Educational Assessment, Interventions, and Outcomes
480 http://ap.psychiatryonline.org Academic Psychiatry, 30:6, November-December 2006
Visualizing the Future:Technology Competency Development in Clinical Medicine,
and Implications for Medical Education
Malathi Srinivasan, M.D., Craig R. Keenan, M.D., Joel Yager, M.D.
Received February 2, 2006; revised May 1, 2006; accepted May 23,2006. Drs. Srinivasan and Keenan are affiliated with the Departmentof Internal Medicine, University of California, Davis, Sacramento,California. Dr. Yager is affiliated with the Department of Psychiatry,University of New Mexico, Albuquerque, New Mexico. Address cor-respondence to Dr. Srinivasan, 2315 Stockton Boulevard, Sacra-mento, CA 95817; [email protected] (e-mail).
Copyright � 2006 Academic Psychiatry
Objective: In this article, the authors ask three questions. First,what will physicians need to know in order to be effective in thefuture? Second, what role will technology play in achieving thathigh level of effectiveness? Third, what specific skill sets will phy-sicians need to master in order to become effective?
Method: Through three case vignettes describing past, present,and potential future medical practices, the authors identify trendsin major medical, technological and cultural shifts that willshape medical education and practice.
Results: From these cases, the authors generate a series of tech-nology-related competencies and skill sets that physicians willneed to remain leaders in the delivery of medical care. Physicianswill choose how they will be end-users of technology, technologydevelopers, and/or the interface between users and developers.These choices will guide the types of skills each physician willneed to acquire. Finally, the authors explore the implications ofthese trends for medical educators, including the competenciesthat will be required of educators as they develop the medicalcurriculum.
Conclusions: Examining historical and social trends, includinghow users adopt current and emerging technologies, allows us toanticipate changes in the practice of medicine. By consideringmarket pressures, global trends and emerging technologies, medi-cal educators and practicing physicians may prepare themselvesfor the changes likely to occur in the medical curriculum and inthe marketplace.
Academic Psychiatry 2006; 30:480–490
Thinking about competencies related to current andemerging information technologies raises several in-
teresting questions for physicians: What will they need toknow about information technology in order to be effectivein the future? What role will technology play in achievinghigh levels of effectiveness? And what specific skill sets willphysicians require to achieve and maintain these levels ofeffectiveness?
To address these questions, we paint the picture of apotential medical future, briefly outline emerging technol-ogies that will shape that future, and discuss how physi-cians may lead in the use of these technologies and, con-currently, expect to use them on a daily basis. We close byconsidering competencies related to medical technologiesand their implications for clinical educators preparinglearners for a new medical world.
To quickly envision how technology has affected medicalpractice over the years, consider these brief scenarios re-garding the assessment and treatment of a mid-40s malewith fever, chills, and a hacking cough.
The Past, Circa 1890
A physician in a horse-drawn carriage arrives at the pa-tient’s home, summoned earlier in the day by the man’swife, who sent her son on horseback to the physician’s of-fice several miles away. At the age of 40, the man is alreadyapproaching the end of his natural life but has now devel-oped a fever, chills, and a hacking cough. Physical exami-nation leads to the diagnosis of pneumonia, an often fatalcondition. The physician prescribes a morphine tonic withalcohol to relieve the patient’s pain and dyspnea. Hespends time comforting the distraught family who realizesthat the patient may die. The physician will return the nextday to the patient’s home. He creates a written patientrecord in his notebook and returns to his private hospital.Using his microscope, he sees the causative organism in
SRINIVASAN ET AL.
Academic Psychiatry, 30:6, November-December 2006 http://ap.psychiatryonline.org 481
the patient’s sputum sample. Therapeutic options are lim-ited. The physician looks through his few books on medi-cine and surgery and discusses the case with a colleaguedown the street.
The Present, Circa 2006
In his urgent care clinic, a physician sees the patient,whom he has never met, for fever, chills, and a hackingcough. The man is in the prime of his life—mid-40s witha young family. He has traveled about 20 miles by car forthis appointment, driven by his wife. The physician logsonto the hospital’s electronic medical record system andquickly reviews prior appointments and laboratory results.After diagnosing pneumonia on the basis of a quickly ob-tained chest X-ray, the physician prescribes antimicrobialagents to be picked up at the local pharmacy. The patient’swife asks about resistant bacteria and further instructionsfor care. Using the in-room desktop computer, the physi-cian does a quick online search for local bacterial resis-tance patterns and prints out current information from aproprietary medical database. The physician asks the pa-tient to call his nurse the next day. If the patient fails toimprove, he is instructed to return to the office for re-evaluation and possible hospital admission.
