Imagine a world where you can monitor your blood glucose level 'live' every time you turn on your iphone.
Imagine being able to just scan a mole on your iphone and using an App to find out if it is cancerous or pre-cancerous.
Imagine having a portable angiogram built into your phone so that all you have to do is place it near your chest and wait for two more minutes.
Imagine being able to monitor the quality and duration of your sleep every night through your smart phone.
Does it all sound far and distant and a remote possibility to you...
Imagine being able to just scan a mole on your iphone and using an App to find out if it is cancerous or pre-cancerous.
Imagine having a portable angiogram built into your phone so that all you have to do is place it near your chest and wait for two more minutes.
Imagine being able to monitor the quality and duration of your sleep every night through your smart phone.
Does it all sound far and distant and a remote possibility to you...
Well, Think again ! This is the present! :)
This was the message that was screaming from the slides of a recent presentation I heard which was titled - "The creative destruction of medicine". It was a fascinating talk by a great orator - Eric Topol on how the digital revolution will create better health care for us all.
What I took away from the talk was this sense of hurtling towards a future where every aspect of our well being would be digitally monitored and controlled. And I know that doesn't sound very welcoming from how I said it - but to my mind this is an alarming trend. Not in the least because I am against technology or against computers - I love all the gadgets that have come along and made almost everything accessible at the press of a button or rather at the touch of a screen; but I do not like the way technology has invaded into the human space and is constantly nudging out the human influence from every sphere of life. It is also distressing to think of all the complications that can possibly arise and that have not really been considered by people in their hurry to promote and adopt technology.
Some of these, are great applications and probably have great potential to reduce medical costs and to widen the influence and reach of quality health care but there are many questions here which need to be addressed carefully and I am worried that the technology 'cloud' is growing much too fast to let everything else catch up with it.
There are already examples of e-consultation, e-supervision, e-care in many hospitals where they have a centralized unit that is constantly monitoring the ICU and its patients through cameras, videophones etc. An example of this I came across recently was from the New Yorker piece by Atul Gawande about the 'Tele-ICU' set up in the Steward health-care system which was testing out this model of intensive care. As part of this telemedicine model, a centralized ICU command center was set up involving banks of computer screens that carried a live feed of cardiac monitor readings, radiology imaging scans, and laboratory results from the ICU patients throughout the Steward's hospitals. Softwares and codes monitored the results and produced yellow and red alerts when they detected patterns that raised concerns. Doctors and nurses manned the consoles where they could turn on high-definition video cameras and zoom into any ICU room and talk directly to the staff or the patients. With a total staff strength of 4, this set up was able to actively monitor and support the ICUs across ten remote hospitals. And with this perspective, when one thinks of the quote from an Indian entrepreneur in the Silicon Valley that medicine needs more software codes than doctors - one can almost understand....
"But" and this is a big glitch for me : technology and computers are invading our lives much faster than we are preparing for them. Imagine the issues that can possibly arise :
- Imagine a time when everyone would be able to access their vital stats and symptoms through their smart phone and have all the necessary tools for diagnosis from google. It would potentially make us all self-diagnosing hypochondriacs (or cyberchondriacs as Dr Topol likes to call them). Are we prepared for computers tracking and telling us about every breath we take or every heart beat of ours? Are we prepared to trust the internet for solving all our problems all the time? Because, as wonderful as this mass sharing of information is - it does leave plenty of room for wrong information to seep through. No one is really keeping track of the accuracy of all information available on the web. And if people lose track of this reality - problems will be less than a "touch-screen" away.
- Imagine issues with privacy... People hack into your accounts, steal your phone or your computer and they can find everything about you including your physical and mental status, disease risks, threats and allergies. People hack into public databases, monitor your search history and they will have access to all the weaponry they need to influence you. What happens when people use health risk to discriminate for employment, insurance, friendship or for that matter anything else. A lot of this is already happening is proving to be a challenge to the regulators!
- Insurance firms already discriminating for pre-existing conditions - how long would it take for risk and lifestyle factors to be factored into the equation... ? Would my risk for diabetes or heart attack (based on genetics, sequencing or family history) justify their over-charging me from adolescence or even adulthood?
