The Digital Age and the Doctor/Patient Relationship

The digital age has had a deep and likely permanent effect on the patient-physician relationship. I can’t tell you how many times I’ve had physicians beg me to provide them with a way to stop their patients from Googling their symptoms and diagnosing themselves before their first office visit and much to their chagrin, my answer is always the same, “You can’t stop them. Get over it.”

The internet acts as an enormous and easily accessible virtual research library for patients, granting them access on the one hand to quality, data-driven information and personal perspectives that can provide tremendous value and on the other hand to information that is no better than old-fashioned quackery.

But this access to information has not translated into improved interactions between patients and their physicians. It is clear to me that we all need help in rethinking how we can best work together, especially because I believe that we are still in the nascent stages of this age of disruptive new tools that delight some and threaten others. Time and time again I hear stories describing the ways in which this technology seems to be moving us backward instead of ahead:

· When Timothy B. Lee went to a dentist highly recommended on Yelp, he was asked to sign a “mutual privacy agreement” that would transfer ownership of any public commentary he might make in the future to the dentist.

· A TechDirt blog post reported that plastic surgeons have sued patients for their online negative reviews and a neurologist sued the son of a stroke victim for negative comments about the physician’s bedside manner.

Instead of pitting patient against doctor, these tools should be increasing our collaboration.

The days of the paternalistic family doctor who dispenses advice and counsel to an acquiescent, unquestioning patient are clearly over, but that needn’t be a bad thing.

Importantly, this issue features prominently in the new proposed CMS rules for accountable care organizations (ACOs) under the Affordable Care Act. An ACO is a network of doctors and hospitals that share responsibility for providing care to patients. ACOs play an important role in healthcare reform because they are intended to make providers jointly accountable for the health of their patients, providing them with strong incentives to cooperate and save money by avoiding unnecessary tests and procedures. While the focus of ACOs is collaboration at the provider level, the end game is all about the patient and increasing the quality of his or her healthcare experience.

In order for ACOs to qualify for shared savings, they must provide patient-centered care that is influenced by the patient autonomy movement. Before becoming CMS Administrator, Don Berwick wrote a provocative article in Health Affairs calling for a new definition of patient centered care as “the experience… of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care.”

In order to facilitate this shift, we need to resolve the current tension between the philosophy that idealizes the physician as always being right and patients’ newfound autonomy and access to information. We need to engage in a thoughtful discussion about how the new disruptive digital technologies can help both patients and physicians get what they need. After all, both have the same ultimate goals: good clinical outcomes and a meaningful relationship.

The good news is that these disruptive technologies can be the very mechanism we need to develop more accountable, quality-driven healthcare delivery systems because they can address some of the significant gaps in patient-physician communications that are so detrimental to the relationship. The Consumer Reports National Research Center conducted patient and provider surveys about the doctor/patient relationship and concluded that patients would get more from doctor office visits if they planned ahead, took notes during the appointments, and conducted careful online research for information. Other studies have shown that patients remember only about half of what physicians tell them during their visit and that 90 percent of patients receiving a new medication reported their physician never described the drug’s side effects. Perhaps most disturbing of all, more than 30 percent of patients were unable to name their diagnosis after being discharged.

Technology, far from being the villainous entities that so many care providers see, can actually improve a patient’s experience and address those disturbing statistics. Websites now provide patients with the tools to prepare for upcoming visits by listening to actual conversations between providers and patients that have the same diagnosis; they can organize their questions before the visit; they can record their visit using digital or mobile recording devices; and they can review the recording after the visit with caregivers and family members to better understand how they can partner with their physician’s advice.

For disruptive solutions to be successful, all of us must be willing to adapt the traditional doctor-patient relationship. Patients and physicians alike are confused and disoriented by the new digital world, even while being empowered by the knowledge they can impart. These cutting edge technologies have the potential to dramatically improve a patient’s healthcare experience, but to get there, we first have to engage in some good old fashioned talk.

Physician Executives Should Support Patient Engagement/Activation

The doctor/patient relationship is certainly changing and evolving. A term I hear a lot today is: “patient engagement/activation.” Why is this concept so important and what does it mean? What can physician executives do to make it easier for our patients to become engaged and activated?

Judith Hibbard has pioneered the study of patient engagement, and she noted that one needs knowledge, skills, and emotional support to actively engage in one’s health care. She identified four behaviors associated with engagement and activation:

1. Self management

2. Collaboration with provider

3. Maintaining function/preventing declines

4. Access to appropriate and high quality care

She also developed a Patient Activation Measure (PAM) tool to place individual patients on a 4 level scale of engagement and activation. (1)

The Center for Advancing Health defines engagement as “actions individuals must take to obtain the greatest benefit from health care services available to them,” and they expanded Hibbard’s work by identifying 43 engagement behaviors that can be grouped into ten categories. (2) Patients who do not successfully engage in these behaviors will not receive optimal health care and will not realize all the benefits of the many scientific breakthroughs of 21^st century medicine. Because of the economic environment, the increasing complexity of medical care, and health care reform, it is becoming more important for patients to take an active and knowledgeable role in their health care.

