The problem with ambition in medicine - don't implement solutions till people are ready for them!

Disclaimer: I work in Surgical Robotics currently, and Kaiser Permanente, featured in the story below is my current insurance provider.

The Story: CNN just picked up a rather sad and disturbing story of a patient and at least one of his family members being given sad news, perceived to be delivered in an insensitive manner, through a telepresence robot.

I suspect the story will gather steam, and much alarm and machination will ensue about robotics, AI, the practice of medicine and so on. Well, the discussion is due, and as much as all of us wish more caution had been applied, the first of hopefully, a small number of such incidents has come to pass.

The link for the story itself is available below.

The Summary: After determining that a 78 year old patient with COPD had but days or hours to survive, the Doctor chose to make that alarming and pithy revelation to the patient's granddaughter, in his presence, remotely.

The patient did die the next day, and the family is rightfully quite unhappy. The hospital has apologized and attempted to mend the situation, but I am sure the issue is not over. Now that at least one news outlet has picked it up, as well as other possibilities that I am shy to speculate here, this issue will probably persist in the public eye, and will most likely lead to arguments that drag technology in medicine in several directions.

I wanted to present a few thoughts of my own.


Timing and Technology: To serve patients and their families better, to make medicine more effective
and cost efficient, technology is always being used to push boundaries. The latest agents of change include, but are not limited to robots in pharmacies, surgeries,  comfort (it has been proven time and again to work wonders with autistic people) and other areas.

There is already immense fear of AI and robotics "taking over". It doesn't help that seemingly intelligent people like Musk and Hawking have said some incredible things about Artificial General Intelligence and Artificial Super Intelligence, while we are at a minimum, decades away from achieving such feats.

That said, it is very important to pick and choose how new technologies are implemented. Clearly the Doctor and Hospital Staff lacked sensitivity in this issue. They might have chose expediency, but that is no excuse for what happened here. It would have been so much easier to ask another Doctor to go up and deliver the news in person. I really don't want to hear nonsense about patient privacy being used as an excuse here.

All Fear and Animosity is NOT Ludditism: The other day, I saw a video posted by the passenger of a car, showing their neighboring driver in a Tesla, in a state in between, quite distracted and fast asleep at about 75mph an hour!

The problem is that, "auto-pilot" and "self-driving cars" are far from reality. Tesla has marketed the false notion that their cars can do this well (they can only do this up to a very limited level, and driver attention is very much required).

This distracted driver, and some of the others who have actually succumbed in Teslas tend to anger, just not me, but several people. This is not Ludditism. This is just a criticism of the lack of responsibility with those who use this particular piece of technology.

The Path Forward: We should start with responsibility, in medicine, as much as everything else. Patients are not soldiers. Neither are their loved ones! You can't command them to adapt to technology. A patient and his or her relatives are already quite anxious, and you can't really expect them to adjust to your attempts at unthinking efficiency.

Responsible, gradual, measured introduction of technological solutions and improvements is essential. Yes, it is very difficult to to time things. But rushing in is not the answer.

As technology moves the needle, we expect AI, robotics, telepresence, AR, VR and paradigms we haven't even visualized yet, to become part of the medical toolkit. This behooves us to make sure that the human side is not lost. Solutions must be implemented with care, caution and compassion. In a heightened state of anxiety, most people will not respond to new, shocking delivery mechanisms thrown at them.

Being Uncaring and Careless have Consequences: When people perceive a technology or solution negatively, it can have serious consequences. Patients can revolt, and that cannot be a good thing.

Heard of bedside manners? Not all lessons are new. Doctors are supposed to have the training, no matter what they treat, how they treat it, and who they treat. This is something that medical schools and residency programs are supposed to cultivate. So clearly, some are not getting the basics right!

The problem is that when too much is being dumped on Doctors, Nurses and the Hospital Administrators as well as Healthcare Systems, things get muddled quite quickly. In fact, this is the kind of chaos by fragmented distraction that some politicians and charlatans are using quite effectively, even as we speak.

Every actor in the healthcare network, including patients and their loved ones, have a responsibility to make sure that there is an effective balance. To this extent, I applaud the family, despite their sorrow, in bringing this to the public eye, so that we get a chance to talk about it, think about it and learn from it. Onward we must march, but with care, caution and compassion. 

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References:

1. The CNN Article: https://www.cnn.com/2019/03/10/health/patient-dies-robot-doctor/index.html

2. Image of Robot: https://www.pexels.com/photo/white-laptop-computer-on-white-desk-1329068/

3. Image of Watch: https://pixabay.com/photos/pocket-watch-time-of-sand-time-3156771/

4. Image of Patient: https://www.pexels.com/photo/medic-treating-patient-1539678/

It is high time the FDA considers taking down DTC ads rather than confounding them further

Word is out that the FDA is trying to curtail the number of side-effects stated in Direct-To-Consumer (DTC) pharmaceutical advertisements, in an apparent effort to try and get consumers to understand the key side effects and remember them. This is apparently considered a benefit to the consumer. How? Don't ask me. I think this is a bad idea, and the focus should be to de-emphasize DTC, so that prescribing medicine goes back in the practitioners' courts and pharmaceutical companies can focus on R&D and Translational Research spending. For years now, I have advocated AGAINST DTC ads.

