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.

Another Information Flaneur Blog You Won't Like

I find it hard to predict what tweets will get retweeted and what blogs will elicit comments and dialogue. I really liked my blog post about becoming an information flaneur http://kentbottles.blogspot.com/2011/06/why-i-am-information-flaneur.html, and yet nobody has seen fit to comment on it at all. Two of the blogs that routinely repost my writing decided to turn this one down.

I am still stunned that nobody retweeted my post about the interview with Red Shea about Whitey Bulger:

KentBottles KentBottles

http://ow.ly/5qfII Fascinating interview with Red Shea, former enforcer for Whitey Bulger {he wants to snap Whitey's neck}

Am the only one who is intrigued by this man struggling to speak coherently while being interviewed on CNN about his criminal past and his relationship with the rat who was once his surrogate father? Guess so.

I am not really looking for validation, but I do find it interesting that my approach to life, information seeking, blogging, and tweeting does not resonate with many of my tribe.

And then I heard a NPR story about people walking out of the movie The Tree of Life when the storyline about a family in Texas veers off into the most amazing pictures of life, stars, and nature. When I saw Tree of Life at the Ritz in Philadelphia about 7 people walked out. The NPR story contrasted those who believed this movie to be one of the best of the last decade and those who walked out. http://www.npr.org/blogs/thetwo-way/2011/06/30/137533978/love-it-or-hate-it-few-are-in-between-about-tree-of-life

Those who liked the movie The Tree of Life are more likely to resonate with the concept of an information flaneur than those who require a linear plot to sit through an entire show.

This morning on twitter I stumbled upon a great story about being an information flaneur.

“Glass and his This American Life production team had given themselves a special assignment: to collect the best stories they could stumble upon far off the beaten path of their day-to-day reporting routines. They followed the standard operating procedure of the Atlanta Journal’s ‘Georgia Ramble’ columnist Charles Salter, who researched more than 500 columns in the late 1970s by roving around small towns of the Peach State in a company car.”

The article and the radio shows both document how powerful and surprising this wandering around approach can be. (http://current.org/news/news1112georgiarambler.html)

Maybe there are at least two kinds of people in this world. Those that like to wander around and those that need a coherent, linear story. I guess I fall squarely into the former category. I sort of like being confused most of the time. After all my favorite Jack Welch quote is “If you are not confused, you do not know what is going on.“

Are Mystery Shoppers Such a Bad Idea for Health Care Quality Improvement?

The decision by the Obama administration to employ “mystery shoppers” to pose as patients to see how difficult it is to get an appointment with a physician has sparked criticism from physicians. However, access to primary care physicians is a very real public policy issue that needs to be understood if we are to successfully care for the more than 30 million Americans who receive coverage under the Affordable Care Act. Is the use of “mystery shoppers” a bad idea?

Dr. Raymond Scalettar certainly thinks it is a bad idea. “I don’t like the idea of the government snooping. It’s a pernicious practice – Big Brother tactics, which should be opposed.” (http://www.nytimes.com/2011/06/27/health/policy/27docs.html?ref=health)

Dr. George Petruncio says, “This is not the way to build trust in government. Why should I trust someone who does not correctly identify himself.” (http://www.nytimes.com/2011/06/27/health/policy/27docs.html?ref=health)

Westby Fisher, MD writes in his blog: “When information gathering trumps patient care - particularly fictitious care - we've got a problem. Is this a new quality standard we can expect from our new government health care initiative?

Just like scam-artists that phish for unsuspecting people's financial information online, governmental appointment phishing should not be tolerated in any way, shape, or form. It is fraud - plain and simple.” (http://drwes.blogspot.com/2011/06/appointment-phishing.html?utm_source=feedburner&utm_medium=twitter&utm_campaign=Feed%3A+DrWes+%28Dr.+Wes%29&utm_content=Twitter)

Several physicians on twitter retweeted Dr. Fisher’s blog post and indicated they agreed with his analysis.

A mystery shopper is a quality improvement tool that has been used in the retail and hotel industry for decades. In 2004 the health care industry accounted for 2% of mystery shopper revenue, but the use in health care is increasing.

(http://www.ncpa.org/sub/dpd/index.php?Article_ID=10273)

In health care, mystery shoppers have been used to provide feedback on every step in the patient experience: making an appointment, environment of the waiting room, encounter with nurses and office staff, and visit with the physician. There has been an increased interest in mystery shoppers by health care providers since CMS started posting patient satisfaction information on hospitals as part of the Website Hospital Compare. (http://www.boston.com/business/healthcare/articles/2007/06/13/on_sly_workers_rate_hospital_service/)

The use of mystery shoppers has been reported to lead to better patient flow and improved wait times, extension of office hours, improved telephone etiquette, better physician communication with patients, and more time with patients answering questions about surgery.