The ten categories of the Engagement Behavior Framework are:

1. Find safe, decent care.

2. Communicate with health care professionals

3. Organize health care

4. Pay for health care

5. Make good treatment decisions

6. Participate in treatment

7. Promote health

8. Get preventive health care

9. Plan for the end of life

10. Seek health knowledge (2)

Recently Klick Pharma invited 19 health care activists from a wide variety of disease states to participate in a conversation about an ePatient Bill of Rights that would support patient engagement and activation. After four hours of conversation, this group reached consensus on the following key messages of such a bill of rights:

1. Shared access to my data

2. Attitude of collaboration and overall respect

3. The patient is the largest stakeholder

4. Transparency and authenticity across all areas

5. Voice of the patient is a legitimate (clinical) source

6. The right to efficient communication with providers who utilize the technology we need (3)

It is not easy for any one patient to follow all of the above suggestions from the three different groups advocating patient engagement/activation. The Medicare Current Beneficiary Survey reported that only 30% of older Americans possess the motivation and skills to actively engage in their health care. (4) Hibbard found that 23% of those surveyed had embraced such behaviors in their health care, but they worried they would falter during a medical crisis. In her survey, 12% wanted to remain unengaged and 29% reported they did not have the knowledge to understand their treatment regimens. (5)

Researchers who have studied patient engagement/activation have found a positive relationship to health status outcomes. (6). Beatrice Golomb and colleagues found patients on statin drugs were far more likely than doctors to initiate discussions of symptoms possibly related to the drugs. (7) Annette O’Connor’s systematic review of the effects of shared decision-making technologies found a 23 percent reduction in surgical interventions among patients using them, with better functional status and satisfaction. (8)

David Mosen and colleagues documented that patients with high PAM scores were significantly more likely to perform self-management behaviors, use self-management services, and report high medication adherence. They were also ten times more likely to have high patient satisfaction scores and five times more likely to have high quality of life scores. (9)

Jessie Gruman has had cancer four times and is the founder and president of the Center for Advancing Health. Addressing an audience of health care providers, she recently said:

As a savvy and confident patient who is flummoxed by so much of what takes place in health care, I am regularly surprised by how little you know about how little we patients know. You are immersed in the health culture. But we don’t live in your world. So we have no idea what you are talking about much of the time. One way to help us feel competent in such unfamiliar environments is to give us some guidance about what this place is and how it works. What are the rules? (10)

Experts in patient activation/engagement suggest that hospitals and medical practices provide each patient with a short guide that explains how best to be a patient in that unique setting. Such a handbook could be printed, a smartphone app, an email, on a website, or a poster prominently displayed in the waiting room. It is important that patients understand how to get after-hours and emergency care, how to make appointments, what accommodations (physical navigation, translation services) are available, what insurance documents should be brought to the office visit, how to get prescription refills, and many other basic kinds of information that often frustrate even motivated individuals. (11)

Another tool that can be individualized for each clinical setting is a written contract or pact that clearly sets out the roles and expectations of all involved in the doctor/patient relationship. Components of such a document might include that patients should tell their provider about all other visits to physicians and alternative healers and that providers will ask about such care and be willing to share information. Another part of such a contract might require the patient to prepare for each visit by writing down a list of concerns and questions and the provider to respond to the patient’s questions and answer questions in a manner that the patient can readily understand. (11)

Another suggestion is that hospitals and medical practices become much more open to new technologies. Many patients find patient social networking sites such as PatientsLikeMe, DiabetesMine, Inspire, Disaboom, and IMedix valuable sources of practical information about living with chronic disease. CureTogether is exploring ways that patients can conduct observational research about their condition that is quite helpful to newly diagnosed patients. Patients are going to continue to google their symptoms and try to diagnose themselves before visiting the physician. Smartphone apps like CareCoach.com can help patients prepare for their visits by listening to actual patient/doctor conversations, recording their office visit so they can go back over instructions and physician advice, and sharing their audio health record of the visit with members of their care team who are unable to accompany the patient to the visit.

By providing guides, compacts, and information about new technologies, physician executives can send a powerful, positive message to their patients. Gruman believes such support communicates that we want our patients to be comfortable, to receive the best possible care, and that we are accountable for our services because we clearly spell out our commitments. (10) Physician executives should embrace patient engagement/activation because it will help our patients get better clinical outcomes and because it is the right thing to do.

