The future of medicine?

It is always tempting to predict the “future of medicine”. Take the current “flavour of the month”- artificial intelligence, IoT, 3-D Printing etc. Mix and match terminology and push it out in the open to a network of “influencers”. Voila!

The “trigger” for this write up was an excellent series by Dr Bryan on 33 charts but more on that later.

At the other extreme is the delusion of techno-optimism. I describe technoptimism as a “faluntin” (an obscure grammatical nuance which describes nouveau terminology without any practical application). Technology trends and policy decisions are shaped by innumerable factors- political dispensation, prevailing policy, macro and microeconomic indicators and unforeseen “tech-trends”. What’s next beyond the current “cutting-edge”?

That is why I usually do not base my opinions from what the technology blogs or VC firms peddle. They have their own vested interests in pushing a narrative that would align with the techno-optimism babble of their investors. Remember VC firms are only a conduit to push out good money on “punting”- like betting on a race horse. The payday is good and there is enough literature (or “intelligence”) on the ground which teaches the new bright-eyed individuals about betting. As such, a significant proportion of these firms depends on marketing their “idea-bank”.

Of course, this remains my personal opinion and is in no way reflective of prevailing “trends”. The future of medicine attracts “entrepreneurs” with a natural “risk-taking” appetite. One of the blog posts that caught my attention from 2016 describes the extreme case of techno-optimism (ironically, the author accepts it as such). It merits a deep consideration, despite my biases.

Healthcare today often results in suboptimal patient outcomes despite doctors doing the best they can within the current system.  Suboptimal outcomes result from the incomplete knowledge and personal biases of today’s system. Medicine has historically been approached according to tradition – the experiential evolution of best practices, and a reductionist system of small trials.  Optimal treatment outcomes require a healthcare system that is instead primed by holistic, scientifically, probabilistically or other statistically-validated data and conclusions presented to patients as cost/benefit choices

We have made substantial improvements in the outcomes- overall survivals or cause specific survivals through focused and ingenious interventions. However, the current bane of trials is the poor representation of the population that it intends to serve. As an example, the current infatuation with the “dose-de-escalation” in oropharyngeal tumours. My only contention is that using modulation as a means to reduce the dose to target tissues is an overkill. In the absence of radiobiological inputs and quantifiable metrics, it is too difficult to extrapolate the ideas. I doubt, if this represents a genuine advance of medicine- they are dealing with early stage tumours that are easy to manage in terms of “recurrence” anyway.

Technology will reinvent healthcare as we know it. It is inevitable that, in the future, the majority of physicians’ diagnostic, prescription and monitoring, which over time may approach 80-percent of total doctors’/internists’ time spent on medicine, will be replaced by smart hardware, software, and testing. This is not to say 80-percent of physicians will be replaced, but rather 80-percent of what they currently do might be replaced so the roles doctors/internists play will likely be different and focused on the human aspects of medical practice such as empathy and ethical choices.

I have my strong doubts on this one too- electronic medical record that was meant to “usher” in the new age of medicine- however, that has not panned out well as a few companies have effectively killed innovation and cornered the market. It has led to an increase in the physician burnout while forcing the process “more inefficient” and inducing policy headaches related to data portability. By reinventing the problem- it has done a huge amount of disservice to the medical community.

Many new findings will be outside the reach of most physicians because of the volume of data and the unique holistic insights that data will provide about a patient’s very complex condition. Hundreds of thousands or even millions of data points may go into diagnosing a condition and monitoring the progress of a therapy or prescription, well beyond the capability of any human to adequately consider.

This is another instance of an extreme techno-babble. Interestingly, this was the premise for ill-fated IBM Watson which purported a “revolutionary advance” of medicine. One of the USP’s of Watson was the promise of “incorporating” the rapidly growing medical literature.

However, look at the piss poor academic literature “market”. I do not see anything different or “new” about it. Nasopharyngeal tumours, to give an example, have been done to death in the South-Eastern geography- patterns of disease manifestations and failures not prevalent in the Western bloc. How do you reconcile to this? What is new about patterns of xerostomia? We have not been in a position to quantify those effects!

Likely the next decade will mostly see systems providing “bionic assist” to physicians and complementing or enhancing their skills. Today’s traditional approaches will get better as new approaches, and even new medicine, is invented. As the 80-percent of physician work is replaced over a few decades, the remaining 20-percent will be AMPLIFIED, making them even more effective, and allowing even the average physician or nurse to perform at the level of the very best specialists.

Here’s another nugget of wisdom!

The primary care physician and maybe even the nurse practitioner may be able to operate at the level of six specialists handling six areas of care for one patient with multiple comorbidities in a more coordinated and comprehensive manner without inter-specialist friction. 

Projects like the Cancer Moonshot will apply rigorous genomic, proteomic and phenotypic tools and within large trials, to optimize the inadequate patient outcomes in oncology practice today.  Though medical textbooks won’t be “wrong”, the current knowledge embodied in them will mostly be replaced by much more precise and advanced methods, techniques, and understandings.

I was keenly following the Project Cancer Moonshot- partly because it promised to usher in the era of “personalised” medicine but also to showcase what a particular company could do. I had a long chat with some of the representatives (almost four years back) and while they had a compelling proposition, they wanted to showcase their own proof of concept and work on “personalised genomics”. I am not sure what came off it, but I am not holding my breath. There is a difference in a service being retrofitted to answer the research questions versus building up a service after the questions have been answered. The former represents shoving the idea in a tight corner that would force the system to “disrupt itself” while the latter represents a genuine perceived need to innovate and adapt to new ideas.

This transformation will happen in fits and starts along different pathways with many course corrections, steps backward and mistakes as we figure out the best approach. Given the importance of having clarity on what I hypothesize as my forecasts, I want to be clear that they are only directional guesses rather than precise predictions. 

I think, this represents an honest confession from the author, and I completely agree that they are NOT precise predictions. The sum total of “innovations” is an experiential process that doesn’t lend itself to definitions. It is an abstraction that appeals and is contentious. The “future” of medicine will remain firmly grounded in the past with its practitioners taking on several roles. However, the role of physicians becomes more interesting- how we will evolve?

Now consider this:

Technology in medicine complicates predictions about physician supply and demand when you consider the advanced practitioner. Because as more of what we once did at the bedside gets offset to diagnostic technology, it becomes easier for someone who is not a doctor to fill the role of healer. As the report suggests, advanced practitioners are expected to weigh significantly in future physician workforce considerations. I suspect that this reality is underrepresented in the report.

From 33 charts

Dr Bryan rightfully argues about the future of the care provider- but the physicians will remain in a quandary. It depends on how we adapt to the oncoming disruptions. The answer is not clear or muddled and depends on whom you bother to ask.

The AI training systems, to give an example, as above, have become increasingly “accelerated” and you could process millions of images from a desktop GPU in a relatively short span of time. Faster, on premise, algorithms will alter the matrix in a significant manner.

I cannot answer the question of “future”- but the slow creep of industrialisation will undoubtedly impact our practises. How far you wish to stretch the time depends on how much willing you are to believe the narrative.