Everyone hears about the magnificent future of medicine. We can’t stop hearing about it. Dr. Watson and his colleagues in Big Digital Medicine promise precision and certainty where the human frailty of physicians (and physician equivalents) offers only superstition and confusion. We are told that the #3 killer of Americans is healthcare. That this is an absurd sentence doesn’t bother us in the least. Someone’s got to be responsible for this mess!
Enter High Technology. It promises a new and radical direction for healthcare. It is romantic technocracy. Worse, it is wrong and dangerous.
The Industrial Revolution of the late 1800’s in America was driven by expectation of abundant productivity pouring forth from the incorporation of rational scientific principles of organization and order in manufacturing. The miracles of the Industrial Revolution – the automobile, the airplane, the light bulb, the telephone – all seemed to spring from the incorporation of uncompromising rationality applied to invention.
A principal evangelist of organization theory, Frederick Winslow Taylor, spread the gospel of scientific management across the land.
Taylor’s theories quickly became central to the philosophy of American education. It was critical to train tomorrow’s workers in the environment of the future workplace. In addition, the regimentation offered by the assembly line allowed schools to manufacture, rather than teach. By the early 20th century, Taylorism had been fully embraced in principle, if not in name, by the school system.
Scientific management, or Taylorism, had four characteristics designed to make the worker “an interchangeable part of an interchangeable machine making interchangeable parts…”: 1) A mechanically controlled work pace; 2) The repetition of simple motions; 3) Tools and technique selected for the worker; 4) Only superficial attention is asked from the worker, just enough to keep up with the moving line.
“What I demand of the worker,” Taylor said, “is not to produce any longer by his own initiative, but to execute punctiliously the orders given down to their minutest details.” 
The Industrial Revolution in America was such a success, and Scientific Management appeared to be the cause. After a while, it was toned down, as it tended to cause riots in the factories. More importantly, as Scientific Management became absorbed into the school environment, concepts in American management accepted the dubious principles that Taylorism is the method for improving everything; that business needs a “stupid class” who represent most workers, who are poor and dull and a “smart class” of leaders at the top; that centralized control at a corporate level is the way to do business, and that Bigger is Better.
Strangely, Scientific Management shares many common assertions with classical Marxism. The division into the classes of haves and the have-nots was not as strongly delineated in America at its beginnings. Industrialization and assembly-line work brought these differences. Between Taylorism and Marxism, the only difference in their concepts seems to be the moral of who controls the enterprise, owns the factories.
What does scientific management have to do with the Big Digital revolution in medicine of the 21st Century? Under the whiz-bang cover, it is nearly identical.
The propaganda about Big Digital Medicine is certainly being pumped to as many potential patients as possible. Doctors don’t notice the propaganda, but the hedge fund managers certainly do. Big Digital Medicine is big money.
A leading German publication offered: Dr. Smartphone – The Medical Profession’s Digital Revolution Is Here
The health care sector is facing a far-reaching and unpredictable revolution. Smartphones are capable of replacing many devices that have become standard in medical practices and some apps will soon be able to provide diagnoses as well. Patients are becoming less reliant on doctors.
A doctor is obviously what you are stuck with if you can’t find the correct app. You know enough to get ready for the information miracle when Dr. Topol is discussing it, and here he is:
The airplane had just taken off when one of the passengers lost consciousness. Eric Topol pulled his smartphone out of his pocket and immediately performed an electrocardiogram (EKG) on the passenger. He used the device to do an ultrasound scan of the man’s heart and measured oxygen levels in his blood. He was then able to give the all-clear and the plane could continue its journey. The man had lost consciousness merely due to a temporarily slowed heart rhythm.
That made me cringe. A single tracing of lead I, even with a pocket echo and and O2 sat, is not enough for me to yell “he’s fine” when a patient drops with a bradyarrythmia.
In old-fashioned medicine, the question would be asked – what made this guy lose consciousness? Perhaps we’re a lot slower today in ruling people out in the ER, or perhaps not.
Dr. Topol is a cardiologist; I’m not. But certainly he’s seen the silent, even painless RCA infarction with a heart rate in the 30’s and loss of consciousness, the RCA infarction that doesn’t show on the EKG until much later when dead myocardium makes its presence known.
What’s changed, and for the worse by far, is the sense of professional obligation to the patient. Tag, you’re it, with this unconscious guy, and you can’t let him go without knowing what made him unconscious, having him restored to normal functioning, and being certain that he’s safe from other life-threatening episodes soon.
Instead, Taylorism whispers to us:
“What I demand of the worker, is not to produce any longer by his own initiative, but to execute punctiliously the orders given down to their minutest details. Only superficial attention is asked from the worker, just enough to keep up with the moving line.”
When once doctors admitted sick patients from the clinic to the hospital, there is instead only the obligation (and ability) to send the patient to the ER, where they practice catch-and-release medicine. Unconscious? Now he’s conscious, so he’s better. Follow up with your primary care physician.
The practice of primary care medicine seems to be gravitating towards whether to send the patient to the ER or not. Most astute high school graduates can do that, with or without a high-price app. That’s not medicine, but it sells to the public.
As the pharmaceutical companies have long known, doctors are a serious impediment to moving medications. As the information technology companies come on line, they are an equal impediment to moving software.
And if your next doctor’s an app, the responsibility for quality assembly-line healthcare product is on you, consumer. You missed your own MI? Well, doesn’t that stink! So sad. But as medicine slides downhill from professional service to packaged product, and products become ready-for-sale at national retail outlets, healthcare becomes much cheaper, because the liability is in the customer’s hands.
Cut your hand off with a Wal-Mart chainsaw, now whose fault is that? Or didn’t thrombolyse grandma fast enough for her stroke, well what a shame!
That is the direction that the Big Digital Medicine miracle draws us. It is no better for patients; but it is much easier to sell.
Pierre François Bosquet observing the slaughter of the Charge of the Light Brigade, offered: C’est magnifique, mais ce n’est pas la guerre: c’est de la folie (“It is magnificent, but it is not war: it is madness.”) We have many magnificent things awaiting us in 21st century medicine.