Correspondence

The Next Transformation in the Delivery of Health Care

N Engl J Med 1995; 332:1099-1100April 20, 1995

Article

To the Editor:

You suggest (Jan. 5 issue)1 a larger role for the computer in the future of medicine. If we observe the uses of computers in other areas of our society, we must wonder this: Are you a prophetic herald telling of the end of medicine as we have known it? And are we on the threshold of a convergence of revolutions — that of managed care and that of cybermedicine? Let us make two assumptions: first, that medicine is becoming a commodity, and second, that algorithms are an empirically valid method for arriving at reasonable diagnoses and treatments.

Insidiously, a new vocabulary, and hence a new way of thinking, have permeated our language. A “delivery system” connects “providers” to “consumers.” (Who uses this language? Not the clinicians or the sick.) The “product” that is delivered can be health care or bottles of sparkling water, commodities that can be dispensed by people or vending machines. The latter are much more dependable and work 24 hours a day in any weather.

The production of algorithms is a cottage industry already. A computer's intelligence is algorithmic in structure. There are obvious advantages in computer-based expertise. Imagine updating the central data bank of every “practicing” computer instantly, everywhere. There would be no inconsistencies of care. There would be no malpractice. There would be equality of care and uniform quality for all.

A human being with skill of some kind, not necessarily that of a physician, will still be needed to listen to the heart, draw blood, take x-ray films, and touch and describe the size of the liver or swollen ankle. But so many problems will be solved that I wonder whether anyone will notice what has been lost.

There is an obvious coldness and impersonality in this scenario. Nevertheless, this seems to be the trade-off that society is making everywhere in the name of economy. We ought to brace ourselves for the time when computers will sweep into medicine. And we also might prepare to let go of some treasured values, such as the doctor–patient relationship. The thorough transformation to which you are pointing implies the obsolescence of this quaint, labor-intensive, yet beloved profession.

Barry Orvell, M.D.
3000 Alamo Dr., Vacaville, CA 95687

1 References

1. 1

   Kassirer JP. The next transformation in the delivery of health care. N Engl J Med 1995;332:52-54
   Full Text | Web of Science | Medline

To the Editor:

It is becoming a truism that humans and computers complement one another. Few of us can compete with personal computers in storing large quantities of information, and none can match the reliability of computers in retrieving data or their speed at performing certain processing tasks. Computers are impartial, immune from bias by the various “frames” that so influence our cognition. People, by contrast, deal comfortably with the epistemology of human problems: naming them, defining their boundaries, and determining their importance in the complex web of patients' other issues, health-related or not. People excel at assimilating masses of information experientially — both consciously, through physical examination, and subliminally, through multiple analogue sensory channels. We use this information to understand context and create meaning, activities we ourselves can barely understand, let alone program computers to do for us.

Most clinical problem-solving requires all the above and more. Patients are best suited to certain of these functions, clinicians to others, and computers to still others. Yet the functions of each are best performed iteratively, in so intertwined and unpredictable a fashion that it would be inefficient at best, and conducive to poor health care at worst, to try to separate them in the majority of clinical situations.

Richard G. Rockefeller, M.D.
Health Commons Institute, Portland, ME 04101

To the Editor:

I have treasured that most important skill taught by my old professor in medical school, himself a student of Osler: the ability to take a good history and express it in a literate fashion. On the occasions when I myself have been a patient, I have noticed an increasing reliance on questionnaires and nonphysician interviewers. I have always noted factual errors in the history as a result. History-taking is hard, time-consuming work, involving clinical reasoning such as that illustrated in the Clinical Problem-Solving articles in the Journal during the interviews themselves. Yet it is indispensable and often very interesting.

After reading your editorial, I fear that the computer would intrude on doctor–patient communication rather than assist it, that the “virtual physician” would become the sorcerer's apprentice rather than a convenient means of access for the physician to the medical library, a role it fills admirably.

Robert B. Price, M.D.
720 Camp Branch Rd., Waynesville, NC 28786

To the Editor:

Having worked with many health care companies and hospitals before entering the medical profession (I am now a first-year medical student), I agree that information technology will transform the system of health care delivery in ways almost unimaginable at present. However, I believe you have overestimated the degree to which this technology can substitute for direct physician–patient contact. Our society is ever eager to jump on the next self-help bandwagon, and from the patient's standpoint an on-line “virtual physician” is an appealing notion, largely because it puts the consumer of medical care in the driver's seat. It seems there is great danger in promoting the notion that the average person can extract the correct diagnosis and therapeutic response from such a system. A good doctor can observe signs and symptoms, the presence or importance of which the patient “surfing the Internet” may be entirely unaware. Skin color and tone, neurologic signs, the sound of the voice, and the smell of the breath can provide essential information to the clinician that cannot be transmitted on line.

I believe that leaders in the medical community, such as you, have a duty to the next generation of physicians not to contribute to the trend to turn the practice of medicine into yet another commodity. I hope that, instead, information technology will help reduce the time we spend on administrative functions so that we can devote a greater percentage of our time to the care of patients.

Jeffrey T. Reynolds, M.B.A.
Yale University School of Medicine, New Haven, CT 06504

Author/Editor Response

Dr. Kassirer replies:

I believe we should vigorously and assiduously denounce attempts to convert medical care into a commodity and that we should eschew language that reflects this trend. I do not like terms such as “providers,” “consumers,” “products,” and “covered lives.” I cannot imagine a time when the uniquely human skills of physicians, such as taking a history, carrying out a physical examination, synthesizing clinical information, and dealing empathetically with the needs of a patient, will be replaced by silicon chips and software. Computers do none of these tasks well.1 I also believe that most algorithms are too simplistic for use in medical care.2

But computers are bound to do more in the future than just lead us to the library or relieve us of administrative tedium. They will enhance our ability to communicate, lead us to relevant information in a time of need, ensure that we have not omitted important tests or treatments, and prevent us from giving combinations of drugs that might cause harm — to name only a few of their potential functions. They might also empower a public with increasing medical savvy to make more of its own medical choices.3,4

Computers are not converting medical care into a commodity; uncontrolled market forces are. Our task is to make sure that the best of medicine is preserved during any technological transformation in the delivery of medical care. We can do so only by staying involved.

Jerome P. Kassirer, M.D.

4 References

1. 1

   Kassirer JP. A report card on computer-assisted diagnosis -- the grade: C. N Engl J Med 1994;330:1824-1825
   Full Text | Web of Science | Medline

2. 2

   Kassirer JP, Kopelman RI. Diagnosis and decisions by algorithms. Hosp Pract 1990(3);23-4, 27, 31.
   

3. 3

   Kassirer JP. Adding insult to injury: usurping patients' prerogatives. N Engl J Med 1983;308:898-901
   Full Text | Web of Science | Medline

4. 4

   Kassirer JP. Incorporating patients' preferences into medical decisions. N Engl J Med 1994;330:1895-1896
   Full Text | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Ruth M. Guzley, Norah E. Dunbar, Stephanie A. Hamel. (2002) Chapter 10: Telehealth, Managed Care, and Patient-Physician Communication: Twenty-first Century Interface. Communication Yearbook 26:1, 326-364
   CrossRef

2. 2

   Sally J. McMillan. (1999) Health Communication and the Internet: Relations Between Interactive Characteristics of the Medium and Site Creators, Content, and Purpose. Health Communication 11:4, 375-390
   CrossRef