I don’t hide the fact that I am a dyed in the wool liberal. I read, and agree with, pretty much everything Paul Krugman writes. But, it’s rare for me to discover the kind of synergy between my Krugman-inspired ire over economic policy and politics generally and the e-Patient movement that I awoke to this morning. In today’s column, Krugman makes the point that higher education does not automatically guarantee a comfortable, moderate wage job. No big insight there, but his argument includes some subtle implications for medical care.
The kinds of jobs that we associate with college education and beyond are also being outsourced to technology. As an example, Krugman points to a recent NYT piece on the role of software in analyzing legal documents. He also makes passing mention of computer assisted diagnosis in medicine. I’ve argued for a long time that much of what I do as a physician could be better done by either machines, or patients themselves. Taking that idea one step further, it’s clear that we’ll need fewer, not more, doctors in the future. I imagine that this morning Paul Krugman would agree.
Here’s a link to his column.
Well, THAT’s provocative!
I get your point, but thinking about my own case, I wonder – how far out into the future are you thinking?
You didn’t mention an aspect that I’ve sometimes cited: this industry seems incapable of not getting fatter every year, with costs rising and quality not improving. That’s a death scenario: value (the ratio of quality to costs) declines to the point where more and more people give up and drop out. That’s also the scenario where utterly disruptive “screw the system” solutions start getting developed.
But my case: sore shoulder -> x-ray -> “Dude, that spot’s not supposed to be in your lung” -> CT “many spots” -> ultrasound “It’s in your kidney” -> biopsy (interventional radiology) -> treatment options etc. How much of that will be done by “Dr. Watson” in 5, 10, 20 years?
Or are you saying that’s the tip of the iceberg that will always need docs (for the foreseeable future), and the vast majority of care doesn’t?
btw, for those who don’t know, Dan Hoch is one of “Doc Tom” Ferguson’s original advisors on the white paper at top right of this site. His bio on the about us page says:
“Dan Hoch is a neurologist based at the Massachusetts General Hospital and is an Assistant Professor at Harvard Medical School. An early developer of online resources for patients, Dan helped found Braintalk and is active in the American Academy of Neurology, the American Epilepsy Society, and the American Medical Informatics Association.”
Provocative, yes, but incorrect: We need more doctors, not less. And especially more smart, scientifically AND verbally-minded, well-trained, kind, caring ones. Part of why patients are taking so much info into their own hands now is precisely because they lack access to competent physicians.
I agree with you, Elaine.
I think this discussion requires looking beyond what doctors are doing “today” versus where they came from and what we wanted them to do. The two are different things.
If you look at it that way, there are and will be a shortage of physicians who do the job that people want, which is less about the mechanics of diagnosis, and more about supporting preferences and decisions _in addition to_ diagnosis.
I don’t want to imply, btw, that computers are on the verge of replacing the diagnostic capacity of physicians. I don’t think this is the case, either.
This book, “A Fortunate Man” is a required read to understand the job of a physician through time. I wrote about it in this blog post:
And noted this quote from it:
“It may be that computers will soon diagnose better than doctors. But the facts fed to computers will still have to be the result of intimate, individual recognition of the patient.”
This book was written in 1966, and I’d say that this assessment is still very true almost 50 years later. Imagine that.
Thanks Ted, I’ll check out that book. (a good example of SM pointing us back to the stacks, information from an earlier era)
Certainly agree about the need for more competent physicians. But I might add that everybody would benefit from a system that didn’t render so many competent physicians incompetent, as well as one that produced more competent patients.
I really like the points made by Roderick Harrison in this recent PBS Newshour interview: http://www.pbs.org/newshour/bb/business/july-dec10/income_09-28.html. In brief, the point I want to emphasize is that companies are no longer paying workers based on their productivity. There has been a shift and now productivity increases due to IT investments and outsourcing all seem to accrue to the C-suite & investors. Somehow, CEOs now seem to believe that they are really worth the tens of millions of dollars (or more) that they earn each year while the standard of living of most of their workers declines each year. My proposed solution: create an IT-driven “CEO in a box”.
