Breaking the medical cartel – patient ordered tests & treatments
This post comes from an oral presentation at Stanford MedicineX - September 28, 2016. A conference about people, technology, and design. Presented in the business track.
You can watch the video, or read the essay.
1 MINUTE SUMMARY
Healthcare will undergo major changes in the coming decades. Most of the work physicians do today will be replaced – either by non-physicians trained in specific competencies or by computers. The digitization of medicine will make routine diagnosis and disease management no more expensive than a Google search.
Today physicians retain monopoly control over medicine by the necessity of their signature to order most tests or treatments. This power was initially intended to protect patients from quackery and harm, but today is used to retain physician control over healthcare.
Allowing patients to order their own tests and treatments has the potential to break the medical cartel and expand the ways healthcare is delivered. This will be good for patients, payers, and even physicians.
===========
Video
Essay
Introduction
Part 1: Future of Healthcare
Replaced by non-physicians
Replaced by computers
Digital medicine, almost free
Part 2: The Current Medical Cartel
Part 3: Erosion of the Medical Cartel
Increased patient expectations
Changed regulatory environment
Patient generated data
Patient generated diagnosis
Patient initiated treatment
Part 4: Required Cultural Shift
Part 5: The Future of the Physician?
Questions & Answers
Future Article
Patients will trust computers, but will they forgive them?
Introduction
Today healthcare is controlled by a worldwide, self-regulated monopoly that holds complete power over medicine. This cartel is made of physicians. I realize writing about breaking up the medical profession is probably not wise; I am part of the system, an Internal Medicine resident in Canada.
Many fellow physicians are quite concerned when they hear the proposal that patients should be allowed to order their own tests and treatments. It is best to start by clarifying: I don’t believe that patients should be encouraged to self-direct their investigations or prescribe their own medications. However, creating the legal right for patients to do so would remove physician’s control over medicine and help spur the creation of non-physician professions and advanced diagnostic technology.
This article is primarily about improving medicine by breaking the medical cartel.
Part 1: Future of Healthcare
In Kevin Kelly’s new book, The Inevitable, he suggests something is “inevitable” if in re-winding a thought experiment to start at different times in history, one arrives in the same place in the future. Twitter may not have been inevitable, but online messaging was.
When I rerun the thought experiment of healthcare, in the end the majority of a physician’s current work is replaced with non-physicians or machines.
Trouble building today’s doctors
To illustrate the problem of care delivery in the current system, imagine the doctor is a robot. A ‘robot’ doctor is a machine that would never be built. It takes 15 years to make one, and costs a third to half-a-million dollars. After the robot is built, one does not know if it will interface well with patients or other care providers. In addition, these robots have very high annual operating costs, and require constant upgrades. The robot receives significant training in skills, that often are never used or required. Instead of creating one massive robot, if one divided the tasks the giant robot doctor did into discrete tasks such items could be re-allocated to other clinicians or machines to perform.
Replaced by non-physicians
For years we have seen non-physicians successfully perform tasks once reserved for physicians. For example, drawing blood or taking EKGs. Now, nursing teams insert central lines with lower infection rates than doctors. Clinical assistants in the operating room harvest graphs. In parts of Africa the concept of ‘task-switching’ has effectively trained non-physicians to perform quite advanced obstetrical surgeries that save the lives. Much of primary care can be provided by nurse practitioners with independent licences. Today clinical assistants care for patients from hospitals to battlegrounds, and pharmacists not only dispense but prescribe and adjust medications.
It is easy to imagine a system where instead of training someone for 15 years in basic science to ultimately perform colonoscopies all day; one could instead train people in specific competencies at the start. With more people trained in individual skills, theoretically availability increases and price drops, while quality increases.
Replaced by computers
The second way the work of physicians will be replaced is with sophisticated algorithms; today this is encompassed with the buzz word ‘artificial intelligence’. Computers will be able to do routine diagnosis and disease management. Machines are particularly well suited to integrate the the increasing amount of patient data with the ever doubling medical literature. This will lead to more personal investigations and treatments.
Digital medicine, almost free
One of the reasons the digitization of healthcare is exciting, other than the benefits of better diagnosis and disease management, is that digital medicine has the potential to make healthcare free. Peter Diamandis, founder of the Xprize, talks about the concept that once something is digitized, it can be democratized, decentralized, and dematerialized. This is important when one looks at healthcare globally.
The WHO chart below shows the systolic blood pressure of men over 18 years around the world. Hypertension in countries like Canada, the USA, and Europe is not that bad when compared to the alarming rates in the majority of the world’s population through Asia and Africa. The same pattern is seen in Figure 2 with fasting blood glucose.
Figure 1: Mean (male) systolic blood pressure worldwide
Figure 2: Raised (female) fasting blood sugar worldwide
Those most in need of healthcare have neither trained physicians or the ability to pay for care. Figure 3 shows shows annual per capita healthcare expenditures in US dollars. Countries such as Canada or the USA spend over $5,000 dollars per capita, whereas many parts of the world only spend $1000, $300, or $50.
