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The end of doctors 

  • A second technology revolution threatens the future of healthcare
  • Healthcare systems that ignore evolving technologies will collapse
  • Most healthcare systems are trapped by three basic failures
  • Doctors are the interpreters and not the processors of medical knowledge
  • Will a computer decide to turn off a life support machine?
  • Who owns the medical information on the Internet?


The role of doctors is about to change more than it has in the past two centuries, as the technology revolution enters a new era. 
 

Radical change 

This is the conclusion of Richard and Daniel Susskind in their book, The Future of Professions, published on 22nd October 2015 by Oxford University Press. They argue that, over the next 20 years, “the second future”, dominated by artificial intelligence (AI) and the Internet, will drive radical changes in healthcare systems, which will involve the transformation of how medical knowledge is made available.

Today, computer systems can delve into vast amounts of patient data, identify trends and make more accurate predictions than doctors. Machines such as IBM’s Watson, which can attain high levels of intelligent behavior is already being used in medicine. In parallel, the Internet provides people with new and effective ways to build communities and share healthcare information. 
 

Never too big to collapse 

Some doctors argue that their activity will never change because it depends on deep expertise, creativity and strong interpersonal skills; none of which can be replaced by computer systems. Earlier, managers of global companies that dominated world markets made similar claims before there enterprises grew obsolete and collapsed.

Twenty years ago, the failure of global companies to meet transformational challenges resulted in 74% of them leaving the Fortune 500 as new technologies and innovations opened the way for agile start-ups and entrepreneurs. The list is long, but here are a few examples. Digital Equipment and Wang Laboratories, once leading computer firms, disappeared completely. Even resurgent giants such as Apple and IBM stared into the abyss of irrelevance, and made painful changes before clawing their way back to the top.
 



In the 1980s the advent of digital photography, software, file sharing, and third-party apps ended Eastman Kodak’s world market domination, during which time Kodak made breakthrough technologies, which included the Brownie camera in 1900, Kodachrome colour film, the handheld movie camera, and the easy-load Instamatic camera. Motorola, another global giant, that developed and built the world's first mobile phone, and dominated that market until 2003, failed to focus on smartphones that could handle email and other data; and as a consequence, rapidly lost share to newcomers such as Apple, LG, and Samsung.

 


 

Dr Devi Shetty, world-renowned heart surgeon, founder, philanthropist, and chairman of Narayana Health, India’s largest hospital group is viewed as the person who will have the biggest influence on 21st healthcare. Here he describes how information technology is set to radically change healthcare:

    
        (click on the image to play the video) 
 

Healthcare systems not immune

The Susskind’s agree with Shetty, and believe that healthcare systems, predicated upon antiquated patient-doctor technologies, face a similar demise to that of large companies that failed to adapt and change. The more successful healthcare systems will be those, that copy large companies who survived by collaborating with smaller, agile firms either as suppliers or partners. Rigid bureaucratic healthcare systems that find it more difficult to innovate will fail.
 

Three reasons for failure 

Failure to address three major challenges accounts for the failure of most healthcare systems. The first is the continued investments in failing antiquated systems, and the consequent failure to pursue fresher, more relevant ones. The second is psychological: healthcare systems and doctors fixate on what made them successful in the past, and fail to notice when something new is replacing it. The third challenge is strategic: healthcare systems that only focus on today, and fail to anticipate the future will fail.

Previous HealthPad Commentaries have illustrated these three failures by the billions spent on failing diabetes education programs over the past decade, while the incidence of the condition escalated. This is because diabetes education and awareness programs fixate on antiquated systems, and fail to embrace, smarter and more effective ones. See: Behavioral Science provides the key to reducing diabetes
 

The concentration of medical expertise

A doctor’s raison d'être is to provide solutions to problems that people do not have sufficient specialist knowledge themselves to solve. Previously doctors were the ‘processors’ of medical knowledge, but with medical information becoming ubiquitous, increasingly doctors are becoming the ‘interpreters’ of medical knowledge. Doctors are gateways to specialist medical information.

In most healthcare systems, doctors are a huge and increasing expense, a large proportion of them use antiquated methods, and the expertise of the best doctors is only enjoyed by a few. This is changing by technological innovators finding ways to make medical expertise more widely available. Also, technology is enabling clinical expertise to be broken down into smaller tasks, which can be better achieved with a machine; telemedicine is just one example.
 

Who owns medical knowledge?

Online healthcare information empowers patients and threatens doctors by providing people with medical knowledge that previously resided in the minds of doctors. Such knowledge, which can help to diagnose illnesses, is free, increasingly common, and controlled by users. An important unresolved question is, who owns this medical knowledge?
  

