attention and feeling like that's a quality interaction.

Shiv: Well, sticking to that point, I'm glad you mentioned that, Tate, because our colleague and former Raise the Line guest Jan Herzhoff, who runs global healthcare markets at Elsevier, tagged some of us when this report came out talking about how the patient-provider relationship has really changed as a result of telehealth. A lot of what we've done over the past two years with Raise the Line is focused on telehealth. We've had on the Chief Medical Officer and President of 98point6, Brad Younggren. We've had Joe Kvedar and Ann Mond Johnson on, who respectively ran the American Telemedicine Association. 

Everyone was talking about how telemedicine has improved convenience and access, and that's true. But this report shows that over half of clinicians actually believe it's negatively impacting their ability to provide empathetic care to patients. So, can you talk a bit more about that finding and what we can do about it?

Dr. Erlinger: Well, I can speak for my own experience. I still see patients and I have been during COVID. I've been primarily remote for the last two years in that engagement, and the impact is certainly there. There's body language. They're just human interactions that in-person interactions capture that telehealth doesn't. That said, I would also say that telehealth has been a fantastic way to take care of relatively routine visits with patients at a minimal inconvenience for them. 

Most of my patients would be classified as the working poor in the clinic that I'm in. For them, traveling to a clinic and spending a couple of hours in transit, waiting, and then going back home -- as for anybody -- is inconvenient but perhaps, especially for them. They may not be being paid during that time, etcetera, and there is no doubt that telehealth in some respects is meeting their convenience needs. 

Is it impacting relationships? Yes. But I don't think it's an "all or none." I don't think the choice necessarily has to be always telehealth or never telehealth. I think the question is can we take advantage of the technology we have to meet patients' needs and just optimize the relative use of in-person and remote engagement. 

Dr. Chuang: And I think we need to get into a discussion with more fidelity…getting beyond the marketing spin and the social media buzz around telehealth. It's just a modality, right? What I mean by that is, let's talk about the various population subsets and where and how I would use virtual care, right? Because it could be televideo, it could be telephonic -- those are modalities -- but it's about providing care virtually through a medium, and we can recall a time when we used to do that in primary care. We used to call that being "on call," right? 

So it's not a new technology. Now, what we can see is when there's an established relationship -- as a subgroup of patient-physician relationships -- I've already got that familiarity with the patient that has a context, there's trust and relationships there. There's the discernment of voice and visual behaviors that have built up over the years that I can already discern. 

I think for that kind of dynamic, virtual care does not lose empathy. It actually enhances the relationship because there's a sense of connectedness when, for reasons like COVID, it forced the separation of a face-to-face connection and encounter. But, for a complex condition, for somebody who's never seen me as a physician, there is that two-dimensional barrier that says, "I see you, but I don't know you and we've never had a relationship to build a therapeutic alliance." 

I think we have to separate those two conversations and get to clinical processes in the context of the clinical relationships and the clinical dynamics and not sort of lump everything in one bucket and say telehealth is cold, or that it solves everything. I don't think it's either-or.

Shiv: That's really insightful. One of our guests was Dr. David Mou of Cerebral, which is one of the largest providers of telehealth for psychiatry. He made the point that a lot of patients receiving psychiatric care via telemedicine get tossed around between different providers. And that's an area where, in particular, you want to have trust and data points. So, I agree that we have to be a little more nuanced with how it works and start training our future clinicians to better deal with technologies like telehealth and remote patient monitoring, etcetera. 

Speaking of training future physicians, we started Osmosis almost a decade ago because we wanted to make learning medicine more efficient and we realized that there was a global shortage of providers that the WHO estimated in the tens of millions. This was in 2015, before COVID.  I've seen recently that nearly one-fifth of U.S. healthcare workers have left healthcare altogether since February, 2020. One in three clinicians is considering leaving by 2024. 