References:

1. Hibbard JH, Stockard J, Mahoney ER, Tusler M. Developments of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res 2004; 39: 1005-26.

2. http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_2010.pdf

3. http://www.klick.com/pharma/blog/2011/09/epatient-bill-of-rights/

4. Williams SS, Heller A. Patient activation among Medicare beneficiaries: segmentation to promote informed decision making. Int J Pharm and Healthcare Marketing 2007; 1: 199-213.

5. Hibbard JH, Mahoney ER, Stock R, Tusler M. Do increases in patient activation result in improved self-management behaviors? Health Serv Res 2007; 42:1443-63.

6. R.M. Epstein and R.L. Street, “Patient-Centered Care for the Twenty-first Century: Physicians’ Roles, Health Systems, and Patients’ Preferences” (Paper prepared for the ABIM Foundation Summer Forum: From Rhetoric to Reality: Achieving Patient-Centered Care, Yountville, California, July 2008)

7. B.A.Golombetal.,“PhysicianResponsetoPatientReportsofAdverseDrugEffects:ImplicationsforPatient-Targeted Adverse Effect Surveillance,” Drug Safety 30, no. 8 (2007): 669–675

8. http://content.healthaffairs.org/content/28/4/w555.abstract

9. http://myweb.facstaff.wwu.edu/knecht/Lectures/Stepping%20stone%20readings/Activation.outcome.pdf

10. http://e-patients.net/archives/2011/06/jessie-gruman-at-icsi.html

11. http://www.cfah.org/pdfs/CFAH_PACT_Special_2010.pdf

Should Hospital Boards Embed Generative Thinking into their Agenda?

Hospital systems and physician groups are faced with unprecedented change demanding decreased per-capita cost and increased quality in American health care. Boards of directors are underutilized resources that must be tapped more effectively in order for such organizations to survive in a time of industry consolidation. Generative thinking is a tool that can help organizations innovate in order to improve patient care and the financial bottom line.

Generative thinking is when a board becomes involved early on with management in trying to make sense of the current environment. For example, any US hospital must figure out strategies and tactics to deal with Medicare cuts, demands for higher quality, and migration away from fee for service to global payments in both the PPACA and the federal budget ceiling compromise that will result in at least $1.5 trillion or $1.2 trillion federal budget cuts staring in January 2012. Local events in each market will be different in each region. Western Pennsylvania hospitals, for example, must effectively respond to the Highmark purchase of West Penn Allegheny and the continuing tensions between Highmark and UPMC.

One way to encourage generative thinking in this setting is to make sure the board is present when a problem is defined because such a definition will affect strategies, policies, decisions, and actions to respond to the above described environment. Boards should help management decide what problems to pay attention to and not just respond to management’s understanding of the environment. Generative thinking has been described as getting to the question before the question and is about values, beliefs, assumptions, and organizational culture that will affect what problems we pay attention to and what strategies and tactics we choose.

The importance of framing the problem correctly was demonstrated by Clayton Christensen in The Innovator’s Prescription when he described the unsuccessful attempts by a company to increase milkshake sales. As Peter Drucker once wisely wrote: “The customer rarely buys what the company thinks it is selling him.” It turns out that 40% of milkshakes are purchased in the morning by long distance commuters who like the fact that it takes a long time to drink and that you can still drive with one hand on the wheel. By defining the job that the milkshake was being asked to accomplish, the fast food company was able to increase sales by making the shakes thicker so it would take more time to drink them on the long commute.

Generative thinking is not the only function of a board of directors. The three different modes of governance are fiduciary, strategic, and generative. The first two are self-explanatory, but the last mode is the least understood and the most neglected by non-profit boards.

Generative thinking requires a greater comfort with conflict and disagreement than is usually present on nonprofit boards. Because generative thinking is about deciding what the real problem the hospital faces in a confusing, unpredictable, and rapidly changing external environment, there needs to be conflicting viewpoints.

Alfred Sloan, GM chairman from 1923 to 1956, once stated: “Gentlemen, I take it that we are in complete agreement on the decision here. Then I propose we postpone further discussion to give ourselves time to develop disagreement and perhaps gain some understanding of what the decision is all about.” John Wooden, the most successful basket coach in history advised, “Whatever you do in life surround yourself with smart people who’ll argue with you.” He won his first NCAA championship in his 16^th year of coaching at UCLA when he stopped hiring yes men and instead chose Jerry Norman as an assistant coach who installed the zone press Wooden detested.

A hospital board needs to understand generative thinking and decide if it wants to be involved upstream in discussions about how the hospita should respond to the environment. If there is agreement about the need to improve this mode of governance, then different methods can be tried to embed the concept into the work of the Board.

