In a recent interview in H&HN Daily about the importance of delivering "pre-primary care" using new communication tools, UCLA Health System's chief innovation officer Molly Joel Coye said that "for providers trained 20 to 30 years ago, it's very often hard to believe that patients want this and will feel comfortable with these new media, these new ways of communicating. But for the younger docs in the practices, they're right there."
My November 2011 column in H&HN Daily, with Don Weaver, M.D., and Edson Pontes, M.D., summarized a discussion among these two distinguished surgeons and me about how medicine is changing from an art to a science, and from reliance on population statistics to reliance on individual and population parameters such as complete numerical descriptions, or complete computational models. These progressive surgeons are perhaps somewhat of a rarity in a cohort that seems, at least in my experience (and, apparently, in Coye's), to be rather more cautious when it comes to accepting major change — let alone welcoming, embracing and even calling for it, as my coauthors did.
Modern Medicine's Demise
The conservative physician mindset seems to me to be epitomized in a popular 2007 book, How Doctors Think, by Jerome Groopman, M.D., who is distinguished both as a physician and as a writer for The New Yorker. He essentially asks patients to help their doctors think better by communicating with them better. There is no harm, and probably some good, in that, but it misses two important points. First is the one Coye makes: There are technologies (which existed when the book was published) that can help in patient-caregiver communications.
The second point, it seems to me, pulls the rug from under Dr. Groopman's feet: The kind of medicine in which the patient-doctor relationship is central is on its way out. Unfortunately, that is the only kind of medicine to many, if not most, physicians who began their careers in the 20th century and were, therefore, brought up in the theory and practice of "modern medicine" that can be said to have begun in earnest in the 18th century. (See Chapter 5 of Sir William Osler's 1921 book, The Evolution of Modern Medicine. An e-text version is available here.)
No doubt Dr. Groopman believes passionately in what he writes. But for the sake of progress, I believe the views expressed in his book must not go unchallenged. Judging by the favorable reviews on Amazon.com, the book was popular especially among lay readers. But he does have critics.
One of them, a semi-anonymous "family physician" who reviewed Dr. Groopman's book on Amazon.com, wrote: "One of the great shames of the book is that, despite his clearly delineating the problems physicians face, Dr. Groopman rejects the modern tools that have been developed to aid physicians in diagnosis: evidence-based medicine, clinical algorithms and practice guidelines. He glibly dismisses these tools again and again, arguing they ‘constrain' a doctor's thinking and fail ‘when symptoms are vague … or when test results are inexact.'"
The reviewer continued his assessment by saying, "Diagnostic tools and practice guidelines, when used in a measured way, can help physicians accurately diagnose many patients without subjecting them to a punishing series of unnecessary diagnostic procedures. Evidence-based medicine helps us to determine what works and, perhaps even more importantly, what doesn't. Instead of a balanced discussion of the benefits and limitations of such diagnostic aids, he simply throws the baby out with the bath water."
The critique seems to me to be accurate and justified. I would further challenge Dr. Groopman's contention that misdiagnoses (which he accepts are far too frequent) occur primarily from "skewed thinking" by doctors, and I would challenge his simplistic solution that patients should learn to help their doctors think. He correctly notes that, through training and experience, doctors develop and apply to an exceptionally high degree the attributes of intellect, clinical intuition, attention to detail, active listening and psychological insight. But he recommends that they apply these impressive and laudable attributes in the service of a medicine that is out-of-date.
The Promise of ‘Postmodern' Medicine
The very title of the 2012 book, The Creative Destruction of Medicine, by Eric Topol, M.D., suggests that modern medicine is so out-of-date it needs to be destroyed. But it has to be replaced by something. That something is what I call "postmodern medicine" to distinguish it from physician-centric and physician-dominated "modern medicine" whose practitioners generally regard their profession as more art than science.
Postmodern medicine is patient-centric and technology-dominated. It relies, Topol points out, on evidence, on genomics, on simulation, on science. The problem, he says, is that most doctors are too "old school" and too set in their ways to embrace these interlopers. For that reason, they cannot be expected to lead the charge into personalized, regenerative, bionic and digital medicine (these are my categorizations of postmodern medicine).
There is no doubt that some doctors, old as well as young, see not just the inevitability and not just the need, but also the opportunity for radical transformation in medicine, for the good of the patient and the good of society, and to reduce those far-too-frequent misdiagnoses ultimately to zero. These doctors can be expected to — indeed, they must — help lead the charge; indeed, some already are.
They will be joined, and eventually may be outnumbered, by nonclinicians inside and outside the health care industry, in particular by the hardware and software engineers and smartphone manufacturers who already are deeply involved in facilitating the "pre-primary care" Coye talks about. We can expect their involvement and their influence to extend into every aspect and every phase of care as the future accelerates.
But it's not all down to the doctor: We also need the Food and Drug Administration, the National Institutes of Health, the insurance industry and all involved in maintaining the status quo of modern medicine to redirect significant resources toward the development of its inevitable and imminent successor.
David Ellis is a futurist, author, consultant and publisher of Health Futures Digest, a monthly online discursive digest of news and commentary on long-range, leading-edge technological innovations and their consequences and implications for health care policy and practice. He is also a regular contributor to H&HN Daily and a member of Speakers Express.
