Cyberutopian Exhibitionism

Cardiac defibrillators the size of a grain of salt.  Robotic, flying bedpans.  The extinction of the doctor.  Spend some time on Twitter and you may see the future.  Because there’s an arms race to ‘break’ the next seemingly implausible health innovation.  And it all seems bigger since the social web draws the technologically savvy who are prone toward technological determinism (that’s the mindset that says, ‘this is inevitable and to resist is futile‘).

This trend to casually predict an effortless medical future is evolving as a type of cyberutopian exhibitionism.  Typically the more outrageous and almost implausible the development, the more likely it is to be delivered in the most knowing, matter-of-fact way.

We may be creeping into Silicon Valley’s ‘culture of limitlessness.’  As Jaron Lanier suggests in Who Owns the Future, “The feeling of being a techie on the verge of escaping limits is ecstatic, manic, and irresistible.

I’m frequently on the verge of escaping limits.  I’m preoccupied with medicine’s weird leading edge.  I’m as deterministic as the next guy and I see medicine as being in the midst of its most extreme transition.  And I try to understand where things are headed.  But I feel uncomfortable with the some of the showcase link bait that does as much to draw attention to ourselves as the emerging developments that will realistically change lives in the near future.

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Book Notes: Who Owns the Future?

WhoOwnstheFutureI recently had a read Jaron Lanier’s Who Owns the Future?  This is a fascinating read that offers a critical look at today’s internet business models.

Lanier is preoccupied with the power of Big Tech and the marginalization of the middle class.  The Internet creates wealth in a very few, Lanier argues, and does so at the expense of the end user.

“The primary business of digital networking has come to be the creation of ultrasecret mega-dossiers about what others are doing, and using this information to concentrate money and power. It doesn’t matter whether the concentration is called a social network, an insurance company, a derivatives fund, a search engine, or an online store. It’s all fundamentally the same.  Whatever the intent might have been, the result is a wielding of digital technology against the future of the middle class.”

Lanier envisions a future where content and ideas are attributable to the individuals who created them.  At the root of his thesis is the belief that information is not some freestanding thing, but rather a human product deserving of attribution and cash.  At its core, this book is about futuristic economics.  Social networks see you as the product, Lanier envisions all of us ultimately as partners.

It’s around this that Lanier builds the argument and makes his case.

He envisions a sustainable system that will continue to honor and reward humans, no matter how advanced technology becomes.

“In the event that something a person says or does contributes even minutely to a database that allows, say, a machine language translation algorithm, or a market prediction algorithm, to perform a task, then a nanopayment, proportional both to the degree of contribution and the resultant value, will be due to the person.”

“The project at hand is to imagine leveraging network technology to create a smoother kind of path to achieving ordinary, middle-class financial security.”

The problem, it seems, are the siren servers.  This is Lanier’s term for those monopolistic entities that control our digital lives.

“Siren Servers gather data from the network, often without having to pay for it. The data is analyzed using the most powerful available computers, run by the very best available technical people. The results of the analysis are kept secret, but are used to manipulate the rest of the world to advantage.”


Lanier’s technosocialist view of the networked world is heady and ambitious.  Regarding the likelihood of its eventuality: I’ll eat my scrub cap on the main stage of Medicine X when Patients Like Me allocates its margins to the patients that selflessly fuel its success.

In the end, Lanier manages to balance a realistic view of technology’s future with the need for humanistic information economy.  His style is easy.  And as one of Silicon Valley’s founding fathers of virtual reality, he knows what he’s talking about.  The first hand historical elements of Silicon Valley’s early days alone are worth the read.  In following his first book, You Are Not a Gadget, Lanier is emerging as one of our generation’s most authoritative critics of technologic advancement.

While I thoroughly enjoyed Who Owns the Future, this book is heavy and recommended only for hard core futurists.

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Book Notes: The New Digital Age

newdigitalageIn The New Digital Age – Reshaping the Future of People, Nations and BusinessEric Schmidt and Jared Cohen take you though a futuristic view of a hyper-connected planet with all of its promises and challenges.  From the future of war and cyberterrorism to virtual hate crimes, online identity and cyber discrimination, the authors offer a unique and thorough take on what lies ahead for all of us.

For those willing to take the leap into The New Digital Age, take some comfort in knowing that it isn’t another technocornucopian book about widgets and gadgets.  It’s instead concerned with humans and our role in our digital future (‘The importance of a guiding human hand in the new digital age.’)  Schmidt and Cohen remind us that despite what communication technology may allow, what we do with it us up to us.  In an increasingly tech deterministic world, this core message bears repeating (so read this paragraph again).

And now for the big caveat:  A book that portends the coming digital age from two of the world’s most prescient thinkers has relegated dialog about health to just a couple of pages.  Really?  The collision course of health and technology is perhaps modern civilization’s most pressing angle.  This omission represents a lost opportunity for readers.

The authors make several references to the coevolution of two civilizations, one virtual and one physical.  Fascinating.