Takeaways

Doctors exist to provide solutions to medical problems. If technology provides better more reliable solutions, the need for doctors dissolves. However, the most convincing objection for the displacement of doctors is an ethical one. Is it morally wrong to leave the decision to turn off a life support machine to another machine?

The debate is just beginning. 

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Gordon Moore
Professor, Harvard University Medical School and world renowned authority on the design and implementation of healthcare delivery systems 
 

'Instead of throwing more manpower at their problems, multiple industries are using information technology to offload work to the consumer, connect the participants up in real time, and create smart, real-time process support.'

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Curing the Problems of General Practice

The Royal College of General Practice (RCGP) and the Centre for Workforce Intelligence (CFWI) agree: too small a supply of GPs will meet a rising tide of demand.  In the UK, spotty shortages exist now, but will become widespread over the next decade.

The causes of rising clinical demand are well known:
  • Continued growth of the things medicine can do
  • Surge of lifestyle diseases
  • Burgeoning patient devices that collect data and require monitoring by clinicians
  • Increased public expectations for access to GPs 
  • Aging of the population
  • Emergence of multiple, complex chronic illness
  • Diversion of GPs to management activities such as commissioning

Little analysis of root causes
Less is known about the underlying causes of the shortfall of supply in GPs.   The RCGP cites lagging GP incomes as a source of dissatisfaction, with consequent dampening effects on medical student choices of general practice specialist careers.   The CFWI models GP supply, but offers little analysis of the root causes of the declining intake to GP careers.  

While both the RCGP and the CFWI repeatedly emphasize the need to make general practice more attractive and increase its uptake, they have few suggestions about how to do so other than promoting it better.  In the meantime, they advocate, as does the NHS, that larger, multi-skilled teams must grow to service the increasing need, and that the key barrier to effective teamwork is lack of integration.

Concerns
I want to raise two significant policy concerns about the direction that the UK is taking to mitigate the primary care “crisis”.  First, I postulate that the reason that medical students are not choosing general practice is less a matter of money than of increasing practice complexity and life style.   Second, I suggest that the “solution” of larger, better-integrated teams is unproven and, further, may actually diminish productivity, and worsen, rather than relieve, the stress of work on GPs while their satisfactions further diminish.  

Lifestyle challenges
There is little evidence that medical students will select GP careers if they earned more.  In fact, over the past five years, during the rapid upturn in GP incomes, dissatisfaction among GPs grew and fewer medical students, especially men, chose to enter general practice.  In the US, studies have shown that life style is an important factor in the diminishing number of medical students entering primary care.   At the same time, corporate primary care is growing, and larger practices with more salaried doctors are becoming the work choice of preference. 

This suggests that young doctors are put-off by the complexity, responsibility, the long hours, and the stress of general practice, and seek to transfer those risks to someone else.  Without fixing this, throwing more money at the problem is unlikely to reverse the trend.   Money, of course, is important, but it’s merely an enabler of career choice and a deterrent if too low. Compensation alone doesn't appear to be a sufficient incentive to chose primary care.   

Multi-purpose teams failing
The idea is seductive that integrated, multl-manpower teams are a solution to the GP shortfall. However, early evidence from America doesn’t suggest that the US-version of integrated, primary care teams (the patient-centered medical home) is achieving the efficiencies and improved care that they were touted to deliver.  Recent studies  (see: Friedberg M.W., 26th February 2014, Journal of the American Medical Association) show some small improvements in quality measures, but no change in cost-effectiveness in a group of enthusiastic early adopters.   

There are many reasons to doubt that simple team integration occurs by encouraging it among those working together, and much to suggest that the cost of integration is a major barrier to a cost-effective strategy to increase manpower.   Information technology, as a field, discovered years ago that taking complex tasks and dividing them among many different subgroups was dis-economic.

Additional manpower not the answer
As long ago as 1975, Frederick Brooks in The Mythical Man-Month argued convincingly that by, “adding manpower to a late project makes it later”.  No surprise then that when one counts the cost of personnel, the coordination mismatches, the communication time, the complexity of handoffs, and duplication of services, teamwork is more a theoretical concept than a practical working model. 

Adopt best practice
What, then, might one consider as a possible solution to the increasing stress, complexity, and uncertainty of life as a GP? What is needed to facilitate integration among and between team members and patients?  Surely, we can draw lessons from other industries.  Instead of throwing more manpower at their problems, multiple industries are using information technology to offload work to the consumer (think of Cash Points), connect the participants up in real time, and create smart, real-time process support. 

