When the Ebola scare took over my hospital, the Chairman of Medicine asked for volunteers to take care of patients who’d be isolated for suspicion of the virus. All consultations would be done via telemedicine: a camera would be installed in the room, and the interview would be done remotely. No physical exam would be required. No contact would occur. This policy felt like an admission that we could do our jobs without seeing the patients and that, on some level, we were afraid of our patients.
After my wife and I had been trying to get pregnant for two years, my older brother, an orthopedic surgeon, asked us why we hadn’t seen a fertility specialist yet. “We really want to do this naturally,” I said. “But you may not be able to,” he replied. “Our fertility doctor told us there was literally no way we could have a child without help.” My wife asked him if he believed that was true, or just a doctor justifying his work. “Listen, if this were fifty or sixty years ago, we’d have been one of those couples who just never were able to have kids or who had to adopt. But, thanks to modern medicine, we were able to get pregnant. I can’t believe I have to explain this to you guys – you’re both doctors.” Eventually, my wife and I did see a fertility doctor, and our daughter was almost certainly the result of intrauterine insemination (at our fertility doctor’s suggestion, we had sex for two nights after the procedure, so it’s at least conceivable that Juno was conceived the old fashioned way). Three years later, when we wanted to try for another pregnancy, I wrote a prescription for intravaginal progesterone that would allow my wife to extend her luteal phase. She was pregnant after three months of these home treatments. We never needed to use artificial insemination, but we did have another medically assisted pregnancy. I understand why medicine needs to keep evolving and advancing.
The website, www.23andMe.com, has been offering cut-rate genetic testing since 2007 via a “Personal Genome Service” kit that sells for $99. The kit contains a vial and instructions on how to provide a saliva sample from which the company can look at thousands of genes that vary among humans. I don’t know what the average person will do with his or her DNA analysis, other than worry excessively about something out of his or her control. My mentor in fellowship often referred to the results of genetic testing as “toxic knowledge,” although his younger colleagues called him a dinosaur for that thinking. I do know what 23andMe wants to do with the genetic data they are accumulating. A board member told Fast Company magazine, “The long game here is not to make money selling kits, although the kits are essential to get the base level data… Once you have the data, [23andMe] does actually become the Google of personalized health care.” Recently, the company announced agreements to share its DNA data on 650,000 individuals with Pfizer and Genentech to help these pharmaceutical giants “figure out new ways to treat disease and design clinical trials.”
In his recent book, The Patient Will See You Now, Dr. Eric Topol foresees a future in which the smartphone will “democratize” medicine by granting patients “unfettered, direct access to all of their own health data and information.” Dr. Topol argues that technology empowers people to learn as much as possible about their health and alter the dynamics, in a good way, between doctor and patient. When patients control their health information, they have the power to personalize their care – they can see which doctors they want to see, when they want to see them, and even where they want to see them. With a smartphone, he says, “you can have ICU-like monitoring in the safety, reduced expense, and convenience of your home.” If his vision for the future doesn’t pan out, Dr. Topol says we can blame medical paternalism and doctors who stubbornly hold on to the “doctor knows best” mantra. In an interview about the book, Dr. Topol clarified: “I don’t believe this technology is replacing doctors at all. This is simply changing the model. Doctors are fully there to review data and provide wisdom, experience, and guidance – not exercise all control.”
Topol doesn’t clarify that this new model of the technologically-savvy patient, the knowledge-is-power patient, already exists. The wealthiest and most educated patients are already doctor-shopping, medicine-shopping, hospital- and clinic-shopping before they walk through my clinic doors. As William Gibson said, “The future is already here – it's just not evenly distributed.” They bring in articles I’ve written, my paragraphs highlighted in yellow and orange. There’s an unspoken message when they show me their preliminary research: You should be honored that I’ve chosen you as my doctor. And, I’ll admit, I am. They are playing to my vanity, and I am a willing accomplice – to a point, at least. At some moment in our encounter, I need to take control of the relationship. I’m okay with eschewing “doctor knows best,” but I won’t abandon “doctor knows better” in my doctor-patient relationships.
In a story from NPR on the increased use of technology by the newest generation of doctors (NPR called them “millennial doctors”), Dr. Rick Snyder, a Texas cardiologist “from the baby boom generation” discussed his worries that young doctors would not forge the same relationships with their patients as his peers did. He compared young doctors today to young soldiers in Vietnam who became over-reliant on technology at the cost of their dogfighting skills. “We as physicians, that's our dogfighting skills: talking to a patient, interacting with a patient,” Snyder said. The same story quoted a recent medical school graduate on how technology had made her last four years of study much easier than expected: “I would wake up at 10 a.m., work out for an hour or so, get some lunch and then video stream for 6 hours and then go to happy hour. It actually was not that bad.”
Our hospital gives each intern an iPad, ostensibly for work, because they can check labs and look at radiology images using our hospital’s medical records app. None do, though. The iPads go home on the first day and rarely surface on the hospital floors. When my wife runs the teaching service, though, she insists that the interns bring their hospital-issued iPads on rounds. “They groan, because they hate having to carry them around, but it helps on rounds,” she says. I should note that my wife rounds on patients at the bedside instead of in a private conference room; few hospital teams still employ this old-school technique of discussing a case directly in front of the patient. “All the patients – regardless of their age, education, language, background – they all want to see their X-rays and CT scans on the iPad. They’re in awe that we can show it to them on a tablet.” It makes it look like the doctors control the technology and, consequently, know what they’re doing.
About once a month, my parents babysit so that my wife and I can go out to dinner (We used to call these dinners “date nights” but corrupted that phrase by once using my parents as a means to go grocery shopping, and the idea of a “date night” to Whole Foods seemed depressing). Recently, when we returned from dinner, I found my father staring intently at his iPhone. “Come look at this,” he said, finally looking up from his phone. He held up his phone, which displayed an EKG strip on the screen. My father is a community pediatrician who’s fighting the good fight against retirement. He turned 70 last year and gripes constantly about how medicine has become too computerized for his tastes. He showed me two silver clips attached to the back of the phone and, resting his fingers on these clips, demonstrated how he could use the phone to read an instantaneous heart rhythm strip. “I was having palpitations,” he explained, “and saw the new cardiologist at the practice. He’s younger than you.” My father took another EKG reading and continued. “He said instead of doing a 3-day home monitor and having to wear one of those annoying machines, I could use this app to monitor my heart rate.” I asked him how he downloaded the app, as I’d never seen him download anything on his phone. “The cardiologist did it for me in the office, and he attached the clips for me, too. I see him next week to go over the recordings and return the clips. It’s pretty neat, isn’t it, that I can do this with my phone?” My father’s face was beaming. He seemed excited to have the kind of medical problem that an iPhone app could evaluate. From the other side of the room, my mother broke from her conversation with my wife to tease my father. “Are you still playing with that thing? The cardiologist said just ten times a day, and I swear you’ve done it 30 times already.” “It’s neat,” my father responded and returned to our conversation. “You should meet this doctor. He reminds me of you.” My father’s hands shook a bit as he took another EKG recording on his phone. He looked like a patient, like someone who was in awe of a doctor. His admiration of the technology in his hands, of this modern style of doctoring, seemed like a concession that he was on his way out of the field. “Are you able to read it?” he asked, handing the phone to me. “It’s just normal sinus rhythm,” I said, scrolling through the last four or five EKG strips. “They’re all just sinus rhythm.” “Well,” my father said, taking the phone back, “I’m going to see the doctor next week, and he’ll review them, too.”