Do you have a Doctor in my size?

First of all, I want to suggest to anybody remotely involved with technology to watch the show Mr. Robot. I have to say that there are many elements of the show that mimic my real life experiences. Ultimately, it’s a show about hackers. But it’s much more. It’s very well acted, very well filmed, and fundamentally makes the argument that we are all already in the Matrix.

Every part of the show is realistic, so that there is really no need for suspension of belief. In fact, realizing just how real the show is might require a Xanax to deal with your disbelief. I consider the show important to watch because perhaps it will succeed in doing something that the tech world has failed to do: make the world understand that progress is more inevitable than death or taxes. People still think they have a choice about whether to join Facebook or do their banking online, or PayPal the cost of a toy they found on eBay. The choice has already been made – the best we can do, as explained to Neo (Mr Anderson), is to understand why we made that particular choice. That will ultimately be the foundation of the discussion we have with G-d when we finally have to answer for our actions in this world.

Now that I have totally frightened and depressed anybody reading this, I’d like to refer to an article that my beautiful wife sent to me a week ago. The article appeared in the New York Times and was titled “how measurement fails. This article discusses something which has actually been reviewed countless times in all other types of literature. There is a principle in physics that if you cannot measure something, it is for all intents and purposes, not there.

Admittedly, this is not as simple as it sounds, and there are physicists who are in a tug-of-war with philosophers over the meaning of existence. For example, there are many physicists who “like” string theory. A lot of effort is being put into it and a lot of resources are being devoted to it. Just to be clear, that means that resources and time are not being devoted to other physical concepts and theories. It is very possible that we will never be able to measure quantum strings, which are sub sub sub atomic units of energy that, the theory goes, make up everything. String theory is very pretty and explains many things that are not explainable otherwise. But if it can never be tested and proven, it ends up being just a lot of very pretty math (which only a few hundred people in the entire world can even understand).

Excluding such exceptions, measurement is still considered to be critical in almost every field. Is your car in good condition? You run some tests to measure it. Is a building up to code? You bring in a building inspector to do measurements and determine if it is or not. Medicine though, has seemed to have fallen between the cracks, and not for altruistic reasons.

I have heard the argument as recently as three years ago that good medicine defies measurement. How can you possibly assign a numerical value to a doctor telling the patient that he or she has cancer? How can you possibly rank surgeons when the patients they operate on are so fundamentally unique? How can you talk about the best or worst of anything when medicine is apparently beyond measurement?

This is of course a ridiculous mindset. Doctors, when they personally need health care, or one of their family members is ill, go to certain other doctors. The intangible “goodness” of doctors suddenly becomes very palpable. I have a personal list of specialists that I use and/or refer family members and friends to. On paper, these specialists are not at the top of their fields. But I personally wouldn’t let anybody else touch me or my loved ones. So if doctors can know who is better and who is worse, there is something that is being measured, even if it is subconscious.

I have heard the argument countless times that outcomes are too variable to be measured. For example, the death rate in a hospital that specializes in cancer will be higher than in the hospital that sits in a local community which is relatively young. The argument, therefore, is that you cannot compare almost anything about these two hospitals. Once again, this is a ridiculous argument.

First of all, if there are two groceries in a neighborhood, you’ll often hear people say something equivalent to “the tomatoes in the grocery at the end of the street are much better than the tomatoes in the grocery at the other end of the street. But for apples, it’s the reverse”. What people do all the time is not compare entire units of functionality, but break it down to individual activities. If I want to get a haircut for myself, I might go to one barber. If my wife wants her hair made up for a special event, she’ll go to a different hairstylist. Comparing between the two is meaningless. However, if I go with my wife and I have the hairstylist cut my hair as well, I may discover that my haircut is the best it’s ever been. If that’s the case, because I am comparing the same action, I can say that the hairstylist is better than my barber.

If I have enough data on everyone who has had an appendectomy, I can compare outcomes of appendix surgery between major hospitals and small community hospitals. I can compare private surgeons to the VA in the United States. With enough data, I can pinpoint the action that I am comparing, and then look at the outcomes between two different medical facilities. The key is to ask the right question, and have all the data that is needed to determine the answer.

There is another factor that is to be considered. Guidelines are the standards by which doctors should be practicing medicine. I say “should” because there are a frightening number of doctors and healthcare facilities that do not follow guidelines to their full extent. It is astonishing that a doctor can treat a patient while being totally unaware of a recently published guideline that fundamentally changes treatment. But that’s the reality. I don’t necessarily have to measure outcomes. What I can measure is whether doctors stick to guidelines and thereby are providing the best possible care that we know how to give.

For example: until a couple of years ago, it was a standard of care to screen all men above a certain age for prostate cancer, using a blood test called PSA. A number of recent major articles based on huge studies have clearly demonstrated that screening men for prostate cancer using PSA causes more harm than good. As such, doctors should not be screening their male patients.

Now, in this situation, I don’t have to wait another 10 to 20 years to see what the outcomes of one doctor’s specific patients are, in order to know whether one doctor is better than another. All I have to do is check whether one doctor is following guidelines or not. The guidelines change based on our constantly changing knowledge base. But at whatever stage those guidelines are, that’s the best we can offer. The best that medicine can offer is for doctors to follow those guidelines.

It is almost frightening how easy it is to measure performance if you simply assess how well doctors stick to guidelines. And if there is a hospital where only 50% of the doctors follow standard guidelines for a given procedure, then that hospital is worse than another hospital where 75% of the doctors follow standard guidelines. Of course, the actual percentage should be 100%. There is no reason for doctors to not follow guidelines. But in the event that a doctor feels that the guideline is inappropriate, that should be documented clearly in the chart.

I know that the following sounds like a conspiracy theory, but this is what I (and many colleagues, including Mulder and Scully) see. Doctors don’t want there to be a simple solution for comparing better and worse health care. Eventually, when it becomes possible to say that one physician is better than another or one health care service is better than another, this will introduce an element of competition that has never existed before, and will force all doctors to dramatically improve their game.

This means that ALL doctors are going to have to spend a lot more time reading to keep up with the most recent guidelines, double checking that they have documented everything they’re supposed to document, and still find time to actually build a doctor-patient relationship. Under these circumstances, doctors will now start yelling at EMR companies to make guideline implementation automated. The doctors will want computers around them and they will want these computers to constantly check in and make sure that the physicians are doing what they are supposed to do. Imagine that – doctors begging to have EMRs.

There are many physicians who really do believe that progress is a tool that they can decide to use, or not use, whenever it’s convenient. They believe that there is something special about physicians that transcends measurement. They truly believe that even in 50 years from now, there really won’t be much of a difference in their specific roles. Maybe nurses will change, maybe hospital administrators will change, but physicians will effectively be untouched. This mindset is so entrenched that I have given up on arguing these points with quite a number of physician acquaintances I have. I’m not sure if they can’t understand what I’m saying, or if they simply refuse to understand it because of its implications.

Progress, as I said above, is inevitable. The roles of physicians will change, and measurement will become a key element of caring for people. It may be that eventually, the financial incentive and ego jump that people get from medicine will fade away. So who will become the doctors of the future – people who want to care for others, and are willing to suffer the slings and arrows that come with the job. If this is the future, I will embrace and I think Mulder and Scully will like it too.

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.