Why doctors are getting their assess kicked by technology

Nerd blog

May 30

Physicians have terrible technology, but they refuse to recognize high-tech as a medical specialty. They must integrate technology as they do laboratory science.

Physicians are certainly suffering from poorly-designed electronic medical records (EHR), but they are also guilty of willful blindness in abdicating responsibility for technology in medicine. This must change.

“We cannot solve our problems with the same thinking we used when we created them.” — Albert Einstein

Physicians have a higher suicide rate than post-combat troops in the military. A lot of this is due to widespread burnout from poorly-designed EHRs. Yes, it sucks, but who is really at fault?

What if this problem was a consequence for a professional stance medicine can choose to reverse? What if it won’t go away until we do?

How physicians are getting their asses kicked

Since the advent of EHR, doctors work an additional extra 10–25 hours a week, usually in meaningless data-entry tasks.

The constant stimulation of stressful popups with little-to-no clinical significance, and lack of relevant prioritization has led clinicians passionate about bedside medicine and concerned about medical errors to become highly critical of EHR. Many physicians feel moral injury from their increasing inability to influence the quality of the cognitive environment they are forced to work in.

Simultaneously, physicians' core clinical roles are being overrun. AI at Stanford predicts patient death and dispatches palliative care docs to the bedside. The US military is developing robots to perform remote surgery on soldiers on the battlefield. Small startups vie to build hand-held diagnostic mini-laboratories which can be sold direct to consumers.

These technologies are not being designed by doctors, they are being designed by computer scientists, electrical engineers, and college kids at hackathons. Why? Because doctors have decided that technology is something they use, not something they make.

Hospital software is commissioned improperly

First, no reputable software designer would excuse the interfaces and circuitous pathways of modern EHRs. EHRs are not only bad medicine, they are also bad technology.

A quick glance at any hospital interface on the clinical market makes human-computer-interface (HCI) specialists wince in pain. Watching even the most adept user navigate an ordering system makes interaction designers cry. It’s undeniably, unbearably, unethically terrible software. And the rest of the technology clinicians get is pretty shit too.

But the problem with medical technology lies in its design, development, procurement, and implementation. Because clinicians have no little-to-no involvement in that pipeline, and the people who do — hospitals, insurance companies, and payors — have no incentive to make clinical care more efficient, in fact, quite the reverse.

Unlike children’s computer games, there is simply no free market for medical software. Currently, the EHR end-user is not utilized until they use the software to order life-saving treatments for patients. And by then, it’s much less useful and more time-consuming than a paper prescription pad.

Simply put, your 8-year-old child has more autonomy and input in the usability of Plants vs. Zombies than your surgeon does on his laparoscopic equipment.

What doctors don’t understand about technology

Doctors are also narcissistic about their specialty as a market. The truth is, despite all the money floating around in healthcare — EHR was a $29 billion industry in 2020 — most early-stage software developers avoid med-tech.

Doctors and healthcare systems are perceived as combative buyers, without disposable cash, who avoid collaborative development and cannot implement technology rapidly enough for in situ development. Even worse, the user isn’t the buyer, and buyers and users have competing interests so startups face a double bind — you literally can’t build software that will make your user happy, and if you do, you can’t sell it.

Most doctors hate technologists because they believe technology development should be useful out of the box, and they should be able to design software by giving orders for its design, instead of becoming lab rats in its development, or heaven-forbid, learning how to build it themselves.

The truth is technology is just like laboratory science, it’s a different discipline, with different rules, and different parameters for success. And doctors know fuck-all about it.

How physicians are currently handling technology

In 2013 I graduated medical school and went to Silicon Valley to acquire high-tech skills.

During med school, an investigation of the medical specialties available to me had revealed that doctors were in for a rude awakening when their profession began to digitize. My mentors were fabulous clinicians, but they were sorely unprepared to influence the software and ontologies that would shortly conscribe their practices in very disturbing ways.

In 2014, I helped launch a virtual telemedicine platform where roughly 60 thousand physicians answered patients' questions by text and video conference. During this period I was emailing 1 million US doctors once a week and working with >1,000 directly on our initial launch. I also obtained a professional certificate in preventive medicine from Stanford University’s Department of Medicine and did translational research contributing to the regulation of e-cigarettes.

It was a trial by fire in interdisciplinary research and a practical PhD in a specialty that still doesn’t exist, that of an MD-technologist.

