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Digital Medicine: The Promise and the Peril

Commencement Address
Jordan J. Cohen, M.D.
President, Association of American Medical Colleges
May 21, 2000

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The Class of 2000! Wow. The very first doctors to be minted in the new millennium. No doubt you're tired already of people telling you that. But it's hard for someone like myself, who graduated from medical school some 40 years ago, to resist the temptation to take note of the new millennium and to marvel at the future you have before you. Forty years ago no one had even dreamt, let alone heard of such things as the Internet, or hand held computers, or genes micro arrayed on a chip. The world of medicine you are entering is so vastly different from the one my classmates and I faced that it literally boggles the mind.

Here's an example. In our wildest dreams, we could never have imagined a colleague by the name of Doctor Number 117. According to a recent article in the Albany Times Union, America's Doctor Number 117 was the one person that a woman from Ohio named Ann Mann trusted to give her advice when her granddaughter broke out in a series of unexplained rashes. On the Internet, Mrs. Mann had a conversation, in real time, with a doctor she'd never met--a doctor whose name, race, and gender she didn't even know. She logged on because she wanted to talk to someone about her granddaughter's illness. She didn't have to make an appointment, she didn't have to take her granddaughter out in the cold, she didn't have to sit for an hour or two in the doctor's waiting room reading old magazines, and she didn't even have to pay a fee. And Mrs. Mann isn't unsophisticated about medicine - in fact, she's a trained paramedic. Yet she chose to seek advice from America's Doctor.com, one of a rapidly growing number of Web sites where physicians, often anonymous, provide medical information over the net-- no stethoscope, no exam table -- just a mouse and a keyboard. At some sites, they even write prescriptions online.

I have to smile at how many words from that story I just told you have been totally redefined since I graduated from medical school. A mouse use to be a little rodent with a tail, a keyboard played music, "real time" was the only time there was, and "on line" was where you stood to wait for a haircut. Times certainly have changed.

Let's consider another example: the e-medicine cabinet. It won't be in your bathroom tomorrow, but the new technology branch of Andersen Consulting has created a "smart" medicine cabinet. It's permanently connected to the Internet; it keeps track of what medications you're supposed to take; it reminds you when you miss a dose; it tells the pharmacy to refill your prescription when you're running low; and it even sets off an alarm if you try to take your partner's medication instead of your own. And that's not all. If its outside sensors detect a high pollen count, the cabinet recommends medication for your allergies. What I don't know is whether it still has that little slot in the back where you can put used razor blades!

As you know better than I, examples abound of fabulous new devices powered by new information technologies, and they are multiplying daily. The upshot of this fantastic technological revolution is nothing short of transformational for the practice of medicine. No doubt about it. A profound and fundamental transformation is underway, and you, the class of 2000, have the extraordinary privilege, not only to experience it firsthand, but to shape its destiny.

The question your generation will have to answer is this; will the up side, the limitless potential of digital medicine to improve the health of individuals and communities, triumph? Or will the down side, the avalanche of impersonal bits and bytes, submerge the ageless power of hands-on, face-to-face medicine -- the power to comfort the sick person; to ease the burden of illness compassionately; to calm the fears; to provide individualized advice in desperate times, as only an experienced, empathetic, caring physician can?

On the up side, the potential benefits of this digital transformation to improve the health of individuals and communities are hard to overestimate. They are truly astounding. What has become abundantly clear is that the availability of information is the key to overcoming virtually all of the barriers we now face to improving personal and public health. Think about it. If we could always get the right information to the right place at the right time for the right person to use, there is no reason why we couldn't · kindle widespread adoption of healthy lifestyles, · maximize people's adherence to proven preventative practices, · make much more timely diagnoses, · render far more accurate prognoses, · select the most appropriate treatment for each individual, every time, · eliminate the unaccountable variations we now see in practice patterns across the country, · improve dramatically patients' compliance with medical advice, and · reduce by orders of magnitude the alarming number of errors the system now produces.

And providing the right information to the right place at the right time for the right person is precisely what the new technological tools that will be at your disposal are increasingly able to do. Both for physicians and for patients.

Given the facts already on the ground, it's not too difficult to foresee some of the major changes in the way medicine will be practiced in your lifetime. I realize the hazards of forecasting. As Yogi Berra once said, "Predicting is risky business - especially about the future." Yogi's caution notwithstanding, let me make ten really safe forecasts. Really safe, because most of these ten futures are already here in some places.

1. Every individual will maintain a lifelong electronic file of their comprehensive health information, and will personally, or through a designated surrogate, authorize access to appropriate providers of that portion of the information needed to deal with current problems.
2. Individuals will maintain their own personalized, medical web pages to which their doctors and others, as directed, will post relevant information and reminders tailored to their specific needs and desires.
3. Doctors and patients will routinely communicate via e-mail and via tele-visits, reducing substantially the hassles now associated with making and keeping routine office or clinic appointments.
4. Using sophisticated on-line devices, individuals will monitor their own health status at home as frequently as necessary to maintain health and to comply with physician-prescribed or self-selected disease management programs.
5. Individuals with all manner of acute and chronic diseases and disabilities will routinely access Internet sites to join virtual communities of similarly afflicted people for support and to share experiences and advice.
6. Many patients with stable chronic illnesses will choose to maintain a cyber-relationship via the net with a respected source of specialized expertise, wherever in the world it may reside, to meet their needs for on-going monitoring and updated advice.
7. Minimally invasive, robotically mediated, micro surgery, powered by advanced information technologies, will greatly reduce the unavoidable trauma, pain, and long-recovery times associated with gaping surgical incisions and with big surgeon's hands mucking around inside the body.
8. Confidential access to automated psychiatric consultation and advice will overcome the reluctance many people feel about seeking help for common and often disabling mental and emotional disorders.
9. Decision support systems will automatically and immediately integrate individual patient information with relevant and updated medical literature, enabling physicians routinely to base their decisions, both in the hospital and in their offices, on the best available evidence, and
10. Reliable information systems will undergird all of the complex processes of care, greatly minimizing the risk of error by reducing reliance on memory and safeguarding against fatigue and unavoidable distractions

How soon we will these and other miraculous transformations be commonly available? To quote cyberspace guru Bruce Sterling, "I used to think that cyberspace was 50 years away. What I thought was 50 years away, turned out to be only 10 years away. And what I thought was 10 years away... it was already here. I just wasn't aware of it yet."

