Thinking about competencies related to current and emerging information technologies raises several interesting questions for physicians: What will they need to know about information technology in order to be effective in the future? What role will technology play in achieving high levels of effectiveness? And what specific skill sets will physicians require to achieve and maintain these levels of effectiveness?

To address these questions, we paint the picture of a potential medical future, briefly outline emerging technologies that will shape that future, and discuss how physicians may lead in the use of these technologies and, concurrently, expect to use them on a daily basis. We close by considering competencies related to medical technologies and their implications for clinical educators preparing learners for a new medical world.

To quickly envision how technology has affected medical practice over the years, consider these brief scenarios regarding the assessment and treatment of a mid-40s male with fever, chills, and a hacking cough.

A physician in a horse-drawn carriage arrives at the patient’s home, summoned earlier in the day by the man’s wife, who sent her son on horseback to the physician’s office several miles away. At the age of 40, the man is already approaching the end of his natural life but has now developed a fever, chills, and a hacking cough. Physical examination leads to the diagnosis of pneumonia, an often fatal condition. The physician prescribes a morphine tonic with alcohol to relieve the patient’s pain and dyspnea. He spends time comforting the distraught family who realizes that the patient may die. The physician will return the next day to the patient’s home. He creates a written patient record in his notebook and returns to his private hospital. Using his microscope, he sees the causative organism in the patient’s sputum sample. Therapeutic options are limited. The physician looks through his few books on medicine and surgery and discusses the case with a colleague down the street.

In his urgent care clinic, a physician sees the patient, whom he has never met, for fever, chills, and a hacking cough. The man is in the prime of his life—mid-40s with a young family. He has traveled about 20 miles by car for this appointment, driven by his wife. The physician logs onto the hospital’s electronic medical record system and quickly reviews prior appointments and laboratory results. After diagnosing pneumonia on the basis of a quickly obtained chest X-ray, the physician prescribes antimicrobial agents to be picked up at the local pharmacy. The patient’s wife asks about resistant bacteria and further instructions for care. Using the in-room desktop computer, the physician does a quick online search for local bacterial resistance patterns and prints out current information from a proprietary medical database. The physician asks the patient to call his nurse the next day. If the patient fails to improve, he is instructed to return to the office for reevaluation and possible hospital admission.

A physician on call in his office in India receives a video-conference call from a patient suffering from fever, chills, and a hacking cough. The patient, located 8,500 miles away in his local med-terminal, is a member of an international health network. In his mid-40s, he is a young man with another 60 to 70 years of life ahead of him. The physician pulls up the patient’s records from his computer terminal. With the patient in the med-terminal, the physician performs a noninvasive MRI-like scan remotely and diagnoses pneumonia. Vital signs are taken automatically by means of pressure gauges. The patient enters a biometric access code to allow the physician to obtain his pharmaco-genomic profile from an embedded microchip to begin counseling. The patient’s personal digital assistant captures key words of their conversation via voice recognition software and displays pertinent patient-related information for the patient to view synchronously. The physician prescribes a long-acting antibiotic, which the patient receives on-site from an injection terminal. His counseling is complete after the patient receives standardized information from a medical database about self-care. The patient uses a continuous home monitoring device (pulse, blood pressure, oxygenation), which routes his vital signs to the local physician network to monitor trends and complications. If the patient’s vital signs fall below acceptable parameters, an ambulance network will be automatically notified and he will be transported to a local hospital for reevaluation and additional therapy. The Indian physician does a quick literature search on aspects of caring for American patients with pneumonia and enters his thoughts and lessons learned into a learning portfolio for his own CME credit. The patient completes his customer satisfaction form on the insurance company’s Web site in order to receive his participation bonus of a reduced copayment.

This view of the future simply extends already existing major medical trends that represent market force pressures for cost containment (1, 2), globalization/outsourcing (3—6), and data consolidation (7—11). Another equally plausible view of the medical future might envision better personal relationships between patients and their physicians (12, 13), using local coverage networks and personal communications modalities (e.g., next evolution of e-mail, home monitoring) to allow longitudinal and home-based interactions. Optimists might even imagine that doctors might make home visits (14—16) because their patient pool has become smaller due to their negotiated rates increasing and with risk pools shared across demographic groups.

The major fallacy of trying to predict a medical future based on present technologies or current social/economic/political trends is that major shifts are difficult to anticipate. For instance, while functional nanotechnology and increased domestic terrorism are recognized as near-future possibilities, the next major paradigm shift is as yet unknown. These shifts (such as Internet-based shared networks, massive inexpensive computing power, ease of international travel, changing unemployment) have a dramatic impact on the medical horizon in unpredictable, nonlinear ways.

