America’s Healthcare Dream
A few Thoughts on Malcom Gladwell’s recent interview on the future of healthcare in America
Malcom Gladwell recently shared some thoughts with Robert Pearl , M.D. of his perspective on the future of healthcare in the United States. I will not be addressing every part of the interview, but rather use it as a starting point for a discussion on the future of healthcare in America.The reality that I see is quite different from the fairy-tale ideals that we all wish would come true and that Gladwell articulated in his interview.
Gladwell addresses the ACA (Affordable Care Act) as an attempt to solve a series of problems and on this stance I agree, and I too support the ACA, but I believe that the creation of the ACA was not the result of a political process. In my opinion the ACA is the product of many economic and technological forces that are now molding the American Healthcare System. These forces include the emergence of “big data” on the medical horizon and Wall Street money entering the hospital arena.
The interview states (I am not sure if this is Gladwell’s or Pearl’s opinion), that “physician leadership will be essential to effectively drive the innovation needed to transform the system” . I have serious doubt that this statement is true. What I have witnessed is that the technology and financial, insurance and hospital industries, along with the Government are in the process of putting in place systems that will ultimately shape the future of the practice of medicine. Although doctors will obviously contribute to the process, they will not be the ultimate decision makers.
I recently attended a conference on the future of digital health where George C. Halvorson, the Chairman of Kaiser Permanente was the keynote speaker: the audience was filled by young dynamic teckies now involved in healthcare and very few doctors were in attendance. Halvorson explained how Kaiser is working at transforming Electronic Medical Records into actionable data, with physician activity being tracked by the minute. If we look into what is happening at Kaiser today we see a system in which decision-making depends largely upon the statistics generated by “big data” being produced. It’s not difficult to imagine this happpening on a more National scale in the near future and shifts such as this will drive the changes in healthcare.
Venture capitalist Vinod Khosla recently predicted: “medicine isn’t a science yet …computers will soon replace a majority of the tasks that human doctors currently perform”.
Because data generation and analysis in medicine is quite complex, and we do not yet have a good enough handle on the analytic platforms and healthcare-specific technological solutions, the imminence of these developments is not yet clear. Nevertheless the flow of data will affect a number of areas including doctor and hospital ratings and tracking of complications.
“Big data” will allow analysis of real life “intention to treat” prospective study outcomes. It is possible that the role of current clinical research will be much changed. Randomized prospective studies will continue to exist but the data will probably be monitored in real time by computers.
Gladwell also comments on the excessive regulation of medicine and called for a more “human interaction” type of environment in the practice of medicine: “In an environment that’s about the quality of human interaction, it’s not appropriate to have 10 volumes of incredibly specific regulations”. While I believe it is important to maintain a human element in medical decision-making I do not foresee that what Gladwell is calling for will come to fruition, but rather that we will witness a progressively more regulated and monitored environment.
An important element that emerges from these considerations is the risk of physician alienation and patient alienation. We will witness resistance on both sides as both parties will feel constrained by the harsh reality of mathematical and technological advances strangling the human autonomy in medical decision making. I believe that keeping both doctors and patients happy is going to be one of the greatest challenges that few seem to be addressing today.
On the physician side we need to make sure that physicians feel confortable in a new role that is more akin to “coach” than decision maker. Another huge priority is improvement of electronic medical records. The current configuration has trasnsformed many physicians into data entry drones: things have gotten so bad that some busy physicians have resorted to hiring a newly-minted healthcare worker, the medical scribe. New systems, possibly based on natural voice recognition, or with touch interfaces need to be developed.
On the patient side we need to be aware that “outcome” is not the only endpoint sought by people: the experience, or more apropos, “end user experience”, is also extremely relevant.
Some have suggested that what I have described will apply only to 2nd class citizens and that the rich of the world will continue to get individualized medicine. “Big data” will exacerbate what we already see as “classes” of medicine: its advent will allow individualized medicine for a select few with the pocket book to fund individualization, while the rest are forced to live with the de-individualized healthcare of the future.
Paradoxically, what is happening in medicine is similar to what is hapening in the economy: the quality of life of the middle class is not being improved, but is rather being degraded. The middle class is being degraded to be equalized with the proletariat class and this is being done in collaboration with the rich, who really don’t need a middle class to thrive, but do need a relatively uneducated proletariat as workers.
I will not be surprised if a pronounced disaffection will develop and progressively lead to exponential growth of a trend that is already ongoing: public mistrust of “official” medicine and it’s diktats, and the expansion of alternative and complementary medicine, a medicine, as I have written elsewhere, whose epistemology still belongs to the realm of the “possible”.
Andrea Vidali, M.D. is a Reproductive Endocrinologist. He lives and works in New York. Follow Dr. Vidali on Twitter : @drvidali, Like Dr. Vidali on Facebook,
Reprinted from http://www.andreavidali.com