References:

Richard P. Chait, William P. Ryan, Barbara E. Taylor, Governance as Leadership: Reframing the Work of Nonprofit Boards. Hoboken, New Jersey: John Wiley & Sons, Inc., 2005.

Manda Salls, Why Nonprofits Have a Board Problem, Harvard Business School Working Knowledge for Business Leaders, 4/4/2005.

Michael A. Roberto, Why Great Leaders Don’t Take Yes for an Answer: Managing for Conflict & Consensus. Upper Saddle River, NJ: Prentice Hall, 2005.

Clayton M. Christensen, Jerome H. Grossman, MD, and Jason Hwang, MD, The Innovator’s Prescription: A Disruptive Solution for Health Care. New York: McGraw Hill, 2009.

Peter Drucker, Managing for Results, London: Heinemann, 1964.

Reverse Innovation & The Cost Crisis of American Healthcare

The realization that the American health care system must simultaneously decrease per-capita cost and increase quality has created the opportunity for the United States to learn from low and middle-income countries. “Reverse innovation” describes the process whereby an inexpensive innovation is used first in countries with limited infrastructure and resources and then spreads to industrialized nations like the United States.

The traditional model of innovation has involved the creation of high end products by companies in industrialized nations and the spread of these products to the developing world by adapting them to function in low and middle-income countries. Reverse innovation reverses the direction of spread with the United States borrowing new ideas and products designed for less wealthy countries in order to deliver health care more efficiently. (1)

Resource challenged low and middle-income countries are different from the United States in at least six ways that can serve as catalysts for such reverse innovation: 1) affordability, 2) leapfrog technologies, 3) service ecosystems, 4) robust systems, 5) new applications, and 6) the absence of intermediaries. (2,3)

These nations can’t afford expensive goods so they have to find inexpensive materials or manufacturing options. They also lack 20th century infrastructure and so they have leapfrogged to newer technologies such as mobile phones or solar energy instead of landlines and petroleum based energy sources. Service ecosystems develop in developing countries because entrepreneurs have to rely on others for help by creating new partnerships like video-game cafés where gamers test new products. Emerging markets require products that work in rugged conditions, and 
customers in poor countries have few product choices, providing market openings for add-ons that update and extend the lives of existing merchandise. (2) Intermediaries such as venture capitalists, universities, and regulators are also often underdeveloped in poorer countries. (3)

An example of how an absence of intermediaries can spur innovation is the Medtronic approach to chronic disease management in nations without adequate medical school capacity to train specialists in heart disease. Sixty nine percent of deaths in such nations are due to chronic disease, but the building of medical training programs takes decades. Medtronic designed a low-cost, pill-sized pacemaker inside a stent that can be put into the heart instead of the invasive intercardiac leads used in the US to electrically synchronize the heart. Remote sensors in the pill-sized pacemaker transmit signals via any smartphone to a cloud-computing infrastructure. Although this new technology was developed for India that has one billion citizens but only 100 electrophysiologists, Medtronic intends to market this low-cost pacemaker in the United States and Europe. (3)

General Electric has embraced reverse technology as a way to survive in an era where economic growth is slowed in the United States and Europe, but growing rapidly in India and China. GE developed a $1,000 handheld electrocardiogram device for rural India and a $15,000 PC-based portable ultrasound machine for rural China. These devices are much more affordable and rugged than their American counterparts, and they are now being sold in the United States. (1)

General Electric has also partnered with Embrace to distribute a low-tech infant warming device that consists of a sleeping bag, a sealed pouch of wax, and a heater. In contrast to traditional incubators that cost $20,000, this new device costs $200 and will help warm the 20 million low birth weight and premature babies born around the world. (4)

OneBreath is a rugged, low-cost ventilator that was designed for use in developing countries that experience large influenza pandemics. By measuring and controlling airflow with software rather than hardware, OneBreath was able to reduce the cost of ventilators from $40,000 (with $180 replacement tubes) to $800 (with 50 cent replacement tubes). (5)

Procter & Gamble is now marketing a honey-based cold remedy created for Mexico in the United States and Europe, and the Center for International Rehabilitation has developed low cost prosthetic and orthotic devices that can be used in rural areas where highly-trained specialists are not available. (6) JaipurKnee has developed a $20 high performance prosthetic knee joint for amputees in India who cannot afford the $100,000 titanium knee joints routinely used in the United States. (5)

The Stanford University BioDesign Program has developed a $20 device for delivering fluids or intravenous drugs into the bone marrow when vascular access is unavailable. The device was invented in India, but it could be used in rural America as well. (7)

The United States is now faced with the challenge of decreasing per-capita cost and increasing quality. Many believe that the high cost of American health care is the major reason that the United States is facing a large federal deficit problem that is hampering the ability of American companies to compete in a global economy. Some believe that the high cost of American medicine also is a major factor in causing and prolonging the current recession. The high cost of health insurance is a problem for employers who then do not give salary increases to their employees. The employees borrow money in order to continue to support their lifestyle. Stagnant employee wages have been cited as a reason for Americans defaulting on their mortgages and car payments, which resulted in the current recession that started in 2008.

