Technological progress has brought many changes in the field of medicine that promise significant improvements in life and health. But these promises are accompanied by perils that threaten medicine as we have known it. In the Spring 2015 issue of Dignitas, trends in women’s healthcare were explored to examine the impact of the exponential expansion of information technology, the invasion of capitalistic market forces, and the encroachment of bureaucratic control. These forces, however, are not peculiar to women’s health alone as they have encompassed all of healthcare. This article will consider the ways in which technological developments are collectively altering the face of medicine by disrupting its foundation—the physician-patient relationship.
Several recent developments have affected the character of medical care, one of which has been a subtle shift in the meaning of prevention. Historically, prevention entailed intervening in a process to prohibit a potential problem from progressing to a more serious condition. But now prevention seeks to impede the initiation of the process through the promises of technology, in particular, vaccinations and genomic medicine. While this is a positive development, it has the undesirable side effect of diminishing physician-patient contact and hindering the need for relationship.
A second notable shift has occurred as we have entered the era of “Big Data” in which data management is rapidly replacing patient management as a primary concern. Patient information is projected to expand exponentially in the near future; acquiring and entering that data will pose the first major challenge. The ability to meaningfully process all of the acquired data, to populate final forms with appropriate data, and to assist patients in personally processing the data will pose additional challenges. These tasks are far from complete. Only in 2011 was health IT or informatics instituted as a new medical specialty by the American Board of Medical Specialties to address these issues.[1] Similarly, Northwestern University has developed a new collaborative venture between physicians and engineers for redesigning healthcare delivery systems.[2] These developments reflect the “systems orientation” that is occupying healthcare concerns and superseding the classic conception of healthcare as a profession.
With the reign of big data, the focus of care is shifting from the individual to population health, substantiated by the proliferation of algorithms and mandated guidelines based on current evidence. This will have tremendous implications for the fiduciary physician-patient relationship. Despite our desire to reimagine medicine as a purely scientific endeavor, we have forgotten that evidence-based medicine is transient and never completely objective, always vulnerable to new data—data that must be subject to interpretation. Moreover, human beings, in our uniqueness and variability, do not fit well into algorithm boxes; population statistics correspond poorly to any particular patient, for patients are persons, not mere data points or statistics . What has been rejected in this shift is the art of medicine—the role for intuitive knowledge and physician judgment in the care of patients.
Not only has the means of practice altered the doctor-patient relationship, but so has the form of practice. As a result of increasing costs of mandated technology, more and more physicians transition from private and group practices to hospital-employed status due to increasing costs of mandated technology.[3] Until recently, governmental control of healthcare extended to hospitals but not to independent physicians who claimed and maintained the sanctity of the physician-patient relationship. But as physicians have moved to employed status, that relationship has been severed, effectively allowing for greater governmental control over the services physicians provide. Not only are physicians subject to governmental regulation to an extent that was not possible in the past, they now are forced to serve the employer, instead of the patient. The increasing transition of physicians to hospitalist status will only augment that outside control.
As technology continues its hegemony over all aspects of healthcare, person-to-person contact will diminish further. Patient portals that lessen contact with clinical staff are already prevalent; patient kiosks eliminate the need for receptionists; and the use of mobile apps for monitoring medical conditions will continue to reduce the need for contact with medical personnel.[4] Video exams and conferencing through the rise of telemedicine, developed for use in remote or rural areas, are predicted to move progressively into the mainstream of medical care due to anticipated physician shortages and demands for efficiency.[5]
Indeed, the stimulus for many of these technological changes is cost, efficiency, and compensation. The need for accurate billing and coding for reimbursement has driven development of the electronic health record (EHR); improved patient care is a secondary concern. The traditional concept of fee-for-service is likewise being supplanted by pay-for-performance, but performance is judged not by the care an individual receives but the health of a particular population, a criterion that is subject to the fickleness of patient compliance and behavior. This renders it an erroneous attempt to quantify quality.
The implications of increasing use of these technologies to the physician- patient relationship suggest that informed consent concerning the costs of care will pose a burgeoning ethical issue. In a market-based healthcare system, healthcare is a commodity and patients are consumers; it then follows that providers are vendors who must disclose costs. But interposing monetary considerations into the interaction will disrupt the traditional fiduciary physician-patient relationship, interfering with care and imperiling trust.
There are great benefits to technological progress. Over the years the gains in knowledge of disease processes, effective methods of prevention, treatment modalities, and technological means of diagnosis and treatment have benefited innumerable persons, changing attitudes and expectations of life and health. Moreover, there has been a great expansion of accessible data about patients and disease processes that has aided the quest for improved health and life. Some other gains are, as yet, merely promises: gains in efficiency, cost control, and enhanced patient education.
But these technological gains must be weighed in the balance against personal and interpersonal losses, and these cumulative losses are significant. Not only is there improved access to data, but that data may also become a burden to physicians who are increasingly bombarded by patient information, a fact that will only accelerate as wearables and smartphones are incorporated into patient management. As more and more data is collected, information management will become an escalating issue for physicians. While such increased data may indeed bring benefits, it must not be forgotten that mere data is not knowledge, and that greater information is not the same as greater understanding.
