#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”.

Operation Ouch! Medical Milestones and Crazy Cures, Inis Childrens Magazine/Childrens Books Ireland, November 2014

From Childrens Books Ireland, a capsule review of a childrens book about medicine. The van Tulleken brothers strike me as quite admirable in their enthusiastic multimedia presence. Again, perhaps a wry scepticism about history-from-below is evident. I didn’t have space to note that while the entries on Fleming, Nightingale and most other figures in the book are irreverent, that on Seacole is very sober and straight-laced:

Operation Ouch! Medical Milestones and Crazy Cures
by
Chris van Tulleken and Xand van Tulleken

History traditionally focused on what were deemed great events – sometimes caricatured as the ‘maps and chaps’ approach. In recent decades, ‘history from below’ has gained in academic prestige, with everyday life and consideration of marginalised, under-documented groups being the focus. The huge popularity of the Horrible Histories series has shown the appeal of history-from-below in a perhaps more literal sense – their focus on bodily functions and gross-out humour may not be to everyone’s taste, but they do provide a gateway into reading about the everyday life of the past.

The van Tulleken twins are Oxford medical graduates who have carved a niche for themselves as presenters of the CBBC series Operation Ouch! This book is the second tie-in volume; the first, Your Brilliant Body, won the 9-11 Best Fact Book award at the Booktrust Best Book Awards in 2014. Medical Milestones and Crazy Cures is formatted as a series of dialogues between the brothers on various parts of the body, interspersed with short profiles of medical notables and some quirky activities that will get the target readership’s attention.

The history-from-below emphasis is even apparent in the vignettes on pioneers of healthcare, with the Jamacian-born Mary Seacole, about whom very little is reliably known, given equal prominence with Florence Nightingale, Alexander Fleming and the rest. The brothers’ dialogues don’t entirely work on the printed page, but that aside this is a handsomely produced tie-in that combines medical history with bodily functions in a way that will appeal to the target readership.

The Boy Who Never Saw Pictures – The Dabbler Blog, May 2014

I came across the paper described in this piece in a book on the pictorial world of children. I also emailed one of the authors, with no reply. It was circulating around my mind for a few years and finally The Dabbler seemed like the right place to write it for.  It was literally only when writing the piece I realised what seems obvious; the authors of the paper were the parents of the boy described.

A certain wry scepticism about experimental psychology is evident here.

As this piece deals with child development, I thought it was an interesting place to start.

Originally published at The Dabbler

Here it is:

Imagine if, in infancy, your parents made every effort to ensure that you never saw a picture. This is what happened to the anonymous subject of Julian Hochberg and Virginia Brooks’s 1962 paper “Pictorial Recognition as an Unlearned Ability in a study of one child’s performance”; a title which has the virtue of describing precisely what they set out to do.

It had been claimed that certain tribal groups, for whom pictorial depictions were unknown, found pictures frightening and inexplicable. Various accounts from David Livingstone himself and others from his era had included dramatic accounts of natives running in fright from pictures of lions and so on. Later, perhaps more purely anthropological, studies had suggested the same thing. Therefore a theory that the ability to recognise pictures as pictures and also representations must be a learnt ability. Hochberg and Brooks observed there is a weaker version of this hypothesis; claimed that learning was needed to recognise line-drawings, but “the naïve recognition of photographs, with their higher ‘fidelity’, would be admitted.” Hochberg and Brooks embarked on their study “to determine whether a child who had been taught his vocabulary solely by the use of objects, and who had received no instruction or training whatsoever concerning pictorial meaning or content, could recognised objects portrayed by two-dimensional line-drawings and by photographs.”

The paper recounts the story of S: “since birth, the subject (S), a boy, had been exposed to and taught the names of a wide variety of toys and other solid objects … S never was told (or allowed to overhear) the name or meaning of any picture or depicted objects In fact, pictures were, in general, kept from his immediate vicinity.”

