Tomorrowsdoc

The Changing Landscape of Our Lives

Over a few decades, innovations like smartphones and the internet have transformed how we live our lives. Technologies we rely on to make life more convenient have gained widespread use. For example, today, 93% of US Americans use the internet. The smartphone concept, although with several iterations since the 1990s, did not gain traction until the last decade, where smartphone ownership in Americans went from 35% to currently 85% (Pew). Improved technology and lower costs likely drove the smartphone to its ubiquitous levels. However, as political scientist, Christian Lous Lange said, “technology is a useful servant but a dangerous master.”

How we use technology in healthcare is equally crucial. Healthcare innovations and scientific advancement move us toward a new health paradigm. We are amid a healthcare revolution that will profoundly change how we provide care. It occurs during a pandemic when we have become increasingly aware of how the environment shapes our health. The novel coronavirus emerged as a spillover from human-animal interaction. We also saw how the pandemic differed depending on the region and socioeconomic background. Today, a disease that didn’t exist a few years ago is driving the research and fueling technological innovation.

Even as we grapple with these changes and their consequences, a thriving doctor-patient relationship remains the cornerstone of exceptional care. The very technologies that enhance health care are the same ones that can stifle it if we neglect the founding principles of patient care. How do we advance healthcare and improve the public’s health while not fracturing the relationships that enhance care, create satisfaction, and make being a doctor fulfilling? These are the challenges for tomorrow’s doctors.   

Technology is a useful servant but a dangerous master.

Christian Lous Lange

Tools, Technology, and Progress in Medicine 

Technology drives discovery. Suppose you invent a device. Beyond the original purpose, there are often other applications that can spawn from it. Scientists and engineers collaborate to develop and refine new tools. In turn, these devices generate new fields of scientific research. It might start with an invention like the microscope. Someone needs the training to interpret what we can and cannot see. Now, multiple fields of science and technology routinely employ microscopes.

The momentum of medical advancement transforms how humans put health into perspective. We owe our understanding of health to discoveries fueled by scientific inquiry. The initial advances started with ways to enhance the senses. These findings produced technologies that improve diagnosis, treatment, and care. This chapter will illustrate how these concepts will shape the view of health and tomorrow’s doctor.

Here are examples of technology through the ages: 

• Anatomy: In the Middle Ages, detailed anatomical knowledge from dissections led to a more refined theory of physiology, or how the body functions. 
• Microbiology: Sensory enhancement with lenses allowed physicians to look through microscopes at the germs that cause disease.
• Radiology: Imaging technology in the nineteenth and twentieth century, with the development of the X-ray machine by Wilhelm Roentgen in 1895 and further advances by Marie Curie in 1914, gave doctors “X-ray vision” and the ability to see deep tissues without surgery. 
• Molecular Biology: Advancements in molecular biology fueled more sensitive and specific tests to improve diagnosis and treatment. 
• Computational Technology and Artificial Intelligence: Improvements in computers and artificial intelligence technology launched a new era of precision medicine and promised a more comprehensive view of health. 

Physicians approach patients now with a vastly different toolset than even in the recent past. Technology expands human senses and computational capability, closing the uncertainty gap. Tools like mammography, ultrasonography, and CT scans can detect disease, even when the patient’s history and thorough exam did not suggest it. Modern medicine refines the lens to evaluate patients.

Research and engineering fuel the evolution of medical care today. As new diseases emerge to accompany chronic conditions, we constantly push science to the limits of discovery to develop tools that guide prevention, diagnosis, and treatment. Technology has provided solutions for approaching the COVID-19 pandemic with more rapid and sensitive testing tools, targeted vaccinations, and molecular-based therapies.

Time has shown that technology drives innovation and enhances our perspectives on health. Technological innovation also provides an approach to construct a more comprehensive health paradigm. Nevertheless, today’s health model is still incomplete and inaccurate, and at times it leads to erroneous diagnoses and treatments. Furthermore, there are gaps in the way we address chronic diseases. We prioritize therapy often while not approaching the underlying behaviors. We continue to develop and refine tools as our accumulated knowledge guides us toward a deeper understanding of the fundamental driving forces of health. 

The sensory boost that comes from technology can be pivotal in developing a new paradigm on health. Imaging advancements such as radiographs (X-rays), computed tomography (CT), and magnetic resonance imaging (MRI) have brought us closer to the source of a disease. They enabled our understanding and fine-tuned our diagnosis. More dynamic technologies to come may help us further understand these questions and refine our sense of the reality occurring within the body.

However, technology has limitations and cannot explain disease when results are “normal.” That is the role of a physician, who has gained experience over many years, honing examination skills, pattern identification, and patient interviewing. A crucial skill that supports this process is empathy. Physicians who express empathy in their interactions with patients gain greater precision in diagnosis and enhance treatment and behavior change. One requirement has been constant in medicine throughout history: the doctor-patient relationship. Listening and examining a patient remain a cornerstone in the era of modern medicine.  

