Medical Technology (Mis)use
Medical technology is defined by “the techniques, drugs, equipment, and procedures used by health care professionals in delivering medical care to individuals, and the systems within which such care is delivered” (p. 4) . This definition includes various applications of technology and refers not only to diagnostic procedures, therapies, and drugs, among other things, but also to medical devices such as instruments, appliances, software, or other artifacts. In this article, we adopt this broad definition of medical technology.
The rapid, continual innovation of medical technology offers opportunities for more effective and efficient health care. Inappropriate use of medical technology can be traced back to (1) the technology itself, (2) the medical technology approval process, and (3) the user. First, medical technology is extremely diverse. It is diverse in the type of mechanisms involved, the disciplines from which the technology originates, the degree of complexity, and the practical applications. Many medical devices have emerged not from clinical research but from technologies developed in other areas and meant for other purposes. Technologies such as lasers, magnetic resonance imaging, and navigation devices originated from physics and were intended for military use or space aviation . The success of technology transfer from research or industry to clinical practice depends on many factors; simply explaining the technology’s benefits to clinicians is not enough . Technology is often presented as a solution, but without a proper understanding of important issues related to the user or the context in which the technology will be used . An additional problem associated with this inadequate use is the so-called science push, a key characteristic of linear models of research-practice relationships . Central to these models is the need to make research findings conceptually and physically accessible through their translation into guidelines, protocols, and/or technology, with an emphasis on implementing the solution instead of defining the problem.
Second, most medical technologies are not adequately assessed for specific health care applications. The Food and Drugs Administration of the USA and the European Commission in Europe require that the validity of each medical device is assessed before applying it in clinical practice . Furthermore, in the Netherlands, hospitals have signed an agreement to guarantee safe use of technology by providing adequate training . However, many medical devices are not used as intended or remain unused because of inadequate design, a lack of infrastructure, and insufficient information regarding maintenance [4, 11].
Third, human factors are one of the principal causes of errors in the use of medical technology [4, 5, 12]. Medical technologies are increasingly based on complex technological principles, often hidden from the user, which can apparently lead to errors.
Based on the previous analysis, we see a gap between the development of high-tech medical technology and the expertise needed to use it safely with individual patients. Engineering experts are responsible for the development and dissemination of medical technology, but are not trained to assess the effects of technology on the functioning of the human body. Medical experts adopt and use the medical technology developed by engineers, although they cannot be expected to fully understand the technological principles of medical technologies or to adequately assess the consequences of variations in the use of specific medical technologies. Engineering science is characterized by understanding the working mechanisms underlying natural or technical phenomena. Modeling such working mechanisms is a powerful tool in engineering, although modeling also implies a certain amount of simplification and elimination of noise. Medical technology that is based on these models developed by engineers is, in a sense, limited, because information might be lost, filtered away as noise. However, this noise often contains relevant patient-specific information that differs from patient to patient. Therefore, for health care professionals to understand how to cope with “noise,” viewed from an engineering perspective, requires an understanding of both the underlying technological principles and the underlying principles of the functioning of the human body.
Technical Medical Expertise
Traditionally, medical problems are defined as diagnostic or treatment selection problems, also called categorization problems : what is the diagnosis for this patient? Which treatment is most effective given this patient’s condition? Knowledge about concepts and their interrelations is required to solve these problems adequately . Clinicians learn to find regularities in patterns of features and interpret them. Over the years, this repeated solving of categorization problems results in the development of illness scripts, a specific type of knowledge representation . Illness scripts allow clinicians to make quick and, most of the time, accurate decisions based on pattern recognition processes .
The problems that clinicians encounter when applying new or existing medical technology are of a different kind; these problems are complex and non-traditional. Technology offers solutions that require clinicians to adequately analyze and define the problem and design a treatment in which these solutions are embedded. Such problems can be described as design problems: solutions to these problems take the form of new plans, protocols, or artifacts . Solving design problems is fundamentally different from traditional medical problem-solving, according to Goel and Pirolli ; it differs in the steps and the underlying knowledge representation needed to solve the problem. To solve design problems, knowledge about concepts and interpretations of these concepts is required, that is, conceptual knowledge . Not only does the problem solver need an understanding of the underlying principles used, he or she also needs to know the functional requirements, namely, what is the designed solution supposed to do? Figure 1 illustrates the differences between a design problem and a traditional medical categorization problem.
