As an example of the promise of digital medicine, Katie Hafner tells the following wonderful story:
Dr. Alvin Rajkomar was doing rounds with his team at the University of California, San Francisco Medical Center when he came upon a puzzling case: a frail, elderly patient with a dangerously low sodium level.
As a third-year resident in internal medicine, Dr. Rajkomar was the senior member of the team, and the others looked to him for guidance. An infusion of saline was the answer, but the tricky part lay in the details. Concentration? Volume? Improper treatment could lead to brain swelling, seizures or even death.
Dr. Rajkomar had been on call for 24 hours and was exhausted, but the clinical uncertainty was “like a shot of adrenaline,” he said. He reached into a deep pocket of his white coat and produced not a well-thumbed handbook but his iPhone.
With a tap on an app called MedCalc, he had enough answers within a minute to start the saline at precisely the right rate.
Gina Kolata also explains how computer-aided design and manufacturing give dentists the technology to fabricate crowns at their offices, in a fraction of the time it used to take: A New Tooth, Made to Order in Under an Hour
And Jane Brody explains how connecting older Americans to the Internet can create opportunities to protect their well-being and reduce national costs for care: E-Health Opportunities for Seniors
The perils of digital medicine
There are also examples of the perils of digital medicine. Abigail Zuger and Milt Freudenheim explain how electronic medical records can lead to confusions and major errors: Which ‘HT’ to Treat: Hypertension or Hammertoe? and: The Ups and Downs of Electronic Medical Records.
Lawrence Altman also warns about the price of technology:
But as in many areas of life, overreliance can lead to abuse... Inappropriate use of antibiotics has led to the spread of drug-resistant microbes that threaten to undo many of the gains the antibiotics have achieved… Doctors may order a test because it is available or out of habit… But the practice can be wasteful, subjects patients to unnecessary radiation and often creates a need for additional tests when an incidental finding is made simply to chase down a possible finding of unlikely significance.
Yet medical learning is still atrociously slow
Yet overall, the mood of the articles is upbeat. The sense is one of progress. There is no reference to the fact that over the last twelve years, preventable deaths in US hospitals have increased from around 100,000 to an estimated 200,000 today--the equivalent of a preventable 747 plane crash somewhere in the US, every day of the year. Or that the U.S. ranks last out of 19 developed countries in preventable deaths in hospitals.
There is no mention of the fact that you are 33,000 times more likely to die from a hospital error than a plane crash. Or that one in five 5 patients in the U.S. suffer harm from medical errors.
Nor is there any mention of the shockingly slow pace at which the great discoveries of scientific medicine trickle down into implementation at the level of the doctor or the clinic.. The time for major medical discoveries to reach even half of the patients in this country is more than fifteen years.
This background makes it easier to see why having a lot of glitzy digital equipment and making great discoveries isn’t much use if the uptake of this potential progress is slow.
Why?
The key: an inappropriate organizational culture
A key can be found in an earlier eye-opening article by Pauline Chen in the NYT about the bullying culture that prevails in the health system.
She explains how medical students, in the acculturation process of turning young men and women into doctors, are routinely subjected to verbal and physical harassment and intimidation as part of the exhausting process of medical education. When medical teachers act like bullies, we should hardly be surprised if the the students, once they graduate, also turn into professional bullies who are slow to learn from those around or below them in the hierarchy.
Chen writes:
One medical school became a leader in adopting such changes. Starting in 1995, educators at the David Geffen School of Medicine at the University of California, Los Angeles, began instituting a series of schoolwide reforms. They adopted policies to reduce abuse and promote prevention; established a Gender and Power Abuse Committee, mandated lectures, workshops and training sessions for students, residents and faculty members; and created an office to accept confidential reports, investigate and then address allegations of mistreatment.
The results of thirteen years of effort however are discouraging:
While there appears to have been a slight drop in the numbers of students who report experiencing mistreatment, more than half of all medical students still said that they had been intimidated or physically or verbally harassed.
No amount of technology can generate learning if the organizational culture isn’t right.
The health sector can learn
Similar organizational cultural problems have been resolved in other sectors. For instance, Malcolm Gladwell in Outliers explains how Korean Airlines used to encounter an abnormal number of fatal crashes. The crashes were not due to technical competence or a failure of technology. They were due to errors of teamwork and communication: in authority-based environments, problems were not quickly solved. People who perceived problems didn’t report them up the line to the pilot or the pilot paid no attention to what he was being told.
The cultural problem was solved at Korean Airlines, not by replacing the pilots, but rather through intensive training on a different way of acting and interacting that was then embedded into the organizational culture. Once this was done, the airline safety problems at Korean Airlines were resolved.
Similar efforts are also under way in parts of the health sector. In Lean Hospitals, Mark Graban gives an excellent account of what can be accomplished in hospitals when excellence and learning become the overriding goals of the culture.
These problems are not going to be solved by new digital technology: they are human problems. It's not the individual doctors that are at the heart of the problem: it's the system within which they are working and the process by which they are trained to become doctors.
The problems of the health sector are soluble. It is time that the medical profession and the medical education system gave top priority to solving them, not on a small scale, but across the board. 200,000 preventable deaths per year in US hospitals are 200,000 deaths too many.
And read also:
It’s not the doctors: it’s the system
Straight Talk On Fixing Health Care: The Innovator’s Prescription
Can Knowledge Be Collected: Lessons from the health sector
The Five Surprises of Radical Management
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Steve Denning’s most recent book is: The Leader’s Guide to Radical Management (Jossey-Bass, 2010).
Follow Steve Denning on Twitter @stevedenning
