Letters

New connections between medical knowledge and patient care

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7118.1309b (Published 15 November 1997) Cite this as: BMJ 1997;315:1309

Human condition is full of decisions that aren't simple yes/no decisions

  1. Austin T Carty, Consultant radiologista
  1. a Royal Liverpool University Hospitals, Liverpool L7 8XP
  2. b St Thomas Health Centre, Exeter EX4 1HJ
  3. c Hillview Surgery, Greenford, Middlesex UB6 7HQ
  4. d Darlington Memorial Hospital, Darlington, County Durham DL3 6HX

    Editor—Weed's arguments in favour of introducing information tools into medical practice are fundamentally flawed.1 He has failed to give any example of how knowledge coupling software works in facilitating medical decision making, let alone in supplanting the unaided medical mind, as he advocates.

    The problem is that computer software is essentially binary. Its natural default is to a yes/no decision. The human condition is full of indecisiveness, and, whatever the character of the doctor, the patient remains human. There can be no contest against the craftsmanship of history taking by an experienced doctor. Heaven forbid that this should be replaced by a questionnaire and a computerised home doctor.

    The profession is less in the backwoods than Weed allows. The success of tools for updating one's knowledge, such as the Oxford Textbook of Medicine, is an example of our openness to the support of information technology. The shift to problem based learning in the curriculums of many medical schools is an acknowledgement of the futility of overloading minds with facts, which do not endure.

    By all means let us harness good software to aid our decision making when we are convinced that it is good. But we must remember that the supreme human qualities of happiness, love, and beauty are impervious to the discipline of digitisation.

    References

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    Intervention of health professionals acts as an inductance, not as a resistor

    1. D P Kernick, General practitionerb
    1. a Royal Liverpool University Hospitals, Liverpool L7 8XP
    2. b St Thomas Health Centre, Exeter EX4 1HJ
    3. c Hillview Surgery, Greenford, Middlesex UB6 7HQ
    4. d Darlington Memorial Hospital, Darlington, County Durham DL3 6HX

      Editor—Weed states that voltage drops occur along the pathway from the origin of medical knowledge to the end professional user, and he calls for an information infrastructure directed at patients as the primary decision makers.1 This hypothesis fails in three ways. Firstly, it assumes that a core knowledge base can be defined. Unfortunately, the relations between health interventions and outputs are often ambiguous and do not always yield to a rigorous analysis. Secondly, with the increasing demands on limited resources, there will always be a conflict between the requirements of individual patients and those of society. A balanced advocacy for both parties can be achieved only by informed professional intervention. Thirdly, a patient centred decision framework based on information systems gives advantages to those who have over those who do not, increasing differences in equity further.

      The intervention of a health professional does not act as a resistor inducing a voltage drop along a knowledge pathway. Rather, it acts as an inductance, modulating and attenuating frequency—balancing the validity of the evidence with the unique needs of the individual and ensuring that resources are distributed equitably between the conflicting demands of patients and society. The next generation may be driven by an information technology/designer label/ soap opera culture, but much of society will still need a shaman/healer/medicine man/health advocate/friend and will lose him at its peril.

      References

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      Patients in most need of medical attention are least able to operate computers

      1. John Edwards, General practitionerc
      1. a Royal Liverpool University Hospitals, Liverpool L7 8XP
      2. b St Thomas Health Centre, Exeter EX4 1HJ
      3. c Hillview Surgery, Greenford, Middlesex UB6 7HQ
      4. d Darlington Memorial Hospital, Darlington, County Durham DL3 6HX

        Editor—Weed provocatively suggests that medical care will improve if expensively educated doctors are bypassed after patients have been educated and empowered to interact directly with intelligent computers.1 He would benefit from spending some time in a primary care doctor's practice. The vast majority of symptoms are not markers of serious disease. The fact that only a tiny proportion ever get presented to a doctor (from 1 in 33 episodes of sore throat to 1 in 456 episodes of fatigue in one study)2 is of general benefit because the dangers of medicalisation—what Illich called “medical nemesis—are prevented.3 An important role of general practitioners is often to reassure patients about the normality of having “symptoms” and to educate them about self care and simple remedies; 90–97% of all consultations are competently managed without specialist referral being required.4 Replacing the doctor with a computer would lead to a massive increase in anxiety as patients tapped in a list of their symptoms to generate lists of differential diagnoses. Just as psychiatrists should not treat their own depression or cardiologists their own high blood pressure, so super-well informed patients cannot be expected to make objective judgments about their own medical care and reasonably assess risks; Weed's analogy with being a traveller choosing a holiday is facile.

        There is also no evidence that ill people would want to interact with a microchip. The human qualities of a doctor, such as listening and not being rushed, are often cited as the key desired aspects of a medical consultation. Also, those patients in most need of medical attention are least able to operate computers or make well informed decisions. Medical information technology would most benefit those who already extract quality care from the NHS through being informed, articulate, tenacious, and unintimidated and insisting on expert opinion; thus inequality in health would be increased.

        It is true that current medical education involves excessive cramming of facts, and rapid access to and ordering of large amounts of information by the human brain are clearly not possible. It has been shown, however, that computer prompting systems, linked to protocols, are an effective way of changing and maintaining best clinical practice,5 and this approach should be encouraged. Although the arrogant, intuitive practices of the expert should be left behind, medical care will not be improved by taking away the patient's impartial doctor and letting him or her swim unaided in a sea of information technology.

        References

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        Information technology has much to offer certain aspects of health care

        1. David J R Hutchon, Consultant obstetrician and gynaecologistd
        1. a Royal Liverpool University Hospitals, Liverpool L7 8XP
        2. b St Thomas Health Centre, Exeter EX4 1HJ
        3. c Hillview Surgery, Greenford, Middlesex UB6 7HQ
        4. d Darlington Memorial Hospital, Darlington, County Durham DL3 6HX

          Editor—Weed has written a helpful article on the place of information and computer technology in medicine in the future.1 His analogy between travel and patient care, however, is inappropriate. Travellers are primarily interested in reaching their destination in the shortest time, in comfort, and in safety. The route is usually irrelevant. Nowadays maps are used by only a minority for personal travel. Air travellers have no opportunity to influence technical decisions before or during their flight. It would be much more appropriate to compare medical care with a repair industry such as the motor industry—except that doctors are not able to “write off” their patients when the repair is too costly.

          I believe that there is an enormous place for “expert systems” in medicine, and I see nothing wrong with cookbook medicine when the recipe is robust and effective. Unfortunately, patients are as fearful about relying on computers for medical decisions as doctors are reluctant. But we already rely on many expert systems, such as the algorithms involved in computed tomography and ultrasonography.

          In my opinion, there are essentially three areas in which information technology and artificial intelligence can lead to a huge improvement in health care. One is making medical knowledge available in an easily assimilated form. Although medical knowledge has always been freely available in modern times, it has been in the user unfriendly form of large textbooks and technical journals. Secondly, information systems could build research and audit into every act of health care. Thirdly, when an aspect of healthcare management becomes robust and effective, sometimes in a small and specific area, it could be handed over to an expert system, with technicians being used, for example, to palpate the spleen when necessary.

          References

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