Will the Future Need Doctors?

May 19, 2012

The following is an Ignite talk delivered at Tim O’Reilly’s 2012 Health Foo – Microsoft Research Center, Cambridge, Massachusetts.

As I see technology advancing around me, I think about what’s going to become of the physician.  Where are we going to fit in?  Will we become obsolete?  Are we headed for a medical singularity?

The good news for me is that despite the health 2.0 movement I’m still more trusted than a social media consultant.

But this question of the doctor’s future is a serious question.  Because what we once did with our eyes, hands and ears is being replaced by diagnostic widgets.  Social and technological forces are conspiring to make the traditional role of the doctor irrelevant.

Every medical generation has been shaped by its technology.  These are the tools that are disrupting everything we understand about a doctor’s role and defining the next generation of provider: genomics, personalized medicine/self quant, nanotechnology, robotics

Notice that we’re no longer defined by the stethoscope.  And probably for good reason: the stethoscope lost its status as a critical diagnostic instrument at some point in the 20th century.  This study demonstrated that some trainees aren’t exactly sure what they’re listening to.  Why should they be?  We’re less dependent on manual tools of physical diagnosis than in the past.

The importance of the physical exam is changing.  A child presenting to an ER with abdominal pain, for example, may be imaged by CT before ever being touched by a doctor.  The physical exam was critical when it was all we had.  We’re becoming dependent upon accessible technology and precise forms of diagnosis.

Clay Christensen and Jason Hwang in The Innovator’s Prescription  describe the landscape of medical care as evolving on a spectrum ranging from intuitive to precise.  Intuitive medicine is care for conditions loosely diagnosed by symptoms and pattern recognition and treated with therapies of unclear efficacy.  As the ‘art of medicine,’ intuitive medicine is dependent upon clinical judgment.  Precision medicine is the delivery of care for diseases that can be precisely diagnosed and treated with predictable, evidence-based treatments.

Looking at medicine’s progression another way….In the 19th century we treated symptoms; in the 20th century we treated diseases; In the 21st century technology we will predict and prevent disease.

There’s an endemic insecurity among the 21st century doctors: we want the precision that technology brings while at once proving that we can still do it all with our hands.  We want to see ourselves just as indispensable as we were 100 years ago.  Intuition is a human element that keeps us most relevant.

As we extend our human abilities with new tools and creeping artificial intelligence makes its way into our workflows we’re entering a new period of posthuman medicine.  This, of course, has huge implications for doctors.

It’s not just technology, but the patient that’s reshaping the physician.  For a couple of hundred years you came to the doctor and they’d tell you what to do.  But then came the internet, and ultimately social networks and the ability to connect.  Patients can now adjust what they’re doing based on the input of others.  Now information finds patients.

Information is the new 3rd party in the exam room.

The social web has created a type of disintermediation.   And the physician encounter is evolving as a more narrowly defined element in an individual’s quest to understand their condition and get better.

In the end I suspect that doctors won’t be replaced but will be radically redefined.  The physician of 2050 will have workflows and ways of thinking that are critical but unrecognizable to today’s physician.

But we’re not prepared.  The next generation is not ready for the changes that are coming.  We’re seeing digital natives appearing in medical school to be trained with analog tools and a curriculum structured for the early 20th century.  We need medical education reform consistent with what is perhaps the physician’s most dramatic transformation in recent history.

Despite my technodeterministic predictions, the physician will always have a role.  But I suspect that over the coming generations technology will take us further from patients.  But this will create a new opportunity and a new uniquely human role for the physician of 2070.  Machines may help us understand what constitutes a real human connection.

“Maybe it’s not until we experience machines that we appreciate the human…The inhuman has not only given us an appetite for the human; it’s teaching us what it is.”  - Brian Christian,  The Most Human Human.


{ 26 comments }

John hamlett May 20, 2012 at 8:05 am

What with genetics and technology dance flying fast and with the possibility of living longer after having bad disease and damage maybe this is as real as the typewriter being replaced by the pc .. I wonder if we all could become less rushed more caring if we manged to live to 200 plus ..two lifetimes, redefines much , marriage forever ? if married at fifty still with that person for 150 years ?gosh I cannot imagine with living with myself

DrV May 20, 2012 at 4:33 pm

I’ve been married 18 years. I’m not sure my wife would put up with me for another 132. I’ll ask her.

Thank you, John.

Angiologist May 20, 2012 at 8:55 am

Replacing human doctors by intelligent machines is an idea that has been surfacing for decades. There is even a “palatable” middle way in which the machine only gathers information as a junior physician would only to later present it to a more senior physician. I believe this approach is hazardous. I believe that by doing so we will eliminate what offers well over 50% of therapy today – human interaction. From a more objective approach – medicine is still one of few fields that actually requires experience, even for the most intelligent and talented. By replacing juniors in many places, opportunities for gaining this experience will be markedly reduced. Will we narrow ourselves to good medicine in central – geographical centers and poor, mechanized medicine in others? I hope not…

Monika May 20, 2012 at 9:20 am

This is the saddest article, that lays out the future for doctors, that I have ever read. Really, “machines may help us understand what constitutes a real human connection”. If Doctors would not have been trained in a technocratic model of medicine, where threy are discouraged to connect to the patient and trust the machine more then their intuition, they would not have ever lost the ability to form and understand a real human connection.

