When I completed my internal medicine residency, my fellow trainees knew I was headed for a rural practice in Vermont. Much to my surprise, they gave me a traditional doctor’s black bag – a beautiful leather bag with pockets inside for instruments, tongue depressors, syringes, prescription pads, and all my tools. It was an extraordinarily meaningful gift that acknowledged a launch into my dream: to make a difference in rural New England.
I still have that bag. I carried it in my car on hundreds of house calls over the 20 years of primary care medicine I practiced in Vermont. I enjoy replaying the memories of so many living rooms and bedrooms of housebound patients and people who faced end-of-life. The ophthalmoscope still works; I recently discarded a pile of expired syringes and drugs that were still buried inside.
Today, providers can no longer go to work with a stethoscope and their well-trained brain and hands. In a hospital or an office, few of us need a black leather bag. But we do need information, and in ways we never experienced in our training. Technology is rapidly changing how we approach the bedside examination.
I could not practice as a hospitalist or a primary care physician without access in real-time to medical databases and formularies. Decision support tools are still in their infancy. However, with every patient I see, I consult medical and pharmaceutical database on my smart phone.
Within a very short period of time, I believe we will be using technology to help us care for patients in ways we have not yet fully considered. There are two dimensions of technology that I believe will dramatically improve care and the connection with our patients.
First, bedside diagnostics. Ultrasound has rapidly become the standard of care for practitioners to insert lines. Now portable ultrasound is available for the bedside physical exam. My former medical partner currently spends most of his time on international medical volunteer missions. He carries a portable ultrasound that is only slightly larger than the average smart phone. The probe looks like a tiny flashlight. In villages in remote Nepal, he is able to ultrasound patients to help diagnose serious illnesses that may require transport to tertiary care institutions. As internet and cell phone accessibility improves throughout the world, there are places where he can ship the images to radiologists in the United States to assist with interpreting and making a diagnosis. I think the average physician in developed countries will soon carry a pocket ultrasound for use throughout the day, whether hospital- or office-based.
Second are the incredible opportunities to use cell phone technology to improve the care of chronic illness. The concept of “crowd sourcing” allows patients and their providers to share information that can dramatically improve chronic illness.
Ninety-one percent of people keep their smart phone within 3 feet of them 24 hours a day. An early experiment in the care of patients with inflammatory bowel disease has yielded dramatic improvements in the disease by tracking people’s activities through their cell phone GPS and accelerometer (passive data), and replies to scheduled texts (active feedback). By tracking activity and cell phone use, early warnings about exacerbations of inflammatory bowel disease have led to interventions that have dramatically improved care without any new drugs and with decreased use of steroids. How many other chronic illnesses could benefit from this kind of tracking? A number of researchers and tech start ups are finding out how.
There are companies utilizing texting to assist patients and their primary care physicians in the daily management of their chronic illnesses. Some of these companies even customize the texting to the demographics of the recipient. In other words, a 30-year-old with diabetes will likely respond to certain words that would not be the same for a 70-year-old. A plastic surgeon has published research showing that texting improves postoperative outcomes.
So the doctor bag, or white coat pockets, of 2013 would likely contain a stethoscope, a portable ultrasound and a smart phone or iPad that would enable continuous data streams between providers and patients. This vital exchange of data would monitor and identify variations that can allow individual interventions to improve care.
I am excited that both patients and providers will find this new world of communication and information a better place to be.
Mark Novotny is Chief Medical Officer, Cooley Dickinson Hospital in Northampton, MA.