EXPERTS IN THE BUSINESS OF MEDICINE
So our good doctor will not succumb to a tyranny of the experts who compile the evidence and write the guidelines. But how about the other experts who deal with the business side of things? The evolution of American medicine into a major industry and a powerful economic engine brought with it a bevy of non-medical experts—managers, economists, efficiency experts, systems designers, etc.—who aim to structure a doctor’s practice and manage her function with an eagle eye fixed on her margin, the bottom line, how much money she brings in above the total cost of her practice. Health care becomes a product, not unlike an industry-manufactured widget, and practices that work to maximize profit in the widget business are expected to do the same for the practice of medicine. This approach is what brought us, among other requirements that are unrelated to the needs of the patient, the fifteen minute office visit. Need to increase doctor efficiency, the experts asked? That’s simple, just speed up the assembly line. Have the doc see more patients per unit time (which obviously means less time per patient).
Well, that approach is not working very well now, and it never will. Health care is not a product, at least not in any sense that resembles a widget. What really drives a thoughtful caring doctor to work harder and do a better job is not how much money she can generate, but how much healthier and happier she can make her patients. This brand of medicine has at its root a personal relationship between you and her. You do not go to see her to buy a product but to experience the complex processes of curing and healing that can only happen when the very best science infuses the genuine care of you as a human being. While financial incentives can change many doctors’ behaviors to the detriment of their patients in the short run, there are easier ways for smart people to make money. Greed doesn’t blend well with the motives that attract most bright people into a medical career. A margin-driven style of health care will not make you heathier and will have little lasting appeal to a dedicated doctor. The good doctor will not forever endure a tyranny of the business experts.
A TYRANNY OF SENSORS?
Sensors are devices that measure things and their readout is in numbers; they are the fundamental tools of digital medicine. The digitizers are convinced that if they can get enough things about you sensed and recorded numerically, they will know all they need to know to treat you as precisely as the state of medical knowledge permits; just follow the numbers. If we buy that idea, then we ought to be about capitalizing on the enormous potential of modern technology to make as many sensors as possible and to make them portable, cheap, and accurate enough to become integral to our everyday life. That is exactly what is in the works, in some cases on a rather grand scale.
Would you believe Moonshot Medicine?187 Astro Teller (although it seems unlikely, we assume that is his real name) likes that idea. Teller, grandson of Manhattan Project physicist Edward Teller, is “the captain of moonshots” at Google-X (or whatever Alphabet, Inc. decides to call it now), the innovation laboratory that brought us the eyeglass computer, the delivery drone, and the internet-beaming high altitude balloon. I mean, how hard can this medical thing be? So, Google-X is taking on a new moonshot project, the human body.188 They’ll collect every morsel of information that there are sensors of any kind to measure from 175 normal people and use the frightening power of their computers to create a definition of health that will be a basis for detecting the earliest evidence of unhealth (our term) and nipping it in the bud. These guys really are thinking innovation.
The National Institutes of Health are also getting in on the act. The Institutes intend to convince one million Americans to wear some sensors of blood pressure, exercise, and other health related information that will be fed to a central repository.189 The information will form a database that will be bigger and more complete than anything that exists now. And, we presume, as the number of personal remote sensors, many of them wearable, proliferates to include measurements of a lot of blood chemicals, DNA sequences, and even environmental conditions and social interactions, the database will expand enormously. Imagine all of those things being sensed and recorded all day, every day, ad infinitum. Anticipating such a possibility, San Diego professor and book author Eric Topol writes that the creative destruction of medicine “is ready to go . . . because for the first time in history we can digitize humans.”190 Our good doctor hyperventilates just thinking about it. This could redefine how she thinks about disease in general, but what gets her so excited is that it could also define your unique biology more precisely than she could have imagined. It could make your doctor a better doctor! You could be healthier! It might even save your life!