Tomorrow’s Clinics: The Doctor is In

What will tomorrow’s clinic be like? About 75% of doctor’s visits are for chronic diseases related to behaviors. Behind these behaviors is a significant overlap of emotional stress and physical illness. Chronic stress can perpetuate trauma, addiction, and a toxic environment as the brain attempts to hold onto unhealthy coping strategies. Currently, doctors provide prescriptions for chronic health conditions, insomnia, and pain, while these cycles continue to erode one’s health. Can we rethink the future of healthcare?

Picture this. You keep a checklist of healthy practices that you follow each morning and into the day. These routines include mindfulness meditation, exercise, nutritious eating, and outdoor time. Additionally, each week you meet online with your physician health coach to review your progress.

In your community, there are several health clubs that people can join that provide health coaching, social activities, exercise and movement therapies, and nutrition counseling. You are a member of one of these and regularly attend it for exercise instruction, focus groups on addressing behaviors, and art activities.

Two years before, you had diabetes because of being overweight after going through a significant stressor. The health club doctor met with you in person several times and listened to your concerns. He addressed the information with a non-judgmental statement— that stress creates a memory in the brain to repeat a behavior that reduces it. However, it may not be healthy in the long run. He mentioned that the brain naturally gravitated to certain foods that helped with stress but caused weight gain.  He encouraged you to start working on your brain’s adaptation to stress, and the behaviors that will lead to health will follow.

What followed was a pathway to your healing that began with including self-care time in the day for deep breathing and meditation, writing out thoughts that collected as worry in the brain, and exercise. You reduced the smartphone time, television time, and other distractions that made your day feel stressed. Rather than choosing ultra-processed foods, you changed to a plant-based diet to help your body and microbiome. The weight came off. After several months, your doctor told you that you no longer have diabetes. Furthermore, rather than provoking sharp emotional pain, the traumatic experience reminds you of life’s importance and informs your future decisions. You have effectively changed its memory.   

Multiple Access Points to Care

Already a reality today, a patient can see a doctor when and where they wish. Access to care has improved with online scheduling applications, freestanding urgent care clinics, and telemedicine. Access affords several positive results, including decreased utilization at higher traffic points, e.g., emergency departments, and improved costs. Telemedicine promises to resolve several barriers that physical clinics cannot, including geographic barriers, cost containment, and even patient outcome benefits (Barbosa, 2021.)

Necessity is the mother of invention. Telemedicine, a concept starting as early as the 1900s with the telephone, has gained steady ground in its use. In 2020, the COVID-19 pandemic became a catalyst for its acceptance, as people had less access to physical clinical visits with social distance measures in place (Vidal-Alaball, 2020.) The advantages of telemedicine include its convenience, low cost, and easy accessibility. Alongside this technology are other devices, including rhythm and pulse ox meters, allowing a physician to better interpret a patient’s health concern from afar.

Healthcare and Technology: The Next Generation

Not only have medical technologies increased our ability to diagnose, but they have also enhanced precision in treatment and follow-up. Frequently, a thorough interview and physical exam are not enough to close in on a diagnosis. My colleagues refer to computed tomography (CT scans) as the “internist’s physical examination,” a comment that usually comes when there are critical CT findings after a low-yield physical examination. Ahead in the future, newer technologies will complement older ones and further increase diagnostic capability and disease understanding.

Get ready for the new frontier in medicine with advances that will radically alter the practice of medicine as we know it. These advances will likely stem from several innovative fronts. I will just briefly scratch the surface of a few of these topics listed below and save the others for a future book.

1. Sensory Enhancement. Improved tools that further enhance and interface with our five senses,
2. Enhanced analysis of complex systems. Better-calibrated diagnostic and treatment modalities, and management of more significant streams of information,
3. Robotics. The use of robotics and other modalities to minimize operative risks and complications,
4. Artificial Intelligence. Incorporation of artificial intelligence and advanced predictive tools of multivariate data to increase scientific understanding and interpretation of complex systems, and
5. Neuroscience frontiers. Greater comprehension of the role of the brain and microbiome in health and illness.

Sensory Enhancement

It is not surprising that historically the most important advancements in understanding health came by way of enhancing the senses. The earliest theories came after years of observations and predictions from the five senses and intuition. From gross anatomy to microscopy, our understanding transformed and became fine-tuned. The greater magnification made possible by electron microscopy necessitated the new disciplines of cellular and molecular biology. Magnifying our scope seems to increase our insight into the more universal health themes.

 With tools enhancing physicians’ senses, there was greater accuracy in determining and treating a problem. Even simple maneuvers used in the 18th century, such as percussion, the act of tapping on the skin, could detect enlarged organs and fluid in the chest. René Laennec invented the prototype of a stethoscope in 1816 after feeling embarrassed examining the heart of a young woman. [1] In those days, a physician would listen to the heart sounds by directly applying their ear to a patient’s chest (Weinberg, 1993). By the 1960s, Harvard Medical School Professor David Littman made the stethoscope design more lightweight. A new generation of stethoscopes, known as “smart stethoscopes,” pair additional technologies to visualize the audio components of the heart and lung sounds and interpret the soundwaves with artificial intelligence programs.