Even with these uncertainties, educators are obliged to prepare their learners for near- and far-future practice scenarios. They need to consider critical elements embedded in these known trends, and devise strategies to help learners meet those needs. Similarly, examining critical aspects of those scenarios (Appendix 1) allows us to describe the spectrum of competencies that physicians may need to develop. Foreseeable major trends in medicine include:

In medicine and the rest of society, the rate of technology introduction and adoption has been rapid. Enhanced competency by physicians may be directly related to technology adoption. The incorporation of new technology in medical practice is influenced by four strong forces, the four "As," which are driving pressures toward greater efficiencies and effectiveness in medical care: accessibility, affordability, accountability, and affability (Appendix 2). These driving pressures are fluid and change over time for any given technology. For example, as more competitors try to develop similar products (such as Internet access providers [AOL, Comcast, telecom companies]), the technologies will decrease in price (affordability). This decrease in price and increase in manufacturing/distribution will increase the consumer’s access to the technology. With each iteration, the consumer will find the technology easier to use and more functional (affability). Physicians will be required to critically assess the cost-benefit-harm-limitations for each new technological tool and be accountable for the use and results of the technologies in practice.

In preparation for this future, physicians will have to decide how involved they will want to be with emerging medical technologies. Some will elect to remain "end-users" of technology, whereas others will participate in developing and evolving those technologies or will interface between the developers and the end-users (Appendix 3). Physicians who are on the development end of technology will, of course, need to develop specialized expertise in those technologies: affecting communication, diagnostic and therapeutic options, data management, self-education strategies and other constantly changing areas.

These major trends will have significant implications for physician training and competency development (51, 52). As with other professionals, all physicians will be required to become "technology literate"—understanding how to use basic software programs, communication/e-mail programs, messaging systems, common organizers, common presentation-related hardware. Psychiatrists, for example, might be expected to acquire skills for interacting with remote patients via teleconferencing (tele-psychiatry) (53). Most of these technologies currently exist and are already being used in tele-consultation. Physicians who bridge two associated fields of medicine (e.g., electronic medical record development) and medical practitioners will require familiarity with practice patterns/usage in the associated fields. As physicians seek additional leadership opportunities, those who are dually trained will enjoy competitive advantages in the medical marketplace, where obtaining and disseminating medical information will become increasingly simple. Medical informatics, the field of managing and interfacing with medical information, will comprise only a subset of the total types of skills that dual competency physicians may acquire.

Future medical school selection committees may be increasingly inclined to recruit physician leaders who bring substantial experiences outside of medicine to their medical education. Because of the increasingly rapid expansion and evolution of the knowledge base, students will need to spend more time learning to assess data critically. With ubiquitous information access, the amount of basic knowledge that physicians will need to memorize may decrease. They will also require skills in new ways of communicating with their patients via remote means. These shifts may encourage some physicians to spend more time than in the past understanding the systems and social implications of practice (health economics, health disparities, evidence assessment, research training, epidemiology).

Currently, the competencies outlined by the ACGME (54) are flexible enough to allow incorporation of the technology-related skills into a standard residency training program. Educators will be faced with an even more complicated task: keeping their core curriculum (e.g., pathophysiology) stable while incorporating new information at a reasonable pace. In Appendix 4, we have mapped a few very basic technology-related competencies for the end-user physician, who may have minimal input into technology development. Educators will need to consider core skill sets for each user type from a competency perspective. Since many of the core skills affect the different areas of medical practice, educators will need to carefully consider how "stacked" they want their competency grids to appear.

Medical educators will be faced with the even more complicated tasks of retaining their fundamental core curriculum requirements (e.g., pathophysiology) while incorporating new information at a reasonable pace. Traditional medical education models are already challenged, as medical students already acquire and assimilate knowledge via their wireless laptops and PDAs during classes, seminars, and at the bedside. Inexpensive, high-quality digital video recording technologies allow easy demonstration of best/worst communication and clinical skills practices in classrooms. As high quality core curricula become universally available through the Web, educators will have to determine the best use of classroom time—how much time to spend to deliver core content and/or using a small group setting to assess learner understanding and push skills in content application. Each of the specific competencies that educators will instruct or encourage will entail knowledge, skills, attitudes, and habits. Some competencies related to the incorporation of these technologies into a medical educator’s practice are detailed in Appendix 5.

Cultural and technological shifts often provoke anxiety about a loss of values or autonomy while simultaneously provoking excitement about new opportunities. The practice of medicine is evolving quickly, and global trends in the marketplace place pressure to reduce cost while increasing quality. The American physician of the future will face international competition, and all competitors will be equipped with powerful new tools for patient care, data management, and communication. Examining these major trends can help educators understand the new technological competencies that will be required of physicians. Medical education itself will evolve in learner selection, content, and methods. Physician leaders in education will help guide the appropriate implementation of medical technologies in practice, fostering practices that use technology to increase accessible, affordable, accountable, and affable medical care.