The Near Future, Circa 2025
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 awayin his local med-terminal, is a member of an internationalhealth network. In his mid-40s, he is a young man withanother 60 to 70 years of life ahead of him. The physicianpulls up the patient’s records from his computer terminal.With the patient in the med-terminal, the physician per-forms a noninvasive MRI-like scan remotely and diagnosespneumonia. Vital signs are taken automatically by meansof pressure gauges. The patient enters a biometric accesscode to allow the physician to obtain his pharmaco-ge-nomic profile from an embedded microchip to begin coun-seling. The patient’s personal digital assistant captures keywords of their conversation via voice recognition softwareand displays pertinent patient-related information for thepatient to view synchronously. The physician prescribes along-acting antibiotic, which the patient receives on-sitefrom an injection terminal. His counseling is complete af-ter the patient receives standardized information from amedical database about self-care. The patient uses a con-tinuous home monitoring device (pulse, blood pressure,
oxygenation), which routes his vital signs to the local phy-sician network to monitor trends and complications. If thepatient’s vital signs fall below acceptable parameters, anambulance network will be automatically notified and hewill be transported to a local hospital for reevaluation andadditional therapy. The Indian physician does a quick lit-erature search on aspects of caring for American patientswith pneumonia and enters his thoughts and lessonslearned into a learning portfolio for his own CME credit.The patient completes his customer satisfaction form onthe insurance company’s Web site in order to receive hisparticipation bonus of a reduced copayment.
This view of the future simply extends already existingmajor medical trends that represent market force pres-sures for cost containment (1, 2), globalization/outsourcing(3–6), and data consolidation (7–11). Another equallyplausible view of the medical future might envision betterpersonal relationships between patients and their physi-cians (12, 13), using local coverage networks and personalcommunications modalities (e.g., next evolution of e-mail,home monitoring) to allow longitudinal and home-basedinteractions. Optimists might even imagine that doctorsmight make home visits (14–16) because their patient poolhas become smaller due to their negotiated rates increas-ing and with risk pools shared across demographic groups.
The major fallacy of trying to predict a medical futurebased on present technologies or current social/economic/political trends is that major shifts are difficult to antici-pate. For instance, while functional nanotechnology andincreased domestic terrorism are recognized as near-fu-ture possibilities, the next major paradigm shift is as yetunknown. These shifts (such as Internet-based shared net-works, massive inexpensive computing power, ease of in-ternational travel, changing unemployment) have a dra-matic impact on the medical horizon in unpredictable,nonlinear ways.
Even with these uncertainties, educators are obliged toprepare their learners for near- and far-future practice sce-narios. They need to consider critical elements embeddedin these known trends, and devise strategies to help learn-ers meet those needs. Similarly, examining critical aspectsof those scenarios (Appendix 1) allows us to describe thespectrum of competencies that physicians may need to de-velop. Foreseeable major trends in medicine include:
• CommunicationEvolution of the doctor-patient relationship into amore client-supplier model (17, 18).Greater emphasis on patient responsibility forhealth (19).
TECHNOLOGY COMPETENCY DEVELOPMENT AND EDUCATION
482 http://ap.psychiatryonline.org Academic Psychiatry, 30:6, November-December 2006
• Information managementAvailability of high quality, transparent medical in-formation for the lay public (20, 21).Internationally available patient medical/pharmacyrecords (22, 23).Stringent new privacy standards, with biometric andother coded data schemas (24–27).User-friendly, decentralized continual education,tailored to individual practices (28).Emphasis on self-directed learning and continuingself-education (29–31).
• DiagnosisDevelopment of pharmocogenomic profiles for in-dividual patients (32–35).Inexpensive high-quality imaging techniques forclinic use (36).Creation of better home monitoring equipment forself/system management (37, 38).
• TherapyInformation management systems for physicianeducation and practice-based updates (39).Compilation of individual patient health statisticsinto searchable databases (40).Testing of complementary, alternative and tradi-tional/local medical practices (41, 42).Increasing emphasis on nonallopathic practice andancillary practitioners (43, 44).
• Quality control and locationDecentralization of medical care via telemedicinetechnologies (45, 46).International standards for medical practice, “in-ternationalizing” medicine (47, 48).Medical outsourcing to other countries for non-emergent treatment (49, 50).
