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Is technology displacing the art of medicine?

Darwin noted that the best theorists made the best observers.

Many of us in the practice of medicine are swimming in technology and yet we seldom carefully observe its appropriate uses and how technology seems to be crowding out the human side of medical care both professionally and economically.

If we theorize that the future of medicine will be ever more dependent on expensive technological tools and skills, where do the cognitive and human parts remain? Is technology becoming the art of medicine? A recent article in the American Scholar noted "As the use of technology increased, the physician considered himself less a practitioner of the Art and more an avatar of science." (1)

Alas.

Of the two broad categories of medical technology to observe, "internal" can be broadly seen as provider-to-provider and "external," more specifically, provider-to-patient.

Internal medical technologies

Medicine, not too dissimilar from many information intensive endeavors, requires internal technology: identification of patients and treatment, access to clinical and financial information and collaboration of care.

If there are efficiencies in innovation in the business process of health care they reside here--less time spent looking for information, richer sources of information and fewer steps in its application. Examples of internal information technology include:

* The identification of patients and treatments--think of bar codes and eventually RFID (radio frequency identifier tags). The Holy Grail of medical information retrieval may finally arrive with "always on" identification of an entire inventory of patients, drugs and personnel merely by scanning the environment. EZPass, Gillette and Wal-Mart pioneered this technology in transportation and consumer goods. Yes, privacy and access to vast databases are concerns, but the trend is probably unstoppable. Managing health care without further convergence of patient information and the most useful medical information is unimaginable.

* Access to clinical information--think of MEDLINE, UpToDate online and HIPPA patient information networks. Huge databases will function as links between published research and individual patient applications. This will probably include traditional and wireless applications of near universal availability of medical treatment options to nearly anyone who can obtain a valid user status from entry level student to post doctoral researcher. Possession of information is already less important than access. Better to own a key to the library than all the books.

* Collaboration and clustering of care--think of professional societies, service lines and disease management all sharing Web-based linkages or professionally published media. Care is expanding horizontally across degrees, specialties, societies or even geographic areas. Competency pushes professional turf issues. If you can contribute meaningfully, you can be a part of a team.

External medical technologies

Medicine, probably the ultimate interface of science and human needs, has more visible external technology as this technology is more directly applied to patients.

Newsworthy innovations, trumpeted by eager journalists, often find many of us expecting the next new thing in health care.

Examples of external technology include nearly all the skills and tools applied to a patient. Some are age-old processes and procedures, some are highly innovative and some of undetermined value. The three broad categories are:

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1. Sustaining

2. Disruptive (2)

3. Research

Sustaining technology

Sustaining technology refers to the day-to-day expectations of patient and provider--everything from blood sugar monitoring to general anesthesia. More often the care is widely available from multiple sources--physicians, certified nurses or physician assistants.

As this can be accessible by many providers, price pressures mount and substitution is more likely. These rights to use sustaining technology are reimbursed at the same rate whether generated by the board-certified physician or the physician assistant.

These sustaining diagnostic technologies serve us amply in such dramatic improvements as: multi channel helical CT, PCR (polymerase chain reaction) DNA lab testing, proteomics for cancer screening or OraSure's rapid mucosal diagnostic testing. Here the trend is the universal engineering mantra--lighter, quicker, faster, fewer parts, higher resolution, wider applicability or at least as many of these features as possible. Digital cameras and DVDs eclipse analog film and tape for many of the reasons mentioned above. Look for similar trends in medicine--detecting smaller bits of information with higher reliability and a greater ability to manipulate the data.

The sustaining therapeutic technologies--think of statins for treating lipid disorders, computer modeling for providing precise dosimetry in radiation oncology, SSRI (seratonin re-uptake inhibitors) for depression, chemotherapy tailored to the biology of the cancer or even two-lead biventricular cardiac pacemakers for heart failure. Here the sustaining technology represents such dramatic options that even the care team remains impressed, commenting, "How did we ever handle this before?" These milestone events soon become expectations for care.

Medicine--always ephemeral--tarnishes quickly with the continual outpouring of innovative medical research and technology. What was merely innovative yesterday becomes sustaining today. Does it cost more? Well, yes.

Disruptive technology

This can best be thought of as innovation replacements in medical technology. Initially, these skills are of more limited availability and likely bypass some of the traditional pathways and providers; some move beyond cure to enhancements; some involve co-production with the patient.

