Diagnosis and therapy of a large group of conditions will continue to be uncertain, but much less uncertain than now. Care of these disorders will be partially digitizable. The digital world can go a long way toward dealing with these conditions, but there is still too much uncertainty to turn the whole problem over to the computer. Some judgments will need to be made in the context of the specific patient, but those are judgments that can be reliably made by advanced health professionals trained specifically for that role. These professionals will be members of a health care team directed by a doctor who will be available when needed.
But treatment of some conditions will continue to be doctor dependent, that is, they will require the personal involvement of a doctor from the outset. These are maladies for which the diagnosis and treatment, in spite of our best efforts, continue to be very uncertain. Increasing information about and understanding of these conditions, coupled with a deeper understanding of each individual patient, will better the odds of success, but care will continue to require the hands-on involvement of a doctor.
Two decades hence, your genome will be fully sequenced and that information will be stored in your special nook in the cloud along with the rest of your –omic profile (proteome, metabolome, interactome, exposome, and maybe even microbiome). Your special cosmic nook will also house all of the other available information related to your health and wellbeing. This will include a reimagined and redesigned electronic medical record that will be a continually updated chronology of your health experience. The door to this information vault will be controlled by your thumbprint and will be inaccessible except with your permission. As science discovers more certain links between individual characteristics and health and disease, this deep knowledge of you and your life experiences will continually decrease the uncertainty in your care. But there will always be uncertainty. Human biology with all of its interrelationships is just too complex. The more we learn, the more we learn how much we don’t know.
THE DIGITAL POWERED DOCTOR
So is there still a place for the healer in this technology-dense medical world of the future? We do not see the good doctor as competing with digitized health care, the hands-on physician pitted against the looming electronic juggernaut. On the contrary, we see this kind of doctor empowered by the digital world and, just as important, we see this doctor, the healer, as an indispensable complement to digital medicine, meeting a core human need that is not accessible electronically.
Digitization will give the doctor more time to heal. Delegating the care of straightforward clinical problems that currently consume large amounts of her time to computers and other health professionals will allow the doctor to focus more on nurturing a healing relationship with the patients for whom she cares. Efficient access to medical information and to individual patient data will make doctors better at their job, more confidently aware of who this patient is, what the problem is in that personal context, and what to do about it. Electronic systems that handle all of the clerical duties that will continue to be an essential part of medical practice will lift an enormous burden from doctors’ shoulders. After all, that is what computers are supposed to be good at but haven’t yet figured out how to do very well in a medical setting. Surely two decades is long enough to remedy that.
But what will be your personal doctor’s role in this world of transformed medicine? First, she will be the professional whom you trust, who knows you, and who is committed to a partnership with you dedicated to keeping you healthy or getting you the best care when you are ill. She will be your reliable source of health information and advice. She will be available for you when you need her. She will be responsible for assuring that your diagnosis and therapy are correct when your condition falls in the full or partial digitization category, and if it turns out that you have been misassigned, this doctor will be there to straighten things out. When, in spite of everything, you are gravely ill or dying, she will hold your hand and likely weep with you and those who love you.
DESTRUCTION, DISRUPTION, OR EVOLUTION?
Probably all of the above. That is why we have limited our speculation to an outcome two decades hence and carefully avoided guessing much about the intervening process. Health care will be transformed, and transformation is seldom painless.
It seems likely that moving toward digital medicine will slaughter some of our sacred cows. The possibilities for radically different ways of getting and assimilating information may threaten traditional clinicians. They may also feel threatened by the emergence of new technology that seems to leave little space for the doctor in the patient-machine relationship. The need to become facile with computers will drive many doctors into retirement or another profession. The technology will disrupt both how medicine is done and how medical care is organized and supported. There will be false starts, blind alleys, mistaken directions taken, untenable promises made and then abandoned, and all of the other obstacles that rear up in the path of major change in a huge enterprise.
But, while there is an enormous health care industry, it is unlike other industries, which deal in goods and services less directly tied to the lives and wellbeing of every one of us. It is simply not imaginable that we will allow health care to go through a phase of total dysfunction, unable to provide essential care for those who need it. The profession cannot allow that to happen, and our broader society would be justly appalled at the thought of such a possibility.
So we predict that the new medicine will evolve, but without the orderliness that we usually expect of evolution. Some things we cherish will be destroyed, how we go about doing things will be disrupted, and the new health care paradigm will only gradually take on a form that works, although we cannot now imagine exactly what that form will be.
