Could Doctors Go the Way of Record Companies?

Those of us who follow health care may be overlooking the big picture. Most of the profound (and sometimes disruptive) changes of the last half century -- computers, the Internet, social networks -- weren't initiated by the political process. They arose at the intersection of technology, economics, and mass social change. So here's something to think about:

Could the medical profession go the way of the record industry?

Consider the path that led to the current crisis in the music business:

1. An industry with a near-total monopoly experiences a minor disruption (in music's case, with the invention of cassette tape recording).

2. It 'relaxes' and assumes the crisis has past.

3. An even better technology comes along (the Internet) that includes lateral as well as vertical connections. (Individuals could only make tapes for themselves; sharing was possible but cumbersome, until the Net and mp3s made it instantaneous and worldwide.)

4. The industry fails to recognize the long-term significance and risks of this new tech.

5. Enterprising individuals use this new technology to distribute "information" of mutual interest - songs - through "P2P" (peer-to-peer) file sharing.

The result? A massive and ongoing implosion of the music biz. (David Byrne provided an excellent overview in Wired, with some corrections on his blog.)

Could the same thing happen to the medical profession? Many people's immediate reaction will be to say 'no.' They'll list the many barriers to what we might call a 'P2PMed' disruption of our medical economy (with 'P2P' here meaning either 'peer-to-peer' or 'patient to patient'.) Doctors are too respected. Regulations won't permit it. Doctors control access to medications. Medical information is walled off behind expensive, subscription-only medical journals. It's unthinkable.

That's pretty much how the record industry reacted in the 1990s. Let's look at those objections:

160 million people looked up medical information on the Internet circa 2007, according to Harris polling data. Yet they still go to doctors. That's true -- just as millions of people made tape copies of music for decades without seriously undermining musical economics.

Each of these searches was a solitary activity. The difference will come when a new technology allows lateral information-sharing in a way that people trust. It hasn't happened yet, but smart people are banking on the idea that it will soon. I agree with that assessment, although none of the many projects I've looked at so far struck me as a breakthrough. But a lot of folks are working on it.

Doctors monopolize access to medications through the power of the prescription pad. That monopoly's already eroding as online pharmacies provide low-cost 'doctor consults,' a legal work-around that allows -- to an sometimes disturbing extent -- easy access to meds. Where there is demand, there will be suppliers.

People won't spend money based on self-referral. The multi-billion dollar complementary medicine industry demonstrates this is untrue. Most "CAM" (complementary and alternative medicine) transactions are based on self-referral out of the traditional MD/patient relationship.

Medical information is walled off. True, but a backlash against the sequestering of research data is already underway. Case in point: A new publication called The Journal of Participatory Medicine hopes to provide peer-reviewed articles on self care for patients, as board member Kevin Kelly writes.

The Journal's Advisory Board reads like a Who's Who of Internet and medical business pioneers (and it's an open-source publication, meaning its content will be free to all). The Journal goal of helping patients take "responsibility for their own health and healing" (in Kevin Kelly's words) aligns with decades of movement toward a more patient-centric model championed by both the Left (as "patient's rights") and the Right (as with high-deductible "consumer-directed health plans").

Once again, the left/right paradigm is ill-suited for new developments... and don't blame initiatives like the Journal if medicine goes the way of record labels. They're symptoms of broader socio-informational change, not its cause.

Not all doctors would go out of business after such a transition, of course. They're still selling some CDs, too. So who would be most likely to thrive after the transformation?

High-touch practitioners: Empathetic, comforting, and warm doctors.

"Mechanics": The most gifted and accomplished surgeons sometimes use this word to describe themselves. We will need talented neurosurgeons, cardiac surgeons, and other "fixers" for the foreseeable future (at least until the self-programmable nanobots take over).

Innovators: Doctors who are always exploring, changing, and trying new things, staying one step ahead of the curve.