This is pretty dire. What are some of the things that you take away from this report about training the next generation of clinicians -- care coordination teams, etcetera -- that can maybe provide a silver lining to this issue of shortages, or is it all sort of doom and gloom at this point?

Dr. Chuang: There are a lot of points of improvement to really address this fundamental problem, right? It's starting from the front end, which is generating interest in STEM and human biology as a starting point. New graduates have asked me, "Should I consider medicine?" I say to them at the heart of it, if you love science and human biology and you feel meaningful work is through working with people and impacting their lives, then the heart of the answer is yes. The rest is just trying to work through and figure out how to find the right fit and role. But the broader system needs to provide support. One of the inputs and feedbacks from this Clinician of the Future Global Report was, "I see the potential, I just need support. I need better training and education and skills development to align where healthcare is going." 

Without that, there's the belief and the feeling that, "You're just leaving me out there and you're just throwing technology at the problem and you expect me to react," which is not a supportive, collaborative type of a dynamic and feeling. But that's only one part of it. It is recruiting. It is dealing with the model of care, the burden and emphasis on reimbursement and financial viability sometimes that becomes an imposition on how you're practicing care. Things like RVUs...all those things do weigh-in and those are things that have to be addressed at the macro level as well. 

But for the things that we can do to set the clinicians up well, it's building the passion in them, helping them feel that this is a worthwhile profession. There's no other profession like it. There is hard work. There is sacrifice. But if those around us that support the healthcare enterprises align and respect that and uplift us, collectively...you know, COVID has shown that we go above and beyond. It's in the DNA. When you're in this business, when you're in this profession, you will step up. We just need some support and skills to back us up.

Dr. Erlinger: I think it is very concerning. I think there has been quite a bit of shift in both the nursing and physician workforce that has been amplified with the stress of COVID. For instance, the burden of traveling nurses as opposed to employed nurses, and the financial burden that puts on institutions. But I think travelers are not the problem so much as just globally, there are quite a few factors, as Ian said, coming into play. 

At least in my experience, physicians experience some frustration with the degree to which they're being micromanaged. There's a lot of looking over the shoulder of physicians in terms of quality metrics and reporting and value-based contracts, and there's a feeling of being commoditized. There's a feeling that throughput and quality metrics constitute your value. 

That's disconcerting for a lot of people to have the feeling that they're being reduced to something that must be measurable in every aspect. They will sometimes view the technology as just a way to measure more, but not necessarily make any improvements. I think that is also a bit cynical, but I think there are lots of pressures that are coming into play here. There are market pressures. There are workforce pressures. There's business consolidation and technology all happening, and many of the physicians still in practice today remember a time when they were training when that wasn't the case. That creates a bit of looking back and seeing a bit rosier picture than perhaps it was. But they remember the days when it wasn't like that. 

So, I think that creates some anxiety, it creates some stress, but there's just a lot of change happening in a lot of different dimensions.

Shiv: Absolutely. One thing I saw in the report, but definitely have heard anecdotally by talking to people in the profession, is that two years into the pandemic, they're kind of shocked at how the public's view has changed. The report shows only 55% of clinicians think the public fully appreciates what the profession has been doing, which seems very low compared especially to the first few months of the pandemic when "healthcare heroes" was a buzzword. Also, only 30% think the government is fully supporting them, which is obviously a result of things like the median medical school debt in the U.S. being at $200,000. 

If we want someone to be a healthcare hero, why do we saddle them with $200,000 of debt? That's a question that some of our partner schools -- like New York University and Kaiser Permanente -- have fully addressed by providing tuition-free education, and we've had people from both those programs on the Raise the Line podcast talking about that as well. Hopefully, many schools will join them.

I know we're coming up on time. Tate, what do you think some of the follow-ups are from this report? What should we be thinking about and doing to make these changes happen?

Dr. Erlinger: One thing is that I think we're planning on doing this annually. The reason that's important is not just for the research itself, but we need to understand global trends and we need to understand them at the pace of change. Doing that annually, as opposed to many, many years between, will be helpful to gain more depth and insight.  