- Another interesting facet that emerged from the question answer sessions with Dr Eric Topol is the regulation of these apps and technologies. I was surprised to know that some of these apps like the one for screening moles is not regulated or FDA approved. It sure maybe a great piece of work and rather accurate but if there are no checks and balances, anything and everything can find its way to the masses and that would be sure shot recipe for disaster. But the regulatory authorities and the control bodies are not yet effective and fully aware of the possible threat of these tools. How do you limit the access of technologies available on the web without being labeled a moral watchdog? Does an approval in one country automatically mean an approval for all others? Does an App or a software that work for caucasians work equally effectively for all other races - after all there are genetic, social and cultural differences among people.... How do you control the spread of the internet without being prejudiced or biased or dictatorial? Apple is already attempting and is fairly successful at establishing a monopoly of sorts in the field with its devices and its Apps. How do you thwart such issues of intellectual property vs public welfare ?
- And then consider the possible impact of genome sequencing. The costs of sequencing an individual's genome have come down so much that it can be afforded by normal people like you and me and the decline is an ongoing process. From being a decade long exercise that it was when it was done the first time, small hospitals can now sequence an entire genome in a matter of hours. Sequencing is being routinely used to shift our understanding of medicine from the perspective of a community to that of an individual - to test drug resistance, effectivity indices, susceptibility to diseases, infections, to diagnose, to give prognosis etc. And there have been some wonderful developments with this tool like the diagnosis of a little boy who suffered from a life threatening disease that couldn't be diagnosed till his genome was sequenced.
But what about risk factors, susceptibility indices and predictions ? Where do these predictions end and where does life itself begin ? We all know that a lot of times statistics are just numbers and more often than not, they are only a guideline for us. They cannot be treated as absolute truths in any way, shape or form. And more importantly, we are far away from a comprehensive understanding of the individual contributions of genes, mutations, variations, SNPs and lifestyle to the development of a disease.
- Another big concern of mine is the loss of human skill and involvement as machines take over. Every new generation of physicians and nurses is more and more dependent on technology and instrumentation. What happens when technology lets you down ? I am not referring to a take over of the world by corrupt robots and self-replicating computers but imagine the situation when it is only a simple power failure. In a world dictated by instruments even that will be debilitating. Will the next generation of doctors and nurses be able to use a stethescope to measure the heart beat and detect any abnormalities or would they be completely dependent on an ultrasound and a cardiogram ? Will they be able to measure the other vitals without their usual fancy gear ? Would they be able to perform a successful surgery without a robotic arm and a pinhole camera guiding them?
People in the developed countries are already losing their ability to carry out simple mathematics - addition, subtraction, multiplication and division - the argument being - "why tax the brain when there are calculators an arms-reach away?". People are unable to type correctly without a spell check and despite the ease of editing and typing, language is becoming more and more abbreviated. A lot of these are the unintended consequences of technology and one must consider them every time we let technology a step closer into our life. I, myself, realized these implications only after the massive power outage in San Diego in september last year. Coming from India, power cuts were a part of our life - there would be one almost every day and we have lived with them. But seeing the effect of that one experience on the American populace made me thank my stars for the training. People here were in a state of panic as they abandoned vehicles on the street. There was panic everywhere as nothing from gas stations to grocery stores was functioning without the checkout counters.
- Another aspect of such technology dominated care that occurred to me was the increasing gap between the western world and the developing countries. While the west is battling with high-nutrition and stress induced diseases, the rest of the world is fighting infectious diseases, microbes, pathogens, malnutrition and poverty. The developing world is generating newer and more potent strains of flu and influenza, antibiotic resistant bacteria. The developed world on the other hand is pouring money to make the already comfortable lives of its people even more easy - leading to an increased incidence of diseases of the affluent - like obesity, diabetes, hypertension etc. But the problem here is that in a world that constantly shrinking, diseases do not remain quarantined - they spread faster than the news of them. The developed nations of the world have a selfish interest in preventing the development and spread of these resistant strains of bacteria and new strains of virus. But instead, they are working on reducing human skill, judgement and influence. To me, it doesn't seem like a wise approach.
- Lastly and perhaps most importantly, we are social creatures. We respond better to words of support and encouragement, a few moments of happiness than to the anti-depressants and prozacs. We need individual and social contact to thrive and flourish. And presently computers are replacing society out of our mainframe. As we spend more and more time on facebook hooked to our iPads and iPhones, we are becoming more and more "I" centric and losing track of the fact that we live in a society and that people are important.
