Nahum Kovalski

The more things change, the less they stay the same.

I was giving a lecture to a group of senior citizens about innovations in technological advances in medicine. This was originally a two hour lecture that I had presented multiple times before, but I got it down to half an hour, leaving out anything that sounded too technical or possibly confusing for people who did not grow up with iPods. There was a question and answer period after I spoke and the first comment was an observation by one of the audience. She noted that as interesting and impressive as all of the new technologies are, what interested her was more time with her primary care physician, i.e. her family doctor. In her opinion, technology was only increasing the rift between her and her human doctor, and she very much preferred the “old times” when physicians would even make house calls. I was not really given an opportunity to respond, and truthfully, I think my response might have been hurtful.

When I was 14, I wrote my first program. The technology at the time required that I type my program, line by line, on to individual paper cards. I used not a regular typewriter but a special device that created holes in the card to match the typed text of the line. When I was done, I was faced with a pack of 50 cards that I passed over to a specialized technician, who then passed the cards into a huge device. A few hours later, I picked up the printed output and lo and behold, I had misspelled one word that required that I return the following day to make the correction and resubmit my program. There were plenty of more serious students who presented with hundreds of cards for their programs. And I remember one person who walked in with three box full of cards, all grouped in sections using rubber bands. Despite all of the effort involved, I was astonished at the possibilities.

I cannot imagine what it is like when someone’s first exposure to computing happens at an advanced age. More so, when the option to use technology is in fact an imperative, I can appreciate that a person feels they have lost a freedom. There are still people, of all ages, who prefer to wait in line inside a bank to get their money from a human teller, rather than deal with an ATM. But the number of such people is not growing. Eventually, they come to understand the simplicity and benefits of the robotic alternative to the human teller inside the bank. And without realizing it, they have joined the new technological age.

When it comes to medicine, an elderly person who is not feeling well may also experience anxiety and all out fear. The purpose of the physician is not just to order blood tests, make a diagnosis and write a prescription, but to listen. The listening part might be critical to the diagnosis, or it might not have anything to do with the problem at hand. The patient might simply want someone to pay attention to the fact that he or she is suffering. When doctors speak of a doctor–patient relationship, there is the assumption that sufficient time has been provided to develop a rapport between the physician  and the patient. Clearly, in an emergency room environment, there is much less time to do so than in a family medicine clinic which the patient has been attending for years, if not decades. But physicians will often argue that technology will never be able to replace this very human interaction.

I personally find this viewpoint problematic, due to comments from the very same physicians that speak so much of the importance of this relationship. I have heard time and time again, more so as time goes by, that physicians have less and less time with their patients. Whether here in Israel or in North America, the common lament is that doctors have only a few minutes per patient, if they want to be able to make a living. I challenge doctors on this point, and plainly say to them that they must decide: if they do not have time to develop a doctor-patient relationship, then speaking of it as the ultimate unique distinguisher from technology is moot. Instead, doctors should be desperate to find technologies that allow them to service the needs of patients who need minimal interaction [such as those needing a refill of a prescription] versus those that are perhaps presenting for the first time, but with a long litany of previous medical conditions and present treatments.

If I told the elderly woman who commented on my lecture that she must embrace email for the majority of her medical needs, she may have retorted that she does not have email, like many people her age. If I told her that technology is directly responsible for her reaching her advanced age, she may have responded nastily or hurtfully that the world has no place for people who are older. If I said to her that the time will come when she will be able to spend half an hour with a medical professional, but it will be a physician assistant, she probably still would have seen this as insufficient [despite the fact that there are many physician assistants who provide even better care than some physicians]. If I’d said to her, that technology is inevitable, and that she should focus her energies on learning not only email but also Skype and Facebook, she probably would have seen me as being totally insensitive. I honestly don’t think that I could have convinced this person that technology will eventually make people’s lives much better, far beyond what it has already given us. When I was a resident, studying surgery, elderly patients with gallbladder disease sometimes suffered severe complications just from the incision. 25 years later, laparoscopic surgery has almost eliminated such incisions and their complications. Specifically, elderly patients were spared long admissions and even death due to this new technology. But once again, even such an example would probably have not been convincing.

In many ways, we are in the midst of a transition from human-based care that is still modeled on the way physicians practiced decades ago, to a brave new world where many diseases will simply no longer bother us. The day will come within the next few decades [not centuries], when a network of sensors will identify health problems before we are aware of them. Such sensors will identify the patient whose heart is struggling, before there is a heart attack or the patient feels any symptoms. Such sensors will make sure that a diabetic patient never suffers from too low sugar. Such sensors will watch us 24 hours a day, seven days a week, constantly feeding data about our health to centralized services. These services will make use of technologies already in existence today, that will analyze and identify problematic patterns. Eventually, we will get a phone call from our doctors, where we are told that we must come in for a visit within the next few days in order to avoid a heart attack or stroke. Such services will automatically take over the mundane and repetitive parts of medicine so that we get our prescriptions on time, but our doctors are not bothered for them. Eventually, doctors will have more time to spend with the specific patients that need it.

