How technology can save the craft of medicine

With the advent of information technology in health care, patients and providers alike have begun to feel a cultural angst about what this means for the future of medicine.

As a recently minted MD with a keen interest in health IT that began with working on Google Health six years ago, I’m decidedly on the forward-looking end of the spectrum in the physician community. I think decision-support algorithms have the potential to reduce errors and save our health care system a boatload of money by passing a greater share of patient care down the ranks to clinicians who are less-highly-trained and, therefore, less expensive, leaving physicians time to focus on more complex cases and interventions. I’m intrigued by the partnership between IBM and Memorial Sloan Kettering to train the supercomputer, Watson, to assess, diagnose, and make treatment recommendations for cancer cases. I’m optimistic about robots placing IVs or performing routine surgical procedures in the future — possibly better than human providers do.

That said, as a touchy-feely people person who romanticizes the days of the old-school general practitioner who knew your whole family, I’m sympathetic to the view that the last thing modern medicine needs is more machines and less humanity. But I think the conversation surrounding this topic has tended to create a false dichotomy between doctors and computers.

In what ways might technology bring more — not less — humanity to doctors and to the practice of medicine?

A fundamental change in the role of the physician is not unprecedented in human history. For hundreds of years, physicians were craftsmen. They learned much about anatomy and developed practical skills in diagnosis and procedures. They relied on reasoning and empiric observation to conclude, as far back as ancient Greece, that purified water and sanitation improved the health of their communities, even though they lacked a scientific understanding of the germ theory of disease, which wouldn’t debut until a couple of millennia later. Early doctors practiced their craft and took cues from the fifth century’s Hippocrates, who considered medicine to be an Art with a capital “A.”

With the arrival of modern medical science and the barrage of knowledge and data that came with it, physicians have turned to more cerebral tasks and have inadvertently become, in some sense, information storage and processing pseudo-machines. Particularly since the debut of evidence-based medicine in the late 1980s, doctors have been forced to memorize ever more medical facts and innumerable diagnostic and management algorithms (all of which are constantly updating) to offer their patients the standard of care. They now also spend much of their time interfacing with computers instead of patients to perform structured data entry in electronic medical records. These tasks are time consuming and resource inefficient, and they distract from direct patient care.

But I think we can turn this curse into a blessing. I don’t think technology will kill the craft of medicine. In fact, I think it may be the only way to save it.

Handing off data storage and processing tasks to machines that will almost invariably perform them more accurately and efficiently than we do could free us from the computational burden we’ve rightly created for ourselves. If phase one of modern medicine was acquiring the scientific knowledge and concepts to dramatically improve health outcomes, phase two is designing information systems to liberate physicians’ inner hard discs and working memories, so to speak, as well as their calendars, leaving more room for the human side of medicine, what I believe we will always do better than machines – caring for patients.

True care demands sophisticated, time-intensive interpersonal communication, relationships, and counseling with patients. It requires internalizing the important distinction between medicine and healing, between treating the body and treating the soul, yet understanding that these are two sides of the same coin, and knowing how to integrate them appropriately into routine care instead of abdicating existential human matters to a chaplain, social worker, or psych referral. When we over-focus on the medicine, we forget how to heal, we forget that merely talking and listening is therapeutic. We think we have nothing much to offer a patient with terminal cancer, or another who suffers from chronic pain without any known organic cause. But even without a cure, we can be healers for such patients.

This kind of healing may already be practiced sporadically or within certain specialties such as palliative care, but it bears little resemblance to what medicine on the whole looks like today. But I think it is better medicine. And letting computers do health care’s more algorithmic work might allow us the time and emotional space to re-establish the Art of healing, to be more, well … human. I feel modern medicine has lost this art, this humanity to science. Perhaps incorporating technology into health care in a very deliberate way can help us find the best of both paradigms, and make medicine and healing one again.

Doctors must undoubtedly still learn the ins and outs of diagnosis and treatment and should reserve the right to overrule computers using their clinical judgment. Besides, some situations simply defy the reductionism of algorithms, like when the machines say a patient is stable, but the seasoned physician just knows she’s about to crash. And, in fact, in our clinical training we are taught when to “trust the patient, not the numbers”, and to develop an instinctive approach to whether that patient in the emergency room bed is “sick or not sick”. As a student, I had plenty of attending physicians tell me to put away my notes on a patient’s vitals and lab results and ask what my gut was telling me.

Such a paradigm shift in how we practice medicine would necessitate big adjustments in how medical schools select and train students. Instead of using science GPA and MCAT scores as a primary weed-out mechanism, admissions committees could initially screen for emotional intelligence, and later delve further into applicants’ communication skills and abilities to synthesize information and observations, think and act holistically, and collaborate with machine-physician counterparts.