Integrators: Doctors who can bring together seemingly unrelated ideas and solutions, whether in diagnosis or in treatment. Integration is the foundation of creativity, and creative doctors will always be valued.

Who'll fail? Doctors who function by rote, who make routine diagnoses, and who connect patients to other resources based on past relationships and not need. Anyone whose expertise and connections are easily replicated on the Internet (think "travel agents") will struggle to survive.

Watching the AMA defend its turf on issues like doctor reimbursement is like watching the RIAA file copyright lawsuits against teenagers, even as its business model collapses around it. You can't fight your own market and win, and you can't fight yesterday's battles. Doctor groups should look more like think tanks and less like a lobbying groups. (Come to think of it, so should the RIAA.)

Predicting this kind of change is not the same thing as endorsing it. But, like it or not, we should be talking about it now.

Because -- like it or not -- it's coming.

RJ Eskow blogs when he can at:

A Night Light
The Sentinel Effect: Healthcare Blog

Comments

[Evergreene44]

People need to stop seeing this as an "either or" war. We can all recognize that the years of education to become a doctor are irreplaceable -- I myself am part of this process currently. But can we really criticize the spread of information and education on the web? While this article could have radical extensions it seems to me that a combination of the two -- inquiry about our own health and respect for those trained in medicine -- can really create a more efficient health system. We need to embrace this era of health information and make it as participatory as Kevin Kelly suggests -- doctors and patients communicating and working together towards a healthier system. And as for the idea that people can be burned by faulty information on the web...it is a valid concern. It makes perfect sense to be wary. But there are so many reliable and fantastic health websites out there (drgreene.com being my favorite), that this fear alone should not stop a movement towards health education.

No one is suggesting "do-it-yourself" surgeries. And no one is suggesting a blindfold over the patients eyes. This is a sensitive subject, obviously, so people need to not assume extremes and keep their minds open...

[atoonce]

It's insane to compare medicine to entertainment. People used P2P to save money on songs. Would you bet your health on something you read off the web? That's why we go to doctors, they possess a wealth of information, training and experience to cut through the data, examine you and your symptoms and prescribe the CORRECT medicine and treatments. No, they aren't perfect, but put them on a scale with self- diagnostics and treament and they are on the opposite ends of the quality spectrum. Perhaps in a hundred years or so, the "robots" will be able perform significant diagnostic and even treatment, but that is a long way off and a gradual process. Again, the similarities to entertainment and medicine are minimal.

[sunnybunny]

Bureaucracy and greed is the problem. Educating oneself to bypass or avoid that bureaucracy can be part of the solution.You can be a lot less vulnerable if you do research to prevent complications and keep an open mind. I hope both the music and medical industries get their act together and start doing the good they are meant to..

[Newtonsrevenge]

The people to blame for the current appalling state of health care in this country are those who have sought to have a monopoly on medicine. Mainly this would be insurance and pharmaceutical, but the AMA is to blame, and some, but not all, medical doctors. However, medical doctors are culpable of letting their field be hijacked by greed and vested interest. And they may lose the game entirely, as a result. People often need many modalities to be healthy. If allopathic medicine were integrated with complimentary medicine, so that all practitioners had the patient's interest at heart, we would not have so many chronically ill people in this country. How do I know that? Because I practice complimentary medicine, along side some excellent medical doctors. Patients are forced to seek information for themselves because it benefits vested interest to keep people ignorant and dependent. The original definition of doctor was "teacher" from the Latin "docere". Doctors should return to their roots.

[Lochmon]

RJ Eskow:

...thank you for a very stimulating, thought-provoking article.

Based on my skimming of the comments, you've garnered more nay-sayers than hands of agreement, but so what? It's a startling thought.

The currently-available home tech is clearly not sufficient for what you suggest, but, again, so what? These things can change fast (especially when we want them to). The question is, is this one of those things?

