Dr. No

Throughout all my blog posts, there has been an underlying theme about the ultimate patient and physician acceptance of future technologies. My attitude has definitely been that “like it or not”, people will accept all of the changes that are coming in medical care, primarily due to the computerized nature of the entire healthcare process. My feeling has been that people of all ages and all backgrounds will eventually “come around” to the clear benefits of new computer-age medicine. As such, it is just a question of time and patience until the entire world wholeheartedly accepts all that siliconized physicians have to offer.

When I was a medical student, one of the hospitals I trained in was very unique, because it housed a hospice on one of its floors. Generally speaking, hospices were seen as a service that was almost opposed in principle to the philosophy of a standard hospital. The hospital was meant to accept patients who had the clear intent to get better, or at the very least to keep fighting for as much time as was medically possible. A hospice, on the other hand, was viewed as a place where the physicians and patients effectively gave up. In a hospice, there was a philosophy of acceptance, and the focus on maximizing the quality of the time naturally left in this world.

I met quite a number of doctors who were very upset by the presence of a hospice within the hospital. these physicians felt that the mere presence of a hospice, in proximity to “real patients”, sent a negative message to all. The anti-hospice physicians were seriously concerned that their patients would effectively commit suicide by “resisting treatment”, all because of a whiff of a hospice patient nearby.

I am not exactly sure where this paranoia came from, and to be honest still exists. Admittedly, medical school focuses on curing patients as often as possible. There is very little discussion of patient management, when modern medicine has little to offer. Occasionally, you might hear a throwaway statement to the tune of “just control their pain and move on”. The dismissive tone of phrases like this definitely sent a subliminal message to all of the medical students that a patient who “refused” to get better, wasn’t really worth our time. Given such a mindset, it is not hard to understand why doctors should be resistant to the idea of people who have accepted their diagnoses as being terminal, and are now focusing primarily on being as comfortable as possible, so that they may enjoy their friends and family and personal activities for as long as they have.

The head of the hospice in the hospital where I was rotating was a fascinating man. Firstly, after only a couple of minutes with him, you already felt calmer and safer. This physician emanated an aura of kindness and true caring. I really can’t say that I experienced such character in all of the other doctors I met. I even seriously considered becoming a hospice physician, because of this doctor. In the end, I chose a surgical specialty. Surgeons were cool and this definitely attracted me. But I can’t honestly say that my career choice was the best match for my personality.

At one point during our session in the hospice, the head physician told us his personal story. He started his career as an oncologist, i.e. a specialist in cancer treatment. Oncologists tend to be very driven physicians, who are always looking for alternative therapies to treat some of the most difficult patients in medicine. You very much need to have a “yes we can” mentality in order to function and even thrive in oncology. Otherwise, it is just to emotionally difficult. The hospice director looked at us and asked the group “why would an oncologist switch to hospice care?”. after about a minute of silence, the hospice director raised his head and said “I got tired of treating patients. I wanted to start taking care of them”.

I have thought about this statement during my entire career as a physician. Throughout my blog, I have constantly spoken of a huge range of technological advances which will make it possible to better diagnose and treat all of the diseases that plague mankind. I have openly challenged the concept that, in 50 years from now, there will still be a need for doctors to provide the “human” component of medicine. I stand by my challenge, because in most cases, doctors themselves do not truly appreciate the value of this human component.

Many doctors see being kind and compassionate to a patient as an effective strategy when there is nothing else that is “medically real” to offer. But when a patient can be helped with surgery or an invasive procedure, I have witnessed doctors becoming openly angry and aggressive when the patient refused the care. I have heard doctors speak of resistant patients as having wasted the doctor’s time.  I don’t think I have ever heard such doctors speak of the need to understand why the patient is resistant in the first place.

Many doctors measure their self-worth in terms of how many patients they cured. When a patient refuses care, for whatever reason, some doctors take this as a personal affront. The patient, rather than fulfilling his or her traditional role, is denying the physician the opportunity to feel important and productive. Given this perspective, it is definitely more understandable why doctors should be so upset when patients prefer not to be treated.

The same doctors’ mindset also explains the resistance of physicians to advanced technology that will eventually replace all of the technical aspects of healthcare. If a computer/android can measure all the vital signs, prep the patient for surgery, decide what radiological studies are necessary, come up with an evidence-based plan for surgery, do the surgery and then handle the patient throughout the entire postoperative period, then many doctors legitimately fear that they will no longer be useful. If the only thing the doctors can provide is the technical aspect of curing a patient, then doctors will be replaced just like assembly-line workers.

What should be happening is that doctors should be exploring fields of healthcare that will still be beyond the range of computerized skills. What happens when the patient says no to a computer, that has just explained why the patient needs a particular surgery. The computer will re-present the mathematical and statistical argument for why the surgery is recommended. But when the patient still says no, the computer might very well develop a migraine.

Digital doctors, at least in version 1, will not be designed to handle patients who have non-quantifiable reasons for rejecting care. A human physician could sit with the patient and eventually figure out that the patient is dissatisfied with life, alone since the death of a spouse, and simply is not interested in extending his or her life. Given the diagnosis that the patient has, he or she might only want pain control, in order to avoid the suffering that comes with the advancement of their disease. It will take time until computers are able to, at least, simulate a compassionate stance on such patient demands. It will take longer for computers to develop the necessary algorithms to self-justify providing pain control when a viable surgical procedure is available.

At least for the next few decades, humans will still be needed to provide the human element in healthcare. I wonder how the admission process for medical school will change when the medical school directors finally realize that rote learning is no longer a key element of medical training. I wonder how the admission board will measure compassion on the part of medical school applicants. Finally, I wonder how the public will perceive physicians once their role as divinely inspired healers is replaced by a new role as humane care providers. Perhaps, doctors will be given the nickname “Dr. No” because it will become their primary function to deal with patients who struggle within a totally computerized healthcare system. If I manage to hang around for another 30 years, I imagine that I will get to personally experience this new reality in healthcare, from the patient’s perspective. And there is a good chance that at some point, I will say “no”.

Thanks for listening

My website is at http://mtc.expert

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.
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