Transformation of health care is underway: The landscape is filled with innovation, and the horizon is dotted with technological possibilities of “Star Trek” ilk. In a recent New England Journal of Medicine Catalyst article, there was a compelling argument for how artificial intelligence (AI) of the future will help deliver us from a high cost, high variability, poorly resourced state and help deliver the IHI triple aim quest we in health care have been on this past decade. At a recent national Health Analytics Summit, the plenary speaker Dr. Daniel Kraft sparked our imaginations and whetted our appetites with advancements that have already been created but not commercially available.
Recently I saw one of my “regular” octogenarian patients for a blood pressure check she scheduled “to restart a medicine we had stopped” after lifestyle modifications improved her hypertension. I have had the privilege to be her doctor for a decade. And in that time, she has steadfastly refused immunizations and prevention efforts( though for my Christmas gift last year, she grudgingly agreed to her first — and only — mammogram). She has frequented Hemlock Society meetings. She has exerted complete control of her health and destiny with consistency and clarity. Despite my wheedling and cajoling, there have been some battles I have not won, and I have ultimately respected her decisions. As I scrolled through her chart, I saw she had a visit with a colleague the week before when she had a fall at work and hurt her ribs. There was an unexpected, very concerning finding on the chest X-ray but she refused further imaging.
We worked through the business side of her elevated blood pressure, the persistent pain in her ribs and her lack of sleep due to discomfort. I examined her and felt confident there were rib fractures not seen on initial imaging. Finally, I asked her how her visit had gone after her fall and (this normally peaceful Chinese medicine soul) let loose. “How dare someone who does not know me tell me I have something in my lung that might be cancer?” She was, in a word, furious. “She should have treated the problem I was there for and said she was going to send my X-ray to be looked at by my regular doctor. Instead, she’s trying to force CT scans on me. She doesn’t know me. You know me.”
She was right. I knew the way to get her to a CT scan was not a fear-based “you have cancer” path. It was logic — a desire to look at her ribs more closely because she was stoic and strong, and I suspected they were broken. It was metaphysics — maybe the universe made her trip on the massage table and fall into the porcelain sink because it wasn’t her time yet. And there was something in there we could fix and cure, and her purpose was not yet fulfilled. It was patience. I spent close to an hour helping her understand a very early lung cancer was not like when her gay friend in the ‘90s, who did not have HIV tests because “your life was over as soon as you did” and who, in fact, died of AIDs not long after. Finally, it was honesty—with the (albeit) ridiculous bottom line, “Even if you didn’t want anything done, I can’t help you die gracefully, get you oxygen and pain control you might need, without a diagnosis for your insurance to pay for those interventions.” An hour into negotiations she left our office for the CT scan (she got the last word when she refused contrast), which confirmed what is most probably a stage 1— curable — lung cancer.
There is no computer algorithm that could have gotten her to that outcome. There are no one-off providers who would have held the key to open the vault of her psyche. Only a longstanding caregiver who has near absolute credibility holds the requisite trust to turn the lock. At the end of the day, if I am totally honest with myself, I am not certain she will trust health care to cure her or if I will have a portal message that she is going to Mexico to follow her Hemlock protocol. I am confident that my human attempt to broker her healing delivered something technology alone could not.
As a physician who trained in the late ‘90s, I have already seen dramatic changes in technology in my medical career. I access answers to clinical questions without relying on memory in a world where the volume of new drugs, tests, and recommendations are exponential. I access patient information wherever I am and no longer have “lost charts” where I am forced to guess at a patient’s medical history. I also see burnout in epidemic proportions in health care providers. How AI will play in the future of medicine will continue to offer a balance of good and bad, success and failure. It is our job to embrace the possibilities, trust the process, but ultimately ensure the net balance is in favor of the patient.
Shannon Dowler is a family physician.
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