Please consider the article you gave us as a draft you've put out for public consideration. I would really like for you to go through the following pages of comments, considering everything said pro-and-con point-by-point... then, with an excellent starting-set of questions, go out and learn what you can of current R&D, and give us an updated & expanded version when you feel it's ready. (Dump the P2P music-sharing comparison though, sez I... it's not necessary, and is in fact counter-pr­oductive--­you've got a good idea here without having to stretch such a metaphor.)

I'd never really considered what you suggest... but to me, with my SciFi tendencies, it makes good sense. One thing we know for sure is that there will be a certain number of tech-savvy doctors who would rather be billionaires than settle for being mere millionaires.

My own commentary on this (with lots of negative reaction)....
http://www.huffingtonpost.com/rj-eskow/could-doctors-go-the-way_b_215892.html?page=2&show_comment_id=25729595#comment_25729595

[alice09]

As someone who supported a husband through medical school and residency (7 years) and now has a daughter studying 24/7 in her first year of medical school, it's ridiculous to suggest that point and click can replace the understanding and fund of knowledge these family members worked so hard to build. That knowledge matters. People read something on the net now and think it's that simple and that it's true. There is a lot of idiocy on the net and a multitude of factors come into play in the care of patients.
The net is also easy pickings for fraudulent, greed driven behavior. Ask anyone who has ordered pet meds from bogus providers (like myself) or gotten burned by Craigslist.

[Lochmon]

Earned reputation counts for even more on the internet than in our own cities and villages; thank you for reminding us of this very important point.

[burndtdan]

Being able to download a song does not make you a musician. God help us if people think they will have the requisite knowledge and skill to be performing serious medical procedures because they looked it up on the internet.

[peterg76]

Despite all the amateurs who were taken in by the WTC demolition hoax, I don't see the Internet displacing professional engineers any time soon. Medicine is simply too difficult to forego the expert with the education and training. But there is certainly a potential for greater empowerment of patients and more critical examination of costs. Over-priced services will become easier to identify.

Reliable medical information is actually plentiful on the web (many medical schools have fabulous resources), provided the user can distinguish pharmaceutical advertising from genuine medical information.

[steppenwolfsayshi]

There is nothing some doctors hate more than informed patients. In my opinion, those doctors should be vets.

[Lochmon]

Many of them, and in fact often the best of them, are veterans. That's what you meant, right?

[steppenwolfsayshi]

Sorry. I didn't mean my comment that way. It seems like a lot of doctors don't know or don't care to take proper medical histories or take proper notes anymore-like they would much rather deal with patients that couldn't speak. I was just imagining what it would be like if patients wanted to be more involved in their care; so many doctors will be wanting to pull their hair out.

I guess what meant was: they should be pathologists.

[sonoffestus]

It is harder to get into Vet school than medical school. True there are fewer of them, but they are still getting the best. Besides who in their right mind would want to be a doctor when you could work without having to deal with insurance companies.

[force fed up]

You're more right then you know. One of the biggest reasons the music industry is hurting is because they are mass-producing garbage and expecting people to buy it up without question. Mainstream music in general has been very generic and uninspiring for the last decade and more and more people are looking elsewhere for new sounds. (hence RIAA's hatred of Bit Torrent) Its not that they're "losing money" on people downloading music, its that they're "losing money" on people downloading music that is not theirs and they have no right to.

The health industry is serving up shoddy service and work at obscene prices and the people are expected to buy it up and like it instead of looking for better deals or different advice.

[Lochmon]

"The health industry is serving up shoddy service and work at obscene prices".....

Excellent. I didn't touch on that in my other posts.

This article has a good proportion of people in the health-care industry making comments, as it should. So let me, as a complete medical layperson, be as clear as I can about something....

I hate hypocritical politicians. I also hate semi-honest politicians who don't have the integrity to expose the guy in the next seat who they know is a fake.

I hate corrupt cops. I also hate cops who would be honest-as-­they-can-b­e, but don't want to be bothered by knowing some of their fellows are on the take.