Depersonalization resulting from the focus on efficiency, evidence, and the EHR is one of the greatest adverse effects of the “new medicine.” But this loss of the individual person goes deeper still. The subjective person is lost through elimination of the personal encounter: technological data gathering has replaced subjective physical findings as diagnoses are no longer based on touch, smell, sight, or even careful physical evaluation, but rather on metrics from diagnostic equipment and other quantifiable data. The shift is one away from a focus on the individual and toward a focus on increased data and population health. This shift exacerbates depersonalization as non-quantifiable factors such as personal context and idiosyncrasies are subordinated to data.
This triad of efficiency, evidence, and the EHR eliminates the narrative on which identities and relationships are built. In the EHR we have “faces” but no story, as personal narrative has no place in the template of the EHR. Instead, the focus becomes gathering data, not listening to stories. Yet, we are a storied people and our stories are central to human life and society—the basis of relationship. Additionally, these stories are performative, not only recounting events but creating identities and giving meaning to the circumstances of our lives. In this sense there is little meaning to the medical history generated in template boxes.
As Sir William Osler presciently stated in 1892, “If it were not for the great variability among individuals, medicine might as well be a science as an art.”[6] What is lost in these technological gains, as Osler so wisely understood, is the art of medicine—that intuitive knowledge that grows out of relational understanding and personal experience—the kind of knowledge that cannot be quantified or objectified. The art of medicine has been replaced by the science of medicine; relational knowledge has been replaced by medical evidence. Alarmingly, it has been predicted that intuition and complex problem-solving skills may potentially be lost as they are replaced by clicking buttons linked to utilization data and reimbursement.[7] Not only will we employ robots, we will become them.
What is lost, therefore, is care—that critical component in healing that is related not to what we do but to who we are as physicians. It is the component that grows out of relationship—out of the sharing of the story, looking into the eyes and the soul of another person, sharing in their joys and sorrow, their pain, suffering, and struggles. The role of the personal relationship in health and healing—the accountability that is so important to caring and curing, even if not wholly efficient—has been set aside, forgetting that the personal relationship is one of the most powerful healing tools of the physician.
Healthcare is a microcosm of technological changes impacting our culture, which is certainly in a tremendous state of transition. There is no doubt that remarkable gains in health and life have been realized through the expansion of knowledge and the progress and promise of technology. But these advancements have come at a great price: loss of the physician-patient relationship. The traditional role of physician as healer in a fiduciary relationship has been replaced by physician as provider of a commodity for the healthcare enterprise, and is now being converted to that of a physician-technician in a healthcare industry—a cog in a wheel. Additionally, the role of the patient has been objectified and reduced to data.
Depersonalization, loss of narrative, and the disintegration of the healing relationship are the tremendous costs of the industrialization of healthcare. Ideally, it would be desirable to retrieve the losses and restore the relational aspects of healthcare without relinquishing the gains, but, given the inertia of technological progress, that is unlikely to occur—or even be deemed necessary. As the wheels of progress continue to roll, only time will tell if the promised benefits outweigh the perilous losses.
[1] Juliana Bunim, “New Medical Specialty Aimed at Harnessing Data to Improve Patient Care,” UCSF Educational Bulletin, December 2013, https://www.ucsf.edu/news/2013/12/110836/clinical-informatics-subspecialty-launched-ucsf (accessed on June 3, 2015).
[2] “Northwestern University Feinberg School of Medicine Center for Engineering and Health,” Northwestern University, http://www.feinberg.northwestern.edu/sites/ipham/centers/engineering-health.html (accessed June 3. 2105).
[3] “More U.S. Doctors Leaving Private Practice Due to Rising Costs and Technology Mandates,” Accenture, October 31, 2012, https://newsroom.accenture.com/news/more-us-doctors-leaving-private-practice-due-to-rising-costs-and-technology-mandates-accenture-report-finds.htm (accessed March 21, 2014).
[4] Alex Rudansky, “Remote Patient Monitoring: 9 Promising Technologies,” InformationWeek, July 30, 2013, http://www.informationweek.com/mobile/remote-patient-monitoring-9-promising-technologies/d/d-id/1110968?page_number=2 (accessed March 17, 2014).
[5] Bruce Japsen, “ObamaCare, Doctor Shortage to Spur $2 Billion Telehealth Market,” Forbes, December 22, 2013, http://www.forbes.com/sites/brucejapsen/2013/12/22/obamacaredoctor-shortage-to-spur-2-billion-telehealthmarket/ (accessed March 14, 2014).
[6] Amalia Issa, “Personalized Medicine and the Practice of Medicine in the 21st Century,” McGill Journal of Medicine 10, no. 1 (2007): 53-57.
[7] Stuart Wolpert, “Is Technology Producing a Decline in Critical Thinking and Analysis?” UCLA Newsroom, January 7, 2009, http://newsroom.ucla.edu/releases/is-technology-producing-a-decline-79127 (accessed June 3, 2015).
Susan M. Haack, "The Promises and Perils of Technological Progress in Healthcare,” Dignitas 22, no. 3 (2015): 8–11, www.cbhd.org/dignitas-articles/the-promises-and-perils-of-technological-progress-in-healthcare.