But wait. Is our usually cautious and thoughtful doctor about to succumb to the tyranny of the sensors? We hope not. More information doesn’t necessarily result in better health care; it depends on how the information is understood and used. Surely the good doctor knows that, and once she comes down from her technological high she will remember the critical value of context. She may even remember a story like this one.
A seventy-five-year-old physician we know191 was in excellent health. He saw his internist twice a year and his physical exam, cardiogram, and blood tests were always normal. He took his daily dose of Lipitor, which dealt effectively with a high cholesterol. His diet was healthy, he kept his weight down, exercised every day, had an excellent relationship with his wife of many years, and lived a happy and interesting life. He started noticing that the detector on his treadmill occasionally failed to register his pulse rate. He was pretty sure that he had a pulse, so he felt for it. He found that when the machine didn’t detect it, his pulse was irregular; most of the time it was completely normal. He had absolutely no symptoms—no pain, no palpitations, nothing. His heart rate had always been normal when he went for his regular medical checkups. He told his doctor about this occasional pulse irregularity on a routine visit and, although our friend’s pulse was regular at the time, his doctor ordered an exercise test. Sure enough, at maximum exercise, his cardiogram showed a period of atrial fibrillation, a fairly common form of irregular heartbeat in a man his age. If this irregular heartbeat is constant, there all the time, it can increase the risk of stroke. But in this patient it was documented to be intermittent, which is not an emergency. However, what the cardiologist on call saw was a seventy-five year old man with atrial fibrillation. He couldn’t believe that this guy had no symptoms. In fact, the cardiologist was heard dictating in his note that “the patient experienced palpitations”; he just couldn’t help himself. Our friend didn’t correct him; he had told the guy otherwise already.
After discussions with several doctors, the cardiologist decided that this irregular heartbeat had to be fixed. He prescribed two pills for the patient to take when he returned home. Those two pills should do the trick. Our friend took the pills, which dropped his blood pressure to frightening levels and caused him to pass out in the middle of a restaurant near his home. He was loaded into an ambulance, had yet another cardiogram, an intravenous line was started, he was given oxygen, and he was delivered to a local emergency room. He had still another cardiogram which showed that his heartbeat was now normal (as it had been when he first went for his regular checkup, before the stress test). The ER doctor checked his blood pressure frequently and found that it was gradually getting back to normal. However, the doctors were worried enough that our friend was admitted to the hospital for an overnight stay where he was attached to a monitor that continually displayed a perfectly normal pulse rate. He remained in bed until his blood pressure was back to normal, where it had been all of his life until he took the pills. He was seen and examined by an attending cardiologist, several residents, and some medical students. He was visited frequently during the night by the nurse on duty. He was finally discharged home the next morning in the very same physical condition that he was in when he went for his regular doctor’s visit the previous day, but with bills from the exercise testing laboratory, the ambulance se
rvice, the cardiologists, and the hospital totaling several thousands of dollars.
In this case, the sensor was the doctor who took his own pulse, and if there is fault in what ensued, it was not the fault of the sensor. The point is that sensed information can drive action independent of the condition being sensed. The proliferation of sensors humming away around the clock will provide a lot of information that has the potential to better refine your care. The good doctor will relish that information, but also will know that her job is not to treat the numbers, but to care for the person providing the numbers. After all, people aren’t easily reduced to numbers, and single-minded attempts to digitize them will not only keep health care from being as good as it can be but will also risk doing serious harm. Beware the tyranny of sensors.
THE DEEPER CONNECTION
Responding to a question during a Medscape interview, Malcolm Gladwell related what his eighty-five-year-old mother wants in a doctor.192 She wants “an individual physician who knows her well, who listens to her, whom she trusts and with whom she can periodically have extended conversations.” Granted she is eighty-five and Canadian, but we suspect that most people want those things too. “I think it’s about this deeper connection we all have to something important,” Dr. Gawande says.
