Sunday, January 3, 2016

“Strangers at the Bedside” and the Internet Economy

In my last post, I wrote about information systems and health care and the challenge of finding and treating the “black swans” which often separates superior medical care from  barely adequate or even bad medical care.  I define barely adequate care as care that inadvertently takes advantage of the body’s tendency to heal itself and represents a doctor and /or nurse being more lucky than smart.  The movement from medicine being an art, a science and a profession to also being a business is today tied to an economy which is rapidly changing as the Internet economy becomes a major factor in our lives and therefore in health care. 

But first, I must pursue some personal history.  In my education and development both as a physician and as a healthcare systems expert, certain books were formative, having a dramatic impact on my thinking.  One such book was “Strangers at the Bedside” by David J. Rothman.  Professor Rothman is a historian by training however he holds the post of the Bernard Schoenberg Professor of Social Medicine and Director of the Center for the Study of Society and Medicine at Columbia University.  To make this personal story more complex, Bernard Schoenberg for whom Professor Rothman’s academic post is named, was a professor of mine at Columbia when I was in medical school and was someone who taught me to look at the social and emotional context that each patient brought with them to the doctor-patient encounter. 

In his book, David Rothman describes the changing dynamic in social and ethical issues in medicine, especially in those issues involving clinical research, end-of-life, and other bioethical dilemmas such as choosing patients for transplants with limited access to donor organs.  He discusses the arrival of sociologists, ethicists, theologians and others trained in the humanities into these decisions that previously were the purview of only the treating physician.  In a future post I plan to write more about David Rothman’s words now twenty-five years after he wrote them.  He does not write about the business people, the management experts and the information technology engineers and their entry into the bedside dynamic yet those may be the more important “strangers at the bedside” in today’s world.

As medicine, health care delivery systems, and health information technology progress, the industry must be informed by more than medical facts and prospective.  Thomas Friedman’s 1999 book entitled “The Lexus and the Olive Tree” in which he describes the drivers behind globalization has nothing to do with health care.  In that book, which came only eight years after David Rothman’s book, Friedman talks of a changing world and speaks about the democratization effect that globalization could have on technology, finance and information.  I remember reading his book when it was first published and believing, somewhat naively perhaps, that he had left out the democratization of health care in his formulation.  I believed that through the internet and through the free movement of health and medical information, health care which is far too important to be left only to doctors, as David Rothman points out so elegantly, was going to undergo a revolution for the better by making the mystery of medicine – the guild aspect of the medical profession – fall to the wayside of an informed, democratized public. 

I was too optimistic.  I minimized the profound complexity of medical care and the fact that people, for the most part, access medical care only episodically and focus on their life issues before focusing on their health issues.  I left out the spiritual dimension of care that is a necessary part of medicine and has been written about so eloquently by people such as Daniel Sulmasy, who wrote another of my formative books, “The Healer’s Calling.”

I also missed the nature of an Internet economy and the tendency towards monopoly that often defines the best Internet companies.  A recent article in The New Yorker by Om Malik entitled, “In Silicon Valley Now, It’s Almost Always Winner Takes All” cogently presented the reasons for this monopolistic tendency to prevail in this “democratized” world.  As Malik writes, “In the course of nearly two decades closely following (and writing about) Silicon Valley, I have seen products and markets go through three distinct phases.  The first is when there is a new idea, product, service, or technology dreamed up by a clever person or group of people.  For a brief while, that idea becomes popular, which leads to the emergence of dozens of imitators, funded in part by the venture community.  Most of those companies die.  When the dust settles, there are one or two or three players left standing.  Rarely do you end up with true competition.” 

Malik writes about the Network effect, often called Metcalfe’s Law after Bob Metcalfe inventor of The Ethernet, which occurs when the value of a product or service goes up with the number of people using it.  It creates a loop of algorithms, infrastructure, money and data and that leads to a winner-take-all approach.  This is especially recognized by the investors who provide the capital for these new companies.  The investor community and the public markets take large risks to predict the next monopolies and in this Internet economy, punish anything less than a monopoly or a duopoly since according to Malik’s cogent analysis, most of those companies die. 

What happens when this winner-take-all type of economy meets health care?  In some ways we have a direct example with Epic Systems which now supplies the hospital software that holds 54% of the US population’s health records.  It is a marvelous system designed by engineers and hospital administrators and is masterful at capturing data for billing purposes and for inventory purposes.  Physicians will tell you it can divert their focus from the patients and while it does make accessing records when not at the bedside easier, it does not tell the patient’s story – their life context and emotional struggles with illness that are critical to good care, in the way it must.  Competition is being shut out because, as Metcalfe’s Law suggests, the more EPIC is the standard and the more data they have, the more monopolistic they can become.  There is an old joke told in the early days of computing (and I am old enough to remember).  It goes, “How many Microsoft engineers does it take to change a light bulb?”  The answer – “None because Bill Gates declared that darkness is the standard.”  Will we define a health care standard that removes the human aspects from care even though those elements are arguably the most important?

Perhaps a good example that is not in health care and not even in the Internet is the story of agribusiness in the United States.  In the food business, four companies control over 60% of grain production.  This came about from a starting point of an America whose food came almost entirely from family farms.  It occurred because the Internet realities of algorithms, infrastructure, money and data have their counterpoints in food production, in land, infrastructure, money and logistics.  The more you control land, infrastructure and logistics, the more money you can raise and the more you can increase control of the market. On the positive side, this has led to more efficient use of farmland, more availability of food to the market on a year round basis, and more consistency in preventing food borne illness.  On the negative side, we have been subject to monopolistic tendencies by these companies, leading to episodic need for lawsuits and regulatory action, a loss of family farms and the communities they supported, and a loss of the unique aspects of local food that can lead to healthier more varied diets.  We have traded efficiency and the positive of availability for a loss of flavor (for those of us who value that), loss of varied nutritional sources, and perhaps potential environmental damage as well (I will let those discussions occur elsewhere).  Management and finance prioritized over dedication and even love of the land and the amazing variety of food the land produces have driven this tendency. 

I now watch the froth of Internet health companies being pursued and funded by venture capitalists and the hope being put into information technology in health care by both government and investors.  I welcome the creativity and the new approaches but wish those to be driven by a desire to improve the care for each unique patient as well as the desire to foster efficiency.  I for one remain enamored of a democratization of health care and repeat a line I wrote earlier in this post and have been saying for years, that health care is too important to be left to doctors and nurses.  However, health care is also too important to leave out doctors and nurses.  It is too important to leave health care only to the management experts and the information system engineers.  Health professionals train and take oaths and have experience that gives them a special voice in protecting the personal aspects of medical care. 

David Rothman states that while “the physicians are alert to numbers and findings from random clinical trials carry critical authority” they also recognize that no two patients are alike and that medicine is inherently uncertain.  Clinicians value experience highly as they realize that only through experience do professionals understand the management of that inherent uncertainty and how individuals can vary from the clinical trials.   Experienced clinicians understand, as I discussed in my last blog, the importance of always looking for the unexpected.  We as patients – and we are all patients at one point or another – should also value that knowledge and experience and always hope to have doctors and nurses, who use technology and who respect our ability to find information for ourselves on the Internet and from other sources.  We should also demand that the technology support health professionals treating us all as the potential “black swan” – the unexpected disease or circumstance and not as a data point in an Internet algorithm or on a balance sheet.  I believe that can only occur if experienced caring clinicians are involved in the development of this new world of the health care Internet economy and ironically do not end up as the new strangers at the bedside.