For a good article on the commoditization of physicians, see Tom H. Lee, MD (the west coast Tom Lee)’s article from a couple of years ago in iHealthBeat: http://www.ihealthbeat.org/Perspectives/2009/The-Great-Commodification-of-Content-Could-Physicians-Be-Next.aspx.
Yes, very provocative! In some ways probably true…but what about the so many times that require a brilliant mixture of art and science for the proper diagnosis and treatment? If I’m the n=1, i want the best, the brightest, the most compassionate and the most collaborative doctor treating me! And we know that the role that a doctor plays with his/her patient can play a role in the ultimate patient success beyond the mere words or Rx treatment…
Having said that, perhaps there are many ‘tasks’ that can be outsourced so that doctors have MORE time to spend engaging with patients and their families to provide the best support and guidance?
Importantly, this line of thinking does suggest that the new value-ad of today’s doctor practicing with today’s IT is different than it was when many docs graduated from medical school… A time to change the game for many…
Interesting viewpoint. Certainly provocative. While I cannot see a future where we would want fewer doctors, I can totally see a future where doctors spend more time with patients and important tasks rather than mundane non-value-add stuff.
Software, like the example you mention for the legal profession, can certainly help to eliminate the administrative burden on doctors. Hopefully this will lead to more face-to-face time with patients rather than fewer doctors. I trust computers & technology, but I believe there is a human element to healthcare that cannot be replicated today with bits and electrons.
I do agree there is “fat” in the healthcare system, but I don’t think eliminating doctors is the best way to achieve efficiency.
On April 29th, 2007 I wrote about The End of the Golden Age of Doctoring and eHealth http://www.ictconsequences.net/2007/04/29/the-end-of-the-golden-age-of-doctoring-and-ehealth/ based on
McKinlay, J. B., & Marceau, L. D. (2002). The end of the golden age of doctoring. Int J Health Serv, 32(2), 379–416.
These authors mentioned “the consequences of globalization and the information revolution” as one of the major extrinsic factors (generally outside the control of the profession) for the decline of the golden age of doctoring.
I think it is worth pointing out this article and contextualise Dan Hoch’s post within a broad perspective :-)
Love to see the reactions!
If you think that Dan was provocative in this piece, you should have seen him, Tom and Richard Rockefeller have long conversations about the VERY OLD Problem Knowledge Coupler 10 years AGO. Three medical free radicals!
That’s what fascinates me. Some people foresaw up to 30 years ago all we are discussing today and presenting as front line innovation! Pure clinical technological innovation moves on at a rapid speed and has done so for a long time. But true innovations about our understanding of the processes of medicine remain very rare, sickeningly so! What’s wrong with a system that refuses to pay more than lip service to these innovations?
Larry Weed, the founder of PKC, thought about pattern recognition and use for faster and more accurate diagnosis long before we started to use the Internet to improve the quality of care received by patients. Still, today, his name usually doesn’t ring a bell, when you try to introduce his concepts. Too bad, IMO.
The Problem-Oriented System, Problem-Knowledge
Coupling, and Clinical Decision Making
A system to assure that relevant clinical patterns can automatically emerge from the chaotic process of everyday medicine.
Provocative yes, but how practical for rural areas or areas of poverty or less technologically advanced areas of the country?
Is a shortage of doctors or health professionals going to serve these populations if technology can’t keep pace? Keep in mind while needed, technological advances can be expensive. What if clinics, hospitals, and centers cannot get adequate funding or foot the bill? What if insurance companies refuse to cover such services? Can the patient really afford the out of pocket cost?
We have a hard enough time finding qualified medical personnel for rural areas, reservations, and remote areas within our borders, not to mention foreign countries. This might be practical and good for urban centers, but what about the rest of America?
Corporatization and automation has occurred in many fields over the years and while the majority has been positive, not all of it has been.
There are still some areas where the human interaction is warranted and necessary. Machines can’t replace everything and aren’t without error. Some are only as effective as their operators/programmers.
I’m not against the concept, I just think it has to be approached with caution and we should not as the saying goes “throw the baby out with the bathwater” and healthcare is not like a scarf or a cookie-cutter: one size does not fit all.
Wow, nice discussion.