Such a regime in the mid-twentieth century was difficult to sustain: “this is not to say that S never had been exposed to picture. There was a Japanese print on one wall of a room through which he frequently passed; a myriad of billboards fronted the highways on which he travelled frequently; a few times (six in all) he accidentally encountered a picture book (which was gently withdrawn) or caught a glimpse of the label of a jar of baby food (these were normally removed or kept covered). (All these encounters were unaccompanied by instruction or naming play)”

You have to love the precise cataloguing of how often the picture book was accidentally encountered, and the regret that the Japanese print and the myriad of billboards happened to float into S’s ken. Not only that “one toy (a top) had picture of elves on it and, accordingly, it was available for play only under strict supervision to prevent any naming in his presence; a high chair had a decal of babies on it, which could be glimpsed (without parental comment) only when S was being placed in the seat.”

Not for nothing do Hochberg and Brooks comment “the constant vigilance and improvisation required of the parents proved to be a considerable chore from the start – further research of this kind should not be undertaken lightly.” This line made me wonder if S may in fact have been the offspring of Hochberg and Brooks themselves, although I can find nothing explicit and no other internal evidence, apart from the absence of any comment as to how S was recruited (there are later papers credited to Julian Hochberg and Virginia Brooks Hochberg)

By 19 months, the boy began to seek out pictures for himself, and testing began. 21 pictures, mixing line-drawings and photographs of the same objects, were presented to S one at a time, “a somewhat unsuccessful attempt being made to convert the test to an interesting game.” After this, the boy was given picture books, but adults did not engage in picture-naming activities with him. This continued for a month, with “free (but monitored) access to still pictures, but motion pictures, TV and picture-naming play still were completely avoided.” Another round of testing along similar lines took place. Both tests were tape-recorded and independent judges assessed if they could identify that picture based on S’s utterances. Hochberg and Brooks were able to conclude that “it seems clear from the results that at least one human child is capable of recognising pictorial representations of solid objects (including bare outline drawings) without specific training or instructions.”

Psychology textbooks and popularisations are replete with certain key case studies and experiments. There’s the case of Phineas Gage, a Vermont railway worker who suffered a catastrophic injury to his frontal lobes and suffered, so the textbook story goes, a spectacular personality change. There’s Little Albert, conditioned to fear furry things including beards and Santa Claus, thereby (supposedly) proving the tenets of behaviourism. There’s the obedience and prison experiments of Zimbardo and Milgram, thereby (supposedly) proving the essential sadism of humankind.

It almost invariably turns out that these stories are more complex than they are presented. Phineas Gage did survive a pole through his frontal lobes; but the most immediate report described him as “in full possession of his reason”, and two years later the Professor of Surgery in Harvard stated he was “quite recovered in faculties of body and mind.” Only later did a narrative of dramatic personality change emerge. The Zimbardo and Milgram experiments have been rigorously criticised on methodological grounds, and certainly do not seem to “prove” all that much about human nature in the end.

Little Albert is perhaps the most infamous experiment from the early years of experimental academic psychology. In 2009, Little Albert was tracked down. Or rather his grave was; for Albert had died of hydrocephalus only a few short years after the experiment. Typically, it turned out the experiments may not have proved all that much after all.

The subject of Hochberg and Brooks’ experiment is, more than likely, still out there (a couple of years ago I found an email for Julian Hochberg and wrote to see if he could update me. I never heard back). Julian, who got his PhD in 1949 from Berkeley, has a web bio on the Columbia University site. A ballet site lists dance films made by a Virginia Brooks and produced by a Julian Hochberg. One wonders did the effort to deprive S of pictures end at 20 months or were there any attempts at extending it.

S’s story is not as striking as Little Albert’s, or Phineas Gage’s, and it doesn’t seem he suffered all that much. It is hard to imagine such a study happening today, not so much due to ethical reasons as that with the endless trumpeting of the importance of the early years of infancy for development, what parent would agree to allow their little treasure to be deprived of any form of sensory stimulation?