Even when each of us is fully wired with the latest sensors and has the complete sequence of our genome on a CD or in the cloud, there will still be a lot of uncertainties that affect our health and wellbeing. The good doctor understands that each of us is best cared for by using the carefully evaluated available evidence as a starting point, but interpreting that evidence in the context of the unique human being she is caring for. This doctor pays close attention to the experts and looks carefully at the numbers, recognizing that she needs all the help she can get to take the best care of you. But she does take care of you.
Perhaps for each branch point on the medical decision tree, there should be three options, yes, no, or maybe. If the options are honestly considered, the maybe branch will get the most traffic. If you are to avoid the tyranny of experts and sensors, you will have to cross the bridge of maybes that connects the hard data and confident expertise to the less certain world of human health and wellbeing. You will need a guide.
Bob Wachter, “My Interview with Atul Gawande,” Wachter’s World, January 6, 2015, http://community.the-hospitalist.org/2015/01/06/my-interview-with-atul-gawande/.
Jeffrey Parks, “How Algorithm Driven Medicine Can Affect Patient Care,” KevinMD.com, January 30, 2012, http://www.kevinmd.com/blog/2012/01/algorithm-driven-medicine-affect-patient-care.html.
Ralph Waldo Emerson, “Quotes,” Goodreads, http://www.goodreads.com/quotes/353571-a-foolish-consistency-is-the-hobgoblin-of-little-minds-adored.
David Eddy, “The Origins of Evidence-Based Medicine—a Personal Perspective,” Virtual Mentor 13 (2011): 55-60.
Dan Mendelson and Tanisha Carino, “Evidence-Based medicine in the United States—De rigeur or Dream Deferred?,” Health Affairs 24 (2005): 133-136.
Paul Krugman,The Economist, November 13, 2003.
Stephen Hicke, Andrew Hickey, and Leonardo Noriega, “The Failure of Evidence-Based Medicine?,” European Journal for Person Centered Health Care 1 (2012): 69-79.
Atul Gawande,“The Mistrust of Science,” The New Yorker, June 10, 2016.
Martin LaMonica, “How the Google X Moonshot Idea Factory Works,” Xconomy.com, September 23, 2014, http://www.xconomy.com/san-francisco/2014/09/23/how-the-google-x-moonshot-idea-factory-works/#.
Alistair Barr. “Google’s New Moonshot Project: The Human Body.” The Wall Street Journal, July 27, 2014.
Jocelyn Kaiser. “NIH Plots Million-Person Megastudy,” Science 347 (2015): 817.
Eric Topol. The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care (New York: Basic Books, 2013).
Personal information, KB and MMEJ.
Eric Topol, “Malcolm Gladwell: Future Docs Need More Time, Not Technology,” Medscape, August 18, 2015, http://www.medscape.com/viewarticle/847711.
CHAPTER 17
The Hope for a Digitally Powered Doctor
Medical judgment can be taught . . . but it cannot be neatly handed
over as the occasion demands it. It is the irreplaceable and
untransferable contribution that the healer makes to the
suffering individual who would be healed.
—SHERWIN B. NULAND193
If, as knowledgeable people claim, we teeter on the brink of a digital cataclysm that will destroy medicine as we know it, what will become of our good doctor? Will she morph into University of California, San Francisco professor Robert Wachter’s Digital Doctor, doing medicine by the numbers, no longer so interested in knowing you as a unique person?194 Will the uncertainties evaporate in the heat and light of technological progress? Is this partnership concept we’ve tried so hard to sell doomed to wind up in a decade or two on a trash heap of anachronisms, relics of a predigital era that are no longer relevant?
Well, it is quite certain that the world of health and medical care will look, feel, and be very different two decades from now. Exactly how it will be different is impossible to predict—too many unknown unknowns—but science, technology, and societal pressures are potent drivers of change. Where that blend of necessity and potential will take us is anybody’s guess, but it will have to deal with human beings, imperfect as we are and capricious as we are capable of being.