(http://www.boston.com/business/healthcare/articles/2007/06/13/on_sly_workers_rate_hospital_service/)

(http://www.pjonline.com/pdf/articles/pj_20040515_mysteryshopping.pdf.2004;272:615-617)

(http://www.ama-assn.org/amednews/2006/09/18/bise0918.htm)

The AMA Council on Ethical and Judicial Affairs studied the mystery shopper question and concluded that a sound program would include:

1) The places that unannounced visits will affect should know about the program.

2) The information should be used for improvement and not punitive actions.

3) Mystery shoppers should not be the sole source of data for evaluating clinical performance

4) The program should not adversely affect access to medical care by legitimate patients.

(http://www.ama-assn.org/ama1/pub/upload/mm/38/a08cejoreports.pdf)

I disagree with my colleagues that a properly planned and implemented mystery shopper program is a bad idea for trying to improve health care. For far too long, we in medicine have been too arrogant to learn lessons from other industries that improve quality. I think we need all the help we can get to take better care of patients.

Not Everything in Health & Wellness Can Be Reduced to a Single Number

"To measure is to know." Lord Kelvin

"If you can not measure it, you can not improve it." Lord Kelvin

Vs.

“Asking science to explain life and vital matters is equivalent to asking a grammarian to explain poetry.” Nassim Nicholas Taleb

“Technology is at its best when it is invisible.” Nassim Nicholas Taleb

How can technology help us live healthier lives? Why did Google Health fail? Why are Klout and Twitter Grader publicly issuing a number to me by name about how influential I am? What do Lord Kelvin and Nassim Nicholas Taleb have to teach us?

I was taught in medical school and pathology residency that health was defined as absence of disease; this definition pleased me because not much important could happen to the patient until I peered into my microscope and rendered a diagnosis. I looked up to Virchow and Rokitansky who were the most important and influential physicians in the most advanced medical centers in the 19^th century.

In the mid-20^th century the World Health Organization (WHO) famously stated: “Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or injury.”

“The dialogue between Asclepios, the god of medicine, and Hygieia, the goddess of health – the external intervention and the well-lived life – goes back to the beginning. Only in the twentieth century did the triumph of ‘scientific’ modes of inquiry in medicine (as in most walks of life) result in the eclipse of Hygieia. Knowledge has increasingly become defined in terms of that (and only that) which emerges from the application of reductionist methods of investigation.” (http://www.amazon.com/Why-Some-People-Healthy-Others/dp/0202304906/ref=sr_1_1?s=books&ie=UTF8&qid=1309114252&sr=1-1)

The WHO rejection of the “absence of disease” definition of health has been warmly embraced by some and largely ignored by many more. After all if the WHO definition means that our wellness is affected by all human activities, what should the Department of Health and Human Services focus on and budget for? The WHO definition of health has “been honoured in repetition, but rarely in application.”

(http://www.amazon.com/Why-Some-People-Healthy-Others/dp/0202304906/ref=sr_1_1?s=books&ie=UTF8&qid=1309114252&sr=1-1)

At one time I thought Google Health would become the Personal Health Record (PHR) that would allow individual patients to keep track of their medical and daily activity data and apply the WHO definition of health to their own life; I blogged about PHRs because I hoped they would solve the enormous problem of hospital based IT systems not communicating with each other.

(http://icsihealthcareblog.wordpress.com/2009/07/17/kent-bottles-thoughts-on-phrs/)

I still remember the excitement when Google CEO Eric Schmidt described Google Health for the first time at HIMSS 2008, and I played around with it. I found it easy to use and understand, but I never really used it for my own health and wellness purposes. The Wall Street Journal had a similar experience: “We signed up for Google Health…and a bunch of other personal health records for a story, but never quite felt compelled to actually use them.” (http://blogs.wsj.com/health/2011/06/24/google-health-r-i-p/)

Google Health failed because

· Patients are not that interested in entering their data into a PHR

· Google underestimated the complexity of health care

· Most consumer health data is not in a structured, machine computable format

· As an untethered PHR, professionals distrusted the accuracy of the data

· Google did not work with or engage physicians in the effort.

· It did not coordinate with technology developers.

