Doctors – A species on the verge of extinction?

Medical Hypotheses (2007) 68, 245–249

http://intl.elsevierhealth.com/journals/mehy

Editorial

Doctors – A species on the verge of extinction? A visit to the 22nd century clinic q Summary Medicine is undergoing profound change, but the basic format of the medical encounter has remained unchanged. Nevertheless, medicine in the 22nd century may be fully computerized, and a possible model is shortly depicted in this paper. Computer applications are constantly increasing their share in medical diagnosis, and may ultimately replace physicians. Treatment decisions have been submitted to standardized treatment guidelines, which may be applied more efficiently by computer applications. Although hundreds of studies have evaluated computerized tools in diagnosis and treatment, the possibility that computer applications may replace human physicians in the future is rarely raised. The effects of this process on doctors and medicine may be tremendous and will probably be felt even in early stages, and therefore, this process should be a subject of open discussion. c 2006 Elsevier Ltd. All rights reserved.



Introduction Medicine is undergoing vast and profound change. The rate of change is astounding and is a part of the rapid change affecting our society. This change is a result of several concurrent processes that include an information surge led by the genomics and proteomics revolution [1–4], economic shifts [4–6], social change in the status of medicine [7,8] and the increasing use of technology in general and the web in particular [9–11]. However, the basic frame of the patient–physician encounter has not undergone a paradigmatic shift. The aim of this paper is to describe one possible future for medicine and to delineate how current processes may lead to it. This importance of this paper is in bringing to open discussion the

q We have received no funding for this manuscript nor do we have any conflict of interest to declare.



possibility that doctors will be, to some extent, replaced by computers and the effects that this process will have on medicine.

A visit to a 22nd century clinic A clinic visit in the (not so far) future will start at home or at the office. The patient will be able to access his personal health account via the internet. Identified by the health services provider, the patient account information will be uploaded from a database including prior history, allergies and a detailed pharmacogenetic profile. Additionally a microchip containing a pre-recorded full scale personal genome scan will be accessed. The patient will then proceed to answer a set of questions that unfold following an anamnestic algorithm based on the patients’ past history, chief complaint and additional information provided in previous answers. The ‘‘MDputer’’ will then generate

0306-9877/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.mehy.2006.08.038

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Editorial

History taking Numerous applications that use anamnestic algorithms are already available [14–16]. Existing products may be time consuming and they will have to undergo significant improvement before they could compete with human physicians [17,18]. However, in principal, the basic logic of history taking may be reproduced by a computer application. Additionally, computerized history taking may have several important advantages. It can be performed on demand, at a place and time suitable for the patient, with no wait. It may easily overcome language barriers that pose a significant difficulty in many settings [19–21]. Finally, computerized history taking may reduce errors of omission compared with human history taking [22]. Figure 1

a set of probable diagnosis. The following diagnostics steps will be determined according to practice guidelines, and the ‘‘MDputer’’ will direct the patient to a service center according to urgency, patient convenience, availability and costs comparison. A full body MRI will be performed and will be compared by a computer application to the patients’ last annual MRI. A panel of blood test will also be drawn. Baseline medical history and genome based risk stratification will be evaluated with the results of the anamnestic algorithm, blood tests and MRI examination, and a working diagnosis will be established along with treatment recommendations. Probable diagnosis will be presented to the patient with the treatment options for a final decision. In most cases, treatment will be delivered to the patients’ home and will be monitored for outcomes, adverse events and compliance by a set of email reminders and follow-up messages (Fig. 1). The records of each and every patient will be analyzed by a global monitoring system that will evaluate system performance and will improve continuously diagnostic and treatment algorithms.

Discussion The proposed scenario, although speculative in nature, is a future projection of a process that has already begun [12,13].

Physical examination The role of physical examination has been receding over the past decades and is replaced by imaging studies. This may be demonstrated by the way in which echocardiography has replaced in many respects the auscultative expertise cultivated by generations of physicians [23–25]. Another example of this trend may include the change in the evaluation of the risk of appendicitis, where computerized tomography aided diagnosis has replaced a diagnosis primarily based on physical examination [26,27]. This trend is expected to continue as imaging technology improves, while becoming less expensive.

Imaging interpretation Computerized imaging interpretation applications have already been incorporated into several fields in radiology as aids to interpretation including, chest imaging interpretation [28–31], mammography interpretation [32–34,] and other fields [35]. Furthermore, it is interesting to note that in some instances the reported ability of the computer application was superior to radiologists and radiologists aided by computer application [28]. Aside from the eventual cost reduction, computer imaging interpretation may have other advantages, retained efficacy for screening procedures and shorter time between performance of the study and the interpretation of the findings. The replacement of human radiologists by computerized tools may precede this process in other fields of medicine because of the advanced state of the tools

Editorial available today and because in this field, direct contact with patients is more limited.