Time travel with us to an elite health care facility two decades into the future—it might well be that the only person we recognize there is the good doctor.
“Sherwin B. Nuland Quotes,” BrainyQuote, http://www.brainyquote.com/quotes/authors/s/sherwin_b_nuland.html.
Robert Wachter, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age (New York: McGraw Hill, 2015).
Larry R. Churchill, PhD, and David Schenck, PhD, “Healing Skills for Medical Practice,” Annals of Internal Medicine 149 (2008): 720-724.
EPILOGUE
AN OPTIMIST’S DREAM
January 1, 2040
Well, thank heavens, at least I lived to see it. These last few years have been the most exhilarating of my long career practicing medicine. Who’d a thunk it? All that gloom and doom the pundits preached at the approach of the digital tsunami those decades ago were misguided. They underestimated the creativity and resilience of us humans when forced by circumstance and opportunity to reinvent what is arguably our most important social activity—caring for our health. For the last few years I have been a better doctor than ever before. I have come closer than I would ever have predicted to being the kind of professional that I dreamed of becoming back when I first realized that what I wanted was to do something with my head and hands that would help other people to be healthy and happy. Well, that’s exactly what I’ve been doing lately and in my wildest dreams I would never have imagined that what has made it possible is the spectacular advances in science and technology that set me free to exploit the immense potential of my relationship with my patients to cure and to heal.
That’s not to say that getting here was painless. It wasn’t. Several times I came close to bailing out. Those courses in advanced computing took a personal toll, but I survived and even came to appreciate how much computer power could expand the possibilities. It was difficult to give up some control, especially to the inanimate world. That still bothers me. I still look over the computer’s shoulder as it does its digital medicine thing. I’m still asking questions of almost everything. Adjusting my financial expectations was a little painful at first, but the rew
ards of escaping the escalating pressures for more “efficiency” from the managers and the chance to focus exclusively on the health and wellbeing of my patients more than compensate for a salary that doesn’t quite match the old productivity based check. I still make a more than decent living. The managers seem surprised that the clinic makes plenty of money by forgetting about how long doctor visits take and paying more attention to how well the patients do. My patient visits take as long as they need to take to do the best possible job and that depends on who the person I’m seeing is and the nature of their problem—the time varies. I’m not at all surprised that this pays off for the managers.
My only regret is that I was ahead of my time. As dramatic as the changes I have been part of are, medicine is just beginning to realize the possibilities. I wish I had forty more years to hang around and watch my profession flourish. Of course if I did, I would have the same regret forty years from now. Change is the nature of this beast we call clinical medicine that we wrestle with every day and the only thing certain about it is that it will keep changing.
SOME OBSERVATIONS ON THE “NEW” MEDICINE
“May you live in interesting times,” goes the Chinese curse. That’s what practicing medicine these days seems like. The world of medicine is changing and the pace of change keeps ramping up. Much of the change is exhilarating—what we understand about human health is expanding and that opens new possibilities for helping people to be well and happy. That is, after all, why doctors do what they do, and the promises of new knowledge and technology that will help them do it better are exciting. In one way, we really look forward to the “New Medicine” that a lot of pundits are writing about these days.
In another way, we worry about where we are headed, worry that the powers that be will get carried away with the technology. If that means doing away with the human dimension of health and healing, then the two camps—science based and humanity based medicine—will be driven even further apart than they are now. Not good. And what really scares us is that the direction medicine takes may not be determined by the doctors and the patients whose interactions are the substance of health care. We worry that the potential of the technology and the inclinations of the health care “experts” (information specialists, people managers, systems designers, etc.) will jump the track leading to better health for more people and lead us into a system that fails to get the most out of the science by failing to recognize that health is essentially a flesh-and-blood human phenomenon.
The tragedy and the paradox that we may be courting is that dehumanizing health care, trusting the whole thing to gadgets and machines, would severely limit the potential of the science and technology. The real power of science and technology to make us healthier and happier is the power to enhance the critical functions of the doctor-patient partnership.
Whoever you people are out there making the crucial decisions about where medicine is going, please, for heaven’s sake, involve some practicing doctors and real patients in the process!
There are reasons for hope. Our optimist’s dream could actually come true. Some forward thinking medical schools aim to produce graduates who are, in the words of Clay Johnston, “the ones who are actually creating a system that’s better for patients and for doctors.”196
Sean Price, “UT-Austin Medical School’s Curriculum Isn’t Designed Just to Train Doctors—It’s Built to Revolutionize Medicine,” Journal of Texas Medicine 113, no. 5 (2017): 28-33.
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