“These civilizations will coexist in a more or less peaceable manner, with each restraining the negative aspects of the other. The virtual world will enable escape from the repression of state control, offering citizens new opportunities to organize and revolt; other citizens will simply connect, learn and play. The physical world will impose rules and laws that help contain the anarchy of virtual space and that protect people from terrorist hackers, misinformation and even from the digital records of their own youthful misbehavior…”

The concluding thoughts were both powerful and reassuring:

“The case for optimism lies not in sci-fi gadgets or holograms but in the check that technology and connectivity bring against the abuses, suffering and destruction in our world. When exposure meets opportunity, the possibilities are endless. The best thing anyone can do to improve the quality of life around the world is to drive connectivity and technological opportunity. When given the access, the people will do the rest. They already know what they need and what they want to build, and they’ll find ways to innovate with even the meagerest set of tools. Anyone passionate about economic prosperity, human rights, social justice, education or self-determination should consider how connectivity can help us reach these goals and even move beyond them. We cannot eliminate inequality or abuse of power, but through technological inclusion we can help transfer power into the hands of individual people and trust that they will take it from there.”

While a provocative read, I’d recommend a pass on The New Digital Age for my health-focused readers.  A must-read, however, for budding futurists.

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Why Vinod Khosla is Right

Recently Vinod Khosla, founder of Sun Microsystems, keynoted Rock Health’s Health Innovation Summit where he offered a bleak outlook on the future of the MD.  David Shaywitz at Forbes has some interesting commentary that’s worth a peek.  Davis Liu and Venture Beat’s Matt Marshall offered nice reviews.  Khosla’s Techcrunch piece, Do We Need Doctors or Algorithms, is required reading for anyone with a lens on the future.

Khosla’s recent views on medicine were best summarized by Shaywitz and are as follows (not verbatim):

  1. Medicine needs disruption.
  2. Entrepreneurs focused on consumers are most likely to disrupt.
  3. Since doctors are part of the system that is the problem, they’re not likely to create the solutions.
  4. In the near future, computer algorithms may well replace doctors (80%).

Despite predictable indignation from the medical community, Khosla’s vision isn’t far off the mark. Much of what we once did with our eyes, ears and hands will be replaced by diagnostic and predictive technology.  This is already happening.  The older generation doesn’t want to believe it.  The millennials don’t know anything else.  I might add, however, that I prefer to position the physician’s future as marked by radical redefinition rather than outright displacement.

I do have issue with the growing belief that physicians lack the capacity to participate in shaping or envisioning the future of health.  Our profession is undergoing what may be its most dramatic change in modern history.  I’m confident that a new generation of medical leaders will emerge that will counter current assumptions about doctors and change.

Khosla’s a remarkable guy with some provocative ideas.  I regret that I wasn’t in the Rock Health audience when he challenged physicians to counter his assertions – not because I disagree but because this subject is in need of visible dialog.  My greater regret is that his challenge was met with silence.

And that tells me either everyone’s on board with Vinod Khosla, or there’s truly no hope for our future.

Book Notes: Abundance

This week I read Abundance – The Future is Better Than You Think, by Steven Kotler and Peter Diamandis.  This book serves up the ambitious vision that, for the first time in history, technology has the potential to ‘significantly raise the basic standards of living for every man, woman, and child of the planet.’

The early part of the book lays out the bold promise of abundance through connectivity, the global availability of water, unlimited energy, education and health care.  The latter part of the book explores three forces fueling the promise: the age of the DIY innovator, technophilanthroy, and ‘the rising billion (everyone with a smartphone is empowered).’  The fuel for abundance will be new transformational technologies such as networks and sensors, AI, robotics, biotechnology, bioinformatics, nanotechnology, and 3-D printing.  The overlying theme of Abundance echoed Shirky’s concept of a cognitive surplus.

Standing in sharp contrast to those apocaholics selling the idea that the Internet will be the end of us, Abundance offers a fresh vision of how technology may actually make the world a better place.  Arguments are well substantiated.  There is a chapter on health that I felt could have offered stronger examples of an abundant future.

Abundance is fodder for the technooptimst and core reading for the aspiring futurist.  I enjoyed the powerful closing remarks of the book which support my core belief that we have the capacity to shape the future:

Proverbs 29:18 tells us: “Where there is no vision, the people will perish.” Perhaps that’s true, but it’s also myopic. Abundance is both a plan and a perspective. This second bit is key. One of the more important points made throughout this book is that our perspective shapes our reality. The best way to predict the future is to create it yourself. So while the Bible offers a warning, it’s helpful to remember that the inverse is also true: where there is vision, the people flourish. The impossible becomes the possible. And abundance for all becomes imagine what’s next.

For another optimistic view of our future you may like Matt Ridley’s The Rational Optimist.

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Will the Future Need Doctors?

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.

Will Things Really Get Worse for Doctors Online?