Everyone who knows science is aware of the reality that while every step forward in science gives us a few answers, it raises many more questions. Be it the baffling example of HIV resistant cohorts of women or the twins with different afflictions and behaviors. The human body is a complex machine and we as yet, do not have a complete understanding of all the parts and their interactions. Without such a clear picture, powerful technology would only release the power of decision making to an unaware and inexperienced public which will end up making important decisions about consulting or not consulting a doctor, ignoring or not ignoring a lesion without full awareness of the consequences.
There are already examples of e-consultation, e-supervision, e-care in many hospitals where they have a centralized unit that is constantly monitoring the ICU and its patients through cameras, videophones etc. An example of this I came across recently was from the New Yorker piece by Atul Gawande about the 'Tele-ICU' set up in the Steward health-care system which was testing out this model of intensive care. As part of this telemedicine model, a centralized ICU command center was set up involving banks of computer screens that carried a live feed of cardiac monitor readings, radiology imaging scans, and laboratory results from the ICU patients throughout the Steward's hospitals. Softwares and codes monitored the results and produced yellow and red alerts when they detected patterns that raised concerns. Doctors and nurses manned the consoles where they could turn on high-definition video cameras and zoom into any ICU room and talk directly to the staff or the patients. With a total staff strength of 4, this set up was able to actively monitor and support the ICUs across ten remote hospitals. And with this perspective, when one thinks of the quote from an Indian entrepreneur in the Silicon Valley that medicine needs more software codes than doctors - one can almost understand....
"But" and this is a big glitch for me : technology and computers are invading our lives much faster than we are preparing for them. Imagine the issues that can possibly arise :
- Imagine a time when everyone would be able to access their vital stats and symptoms through their smart phone and have all the necessary tools for diagnosis from google. It would potentially make us all self-diagnosing hypochondriacs (or cyberchondriacs as Dr Topol likes to call them). Are we prepared for computers tracking and telling us about every breath we take or every heart beat of ours? Are we prepared to trust the internet for solving all our problems all the time? Because, as wonderful as this mass sharing of information is - it does leave plenty of room for wrong information to seep through. No one is really keeping track of the accuracy of all information available on the web. And if people lose track of this reality - problems will be less than a "touch-screen" away.
- Imagine issues with privacy... People hack into your accounts, steal your phone or your computer and they can find everything about you including your physical and mental status, disease risks, threats and allergies. People hack into public databases, monitor your search history and they will have access to all the weaponry they need to influence you. What happens when people use health risk to discriminate for employment, insurance, friendship or for that matter anything else. A lot of this is already happening is proving to be a challenge to the regulators!
- Insurance firms already discriminating for pre-existing conditions - how long would it take for risk and lifestyle factors to be factored into the equation... ? Would my risk for diabetes or heart attack (based on genetics, sequencing or family history) justify their over-charging me from adolescence or even adulthood?
- Another interesting facet that emerged from the question answer sessions with Dr Eric Topol is the regulation of these apps and technologies. I was surprised to know that some of these apps like the one for screening moles is not regulated or FDA approved. It sure maybe a great piece of work and rather accurate but if there are no checks and balances, anything and everything can find its way to the masses and that would be sure shot recipe for disaster. But the regulatory authorities and the control bodies are not yet effective and fully aware of the possible threat of these tools. How do you limit the access of technologies available on the web without being labeled a moral watchdog? Does an approval in one country automatically mean an approval for all others? Does an App or a software that work for caucasians work equally effectively for all other races - after all there are genetic, social and cultural differences among people.... How do you control the spread of the internet without being prejudiced or biased or dictatorial? Apple is already attempting and is fairly successful at establishing a monopoly of sorts in the field with its devices and its Apps. How do you thwart such issues of intellectual property vs public welfare ?
- And then consider the possible impact of genome sequencing. The costs of sequencing an individual's genome have come down so much that it can be afforded by normal people like you and me and the decline is an ongoing process. From being a decade long exercise that it was when it was done the first time, small hospitals can now sequence an entire genome in a matter of hours. Sequencing is being routinely used to shift our understanding of medicine from the perspective of a community to that of an individual - to test drug resistance, effectivity indices, susceptibility to diseases, infections, to diagnose, to give prognosis etc. And there have been some wonderful developments with this tool like the diagnosis of a little boy who suffered from a life threatening disease that couldn't be diagnosed till his genome was sequenced.
