Such a good question from my friend David Shaywitz, MD, PhD, (and co-author with me of the book Tech Tonics). David has spoken and written about this this theme frequently, and most recently at the Health 2.0 conference held last week in Santa Clara, CA. He and I and 2000 of our closest friends were there to talk healthcare technology. Isn’t it ironic that it takes that level of human interaction to talk about the ways healthcare can disintermediate humans from healthcare?
What struck me so loudly at the conference was how easy it is for us all to forget how human the healthcare experience really is. I moderated and attended numerous sessions at the conference, each a twist on the theme of how technology can make healthcare delivery more accurate, more efficient, more effective than anything we have going today. David participated in a session with Matthew Holt, Vinod Khosla and Dr. Jordan Shlain, who could not be farther part from each other on the topic of doctor vs. machine (David played the role of moderate guy in the middle), Mr. Khosla backed away or at least clarified his earlier statements about how 80% of doctors will be unnecessary in the coming new age of healthcare technology. His revision was that 80% of all diagnosis will, in the future, be done by computers, not doctors, because computers are far better at seeing a holistic view of a patient and taking in all of the relevant data. He talked about how certain digital technologies can know everything about you, including when you are sleeping and when you are awake. It made me think that Santa Claus must be worried about being replaced by an app.
Honestly, it is hard to argue with Khosla’s theory on diagnosis (although Jordan vociferously did). As for me, I have recently seen for myself, and not for the first time, the limitations of a physician when it comes to a complex case. I spoke to the doctor of a friend, who asked me to call that doctor and help the friend understand what really was going on. While not a doctor, I play one in my alleged work life at times, or at least try to think the way they might. And when I spoke to this doctor to find out exactly why he was recommending a particularly invasive form of treatment, I found out that it was basically a Hail Mary pass with no obvious receiver—he had essentially no working diagnosis and this was the only idea he had—that surgery might work because he had seen it work before and he had nothing else to offer. Never mind that he was working with an unclear diagnosis. Never mind that there was no clinically obvious indication that the surgery was the solution. And particularly never mind when I suggested that this was a very concerning situation; I got told that he was pretty damned experienced, that his colleagues, with whom he had consulted, were pretty damned experienced, and, while he only implied and didn’t say this, it was clear that he did not think me so damned experienced. When I spoke to my friend afterwards, my advice was “buyer beware,” or caveat emptor for those of you with fancy educations.
Since I have pretty much made a whole career working in situations where there were better ways to do things than relying on healthcare guesswork, I demurred. I said it is too bad we can’t feed this entire patient’s chart into Watson and see what diagnosis pops out the other side. I immediately started casting around for ways to get a more thoughtful second opinion. I found myself personally lamenting the lack of technology to take a broader view than what this one group of doctors had in their own heads. I felt, for just a minute, like Vinod Khosla without the controversial beachfront property. It was exasperating.
On the other hand, I also had a recent experience with a doctor where my diagnosis was pretty obvious (at least to her), but the personal reassurance I got from the literal hug and laying on of hands was the thing that made me feel much better (also some pretty awesome antibiotics that could probably kill an entire colony of Vikings). The doctor called me at home to check on me (as did David Shaywitz and his wife, both doctors who obviously care about people). The doctor asked me about my stress levels and told me how that wasn’t helping. She suggested both the anti-Viking drugs, but also some lavender aromatherapy and warm baths. It was a very human touch and it made me feel a whole lot better. The aromatherapy thing probably didn’t provide an ounce of “real” cure, but it felt damn good and was stress-reducing. In that moment, a machine was definitely not the medical answer for me, but then again, it wasn’t that complex of a situation (and I am all better now, thank you, and it wasn’t Ebola so you can hug me without consequence, at least if you know me and I like you).
While I was at Health 2.0 I learned a new term: DiPhy. It was said by one of the people on my panel about The Business of Healthcare (and Pokitdok’s solution in particular). Being a nearly native California, when I hear “DiFi” I think Diane Feinstein, one of our state senators, and a particularly good one if you ask me. But this guy meant the digital-physical bridge; in other words, the path between man and machine that we need to walk effectively to make the most out of technology and keep the right amount of humanity in the picture. This was a big theme throughout the conference and one that is so compelling to me.
Bernard Tyson, chair and CEO of Kaiser Permanente, in his conference keynote address, said that “technology will continue to encourage and move that level of innovation out into the hands of consumers who can make different choices” about their care, but will never replace in-person caregiving. “There will always be the need for the human touch, human capabilities housed inside an individual,” he said. “In my vision, hospitals and health centers will have tech-enabled apparatus to help human intelligence make the right choices.” And of course he is right.