Figure 3: Per capita total expenditure on health in USD
The digitization of medicine enables the possibility to provide high quality medical diagnosis and management through one of the most widely democratic platforms – the mobile phone. Ownership of smartphones continues to increase, and global internet access is not that far away. This interconnected mobile platform presents many opportunities for the future of healthcare delivery.
Part 2: The Current Medical Cartel
Currently medicine is a cartel. Monopoly privilege was given to physicians in each country at a different times in their development. Overall, the general goal was the same, to help protect patients. Such a system made it illegal to practice medicine without a valid licence.
Over the last few decades doctors have prioritized protecting their work & income over protecting patients. Physicians push back whenever non-physicians groups such as nurse practitioners, clinical assistants, EKG technicians, phlebotomists, pharmacists, or paramedics want to expand their scope of practice. Despite this, each of these groups has shown they have the ability to successfully perform jobs previously exclusive to physicians.
We also see that doctors are reluctant to give control to patients. There was a time when clinicians thought patients wouldn’t be able to take their own blood sugars to manage their insulin, or titrate their diuretics in heart failure. Both of these predictions have been shown to be erroneous. Blood pressure cuffs initially were only sold to clinicians. Now patients are encouraged to take their own blood pressure at home. Home lab testing had been considered unadvised, but now home pregnancy tests are common.
It has only been over the the last few decades (or years, depending on your country) that patient’s are legally permitted to read their medical record. Physicians presumed such knowledge should be kept from the patient for the patient’s own benefit. However, this thinking has proven false. Patients in countries such as Denmark have had open online access to their medical records for over a decade. Definitive proof of the self reported benefits of access to medical records was shown in the OpenNotes study where patients did not only have access to their labs, but also the notes their physicians wrote about them. 50 years ago 95% of physicians would routinely withhold telling their patients they had cancer; today that is considered malpractice.
It is hard to imagine the same cartel that has been reluctant to give up small parts of their work, welcome with with open arms a future where the majority of their work is rapidly replaced.
Part 3: Erosion of the Medical Cartel
Today’s medical cartel is being weakened from five different directions.
Increased patient expectations
First, patient’s expectations have changed. They are much higher. Physicians are no longer accepted ‘de-facto’ as the definitive truth. One in three patients in North America go to alternative care providers (naturopaths, chiropractors, etcs), and when they do three quarters of these patients do not tell their medical doctor. Today’s doctors need to make the case to patients they are deserving of trust and that they have the knowledge to help.
Changed regulatory environment
The second way the cartel is being eroded is with changes in the regulatory environment. Tight budgets and expanding healthcare costs makes governments willing to expand the practice of less expensive non-physicians alternatives. We have seen expanded practices of independent nurse practitioners, clinical assistants, pharmacists, and paramedics.
Patient generated data
Third, patients generate increasing amounts of data about themselves. Not long ago patient data was only generated in the doctor’s office or on ordered tests. Today patients can sequence their own genome. One can order home tests for HIV, glucose, cholesterol, hepatitis, or pregnancy. In 2015 Arizona changed their law to permit patients to order their own blood work without a physician’s requisition. Many are shocked to learn in fact in more than half of states some form of “direct access testing” (ordering labs without a physician’s requisition) is permitted to some extent. This decade patients will generate even more data as we move away from elementary activity monitors to sophisticated biosensors.
Patient generated diagnosis
Fourth, patients are slowly beginning to be able to generate diagnosis. I fully recognize this area is highly underdeveloped. Online diagnostic tools are generally inaccurate. Even paid services such as dermatology apps on smartphones have been shown to routinely misdiagnose. However, the limitations of machine diagnosis stem from immaturity and not because we have reached the technology’s maximal potential. In the last twelve months, Google’s DeepMind Health has claimed to diagnose images of diabetic retinopathy better than trained ophthalmologists. It is not too far off before computer diagnosis will be more reliable and accurate than physicians.
Patient initiated treatments
Finally, patients are initiating their own treatments. The eyeglass industry has changed with the ability of patients to purchase glasses and contact lenses online. There are more over-the-counter medications than before. Depending on your jurisdiction pharmacists can dispense a wide array of medications such as pills for high cholesterol, gastric reflux, and strong pain killers.
The question of antibiotic stewardship always arises. In many ways we have already entered the wild west. Physicians have not been successful in antimicrobial stewardship. Physicians routinely prescribe antibiotics for conditions they suspect is viral. Antibiotics are easy to access in many developing countries. Antibiotics are easily found off the streets of New York illegally in delis and bodegas. Pet stores sell antibiotics off the shelf. Online, one can purchase almost any medication*, and depending on the jurisdiction of the online retailer a physician’s prescription may not even be required. (*The main exception is ‘controlled substances’, such as narcotics and benzodiazepines).
Part 4: Required Cultural Shift
Ultimately, the best way to move forward in a world where patients have increasingly easy access to data, diagnosis, and treatment is not through the creation of stronger cartels and regulation, but through a cultural change. No longer are people entirely ‘outsourcing’ their entire health to doctors. They need to tools and knowledge to be able to help advocate and care for themselves and their families.