But what about risk factors, susceptibility indices and predictions ? Where do these predictions end and where does life itself begin ? We all know that a lot of times statistics are just numbers and more often than not, they are only a guideline for us. They cannot be treated as absolute truths in any way, shape or form. And more importantly, we are far away from a comprehensive understanding of the individual contributions of genes, mutations, variations, SNPs and lifestyle to the development of a disease.
- Another big concern of mine is the loss of human skill and involvement as machines take over. Every new generation of physicians and nurses is more and more dependent on technology and instrumentation. What happens when technology lets you down ? I am not referring to a take over of the world by corrupt robots and self-replicating computers but imagine the situation when it is only a simple power failure. In a world dictated by instruments even that will be debilitating. Will the next generation of doctors and nurses be able to use a stethescope to measure the heart beat and detect any abnormalities or would they be completely dependent on an ultrasound and a cardiogram ? Will they be able to measure the other vitals without their usual fancy gear ? Would they be able to perform a successful surgery without a robotic arm and a pinhole camera guiding them?
People in the developed countries are already losing their ability to carry out simple mathematics - addition, subtraction, multiplication and division - the argument being - "why tax the brain when there are calculators an arms-reach away?". People are unable to type correctly without a spell check and despite the ease of editing and typing, language is becoming more and more abbreviated. A lot of these are the unintended consequences of technology and one must consider them every time we let technology a step closer into our life. I, myself, realized these implications only after the massive power outage in San Diego in september last year. Coming from India, power cuts were a part of our life - there would be one almost every day and we have lived with them. But seeing the effect of that one experience on the American populace made me thank my stars for the training. People here were in a state of panic as they abandoned vehicles on the street. There was panic everywhere as nothing from gas stations to grocery stores was functioning without the checkout counters.
- Another aspect of such technology dominated care that occurred to me was the increasing gap between the western world and the developing countries. While the west is battling with high-nutrition and stress induced diseases, the rest of the world is fighting infectious diseases, microbes, pathogens, malnutrition and poverty. The developing world is generating newer and more potent strains of flu and influenza, antibiotic resistant bacteria. The developed world on the other hand is pouring money to make the already comfortable lives of its people even more easy - leading to an increased incidence of diseases of the affluent - like obesity, diabetes, hypertension etc. But the problem here is that in a world that constantly shrinking, diseases do not remain quarantined - they spread faster than the news of them. The developed nations of the world have a selfish interest in preventing the development and spread of these resistant strains of bacteria and new strains of virus. But instead, they are working on reducing human skill, judgement and influence. To me, it doesn't seem like a wise approach.
- Lastly and perhaps most importantly, we are social creatures. We respond better to words of support and encouragement, a few moments of happiness than to the anti-depressants and prozacs. We need individual and social contact to thrive and flourish. And presently computers are replacing society out of our mainframe. As we spend more and more time on facebook hooked to our iPads and iPhones, we are becoming more and more "I" centric and losing track of the fact that we live in a society and that people are important.
Everyone who knows science is aware of the reality that while every step forward in science gives us a few answers, it raises many more questions. Be it the baffling example of HIV resistant cohorts of women or the twins with different afflictions and behaviors. The human body is a complex machine and we as yet, do not have a complete understanding of all the parts and their interactions. Without such a clear picture, powerful technology would only release the power of decision making to an unaware and inexperienced public which will end up making important decisions about consulting or not consulting a doctor, ignoring or not ignoring a lesion without full awareness of the consequences.
At this point, while I am marveling the growth of technology and its impact, I am worried about its influence and about where it is leading us.
I wish and hope that people would think about the full consequences of their words and actions before they pick one side or the other and advocate. I am only reminded of the childhood story of the Arab and his camel in the desert. We should be careful about how much we let something big into our life....