The question is, if in this brave new world, will there even be a need for a formally trained physician to see most patients. Between computers that can truly mimic human thought and speech, and expansive medical guidelines derived from computer assisted research, and different types of non-physician health workers, it may very well be that only the sickest of the sick will need a uniquely trained human professional that will still be called a physician. Within a few decades, the idea that someone needs a human physician, will truly spark significant anxiety and fear, for such patients will have to be the exception rather than the rule. One thing is for sure:  both for physicians and patients, nothing will stop the tremendous pace of advancement in all forms of technology. For those who refuse to embrace this, I am sad to say that they will find themselves  truly left behind.

What could I have said to the woman who commented on my lecture, that would have been uplifting and calming. I could’ve said to her that she should look at her situation as an opportunity. If her doctor has less and less time to spend with her, then the trick is to maximize the efficiency of the time. If she knows how to use email, she should ask her doctor if she can email her request for refills. She may find that her doctor is happy to receive such emails in order to streamline the doctor’s daily work. It may be that she can even use email to ask simple questions. For example, she may want to ask if she can travel on a plane even though she is taking high blood pressure medication. Such a question really does not require a full visit with her doctor. And once again, eliminating such visits saves everyone time, money and their patience. The same woman may discover that having such access to her doctor is freeing. If she wakes up at two in the morning with a pain in her foot, she may simply send an email to her doctor describing the pain at length and asking if it merits a visit. In the response, if the doctor does ask her to come in, the doctor  will already have the detailed description of the pain. This will unquestionably save time and allow the doctor to immediately focus in with more specific questions and decide on continuing care. Once the patient has left the doctor, he or she would not need to worry that they forgot to ask “one more thing”. The option would always be there to send another email with that additional question.

I am putting aside the issue of compensation to the doctor for the time needed to answer such questions. And I am also avoiding the discussion of potential medical legal risk in interacting with patients in such a way. There are answers to these dilemmas. The point is that even the same elderly woman who felt abandoned by her human physician, could find a way to use a decades old technology [email] to dramatically enhance her healthcare and reduce her anxiety. The same woman would begin to feel that she has her physician on-call 24/7, even though the physician only spends a total of an hour per day reading such emails. There are many family practices that are run by multiple family doctors. In some cases, each of these doctors takes call, primarily in the form of answering phone calls after hours. The same doctors could also respond to emails after hours. Once again, an old technology can greatly enhance the patient’s sense of security.

When physicians speak of the doctor-patient relationship, they are also speaking of activities that happen when the patient is not sitting in front of the doctor. If both physicians and patients begin to use communication tools, such as email or Facebook, they may find that everyone is happier. I am purposely avoiding the issue of privacy, as there are those who argue that email is insufficiently protected and could allow for personal information to leak out. All the more so can be said about Facebook. Personally, I really don’t care if someone finds out that I or someone I love has high blood pressure or even cancer. I am ready to use any technology available to make sure that I have access to the best possible care.

Even when a person is feeling perfectly well, there is still an opportunity to use technology to keep themselves healthy and to provide answers, if they have times when they do not feel well. There are countless easy-to-read websites that have in-depth discussions about every medical topic available. And yes, physicians use these websites as well. It definitely happens that both a physician and patient have read the same website about a particularly difficult diagnosis. All one needs is a cell phone and Google to learn constantly about any topic they want. There is a general principle in medicine today, that a properly informed patient is an empowered patient. There is no one who will care more about you, than you. No one will have the same patience to spend hours on the Internet looking for information that is pertinent to their condition, than the patient him or herself. The beauty of mobile phones and most tablets today, is that their interfaces are very simple to use. The link to Google is right there on the first screen you see, and you can take as long as you like to type a description of what concerns you. If you read something that sounds frightening, then once again, you could use email to verify it with your personal doctor. In fact, you could ask your doctor for a selection of a few websites that do contain reliable medical information. It could be that you will get stuck on some of the words, because they are professional medical terms. But the same search engine can also function as a dictionary. And of course, if amongst your email buddies, you have someone with a similar problem, you can spend as much time as you want communicating back and forth in learning more about your own health.

There is a well-known quote that says that the only constant in life is change. Perhaps, this is what I should have said to the woman who commented on my lecture. Perhaps I should’ve offered her just a few more minutes of my time to discuss some of the points that I noted above. She wanted to feel safer. And part of the doctor-patient relationship is finding a way to do so, even when the answer is more and more technology.

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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