The best analyses of the sad ending of Google Health can be found here (http://www.readwriteweb.com/archives/google_health_why_its_ending_what_it_means.php), here (http://chilmarkresearch.com/2011/06/24/rip-google-health/), and here (http://www.nytimes.com/2011/06/25/technology/25health.html?ref=health)

Because I am no longer protecting the narrow interests of pathology, the WHO definition of health continues to ring true. Since all human activity affects health and wellness and since we have such poor memories, how does one better understand one’s own body and mood? The personal informatics (http://personalinformatics.org/) and quantified self movements (http://quantifiedself.com/) are true descendants of Lord Kelvin; they believe that scientific, objective, quantified measurements can lead to behavior change that can promote wellness and health. Dr. Joseph Kvedar changed his attitude about yard work when the data from his Bodymedia armband convinced him that he burned more calories doing gardening than bicycling (http://www.technologyreview.com/blog/themeasuredlife/26918/?ref=rss) Shaun Rance used the anonymous website drinkingdiary.com to reduce his drinking after his father received a diagnosis of end-stage liver disease. Jon Cousins built Moodscope, a self-tracking system to manage his bipolar affective disorder; he even shares his personal mood data with a few friends. His self-tracking metrics are supplemented by human sympathy made possible by his online connections and community. (http://www.nytimes.com/2010/05/02/magazine/02self-measurement-t.html?scp=1&sq=nytimes+sunday+magazine+quantified+self+wired&st=cse&pagewanted=print)

While much that is written about self-tracking celebrates the potential of measurement to help the individual with sleep, exercise, sex, food, weight loss, mood, alertness, productivity, and spiritual well being, there is a dark side to the movement. Alexandra Carmichael, one of the founders of CureTogether where patients conduct research on diseases, wrote about why she stopped monitoring 40 measurements about herself: “Each day my self-worth was tied to the data. One pound heavier this morning? You’re fat. Skipped a day of running? You’re lazy. It felt being back in school. Less than 100 percent on an exam? You’re dumb.” (http://quantifiedself.com/2010/04/why-i-stopped-tracking/)

Google Health failed largely because consumers did not see the value of a PHR and because it was time-consuming to input data. Gary Wolf thinks four things have changed that make self-tracking easier and more acceptable:

· Electronic sensors got smaller and better

· People carry smartphones that are powerful computers

· Social media made it normal to share everything

· The development of the cloud

Other researchers believe that technology may support health and wellness not by having individuals self-track, but by monitoring our social networks. This approach has been called the social contagion theory of disease, and much can be learned without the individual doing anything except carrying around his smartphone. (http://www.amazon.com/Connected-Surprising-Networks-Friends-Everything/dp/0316036137/ref=sr_1_1?s=books&ie=UTF8&qid=1309114482&sr=1-1)

By analyzing the famous Framingham Heart Study, Nicholas A. Christakis and James H. Fowler were able to map 5,124 subjects for a connection web of 53,228 ties between families, friends, and co-workers. Obesity appears to spread among friends like a virus. “When a Framingham resident became obese, his or her friends were 57% more likely to become obese too.” “A Framingham resident was roughly 20% more likely to become obese if the friend of a friend became obese.” “You may not know him personally, but your friend’s husband’s co-worker can make you fat. And your sister’s boyfriend can make you thin.”

This social contagion process seems to also work for drinking, smoking, loneliness, and happiness. Christakis and Fowler believe that “these behaviors spread partly through the subconscious signals that we pick up from those around us, which serve as cues to what is considered normal behavior.” (http://www.nytimes.com/2009/09/13/magazine/13contagion-t.html?_r=1).

Alex Pentland, director of MIT’s Human Dynamics Laboratory, uses cell phone data to identify the influencers in any social network that are most likely to change other people’s behaviors. Dr. Pentland says, “Just by watching where you spend time, I can say a lot about the music you like, the car you drive, your financial risk, your risk for diabetes…We are trying to understand the molecules of behavior in this really complete way.” (http://online.wsj.com/article/SB10001424052748704547604576263261679848814.html)

Although I have never been studied by MIT, I have been assigned a number that supposedly indicates how influential I am. According to Twitter Grader I am ranked 88,837^th out of 9,826,593 with a grade of 100 out of 100. Klout states that I am a “pundit” with a score of 69 out of 100. PeerIndex gives me a score of 18. What do these numbers really mean? I have no idea.

“Now you are being assigned a number in a very public way, whether you want it or not,” said Mark W. Schaefer of Rutgers University. More than 2,500 companies are now using klout data, and special offers are just starting to come into my email box. The CEO of Klout of course thinks this is a great idea: “For the first time, we’re all on an even playing field. For the first time, it’s not just how much money you have or what you look like. It’s what you say and how you say it.” Others are not so sure and worry about creating social media caste systems and that such rating systems lack sentiment analysis (negative comments can be as affective as positive comments in raising one’s score). (http://www.nytimes.com/2011/06/26/sunday-review/26rosenbloom.html?ref=opinion)