The diagnostic process The editor of the ‘‘Case Records of the Massachusetts General Hospital’’ has written in an editorial published in 2003, that ‘‘Now, at the turn of the 21st century, advances in diagnostic techniques mean that very few cases are real diagnostic mysteries’’ [36]. The current process of diagnosis includes establishing the probability of different conditions based on a set of parameters. This process is one in which computerized algorithm excel in [37], and have replaced humans in many fields of modern life. Diagnostic applications are being continuously studied [17,38–41] with improving results as applications evolve. The number of published reports has risen almost exponentially over the past several decades [39]. Although these applications are considered in most parts only as consulting aids [37,42,43], there are some indications that they would not remain that way indefinitely [44].

Treatment Treatment decisions have changed in the past century as well. Personal clinical experience has lost its place as a prominent tool in decision making. It has been largely replaced by clinical guidelines and data based on large clinical trials. However, guidelines implementation by human physicians is problematic [45,46] and the volume of data from clinical trials is overwhelming [47]. The surge in investigational information and the rate of development in medical science has made it increasingly difficult for doctors to remain updated. There is often a significant time lag between publication and implementation in the field [48]. Additionally, physicians are forced to concentrate efforts on small subspecialty fields in medical literature. Computer applications have a distinct advantage in this respect. Practice guideline implementation may be performed with greater efficiency and standardization [45], and updating may be performed in a centralized manner by dedicated personnel [19]. Several studies have demonstrated these capabilities [43,49,50–52]. One of the more striking examples was published in 1999 [53], in which a computerized protocol has achieved superior results in the ventilatory management of patients with adult respiratory distress syndrome, with only 0.3% of the instructions generated by the comput-

247 erized protocol overruled by the treating physicians. Other treatment related tasks that may be increasingly difficult for humans to perform, may be done efficiently by computer applications. These include dose adjustment for drug interaction, renal insufficiency and pharmacogenetic factors. Several studies have demonstrated the possible benefit of computer application in dosing of toxic medications and in improving medication dosing [54].

The role of humans in the future computerized medical healthcare system One of the greatest obstacles in the way of full implementation of a computerized healthcare system will probably be patients’ reluctance to ‘‘give up’’ the human doctor because of the value of human inter-relation and issues of patient trust. As stated before the process will be a gradual one and it will be accompanied by a parallel change in society in general, with an increase in the current trend of replacing human customers’ service with a computerized one. Another possible solution to the reluctance of patients to entrust their health solely in an automated system may be the use of human intermediaries, which may still be called doctors, but will have a greatly decreased level of independence and qualification compared with today’s doctors. Moreover, humans will probably continue to be a part of medical services even in the futuristic scenario depicted above. Two groups of workers may emerge: (1) Monitoring, quality assurance and algorithm improvement will be performed by a small group of researchers and physicians. (2) Medical technicians will assist in the routine operation of the computerized medical service by feeding necessary input into the system, performing manual procedures and providing telephone customer support. However, their role will be significantly different then today’s doctor.

Conclusion Although many published reports have discussed the use of computer applications, the notion of computers eventually replacing physicians is rarely suggested [44]. However, this process has already started and I feel that it should be openly discussed as it is bound to have profound impact on physicians around the world in the near future. It will probably be a long and gradual process but its effects on doctors’ position in society, professional

248 interest and remuneration will be felt from the early stages [9]. Whether or not the vision presented above will one day become reality is something that only time may tell. As a doctor I personally hope that if it comes it will be after my days. However, this vision should serve as a reminder, that our greatest advantage as human physicians is the fact that we can emotionally relate to our human patients, everything else is probably, at least to some extent, replaceable.

General statement Articles cited in this manuscript were retrieved using the Medline database. The search was conducted with relevant search terms such as ‘‘computer’’ or ‘‘computerized’’, ‘‘application’’, ‘‘diagnosis’’ and ‘‘decision support’’. Review or original research articles published in the English language were reviewed according to relevance to the subject of the paper.

Acknowledgements I thank my father, Prof. Emanuel M. Landau for his help in idea conception. I would also like to thank Mr. Yasha Rozov (Inkroom.com) for the illustration.

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Dan-Avi Landau Liver disease unit, Tel-Aviv Sorasky Medical Center, 6 Weizman St., 63426 Tel-Aviv, Israel Tel.: +97236973972. E-mail address: [email protected].