The Impact of Technology in Health Care: A View from the Trenches

Being in my mid thirties, it’s given me a unique view of how technology has impacted health care and medical training.  On that note, I thought I would share my experiences from my early days logging on the Al Gore with my 2400 baud modem to accessing virtually any information today on my iPhone.

So I Tied an Onion to My Belt…

Looking back certainly adds perspective and in my case a feeling of awe and wonder as to where technology will take us in another ten or twenty years…  At the same time, it makes me feel just a little bit like Grandpa Simpson:

“We can’t bust heads like we used to. But we have our ways. One trick is to tell stories that don’t go anywhere. Like the time I caught the ferry to Shelbyville. I needed a new heel for m’shoe. So I decided to go to Morganville, which is what they called Shelbyville in those days. So I tied an onion to my belt. Which was the style at the time. Now, to take the ferry cost a nickel, and in those days, nickels had pictures of bumblebees on ’em. Gimme five bees for a quarter, you’d say. Now where was I… oh yeah. The important thing was that I had an onion tied to my belt, which was the style at the time. You couldn’t get white onions, because of the war. The only thing you could get was those big yellow ones…”

After graduating from high school, I started a bachelor of science degree with a specialization in pharmacology at the University of Alberta.  I can still remember feeling excited over the awesome computing power of my then new Windows computer sporting an Intel 80486 dx2 66 Intel processor.

At the time, it cost (in 1993 dollars) a whopping $3500 Canadian.  In terms of technical specs, it had 4 MB of ram and ran at 66 mhz.  In contrast, today I’m writing this blog on a MacBook Pro ($1900 cdn) laptop that has 1000 x the RAM.  In terms of processing power, the 80486 from Intel was rated at 54 MIPS (million instructions per second) compared to 82,000 MIPS in the MACS Intel Core i7 [Wikipedia].  If you don’t get sucked into the allure of owning a Mac like myself, you can probably buy a Windows computer with similar features for around $500 cdn.

What’s Moore’s Law?

On that note, computer processing power is roughly increasing at an exponential rate and following Moore’s Law.  However, according to Gordon Moore himself (2005), this rate is unsustainable:

“In terms of size [of transistors] you can see that we’re approaching the size of atoms which is a fundamental barrier, but it’ll be two or three generations before we get that far—but that’s as far out as we’ve ever been able to see. We have another 10 to 20 years before we reach a fundamental limit.”

Dial-Up Modems and the Internet

Back to my onion belt story…  I can still remember the day my friend Jeff called me up and said, there’s this thing called the Internet that you can access through the University of Alberta…  Back then, the experience was limited to the joy of listening to your dial-up modem connect to the Al Gore and using FTP sites to download files which generally took hours.  Oh, and you could also create an email account though the utility of which was fairly limited since hardly anyone used email.

“During my service in the United States Congress, I took the initiative in creating the Internet.”

-Al Gore, CNN (March 9, 1999)

The Rise of the Cellphone

During the last few years of my undergraduate degree, cellphones started to become slightly more than just a novelty item.  Their usage shifted from the stereotypical hairy chested guy with his shirt buttoned down driving a Mercedes convertible while talking on a Motorola brick phone to more mainstream use.

In some ways, cellular phone users were a little annoying.  In fact, a friend of mine named Danny used to quip, “It’s six o’clock, bring out the cellphones.”  You see, it took our culture a few years to adjust to the technology.  I can remember the nuissance factor was fairly high to be studying during exam week and see throngs of what seemed like loud and obnoxious people pulling out their phones at six o’clock.  Why six o’clock?  Daytime minutes used to cost around 65 cents per minute!

By the time I started medical school in 1997, I was still using the same computer.  Web browsing had largely replaced using FTP sites and the tech boom was in full swing.  However, I never really used the Internet or my computer for much of anything for my medical training other than basic wordprocessing.

Medline and the Photocopier

While involved in a research project as a summer job after my first year of medical school, I did use Medline to research topics which was extremely useful.  As useful as it was for researching topics, online journals didn’t exist.  This meant that you had to fill a copy card with money and go to the medical sciences library and wonder around forever to collect all of the hard copies of the journal articles.

What next?  You had to manually copy each page with a photocopier…  If you were really lucky, the library didn’t carry that particular journal which meant that you would have to have one of the librarians have a copy of the article delivered in the mail.

Note Taking Groups vs. Pod Casts?

In the older, now obsolete didactic medical school training model under which I trained, we used to sit through classes from 8 am to 5 pm , five days per week.  We spent thousands of dollars on heavy medical textbooks which we had to lug around and of course, read.  With the exception of our anatomy and other labs, we spent roughly seven hours per day writing down notes as fast as we were able.

To supplement our scrawled notes, we used to have a mandatory note taking group.  Basically, this meant that each lecture was assigned to one of the roughly 100 people in my class to tape record and then transcribe the lecture.  If you think that spending seven hours per day sitting in lectures recording notes sounds like an inefficient process for learning, you’d be correct.