This is particularly important in light of the shift in US healthcare to (allegedly) put the consumer/patient/human being back into the center of the process of care delivery. People have learned to trust machines over experts before: we use ATMs instead of bank tellers, we can dispense our own frozen yogurt (with toppings!) instead of waiting in line for the high school kid behind the counter. We buy airline tickets on the web and have even given up bars for Tinder and Match.com. But when the going gets tough, and the machines are out of chocolate or cash or we can’t get from point A or point B, we want a human to help us. Convenience is nice, but it is no substitute for a warm body that wants to help.
I thought this point was brought home particularly profoundly in the always amazing Unmentionables program led by Alex Drane during the Health 2.0 conference. Rather than focus on how technology can improve healthcare, the talk was about how human people really are and how those things that make us human can really screw up our health. Esther Perel, author and relationship therapist, talked about how bad relationships and bad sex can ruin one’s state of mind, leading to poor health. Dr. Vic Strecher, professor at the University of Michigan, talked about finding a purpose-driven life after coming back from the death of a child and how this can amplify stress and poor health; Kent Bradley, President of Safeway Health talked similarly about how important it was to find motivation and a life without regret, particularly in the face of losing a beloved brother. Pulling it all together was Alex’s and Susannah Fox’s (RWJF Entrepreneur in Residence) discussion of a recent Robert Wood Johnson Foundation study called The Burden of Stress in America, downloadable HERE. The study’s key findings were these:
- When asked if they had had a major stressful event or experience in the past year, almost half of all respondents (49%) reported that they had. More than four in 10 (43%) of these respondents reported stressful events and experiences related to health.
- People who identified as being in poor health were more than twice as likely (60%) to report experiencing a ‘great deal’ of stress within the past month. Eight in 10 (80%) of those in poor health reported that their own health problems contributed to their stress, and more than half (58%) attributed the health problems of a family member.
- Close to three-fourths of those polled (74%) identified their health as a sphere affected by stress. The most commonly reported effect on health was poor emotional well-being (63%), followed by problems with sleep (56%), and difficulty thinking, concentrating or making decisions (52%).
- Only one-third (34%) of those polled who reported having a ‘great deal’ of stress within the past month said that they had a great deal of control over the stress in their life. Four in 10 (40%) said they had some control.
Bottom line: major human experiences and traumas that cause stress are a leading cause of poor health, chronic illness, etc. Failure to recognize this when treating a patient will undoubtedly compromise outcome. And my conclusion from this, other than that I want to be Alex Drane when I grow up because she is the 8th wonder of the world, is that we shouldn’t even be striving to replace doctors with machines, but should be striving to do a better job of equipping doctors to be the empathic, intuitive, out-of-the-box thinking half of a duo that includes data and technology and algorithms as the other half. Scientific skills are necessary, but not sufficient for good medicine (I know some of you are saying, “duh”) just as much as empathy and caring are necessary but not sufficient for good medicine. Technology adds a huge advantage to healthcare by feeding the knowledge engine that is man with data that man cannot readily access on his/her own. When that DiPhy thing reaches true balance, we will have achieved healthcare nirvana.
First, thank you! I loved being part of the Unmentionables panel and am grateful that so much of what we were beaming out to the audience got reflected back here and elsewhere.
Second, I appreciate how you wove these themes together. I think we are reaching a new level in the health-tech industry and I’m trying to think of a way to describe it: the post-launch era? The let’s-get-real layer?
My wish for a let’s-get-real post-launch era would be to spread the word about the possibilities we see. The gap between what we see at Health 2.0 and other, similar conference and what we see happening in our own communities is vast.
For example, check out Wendy Lynch’s post about trying to advise a friend about her shoulder surgery:
” I was almost certain that if she was having work done on her kitchen, she would be getting competitive bids, asking for references and looking up the vendor on the Better Business Bureau. But not for her shoulder.”
http://www.cfah.org/blog/2014/have-you-seen-your-options-patients-should-make-safe-effective-economical-necessary-choices
As for IBM Watson, I see a lot of promise but I also would want a doc like Jordan in the room if my life were on the line. Here are a couple of posts I’ve written about big data & Watson in case anyone wants to dig in:
http://susannahfox.com/2012/12/30/thinking-critically-about-big-data-and-health-care/
http://susannahfox.com/2012/06/11/watson-a-love-story/
The insight in the comments on those posts far exceed my own, btw.