The more I read the more warnings I hear about doctors online.  It seems that as more doctors interact online, the more problems we can expect to encounter.  According to authorities, things are about to get worse for all of us.  Imagine the clinical chaos we can expect come 2050.

Or maybe not.

The problem with this pessimistic view is what Matt Ridley has referred to as extrapolationism: the assumption that the future is just a bigger version of the past.  What’s bad now will be worse later.

But as history has taught us, the future is not simply an extension of the past.  We have a remarkable capacity to correct ourselves.

Going forward:

  • Doctors will learn from experience.
  • Digital professionalism will be part of every medical student’s curriculum
  • We’ll be smarter.

So pay no attention to the apocaholics who have hijacked the public discourse on doctors and social media.   And don’t expect the sky to fall any time soon.

For a realistic view of the future of the human race, read Matt Ridley’s The Rational Optimist.

DeLange VIII and the Future of Education

School isn’t what it used to be.  Higher education is changing dramatically.  As barriers to information and human connection dissolve, institutions that once existed as the sole means of connecting people to learn find themselves evolving .  Activity and thought once silo’d within universities are increasingly present on a global, collaborative stage.  Everything we think about education, research and collaboration is changing.

That’s what they’ll be thinking about early this week at the Delange Conference VIII – The Future of the Research University in a Global Age at Rice University.  Delange is a forum for educational leaders and visionaries to contemplate the evolving ecosystem of research universities in the global age.

This conference offers a powerful lineup of speakers including:

  • Paul Yock, Martha Meier Weiland Professor of Medicine and BioEngineering; Director, Biodesign, Stanford University, “Setting the Stage for Collaborative Innovation in Global MedTech”
  • Charles Vest, President Emeritus, MIT, “Openness, Brain integration, and the Meta University”
  • John Seely Brown, Visiting Scholar, University of Southern California, Co-Chairman, Deloitte Center for the Edge.  “New Models of Learning, New Modes of Engagement – Cultivating Resilient Learners, Designers, and Researchers for the 21st Century”
  • Cathy Davidson, Ruth F. DeVarney Professor of English and John Hope Franklin Humanities Institute Professor of Interdisciplinary Studies, Duke University, “The Future of Learning”  (I’m told that I’ll have a few minutes to interview Davidson about her new book, Now You See It.  This book is amazing, by the way.  Look for our exchange here early next week)

I’ll be at DeLange in person and chiming in on Twitter at #DeLange8. What’s cool is that you can watch the webcast for nothing.  This is a remarkable opportunity to tune in on some big thinking around the future of education.

Now let’s think about a similar meeting on the future of medical education.

The De Lange Conferences are made possible by an endowment established at Rice University by C. M. and Demaris Hudspeth in memory of Demaris’ parents, Albert and Demaris De Lange. 

Book Notes: The Creative Destruction of Medicine

It’s arrived: The Creative Destruction of Medicine – How the Digital Revolution Will Create Better Health Care, Eric Topol’s prescient view of the near future of medicine.

This book details how four areas of digital medicine – wireless sensors, genomics, imaging and health information – are about to undergo a super-convergence marking perhaps the most disruptive period in medicine’s history.  Topol describes a coalescence of “the rapidly maturing digital, nonmedical world of mobile devices, cloud computing, and social networking with the emerging digital medical world of genomics, biosensors, and advancing imaging.”  An overarching theme in The Creative Destruction of Medicine is the inevitable march from population medicine to the science of the individual.

So why is this book is important?

We need to see the future.  Only by understanding the future are we able to plan for the needs of our next medical generation.  I’d like to put The Creative Destruction of Medicine into the hands of every professional medical educator and ask ‘are we preparing the physicians for the work that lies ahead?’  If not, this book should serve as a starting point for a conversation surrounding medical education reform.

It emphasizes the expanding role of the patient.   Medicine is increasingly anchored to the individual.  Creative Destruction makes it very clear that consumers will drive many of the changes currently brewing in health care.  This is perhaps the first book accessible to patients that clearly characterizes the changing face of medicine.  Every patient should read this book in order to understand the rapidly evolving role in they play in their own care.

It brings elements of a manifesto.  Any book that describes the state of the medical profession as sclerotic or ossified should have your attention.  The Creative Destruction of Medicine is a call to action for doctors and patients alike.  We must see our world and our job as doctor and patient very differently.  In a profession so uncertain of its future, we need precisely the vision and critical dialog offered here.  The final chapter confronts the challenges facing the creative destruction and reads like a commencement address.  I read this twice.  Pure gold.

Eric Topol knows what he’s talking about.  And as a master clinician, researcher and communicator, Topol is the man perfectly positioned to tell this story.  It’s this authority and breadth of experience that makes The Creative Destruction of Medicine so plausible.

Buy five copies, read one and gift the other four.  I suspect that 150 years from now when historians are looking back at the most dramatic flexion point in medicine’s history they’ll reference this book as one of the first to identify the start of medicine’s creative destruction.

Join the dialog on Twitter at #CDoM

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