The role of technology
Digital infrastructure for general practice has failed to keep up with the rest of the world.  The electronic medical record documents what has been done but does little to help doctors and other health workers to do their work. There is no infrastructure to help patients. Information technology should be providing an infrastructure to make general practice easier and better to do. 

Merely throwing non-GP manpower at their problems will make the life of the GP more complicated and less satisfying.   It is time to invest in true infrastructure innovation in the NHS.  It won’t be cheap, but it is the only answer to the threat that general practice will fail to meet the needs of the population in future.    
 
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Gordon Moore
Professor of Population Medicine
 Harvard University  Medical School

'We must tap into the largest unused source of manpower: the patients themselves.'


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Meeting the challenges of affordable quality healthcare

Health care systems throughout the world are about to be hit by a tsunami.  Dramatically escalating GP demand is driven by the growth of life-style-related chronic illness, the surge of baby-boomers, a primary-care doctor shortage in some countries, and, in America, the surge of unmet needs now paid for by Obamacare. Either the current system will seize up, or new ways of caring for patients must be found.

Traditional responses unsustainable
Typically, healthcare systems respond to increased demand by adding manpower: usually nurses and other health workers. Increasing manpower reduces the potential for economies of scale in which increased volume reduces costs. Even worse, with additional workers added to a healthcare practice, efficiency actually decreases as downtime, communication costs, turnover, coverage, duplication and re-work increases. 

Healthcare systems must find a way to reduce the costs as they struggle to meet this surge of demand.  The old manpower-based responses, which at first seem attractive solutions, are unsustainable in the long run.

4 musts
What are the answers? 
  • First, we must tap into the largest unused source of manpower: the patients themselves.  Anyone who cares for patients with diabetes, smoking, or high blood pressure knows that the best plans of GPs often are not carried out despite many repeated visits to the doctor or nurse. 
  • Second, to activate patients, care support for them must be truly patient-centred.  Patients need help to gain confidence necessary to take control of their own therapeutic pathways. Such a system of support requires “having your doctor in your pocket”, which should be entertaining, engaging, educational, available 24/7, continuously helpful, personalized, and safe.
  • Third,having your doctor in your pocket,” can only be achieved if IT is used in new and innovative ways.  The most cost-effective avenue by which we can move patients with chronic illnesses to become more actively involved in their own care is through the Internet, where dramatic shifts in user interfaces, devices, and process interactions are taking place almost daily. By transferring expert knowledge to patients and thereby creating a truly patient-centred system, caring for ones’ own illness will be no more difficult than using a cash machine or mastering a smart phone.  
  • Finally, if the Internet can facilitate the transfer of knowledge from the medical system to the patient, then also it can facilitate the transfer of expert health knowledge to lower the cost of all clinical personnel from doctors to nurses to health coaches.  If guidelines, such as those produced by NICE in the UK, are built into the process of care that health professionals use, we would have developed a system that significantly extends the capacity of health professionals while maintaining the safety and quality aspects of care that increasingly people expect and demand.  An apt analogy is the way that today’s cockpit technology enables all pilots to be as good as the best.  Through the use of technology, we can do the same in medical care.
The past is no indication of the future
Today, healthcare is largely using IT to reproduce what doctors have done in the past. The electronic record is little different to paper records.  In the evolution of any new technology, its application development goes through this stage. However, we must put IT to use in doing new things, in innovation that reduces our dependence on expensive manpower and in producing more value for less money.

Making such a transition will not be easy or inexpensive.  But the costs of remaining the same and trying to meet escalating healthcare demands by adding more costly inputs are higher and more threatening in the long run.  We should be investing in the future, not tinkering with the present.  
 
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3 years, 11 months ago

Evidence from a recent survey of people with diabetes, suggests patient outcomes will improve if GPs provide healthcare information in video clips rather than paper pamphlets.

Traditional patient information is failing
“An indication that the current paper and web-based diabetes information is failing to improve patient outcomes is the fact that the incidence rates of diabetes in the UK are escalating. Currently, a plethora of diabetes information is provided either in paper pamphlets or as digitalized text on websites, but patients want healthcare information in video clips, and greater connectivity with their health providers,” says Dr Seth Rankin, managing partner, Wandsworth Medical Centre, who conducted the survey.

Despite the NHS spending £10 billion each year on diabetes care, between 2006 and 2011 the number of people diagnosed with diabetes in England increased by 25%: from 1.9 million to 2.5 million. Today, 3.8 million people have diabetes, and this number is expected to increase to 6.2 million by 2035. In 2013 there were 163,000 new diagnoses of diabetes in the UK, the biggest annual increase since 2008, and the five-year recurrence rates of diabetic foot ulcers are as high as 70%. The population increase over the past decade only explains some of these increases.

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