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I don’t trust humans to hear what I have to say

Doctors and patients need to find more effective ways of communicating with each other
Illustrative photo of doctors on their way to an emergency room, October 31, 2012. (Moshe Shai/Flash90)
Illustrative photo of doctors on their way to an emergency room, October 31, 2012. (Moshe Shai/Flash90)

A tremendous amount has been said and written about the loss of human contact between physician and patient, as computers become more and more present all around us. It is in fact one of the dreams of those developing the future of medicine, that everything from nanomachines circulating with our blood cells up to full size scanners that could take a complete snapshot of our health in a moment, that there be less and less of a need to depend on human doctors. While the human approach requires the painstaking process of understanding the history of the illness and then working through examinations and tests to try and hope to make a diagnosis, it is hoped that within the next few decades, computers will keep us healthy without us even realizing it.

Unfortunately, people base their impression of the potential of medical computing, on first level services available today, that are often more of a proof of concept than a real, usable product. The simplest and most obvious example is a classic present-day story of the patient who sits idly while the doctor types endlessly into a standardized form, that is meant to capture every nuance of every disease in every individual. This is obviously not the endpoint of electronic medical records [EMRs]. The time will come when a doctor will be able to focus entirely on the patient during a visit, without the noticeable intervention of silicon. Yes, it may take another 20 to 30 to even 40 years, until computers are that smart. But there is no way to get from here to there, without going through the difficult steps in between.

I should point out a pet peeve of mine, that there are supposedly so many brilliant physicians around, and yet none of them seems to be able to come up with a model for an interface that would streamline their own work and make the patient feel comfortable. I am not talking about physicians writing the actual software. I am talking about sitting with designers and developers and artists and coming up with a series of snapshots that would not only simplify the process of examining a patient, but also incorporate a whole set of functionality under the surface, that would protect both the patient and doctor from ridiculous errors, ignorant mistakes, lapses in knowledge, and failing to identify subtle clues to the correct diagnosis. But I digress.

So it is fair to say that many people fear the loss of the human element in the doctor-patient relationship. But there are also people [backed by a few studies] that admit their hesitancy in sharing certain details with human physicians. I remember back when I was a resident, when HIV was still relatively new and disproportionately frightening to many. While in the ER, I had an interaction with a patient who was suffering from AIDS. I entered the examining room, in the midst of a discussion with a colleague and very nonchalantly double gloved and then turned to the patient, the big smile on my face, and said my standard line “hello, I’m Dr. Kovalski. How can I help you?”.

It was at that moment that I noted physical signs consistent with tremendous emotional relief. I could feel emanating from the patient the sheer exhaustion that he had experienced from the cold and distant attitude of most physicians, because of his condition. He suddenly returned my smile and could not stop expressing his appreciation  at my managing his case. I didn’t have a private practice, but he kept asking me for my contact information in case he should need care again. I think it’s fair to say that the doctor-patient relationship had failed this particular patient. Interacting with humans was a nightmare for this person. And until today, I remember his face and his words. The problem is that once he left the emergency room, he was back to dealing with humans who made it more than clear that they would prefer not having to deal with him.

As strange as it may sound, there is another group of individuals who suffer from severe discrimination on the part of physicians. I am speaking about  the morbidly obese. There are countless studies that show that until today, attitudes towards the morbidly obese have not significantly changed. On every measure of the doctor-patient encounter, the scores are poor as the weight of the patient increases. One would think that the morbidly obese are carrying a deadly virus far beyond that of Ebola. The general population eschews the morbidly obese. And the caring, wonderful physicians out there, act, most of the time, in the same way.

As someone who has been morbidly obese most of my life, I share these people’s pain. In fact, at one point I thought of changing my specialty and becoming a Bariatrician, a physician specialist in obesity. And I remember being told by already practicing Bariatricians that I would succeed beyond my wildest dreams for one simple reason: I smiled at my patients. This group of patients suffers from prejudice and boorishness, no matter what EMR the doctor is using. The problem is not the software – it’s the human beings.

There was a study I read in the past year that demonstrated how patients would feel more comfortable sharing certain information with a computer but not with a human.  Many physicians are judgmental, and overtly patronizing. I remember an incident with my mother-in-law in which I presented an idea to a world-class expert in oncology. The manner in which he dismissed my idea was nothing less than insulting. For someone who deals with people at their most vulnerable, I was honestly disgusted by this physician’s behavior. Would a computer treat me and my late mother-in-law the same way? Would ego become an issue once we taught computers to be doctors?

The psychiatric sciences are in many ways the most sensitive of all. Imagine the human patient telling a human physician that he has sexual desires of the type considered severely elicit by the community. This by the way could be something as “simple” as a religious person falling in love with a nonreligious individual. It of course becomes more complex for many, if the couple is of the same gender. And if there is a significant age disparity between the two members of the couple, this could end up being a severe legal infraction which would rob the older member of the couple of his or her freedom for an indefinite period of time.

Psychiatrists and psychologists are a unique group of practitioners. For most patients, there is no CT scan that will verify the psychiatrist diagnosis and there is no medication that will eradicate the problem. Especially for psychologists, they’re not physicians and therefore they cannot prescribe medications. It is a well-known adage that to the man with a hammer, every problem looks like a nail. To the psychologist who must only rely on the power of speech, it could very well be that a case will be mishandled due to the personal prejudices and moral failings of the practitioner, rather than the reliance on medications, technologies and other treatments.

Contrarily, a computer system that could mimic perfectly the entire process of evaluating a patient for psychiatric illness, would probably succeed in finding the path to management or even a cure, better than any human. A computer system would not have body language that indicates displeasure or disgust or disinterest at what the patient was saying. There are formal studies that have demonstrated that certain psychiatrists and psychologists literally fall asleep at various points during their meetings with their patients. Computers would never do so.

Yes, a computer can be hacked. Yes, a person’s personal information could be spread across the Internet. But that’s the same situation as already exists today. The difference is that a computer could be programmed or taught to be empathetic and considerate, independent of the patient. A computer with keep all secrets and respect the ethical codes that bans any physician from sharing personal details about the patient with others.

A computer would not panic due to personal history, and mismanage the patient’s care due to personal biases. For myself, I would be far more willing to share my deepest darkest secrets with a computer than with any human. As much as we all live in the global village, it is still a village. As such, the barber talks to the butcher who talks to the psychologist who decides to break the trust of the primary patient. Computers wouldn’t do this.

Fear not silicon. But beware the human heart

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.
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