Likelihood of Technology Adoptionby Physicians and Society
In medicine and the rest of society, the rate of technol-ogy introduction and adoption has been rapid. Enhancedcompetency by physicians may be directly related to tech-nology adoption. The incorporation of new technology inmedical practice is influenced by four strong forces, thefour “As,” which are driving pressures toward greater ef-ficiencies 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 competitorstry to develop similar products (such as Internet accessproviders [AOL, Comcast, telecom companies]), the tech-nologies will decrease in price (affordability). This de-crease in price and increase in manufacturing/distributionwill increase the consumer’s access to the technology. Witheach iteration, the consumer will find the technology easierto use and more functional (affability). Physicians will berequired to critically assess the cost-benefit-harm-limita-tions for each new technological tool and be accountablefor the use and results of the technologies in practice.
Physician Role Adoption and CompetencyDevelopment
In preparation for this future, physicians will have todecide how involved they will want to be with emergingmedical technologies. Some will elect to remain “end-users” of technology, whereas others will participate in de-veloping and evolving those technologies or will interfacebetween the developers and the end-users (Appendix 3).Physicians who are on the development end of technologywill, of course, need to develop specialized expertise inthose technologies: affecting communication, diagnosticand therapeutic options, data management, self-educationstrategies and other constantly changing areas.
These major trends will have significant implications forphysician training and competency development (51, 52).As with other professionals, all physicians will be requiredto become “technology literate”—understanding how touse basic software programs, communication/e-mail pro-grams, messaging systems, common organizers, commonpresentation-related hardware. Psychiatrists, for example,might be expected to acquire skills for interacting with re-mote patients via teleconferencing (tele-psychiatry) (53).Most of these technologies currently exist and are alreadybeing used in tele-consultation. Physicians who bridge twoassociated fields of medicine (e.g., electronic medical rec-ord development) and medical practitioners will requirefamiliarity with practice patterns/usage in the associatedfields. As physicians seek additional leadership opportu-nities, those who are dually trained will enjoy competitiveadvantages in the medical marketplace, where obtainingand disseminating medical information will become in-creasingly simple. Medical informatics, the field of man-aging and interfacing with medical information, will com-prise only a subset of the total types of skills that dualcompetency physicians may acquire.
SRINIVASAN ET AL.
Academic Psychiatry, 30:6, November-December 2006 http://ap.psychiatryonline.org 483
Implications for Medical Training
Future medical school selection committees may be in-creasingly inclined to recruit physician leaders who bringsubstantial experiences outside of medicine to their medi-cal education. Because of the increasingly rapid expansionand evolution of the knowledge base, students will need tospend more time learning to assess data critically. Withubiquitous information access, the amount of basic knowl-edge that physicians will need to memorize may decrease.They will also require skills in new ways of communicatingwith their patients via remote means. These shifts may en-courage some physicians to spend more time than in thepast understanding the systems and social implications ofpractice (health economics, health disparities, evidence as-sessment, research training, epidemiology).
Currently, the competencies outlined by the ACGME(54) are flexible enough to allow incorporation of the tech-nology-related skills into a standard residency training pro-gram. Educators will be faced with an even more compli-cated task: keeping their core curriculum (e.g.,pathophysiology) stable while incorporating new infor-mation at a reasonable pace. In Appendix 4, we havemapped a few very basic technology-related competenciesfor the end-user physician, who may have minimal inputinto technology development. Educators will need to con-sider core skill sets for each user type from a competencyperspective. Since many of the core skills affect the differ-ent areas of medical practice, educators will need to care-fully consider how “stacked” they want their competencygrids to appear.
Medical educators will be faced with the even morecomplicated tasks of retaining their fundamental core cur-riculum requirements (e.g., pathophysiology) while incor-porating new information at a reasonable pace. Traditionalmedical education models are already challenged, as medi-
cal students already acquire and assimilate knowledge viatheir wireless laptops and PDAs during classes, seminars,and at the bedside. Inexpensive, high-quality digital videorecording technologies allow easy demonstration of best/worst communication and clinical skills practices in class-rooms. As high quality core curricula become universallyavailable through the Web, educators will have to deter-mine the best use of classroom time—how much time tospend to deliver core content and/or using a small groupsetting to assess learner understanding and push skills incontent application. Each of the specific competencies thateducators will instruct or encourage will entail knowledge,skills, attitudes, and habits. Some competencies related tothe incorporation of these technologies into a medical ed-ucator’s practice are detailed in Appendix 5.