Disruptive technologies eliminate steps in both acute and chronic care--think of cardiac drug eluting stents replacing cardiac bypass surgeries; "curing" obesity with gastric bypass surgery or HPV (human papilloma virus) detection replacing Pap smears for cervical cancer detection. Students of economics recall Schrumpeter who observed that optimal expenditures in a capital market were often matched by elimination of services no longer necessary. Said another way, if a service or care can be eliminated or diminished by a healthy alternative, it usually will. Medicine is a huge capital market. Pressures to find alternate medical pathways are unceasing.

Disruptive technology pushes farther than medicine's usually ambitious expectations for treatment or cure. Included here are performance-enhancing surgery and medications--think of wavefront-guided laser lens sculpting for better than 20/20 vision or Provigil (modafinil), a memory enhancing drug used to combat fatigue. Medicine's newest frontier moves beyond curing and now presses on toward augmentation.

Additionally, co-production of care with patient involvement disrupts some traditional physician involvement--think of home blood pressure monitoring, personal blood sugar monitoring or even home dialysis. Additionally, a great number of patients, after scouring the Internet, discover reasonable information before visiting a physician. Why encourage co-production with patients? The patient (or customer) is the least expensive member of the team; ask Dell, Wal-Mart, or Southwest Airlines. Recall that a well-informed patient can become a valuable time-saving resource.

These disrupters are generally simpler, involving fewer steps in diagnosis or treatment, with less risk to the patient and potentially less cost per case--though for payers, possible increased utilization.

Here, the technology is more narrowly owned and notably pulls money from sustaining technologies as global reimbursement helps channel this discourse. In a succinct phrase borrowed from the evolving treatment of coronary artery disease, we see how this technology--drug eluting cardiac stenting--can "bypass the bypass."

The winners here are the pharmaceutical manufacturer and usually the patient. The losers are the cardiovascular surgeons and the surgical suites. Medical economic Darwinism stakes another claim.

Research technology

A sizable amount of health care spending can be thought of as inquisitive, as it thrives neither entirely as sustaining in well-established pathways nor is significantly disruptive in changing patterns of care.

Long before our diagnostic testing and therapeutics reach a level of expectations or even possibilities, they exist as research protocols--the questions of bioengineering or pharmaceuticals looking for applications.

Even when a test or treatment has a well-established use, medicine always seems to be asking "What's next?" "Why not?" or "How else can it be done?" This often very expensive process looks to answer questions with no immediate application: the human genome project, stem cell research, anti-viral pharmacology, oncogene research and much that might qualify for NIH funding.

When day-to-day medicine runs out of answers, research technology becomes the mentor for many of us. Spending for all of this technology has already required government support--there seems to be no cap on curiosity. Medical economic Darwinism momentarily is held in check.

Cumulative spending for external technologies

So here we have our buckets of technology, none fully funded and ready to hold more.

By 1994, 14 percent of our GNP went for the costs of medical care with little restraint in sight. (3) Today, the expectation for both patients and their caregivers remains nearly unrestricted access to the next best thing in medicine and that usually means some application of technology.

The $40 visit to a primary care provider generates an $800 MRI for a headache workup. The 99213 intermediate office visits with $10 co-pay for joint pain costs an additional $400 in testing for autoimmune disorders. A $20 prenatal visit generates $375 for an ultrasound and nearly $1,000 if genetic testing is included.

The economics of paying for all this medical technology can be understood with three concepts:

1. Baumol's economic disorder

2. Wrapping of care

3. The classic fisherman's paradox.

Baumol's economic disorder

Medicine remains an overlap of one-of-a-kind human skills and a vast range of state-of-the-art diagnostic and therapeutic tools. Do the words simple or efficient ever drive medical decisions when faced with life-changing illnesses?

The distressing trend about medicine today is that cognitive skills learned over many years, with rapid pattern recognition and astute clinical decision making are disproportionately underproductive by comparison to the rest of the economy.

The revenues of a typical technology business, Verizon for instance, is $294,000 per employee. (4) Even with a hefty addition of internal technology, the revenues of a top 100 health system are approximately $100,000 per employee. (5) Why?

Medicine, for all the discussion about innovation and redesign, still remains a profession--one patient, one pair of hands, and one pair of eyes at a time. The persistent economic limitations of one-at-a-time productivity were discussed by William Baumol from NYU in the 1960s using Mozart as an example:

"When Mozart composed his String Quintet in G Minor (K. 516), in 1787, you needed five people to perform it--two violinists, two violists and a cellist. Today, you still need five people, and, unless they play really fast, they take about as long to perform it as musicians did two centuries ago. So much for progress. An economist would say that the productivity of classical musicians (and health care workers) has not improved over time, and in this regard, the musicians aren't alone. In a number of industries, workers produce about as much per hour as they did a decade or two ago. The average college professor can't grade papers or give lectures any faster today than he did in the early nineties. It takes a waiter just as long to serve a meal, and a car repair guy just as long to fix a radiator hose (or in medicine, to do a physical examination)... Economists call this phenomenon "Baumol's cost disease." (6)

Wrapping of care

If the cognitive skills of medicine are relatively under-reimbursed and technology is ever more marketable, astute medical business practices begin to wrap the patient or the disease, including as many of the diagnostic and treatment options as possible.

