“20 Percent Doctor Included” & Dr. Algorithm: Speculations and Musings of a Technology Optimist

Healthcare has a radical opportunity to reinvent itself.  Healthcare today often results in suboptimal patient outcomes despite doctors doing the best they can within the current system.  Suboptimal outcomes result from the incomplete knowledge and personal biases of today’s system. Medicine has historically been approached according to tradition – the experiential evolution of best practices, and a reductionist system of small trials.  Optimal treatment outcomes require a healthcare system that is instead primed by holistic, scientifically, probabilistically or other statistically-validated data and conclusions presented to patients as cost/benefit choices. It is time to move beyond the stethoscope, which remains the iconic diagnostic tool for most healthcare professionals worldwide, 200 years after its invention.

Technology will reinvent healthcare as we know it. It is inevitable that, in the future, the majority of physicians’ diagnostic, prescription and monitoring, which over time may approach 80-percent of total doctors’/internists’ time spent on medicine, will be replaced by smart hardware, software, and testing. This is not to say 80-percent of physicians will be replaced, but rather 80-percent of what they currently do might be replaced so the roles doctors/internists play will likely be different and focused on the human aspects of medical practice such as empathy and ethical choices.  Healthcare will become more scientific and more consistent, delivering better-quality care with inexpensive data-gathering techniques, continual monitoring, more rigorous science and more available and ubiquitous information leading to personalized, precise and consistent (across doctors) insights into a patient. Disease will be measured not by the symptoms it creates but objectively evaluated by the metabolic pathways or physical parts it affects. Many new findings will be outside the reach of most physicians because of the volume of data and the unique holistic insights that data will provide about a patient’s very complex condition. Hundreds of thousands or even millions of data points may go into diagnosing a condition and monitoring the progress of a therapy or prescription, well beyond the capability of any human to adequately consider.

This evolution from an entirely human-based healthcare system to an increasingly automated system that enhances human judgment will take time, and there are many ways in which it can happen. Likely the next decade will mostly see systems providing “bionic assist” to physicians and complementing or enhancing their skills. Today’s traditional approaches will get better as new approaches, and even new medicine, is invented. As the 80-percent of physician work is replaced over a few decades, the remaining 20-percent will be AMPLIFIED, making them even more effective, and allowing even the average physician or nurse to perform at the level of the very best specialists. Doctors will be able to operate at substantially improved levels of expertise in multiple domains, and they also will be able to handle many more patients. The primary care physician and maybe even the nurse practitioner may be able to operate at the level of six specialists handling six areas of care for one patient with multiple comorbidities in a more coordinated and comprehensive manner without inter-specialist friction. This transition will affect each group of actors in the current system differently. Internal medicine will be transformed to the greatest extent. Procedure-based medicine may take longer due to the nature of the surgical art, and procedure-volume based incentives. Some constituencies will be affected favorably in some dimensions and worse in others, but the net benefit will be substantially positive for society and individual patients.  It is likely that a focus on science, data, and personalization will lead to plenty of unintended benefits that we cannot anticipate today. Nurses will be made much more capable by technology, often replacing the functions only doctors perform today. New medical insights, including ones we cannot yet envision, will be commonplace, and the practices we follow will be substantially better validated by more rigorous scientific methods.  Projects like the Cancer Moonshot will apply rigorous genomic, proteomic and phenotypic tools and within large trials, to optimize the inadequate patient outcomes in oncology practice today.  Though medical textbooks won’t be “wrong”, the current knowledge embodied in them will mostly be replaced by much more precise and advanced methods, techniques, and understandings.

My statements are not forecasts that the hospital burn unit or emergency department will run without any humans on staff. Though the early changes will appear underwhelming and clumsy, in a few decades they will seem obvious, inevitable and well beyond the changes we might envision today. Expect today’s expert doctors to think these changes are implausible when they are asked about this possibility, and expect the classic response of “human judgment will not be replaced by technology”.  To them I say: The nature of technology’s exponential curve is non-intuitive for humans; the capabilities of smart technologies in 2030 (hardware, software, tests) are hard to imagine, just as today’s smart phones were unimaginable 15 years ago. Even most software experts are unqualified to judge where technology will lead in two decades, let alone doctors who have little familiarity with the rate of progress and possibilities in these areas. The role humans will play in this is hard to define exactly but I suspect strongly that their role in healthcare will change materially.  It is possible that a much more cooperative system leveraging the respective strengths of both humans and technological systems may also evolve, as proposed in the book Race Against the Machine.  However, the core functions necessary for complex diagnoses, treatment, and monitoring (as a significantly expanded function of healthcare) will more than likely be driven by machine judgment instead of human judgment alone.  In fact, as Atul Gawande pointed out, some studies showcase that “our attempt to acknowledge and deal with human complexity [in human ways] causes more mistakes than it prevents.” 

This transformation will happen in fits and starts along different pathways with many course corrections, steps backward and mistakes as we figure out the best approach. Given the importance of having clarity on what I hypothesize as my forecasts, I want to be clear that they are only directional guesses rather than precise predictions. Further, though many different disciplines will contribute to the innovation in medicine like biological research or new device development, I am mostly concerned with the contributions of digital health technologies (smart hardware, software, tests) to medical innovation. This should not be underemphasized, as these contributions, though potentially the most significant, are also the most variable, and hardest to predict in direction, timelines and scope and the ones that will face most resistance from human practitioners and organizations who will likely try and delay them.  The rates of progress in internal medicine, procedural medicine, acute care, chronic care, diagnosis etc. will each have its own tortured path to this much better place. The other sciences will continue to contribute much more fundamental insights into human well being.

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