So what can we conclude from this dizzying tour of health, wellness, measurement, technology, and life. I think we need both Lord Kelvin and Nassim Nicholas Taleb to guide us. I think it is a mistake to choose the WHO definition over the absence of disease definition of health, as though they are polar opposites. There is a continuum of meanings for the word health. “At one end of that continuum is well-being in the broadest sense, the all-encompassing definition of the WHO, almost a Platonic ideal of the Good. At the other end is the simple absence of negative biological circumstances – disease, pain, disability, or death.” (http://www.amazon.com/Why-Some-People-Healthy-Others/dp/0202304906/ref=sr_1_1?s=books&ie=UTF8&qid=1309114252&sr=1-1) I think Google will in the future realize they shut down Google Health too soon. As smartphones and sensors make it easier and easier to automatically input data, people will want a place to store all of their observations of daily living and medical data. Taleb is right; technology is at its best when it is invisible. However, some of the most important things in life are not reducible to a number or a PowerPoint slide with bullet points. Twitter Grader says I am 100 out of 100; Klout 69 out of 100; and PeerIndex 18 out of 100. Not all of these rankings can be accurately measuring my influence to my twitter community and readers of my blog. And let’s not forget what we are learning from social contagion theory; it is not just about the individual. I also think that there may be something to the Keas approach which, as I understand it tries to use game theory to make it more fun to use technology to help us change unhealthy behaviors. Tom Chatfield’s Fun Inc: Why Gaming Will Dominate the Twenty-First Century and Jane McGonigal’s Reality Is Broken: Why Games Make Us Better and How They Can Change the World certainly gave me many ideas about how to create flow for human beings in the service of individual and population health.

Why I Am an Information Flaneur

While reading the New York Times Sunday Book Review (in a hard copy format that got my fingers dirty with ink) I came across this quotation in a Evgeny Morozov book review of The Filter Bubble by Eli Pariser:

[Citizens] should not be content as mere passive recipients of tweets, pokes and bytes; they should aspire to become what some Internet scholars call “information flâneurs,” treading the unbeaten paths in cyberspace and defying the narrow categories stealthily assigned to them by Web services. http://www.nytimes.com/2011/06/12/books/review/book-review-the-filter-bubble-by-eli-pariser.html?ref=books

Here is a video of Eli Pariser discussing the filter bubble

http://www.ted.com/talks/eli_pariser_beware_online_filter_bubbles.html

I had never heard of a flâneur before and quickly went to Wikipedia where I learned that Charles Baudelaire expanded the definition of this word, which means stroller to define “a person who walks the city in order to experience it.” Now I admit that Baudelaire is one of those French authors I realize I am supposed to know, but I don’t remember ever reading. The concept of a flâneur has influenced social science theory of urban life, architecture, and photography. The Wikipedia article also mentioned that Nassim Nicholas Taleb endorses the concept in his essay on why he walks in The Black Swan, a book I have read twice. When I finally found my copy of The Black Swan, I discovered that I had indeed underlined the passage about walking and flâneurs. My memory is not what it used to be; it is increasingly harder and harder to remember what I read and where I left that book I remember as being important.

Later the same day I noticed a tweet about Ethan Zuckerman writing about serendipity. I had never heard of him, but his lengthy blog version of a keynote speech was all about cities and mentioned the flâneur concept. Talk about serendipity.

http://www.ictdev.org/pulse/20110512/ideas/chi-keynote-desperately-seeking-serendipity

I was even more surprised when I read the first comment on his blog from Marian Dork who gave a link to his article The Information Flaneur: A Fresh Look at Information Seeking http://mariandoerk.de/ This article has validated my approach to information gathering of wandering around and finding things I did not know I was looking for. This approach to Internet behavior came about because I am always looking for a specific book in my house that is hard or impossible to find. However, even when I fail to locate the original book I am looking for, I often find another more pertinent book I did not realize I owned.

I have now changed my twitter profile to proclaim that I am an Information Flâneur. Here are some things I have learned in the past few weeks by poking around twitter and the World Wide Web. With the lens of hindsight, I now realize I have been concerned with how disruptive technologies will affect the future of health care.

Here is my blog on a recent New York City session on living with man-made machines (I was excited that the WSJ.com picked up my post):

onespot.wsj.com/.../how-robots-will-teach-us-who-we-are-as

And here is an thought provoking video with a view of the future of medicine by Daniel Kraft of Stanford University:

on.ted.com/Kraft11

And here is a blogger who is thinking about the relationship between playing video games and becoming a surgeon:

http://ow.ly/5gK5f

A physician at PartnersHealth in Boston thinks we need to move from being couch potatoes to being advocates of the quantified self-movement:

http://chealthblog.connected-health.org/2011/06/13/from-couch-potato-to-quantified-self-this-journey-must-be-defined-and-encouraged/

And last but not least, a medical student at Upstate Medical Center in Syracuse, New York predicts what medicine will look like in 20 years when he will still be practicing and I will be 79 if I am so lucky:

http://adjacentpossiblemed.blogspot.com/2011/04/healthcare-in-20-years-in-500-words.html

I will continue wandering around the information in my world, and I will continue to try to make meaning of my place in the world by writing blogs. Dork writes, “The flâneur is an urban wanderer, who leisurely walks through streets and squares interpreting and re-imagining the city. Following the flâneur’s attitude toward the city, the information flâneur sees beauty and meaning in growing information spaces. By envisioning the information flâneur as a curious, creative, and critical persona, we promote a shift from negative concepts such as needs and problems towards positive information experiences.” I just thought I was trying to figure what is going to happen in healthcare in these confusing time

AI Experts On Robots and Living with Thinking Machines

On Saturday June 4, 2011 I took a Megabus from Philadelphia (one-way fare $8.00) to Hunter College in New York City to attend Man-Made Minds: Living With Thinking Machines, a World Science Festival program.

