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I miss my brother

My relationship with my brother was much more of an intellectual one rather than throwing the baseball around.
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)

My brother passed away many years ago, having succumbed to a metastatic cancer that dogged him for years. I was 24 at the time and now I am 52, so you can do the math. My brother was in the middle of his PhD work in physics at McGill University in Montréal Canada. He was surrounded by geniuses, which was appropriate, as he was a genius too.

I do not use the term “genius” lightly. There is a tendency to make use of extreme terms such as “brilliant” and “unique” in order to reflect our emotional response to a person or event. Strictly speaking, these terms should be used only when analytically appropriate. For example, there are strict definitions for the term “brilliant”. While it may be pleasing to refer to all of our acquaintances and especially our children as being brilliant, this clearly dilutes the term, and leads us to under appreciate those that truly excel.

I was reading the following article about mistakes in mathematics. This article speaks about the top minds in the field of abstract mathematics, and describes how these top-level mathematicians deal with the possibility, and occasional reality, of making errors that may take hundreds of years to discover. This article reminded me of many of the discussions I had with my brother, where he would tell me stories about some of the top minds that he had the good fortune to work with.

My relationship with my brother was much more of an intellectual one rather than throwing the baseball around. First of all, I was lazy and preferred watching TV to going outside. Secondly, although I really didn’t understand much of what he said, I really enjoyed the way he said it. So in the end, our exchanges were about physics and math and religion and other simplistic topics.

He once told me a story about a class that he attended as an honors student in undergraduate physics. The professor, who was very appropriately named Dr. Sharp, explained to the class that he was about to show them a proof that they would never use, but should nevertheless have imprinted on their subconscious. My brother told me how after 15 to 20 minutes of the professor writing on the blackboard, the entire class had become lost. When a class of 11 honors physics students get lost, the topic is most likely very complicated.

Actually, I must correct myself. There was one student in the class who was not only following the proof, but was actually correcting Prof. Sharp. This classmate of my brother raised his hand at one point and informed Prof. Sharp that he had accidentally written a “-” where it should have been a “+”. Not only was this student following the proof, he was correcting it. It is of note that this student ended up working with Stephen Hawking.

Through these stories, I developed a tremendous admiration for physicists and mathematicians. I am not being self-deprecating nor am I looking for compliments when I say the following: it is a simple fact that I do not have anything near to the mental capacity to seriously study advanced physics and/or mathematics. But my brother did. What was even more special about him was that his mind extended to multiple areas of interest: history, politics, religion (not only Judaism) and more.

He told me once how he dealt with the frequent question of merging science and religion. My brother wore his kippah at the lab, and this definitely sparked a number of conversations with his colleagues. He was once asked how he can simultaneously believe that the universe is approximately 6000 years old, and also believe that by physical measurements, it is many billions of years old. In a very rabbinic fashion, he answered in a way that has stayed with me for all these years. He simply stated that there is only one truth. Physicists like this concept. When faced with contrary findings or theories, they always remember that there is only one truth. As such, my brother would simply state that both measurements of the age of the universe are true, and both are part of a single truth. It is our task to find how these two totally disparate measurements can coexist. In other words, it’s our problem, not G-d’s.

The article I linked to above speaks about the occurrence of mistakes in the most complicated mathematics that human beings can master. And because of the nature of these mathematics, proving a theorem and at the same time, identifying mistakes in that theorem, becomes a Sisyphean task. It also seems somewhat wasteful to have  the most brilliant minds on the planet spend their time proving theorems that they have already deduced.

One would think, especially in this day and age of digital miracles, that computers could assist mathematicians in the more tedious and time-consuming parts of their work. The article goes on to explain how this is actually implemented. The author of the article does a masterful job of describing this issue, and I strongly recommend that you read and enjoy the original article rather than follow my inadequate summary of the material. What I took away from this article was the overt willingness of these great minds to accept the fact that they make mistakes. More so, there is definitely a willingness amongst a good number of these geniuses to use computers to assist them in identifying those mistakes.

There truly does not seem to be an issue of ego in this matter. Admittedly, even in the article, there was recognition of the fact that the pressure to publish also affects mathematicians. But from my experience of my brother and from the comments in this article, there truly seems to be a focus on uncovering the truth. And this drive for the truth seems to overwhelm the personal standing of an individual mathematician or physicist, in their professional community. More simply put, mathematicians and physicists really want to know what’s happening in the world around them, without any sugar coating.

I think that anyone who has read my previous blog posts, can readily predict what I am about to say. It greatly saddens me that I fail to see such pursuit of the truth in the medical profession. Time and time again, I come across examples of physicians who know the truth [based on controlled studies that have been done and have had their results tested and proven] but ignore it.

Doctors know they are supposed to wash their hands before seeing a patient, but they don’t. Doctors know that they should be far less liberal with the dispensing of antibiotics, but they continue to write endless prescriptions just to get the patient out of the office. Doctors with even a modicum of intelligence and insight realize that computer assistance will become fundamental to the practice of medicine in the years and decades to come. Nevertheless, countless leaders in the field of medicine continue to speak to the inability of computers to perform the art of medicine.