The Icahn School of Medicine at Mt. Sinai in New York has already begun to experiment with a program that allows liberal arts college students to gain early acceptance and skip the MCAT and undergraduate science course requirements altogether. It’s been so successful at creating students that can not only pick up the necessary science but also become more sensitive doctors, that last year Mt. Sinai announced an expansion of the program. By 2015, about half of their incoming students will be admitted through this “FlexMed” program. And perhaps selecting students this way would obviate the need for what I considered remedial communications skills training in medical school, or the clunky instructions of the scientist’s scientist trying to teach communications — for example, in my first year of school, when a handout prompted us to “place your hand on the patient’s shoulder in a reassuring manner” during the physical exam. Yikes.

If this is truly an opportunity to save the art of medicine and healing, then providers and technology experts everywhere should focus on building new products and services that give clinicians the bandwidth to be more human again, to salvage and rebuild what’s left of their therapeutic relationships with patients. One example that I encountered in my clinical training and in the literature is that both patients and doctors barely tolerate desktop computers in the exam room because of the feeling of too much time looking at a screen instead of the patient — but almost everyone loves tablets. This simple change in user interface has a profound impact on whether people feel like there’s a barrier to their interaction or an enhancement. A tablet computer sporting useful diagrams that doctors and patients look at together can enable shared decision-making, which could be the impetus for a stronger connection with the confused patient sitting on your exam table looking for medical answers, but also human reassurance.

Thoughtfully implemented technology and design – from information systems at large medical centers to the workflows in small community urgent care clinics — have the potential to solve problems such as cost and inefficiency by innovating and fundamentally changing our models for health care delivery.

But they should also just make us (both patients and providers) feel good. They should delight us the way that consumer technology already does every day. And they should help us feel more human, perhaps even by being less conspicuous. When technological innovations in health care become so intuitive and seamless that they allow doctors to spend more time with patients than they spend with computers, we’ll know we’ve made a good start.

Amanda Angelotti is director of product and policy, Iodine.  She can be reached on Twitter @amandalotti.

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  • azmd

    Gee, look at that. Another person who thinks that “saving the craft of medicine” will involve having the less-sick people seen by mid-levels providing algorithm-driven care, while the MD is run into the ground seeing all of the tough cases hour after hour. And if this model is so attractive, why is the writer not out working in a “patient-centered medical home,” rather than pursuing non-clinical work with tech companies?

    • Dr. Drake Ramoray

      I was merely going to point out another person pursuing entrepreneurial tech activities and doesn’t spend a significant amount of time thinks technology will make medicine better. There is a surprise.

      • Amanda Angelotti

        Sorry to disappoint! But don’t you think the argument I’m making is a little different from the usual “technology will save everything”? (In fact, I don’t believe that at all.) I’m enjoying my work and think I’ll be useful in helping the folks in tech who need greater guidance from people with clinical backgrounds.

    • Amanda Angelotti

      You know I agree with you. I’m one of those liberal arts-types who found medicine too algorithmic, and I was miserable like you said… But that’s my point in this piece. Off-loading the data analysis could leave room for doctors and the institution of medicine as a whole to be more holistic in their approach to patients, which would not only be more compelling to people like me, but I believe in my gut that it would be better medicine — with better outcomes and no doubt more satisfaction for patients and doctors alike. I think most people would consider holistic medicine and technology at odds with one another, but I think they have the potential to be a very powerful combination.

      Ultimately it’s not really about technology, and I’d actually say that without rethinking and a deliberate sharp turn in how we’re implementing tech in healthcare, it will become ever more empty of humanism. I was a square peg in a round hole, and you’re right that the system as it is continues to draw students with little interest in the kind of healing, holism, and therapeutic relationships with patients I’m talking about. But maybe the tail is wagging the dog here. Isn’t it worth thinking about if that’s the kind of medicine we really want, not just for ourselves as doctors, but for when we become patients, too, as we all inevitably do?

      • azmd

        I was an art history major at a small women’s liberal arts college prior to going to medical school, so I am sympathetic to the issues you raise. I was also a little bit miserable and out of place in med school, but ultimately I was able to find clinical work which I found stimulating and rewarding.

        However, as the years go on, trends in medical practice, including thoughtless applications of technology are making my work less rewarding than it used to be. I don’t feel that the solution is to opt out of clinical practice, though. Change in our profession will likely only come from within, driven by those of us who continue to practice, but also make time to speak up and get involved in advocacy for our profession that is genuinely informed by involvement in active clinical practice, as well as getting involved in medical education so that we have an opportunity to help our trainees think early on about how they want their professional lives to look, and how to be effective change agents to achieve those goals.

        I guess I would furthermore say that what drove me to involve myself in organized medicine and advocating for our profession, was not actually my experiences as a doctor, but my experiences as a patient and a mother of patients. Once you’ve had a few of those, you really do have a sharper view of how dysfunctional our healthcare system has become. But ultimately, I think that true change can only come from within our profession, which is to say from people who are really doing the work, not those who have obtained the education but then opted out of the work because they see that it has become burdensome to do.