Innovative, patient-specific applications of technology should be carefully designed and provided by a professional specifically trained to do so: the Technical Physician. Technical Physicians are trained to begin from the patient’s perspective while also assessing technological possibilities and the consequences of medical technology use like an engineer. These professionals learn to understand medical technology use as the complex interaction between the human body and the technologies’ underlying principles; they acquire the ability to translate knowledge and skills between the technical and medical domains. They accomplish this not by traditional, one-directional knowledge transfer from the technical to the medical domain, but act more like engineers by integrating the two domains when analyzing medical problems (diagnosis) and designing medical solutions (treatment).
Previous research has suggested that superior or expert performance is only possible in one particular domain [18, 19]. In general, expertise comes with great advantages, such as rapid detection of relevant information, successful self-monitoring, effective problem-solving, and generation of the most satisfactory solutions . However, there are also drawbacks to being an expert . Research has shown that expertise is domain-specific, such that experts do not excel in domains in which they have no experience (see, e.g., Joseph and Patel ). In certain situations, expert clinicians might therefore apply pre-existing knowledge to non-routine or unfamiliar situations without the ability to see new possibilities or greater complexity; they are “routine” experts [22, 23] at solving categorization problems.
Solving design problems, which we recognize to be similar to engineering problem-solving, requires individuals to acquire other qualities and expertise. These individuals need to be able to transfer their knowledge to novel situations at the right time and in the right way; they are “adaptive experts” . This successful transfer depends on an abstract knowledge representation that includes the interrelationships between core concepts [25, 26]. Furthermore, a key factor seems to be that individuals engage in a thorough search for solutions, which implies that adaptive experts have a certain attitude towards problem-solving that other experts lack. Adaptive experts are characterized by the ability to flexibly transfer knowledge and skills to infrequent and non-routine situations and a positive attitude towards creating knowledge, which makes them different from other experts [24, 27].
Current medical practice with its high rates of technological change requires professionals who can successfully adapt to ongoing technological changes, that is, adaptive experts . Palonen et al.  argue that adaptive expertise is most important in emerging fields. In technical medicine, an emerging field, professionals solve design problems at the intersection of the technical and medical domain, which requires effective transfer of knowledge and skills between these domains. Adaptive experts transfer what they have learned to new situations, adapt flexibly to different task conditions. and demonstrate satisfactory performance for infrequent or non-routine problems [24, 29].
Design problems also require a specific problem-solving approach that is characterized by creativity, analysis, and synthesis in order to result in an affordable solution . These characteristics, creativity, analysis, and synthesis, are embedded in scientific evidence from the technical and medical domain. Therefore, we give the name “research-based design” to this “research-driven” design approach. Through applying the designed solution, relevant and usable knowledge is developed. It is a systematic problem-solving process that defines the problem, assesses the needs through reviewing previous studies and epidemiological evidence, designs a solution, has clear research goals that result in observable and evaluative outcomes, and is grounded in theory .
This research-based design practice brings research and practice closer together through having academic researchers work directly together with clinical practitioners in designing technical medical solutions for medical problems. Engaging practitioners in the co-creation of new knowledge, which is common in design research projects, is a powerful process for promoting the uptake and use of new insights among participants . This research-based design model has the potential to become increasingly important for the medical disciplines, insofar as it can be introduced to increase the robustness of the practices of professional technical medical designers and contribute to practice-based theory building in the arena of medical technology and its procedures. Moreover, the model prescribes starting out with analysis to define the problem for which a solution will be designed. This engineering approach fits well with the appropriate and deliberate use of technology for solving medical problems.
In summary, Technical Physicians work on design problems in clinical practice that involve medical technology. Therefore, they need to understand both the functioning of the human body and the technology. As scientists working in clinical practice, in close collaboration with other health care professionals and with the goal of creating relevant and re-usable knowledge, they should be research-based designers. As practitioners in clinical practice, they also need technical medical skills, including the skills to perform reserved procedures, that is, procedures that only a licensed physician is legally allowed to perform according to the law in the Netherlands, and must display appropriate professional behavior. To become adaptive experts, Technical Physicians should be able to critically evaluate their decisions and actions with the patient’s welfare in mind and to adjust their behavior accordingly. As adaptive experts, they need the cognitive flexibility to come up with appropriate responses to novel situations and to review multiple perspectives when considering solutions to new problems. These specific features of the problem-solving approach of Technical Physicians, together with the key characteristics of Technical Physicians, were translated and integrated into a Technical Medicine curriculum.