Today, from what I gather, the process itself has been extensively revised with a  shift towards a combination of more self-directed learning and small group discussion.  If you miss a lecture, you can watch an online Podcast at 1.5 x or higher speeds  if you like.

Clerkship and the Palm Pilot

For medical school, much of the actual learning tends to happen during the clinical clerkship.  When I look back, much of my coursework in the first two years of my medical school was not particularly clinically useful.

For example, on the first day of my first clinical rotation, I could have probably told  you which cytokines were thought to mediate proliferation and differentiation of hematopoietic stem cells or been able to tell you about the signs and symptoms of Chagas disease, but I wouldn’t have had much of a clue about how to properly manage something common like diabetic ketoacidosis  (without looking it up.)

On that note, back in the day, medical students used to fill their clinical jackets with references such as a Tarascon Pharmacopoeia, The Washington Manual of Therapeutics, a relevant On Call pocketbook, and other references.  All in all, it amounted to a significant amount of weight to lug around.  Worse yet, you had to manually flip through these references books to hopefully find some relevant and useful information.

Hm, technology isn’t the only thing that’s changed… That’s me 10 years ago at my medical school graduation!

As for residents, the trick back then was you could tell how far along a resident was in their training by how many references books were in their pockets.  I can recall the feeling of slight envy seeing senior residents seemingly effortlessly glide around the wards carrying nothing more than their stethoscope, a reflex hammer, and drug dosage guide…

Then came the Palm Pilot.  It was a game changer.  With a basic Palm Pilot and a subscription to Epocrates, you could quickly look up clinically relevant information without the need to lug around a library in your pockets.

The Dirty Secret…

It’s a common stereotype that doctors have terrible hand writing.  In fact, it’s probably even true.  Contrary to popular belief, pharmacists themselves don’t actually possess some magical or innate ability to decipher scrawled writing.  What they do have is the relevant medical training to read prescriptions as well as the ability to call physicians to confirm if they can’t actually read them.  Today, that’s even less of an issue as most prescriptions are printed from EMRs (electronic medical records).

Those of us old enough can still remember the welcoming feeling walking into a MediCentre seeing the familiar rows of medical files stacked to the ceiling on movable storage devices located behind the administrative counter.  Fortunately, for those working on the other side of the table, they’re largely a thing of the past.  With the ease of viewing test results and clicking to have patients return for follow-up through an EMR, I can’t even imagine going back to the old system.

One of the few remaining vestiges of paper charting in Alberta are encounters recorded during emergency room visits.  Though I myself still come across plenty of prior ER encounter notes where I struggle to decipher a single word, information can be cross-checked with the tests ordered during that visit along with the salient results.  In addition, patient admission histories and discharge summaries are dictated and transcribed.

Dr. Google – The Good, Bad, and the Ugly

“A physician who treats himself has a fool for a patient.”

-Sir William Osler

Ever for those who have adequate medical training, self-diagnosis is a very bad idea.  For people without medical training looking to Dr. Google to make a self-diagnosis, it’s even worse.

I could tell you countless stories of patients who type their symptoms into Google and show up to the emergency room with a self-diagnosis of Dengue fever when they really just have a run-of-the-mill viral gastroenteritis…  No, you’re not likely to catch Dengue fever here in Edmonton….  In those instances, patients can causes themselves undue stress and anxiety.

Alternately, for those looking for medical information on the Internet, it’s of vital importance to use trustworthy resources like WebMD.

[box type=”note”]In the recent past, the adage for medical students learning how to do procedures (okay, simple procedures not laparoscopic surgery) was, “see one, do one, teach one.”  Today, that’s been somewhat jokingly replaced by, “Just YouTube it.”[/box]

Changing the Role of Doctors

Relative to the practice of medicine, the access to information available with the advent of the Internet challenged physicians to redefine their role.  Older physicians often lamented the availability of information on the Internet since it led to patients challenging their authority.  What’s more is that many found it difficult to adjust to a brave new world where a patient can spend hours reading about a medical condition and show up with more factual (not contextual) knowledge about a particular medical condition than their doctor.

That being said, if you want to have the depth of understanding that a physician has, you’re still going to probably need to go to medical school.  For example, one frequently cited statistic is that medical students learn 13,000 words alone in just their first year of training.

What the Internet was probably largely responsible for was the paradigm shift from physician-centered to patient-centered medicine.  In the past, people had very limited access to medical information.  What they did have wasn’t particularly useful since the information wasn’t searchable.

Whereas once the medical profession (like many other professions) defined itself by its privileged access to information, today doctors realize that the availability of information is largely a good thing provided it’s used appropriately.

Where Are We Headed?

In the evolution of medicine, medical training, and health care delivery itself, change over the past ten years alone has occurred at a historic rate.  With iPhones, iPads, EMRs, Pod Casts, and even robots that perform surgery, it’s incredible to bear witness on how technology is changing the practice of medicine.  Even for those who graduate from medical school this year, it’s hard to imagine what their day-to-day lives will look like practicing medicine 10 or 20 years from now.

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