With this year's momentous transition from the 2nd to the 3rd millennium, we have not only crossed an irreversible temporal threshold, we have crossed a threshold of irreversible, fundamental transformation in the way doctors interact with their patients, and in the way their patients interact with them and with the rest of the health system. How could there be a more exciting time to begin a career in medicine?

But so far, I've spoken only of the awe-inspiring up side of this transformation. Is there also a dreaded downside to digital medicine that could vitiate its benefits? The answer, I'm afraid, is yes, that is if we allow ourselves -- and our patients -- to be lulled into the misguided notion that the doctor-patient relationship is based on nothing more than the transfer of information.

To be sure, as I've just emphasized, much of what modern health care is all about is, indeed, the transfer of information. And to be sure, one of the time-honored roles doctors have played is in conveying specialized information to their patients, information that was otherwise inaccessible to them.

But is that all doctors do? Certainly not. And I know that's not all you've been taught to do. First of all, doctors possessing the skills you have acquired are not passive conduits of information. Doctors deal not with generic classes of abstract patients, but with unique individuals. As a doctor, you will be expected to gather all the relevant facts about one particular individual at a time; analyze and sift those facts to extract the nuggets of real meaning; synthesize those nuggets into a coherent representation of that patient's reality; and, most important, make a discretionary judgment about the best course of action for that one unique person. Discretionary judgment! That's a term I'd ask you to remember.

Arguably the most complex task of which the human brain is capable. Certainly the task for which physicians, the most highly trained of health professionals, are uniquely qualified. The product of keen intelligence, years of arduous schooling, and still more years of hard-won experience. Discretionary judgment - the ability to make fine distinctions among alternative possibilities, to draw valid conclusions from a unique set of circumstances, to combine intelligence, reason, understanding, and intuition in order to discern the likeliest path to a successful outcome.

Discretionary judgment cannot be digitized.

But even that's not all that real doctors do. We know that when people get sick they want someone to care for them - to care for them as human beings. Which means more - much more than having someone provide accurate information on a computer screen. It means yielding to the security of a human relationship. It means tapping into the genuine concern of a trusted professional, not tapping into an anonymous chat room. It means experiencing direct physical contact with someone who cares, someone we can rely upon, and in whom we can entrust our well being. I hope you'll always remember Francis Weld Peabody's most famous admonition: "The key to the care of patients is caring for the patient."

Caring, like judgment, cannot be digitized.

I concede that people who "grow up digital" - as most of your patients will have done -- may be more comfortable operating in cyberspace than previous generations were, and they may even have a preference for health information delivered by bits and bytes. But growing up digital does not mean growing up in silicon. Evolution has taken eons to refine our human sensibilities, to hard wire our instincts, to attune our complex natures to harmonize with the vicissitudes of the natural reality in which we life. A mere generation of immersion in the virtual reality of electronic communication cannot eradicate our need, especially when ill, for human contact, for a trusting relationship, and for a caring physician.

So, this fundamental transformation of medicine, of which you are now privileged to be a part, holds the promise of untold benefits for mankind - for the relief of human suffering, for major improvements in the quality of medical services, and for the enhancement of health for everyone. But those benefits will be realized, undiminished, only if you and your colleagues are able to deepen the roots of our profession's timeless ethic of service to people.

What are those roots? They are communication, respect for the individual, compassion, honesty, and, above all, caring. Roots that, admittedly, are already straining under the extraordinary pressures of today's competitive health care system. Especially pressures on time. I would remind you, however, that the winds of change are blowing more strongly than they ever have. And they are sweeping away many of the mundane chores that now require vast amounts of human effort. Information technologies are transforming those chores into automated processes. In their place will be time.

My plea for you is to use that time wisely for strengthening the human bonds that technology cannot possibly forge. Take that time to listen to your patients. Listen for sure to their complaints, but not just to their complaints. Listen also to their stories; get to know them as people. Listen hard for what scares them. Understand their dreams and their disappointments. Teach them how to live healthier lives. Be alert for opportunities to counsel, to comfort, to encourage. No website can ever hope to do that. That's what doctors do. And that's what you can do to ensure that the quintessential nature of the doctor/patient relationship endures.

As Bruce Springsteen wrote: "I ain't lookin' for prayers or pity. I ain't comin' 'round searchin' for a crutch. I just want someone to talk to, and a little of that human touch. Just a little of that human touch." And I'll take my leave with the words of another one of America's great philosophers - this one is a doctor, as well - none other than Dr. Seuss. Here is what that good doctor has to say in his last textbook, Oh, the Places You'll Go:

"Congratulations! Today is your day. You're off to Great Places! You're off and away!

You have brains in your head. You have feet in your shoes. You can steer yourself any direction you choose.

You're on your own. And you know what you know. And YOU are the guy who'll decide where to go."

And as you go, let me say: Take care! Be caring. And good luck.

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