THE DOCTOR AS HEALER
We humans cannot be reduced to numbers, and we have needs that cannot be fully digitized. Care of human disease has always involved a healer. That role addresses a fundamental human need that will still be integral to humanness two decades or even two millennia from now.
The doctor we’ve described in this book is a healer. What does that mean? In an effort to bring some rigor to the definition of the art of medicine, Larry Churchill and David Schenck at Vanderbilt’s Center for Biomedical Ethics and Society interviewed fifty practitioners who were considered expert healers by their peers and looked for what their interactions with patients had in common.195 They found eight themes: do little things (small courtesies, congenial manner); take time and listen; be open; find something to like, to love; remove barriers; let the patient explain; share authority; and be committed and trustworthy. Although, as mentioned earlier, we would add touching, our good doctor passes the healer test with flying colors. And, as we have said elsewhere, there is plenty of evidence that patients of these healers do better because of that relationship.
There is no magic or mystery involved in modern healing. It is just that there is an element to healing that depends on how flesh-and-blood humans interact with each other. The value of the healer is a lot more than how she diagnoses illnesses and decides on therapies. No matter how those medical care transactions are accomplished, we will still need a healer.
SOME PREDICTABLE EFFECTS OF SCIENCE, TECHNOLOGY, AND SOCIETAL PRESSURES
We’re not foolhardy enough to attempt to paint a detailed portrait of health and medical care two decades from now (although neither of us is likely to be around to have to defend it), but some generalities that will have a major effect on how you and your doctor relate can be pretty confidently predicted.
Social pressures, including economics, accessibility, disparities in quality, politics, and ethical issues will force organizational changes. It has been predicted that mergers of most major health systems will result in a few megasystems which serve populations large enough to support both usual and sophisticated medical care and the education of health professionals in the necessary spectrum of specialties. So our ideal doctor will likely be employed by an organization with its own culture, responsibilities, and reward system. This will almo
st certainly mean that she will be paid a more-or-less fixed salary that will likely be less (corrected for inflation) than she might be able to make in a current margin-driven practice. We predict, however, that the most successful health care organizations will recognize the human and the monetary value of this breed of doctor and will support and reward her appropriately.
The science and technology will radically change how data is obtained, stored, protected, and interpreted. The explosion of information about health and disease and the technology for dealing with that information will affect how the relationship between evidence based and personalized medicine affects care. We represented that relationship graphically earlier, plotting flexibility as a function of uncertainty. The adjacent figure reproduces that graph and adds implications for how health care might be done in a decade or two. The proliferation of wearable and other remote devices for measuring health related variables, increasingly sophisticated analytical strategies, the universal availability of information via the internet, the interpretive power of computer algorithms (Archimedes? Watson?), and the ubiquity of the cloud will shift many conditions to the left on the flexibility/uncertainty curve. Health care could look something like this:
As more and more reliable general and personal information relevant to diagnosis and therapy of conditions accumulates, uncertainty will be reduced. That will decrease the need for the flexibility that is essential to adapting the evidence to an individual person. For a growing number of diagnoses and therapies, uncertainty will be reduced enough that care can be digitized, that is, done entirely electronically without any direct involvement of a health professional, with minimal risk of errors. Otitis media, an ear infection common in children, is a simple example. Your smart phone might have an attachment and an app that detects a red and bulging eardrum, impedance audiometry could indicate fluid in the middle ear, and an at-home simple test of samples of material from the ear canal would indicate the presence or absence of bacteria. Those data would be automatically entered into the appropriate website and you would be handed a diagnosis and a treatment plan. If the infection was bacterial, a prescription for the appropriate antibiotic would emerge from your printer or be sent electronically to your designated pharmacy. You’d make follow-up smart phone measurements every couple of days. The computer would keep you informed of your kid’s progress and would let you know if something else needed to be done or would alert your doctor if things weren’t going as expected. Such streamlining of the care of simple problems could save a lot of time and money.
The Good Doctor Page 17