American health care organizations are facing decreased revenues due to decreased volume of hospitalizations and office visits by unemployed workers, Medicare cuts contained in the Affordable Care Act, and cuts resulting from the budget deficit ceiling compromise passed by Congress that will result in January 2012 with either a $1.5 trillion or a $1.2 trillion decrease in federal spending. At a time when it clear that health care providers will be receiving less revenue, it would be wise to adopt inexpensive innovations that have been created for less developed countries. Reverse innovation may be one way that American medicine can decrease per-capita costs and increase quality at the same time.

References:

1. http://hbr.org/2009/10/how-ge-is-disrupting-itself/ar/1

2. http://www.businessweek.com/innovate/next/archives/2009/04/5_tips_for_tric.html

3. http://blogs.hbr.org/govindarajan/2011/05/patient-care-in-the-cloud.html

4. http://www.genewscenter.com/Press-Releases/GE-Healthcare-Partners-with-Embrace-to-Help-Address-Infant-Mortality-in-Rural-India-Through-Affordable-Infant-Warmer-2d80.aspx

5. http://blogs.hbr.org/govindarajan/2011/09/how-to-build-a-reverse-innovat.html

6. https://www.iconsinmed.org/content.cfm?id=595E75&searchIT=1

7. http://biodesign.stanford.edu/bdn/india/BiotechNews2010_story1.pdf




Avatars, Computers, and Robots Are Coming to Primary Care

Within in five years primary care providers will begin being replaced by sociable humanoid robots, avatars, and computer programs. Within ten years you will no longer hear any complaints about medical students choosing specialty residencies over family practice because the role of the physician will be completely redefined to complement a rules based approach to the diagnosis and treatment of many diseases. This transformation is inevitable because of demographics, economics, and progress in artificial intelligence, but the academic leaders of medical education and health policy are largely ignorant and unprepared for this massive disruption.

It is hard to understand this change because it requires us to challenge the conventional wisdom that we need more doctors and that a trusting relationship can only be had between two human beings. It will also require us to understand the implications of the evolving relationship between human beings and technology, and how disruptive innovations change industries.

Many do not see this future because they fear it. Samuel Stenes, MD spoke for many physicians when he posted the following comment on a blog I wrote about this subject: “You are truly out there. People do not want that cow waste, but the profession has been sufficiently depreciated that anarchy care will rule.” (1)

Philosopher Roger Scruton makes a similar eloquent argument about trusting relationships requiring two human beings:

In real life, friendship involves risk. The reward is great: help in times of need, joy in times of celebration. But the cost is also great: self-sacrifice, accountability, the risk of embarrassment and anger, the effort of winning another’s trust. Hence I can become friends with you only by seeking your company. I must attend to your business... When I relate to you through the screen there is a marked shift in emphasis. Now I have my finger on the button. At any moment I can turn you off...Of course I may stay glued to the screen. Nevertheless, it is a screen that I am glued to, not the person behind it.” (2)

Professor Andy Clark of Edinburgh University works in the “embodied cognition” and “extended mind” fields of philosophy, and he has an entirely different take on this issue. Citing studies that show that research subjects who are prevented from using hand gestures perform poorly on tests of mental ability, he concludes that some of the activities that enable us to think and create trusting relationships occur outside of our body and brain. “Evolution and learning don’t give a jot what resources are used to solve a problem. There is no more reason, from the perspective of evolution or learning, to favor the use of brain-only cognitive strategy than there is to favor the use of canny (but messy, complex, hard-to-understand) combinations of brain, body, and world.” (3)

The health care problem that the United States needs to solve is how to increase the quality and decrease the per-capita cost in an era of aging Baby Boomers, inadequate numbers of primary care providers, and a struggling economy that cannot support spending 18% of its GDP on health care. The messy, complex, hard to understand solution is that sociable humanoid robots and computer programs will replace human providers in diagnosing and treating some diseases.

