Doctor-patient relationship Become a threesome with machines

The use of artificial intelligence (AI)-based diagnostic and management systems and automated smartphone-based monitoring allows technology to insert itself between doctor and patient, which could fundamentally alter their relationship, according to a British expert.

“There is no escaping these fundamental forces,” said John Wyatt, Emeritus Professor of Neonatal Paediatrics, Ethics and Perinatology at University College London.

He told the Royal College of Physicians’ Med+ 2021 conference on October 27, however, that there will “always be a place” for a “compassionate human expert”.

If physicians” have a role, then one of those roles…is that of the concept of the “wise friend”, and of rediscovering and re-emphasizing the importance of clinical intuition and art of medicine”.

He added that “the expert consultant knows what the rules are and knows when they can be broken and when they shouldn’t be, and that’s something no machine can really know.”

Impact of the pandemic

Professor Wyatt began by noting that the COVID-19 pandemic has had a “tremendous impact” on the way medicine is practiced, and so the question is, “How do we react to this, and in particular how do we think- us to the implications? “

He cited the example of a GP practice which, at the start of the pandemic, had switched to an online GP consultation system on smartphones, which led to “all kinds of interesting and challenging problems”. .

One was that, for many young people, communicating with a GP via smartphone “was very similar to being involved in a WhatsApp conversation, and therefore all the normal rules and etiquette [of a consultation were] lost”.

‘People were incredibly flippant’ and ‘often very rude’ and ‘informal’, he said, and sent photos of ‘private body parts’, with the result that the practice ‘had trouble understanding how the hell do you practice medicine” in this context.

Wearables

Professor Wyatt continued that another area of ​​technology development with far-reaching implications is in wearable technologies, such as fitness trackers like Amazon Halo, which have an “extraordinary ability to monitor different physiological variables”.

He continued that an incredible amount of data can also be inferred from how an individual uses a smartphone, a process known as digital phenotyping.

For example, artificial intelligence systems can determine an individual’s mental state and predict a seizure based on the nature and quality of their speech, intonation, facial expression and eye movements, from how they move the smartphone and use the keyboard, their social media engagement, and even their internet search activity.

Professor Wyatt believes this is “just a taste of what’s to come”, as the combination of smartphone and wearable technology is “an extraordinarily powerful tool for monitoring a wide range of physiological variables”.

But, he asked, how is all this data monitored and stored? There are also privacy and reliability issues, which have been highlighted by recent revelations about Google’s DeepMind and IBM’s Watson systems.

Trio

All of this begs the question: “As the patient takes more and more control of their own care using technology, where is the doctor in the care pathway?

“I suspect that one of the implications that occurs is that instead of the person-to-person relationship – a duo between doctor and patient, which we are traditionally used to – there is now a kind of trio . “

He explained, “There’s the patient, there’s the doctor, and there’s the machine, and there are complex three-way relationships between this trio,” leading to the question of how “we learn to navigate through it all.”

Professor Wyatt thinks this could lead to the “fragmentation of traditional doctor-patient care pathways and decision-making processes”.

He continued: ‘There are obviously huge privacy issues’, particularly in telemedicine calls, as someone else may be ‘in the room’ with a patient and there may be ‘influences “unknown how he reacts.

Additionally, the lack of a physical exam could lead to “misdiagnosis and mismanagement” due to an inability to assess individuals accurately, and there are “all sorts of problems with remote prescribing.”

Professor Wyatt said underlying the “very rapid” introduction of AI and digital technologies into healthcare are technological advances, with hardware and software becoming more powerful and cheaper, and the accumulation of “massive sets of health data”.

The NHS, he said, “is seen as a particularly attractive source of ‘big data’ for commercial enterprises, because “the larger the dataset, the more accurate pattern recognition can become”.

The result is “massive” investment from “all the big players” and many commercial start-ups, all hoping to tap into the “absolutely astronomical” potential profits.

The NHS is also seen as ‘ripe for automation’ due to its ‘very high levels of staffing, inefficient practices, outdated technology, low productivity etc.’.

Quick diagnosis

He said the drivers of automation are increasing speed, accuracy and economic efficiency, through the rapid scale and replication of effective technologies in health systems.

The goal is to achieve more accurate and faster diagnosis and image analysis, especially in the area of ​​rare diseases and unusual presentations, as well as better prediction and monitoring of treatment responses, alongside to the “democratization” of specialist knowledge in “low-resource” settings.

But this could come at the cost of hidden biases, errors and discriminations in pre-existing health databases.

Further, commercial interests raise concerns that “most of these healthcare algorithms are in fact proprietary and protected by patents and non-disclosure agreements…and so it is often not possible to…question the algorithm”.

There are also issues such as how to “maintain human action and oversight” of automated systems, and how to judge when automated systems “suggest actions that conflict with clinical experience.”

“And one of the questions about all automated systems and especially machine learning is, when they fail, do they fail in a safe way?” Professor Wyatt asked.

Intangible assets

Following her presentation, Session Chair Sonia Panchal, Consultant Rheumatologist at South Warwickshire NHS Foundation Trust, asked what are the challenges facing health technology clinicians today as a result of the COVID-19 pandemic .

Professor Wyatt replied that there are currently “huge pressures on the health service, and in particular on the backlog…and I think that, increasingly, health officials will be looking at these issues efficiency and scale… and say, how can we get more out of the existing workforce?”

“And the obvious answer is technology…to increasingly relieve human beings and put them into automated systems.”

This will create “tremendous pressure” to introduce such systems, and his “concern” is that clinicians’ jobs will be scrutinized and someone will say, “You don’t need to do this, you don’t need to do this, you just focus on the others and we will remove these other tasks.”

Dr Panchal added: “Yet sometimes these are the tasks that you need, to be able to do the tasks that you are actually there for.”

“It’s a holistic thing,” Professor Wyatt said, adding that “technological thinking is always focused on measurable outcomes…and the problem, of course, is that these totally intangible but important things about comfort, care and compassion” cannot be measured or have their importance demonstrated.

No funding declared.

No relevant financial relationship declared.

Med+ 2021: Session Ethical and moral dilemmas for doctors in the digital age. Presented October 27.

James G. Williams