Just as the microscope revolutionized medicine, modern-day innovations will blaze a path in our understanding of medicine. Over the last century, technologies, such as radiography, computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography (US), and nuclear imaging have given physicians a more remarkable ability to diagnose. Flexible fiberoptics allow pulmonologists and gastroenterologists to visualize, sample, and interpret complex processes. In brief, technology will enable physicians to get closer to a disease site and tell them what they need to know about it.

Improved Analysis of Complex Systems

The scientific method provides a basis for objectively assessing the difference between an experimental and a control group. The gold standard is the randomized control trial (RCT.) The attempt of this trial is randomization and to monitor for a significant change in the experimental group compared to the control group.[2] A RCT confines each study to only test for one effect. Scientific advancements will most certainly incorporate technologies that enable the capture of multiple measurements on dynamic systems. A new experimental design will likely follow from our ability to capture mass amounts of data.

The scientific understanding of complex systems, including the human body, has been fraught with limitations in modeling and understanding the multiple interactions. The scientific method often employs a reductionistic approach to the components to test each part as if in a vacuum, science is heading in the direction where it will be possible to analyze multiple interactions simultaneously. With more advanced computational abilities, artificial intelligence systems, and specialized laboratory and genetic testing, we are heading toward individualized care, often called precision medicine. A person may soon be able to get a readout of the systems out of imbalance, address these issues preventively, and find which therapeutic options are preferable (Gameiro, 2018).

The marriage between supercomputers and genomics seemed inevitable. The amount of information stored within our genetic code, although finite, is vast. Computers were necessary to assist in sequencing, pattern determination, and modeling. Beginning with the Human Genome Project, the time it takes to completely sequence the human genome decreased from fifteen years to a little more than an hour. [3] Faster sequencing speeds brought the cost down substantially; Steve Jobs was one of the first to have his genome sequenced at the price of approximately $100,000. Now, this process would cost $100 (Fikes, 2017). Newer methods contributed to the end-to-end sequencing of the human X chromosome, which was otherwise impossible before (Miga, 2020).

Concluding Remarks: Progressing Toward a New Perspective on Health

Concluding, I wanted to mention a counterthought to genetics being merely a predetermined code. The central dogma in molecular biology states that the flow of information starts with the transcription of genes into RNA; ribosomes read the RNA and encode it into a particular protein. However, there is still much to learn about how cells encode multiple proteins from the same genetic material through alternate splicing. Here is more on genetic testing. Further, how the body interacts with the environment and, over time, through aging influence the proteins produced.

The human body manifests its genetic code and its adaptation to the environment. Added to this is how the brain interprets and adapts to it. A more rigorous understanding requires scientific inquiry into the intersection of the body and the environment— the science of epigenetics. As we venture deeper into this world of complexity in the genome, broader themes of health and evolution will emerge that will inform how we view health and how doctors practice medicine.   

The public’s health rests in how we educate the next generation of doctors. These students will inherit a legacy of chronic disease management in healthcare. Newer technologies will assist them in envisioning health with a sharper resolution as they design strategies to promote health.    

At first glimpse, it may appear incongruent that technology would have a role in advancing our perspectives on health and the human body, the man versus machine paradigm. But, just like the microscope did in the 1700s, developing technologies like supercomputers, advanced radiologic modalities, and artificial intelligence are tools that enable us to extend the senses and catapult our understanding into new dimensions of science. At one point, our technology will become increasingly simplistic in design but may interpret more than the most renowned physicians of the past could only hope to understand. Yet, tomorrow’s doctor will be at the helm of these tools, guiding the patient along their journey toward treating disease and finding optimal health.

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[1] Laennec coined the term from the Greek words, “stethos” meaning chest and “scope” meaning look. It was a monoaural stethoscope for “one ear,” as a doctor was only able to listen with one ear. In 1851, Arthur Leare invented the binaural version, “two ears.” George Phillip Camman also has been credited for this invention.

[2] Placebo means “I shall please” in Latin. Even though placebo is an inert ingredient, it is not uncommon to measure some effect in this group, at least in part suggesting that there is some response to factors generated from the brain.  

[3] In 2012, scientist at the University of Leicester printed the complete human genome. Something that has a combined length of 200 nanometers (1 nm = 10 -9 meters) took 130 volumes to fill with its Cs, Gs, As, and Ts.

Bibliography

Fikes, B. Focus: New machines can sequence human genome in one hour, Illumina announces. The San Diego Union-Tribune. Jan 9, 2017.

Gameiro GR, Sinkunas V, Liguori GR, Auler-Junior JOC. Precision Medicine: Changing the way we think about healthcare. Clinics (Sao Paulo). 2018; 73: e723.

Miga K, Koren, Phillippy AM, et al. Telomere-to-telomere assembly of a complete human X chromosome. Nature. 585, 79-84. 14 Jul 2020.

Pew Research Center. Mobile Fact Sheet. http://www.pewresearch.org/internet/fact-sheet/mobile/

Rand Corporation. 2017.

Vidal-Alaball J, et al. Telemedicine in the face of the COVID-19 Pandemic. Aten Primaria. 2020. 52(6): 418-422.

Weinberg F. The history of the stethoscope. Canadian Family Physician VOL 39: October 1993.