Clayton M. Christensen, Jerome H. Grossman, MD, and Jason Hwang, MD in The Innovator’s Prescription provide a framework for understanding how disruptive technologies are making the current business models for diagnosing and treating chronic disease obsolete. They divide chronic diseases into two types: intuitive chronic diseases and rules-based chronic diseases. Intuitive chronics diseases such as lupus, back pain, and schizophrenia lack clarity in diagnosis and treatment and so at the present time still require a human physician working in a multidisciplinary solution shop such as a tertiary care hospital. Rules-based chronic diseases such as Type II diabetes, GERD, and heart failure are well enough understood scientifically that a computer following an evidence-based medicine protocol can diagnose and treat the patient.

But computers are not that smart and patients will never accept such an arrangement. The first objection does not stand up to scrutiny when one thinks about the implications of the four year Watson/Jeopardy! Project at IBM. Columbia University Professor Herbert Chase, MD believes computers will replace physicians as expert diagnosticians (4) by utilizing the same methods that defeated human Jeopardy champions: taking a question about a patient’s symptoms, analyzing the question, generating a differential diagnosis, collecting and evaluating the entire medical literature on the subject, and coming up with a diagnosis with a measurable level of confidence. David Ferrucci the leader of the IBM Watson project explains how Watson can do this in a 20 minute video (5), and Stephen Baker’s book Final Jeopardy: Man Vs. Machine and the Quest to Know Everything is a fascinating description of the development of Watson by a twenty person team at IBM.

United Hospital in Saint Paul, Minnesota is already taking a similar approach by using Isabel to search the medical literature in real time to generate a differential diagnosis for the hospitalized patient based on the patient’s symptoms and medical history. “Isabel is like a medical Google. It doesn’t think but it searches and sorts and shows you what it’s found,” says Scott Tongen, medical director for quality at United. Tongen notes that such a system can help with the number one reason for mistakes in diagnosis: early closure on a diagnosis with confirmation bias preventing the physician from considering alternative causes for the patient’s illness. (4)

Studies are starting to appear that document improvements in diagnosis with the use of computer technology. Computers outperformed radiologists in diagnosing Alzheimer’s Disease; Face identification software did better at diagnosing acromegaly than endocrinologists; a 2010 British Medical Journal study of a pediatric computer-aided diagnosis tool revealed a higher rate of accurate diagnosis of urinary tract infections, pneumonia, and bacteremia compared to the performance of emergency room physicians. (4)

The Watson approach to improving diagnosis by searching the entire medical literature is not the only way computers will change clinical practice. Dr. Joseph C. Kvedar of Partners HealthCare’s Center for Connected Health has developed the concept of emotional automation, and he believes that humans can and will develop trusting relationships with sociable humanoid robots (6). Kvedar notes that humans have a tendency to anthropomorphize objects such as pet rocks and tomagotchis, and Sherry Turkle of MIT has famously observed that smartphones and tablet computers have transformed our relationship with technology. “It is different now that we carry our second self with us. We think with the objects we love and we love the objects we think with. (7)” Kvedar believes that Karen the virtual wellness coach/avatar who motivates human patients to exercise more than a control group and hospital patients who preferred a robot discharge planner to a human one are examples of humans learning to trust technology in a healthcare setting. The robot was favored because it was not in a hurry and did not talk down to the patients being processed for release from the hospital. (6)

Technology is also beginning to change clinical practice when therapists use digital worlds with autonomous, virtual human avatars to help patients work through problems with social anxiety, drinking, gambling, post-traumatic stress (8), and agoraphobia. Therapists can discuss the patient’s feelings when the virtual bartender asks the patient’s avatar if he wants to order another drink. Different coping mechanisms can be practiced in real time in virtual situations that are experienced as real. In one study, people with social anxiety disorder confessed more of their personal flaws, fears, and fantasies to virtual avatars programmed to be socially sensitive than to live real therapists. (9) B.J. Fogg of Stanford has written extensively about what he calls “captology:” computers as persuasive technology, and his thinking needs to be integrated into clinical practice. (10)

Nick Yee has described the Proteus Effect where video game or digital world avatars change how we behave in virtual environments and in real life. Subjects given more attractive or taller avatars disclosed more personal information and bargained more aggressively than unattractive, shorter avatars. Yee has shown that the subject’s perception of his or her own attractiveness persists outside of the game or virtual world to affect participation in real life online dating. Yee writes that providing users with “fit, athletic avatars in exergames may encourage longer and more engaged exercise sessions than if they were provided with normal-looking avatars or avatars modeled from their own bodies. (11)”