More reading:
1) Eric Topol's tough prescription for improving medicine
2) Big Med By Atul Gawande in the New Yorker
3) One in a billion : A boy's life, a medical mystery
So this I must confess is going to be a biomedical engineer's perspective and also comes from a person who hates going to doctors except to the best doctor in my world, my family's physician who now lives in a different continent and knows 3 generations of my family. Apart from the fact that developing such apps and techniques are extremely innovative and interesting, it is true that a lot of thought goes into these devices. I have been part of a group called developing devices for the developing world. Our target groups are isolated populations around the world. Rural India, Tribes in Africa, People living in the Amazon basin to whom even today doctors are grandmoms and granddads who believe they know how to cure diseases. The FDA approval less devices that you are talking about however require patents and the patents are peer reviewed like any other scientific paper is. So all is not bad, there are standards that these devices have to meet. Then with growing human population there is a large scarcity of trained doctors. They are over worked and fatigued and hence overpaid and expensive. If however I knew I had high BP and went with a standard report from my iPhone this reduces the time the doctor needs to spend on diagnosing. More people who are less trained can help with diagnosing common ailments. And of course specialists are not getting out of fashion any time soon. Also, the other point is with genome sequencing etc we can provide personal healthcare. Right now we all take 500 mg of paracetamol irrespective of how much are body requires. I believe it would be a good idea to know how much exactly your body requires that is an improvement in healthcare and if technology provides it so be it. I don't think it is fair to stop/slow down progress in technology because FDA and security can't keep up with it. It is more important to strive to get quality healthcare where it is required when it is required. If anything we should worry about why FDA/ security can't keep up not the other way round.
ReplyDeleteRafiki: Thank you for your views and the clarifications. Now, let me begin by saying that I agree with you on a lot of accounts such as the need for technological innovation, the scarcity of doctors, the plight of healthcare in developing countries etc.
DeleteAnd as you see, I haven't been against the technology also. While it is good to know that the non-approved apps and devices are patented and thus subject to peer scrutiny (I didn't know that) - don't you think that it also limits their wide and easy reach... ?
We all know how suffocating and financially driven patents are ?
Yes, the developing world needs all these technologies but very little gets translated. The one successful movement i knew of was a cervical cancer screening, i think, in rural Maharashtra that was done with a small on site PCR based approach. But this also needed clinicians to set base at a village or to have a mobile clinic. I understand that there is a shortage of personnel in the health industry but in my opinion, the answer is to remedy that by reducing the costs of education and motivating children and not try and replace human judgement with computers.
I am not saying technology is bad, just that it is very powerful and we don't yet have a system to manage it. While monitoring your BP would help the physician in the diagnosis, it would only help if you went to the physician. Many people are quite capable of exercising their own discretion most of the time and either taking off-the counter pills or remedying things at their end. I just think that incomplete knowledge is dangerous and technology gives people just that. I just think that even as the apps and other technological innovations gain ground, people have to be educated and made aware of all these challenges. Also, the personnel in the health sector should not become overly dependent on technology. One must embrace technology - definitely but one must also know the flaws and very few people are trying to bring those to the fore.
As for the regulatory bodies, that is a complex problem beyond the FDA and the USDA. I cannot even say that what is approved for americans should be allowed blindly elsewhere because we all know that different races have these genetic idiosyncracies and most studies are based on a western population. Every country must have a right to regulate the standard of care to its populace but modern technology is able to breach those constraints very easily.
And while it is important to ask the regulatory bodies to be more efficient, i think i can understand why they are not. After all, there are hundreds and thousands of inventors while a relatively small number to exercise the checks and balances. Also, inventions are incremental by nature while every one of them will need to be regulated with the same rigor. To me that is almost fait accompli.
As for sequencing, and individual genome based analysis : yes, i completely agree that it is a very helpful tool. There are a lot many drugs in the market today to which only a small percentage of the population responds (and i am not talking about chemotherapy for cancer). It would benefit us all to have prior knowledge and have our personalized drugs and therapies. But are we ready for genomics at this scale. To know out individual risks of cancer or alzheimers or response to drug... I am not sure, how I would react to knowing that i have a 90% risk for cancer or dementia or alzheimers or MS. Wait for the day, give up or try and forget that you ever came to know of it. And then there are ethical concerns with right to privacy?
And so, when i wrote this post, i had no clear answers, just a whole lot of concerns that I think they are important enough to be considered while being swept off our feet by technology.