1. Why am I against DTC ads?

The United States is one of the few countries that actually allows DTC ads of this nature. And I have a few critical reasons why many of us, and not just me, are against DTC ads.

1.1 An uninformed public is either given unnecessary hope, with some advertisements. Advertisements have a misleading way of sounding positive, and appear to offer a single point solution, that is quite effective. Needless to say, we don't know how age, sex, gender and other factors differentiate the effectiveness of treatments for many conditions in various patient groups. And where, we do know the effects, the advertisements simply ignore to state such information. Sure, there too, we could be like the FDA and pretend that information overload is the problem. However, when the Doctor finally informs the patient that the drug wont work on them (or tell them so after a few courses of treatment and the associated side effects take their toll), there are the 5 stages of grief, the second opinions, the ensuing loss of trust, the negative effects are too numerous to recount.

1.2 Confusion is the next problem. As the old joke in many television situation comedies (which run the advertisements they mock) that a simple headache medicine could include side-effects ranging from death to, yes, you guessed it, headaches.

Now, let us say that you found a headache medicine or allergy medicine that did indeed have side effects ranging from death to headaches. If you mentioned death only, does that make the patient feel relieved or better prepared? Or, if you leave out the headaches, and the Doctor only mentions them in passing, does the patient take that side-effect seriously? Do they decide to take the medicine? And if they are indeed plagued by headaches from taking the medication, then what?

1.3 Unnecessary Fear is the next problem. Imagine watching a cholesterol ad that warns you of cancer, heart disease or rectal bleeding? This is why the solution is not to MAGNIFY the main side effects. That somehow just makes the problem worse, not better.

1.4 The drug ads are also comically nightmarish. First of all, who in real life walks around telling people they have "moderate to severe Crohn's disease". If they did, it would actually be indicative that they need help of a different kind. And some of the so-called patients appear so deliriously happy after medicating themselves, it almost appears that something else is being advertised. Are you surprised at all that the United States is suffering from an opioid crisis?

Then there are the ads that are downright creepy. While the FDA has agonized over the presence of dogs, I would be more worried about ads that show a patient wandering through some ghoulish cartoon world, right out of the mind of someone who has consumed quite a quantity of hallucinogenic mushrooms.

Now, let me dismantle the reasoning behind this misguided effort at distilling DTC ads to accentuate fear, confusion and misinformation:

2.1. It is based on a study conducted with almost no rigor. The FDA asked 1500 people to watch a few advertisements, asked a few questions and mixed up a cocktail of street-side psychology and came to conclusions. This makes absolutely no sense at all. And this somehow took them years to get to.

2.2. Who decided information retention is the problem? This is what perplexes me. The problem here is patients who probably don't even understand what they ail from fully well, walking into the Doctor's office, demanding to be prescribed WEIRDCONSONANTFILLEDNAMEERASTUMINALIBAB because they watched an ad, that, sure, told them they could have nasal bleeding or brain cancer and something something, but that woman was up the next day smelling flowers and high-five-ing strangers. You see, if we get past all that distraction - the basic problem is - patients should not be making any decisions on their prescription (why have Doctors go through medical school at all then?) and should really leave this to professionals.

2.3. When was the last time a practitioner said, "Phew, I almost forgot about, but I am glad Patient X brought up EASYTOFORGETEXA for his moderate to severe such and such"? (Yes, the "moderate to severe" thing PISSES ME OFF, and to be clear, there is nothing moderate about how much it pisses me off.)

The Solution

This is one of several favorite quotes from one of the shows I love the most, House M.D. :

Dr. Gregory House: You wake up in the morning, your paint's peeling, your curtains are gone, and the water is boiling. Which problem do you deal with first?
Dr. Eric Foreman: House!
Dr. Gregory House: None of them! The building's on fire!

See, the problem is not that there is too much information in DTC ads, or that the amount of side effects retained is the problem. The dog running around in the ad is most certainly NOT the problem.

The problem is the burning house, that is, the fact that we unleash ads about NEARXIGA on people till 11PM, after which the "Non-Attorney Spokesperson" shows up and scares the living lights out of you and does not leave before letting you know that the FDA knows NEARXIGA kills, and equipped with this information, should you notice you've just died, call them.

What the FDA needs to do is to advice pharmaceutical companies to advertise as less of their drugs as possible and focus on spending money over new and more effective therapies. It is that simple. And in fact, that is exactly what a "business friendly" FDA ought to do.

And everyone should watch Dr. House.

Subscribe and Support, Please!

Did you enjoy this post? Please subscribe for more updates, using the sidebar. Have ideas or blog posts you'd like to see here? Contact me at yamanoor at gmail dot com.

References:

1. The Forbes Article: https://www.forbes.com/sites/arleneweintraub/2017/08/29/fdas-gottlieb-wants-to-rein-in-risk-info-in-drug-ads-but-will-he-succeed/#74f9bf7e2042

2. Dr. House Quotes: http://www.imdb.com/title/tt0774238/quotes

3. Image Courtesy, Pexels: https://www.pexels.com/photo/colors-colours-health-medicine-143654/