Conclusions
Cultural and technological shifts often provoke anxietyabout a loss of values or autonomy while simultaneouslyprovoking excitement about new opportunities. The prac-tice of medicine is evolving quickly, and global trends inthe marketplace place pressure to reduce cost while in-creasing quality. The American physician of the future willface international competition, and all competitors will beequipped with powerful new tools for patient care, datamanagement, and communication. Examining these majortrends can help educators understand the new technolog-ical competencies that will be required of physicians.Medical education itself will evolve in learner selection,content, and methods. Physician leaders in education willhelp guide the appropriate implementation of medicaltechnologies in practice, fostering practices that use tech-nology to increase accessible, affordable, accountable, andaffable medical care.
TECHNOLOGY COMPETENCY DEVELOPMENT AND EDUCATION
484 http://ap.psychiatryonline.org Academic Psychiatry, 30:6, November-December 2006
AP
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SRINIVASAN ET AL.
Academic Psychiatry, 30:6, November-December 2006 http://ap.psychiatryonline.org 485
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486 http://ap.psychiatryonline.org Academic Psychiatry, 30:6, November-December 2006
AP
PE
ND
IX3.
Fiel
dso
fE
volv
ing
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wle
dge,
Wit
hSo
me
Exa
mpl
es
Do
mai
nE
volv
ing
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dSk
ills
for
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sici
anD
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opi
ngT
echn
olo
gy
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vidu
alpa
tien
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nce
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ning
inge
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gnan
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enci
ng.U
nder
stan
ding
ofge
netic
patt
ern
varia
tion
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vidu
alda
tase
arch
inte
rpre
tatio
nH
ealth
serv
ices
rese
arch
trai
ning
for
data
base
man
ipul
atio
nan
dco
nstr
uctio
nfo
rus
eful
quer
ies.
Prog
ram
min
gsk
ills
and
data
base
cons
truc
tion
skill
sus
eful
,via
med
ical
info
rmat
ics
trai
ning
Und
erst
andi
ngcu
ltura
lnor
ms
for
deci
sion
-mak
ing
Cul
tura
lant
hrop
olog
yan
dfie
ldex
perie
nce
with
nativ
e/se
lf/ot
her
cultu
res
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erst
andi
ngin
divi
dual
care
pref
eren
ces
and
expe
ctat
ions
Com
mun
icat
ion
and
liste
ning
skill
str
aini
ng,i
ndiv
idua
land
syst
ems
chan
gest
rate
gies
Dia
gno
stic
opt
ions
New
noni
nvas
ive
imag
ing
and
test
ing
tech
nolo
gyA
lgor
ithm
and
mat
hem
atic
str
aini
ng.T
rain
ing
innu
clea
rph
ysic
s.Pr
ogra
mm
ing
skill
sU
nder
stan
ding
cultu
ralv
aria
tions
indi
seas
epr
esen
tatio
nC
ultu
rala
nthr
opol
ogy
and
field
expe
rienc
ew
ithna
tive/
self/
othe
rcu
lture
s.Et
hics
trai
ning
toun
ders
tand
soci
etal
confl
ict
The
rape
utic
opt
ions
Nan
otec
hnol
ogy
Trai
ning
inna
note
chno
logy
desi
gnan
dde
velo
pmen
t.C
hip
desi
gnan
dha
rdw
are
desi
gntr
aini
ngG
enet
icm
anip
ulat
ion
Che
mis
try/
gene
tictr
aini
ng.P
rote
omic
san
dce
llula
rbi
olog
ytr
aini
ng.S
oftw
are
prog
ram
min
gsk
ills
Cus
tom
ized
phar
mac
eutic
als
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mis
try
and
cellu
lar
biol
ogy
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ning
.Res
earc
htr
ials
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ning
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agem
ent
and
mar
ketin
gtr
aini
ngU
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stan
ding
neur
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nitiv
e-be
havi
oral
links
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roco
gniti
vebi
olog
ytr
aini
ng.M
anip
ulat
ion
and
use
ofne
ural
imag
ing
tech
niqu
esN
on-p
harm
aceu
tical
inte
rven
tions
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ing
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rnat
ive,
com
plem
enta
rym
edic
ine
via
heal
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rvic
esre
sear
chan
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inic
altr
ialt
rain
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istic
alan
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tanc
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nst
rate
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and
liste
ning
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ithou
tfa
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inte
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ti-lin
gual
popu
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tiple
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med
iare
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ndad
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aini
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confl
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cala
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mm
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ngto
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ipat
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ize,
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ging
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am
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tent
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ram
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tral
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nst
rate
gies
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ning
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iona
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tent
deliv
ery,
soft
war
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ogra
mm
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stra
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ym
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nism
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mul
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chno
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skill
spr
actic
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onte
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astic
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anuf
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rnat
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ndar
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tfo
rm
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alpr
actic
eH
ealth
serv
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rese
arch
trai
ning
for
asse
ssm
ent
ofef
ficac
y,co
nten
tex
pert
ise.