DrV May 20, 2012 at 4:29 pm

As the quote suggests, it’s by missing the human touch that we will most powerfully value its presence. Brian Christian’s book is important in understanding our emerging, but complex, relationship with technology.

The five minute format of Ignite does not allow every detail to be shared. But perhaps you’ll be reassured to know that I don’t think intuition is going anywhere.

Federico Uribe May 20, 2012 at 11:15 am

I’m not agree with many of your sentences. I’m Also medical doctor with 30 years of clinical practice. The patients with more educational records an acces to informarion are usualy the most “nervous” and hypocondriac and who more ask for medical advice. When a person have fragmentary information about something make many wrong interpretation about symtoms, illnes ,pains,etc. Beside of this you are ignoring the emotional needs of human bings. We are not “cars that only need to change for example one door,etc. We have deeps emotional concern that have psychosomatic impication tha one sofisticated machine w’t understand.
In summary with the same profession we are in two diferent sides of medical understanding.
Have a good day.
F. Uribe.

Jim Salwitz May 20, 2012 at 12:24 pm

Fantastic piece.

I believe the role of doctors will continue to be to act as the interface between software/hardware and wetware…i.e. they will be the bridge from human to machine.

jcs

DrV May 20, 2012 at 4:30 pm

Amen. Shoulda said that and saved myself 700 words.

Jet Brou May 20, 2012 at 2:43 pm

I graduated from med school in 1982. I’ve been a fellow/private pract pulm-CCM doc/academic teaching physician all that time (boarded in 4 specialties/int. med.-based) So the stethoscope is out of favor, eh? I believe the physical exam is too – for much (most?) of the current crop of doctors. That would be why so many obvious physical findings are discovered by me in my office and end up leading to helpful and life-extending treatments. Sure we have many ‘tests’ that can make the diagnosis (in a week), but why not use the built-in tools we have when we first see a patient?
I recently saw a 20+ year-old with a 3/6 diastolic murmur to go along with his 10 cm ascending aortic aneurysm – seen by 4 ER docs in the previous 4 weeks – no one listened! The best detective uses all the tools available to him. A physical exam takes 3-4 minutes (unless something crops up). Yes, physical exams are mostly normal; but when they are not, they can change the course of events. Will the future need doctors – yes…but will the doctors be worth seeing ? Testing without context is often unhelpful. PS: Evidence-based medicine recs are based on statistics and are therefore exactly 5% wrong. The ‘art’ of medicine is knowing when to disregard the cookbook.

Robin Hood June 16, 2012 at 9:26 am

So, do you have a guess what would have happened to that 20+ year old if had trusted those 4 ER docs and never came to you? Its time now to look for technological solutions because all doctors cannot give the same level of care, nor do they have the same level of expertise. Technology should be leveraged as much as possible for the democratization of health and make the knowledge of super docs like you available to the masses and not to a privileged few. For God’s sake, lets now transform medicine from an ‘art’ to a ‘science’.

Robin Hood June 16, 2012 at 9:27 am

Btw. do you have a statistics of the error rate with human-based medicine?

Bruce Ramshaw May 20, 2012 at 3:04 pm

As a physician, I am very hopeful about our future role in healthcare. I think the most important innovation in healthcare will be in the creative destruction and re-design of the system structure for how we deliver patient care. Team-based care designed around definable patient groups and patient problems (complex systems science based) should replace the individual physician practice model based on physician specialty (reductionist science based). These teams will provide compassionate care coordination (develop loving care relationships with patient and family and be accountable for the entire cycle of care) and use the principles of continuous clinical quality improvement (to define, measure and improve the most important process- the patient’s entire cycle of care). I believe the physician of the 21st century will be a servant leader on these teams.

DrV May 20, 2012 at 4:31 pm

Wow. My pulse quickened when I read this. Servent leader. Thank you, Bruce. You should elaborate on this concept somewhere.

Robin Hood June 16, 2012 at 9:29 am

A very pragmatic viewpoint.

Dr George Margelis May 20, 2012 at 8:05 pm

I think Bruce Ramshaw has really captured the new role of the physician in a technology enabled future. Coordinated team care led by a physician in conjunction with the patient and their caregivers is the future, but we need to work out how to train our future physicians to take on this role. We also need to educate the technology industry of this new paradigm of care. Unfortunately much of the rhetoric we hear from the technology industry is about severing the physician patient bond. I believe technology will actually allow us to strengthen that bond, equalize the power between the two parties, and enhance the two way communication between the various parties.

DrV May 21, 2012 at 7:54 am

Bingo. It’s assumed that technology and patient connection are mutually exclusive. And yes, there are those who believe that these tools will draw us closer. There’s a bigger discussion for that. Thanks for your insight, George.

