Dr. David Goldbloom, CAMH Senior Medical Advisor, and Dr. Gratzer have a light-hearted conversation in which Dr. Goldbloom predicts 5 things that may be in store for the future of medical education and about how technology challenges the norms and expectations of the role of clinicians.
Dr. David Goldbloom, CAMH Senior Medical Advisor, and Dr. Gratzer have a light-hearted conversation in which Dr. Goldbloom predicts 5 things that may be in store for the future of medical education and they consider how technology challenges the norms and expectations of the role of clinicians.
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September 25, 2019
Double Take with David Goldbloom
David Gratzer: We're joined now by Dr. David Goldbloom, who is a senior medical adviser here at CAMH. And he's been very much involved in education and technology through his career, which includes time as Physician in Chief here at CAMH. Dr. Goldbloom, welcome.
David Goldbloom: Thank you. Nice to be here.
David Gratzer: Dr. Goldbloom, we've had an animated discussion talking about the past, present and future of technology and medical education. Let's put you on the spot. What do you think are things we might see in the future? Let's be specific in our ask. What are five things?
David Goldbloom: I would offer five predictions, comfortable in the knowledge that I won't be around to be held accountable for them in a couple of decades. First is that millions more people will be reached in terms of mental health through the assistance of technology than we are currently able to do with our human complement. The second is that technology will reinvent the role of clinicians. Clinicians will not disappear, but how they work will change much as it is changing for dermatologists, radiologists, neurologists and other clinical brethren. The other thing that will change dramatically is how we do research. Because our current ways of evaluating things therapeutically, with the golden aura of the randomized controlled trial, will change dramatically with the impact of technology because technology changes far more rapidly than any form of psychotherapy and more rapidly than any medication. So we will have to come up with new research paradigms. The fourth will be that the human factor will not disappear in our lifetime. And indeed, the most recent article that I've found is about the therapeutic alliance in digital mental health interventions and how we can come up with ways of establishing that. And related to that, my fifth and final point would be as humans, we are relentless, anthropomorphizers. And it is no accident that Alexa and Siri have names so that we take these inanimate artificial things and we humanize them, much as we do with our pets. So I suspect that the technology will also morph to be more and more human-like. And then, of course, raise those big philosophical questions of what is it to be human.
David Gratzer: You see the field of psychiatry dramatically changing in coming years. What are the implications for medical education in light of that?
David Goldbloom: Well, I think medical education is playing catch up. And when I say playing catch up, certainly when I trained, a lot of our reading was based on writings done generations earlier.
David Gratzer: And so how should medical education change accordingly?
David Goldbloom: If you think of our various Can-Meds roles, one of our roles is ultimately to be an expert – and we need to have expertise in the new technologies. That means familiarity. I think that also means taking them for test drives, experiencing them wherever possible, so that we can make informed recommendations to our patients who turn to us for our expertise.
David Gratzer: John Torous has a paper recently published looking at patients who use a mental health clinic in the Boston area. And he talks about whether or not they download apps. Patients 26 and under, something like 100 percent of them, have downloaded a mental health app. It's a different world.
David Goldbloom: Totally. And as Torous has pointed out, there are now about 10,000 mental health apps out there. Doesn't mean they've all passed the smell test of evidence to support their efficacy, but this is mushrooming rapidly. And, yet, I find even among some of my younger colleagues and my trainees, they've never looked at any of these apps.
David Gratzer: But just as a generation ago, we might have helped our patients pick a book on cognitive behavioural therapy, we might turn around and help them pick an app on cognitive behavioural therapy.
David Goldbloom: Absolutely.
David Gratzer: Any therapies are interesting. I mean, some of our colleagues are very hesitant on this, and yet, I mean psychotherapy is about trying to form a connection, and that might be in person, but that might be over the Internet as well.
David Goldbloom: And look, I have seen with patients who I have recommended apps to, that they rapidly personalize those apps. And the app makers are very smart to have a little avatar or a figure, a funny looking robot, who nudges you and stuff. So it quickly humanizes.
David Gratzer: David Clarke makes a point, as you know he's the psychologists at Oxford who's been very involved in expanding psychological services in England, they're now experimenting with online therapies. And they've asked people if they feel more connected with an online therapist than an in-person therapist. And intuitively, you'd say: "Well, how can that be? Your in-person therapist you've shared space with. He passed you a tissue during an unsettling moment in your last session, and the online therapist just pops you an e-mail?" It turns out people feel more connected with the online therapist, at least with the people he's had contact with, on the grounds that the therapist is much more available than once a week. Send them an email on a Sunday, you get a response Monday morning. Tuesday, a response that afternoon, and so on.
David Goldbloom: Look, this is about challenging our own norms, values and expectations as clinicians. Because, generally, people are conservative and not in a big hurry to change what they do. They look for evidence that reinforces the value of what they've been doing for a long time. Many years ago, more than two decades ago, we did a study looking at therapeutic alliance for patients seen via televideo versus in-person in the office. And we found that it was no different. But people still say to me, you know, I don't think I would feel comfortable seeing a patient on a television monitor. It's just not the same for me as all the nuance that I observe when they're sitting in my office. Well, frankly, what counts is not your sense of the nuance, but how did the patient like it and did the patient get better? The rest is icing.
David Gratzer: You bring up televideo. You were actually involved in some of the early experiments here at CAMH, some of the earliest experiments in North America, no?
David Goldbloom: No. In fact, the first use of televideo that's documented in the peer-reviewed literature, I think goes back to Nebraska in 1957. And the latest evidence from Ontario, more than half a century later, is that about 7 percent of Ontario's psychiatrists do televideo work, despite half a century of evidence that this is a great way to overcome the geographic and distribution disparities that exist in almost every jurisdiction.
David Gratzer: Is that a failure of education? Is that a failure of doctor culture? We're using our phones for everything. You suggest not only do relatively few of Ontario's doctors use this technology, but demographically it tends to be older psychiatrists, not younger psychiatrists. What happened?
David Goldbloom: Are you suggesting I'm an older psychiatrist?
David Gratzer: This isn't about you (laughs).
David Goldbloom: Because I'm just prematurely grey (laughs). Yeah. I think it is a failure of education. I think it's a failure to inculcate new models into the curriculum sufficiently aggressively. And I also think we model behaviour as clinicians. So if we're not doing it, the students would say, well, why should I do it?
David Gratzer: What do you think is the downside? So technology continues to change society. Technologies continue to change medical education. What do you think is something we should be wary about?
David Goldbloom: Well, I think the first thing we need to be wary about, and I say this as somebody who's not involved with any social media of any kind, is that people are suddenly waking up to the privacy concerns that have existed since the creation of supposedly "free" social media platforms. And similarly, there have to be significant concerns about privacy in relation to technology. Now, I happen to believe these are not insoluble problems, but we can't be asleep to them. Frankly, before this technology, it was easy enough to have a paper chart faxed to the wrong address, or left in the backseat of your car that somebody could nick. So there have always been privacy concerns – whether it's a conversation in the elevator or something else. But they seem to be magnified by the technology. So the very thing that can increase access, can increase risk in terms of privacy. And I think that's one of the big challenges that needs to be addressed.
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Until next time.