Writing

The pace of life has reached unprecedented levels, propelled by rapid digital acceleration, generative artificial intelligence, and an emphasis on remote work, virtual interactions, and technology-driven solutions. The coronavirus disease 2019 pandemic acted as a catalyst for the integration of technology into various aspects of work and life. This shift not only enabled continuity during the crisis but also set the stage for longer-term changes. Calendars are now tightly packed from 1 virtual meeting to the next eliminating “in between” times when informal conversations occur, ideas are shared, impromptu brainstorming blossoms, and when life can slow down. Artificial intelligence (AI), with its generative capabilities, has accelerated communication creating further efficiencies but threatening cognitive overload.

This issue of Neurology® Education brings together multiple conversations in the literature, many centering on the tremendous upsides and potential threats that are posed by emerging technologies and in particular, artificial intelligence. In their viewpoint, Dr. Gottlieb-Smith and colleagues¹ forecast the ability of AI to promote equity in residency recruitment. Articles by Loebel, Osgood, Zakin and colleagues describe how technology is currently expanding the reach of teaching, enhancing the quality of instruction, and facilitating soft skill training.^2-4 Yet, threats exist. Dr. Adina Wise chronicles the history of the medical record's role in education. She discusses the risks posed by the emergence of open notes which allows for patient access to clinical records. She forecasts challenges posed by generative AI.

Clinical documentation is integral to the practice of neurology. We now enter an age where generative AI can be deployed into the examination room, listen to the patient-provider interaction, and document key aspects of the encounter. For me personally, my last clinic was entirely scribed by a fully integrated AI system within the patient's chart which captured the meaning of my conversation, examination, and plan for each patient. With this powerful tool comes great hope for a shift back to patient-centered care—where the provider is not principally a typer but is again a listener, diagnostician, and healer. These technological advancements are a welcome relief for many clinicians, who are overwhelmed with paperwork, prior authorization requests, best practice advisories, and clinical documentation demands. However, what is the implication for education in shifting the role of clinician from writer to reviewer and editor of the clinical record.

Writing is a way of slowing down thinking. It is a practice that helps us to process our thoughts deliberately and reflectively. In patient care, writing is not just about completing a clinic note, documenting the encounter, justifying clinical charges, and supporting billing practices. Writing can serve many more critical purposes allowing for creative expression, cementing patient ownership, building character, and facilitating reflective practice.

Author Julia Cameron is among one of the more prominent voices to describe the importance of writing as an outlet of creative expression. She gained widespread recognition for her book The Artist's Way, which introduces a series of exercises and tools, such as “morning pages” and “artist dates,” designed to help individuals connect with their inner selves.⁵ Her methodology reinforces the idea that creativity is not just a talent but a practice that can be nurtured and developed. But like any other practice, will we become rusty without exercise?

In academics, writing is a vital means of scholarly dissemination. Through writing, researchers, educators, and scholars communicate their findings, theories, and insights to the broader academic community. Writing allows for sharing of research findings with peers, enables replication, and interprets data into the larger academic conversation to advance a field of study. Debate is ongoing over the risks, challenges, and opportunities for AI to transform academic writing.⁶ However, it is our clinical documentation that occupies that greatest portion of our writing time.

Changes in how and what we write have implications for education. Writing is a critical method for learning, training, and becoming a health care professional. In clinical documentation, writing is a means of taking ownership in patient care. When trainees document patient interactions, treatment plans, and clinical observations, they are not merely recording information—they are engaging in a process that enhances their sense of responsibility, commitment, and duty to the patient. This has been witnessed. In the early 2010s, a trend toward limiting medical student documentation grew out of concerns over liability, compliance, billing, and technological changes. This retraction from student documentation threatened trainees' ability to develop a sense of patient responsibility. Decision ownership is a feeling among trainees that they have responsibility to make decisions that are in the long-term interest of their patients.⁷ Responsibility, ownership, decision making, and documentation are tightly linked. While the pendulum has begun to swing back and academic centers are incorporating methods for students to take ownership through meaningful note-taking, the future of clinical documentation in an AI-integrated era could bring new challenges.⁸

Writing can also serve as a tool for developing core character skills. Writing is a reflective practice where curiosity and intellectual humility can be fostered. When a trainee sits down to write their note, an opportunity is created to research the latest evidence, review guidelines, or consult best-practices to incorporate into clinical decision making. The note becomes an impetus to pause and reflect. This process not only expands knowledge but also fosters skills in curiosity. The act of writing can function as a trigger to the complexities and inherent uncertainties in medical practice. Documenting a patient's case frequently requires that a provider consider the various potential outcomes. This prompts recognition that there may be multiple valid approaches to treatment. Acknowledgement of uncertainty is a critical aspect of trainee maturation and tempers overconfidence.

Writing is an intentional act. In an age of fast-paced communication and constant information overload, writing offers a necessary pause for deliberation and reflection. This could not be a more important skill for medical trainees. When we write, we are not merely recording data, we are actively engaging with it. Writing enables us to break down complex concepts, acknowledge our commitment and duty to the patient, and wrestle with the challenges that underlie medical decision making including societal, environmental, and other drivers of care inequity.

As we further integrate new technologies into clinical care and teaching, are we fully considering the downsides and the upsides? How are we studying the implications of these new technologies in neurologic training? Recent work shows that machine learning can be used to evaluate resident documentation in a way that was not previously possible. Large language models can review a volume of documents that has never been practical or feasible and provide real-time feedback to trainees and program directors.⁹ This offers tremendous opportunity,¹⁰ but are we ready for the cost?

As you enjoy this issue of Neurology: Education, take a pause to slow down your thinking and happy reading.

Study Funding

No targeted funding reported.

Disclosure

R.E. Strowd serves a consultant for Monteris Medical Inc. and Novocure; he receives an editorial stipend as Editor of Neurology: Education and has received research/grant support from the American Academy of Neurology, American Society for Clinical Oncology, American Board of Psychiatry and Neurology, and Jazz Pharmaceuticals. He has received support as a lecturer for Lecturio and Kaplan. He receives book royalties from Elsevier. Go to Neurology.org/NE for full disclosures.