Wednesday, May 8, 2013

The future of medicine is low-tech and high-touch

Last month, one of my students told me about his experience at TEDMED, the future-oriented medical conference that bills itself as "a celebration of human achievement and the power of connecting the unconnected in creative ways to change our world in health and medicine." He recounted how one speaker showed off the Remote Presence Virtual + Independent Telemedicine Assistant, which news outlets quickly dubbed the "Robo-Doc." This high-priced gadget is designed to provide remote medical services to patients who wouldn't otherwise be able to see real-life doctors, but my student told me that the presentation didn't talk about that much. Instead, he felt, the speaker's message seemed to be: "Robots are cool, so let's make more of them."

Along similar lines, a recent TEDMED blog post on the smartphone physical describes how a team led by an enterprising Johns Hopkins University medical student created a virtual "checkup" from a combination of smartphone-powered devices. These devices measure standard physical examination parameters such as body mass index, blood pressure, and visual acuity; and less routine tests such as oxygen saturation, electrocardiography, lung function testing, and carotid artery visualization. In addition to collecting far more data than the traditional checkup, the smartphone physical touts the advantage of using devices that are "smaller and less invasive" - no more "fumbling" to take a patient's blood pressure, for example. One commenter gushed, "Getting a smart phone physical was so fun. I got an EKG and an ultrasound of my carotids in under three minutes." So what's not to like?

I'm hardly a Luddite when it comes to adopting the latest in medical technologies, including electronic health records and smartphone apps. But I think it's worth asking how likely it is that high-tech innovations such as robo-docs and smartphone physicals will actually improve patients' health outcomes. For the latter, the answer is not likely at all. A comprehensive review of the evidence on traditional checkups in adults found that they increase the number of diagnoses per patient, but have no effects on hospitalization, disability, worry, absence from work, morbidity, or mortality. Based on other systematic reviews, the U.S. Preventive Services Task Force recommends against doing EKGs, spirometry, or carotid artery ultrasound in healthy adults because the harms of these screening tests outweigh any benefits. False positive results on that 3-minute EKG and ultrasound may lead to an unstoppable cascade of costly cardiovascular stress testing and invasive coronary or carotid angiograms, which can cause serious adverse effects.

If you really want to see the future of medicine, skip TEDMED and head over to Camden, New Jersey, where a family physician named Jeffrey Brenner showed that providing intensive primary care to patients with the most complex illnesses dramatically improved disease outcomes, quality of life, and health care costs. Then hit the road for Lancaster, Pennsylvania, where a similar program empowers "super-utilizer" patients to take control of their health care by providing them with comprehensive, multi-disciplinary case management and social support. On your way, stop by Health Quality Partners in Doylestown, PA, which has improved outcomes and reduced hospitalizations and costs for the sickest Medicare patients through the revolutionary innovation of - wait for it - regular nurse home visits. Here's what Dr. Brenner told Washington Post Wonkblog columnist Ezra Klein when asked what he thought of the Doylestown program:

"There is a bias in medicine against talking to people and for cutting, scanning and chopping into them. If this was a pill or or a machine with these results it would be front-page news in the Wall Street Journal. If we could get these results for your grandmother, you’d say, ‘Of course I want that.’ But then you’d say, what are the risks? Does she need to have chemotherapy? Does she need to be put in a scanner? Is it a surgery? And you’d say, no, you just have to have a nurse come visit her every week."

Later in the column, Klein reflects:

We’ve been conditioned by “Grey’s Anatomy” and hospital rooms to believe that saving lives is a complicated, heroic business. And it is — after people get very sick. But keeping them from getting very sick doesn’t necessarily require the discovery of new molecules. It requires someone who has a relationship with them to stop by once a week to see how they’re doing. The problem is, it’s hard to make money off it.

Pop culture and perverse financial incentives inherent in fee-for-service payment reinforce a bias for health care services that are high-tech and low-touch. Yes, robots and smartphones can and will play vital roles in the future of medicine. But if we really want sick patients to have the best chance to get better - and healthy patients to avoid getting sick in the first place - then we should do everything in our power to support low-tech and high-touch interventions too. A logical first step would be for Medicare decision-makers (this means you, Marilyn Tavenner) to reconsider their short-sighted decision to cut off funding for the Health Quality Partners program in June.


  1. Wholeheartedly agree. . . another good reference is "The Seventh Element of Quality:
    The Doctor-Patient Relationship" Mendoza, Fam Med 2011.
    The doctor patient relationship is low tech, hi return.

    I do believe in hi tech IF AND ONLY IF it is a tool in our tool box that we use appropriately to enhance our service and relationship. AND SAVE cost while improving outcomes.
    Caution the millions of under-served or rural patients who may not even have decent net access.
    Side note: I get a little worried about Dr. Topol using Medscape as a vehicle to push too much hi tech. I am concerned it will hit the political realm and become part of policy and law.

  2. I think you are dead on but the public is slow "afoot" when it comes to some of these ideas. What is needed is a tv series that is edgy that quietly introduces these ideas into the mainstream. If people knew the real risks associated with false negatives they would squirm when some one promoting a gimmick approached them.