I think I hate supervisors who make exchanges for advancement, although I'm not sure I've encountered such. Apparently I'm better at choosing bosses than I am at choosing wives.

But when it comes to real life-and-death realities, I most of all hate the incompetent doctors we all know are out there, and I also hate you more-competent doctors and health-care professionals who do not have the personal integrity to drive the charlatans out of the business you swore Hippocrates' Oath to uphold.

Until you guys can police yourselves with integrity, do not even talk to us about limiting malpractice.

[Lochmon]

"The health industry is serving up shoddy service and work at obscene prices".....

Excellent. I didn't touch on that in my other posts.

This article has a good proportion of people in the health-care industry making comments, as it should. So let me, as a complete medical layperson, be as clear as I can about something....

I hate hypocritical politicians. I also hate semi-honest politicians who don't have the integrity to expose the guy in the next seat who they know is a fake.

I hate corrupt cops. I also hate cops who would be honest-as-­they-can-b­e, but don't want to be bothered by knowing some of their fellows are on the take.

I think I hate supervisors who make exchanges for advancement, although I'm not sure I've encountered it. Apparently I'm better at choosing bosses than I am at choosing wives.

But when it comes to real life-and-death realities, I most of all hate the incompetent doctors we all know are out there, and I also hate you more-competent doctors and health-care professionals who do not have the personal integrity to drive the charlatans out of the business you swore Hippocrates' Oath to uphold.

Until you guys can police yourselves, do not even talk to us about limiting malpractice.

[Lochmon]

Double-posted, and I apologize, but my goodness... nearly two hours between the posts. The first hadn't shown up when I thought I hadn't posted at all.

[davidmoultrup]

As a life-long health care professional, I am fully aware of the MD's and other professionals who need to be relegated to cooking fries at a fast food joint. There's no excuse for them. On the other hand, to think that healing is about high-tech gizmos is so far off the mark it's not even a debate. Even with an increasingly educated population there's a need for true experts to engage people in the emotional journey of healing, whatever the symptom. There's simply no high tech toy that is ever going to do that.

[Lochmon]

TYVM for the first part.

For the rest...

...you got useful info on your PC loaded from a disk? Do you have any problem with everyone else having that info?

Do you think it's good most people have thermometers? and are you aware what a relatively recent development that availability is?

It's good that people have triple-antibiotic available, right? Even doctors didn't have such until recent decades.

You do approve of the advances that make it so much easier for diabetics to self-diagnose?

Many health clubs are now less about lifting insane amounts of weight and instead offer cardio / respiratory equipment providing biofeedback to users. Do you approve of this kind of high tech toy?

I would hope that you are glad the best nurses can handle anything a doctor of 50 years ago could handle, and most of what a doctor of 20 years ago could handle. (And many are even better than that.)

Are you effective without high-tech? If you parachuted into a Brazilian rainforest sans supplies, you'd still be the most effective healer around, I bet. But... medicines missing, you'd be real interested what the little old ladies say about local plants, right?

Back in the civilized "tech" world, you hear of a startup company building a prototype diagnostic unit determining temperature, blood pulse & pressure, basic blood chemistry, rudimentary EKG and EEG... $200 in parts. You gonna invest in this "high tech toy"?

Just fishing for more info from you, David....

[no body]

Part 3 of 3
Step 3 - Wrap the hospitals and Health care insurers in a Services-Oriented Architecture (SOA). Think of going on an internet shopping spree and all the forms you've filled out. Now envision where there is no user interface and your shopping trip could be completed and validated in the blink of an eye.
Pros - Because the medical community has its own very precise terminology, what’s covered, partially, wholly or not at all by an insurer can be checked using a webservice in real-time. This would allow the patient and doctor to choose the right treatment according to effectivety and cost. The use of webservices at the hospitals is to allow the use of workbooks without having to replace any of their current systems because it can be placed on top or as a step in a workbook/workflow.
Cons - A lot of layoffs at both the Health care insurers and the doctor's offices.
Since the technologies I proposed using are at least five-years old and use XML and XSD (XML Schema for validation), the health care savings and costs can be measured accurately. Director Orsag's 700 billion dollars by using "Best Medical Practices", Senator Sanders 400 billion dollars in administration fees, malpractice insurance rates, medical errors and prescription drug costs are all addressed, if this system were adopted. But what a whirlwind of change it would be.