Hea
lthad
voca
cytr
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ngM
onito
ring
and
enfo
rcem
ent
ofpr
actic
evi
olat
ions
Educ
atio
nala
sses
smen
tex
pert
ise
and
heal
thad
voca
cytr
aini
ng.G
over
nmen
tala
ndpo
licy
trai
ning
Rem
edia
tion
stra
tegi
esfo
rsu
bsta
ndar
dph
ysic
ians
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nalc
urric
ulum
deve
lopm
ent,
facu
ltyde
velo
pmen
t,co
mm
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atio
nsk
ills
trai
ning
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deci
sion
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anal
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vacy
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ving
priv
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dard
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ngin
med
ical
ethi
cs,m
edic
alec
onom
ics,
med
iare
latio
ns,a
ndhe
alth
advo
cacy
New
met
hods
ofen
surin
gun
ique
info
rmat
ion
acce
ssTr
aini
ngin
biom
etric
s,ge
nom
ics,
and
com
pute
rpr
ogra
mm
ing
SRINIVASAN ET AL.
Academic Psychiatry, 30:6, November-December 2006 http://ap.psychiatryonline.org 487
AP
PE
ND
IX4.
Rel
atio
nshi
po
fSo
me
Tec
hno
logy
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ated
Co
mpe
tenc
ies
toA
CG
ME
Co
reC
om
pete
ncie
s
AC
GM
EC
om
pete
ncie
s
BA
SIC
Co
mpu
ter
and
Info
rmat
ics
Co
mpe
tenc
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ient
Car
eM
edic
alK
now
ledg
eP
ract
ice-
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edLe
arni
ngIn
terp
erso
nal
Co
mm
unic
atio
nP
rofe
ssio
nalis
mSy
stem
s-B
ased
Pra
ctic
e
Co
mpu
ter
ope
rati
on
skill
sD
emon
stra
teab
ility
tous
eco
mpu
ters
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rage
/bac
k-up
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rddi
sk,fl
ash
driv
es,C
D/D
VD),
and
rele
vant
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war
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seco
mm
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rics,
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488 http://ap.psychiatryonline.org Academic Psychiatry, 30:6, November-December 2006
AP
PE
ND
IX5.
Co
mpe
tenc
ies
Rel
ated
toU
seo
fT
echn
olo
gyin
Med
ical
Edu
cati
on
and
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ient
Edu
cati
on
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elo
ping
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cati
ona
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eria
lB
asic
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wle
dge:
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educ
ator
shou
ldbe
able
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scus
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hara
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reng
ths,
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ses
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mun
icat
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reso
urce
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cial
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alan
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hica
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ted
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rus
e,co
pyrig
hts,
acce
ssib
ility
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AA
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ole
ofte
chno
logy
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iain
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icat
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reed
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iona
lprin
cipl
es(e
.g.,
adul
tle
arni
ng)
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s:Th
eed
ucat
orsh
ould
beab
leto
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evel
op,m
aint
ain,
and
mod
ifya
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page
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uce
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tron
icsl
ides
/ove
rhea
dsus
ing
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orsi
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ms
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still
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oclip
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teba
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laye
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gita
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eras
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itor/
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CD
proj
ecto
rs,c
ompu
ter,
etc.
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e/vi
deo
files
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vide
high
qual
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deos
and
grap
hics
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thes
esk
ills
topr
oduc
ein
tegr
ated
mul
timed
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esen
tatio
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nclu
ding
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linea
rhy
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edia
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enta
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ricu
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pmen
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ean
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luat
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lect
reso
urce
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ater
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digi
tali
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mat
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loca
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docu
men
ts/a
rtifa
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text
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sete
chno
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inth
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tern
alco
mm
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SRINIVASAN ET AL.
Academic Psychiatry, 30:6, November-December 2006 http://ap.psychiatryonline.org 489
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