Are too many or not enough docs the right question? Some places have too many and some too few – looking at population access measures for primary care. And I won’t comment on specialists; Dartmouth Atlas data has told us for years that what people get depends the number of specialists and hospital beds.
Continuing on Ted’s theme, the issue is What should care be and look like? People have – and always will – balance getting their own information with getting information from experts (docs/nurses/etc). The Internet blows up the former. And we need the latter. Yet now, we need to be even more “expert” – not just tolerating patients-getting-their-own-information or even encouraging it, but driving it, too. Because staying with our decades-old model of care is insufficient and unsustainable.
Plus, self-care and social support has positive effects we have to stop ignoring.
Without question, we need fewer doctors who conduct themselves as if they, like computers, have no soul.
We need more doctors who realize they are treating patients with a soul, and are supported by computers so that they can spend more time doing what humans do better than computers: listening with a discerning ear, asking the right questions, assessing nonverbal cues and clues, empathizing, and providing compassionate care.
We need patients who know how to use computers so that they can find a high quality doctor, and will know how to best collaborate with that doctor once in the office.
If the above can be better approximated, I would anticipate health care would be delivered in a more effective way, recommendations would be pursued in a more effective way. So in that case, I would agree that we might need fewer doctors. But that’s predicated on quite a few big changes to the current system.
It is peculiar that all of the commenters believe we need more physicians but describe their ideal requirements to be based on quality and not quantity. I have been in the medical field for 20 years and have witnessed the US possessing enough physicians for now and the future. What we haven’t done is correctly distribute them geographically. The trend is for most people to choose to practice in large urban areas because that is where the large hospital systems are located to support specialty care equipment/ device needs. What the literature has failed to take into account is the number of foreign born/ foreign trained physicians, use of midlevel practitioners, and off shoring of physician labor (medical tourism). The market will always adopt to solve a solution.
THERE ARE JUST TOO MANY PHYSICIANS IN THE UNITED STATES, ESPECIALLY PRIMARY CARE ONES. HOW DARE I SAY THAT YOU SAY? JUST TAKE A LOOK AROUND. THE WORK FORCE IS FINE, MORE THAN FINE. ACCESS TO CARE IS A DIFFERENT STORY. A PHYSICIAN GLUT IS THE WORST THING THAT CAN HAPPEN, EVEN WORSE THAN A PHYSICIAN SHORTAGE. DOCTORS TEND TO OVER CHARGE AND OVERTREAT IN ORDER TO KEEP THEIR OVERHEAD. AS PHYSICIAN NUMBERS GROW, SO DOES THE COST OF CARE. OBVIOUSLY PEOPLE WHO BENEFIT FROM A DOCTOR GLUT ARE ALWAYS FOR AN INCREASE IN NUMBERS. LETS SAY THE AAFP (AMERICAN ACADEMY FOR FAMILY PHYSICIANS) WITH OVER 100,000 MEMBERS GET OVER 30 MILLION DOLLARS (YES YOU READ RIGHT)JUST IN ANNUAL FEES PER YEAR FROM EACH PHYSICIAN…DO YOU THINK THERE IS EVER GOING TO BE TOO MANY FAMILY PHYSICIANS IN THEIR EYES? OF COURSE NOT AND THEY KEEP PUSHING THIS AGENDA OF A “PRIMARY CARE SHORTAGE” WHICH IS BOVINE EXCREMENT, THEY JUST WANT THEIR GREEDY LITTLE HANDS FULL OF FAST CASH. AND SO DO BIG HOSPITALS AND BIG MEDICAL GROUPS WHO BENEFIT FROM AN INCREASINGLY COMPETITIVE MARKET OF PHYSICIANS (PEOPLE WILLING TO WORK MORE FOR LESS) WHICH IS ABSOLUTELY BEAUTIFUL IN THEIR EYES (SAME PROFIT, LESS PAY). REMEMBER, MONEY TALKS AND THEY WILL NOT BE HAPPY UNTIL PHYSICIANS ARE RIPPING EACH OTHER APART FOR A LOW PAYING JOB WITH SOME EXTRA CALL. THIS IS ALREADY A REALITY IN CANADA AND OTHER COUNTRIES.