[no body]

Part 2 of x
Step 2 - Create electronic medical workbooks maintained by the Government and Health care Industry that would represent "Best Medical Practices" for all the different treatments using IBM's open-source Darwin Informational Typing Architecture (DITA) for views and workbooks.
Pros - Because the workbooks are XML-based each treatment can be checked for accuracy and completeness in real-time. Medical errors would head lower because the workbooks can be designed to check that all the necessary steps were taken for the treatment. In addition, because "Best Medical Practices" were followed and the workbook stored at a third-party punitive damage awards should also head to zero. Another plus is that distribution of new or updated workbooks is done at the telecom-level, it could be achieved in a matter of seconds.
Cons - None that I see, except maybe lawsuits in the battle for the best effectivety rating amoung pharmas.

[NotBrainwashedByMedia]

Can I get the last few minutes of my life back please???

This comparison is ridicules... About as ridiculous as me having a backache, going to Google and finding out I have Multiple Myeloma!

[NotBrainwashedByMedia]

Now I can't even spell... Help!

[steppenwolfsayshi]

What a joke!
Can you image going to a doctor for a backache and getting diagnosed with Multiple Myeloma?
Me thinks they would tell you to take some tylenol and take walks everyday-the same as the Google would.

[steppenwolfsayshi]

Sorry, that was unclear. You would need a really good doctor to eventually make that kind of diagnosis. But the months and months before it was made, you could just as well treat yourself with info from the internet.

[Lochmon]

I looked it up on Google for you... it turns out you slept on your trombone.

[no body]

Part 1 of x
Interesting how your thoughts align with the following freeware solution to Health care IT:
Envision an electronic loose-leaf notebook (not computer) that has pages, workbooks, outcomes that represents your medical history. Where the pages and workbooks can be checked for accuracy and completeness. And then we need to complete the following three steps:
Step 1 - Store all doctor's office patient records following HIPAA regulations at the local-telecoms. No name and address. Hospitals could use cloud computing with a locally located third-party controlled server (SaaS.)
Pros - The telecoms are big enough, have the redundancy, the geographical reach, the competition, the bandwidth, on-call staff and their business model is based on providing reliable services at a low cost. They can provide better security for the patient's records than at a doctor's office. And because the records are more centralized it would allow real-time studies of the effectivity of treatments and "Best Medical Practices".
Cons - People may not want their records open to research. This would be a voluntary effort, otherwise the record would be encoded using the doctor's electronic certificate of use, but I would hope that a statistically significant portion of people would allow their records to be used for research. Another con would be the layoffs at the doctor's office as the telecoms offer more and more services like billing, reminder calls, the list is endless.

[KillTheMessenger]

Nobody... my doctor has my complete medical records from the day since I went to my first physician here in the US. They know all about me that they need to know. The only thing they don't have is those x-rays from my surgery in Germany some ten plus years ago. And that doesn't matter because there is not a thing one can do about that part of my body.

And, yes, I have complete web access to that data.

If your provider does not have that, the problem is with YOUR provider, not with the state of medicine in the US in 2009.

[no body]

I think you're thinking of a printed record which can be viewed by a human vs an XML record which can be validated for accuracy and completeness using an XML Schema. In otherwords, printed records require human intervention whereas XML records can be processed programmatically.

[KillTheMessenger]

Complete patient record formats (not in XML but binary) have been defined about twenty years ago with complete implementations being available around 1995 to the best of my knowledge. None of this is new or exotic IT.