Bridget Stephanou May 21, 2012 at 5:15 am

What the future needs, is to recognise that our Doctors must be enabled to be able to continue to practice safely with passion, dedication and commitment, to offer the patient safe quality care outcomes and for this to have a positive holistic impact to their health and wellbeing. We need to collectively ensure this happens in a variety of ways. We must ensure that there are not only supportive structures/systems in place to care and support the patient but these must be offered and provided to all Doctors in practice. The holistic needs of Doctors which must include emotional needs, must be met so that they are not only supported via training and development but also by caring for our Doctors within their practice. If our Doctors are listened to, valued for their dedication, offered the most simple interventions such as the opportunity to have healthy rest intervals, to be able to eat and hydrate themselves regularly and to ensure that their practices are well supported also both with specialist human resources teams and realistic financial resources to reflect the true needs of that specific care service department. The future of Technology is not to replace Doctors, surely it should be there to support them in their day to day practice, so that they may be able to continue to practice their vocation in manner which promotes their self confidence, their knowledge and thus valuing them and raising their morale and self worth both as a professional and as a human being. This will I know result in safe, quality care outcomes.
I would also like to simply say that to all the Doctors out there…you are part of a specialist multi disciplinary team..please listen, involve and value all your frontline staff …and continue to care for and champion the voice of your patients as we are all here to serve them and provide health and social care services in their best interests. In your busy days, please endeavour to stop and reflect a moment to see in front of you, the person not the patient.

Natalie Hodge MD May 21, 2012 at 1:04 pm

Thoughtful post Brian.

Robots are doing the surgeon’s job. Apps, vaccinations, and new pharma have displaced most of the general pediatrician’s job ( mine) . Emerging genomics makes obsolete the history and physical exam ( just take a look at the latest Baylor screen to see what we DON”T have to figure out) I hope those responsible for creating our medical students education are paying attention… We must rapidly adapt as physicians to the new health economy that is emerging as Clay so eloquently predicted. Great meeting you BTW at Doximity Summit, hope to see you at more events like that as we move forward through our careers and life…

Best, Natalie
http://www.healthergy.net
http://www.personalmedicineofkentucky.com

Natalie Hodge MD May 21, 2012 at 1:10 pm

Oh, one more thing, Frederico’s comment notes that he fears and dislikes the PHR, take heed of Clay’s Prediction, the PHR is the major disruptive force that helps determine who of us in healthcare will come out on top. ( AND IT MAY NOT BE US PHYSICIANS, is the implication) Transparency will rule the day. Ignoring this important principle of the future I think will prove dangerous. I know it takes more work, writing everything down, but as you get used to DOING IT, it is freeing, patients love it, and it REALLY helps them modify their behavior and adapt healthy lifestyle… my 2 cents…
Natalie

Federico uribe May 21, 2012 at 6:59 pm

Hello Nataly. The free acces to internet cientific information for the patient breakdown the “monopolistic”power of MD to knowlege. This will bring change to medical practice but also “empower” the “patient” for be one more active part in her or his health decision. The Medical Doctor will be allways present because is the person with more width point of view and his or her daily work give one privileged voice in whichever medical action that will be necesary to take. Besides of this It will be allways important for a person with one ailment to have one informed professional at your side. The things change, but the esence remain. Finally we are the shamans of the society. Have a good day.
Federico Uribe.

Dr George Margelis May 21, 2012 at 7:44 pm

I suggest you keep an eye on what is happening in Australa. The government is about to launch a national PHR project, giving every Australian access to their own Personally Controlled Electronic Health Record (that’s their nomenclature).
Plan is to have primary care providers produce summary records and link that up to pharmaceutical data and national insurance billing data, and hopefully more.
Have a look at http://www.ehealth.gov.au for more details.

Ab-man May 21, 2012 at 10:37 pm

Just imagine what might happen to us if some natural cataclysm or a war erupted destroying most of the hi tech medical equipment. Most of today’s young docs would find themselves useless diagnosing our diseases.

Suji May 22, 2012 at 1:56 am

I still believe that human touch is much better than having robots to treat human beings. Doctors will forever be the front liners in dealing with patient treatment and management. Doctors are considered as our heroes.

Federico uribe May 22, 2012 at 12:59 pm

The knowlege that have de medical doctor allways have been close to anybody. Before in the books or in the oral tradition of one comunity. Now is closer tan before. At only one PC touch in Internet. But the Doctors are one the forces that shape the social reality. The human fragility will need allways from people that have as “one profession” to give help to one illnes person.

mike spiegelman, md May 23, 2012 at 11:14 am

The sick, scared, and dying patient will always need humanity. This becomes more important with increased digital medicine.

David Lester May 28, 2012 at 7:28 pm

This is a very thoughtful article. Thank you Bryan. While the 19th century focused on the symptoms and the 20th on the disease. Perhaps the 21st century with all its technologies will focus on the patient. Don’t forget that these are all enabling technologies. They are to help the doctor, the insurer, the health economist, and so on and so on. But don’t forget it ultimate is about PATIENT care! Here’s to the continuation of physical exams.

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