Rodney Brooks, who until recently was Panasonic Professor of Robotics at MIT and who now is Chief Technology Officer at Heartland Robotics, was the first expert to speak, and he emphasized a very practical approach that was not too concerned with any negative consequences of living with thinking machines. Brooks comes across as the typical, can do engineer who wants to revitalize American manufacturing by providing workers with robotic tools. For Brooks everything from ant behavior to robot behavior to human behavior comes down to simple rules and computation. I thought he did a nice job of explaining the concept of the “uncanny valley.” Although he did not mention Masahiro Mori who coined the term in 1970, Brooks discussed how the “uncanny valley” idea holds that when avatars look and act almost, but not perfectly, like actual humans, humans respond negatively to the robot. The " uncanny valley" is a dip in the graph of the positivity of human reaction as a function of a robot's lifelikeness. (http://en.wikipedia.org/wiki/Uncanny_valley) Brooks also showed videos of Kismet and Domo that highlighted how important eye contact is for sociable humanoid robots. Here is an article where Aaron Edsinger, Domo’s developer, talks about how eyes are critical for human to robot interaction (http://www.livescience.com/1419-robot-eyes-humans-human-eyes.html). Here is a simple overview video of Brooks on robots (http://www.youtube.com/watch?v=C9p8B7-5MTI), and Steve Talbott has a nice article on the Brooks approach to robotics here (http://www.southerncrossreview.org/43/talbott-hal.htm).

David Ferrucci described the four-year Watson/Jeopardy! Project that involved about 20 people. He explained in a clear and concise way how Watson takes a question, analyzes the question, generates hypotheses, collects and evaluates evidence, weighs and combines the final answer to reflect a level of confidence, and then provides the answer. Here is a 20 minute video that goes into more detail than Ferrucci did at Hunter College in New York yesterday (http://www.youtube.com/watch?v=3G2H3DZ8rNc) I also can recommend Stephen Baker’s book Final Jeopardy: Man vs. Machine and the Quest to Know Everything (http://www.amazon.com/Final-Jeopardy-Machine-Quest-Everything/dp/0547483163/ref=sr_1_5?s=books&ie=UTF8&qid=1307315691&sr=1-5).

Eric Horvitz of Microsoft was perhaps the most relevant to my interest in robots and the future of medicine. His demonstration of the avatar assistant on a computer screen outside his office really drove home how powerful robots can be. Because this computer program has been learning about Eric for over 10 years, she can predict that he will not be attending a meeting that is on his schedule for 4:00 PM, and she offers that time to a colleague (who she recognizes by name) who needs to talk to Eric. This New York Times article shows a picture of the computer assistant and describes how capable she is in helping Eric run his life (http://www.nytimes.com/2010/06/25/science/25voice.html?pagewanted=1) Horvitz’s homepage has a great list of papers for the general reader that I have started to sample (http://research.microsoft.com/en-us/um/people/horvitz/layreader.htm). Horvitz showed an impressive tape of a medical kiosk where an avatar speaks directly and convincingly to both the mother and the child who has diarrhea. After asking several questions, the avatar decides the child is not sick enough for immediate attention and makes an appointment for the child with his doctor later in the week. The moderator Faith Salie got a big laugh when she noted that the avatar was much more compassionate in relating to the child and his mother than the human triage nurses she has encountered in New York City Hospitals.

Hod Lipson who directs the Creative Machines Lab at Cornell University’s School of Mechanical and Aerospace Engineering and Computing and Information Science provided the most futuristic and revolutionary perspective on living with thinking machines. Lipson’s development of evolutionary robotics where machines self-replicate and self-assemble provides a new lens to look at what is consciousness, what is self-awareness and what it is to be human. What fascinated me was his simulation of evolution to allow machines to learn without any human developers or programming. The machines were able to learn because they probed their external world and only those that were successful get to breed new generations of machines. I must admit that I was blown away by this approach having the robots “discover” or “learn” basic laws of physics like Force = Mass X Acceleration. It is also hard to wrap my mind around these robots discovering basic laws of the universe that we humans cannot yet understand ourselves. The NY Times has a nice article about this amazing idea (http://www.nytimes.com/2009/04/07/science/07robot.html?scp=1&sq=%22april%202,%202009%22%20hod%20lipson&st=cse). For a video where he demonstrates some of this approach please go to http://www.youtube.com/watch?v=lMkHYE9-R0A.

