Engaging clinicians and the evidence for informatics innovations

A few weeks ago Richard Gibson from Gartner spoke to members of the CCIO group. It was a fascinating, wide-ranging talk – managing the time effectively was a challenge. Dr Gibson talked about the implications for acute care and long term care of technological innovations – as might be obvious from my previous post here, I have a concern that much of the focus on empowerment via wearables and consumer technology misses the point that the vast bulk of healthcare is acute care and long term care. As Dr Gibson pointed out, at the rate things are going healthcare will be the only economic, social, indeed human activity in years to go

One long term concern I have about connected health approaches is engaging the wide group of clinicians. Groups like the CCIO do a good job (in my experience!) of engaging the already interested, more than likely unabashedly enthusiastic. At the other extreme, there always going to be some resistance to innovation almost on principle. In between, there is a larger group interested but perhaps sceptical.

One occasional response from peers to what I will call “informatics innovations” (to emphasise that this not about ICT but also about care planning and various other approaches that do not depend on “tech” for implementation) is to ask “where is the evidence?” And often this is not a call for empirical studies as such, but for an impossible standard – RCTs!

Now, I advocate for empirical studies of any innovation, and a willingness to admit when things are going wrong based on actual experience rather than theoretical evidence. In education, I strongly support the concept of Best Evidence Medical Education and indeed in following public debates and media coverage about education I personally find it frustrating that there is a sense that educational practice is purely opinion-based.

With innovation, the demand for the kind of RCT based evidence is something of a category error. There is also a wider issue of how “evidence-based” has migrated from healthcare to politics. In Helen Pearson’s Life Project we read how birth cohorts went from ignored, chronically underfunded studies ran by a few eccentrics to celebrated, slightly less underfunded, flagship projects of British epidemiology and sociology. Since the 1990s, they have enjoyed a policy vogue in tandem with a political emphasis on “evidence-based policy.” My own thought on this is that it is one thing to have an evidence base for a specific therapy in medical practice, quite another for a specific intervention in society itself.

I am also reminded of a passage in the closing chapters of Donald Berwick’s Escape Fire (I don’t have a copy of the book to hand so bear with me) which essentially consists of a dialogue between a younger, reforming doctor and an older, traditionally focused doctor. Somewhat in the manner of the Socratic dialogues in which (despite the meaning ascribed now to “Socratic”) Socrates turns out to be correct and his interlocutors wrong, the younger doctor has ready counters for the grumpy arguments of the older one. That is until towards the very end, when in a heartfelt speech the older doctor reveals his concerns not only about the changes of practice but what they mean for their own patients. It is easy to get into a false dichotomy between doctors open to change and those closed to change; often what can be perceived by eager reformers as resistance to change is based on legitimate concern about patient care. There are also concerns about an impersonal approach to medicine. Perhaps ensuring that colleagues know, to as robust a level as innovation allows, that patient care will be improved, is one way through this impasse.

 

#irishmed, Telemedicine and “Technodoctors”

This evening (all going well) I will participate in the Twitter #irishmed discussion, which is on telemedicine.

On one level, telemedicine does not apply all that much to me in the clinical area of psychiatry. It seems most appropriate for more data-driven specialties, or ones which have a much greater role for interpreting (and conveying the results of!) lab tests. Having said that, in the full sense of the term telemedicine does not just refer to video consultations but to any remote medical interaction. I spend a lot of time on the phone.

I do have a nagging worry about the loss of the richness of the clinical encounter in telemedicine. I am looking forward to having some interesting discussions on this this evening. I do worry that this is an area in which the technology can drive the process to a degree that may crowd out the clinical need.

The following quotes are ones I don’t necessarily agree with at all, but are worth pondering. The late GP/anthropologist Cecil Helman wrote quite scathingly of the “technodoctor.” In his posthumously published “An Amazing Murmur of the Heart”, he wrote:

 

Young Dr A, keen and intelligent, is an example of a new breed of doctor – the ones I call ‘techno-doctors’. He is an avid computer fan, as well as a physician. He likes nothing better than to sit in front of his computer screen, hour after hour, peering at it through his horn-rimmed spectacles, tap-tapping away at his keyboard. It’s a magic machine, for it contains within itself its own small, finite, rectangular world, a brightly coloured abstract landscape of signs and symbols. It seems to be a world that is much easier for Dr A to understand , and much easier for him to control, than the real world –  one largely without ambiguity and emotion.

Later in the same chapter he writes:

 

Like may other doctors of his generation – though fortunately still only a minority – Dr A prefers to see people and their diseases mainly as digital data, which can be stored, analysed, and then, if necessary, transmitted – whether by internet, telephone or radio – from one computer to another. He is one of those helping to create a new type of patient, and a new type of patient’s body – one much less human and tangible than those cared for by his medical predecessors. It is one stage further than reducing the body down to a damaged heart valve, an enlarged spleen or a diseased pair of lungs. For this ‘post-human’ body is one that exists mainly in an abstract, immaterial form. It is a body that has become pure information.

Now, as I have previously written:

One suspects that Dr A is something of a straw man, and by putting listening to the patient in opposition to other aspects of practice, I fear that Dr Helman may have been stretching things to make a rhetorical point (surely one can make use of technology in practice, even be something of a “techno-doctor”, and nevertheless put the patient’s story at the heart of practice?) Furthermore, in its own way a recourse to anthropology or literature to “explain” a patient’s story can be as distancing, as intellectualizing, as invoking physiology, biochemistry or the genome. At times the anthropological explanations seem pat, all too convenient – even reductionist.

… and re-reading this passage from Helman today, involved as I am with the CCIO , Dr A seems even more of a straw man (“horned rimmed spectacles” indeed!) – I haven’t seen much evidence that the CCIO, which is fair to say includes a fair few “technodoctors” as well as technonurses, technophysios and technoAHPs in general, is devoted to reducing the human to pure information. Indeed, the aim is to put the person at the centre of care.

 

And yet… Helman’s critique is an important one. The essential point he makes is valid and reminds us of a besetting temptation when it comes to introducing technology into care. It is very easy for the technology to drive the process, rather than clinical need. Building robust ways of preventing this is one of the challenges of the eHealth agenda. And at the core, keeping the richness of human experience at the centre of the interaction is key. Telemedicine is a tool which has some fairly strong advantages, especially in bringing specialty expertise to remoter areas. However there would be a considerable loss if it became the dominant mode of clinical interaction.  Again from my review of An Amazing Murmur of the Heart:

 

In increasingly overloaded medical curricula, where an ever-expanding amount of physiological knowledge vies for attention with fields such as health economics and statistics, the fact that medicine is ultimately an enterprise about a single relationship with one other person – the patient – can get lost. Helman discusses the wounded healer archetype, relating it to the shamanic tradition. He is eloquent on the accumulated impact of so many experiences, even at a professional remove, of disease and death: “as a doctor you can never forget. Over the years you become a palimpsest of thousands of painful, shocking memories, old and new, and they remain with you for as long as you live. Just out of sight, but ready to burst out again at any moment”.