Why humans will never successfully be able to care for humans

I am presently looking at one of the newsletters I regularly receive and it has an excellent summary of the key features of a patient-centric healthcare system. The concept here is to treat patients like human beings rather than diseases, and to elicit patient participation in their own care. There is already significant evidence, which admittedly seems self-evident, that  patient involvement in their own care yields better results. At the very least, the patient does not feel like an outsider, when it comes to their own fate.

Once upon a time, if the patient dared ask a question, the answer would be “young sir, you are not a doctor. We are taking care of you and you just have to let us do our job”. And be sure that this statement was made, dripping with cynicism, with the clear intent of making the young patient and the family members around him, basically, shut up. You did not question doctors since obviously you were incapable of understanding their advanced science and thinking. And this attitude has carried over the millennia. It is literally only in the last couple of decades that there has been a growing level of respect for opinions other than that of the physician.  And much more recently, there has been a formalization of inclusion of the patient in the healing process.

In alternative health care, there is a tremendous emphasis on the role of the patient in their own cure. But classical medicine has always looked down on this approach. Thankfully and finally, things are changing.

There are five points listed in the summary of the article I was reading. And I’d like to address each one, while asking the question whether there is a reasonable chance that human physicians and other healthcare workers can succeed in the listed task.

The first point raised is to “Gain a deeper understanding of the patient to drive personalized engagement”. A great deal has been said about this in the last few years. It is important to understand the psychosocial background of the patient in order to understand and properly document the patient’s behaviors, all of which is important to the healing process. If a patient is depressed, then this will negatively affect outcomes. On the other hand, a positive attitude (and doctors actually washing their hands)  seems to almost magically improve cure rates.

The question is how to gain this deeper understanding of the patient. Without going into the available tools within the field of psychology and psychiatry, to understand the true persona of a person, I would argue that human beings are basically incapable of understanding the drives and behaviors of other humans. What is necessary is to observe humans as they act out their day and to infer from this there true personality.

So rather than ask the patient if he or she gets upset when another driver cuts them off on the freeway, it would be far more accurate to monitor their heart rate, blood pressure and maybe even brain activity during an episode of being cut off on the freeway. Rather than ask the patient if they feel safe in a given environment, it would be much more effective to monitor all the elements I noted above to see whether the patient is telling the truth. The idea is not so much as to create a lie detector. Instead, the intent is to identify how the individual actually does respond to various stimuli.

This information, linked to other health information, and processed by supercomputers that employ algorithms capable of analyzing billions of lines of data, will yield a proper and ideally, accurate answer to the task of gaining a deeper understanding of the patient and how to personally engage with him or her.

The next task noted, is to “Enable collaboration across the entire care ecosystem to impact clinical outcomes”.  Human beings do not collaborate. Human beings have the incredible capacity to fight amongst themselves even when their welfare is dependent on unity. Admittedly, there are very romantic tales retold of how people came together to fight a common enemy, whether in fairy tales or in real life during the war to end all wars, and the wars that followed that. But the general tendency of people is to be concerned about their ego, personal status, personal wealth, political standing, potential future gains and the like.

Collaboration can be thought of as negotiation that leads to a win-win situation. But this kind of negotiation takes time. And sometimes there is no win-win situation to be had because of the personal interests of both sides. I have been in multiple meetings where supposedly all members present wanted the same thing. Yet the opposing sides had an interest in different secondary gains and as such, the negotiations went on and on and never completed.

I personally spent seven years working on and off on a project that could have brought tremendous health care to one of the African nations.  The project fell through at a very advanced stage, but I was not even able to get an answer as to what was the cause of the failure. The people involved from my part were not looking to make a fortune off of this project. They were looking to pay their bills and make a reasonable profit. Somewhere along the way, somebody was looking to gain something that was not spelled out and was not anticipated. And as such, countless people continue to die for absolutely no legitimate reason.

Computers have no problem collaborating. They will work 24/7 modifying data and preparing it for transfer to any location that has been specified. They do not care who gets the data. They do not care who sends the data. They do not care who does more work in order to have the data be transferred. They don’t change their minds at the last moment. Once you press the button go, all you have to do, as a human, is to walk away and let the computers do their jobs. It is now considered a tremendous achievement that major electronic health record systems are actually sharing information with other systems. The reason this did not happen until now had nothing to do with the technical aspect of writing the software to complete the transfer. It had to do with ego and with greed. So allow computers to handle data transfer and there will be no problem.

The third point raised is to “Empower patients to be a part of managing their own care”. As I noted above, doctors are only now becoming comfortable with the concept of the patient being involved in his or her health care. Doctors are not yet comfortable with the idea of patients actually making decisions without the doctor’s approval.

This is not an unreasonable concern. If a patient decides to take one medication versus another, the doctor should be aware of this. But that’s not a problem. If the computer system involved has determined that a patient would best benefit from one of two or three different antihypertensives, then the patient can directly interact with the computer to gain an understanding of the true benefits and downsides of each of these medications. At that point, the doctor can be presented with the patient’s wish and the doctor can write the prescription.