The moderator Salie seemed to be shocked that all the panelists appeared to endorse the prediction that eventually robots will be built that will be hard to tell apart from human beings. Only Horvitz seemed concerned about unintended consequences which concerns me. Horvitz at least brought up two obvious candidates for unintended consequences: Criminal Artificial Intelligence and liability issues around autonomous systems that cause unexpected damage to humans or property.

The evening ended with each expert providing a take home message. Rodney Brooks, ever the practical, optimistic engineer, emphasized robots increasing our manufacturing productivity. David Ferrucci observed that computers and AI will allow us to learn and make new discoveries from the large amounts of data now swamping us humans. Eric Horvitz, the most thoughtful and philosophical of the bunch, said robots will teach us who we are as humans. Hod Lipson described AI as a new lens to look at what consciousness is, what self-awareness is, and what it means to be human.

Physician Executives Should Not Ignore How Smartphones Will Transform Healthcare

Physician executives who ignore smartphones and their healthcare applications will miss the most important disruptive technology trend in the next five years. Physician executives who understand how smartphones will transform the industry for providers, payers, patients, and employers will thrive in their careers.

Rajeev Kapoor, a former executive at Verizon, describes the smartphone-enabled transformation: “The paradigm of healthcare has changed. You used to bring the patient to the doctor. Now you take the doctor, hospital, and entire healthcare ecosystem to the patient.” (http://ow.ly/3GIir) Susannah Fox of the Pew Research Center’s Internet and American Life Project offers a specific example when she talks about the celiac disease patient who uses her smartphone to evaluate food products in the grocery store. “You cannot call your gastroenterologist every time you buy a new product.” (http://e-patients.net/index.php?s=fox) David Jacobson of Wellpoint notes that “The technology of telehealth is well ahead of the socialization of the telehealth idea and we are at a tipping point for utilization to begin taking off.” (http://ow.ly/3GIir)

The Global mHealth Developer Survey found that today 78% of respondents said that smartphones offer “the best business opportunities for mobile healthcare” in 2011; by 2015, 82% said smartphones would dominate the industry. Cell phones, tablets, and PDAs trailed smartphones in popularity according to the survey. (http://ow.ly/1aVf9V)

Smartphones run on a specific operating system and can download applications (apps) that run on the operating system. The most popular operating systems in the United States are iPhone, BlackBerry, Windows Mobile, Palm, Web, Symbian, and Android. (http://ow.ly/3GIwf) We are just beginning to discover how to harness the smartphone’s computing power, cameras, audio, video, motion sensors, and GPS functions to better manage health and wellness. (http://ow.ly/3gVzg)

In contrast to the rather slow adoption rate for both health information technology and personal health records, smartphone use is skyrocketing. In October 2006 15% of Americans owned a smartphone; by December 2009 that number was 42%. Surprisingly, one report noted that the smartphone market was “unfazed by the recession.” (http://ow.ly/3GIwf) In late January 2011 Apple reported that someone downloaded the 10 billionth app for the iPhone. (http://ow.ly/3IlLY) That lucky smartphone user received a $10,000 gift card to the iTunes store.

Why are smartphones so popular? The ability to carry around a handheld computer that is user-friendly and that allows users to do things anywhere at any time is attractive. One research whitepaper coined the term “care anywhere” for smartphone-enabled health care. (http://ow.ly/3GIir) But it has to be more than just that when people routinely say they “love their iPhone.”

MIT’s Sherry Turkle in her book Evocative Objects: Things We Think With writes “We think with the objects we love, and we love the objects we think with.” She also emphasizes how important it is that we carry this “second self” with us at all times. Mark Rolston, chief creative officer of Frog Design, observes that people grieve when they lose a personal electronic device. “You are leaving your brain behind,” he says (http://ow.ly/3jjCG).

Joseph Kvedar, MD, director of the Center for Connected Health at Partners HealthCare in Boston, states that humans find it easy and natural to anthropomorphize pet rocks and tomagotchis, and that we are truly forming trusting relationships with our smartphones. (http://e-patients.net/index.php?s=fox) In her new book, Alone Together: Why We Expect More from Technology and Less from Each Other, Turkle explores the positive and negative consequences of this love affair with smartphones and other forms of technology.