Let’s keep talking — this is a great starting point for what is next in health & health care.
Thanks Susannah, maybe it should be called the life layer or the seven layer cookie! Loving the dialog and will read your items for sure. Lisa
Hi, Susannah Fox’s twitter pointed me here and I wanted to note that I find your last comments about the computer “half of a duo” to be both accurate in terms of “likely deployment” and optimistic in terms of capabilities. I think a major, outstanding challenge remaining in healthcare is the ability for a computer to make sense of the sorts of data that might be generated from a clinical encounter, and ascribe some sort of cause to them. Looking at the best data basis for drawing conclusions – Peer-reviewed literature – It’s difficult to be able to reconstruct any “reasonability” matrix that a computer could readily draw from to make decisions. The second best data set, other data in electronic health records, is typically insufficiently aggregated to allow for a meaningful and reliable computer decision.
For the time being, what I think is most promising, is the ability for a computer to offer *unlikely* but devastating alternative hypotheses, along with probability bands. I.E., a human might use a heuristic to determine what’s likely to be occurring based on their past experience, whereas a computer might say “Here’s the next 3-4 most likely diagnoses.” There are some firms that offer products along these lines, but the market is still fairly immature.
Thanks for your thoughts and your great recap, though!
Thanks Dave! I agree it’s challenging but technology can be a great extender to patients between visits and when diagnosis is defying obvious human logic. There are other good use cases as well, but people will always want, in the end, to be cared for by people, I think we both agree. Lisa
Lisa,
Your post is on point with respect to “forget[ing] how human the healthcare experience really is. Health and health care is social and interpersonal as you already know. While 70% of health occurs outside the doctor’s office or hospital….the caring part occurs within the confines of these organizations which are made up of people not machines. People with fears, motivations, goals and aspirations that only another human can address. But then I the patients’ perspective has never seemed to matter much to the HIT folks who are arrogant enough to think they are going to save the world. How many Health 2.0 presentations were by patients not being paid (like doctors are by pharma) to speak at the conference?
In truth, the rise of the #HIT Industry and HIMSS as a lobbying group for health care technology spending is second only to big pharma. Yet I sense that HIT and HIMSS are unintentionally doing more to harm the doctor-patient relationship and the long term care/health of people than the pharmaceutical industry ever has. How? By attempting to disrupt the therapeutic relationship between the doctor and the patient. Simple things like touch and the spoke word have been shown in the research to heal. The same cannot be said of digital ones and zeros.
The solution? I would like to see every HIT pundit identify any financial interest they have when pontificating on the virtues of HIT. Just as we expect doctors to announce any financial support from pharma or bio tech, we should demand that clinicians be transparent with respect to financial support from HIT. I would also like to know if these pundits have actually used their solutions in a life threatening health situation.
If we need further evidence of the breakdown in person-to-person communications (my professional interest) we need look no further that the Dallas Ebola case which was the result one a clinician not listening when the patient said “I Am From Liberia.” Won’t it be a pity if the human race dies out because we forgot that the essence of life and health is social and not digital?
Steve, there is a good case for what you recommend; I always appreciate it when speakers explain their own biases/conflicts. I agree there should be more patients in the discussion. Lisa
I am an analogy kind of guy. And because I am a guy, I’m also fond of the dreaded sports analogy.
We use technology to record the statistics of our favorite sports, and then we hash and rehash what we think happens on the field of play. We have added layer upon layer upon layer of technology to sports including instant replay, over the field hover cams, even recently GPS’d (is that a word?) individual soccer players during the World Cup to track how far and how fast they run, but we have never replaced the players themselves – because that is essentially not the point. We want to understand the game, improve the game, and make the game more accessible from every perspective. But we have to recognize that even if a car can beat Hussein Bolt in the 100 yard dash, even if a potato cannon can cast a baseball further than Derrick Jeter can throw one, and even if Watson can offer up better diagnoses than the average doctor better than 80% of the time – no technology matches the overall capabilities of an intelligent, trained, experienced human being – not even close.
We should consider our augmentation of the healthcare process in just the same way. Technology can be used to help us understand how to play the game, but it is silly to consider “replacing” caregivers with computers. Every tool needs a person to wield it. So let’s all stop the sci-fi pretension.
Admittedly, when things get out of kilter, (as they often are with EHRs today), then we need to remember that the tool was created for the doctor and the patient, not the doctor and patient for the tool.
Love your blog.