After a busy three years, I attempted to return to a US or Canadian medical residency and met an impenetrable wall of resistance. I was not welcome back in clinical medicine. No residency would take me because I was considered to have deserted my clinical training. At first, I was incredulous, surely my beloved physicians would understand that I had brought Prometheus’s promised fire back to them? Surely they saw the value of having a resident who loved bedside medicine, but knew enough about med-tech to help their program from becoming obsolete?

It would appear not. I made hundreds of applications to more than 30 specialties including general practice in both the US and Canada with no success. Time and again the response in interviews with otherwise outstanding clinicians was, “What have you been doing of relevance to medicine since medical school?”

I faced a cabal of ignorance about Moore’s law, blind arrogance about how much of a doctor’s job could, and would shortly be, delegated to a robot or AI, and complete failure to anticipate the moves of larger forces in government and healthcare who were actively reducing physician’s power because of their economic gatekeeper role in healthcare spending.

I left clinical medicine completely in 2019, with regret but resolution. The writing was on the wall, bedside medicine was the best part of being a physician and it was fighting for preservation in an overwhelming wave of data-entry doctors who seemed to be choosing to dumb down and digitize their work and then be replaced by AI.

What if physicians embraced technology?

What healthcare systems, high-tech companies, and venture capitalists generally misunderstand about doctors is that they are plenty smart, just ignorant about high-tech development. And ignorance is correctable.

Doctors are smart, compassionate people who are overwhelmed and guilty of willful blindness when it comes to technology. They have abdicated the responsibility for the design and development of technology to non-clinical professions, then externalized their frustrations with the consequence of this professional decision.

Yes, physicians are stubborn by nature and slow to adopt tech cycles. That doesn’t mean they don’t do it, they just do it late. And in high-tech, late is after it’s built.

Physicians should incorporate high-tech the way they have incorporated bench research. In other words, actively select candidates with high-tech experience, reward mid-career forays into high-tech development, and enable high-tech dabbling for senior physicians the way they do lab research.

Every human adult is frustrated with technology. The 21st century is one long click-bait, spinning wheel, spam phone call, and interminable support queue. The digital world is under assembly and we are living in a construction zone. Doctors are not alone in their frustrations, they are simply failing to take responsibility for their profession. And predictably, their avoidance of the problem, is a problem, that is causing them… problems.

Doctors would make good technologists

While most physicians feel honor-bound to participate in bench research in the course of training, they have minimal respect or competence in how technology is designed or developed.

When I first left my medical training I lacked the intellectual humility and collaborative problem-solving skills necessary to participate meaningfully in software development projects. I was simply not trained to be good at complex cognitive collaborations, and I didn’t have the minimal tech skills needed to work collaboratively at speed; GitHub, Google Docs, lateral skills transfer, and multi-channel comms — technologist stuff that is learned as a trade and not taught in schools — the bedside medicine of the tech world.

I was the product of my career choice. Doctors are trained to be authoritative and responsible, similar to the military (another discipline that is failing badly in technology development this decade). They are socialized and incentivized to be competitive, secretive, memorize and regurgitate information, and conform to hierarchy.

In contrast, technologists are trained to be anonymous, open, and irresponsible, putting out broken or barely developed software and learning to “break shit” to discover the world by trial and error. They are socialized and incentivized to solve problems collaboratively and stay contemporary by borrowing everything real-time from internet forums. Doctors structure their information; technologists assess it for utility.

In many ways, the heroes of these two disciplines are two diametrically different people.

But this contrast — although real — is merely an ideal. The same divergence could be seen between the ideal internist, and the ideal bench researcher. Or the ideal astronaut and the ideal entrepreneur.

Just because they are different jobs, doesn’t mean they aren’t related.

In 2021, many of the medical specialties that are the most lucrative in both the US and Canada are the ones that have embraced technology wholeheartedly — diagnostic radiology and ophthalmology. Every medical discipline accesses pathologists and public-health doctors which are also heavily lab-based, and research-based specialty.

COVID-19 has changed the medical technology landscape, and for the first time in many years venture capital is investing heavily in medical technology. Simultaneously Doctors have an opportunity to belly up to the table, and participate in the design and development of medical apps that run over EHR interfaces like the Harvard SMART Platform.

Physicians can do better. And doing better, starts with a paradigm shift. I wholeheartedly believe that when they do, everyone will benefit.