Demographics will also drive increased use of smartphones in health care. The first of the 78 million baby boomers will turn 65 in 2011 and as the sandwich generation who are concerned about the welfare of their children and their parents, they know the importance of health and wellness. Boomers also lead all generations in technology spending, and they will use smartphone technology to foster ongoing independence for themselves and to care for their relatives who live across the country. John Sherry, Director of User Experience Design for Intel, observes, “A number of economic, generational, and societal factors combine to make boomers likely early users of remote health monitoring and management products.” (http://ow.ly/3GIPJ)

Smartphones will transform healthcare by offering solutions in four classes of activities: communication, transactions, knowledge, and integration of information. (http://ow.ly/3GIir)

Communication

Communication between all players in the healthcare space will be changed by the use of smartphones. The most obvious arena to examine is the patient/doctor relationship. People who access scientifically sound advice through their smartphones wherever they find themselves can become more independent, empowered, self-managing patients as the above celiac example shows. Smartphones also make patients more likely to participate in online conversations with other patients on social media websites like PatientsLikeMe and DiabetesMine. Patients want to communicate with their physicians via email, but physicians have been slow to accommodate this desire. Although many consumers have not been able to use smartphones for communication with their provider, 85% of those that have connected with their doctor by means other than face-to-face were satisfied with their discussion. (http://ow.ly/3GIir)

Physicians worry about patient compliance, and 88% would like their patients to be able to monitor their weight, blood sugars, and vital signs on their own. 66% of physicians said they would like to use email for administrative communications like appointment reminders, but only 23% of consumers preferred communication by email for such simple communications. (http://ow.ly/3GIir) Forty percent of physicians said 30 percent of office visits could be avoided with the use of remote monitoring, email or text messaging with patients. (http://ow.ly/3GIPJ) A Mayo Clinic two-year study found that e-visits could replace in-office visits in 40 percent of 2,531 cases. (http://ow.ly/3GIir)

The Good Shepherd Health System developed their own iPhone app to help physicians access medical records, track vital signs, order medication, and coordinate care with other team members. Physicians from Duke, Harvard, and the John Theurer Cancer Center have worked with Zibbel, a health solutions technology company, to create a smartphone enabled virtual network for mobile cardiology and oncology consults between experts. (http://ow.ly/3GIir)

Smartphone technology can also change and improve communication between consumers and their pharmaceutical companies, health plans, employer, and health system. Michael Mathias, Aetna’s chief technology officer comments, “The days of mass communication are over. We can now deliver customized communications through mobile apps, online, telephonically, or through mail based on our understanding of how each member wants to be communicated with.” (http://ow.ly/3GIir)

Kaiser and Mayo are both developing smartphone apps to help patients managing chronic conditions and healthy consumers who want to stay fit. Scott Eising of Mayo Clinic says, “We’re a very content-oriented organization. In our research into the mobile health consumer, we found that people are looking for very action-oriented information.” Mayo Clinic has launched Mayo Clinic Meditation and Symptom Checker iPhone apps so that we can “take care of patients here and ‘there,’ whether at home or at work.” (http://ow.ly/3GIwf)

Qualcomm is creating “the clinic without walls” to take care of its 12,000 employees in the San Diego area. Using the Myca Health platform, Qualcomm’s health staff can consult remotely with mobile employees via smartphones. “People are so connected to phones, they’re an extension of themselves. You can’t have your doctor with you all the time but the phone can keep you on the right path toward health and wellness,” states Dr. Marion Zabinski. (http://ow.ly/3GIwf)

Merck Serono has developed a smart electronic injection device with two-way Bluetooth communication functions that track all injections made by the patient. When an injection is missed, nurses contact the patient to remind them to adhere to the treatment plan. (http://ow.ly/3GIir)

Transactions

The ability of consumers to use smartphones to book a flight or make a hotel reservation has revolutionized the travel industry, and many predict health care will soon follow suit.

The first area in healthcare that has utilized smartphones for transactions is e-prescribing. The most common prescription orders that a doctor uses can be automatically populated on their smartphone. Donald Burt, MD, chief medical officer of PatientKeeper, says their 25,000 physician users spend 20 percent of their time on their smartphone. Trusted nurses can post prescription order request on smartphones, and the physician can modify or approve the order no matter where they are located physically. A PricewaterhouseCoopers 2010 survey found that over 80 percent of both specialists and primary care doctors were interested in e-prescribing using their smartphones. (http://ow.ly/3GIir)

Aetna has made transaction functions such as physician finder and claims check available on smartphones. CVS Caremark has iPhone apps for prescription drug information and patient management of drug refills as well as for retail location finder functions. (http://ow.ly/3GIir)

Knowledge

Allowing physicians to have access to the latest evidence-based medicine knowledge at the point of care may be the most exciting and important application of smartphone technology. In a national survey, one third of physicians responded they make decisions based on incomplete information in nearly 70 percent of the patients they see. (http://ow.ly/3GIir) Lay people are also utilizing this technology to become wiser consumers of health care.