Number two, I think we have to begin to take deeper dives in a certain area. Healthcare is not one thing. There's an ambulatory experience. There's an emergency room experience. There's a surgical experience, etcetera. All of those experiences are quite different for the physicians, the nurses, the patient, and their families. I think we have to be going into a little more detail around the types of care, what those experiences are, and kind of break them apart a bit. They're not all monolithic. 

Another thing I think we could do is begin to look at some of the big fears and gaps. One of the ones we've talked about, and I think we as a company are positioned to do it, is potentially help with the information overload. There's technology, yes, but there's also information overload. It used to be that you would carry in your pocket, in your white coat, a little book or two and you would use them as references. That's basically what you had, or you could go into the library and read a textbook.

The pace of information coming out in medical literature is overwhelming. It's not realistic to think that anyone's keeping up with the sheer volume of publications coming out and making sense of that. We need to be, I think, a little smarter, a little more strategic, a little more creative about getting information to the point of care for reference -- for making sure they're following the latest guidelines -- but making that easy to do. Make it easy to find and easy to act on in this limited time period that you have. 

Ian raised another point, which is, what is it that people are wanting in terms of enhanced training with technology? What does that really reflect? Does that reflect the true deficit of technological understanding? Or, does it reflect the information overload? I don't know the difference here yet, but I think we should tease that apart, and I think we can get acting very quickly on some things. Other things are going to take conversations with medical schools, with government entities. You raised the issue of student debt. There used to be, and perhaps there still are in some cases, student loan repayment programs that are critical to helping people fund their graduate education. 

So, I think there are lots of steps that could be done, but those are some ideas.

Shiv:  I'm really glad you guys have highlighted this in this report because, as you know, we collectively work with hundreds of medical, nursing and other health care programs. Many of them -- I'll call out folks like Warren Wiechmann at UC Irvine or Johannes Vieweg at Nova Southeastern, or Mark Triola at NYU -- are very ahead of the curve in terms of adopting some of this training, adopting some these forward-looking practices that come out in your Clinician of the Future Global Report.

The other thing I really want to point out that really stuck to me was that, in the report, 66% of the clinicians believe patients will be more empowered to take care of their own health. As you know, we call this podcast Raise the Line, which is about how we train more clinicians of the future and how we improve healthcare quality, but the other piece of that is to flatten the curve. How do we reduce the demands on the healthcare system through more preventive medicine and providing the data and education directly to the patient, which is a big focus of what we do at Osmosis.

Dr. Erlinger: This is a really critical point. I really like that you raised that, Shiv, because especially in primary care where Ian and I come from, there's so much that the patient has to take on. Making it easy for patients to manage their diabetes, removing barriers, allowing self-management -- those are huge advances that could both alleviate pressure on the healthcare system, but also improve this relationship. I think you're right. It's been going on for quite some time that patients have access to more information. They're coming in offices with articles and with Google printouts. That's been going on for some time, and that's great to me. That was disruptive when it started, but now it's sort of part of the conversation between two people. 

I think it's a really important point to sort of champion self-empowerment or patient-empowerment.

Shiv: Yeah, definitely. Ian, do you have anything to add to that point? 

Dr. Chuang: The reality is right now, on my smartphone, there's more personal biometric and clinical data about myself than there is in an EMR, right? There's a huge potential to tap into that, and with a motivated, engaged patient, there's an opportunity to be more precise and provide proficient care if we can connect the data there with the clinician and a consumer that's engaged. 

The other point I would make is if we can think of the role of clinicians not by job title but by skillsets, there's a huge potential to expand the resources necessary, especially around primary care. Case in point: we've got two pilot programs outside of North America -- one in India and one in Cambodia -- where we're basically bringing knowledge and skills to rural communities where there is no luxury of bringing a doctor or hospital to the last mile in the community. Instead, we have trusted resources, like the ASHAs (Accredited Social Health Activists) who are just basically the community grandmother, who are trusted based on their role in the community. 