It is remarkable that people graduate from high school without being taught basic lifesaving skills such as CPR, the signs or symptoms of a heart attack or stroke, what diabetes or high blood pressure is, and how to prevent them. Furthermore, physicians have not clearly communicated to the public how they evaluate evidence or think. Patients do not understand why physicians may disregard some tests or treatments but value others.
A necessary component in creating a environment to break the medical cartel is educating patients of the dangers in ordering tests or treatments themselves. The public has been educated on other topics, such as the dangers of smoking or taking street drugs.
Part 5: The Future of Physicians
The digitization of medicine opens a future where routine diagnosis and disease management is almost free and available worldwide. Where does this leave doctors?
Today physicians are paid to do high volume repetitive tasks. There is little incentive to become involved in a complex case. In the future physicians will work with the most unwell patients. Those that fall outside the algorithms. Those with diagnosis that remain unknown, and treatments that remain ineffective. Such patients are ones that the current medical system serves the least well.
Physicians will actively work to advance the science and delivery of medicine. Physicians will work in new fields will emerge - consider organ printing, genomics, systems biology, or building new healthcare systems that can provide better diagnosis, compassion, and care. There will be no shortage of work.
Conclusion
Allowing patients to order their own tests and treatments has the potential to break the medical cartel and expand the ways healthcare is delivered. This will come with risks, but so does maintaining the status quo.
Question & Answers
Q1: We have seen the democratization of knowledge in areas such as such as mathematics or computing via MOOCS – massive open online courses. That hasn’t happened to the same extent to the medical school curriculum. Do you think that should or will happen?
There are a lot of online medical resources, although they haven’t yet been formally compiled into a medical curriculum. There remains the perpetual question: why does it always seem the number of physicians is inadequate? From a self interested perspective, physicians do not desire a surplus of doctors as that means salaries may not remain as high. Some countries have twice the number of physicians as Canada, but those physicians are paid half the amount. There are some alternative education systems & online start-ups in this area focused on training people in the developing world.
Q2: One of your arguments was that training technicians, such as to perform colonoscopies, will lead to better streamlining of care. However, isn’t one of the criticisms of current medicine that care is fragmented and nobody is managing it? Are there not today too many specialists that do not talk to each other?
I believe the electronic health record will become the quarterback of care. Although this sounds at first impersonal, it is practical. The level of follow up, the numbers of tests and investigations, and the number of people interacting with a single patient requires a highly robust electronic system to track these interactions and coordinate and schedule care. This is something software can do well. The electronic health record can help alert patients and clinicians of things to follow up on, and facilitate communication between clinicians and patients.
Q3: Is a patient’s ability to understand their care based on their education. In the United States the average reading level is quite low. How does this affect patient choices? Are they informed well enough to understand the risks of taking antibiotics, or the ongoing vaccination debate.
It is important to create easy to use systems where people can know that the information source they are using is reliable. This is important whether you are a patient, nurse, or doctor. Traditionally validation has been done by government; however, one can imagine independent agencies forming that are built upon validating medical apps & medical diagnostics. If you purchase a painting at Christie’s auction house, you expect that it will not be a fake. The entire reputation of the agency is built upon their claim of authenticity. Similarly agencies can be founded that validate authenticity and reliability of both healthcare diagnostic applications, but also other areas such as online pharmacies.
Q4: Is there room for a different type of work for physicians? Such as health broker? Where the physician actually would be skilled in understanding the bigger picture, and helping support patients in making decisions based on all the data they bring with them? In this way the physician helps the patient to manage that knowledge in a more efficient way and also provide a human component to treatment.
I agree that in the future physicians will be seen as consultants on healthcare. Highly trained individuals who can offer guidance, insight, and empathy into the data & knowledge that a patient & their care team has.
Today much of healthcare works in a strange manner. For the most part, regardless of your entrance complaint, you are triaged to see a doctor at the start. However, this is not seen in other industries. For instance, if your car makes a funny noise you don’t immediately consult the engineers at Toyota. People first search online, or ask their friends. Then they may ask the mechanic down the street. Lastly they go to the final dealership. In this manner one escalates through a natural cascade of expertise.
Healthcare can develop a similar cascade of expertise that patients will be able to move through. It may start with online resources, diagnostic applications, incorporate wellness experts, nurses, and clinical assistants. Ultimately, physicians will be able to offer more expertise than others in the cascade.* However, they are not the starting point as a resource they have low availability a high cost of operation high. (*The difficult in a cascading systems is that each level requires knowledge to know when to ‘refer upstream’ when a question is beyond the depth of their competency.)
Future Article
Patients will trust computers, but will they forgive them?
As medicine becomes ‘digital’ it risks becoming sterile and impersonal. How can we build a healthcare system that’s founded on a strong digital information system, but that comforts suffering, support patients, and is ultimately delivers human care.
Thanks to: Don Houston, Liam Black, William Turk, and Alex Izydorczyk for suggestions and/or editing.