        • Amanda Angelotti

          Wow, what a personal attack that has virtually nothing to do with what I’ve written in my article! My reasons for leaving practice are many and personal, thanks.

          I think the best way to make the application of technology in medicine (which will come whether you like it or not) less thoughtless and more thoughtful is for more doctors to get involved building it — yes, even underachieving dropouts like me. :)

  • toolate

    We’d all like to sit in lovely offices playing with computers instead of working in nasty spaces filling out rubbish paperwork while admin bully us and pts threaten us. Making life and death decisions, for what.

    How do we get to your spot, that’s the only thing I want to know.

    • Amanda Angelotti

      Thanks for your comment. I really look forward to when there’s not such a divide between the people building stuff for medicine and the people using it. That’s part of why I’m doing this work now.

  • Amanda Angelotti

    HIPAA is policy, not technology, though unfortunately it’s had a lot of negative impacts on the implementation of health-related technology.

    That said, your point is well taken, but there are plenty of technologies that are used in medicine every day without complaint (as far as I know), such as EKG and ultrasound machines — even simple, old-school stuff like telephones and pagers — and it’d be hard for you to argue that those things don’t improve medicine and help you do your job. I think it’s easy to take those things for granted because they’re well-integrated into the physician workflow. They work, so they’re less visible and more seamless.

    That said, it’s worth pointing out that this article was not about how tech can make it easier or more efficient to practice medicine, but how it could (ostensibly paradoxically, and only if implemented thoughtfully and deliberately) spur a rethinking of the role of the physician to take advantage of our more human capabilities if we offload more algorithmic work to machines.

  • Amanda Angelotti

    EMRs are a pain now, but they’re very nascent and will improve. And there’s plenty in them that I’d consider more treatment-related than administrative, that’s making sure patients are caught up on preventative care and keeping multiple providers better informed about a patient’s status. I think it’s easy for them to feel like they’re strictly administrative because most of them were built for that purpose — namely, for billing — but we will (we must) get better at building them for patient care and physician workflow.

  • Amanda Angelotti

    Couldn’t agree more! Thanks for your comments.

  • Amanda Angelotti

    Hi Amy — Yes, I do think there’s some divide, in that younger generations of MDs expect technology rather than see it as a new obstacle they must overcome. However, they also expect said technology to be slick and work well… sophisticated user interfaces and user experience, plus polished design. Most of what we see in medicine (even the brand new EMRs) comes off as extremely clunky. I’m painting with broad strokes here, but I think when older generations encounter the clunky stuff, they want to throw the baby out with the bathwater, whereas younger generations are more likely to accept tech as a fact of life but feel strongly about wanting to improve it.

    Fortunately, there’s a big wave of tech industry interest in health, but it’s essential that the enthusiasm and money that comes with it is directed and guided by people with clinical experience. I’ve met way too many tech and design folks who don’t really understand the problems in medicine that need solving. There’s already been a lot of wasted VC money building products that patients and doctors don’t really need/want and won’t improve care, cost, or efficiency.

  • Amanda Angelotti

    Thanks for speaking up :). I feel passionate about helping those in the trenches who don’t have time to manage product development.

  • dfs

    After thoughtfully reading this post and the ensuing comments I was a little disappointed, although not surprised, to see the cynical response of some readers. I agree that there are too many blogs, business reports, and VCs singing the praises of technology in health care without substantive arguments or evidence, but adopting an “us vs. them” or “doctors vs. technology by non-doctors” approach is certainly not a productive response.

    To voice concerns with the “thoughtless applications of technology” in medicine while criticizing an article that explicitly emphasizes the importance of “thoughtfully implemented technology and design” is hasty and counterproductive. Instead, let us channel these concerns towards critical collaboration. Just as I would not expect a medical school graduate without further clinical training to independently provide my health care, I would not expect a busy clinician to independently design, develop, and implement the tools necessary to create a better health care experience. Practicing physicians are, without a doubt, vital contributors to the process, but so are those individuals who have enough clinical experience to speak the language and empathize with the pain points while also having the knowledge, motivation, contacts, and time to help move things forward.

    About to begin residency myself after an MD/PhD program, I am inspired by and appreciative of those physicians who have found ways to thrive as clinicians while also innovating, advocating, and teaching – but to do so is incredibly challenging, time-intensive, and simply not realistic for all physicians. Rather than criticize those individuals who “opt-out” of direct patient care to devote their time, energy, and passion to a common goal of improved health care, let’s agree to agree that technology can improve health care, and work together to ensure that it will.

    • Amanda Angelotti

      Thanks for this thoughtful response. 100% agree that we are all on the same team. :)

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