For example, a patient with heel pain could have an office evaluation, in-office blood work, X-rays, steroid injections, extra corporeal shock wave treatment, orthotics, physical therapy and/or surgery. Providing all of these options is known as wrapping. The more a disorder can be wrapped, the more technology can be applied to it.

Probably most difficult for the current practice of medicine is the differentiation between cost effective care, best practice care--or for the cynics, the most reimbursable practice of care.

The fisherman's paradox

The classic fisherman's paradox involves the overfishing of the deep-sea banks. As more fishermen arrive, their individual take is relatively less. So each in turn gets a bigger net and more powerful sonar. Still the take is less.

Soon the fishermen have larger boats, even bigger nets and stay out all night. Of course, the fishing never improves. It deteriorates. One could argue that initially there were more fish caught, but not more of the best fish.

The vast expanse of externally applied patient technology is similar to the fisherman's paradox. We have purchased more expensive imaging and built more facilities, owned and operated all night long, but are we assembling more of the best care?

When the fishermen finally discovered aquafarming they called in the medical practice consultants to explain limited provider panels and gatekeepers. The fish were getting bigger but they all looked oddly the same. Alas.

At the interface

As the cognitive (non-technological) skills in medicine remain one-to-one, it is doubtful if these patient encounters can generate significant profitability when compared to the rest of a technologically leveraged medical economy. Being able to generate added sustaining or disruptive technology certainly makes business sense.

Owning the technologies or replacing existing technology with restricted access is the best financial outcome in the short run. But of course, this becomes prone to overproduction or overfishing.

Consider the wrapping of an orthopedic or podiatric patient, how much of the global funding will be allotted by a payer for a pediatric well baby visit when all this technology has been paid for?

Is it possible to redesign the process of care, pulling back from becoming relentless appliers of technology? Or has the dance of technology become so rapid, the tempo of change so unremitting, that the human skills of medicine begin to vanish--economically crowded out by the expensive tools we progressively apply for care?

Everyone wants the best results and the understanding that makes it so.

* The patient wants the optimal human outcomes.

* The providers want compensation for their skills, education and, at times, personal risk.

* The payers desire economic results in their spreadsheets. Or barring that, cost effective testing, procedures, surgery, medications and interventions.

The caregivers have been the value added component to all these.

What continually vanishes in our quickening dance with technology is often the wisdom of appropriate care, time spent listening to patients, and much that really can be called the human interactions--that which is the best of the art of medicine. Three decades later it is well worth rereading Lewis Thomas who wrote:

"We have what is best termed 'halfway technology' ... The media tends to present each new procedure as though it represents a therapeutic triumph, instead of the makeshift that it really is ... It is characteristic of this kind of technology that it costs enormous amounts of money ... and requires no end of new highly trained people to run the enterprise."--Lewis Thomas, The Lives of a Cell, 1974

IN THIS ARTICLE ...

With the rapid pace of technology and the near-constant buzz about new medical advances, the human touch--the art of medicine--often gets lost in the rush.

Notes

1. Nuland, S., "The Uncertain Art." The American Scholar, Winter 2003, p. 121.

2. Christensen, CM. The Innovator's Dilemma: When New Technologies Cause Great Firms to Fail. Boston: Harvard Business School Press, 1997.

3. Socio-Economic Factbook for Surgery 1996-1997. Chicago: Am College of Surgeons, 1996.

4. Business Week, Aug 4, 2003 p 58.

5. Personal experience

6. Surowiecki, J, New Yorker, July 7, 2003.

7. Thomas, L., The Lives of a Cell, New York: Viking Press, 1974.

Jay R. Jackson, MD, is an OB/Gyn in York, Pa. He can be reached by e-mail at Jaxn403@att.net This article will be published in the forthcoming Handbook of Technology Management in Public Administration, New York: Marcel Dekker, 2004.

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By Jay R Jackson, MD
COPYRIGHT 2004 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2004, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Title Annotation:Special Issue: Health Care Technology
Author:Jackson, Jay R.
Publication:Physician Executive
Geographic Code:1USA
Date:Mar 1, 2004
Words:2561
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