If the doctor has a legitimate reason, based on the literature and his or her knowledge of the patient, not to prescribe that specific medication, then this can be entered into the computer as a challenge to the decision. How this challenge is handled will need to be decided on by a very senior panel of physicians and programmers. But in the vast majority of cases, the doctor (rather than the patient) will be the one who is informed of a medical decision that has been made. This is an exact reversal of the present-day situation, whereby doctors make decisions all the time, and do not explain the logic to the patients.

Understandably, doctors aren’t happy about this. If the question is asked whether the time will come when there is no need to ask human doctors for their input, the answer is, of course. The computer system with all of its knowledge about the patient and a complete understanding of the medical literature will always choose at least as well as the human doctor. And if the human doctor is not as up on his pharmacology as the medical  computer, the computer will invariably choose better.

The next point raised is “Proactively manage high-risk patients to reduce untimely readmissions”. Doctors consistently complain that the present health care system makes it impossible for them to develop a proper  doctor-patient relationship. This relationship requires time and focus. Due to monetary constraints, doctors argue that they simply do not have the time to spend with the patient in order to develop this close relationship. If the doctors were paid more per patient, then the doctors could see fewer patients per day and thus give each patient all the time that he or she needs.

The problem is that there are more and more people seeking physician care. Part of this has to do with the fact that the population is aging. The doctors’ solution is to make more doctors. Let’s just open up more medical schools and pump out more physicians who will spread out evenly across the entire country and provide the necessary health care. And of course, the doctors will do this while being compensated much more than they are being paid now. (Yes, I am being facetious).

The alternative is to have patients being constantly monitored by a network of sensors that are worn, implanted and even hung off the walls of their homes (or present in the walls). The computer system monitoring the human will know 24/7 exactly what the status is, of the person. If the person’s sugar goes too low because of a medication he or she is taking, the patient will be informed of this and will be able to take action before losing consciousness. And of course, this negative event will be recorded with all of the necessary details and will be transmitted back to the central database.

At this point, it may be a physician or some other health care professional or a computer that decides to modify the medications being taken. Independent of who/what decides, the computer system will continue monitoring the patient to see if there are any problems.

When patients leave the hospital, they often return to a home where there isn’t even the most basic medical care. But in the future when computers are constantly monitoring our welfare, the health care in a personal home will be nearly equivalent to the health care in a formal hospital. Robots that can perform ACLS (advanced cardiac life support) and deliver electric shocks to the chest will be standard utilities in any home where an individual has heart disease. The same kind of robots will exist in the homes of patients with diabetes and will inject glucose in the event that the diabetics’ sugar goes too low.

If the patient falls, then there will be immediate notification of the appropriate authorities and once again a robot will be able to help the patient sit up. Considering that ultrasound can be used to detect broken bones, it may very well be that ultrasound or other types of scanners based in the home will already evaluate the patient  before an ambulance arrives. In this way, the hospital will already be aware of the fact that the patient has broken his or her upper leg, and treatment will be able to be started as soon as the patient arrives at the hospital (if not already in the ambulance). Readmission will require a very unique situation where home monitoring and treatment will not be able to provide everything that the patient needs. As such, readmission rates will go down, but only because of constant computer monitoring and management, that keep the patient safe at home.

The last point raised is “Increase caregiver productivity while reducing operational costs”. I don’t think I really need to elaborate on this point. If you look up at the previous four points, you will realize that the human element will eventually be eliminated. Quality of care will improve, costs for delivering quality care will be reduced, outcomes will be better, and we will all benefit from better health.

Doctors still, almost pathetically, insist that there will always be a need for doctors. I suspect that there will be a need for some human type of medical specialist who will still be around to answer questions and to help in the further development of medically-based computer systems. But the number of such individuals, who may by the way require many more years of training and will be paid extremely well, will be smaller, much smaller, than the population of doctors around today. With computers delivering care, there will be nowhere in the world  that is too remote to properly monitor and manage any patient. The idea of focusing facilities in hospitals will change.. The best distribution of facilities will be based on hard data that comes from patients who live across a particular country. It may turn out that once you look at the data, it makes much more sense to put a hospital in a region that was previously considered of low importance.

Medicine is still based on a lot of guesswork and suffers horribly from the failings of human beings. One cannot expect more from humans than their best. But if we want a medical care system that really takes care of us, we effectively have to eliminate (or at least greatly minimize) the human component. Computers of sufficient capability will be able to deliver care anywhere, any time, to anyone for as long as needed, and will never get too tired so as to make a mistake in dosing. We have to accept this new reality and we have to work towards it. And whenever a physician raises his or her hand to try to argue that there will still be a need for doctors in the future, a hush should come over the room, and the moderator of the discussion should politely ask the doctor to lower his hand, as his question is no longer pertinent.

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.