Will patients embrace technology or refuse to form trusting relationships with sociable humanoid robots? I don’t know, but the rapid adoption of smartphones and initial studies indicate some may welcome technological solutions to common problems. A qualitative Beth Israel Deaconess Medical Center study utilized focus groups in Boston, Portland, Tampa, and Denver, and the subjects fully expect that computers will be increasingly used in health care and substitute for face-to-face physician encounters. “Patients know how busy their doctors are and they want to reserve us for what they really need us for – treating serious illness...They may be more than happy to rely on computer protocols and ‘faceless doctors’ to help them manage garden-variety medical problems,” says senior author Tom Delbanco, MD. Stephen Downs of the Robert Wood Johnson Foundation commented on the study, “Year after year, people have seen information technology transform one industry after another and, more to the point, transform their everyday experiences. This is the age of the iPhone, Facebook and Google Maps, yet health care feels very much the same. This study suggests that people are ready for change – they want a modern health care experience.” (12)

During Man-Made Minds: Living With Thinking Machines at the World Science Festival in New York City, Eric Horvitz of Microsoft showed a tape of a medical kiosk avatar interviewing a mother and her child who has diarrhea. After asking several questions, the avatar decides the child is not sick enough for immediate attention and makes a clinic appointment for the child for later in the week. The moderator of the panel of artificial intelligence experts got a big laugh from the audience when she noted that the avatar was much more compassionate in relating to the child and his mother than human triage nurses she has encountered as a mother taking her child to New York City Hospital emergency rooms. Anyone who is not familiar with recent advances in artificial intelligence needs to acquaint himself or herself with Horvitz’s avatar assistant on a computer screen outside his Microsoft office. Because this computer program has been learning about Horvitz for over 10 years, she can predict that he will not attend a meeting on his schedule for 4:00 PM and she can offer that time slot to a colleague who she recognizes by name and who needs to meet with Horvitz. It is perhaps relevant that all four artificial intelligence expert panelists predict that robots will be built that will be hard to tell apart from real human beings. (13)

It would be wise for health policy and academic health care experts to educate themselves about recent developments in artificial intelligence and computer technology; the implications for health care delivery are enormous and may change projections about cost, workforce requirements, and the training of health care professionals.

References:

1. http://thehealthcareblog.com/blog/2010/12/16/will-avatars-robots-and-video-games-replace-doctors/

2. http://technology.timesonline.co.uk/tol/news/tech_and_web/the_web/article5139532.ece

3. http://opinionator.blogs.nytimes.com/2010/12/12/out-of-our-brains/

4. http://www.acphospitalist.org/archives/2011/08/diagnosis.htm

5. http://www.youtube.com/watch?v=3G2H3DZ8rNc

6. http://www.youtube.com/watch?v=7DQGNQRVhjI

7. http://www.nytimes.com/2010/12/03/technology/personaltech/03TOUCH.html

8. http://bits.blogs.nytimes.com/2009/10/22/a-virtual-clinic-to-treat-the-stresses-of-war/

9. http://www.nytimes.com/2010/11/23/science/23avatar.html

10. B.J. Fogg, Persuasive Technology: Using Computers to Change What We Think and Do. San Francisco: Morgan Kaufmann Publishers, 2003.

11. http://www.healthgamesresearch.org/our-publications/research-briefs/the-proteus-effect

12. http://www.rwjf.org/pioneer/product.jsp?id=42849

13. http://kentbottles.blogspot.com/2011/06/ai-experts-on-robots-and-living-with.html

The Department of Human Nature: The Pervasive Sins of Doctors and Others

The essence of professionalism is to be constantly striving to take better care of our patients. “The aspiration to do better, coupled with commitment and a sense of personal responsibility will drive knowledge seeking” and empathy and compassion for those who are our patients. http://www.amazon.com/Educating-Physicians-Jossey-Bass-Foundation-Advancement/dp/047045797X/ref=sr_1_1?s=books&ie=UTF8&qid=1311109510&sr=1-1

And yet we know that during medical school students become less compassionate and less altruistic; the largest drops in empathy have been documented between the beginning and the end of the first year and between the beginning and end of the third year of education. http://www.amazon.com/Educating-Physicians-Jossey-Bass-Foundation-Advancement/dp/047045797X/ref=sr_1_1?s=books&ie=UTF8&qid=1311109510&sr=1-1

And we also know that there have been recent revelations of numerous occasions where practicing physicians have failed to live up to the ideal. The Wall Street Journal documented spine surgeons who did large numbers of spine surgery and received large payments from a medical device manufacturer. (http://online.wsj.com/article/SB10001424052748703395204576024023361023138.html) Pro Publica has shown that faculty at prestigious medical schools have failed to comply with university conflict of interest policies (http://www.propublica.org/article/medical-schools-policies-on-faculty-and-drug-company-speaking-circuit/single) A Maryland cardiologist has had his medical license revoked and his hospital had to pay back Medicare millions of dollars because of allegedly inserting stents in patients who did not need them. (http://articles.baltimoresun.com/2011-07-13/health/ms-md-midei-license-revoked-20110713_1_midei-unneeded-stents-stent-business)

How can we support our fellow physicians and medical students so that we all strive to become the best caregivers we can possibly be? Is the problem with living up to the ideal a specific problem within medicine or is it a more general problem of human nature and the current cultural environment?

