Computerized Medicine is No Solution by Steve Vaughn MD
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.[1]
“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.” [2]
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.[3] 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[4]. 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.
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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.
[1] The Underground History of American Education: A School Teacher’s Intimate Investigation Into the Problem of Modern Schooling, by John Taylor Gatto 2000
[2] Principles of Scientific Management, Frederick Winslow Taylor (1911)
[3] e.g. see Scientific Management in Action: Taylorism at Watertown Arsenal, 1908-1915 by Hugh G.J. Aitken
[4] Der Spiegel (International) by Martin U. Mueller, 7/20/17
Larry, I don’t think I’ve ever seen such a resounding endorsement of a physician’s character, than having been denied reappointment to two major Harvard teaching hospitals. Much of my medical education took place in Boston, and I am a Latin School boy, for those that understand the Boston mindset.
Bill Deresiewicz, a former Yale professor of English, wrote a powerhouse book entitled “Excellent Sheep” which contains some of the most powerful analysis and criticism of the educational system. You can find his works at https://www.billderesiewicz.com/books/excellent-sheep . He was not asked to tenure at Yale, and no surprise – he believes that a Yale education is supposed to “how to think critically and creatively, and how to find a sense of purpose.” No sensible tenure committee wants loose cannons like that aboard.
Academia insists that since it has taught you to think, it is your life’s duty to pay back academia with the service of your intellect. It has been called “instrumental reason,” or the principle that the mind itself is a tool to be controlled, bought and sold. Academia prefers faculty more along the idiot-savant model, those that given a topic to think about, will churn out answers; but not one that generates its own questions, for such habits are caustically disrupted to the order and direction of the academic industry.
Thank you for demonstrating that excellence is not a certificate to be given by boards and committees, but is a human achievement. I expect you will enjoy reading “Excellent Sheep.”
The DPC movement is heretical to academia, because it depends on the principle that competence and excellence can be achieved by one’s own effort, rather than by accolades, time and tenure. There is Hope – and it is not a subscription seminar series at Harvard.
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.
Are you thinking of only acute visits, and if so do you think we have nothing to offer but referral to ER?
Are you thinking of chronic care, where our main goal is to keep them out of the hospital? Do you think an astute high school grad could do that?
This sounds kind of like the impression of outpatient primary care that inpatient administrators and Watson promotors have. I think a lot of specialists fall for this kind of thinking about primary care, due to lack of exposure that needs to be fixed in our education system. Those of us doing it are too busy trying to make a living doing this essential service to position ourselves around these thought leaders enough to correct their thoughts.
(I once had a hospital administrator tell me she didn’t know much about outpatient medicine because her kids hardly ever needed to use it. I did manage to tell her she still wouldn’t know much about it if they did, but that is what they would consider adequate exposure and probably one good reply to an offhand comment during a rare chance to communicate can’t change that kind of thinking.)
Thank you. I share your fury with the mindlessness. They don’t understand what’s coming, and it’s not pretty. There is an American superstition that the right gizmo or combination or Congressional bill or quality rating system or pay-for-performance thingie that will provide for a magic healthcare system that everyone demands. They don’t understand.
Wow, great comment LJ! The hospital “team” system allows those with the least training to have a voice in patient care. I have had my decisions “reversed” by all sorts of people without MD after their name.
Racing down the Corporate Retail pathway, end-stage American medicine is quite near, within ten years will closely resemble large-animal, large-herd veterinary services, where the goal is to maximize the quantity and quality of meat at the market. Vaccinate them, chip them, track them.
Even for-profit animal husbandry companies have a measure of success – dollars made at the market. How are we to apply such measures in the human population? Should people be cared for to the degree that they can generate future earnings? What do we do with “downer” humans?
Thank you for your service to humanity, LJ. I am always impressed and amazed by cardiology and what the cardiologists do. Even if you are followed by much lesser people, you have set a standard for healthcare to which we can rise again.
Reversed?! I have been denied reappointment to two major Harvard teaching hospitals for being disruptive (translation: successfully interfering with the right of designated random, impersonal, and relatively half-baked beginners to kill my patients, and/or openly objecting to harmful interventions or major policy decisions made without my knowledge and assent even though I was the admitting physician of record.) To quote one Chief of Medicine and holder of an Endowed Harvard Professorship, “Larry, we are trying to establish a culture of affirmation.” The natural follow-on to Pass-Fail if everyone passes. My response: Mother Nature is not impressed by your feelings; screw-ups kill, errors have consequences, the laws of physics, chemistry and biology pertain regardless. Get over your feelings, think thoroughly, learn always, work hard, and care deeply.
Nails it!
We put 3 children through private schools despite living in a town with highly ranked public schools, because we felt they would be more processed than educated and that the public schools were more beholden to impersonal rules generated by management rather than to children and families as individuals. Pretty much the same in medicine.
I am now in the process of winding up a solo practice in cardiology, where the focus was always on the patient as a unique individual whose specific biology and persona required that I integrate the medical facts, the underlying anatomy and physiology, and their personality and worldview before giving advice or prescribing treatment. An integral part of this approach was maintaining open and direct communication with 24/7 access through my office, cell phone and email. I also saw to it that I was an integral component of their inpatient care when illness or procedures took a patient to the hospital.
In recent years, the direct hospital component of the continuum of their care began to conflict with the hospital “team” system where the assumption was that the patient would be turned over to a constantly-changing group of strangers with whom there was no human bond and who would treat them as faceless units to be managed according to “evidence-based” formulae derived from statistical analysis of a deliberately anonymous and homogenized data set. As I try to find the best fit between existing systems and practices and the individual patients who must now go elsewhere for their specialty care, it is clear that the model of my practice is not fully replicated. It is unlikely that many of them will find a cardiologist who will be at their bedside through their hospitalization, since clinic-based doctors are all busy in the office and turning the crank for the System. Those who join the hospital practices will encounter time-limited and relatively superficial interactions with staff physicians and evanescent relationships with trainees, and they will find it very difficult to reach these persons through the hospital call system. There is nothing to suggest that this change from individual practice and individual responsibility to the fully industrial model (as described in your post) is going to slacken, much less reverse, in the foreseeable future.