Tuesday, September 18, 2012

Defining a Doctor’s Role


What is the future of medical practice and of clinical care?  What is the future role of doctors?  There is an old joke about the airplane cockpit of the future.  It goes that the flight crew manning that cockpit will consist of a pilot and a dog.  The pilot’s job will be to feed the dog.  The dog’s job will be to bite the pilot if he tries to touch anything. 

In the same vein, this linked blog by Dr. Davis Liu reports the observations of a primary care doctor who attended the   HealthInnovation Summit hosted by Rock Health in San Francisco.  In a report that seems sometimes like that of an alien being plucked down in the middle of a football game, trying to understand the culture and values of earth,  this intelligent physician seems to be both a bit confused and also enlightened by what he heard.  For me, the comments by the keynote speaker that he reports on reflect the changing definitions of medical care and the changing role of the physician. 

That keynote speaker was Vinod Khosla, co-founder of Sun Microsystems.  He is quoted in this blog as saying: “Health care is like witchcraft and just based on tradition” and that technology had to stop doctors from practicing like “voodoo doctors” and be more like scientists.   It sounds to me like someone needs to add a dog and a doctor to this vision of technology's role in the health care office of the future.

Mr. Khosla went on to say, according to Dr. Liu, that the “machines”  should do “80%” of what doctors currently do and that the machines should be developed by people who are not in health care as the knowledge of health care is a disadvantage in developing these new technologies.  I have actually heard this argument from many entrepreneurs in the past.  The argument that being steeped in a discipline, while giving one in depth knowledge, also give one certain paradigms  which impede the ability to think creatively about problems.  And in some ways I have come to agree with the argument as having a set of fresh eyes working with experts often can be the proper shock to challenge the “petrified opinions” that Mark Twain talks about that invariably develop as part of professionalism.  (Twain’s full quote is “Loyalty to petrified opinion never broke a chain or freed a human soul.”)

But the central core of Mr. Khosla’s argument may fundamentally misunderstand the role of the physician.  Or it may be that I am romanticizing the role of the physician in a way that reflects a world that no longer exists.    If the definition of a doctor’s role in medical care is to diagnose and prescribe treatment for illness based only on the pathophysiology of the disease, then I agree that 80% of that can be done by a machine.  Perhaps more!  If a doctor’s role is to understand the person who has the disease, as William Osler said (“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”) then I question whether a technology can sort through the personal beliefs, the feelings, the social aspects, the finances, and the spiritual beliefs that go into any medical decision, however big or small.  Even if that is possible, I doubt it possible for a technology to form a “human” relationship akin to the strong person/health professional relationship that can help in overcoming the barriers that we all have due to our own personal characteristics and situations that impact our own ability to swim through the rapid currents of health care. 

But doctors are now being trained to be more scientific.  They are paid by a system that encourages them to practice strictly according to “evidence” which means scientific evidence based on pathophysiology alone and are also paid to spend precious little time actually listening to people and learning who they are as people all in the name of efficiency and science. 

Without that perhaps “soft” role of physicians, then I find myself agreeing with Mr. Khosla.  Perhaps it is time to just accept that physicians are no more than diagnosis and treatment machines and that they are no longer the confidantes, supporters, and even at times friends that the profession used to be.  Perhaps this priestly function of medicine is gone. 

While that may be the case, let us not forget that good care requires that we understand people with all their irrationality and with all of their own reasons for following or not following “science”. 

Perhaps in the area of science that involves technology, Mr. Khosla is right in assuming that good entrepreneurs and good programmers are the answer even perhaps the complete answer.  In the areas of science that involve human behavior (and medicine is more about human behavior than it is about the pathophysiology of disease) the answers are not often found in binary code or proper investments.  The answer may be a new professional.  The answer may be to relegate physicians to being diagnosticians and prescribers of therapy rather than to be the Doctor that I grew up aspiring to be.  Or the answer may include changing incentives and standards to include that human role for physicians. 

I don’t know the right answer.  I only know that Mr. Khosla’s vision is an important one but it is fundamentally wrong if it ignores the human aspects of caring, listening, understanding and human problem-solving that is so necessary in medicine.