You equip them with the knowledge, you help them stay within the skills that we've taught them. They are excellent resources to provide, in this case, primary maternity care. So, that's an example of thinking differently, thinking outside the box, beyond the traditional brick-and-mortar structure of healthcare, beyond traditional title-based job role definitions of what is primary care, but rather the skills to provide primary care. Then, the potential is great.

Shiv: I'm glad you mentioned that. This is, again, one reason I like this report. It takes a real global view of the problem and it's very interconnected, right? When there's a brain drain of African doctors to the U.S., as an example, then we're making the situation worse in Africa, potentially. It’s important for us to look at this globally, and that's certainly one of the appeals of Elsevier as a whole when we decided to join you all.

I wanted to wrap up with two questions. The first is, given that our audience is comprised of millions of current and future healthcare professionals, what advice would you give to them about meeting the challenges of COVID and beyond and becoming a clinician of the future? I'll start with you, Ian, and then go to you, Tate. 

Dr. Chuang: So, I would say, if you love human biology and you feel rewarded when you're connected with people and contributing to their health and well-being, then medicine as a profession is the right focus. What your job may look like is wide open as exampled by all three of us here, right? We are still physicians at our core. We are still knowledgeable in medicine, but then where and how we apply it is, right now, highly variable because across the whole healthcare ecosystem, there are multiple opportunities where a physician, a clinician with the medical background, is necessary to innovate, to drive the necessary changes to achieve a better healthcare system.

Dr. Erlinger: It's a great question, Shiv. I'm lucky enough to be with undergraduate students in my clinic. It's a volunteer clinic, so I'm with undergraduate pre-med students all the time. I will give the same advice that I give to them -- which is kind of similar to Ian's -- which is, whether you decide to go into medicine may have a number of factors involved, but the medicine of today is certainly broader. And what I mean by that is there's technology. We're in a technology company, for example. There are just so many different things that can be done that were not really possible 30 years ago. You see more and more health care workers with hybrid jobs where they're seeing patients, but they're also in tech or other organizations.

My thought is to keep an open mind. Create your future, create a path for the physicians or the nurses that follow you, in a sense.  Be open-minded in terms of what that career could look like for you. That advice may not apply always, you would think, to some surgeons for example, but my last boss in informatics was a vascular surgeon. So, it does apply. It's a profession that's evolving. It's a profession that will always be evolving and going through changes as society changes. That creates opportunities.

Shiv: Absolutely. One of the privileges of hosting this podcast is meeting clinicians like you all who are not only clinicians of the future, but creating the future. That's been inspiring to see. My last question is open-ended. Is there anything else you'd like to let our audience know about this report, about Elsevier, or about you guys individually?

Dr. Erlinger: I would look at this report really as a call to action. There are some alarming numbers in here, but healthcare has always responded and tended to meet the needs of the communities that they serve. We need to be diligent and we need to look for and test solutions across a broad range of things, but I would not look at this as some sort of apocalypse for medicine. I think we have gone through waves of this before, and we will again. What is great about the profession is it tends to respond.

Dr. Chuang: I would agree. It's a start. It's creating awareness. It's generating conversation, and that's a necessary prerequisite to start engaging the broader stakeholders that are necessary to collaborate together to come to a solution and start to whittle away at these challenges to achieve the opportunity. 

Shiv: Awesome. I think it's pretty inspiring. My hope is that our audience takes the time to read the report, to engage, to, as we said, create the clinician of the future. We have a great opportunity ahead of us. 

With that, Tate and Ian, thanks so much for taking the time to be with us today. 

Dr. Chuang: Appreciate it. 

Dr. Erlinger: Thank you.

Shiv: With that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show, and remember to do your part to flatten the curve and raise the line. We're all in this together. Take care.