I am worried that the difficulty of becoming and continuing to be a compassionate, master physician is complicated by the mixed messages that we send and receive as we practice in an environment where there is conflict between the ideal culture and the real culture. In medical school this concept has been identified as the informal or hidden curriculum where medical students sadly emulate the unprofessional behavior of physicians and staff, instead of the lofty ideals listed in the catalogue. Everywhere I look in modern society I find a similar tension between what we say our ideals are in pamphlets and guidelines and how we actually get work done and manage our careers.

Billionaire Raj Rajaratnam is a very successful investor who is a graduate of the Wharton Business School at the University of Pennsylvania, one of our best and most prestigious MBA programs. He has also been convicted on several counts of insider trading. According to a profile in The New Yorker, Rajaratnam liked to call himself a “rogue” and encouraged his employees at Galleon to “get an edge” when making investments. The article states that Rajaratnam’s view of human nature was similar to Willie Stark’s in All The King’s Men: “Man is conceived in sin and born in corruption and he passeth from the stink of the didie to the stench of the shroud.” His younger brother Rengan, who graduated from the Stanford University School of Business is quoted as believing, “Everybody is a scumbag.” My impression is that insider trading is rampant among investors on Wall Street. http://www.newyorker.com/reporting/2011/06/27/110627fa_fact_packer?currentPage=2

The culture that Rebekah Brooks encouraged as editor of The News of the World featured cynicism, cut throat internal competition, and gallows humor. Phone hacking and using criminals as sources for exclusive scoops were standard operating procedures. "We used to talk to career criminals all the time. They were our sources," says another former reporter from the paper who also worked for Murdoch's daily tabloid, the Sun. "It was a macho thing: 'My contact is scummier than your contact.' It was a case of: 'Mine's a murderer!'”

“It was a don’t-get-caught culture,’ said the reporter of seven years’ standing. New staff would be given the cold shoulder until they’d proved themselves to be ‘thoroughly disreputable’ so their colleagues could trust them.

It was no place for anyone to pipe up and say: 'This doesn't seem ethical to me.' That would have made you a laughing stock." The News of the World, which was Britain’s most popular Sunday tabloid has been shut down, and at the time of the writing of this blog, the entire Murdoch media empire seems threatened by the phone hacking scandal.

http://www.reuters.com/article/2011/07/16/us-newscorp-notw-brooks-idUSTRE76F0O420110716

At first the Murdoch executives contended that the phone hacking and questionable reporting practices were limited to a single bad apple. Now it is clear that is not the case. We are now being told that the problems are the ethics of the British tabloid press, and that the Murdoch American companies are ethically run. However, David Carr of the New York Times has discovered what appears to be a similar culture at an American Murdoch company. Paul V. Carlucci the executive in charge of News America used to show the sales staff the scene in “The Untouchables” in which Al Capone beats a man to death with a baseball bat. Robert Emmel, a former News America executive who became a whistle-blower, testified in a civil suit with a competitor that Mr. Carlucci was clear about the guiding corporate philosophy.

http://www.nytimes.com/2011/07/18/business/media/for-news-corporation-troubles-that-money-cant-dispel.html

A disturbing and thought-provoking Christian Science Monitor article asks the question is the US a nation of liars? It summarizes the recent court cases of Barry Bonds who was found guilty of giving evasive answers to a grand jury, Casey Anthony who lied to police officers investigating the death of her child, Roger Clemens who was tried for allegedly lying to Congress about his steroid use, Anthony Weiner who resigned from Congress after admitting that he lied about his Twitter photos, and the Atlanta public school teachers who lied about tampering with student tests to make their schools look good.

David Callahan, author of The Cheating Culture, states, “Every day there’s new evidence of successful people who have cheated to get ahead, and it creates cynicism.” Douglas Porpora of Drexel University in Philadelphia, comments, “At a certain point, you’re watching all these jerks and you say, ‘What am I, a schmuck?’ A lot of people want to do the right thing, and after a while they say, ‘You know what? I’m going to follow the jerks.’”

http://www.csmonitor.com/USA/Society/2011/0719/Is-US-a-nation-of-liars-Casey-Anthony-isn-t-the-only-one

The problem of unethical behavior in medicine appears to be part of a much larger societal cultural problem. We need to hold each other accountable; we need to speak out when we see wrongdoing; we need to accept constructive criticism from our peers; we need to provide better role models for our medical students and colleagues. We need to be professionals who really do care more about our patients' well-being than our income or status in society.