Epocrates is perhaps the best example of a mobile reference resource that physicians turn to in real time for information about the patients they are seeing right now. Epocrates’ drug reference app is the most popular free medical download for iPhones, and one study documented that 60 percent of Epocrates users avoided three or more medical errors a month. More than 125,000 doctors use Epocrates on iPhone and iPod touch devices. (http://ow.ly/3GIwf)

UpToDate is another evidence-based, peer-reviewed information resource available via smartphones. Over 400,000 providers use UpToDate for their synthesis of the medical literature, the latest studies, and treatment recommendations. (http://www.uptodate.com/home/index.html)

Skyscape has put together the largest library of medical resources that is available for smartphones, and the Medical Encyclopedia from the University of Maryland was one of the top ten free apps in the iTunes Store in December 2009. FDA Recalls is a free app for iPhones that keeps clinicians on top of which products have recalled by the manufacturer. (http://ow.ly/3GIwf)

Diagnostic tools for clinicians are too numerous to catalog. Examples include Diagnosaurs for general diagnosis, ARUP Consult for laboratory, OsiriX for digital imaging, Instant ECG for ECG interpretation, Vigilance for Emergency room situations, AirStrip OB for obstetrics, and American Well for remote physician consultations. (http://ow.ly/3GIwf)

Consumers are also using smartphones apps to keep abreast of medical knowledge. The Evincii app matches symptoms to over the counter medications, and the Mayo Clinic Symptom Checker iPhone app became available in early 2010. (http://ow.ly/3GIwf) Consumer interest has been highest in fitness and weight control apps (Tap & Track, iTreadmill, Walk It! And Pedometer-Widget), Diabetes Management (Glucose Buddy, Handylogs Sugar), High Blood Pressure Management (HeartWise, My Blood Pressure and Heart Rate), sleep hygiene (Sleep Cycle Alarm Clock, Smart Alarm Clock), Stress Reduction (Stress Free with Deepak Chopra, Rage Eraser), and First Aid (Pocket First Aid & CPR). (http://ow.ly/3gVzg)

Integration of Information from Diverse Sources

Perhaps the biggest challenge for both consumer and physician is how to integrate all of this information that is available via smartphones. It truly is like drinking from a fire hose, and the amount of information can be overwhelming.

Health systems have been focused on implementation of the electronic medical records, and the Patient Protection and Affordable Care Act has provided billions of dollars to support rapid adoption. Unfortunately both the hospital systems and the Office of National Coordinator have largely ignored the importance of integrating mobile health into other health information technology efforts. For example, two thirds of physicians in a national survey said they were using smartphones in their practice that are not connected to either their office or hospital HIT systems. Thirty percent of physicians said their health systems or medical group would not provide support for smartphones. (http://ow.ly/3GIir)

Many physicians and hospital administrators, tired of wearing multiple devices on their belts, have wanted their IT Departments to consolidate all messaging functions to smartphones. Most hospitals already have invested in pagers, cell phones, Vocera badges, SpectraLink Wi-Fi phones, and two-way radios, and what works for maintenance staff may not work for ICU nurses. A research white paper reporting on the experience of smartphone early adopter hospitals recommends supporting a variety of devices at the present time, but it also warns against being too slow to adopt smartphones. It also points out that work processes have been designed around the currently employed technologies and replacement by smartphones will necessitate work process redesign which may result in cost-savings. (http://ow.ly/3HalT)

Smartphones in health care will not live up to their full potential if integration is not successful. No matter how many readmissions for congestive heart failure remote weight monitoring at home could avoid, such programs will fail if the information does not appear in the office or hospital medical record.

Joseph Kevdar, MD, director of the Center for Connected Health at Partners HealthCare, stated that while “sensor technology may be rapidly becoming commoditized, integration with EMR and data aggregation systems is not something we have done well. We need to get better at gathering information, adding logistical software to get to the intersection of all the data and population health management.” (http://ow.ly/3GIir)

There are technological advances that are promising, according to Kvedar. Emotional sensors predict the patient’s mood by analyzing their voice (Cogito) or by facial recognition (Affectiva). Bodytrace’s wireless weight scale, Telecare’s wireless glucometer, and Vitality’s GlowCaps device all can find mobile networks when the sensor is triggered and so transmission of clinical data does not require the patient to do anything. (http://ow.ly/3K2FR)

Conclusion

Smartphone technology is already transforming the healthcare industry, but many physician and hospital leaders have not thought through the implications of their widespread adoption by both consumers and physicians. By understanding the implications of smartphones for communication, transactions, knowledge, and integration, leaders can begin to map successful strategies and tactics during a time of delivery system and payment reform. As John Mattison, MD, of Kaiser Permanente states, “The new wellness delivery channel for ubiquitous care will be the smartphone, and it will happen sooner than you think.” (http://ow.ly/3GIwf)