In my previous place of employment, I had the opportunity  to design from scratch an electronic medical system that primarily serviced the needs of the physicians. This is by no means a trivial or self-evident point. The primary complaint against almost every EMR in the market is that their focus is on collecting administrative information that does not contribute to the welfare of the patients. The EMR that I designed placed clinical  factors first. My EMR also dealt with administrative needs, but did so in the background without involving the physicians. This led to a streamlined interface that was comfortable and very easy to learn.

Since I had designed the code, I also was able to constantly modify it, in order to enhance its clinical value. I should note that I was very fortunate to have a colleague who worked alongside me for years, developing major components of the system. Although she herself was not a physician, she quickly learned the issues at hand and greatly assisted me in bringing my EMR to life, in “my image”. In any case, I had full access to the code and could modify it as I saw fit.

Being both a senior physician with more than two decades of experience, as well as the software developer of the EMR, allowed me to bypass the committee-based approach to EMR development that is common in most medical institutions. In my head, I would have my IT lobe speak to my medical lobe and work out the best solution for a given clinical need. The amount of time that my approach saved is was tremendous (and probably translated into months, if not years, of saved time).

When it came to designing clinical assist tools [tools that would watch over the physicians and guide them away from error and towards proper medical management], my EMR really began to shine. In one case, we were able to reduce by half the number of unnecessary antibiotic prescriptions for sore throats, via the incorporation of a pop-up that required justification of the prescription. The change we encountered in prescribing patterns was overnight. Since the doctors could no longer just write “fever” or “sore throat” and then write a prescription, the same doctors realized that in most cases the prescription was not necessary.

We saw such precipitous changes in a number of clinical activities. Tests that were not being ordered when they should have been, began to be ordered appropriately after the incorporation of a clinical assist tool that reminded the doctors to order to test. When giving a certain medication could be problematic, the physicians were simply not allowed to order the medication until they explained why they were overruling protocol. The end result was a drastic drop in the inappropriate use of these certain medications.

Ultimately, physicians desperately need to recognize their fallibility  and their limited capacity to stay up-to-date with the barrage of new medical information. Things change so quickly in the medical world that a physician can find him or herself out of date within a year of failing to read medical updates. If mathematicians and physicists can appreciate the benefits of computers in their work, why can’t physicians come to the same conclusion? If genius minds in the hard sciences can overcome their ego to admit their own mistakes, why do physicians insist on acting in a way which is totally error-prone?

Considering the relative intelligence of physicians in comparison to mathematicians and physicists, perhaps doctors simply lack the mental capacity to understand the importance of accepting their own fallibility. My approach is actually quite practical – I no longer rely on physicians to be sufficiently self-aware to follow guidelines and protocols. It is my belief, which is reflected in the code I have written, that physicians must be taken by the hand and guided through the majority of their day-to-day work. It is actually based on this belief that I see no legitimate argument against the incorporation of physician assistants and nurse practitioners into the regular medical work that is performed around the world. These healthcare providers do not need an MD in order to assess their patients and follow along with  an advanced computerized clinical  protocol.

Does all this computerization reduce physicians to technicians? Well, it doesn’t reduce mathematicians or physicists to technicians. Simply put, physicians have to find those elements that are unique to them and which are still not provided for, by the most advanced computer systems. And this will be the same situation in 30 years from now when, by Moore’s law, computers will be a million times more capable than they are today. In 50 years from now, computers will likely be at least a billion times more capable than they are today. No one can predict how all of this incredible computer capability will manifest. But I can say that the practice of medicine will fundamentally change with all of this available CPU processing. Physicians who fail to ride this tsunami of innovation will quickly crash against the shore. Patient care, on the other hand, will continue to improve as, to say it bluntly, physician involvement is more and more contained over time.

I miss my brother. I know that he would smile and even laugh at some of my blogs that talk about  the world of medicine smashing up against the wormhole of IT. I know he would’ve read this particular article about mistakes in mathematics and thoroughly enjoyed it. And I would’ve loved to have heard his impressions of this article and perhaps a few more stories from his own experiences.

I miss my brother. I miss his genius. I miss his unique perspective and his vision, that was not limited by the neuronal mess that makes up my own brain. I knew that he could give me answers in a way that pretty much no one else could. To this day, I still find myself suddenly straightening up and finally understanding a comment that he made to me all those decades ago. I am still learning from him. That is also the mark of true genius.

To my medical professional colleagues, I wish to say “wake up”. Do what you need to do to come to understand how computers are essential to protecting our patients from our errors. Find a way to work together with EMR designers to create systems that streamline your work and guide you towards the best possible care that you can then provide to your patients. Learn from people who are so much smarter than you are. They have a great deal to say and to teach. Listen to what they have to say.

I will end this long blog post with a recent story that I heard, related to the discovery of the Higgs boson. In the simplest of terms, had the physicists working on this project failed to demonstrate the presence of this subatomic particle, it would likely have demanded a complete rethinking of some of the most fundamental concepts about our universe and its origins. When one of the physicists was asked about the repercussions of such a discovery, that would effectively nullify decades of research and theoretical work, his response was akin to “that would be really cool”.

Imagine a medical world where doctors embrace error because they know that it is the way to finding the truth. Imagine a medical world where doctors work together purely for the welfare of the patients, because delivering proper medical care is why doctors became doctors. Not their salaries, not their bonuses, not their offices – doctors became doctors for the people they treat.

Thanks for listening for so long

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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