• The acceleration of innovations appears to be taking its toll on ethics, which can’t keep up; and in the United States the PATRIOT Act could be taking a toll on the acceleration of innovations, which is being denied the contributions of foreign scientists.
• Surgical procedures are being broadcast live over the Internetto beef up hospital sales of profitable surgeries.
• Like the amateurs using cheap but powerful technology to snatch prestigious NASA prizes out of the hands of professional astrophotographers, technology is giving patients the power to thumb their noses at doctors, and the signs are that they are wielding it.
• In summarizing eight major healthcare trends educed by one analyst from press articles, we note the omission of technology as a trend spoiler. The predicted trend of ongoing healthcare staff shortages, for example, could be halted or even reversed by robots in the pharmacy, in the lab, and in the OR.

Ethics of Innovations

Ten years ago, the notions of obtaining matured eggs from an aborted fetus, creating a hybrid embryo, or finding a perfect stem cell tissue match for a sick child, all seemed science fictional and therefore a waste of time debating the ethics thereof. But when such notions rather suddenly emerge as science fact, the window of opportunity for making moral objections that could either prevent them, or at least that could force appropriate safeguards to be developed and enacted, has, by definition, closed; and the unthinkable, by default, has become acceptable.

Even if some time may be available for ethical debate, and even if most scientists are ethical, a market-driven, profit-focused, essentially ungoverned and increasingly unregulated world — where advanced science can be done by a handful of unethical scientists working in garages and backed or encouraged by unethical corporations controlling unethical politicians — mitigates against the triumph of ethics.

John Crace’s thoughtful and disturbing article in the Guardian (reference below) suggests some measures, such as getting democracy to work and educating and involving the public and undergraduate biologists. But his prognosis is not optimistic. He quotes the director of Save British Science: “It’s hard to predict what the ethical concerns will be in 10 years’ time, as we can’t imagine what science will be capable of; all we can say is that they won’t be the ethical concerns that bother us now.”

Health Futures Digest shares these concerns, and is published partly in hopes that by providing advance notice of technologies likely (absent global regulation) to emerge over the next 20 years, it is providing a window of opportunity in which to consider their ethical implications before they become faits accomplis.

Reference: Crace, John (2003). “Pushing back the frontiers.” The Guardian, July 15.

Technological McCarthyism

In a commentary on “Biotech’s Big Chill,” an article by Yale historian and National Research Council Science, Technology, and Law Panelist Daniel J. Kevles, Technology Review writer Robert Buderi worries that terrorism-inspired U.S. xenophobia is bringing the country “perilously close to something similar to McCarthy’s 1950s” in setting up stringent barriers to foreign scientists wishing to study, work, or obtain biological research materials in the United States. While recognizing that some restrictions, such as limiting access to deadly biological agents, are prudent, the current blanket restrictions seem “both lazy . . . and undemocratic . . . [and] just the edge of the storm cloud looming on the horizon for foreign researchers in this country.”

He reminds us that the presidents of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine warned last December that these barriers had had “serious unintended consequences for American science, engineering, and medicine” as a result of impaired research collaborations, the prevention or delay of approvals for “outstanding young scientists, engineers, and health researchers” to enter the country, and the hampering of international conferences.

Health Futures Digest has commented favorably on IT’s contribution to acceleration in research by expanding research from parochial to global; by taking it from handfuls of researchers collaborating on a given topic to hundreds and perhaps thousands. The PATRIOT Act would seem in danger of reversing this overall beneficent trend.

Reference: Buderi, Robert (2003). “Technological McCarthyism.” Technology Review, July/August.

Telly Surgery

Video of a laparoscopic prostate cancer surgery at Massachusetts General Hospital was recently transmitted live over the Internet. One result was “dozens of telephone calls from doctors referring patients and from patients themselves who wanted to sign up for the same operation,” reports the Boston Globe‘s Liz Kowalczyk.

The practice is not new; surgeries have been taped for educational purposes for years, cable TV health channels often show real operations, and slp3D Inc. broadcast the first Internet operation from Hartford Hospital in January 2000. But the practice is growing, as much for its success in marketing lucrative procedures to patients and referring physicians, as for their education.

Reference: Kowalczyk, Liz (2003). “Surgeries on Web find favor with hospitals.” Boston Globe, July 16, p. A1.

Technology-driven Change in the Doctor-Patient Relationship

More and more people look for information about a medical condition online, often before consulting their doctor. In empowering patients, it can hurt the doctor-patient relationship.

The Wall Street Journal‘s Laura Landro notes in particular a growing combativeness among self-informed patients, led (by their own experience or advice from others) to expect intimidation, resistance, or hostility from physicians. A recent AARP magazine article, for example, incited readers to “Take a hard look at your primary care doctor,” “Make hurried doctors listen,” and Do your own research on your condition, and “offer the doctor copies.”*

Pew Charitable Trust surveys have found that the Internet — online support groups and communities in particular — makes people feel more independent of their doctors, empowers them to ask more informed questions during appointments, reduces fear of the unknown, and changes their relationships with their doctors — not always for the better. A physician consultant to Pew concludes that patients are ahead of his fellow physicians in understanding and using high-quality Internet health resources.

The trend is inexorable. Consider that sub-$500 digital cameras, camcorders, and even webcams enable backyard astronomers to shoot pictures of the cosmos that only professional astronomers using equipment at the largest observatories on Earth could have achieved a few years ago — and the amateurs are winning prestigious NASA astrophotography awards to prove it. Leander Kahney’s article in Wired News explains why, in fascinating detail; but the point we want to emphasize is that medical technology — including the Internet — similarly empowers patients, family members, and unlicensed practitioners to compete with professional caregivers.

While Landro points out sensible cautions against quacks and self-diagnosis without professional confirmation, these various articles should serve as further credible evidence to doctors that their world is changing.

* Additional discussion of this issue can be found in section 2e of the W.K. Kellogg Foundation-commissioned paper offered for free download from Health Futures Digest.

References: Landro, Laura (2003). “Internet Use for Medical Data Shifts Doctor-Patient Roles.” Wall Street Journal, July 17; Austin, Elizabeth (2003). “I’m afraid I have bad news… Twelve steps to handle a disturbing diagnosis.” AARP Magazine (46)3A:28-32, May/June; Kahney, Leander (2003). “Backyard Paparazzi to the Stars.” Wired News, July 21.

Healthcare MegaTrends 2004

After thoroughly analyzing some 5,000 newspaper articles, physician-writer Richard Reece sees consumers driving healthcare in eight new directions:

1. From a youthful society with low health costs to an aging society obsessed with costs and looking younger
2. From inpatient care to outpatient care
3. From prescription drugs as an incidental expense to prescription drugs as an intolerable cost burden
4. From costs absorbed by employers to costs shifted to employees
5. From national to world concerns about infectious disease
6. From enough physicians and nurses to a shortage of both
7. From laissez faire medicine to activist programs to prevent and manage disease
8. From a la carte care to standardized care to improve quality, consistency, and outcomes

The greatest challenge, he feels, will be to sustain the current system and its safety net while becoming more responsive to consumers yet shifting costs to them. He points to the Veteran’s Administration and Kaiser as successful models, primarily through their investments in electronic medical records, which improve quality while lowering costs.

Reece’s article in HealthLeaders furnishes the substance of each trend, which Health Futures Digest generally (though not entirely) supports; with one critical proviso: technology is bound to exacerbate or attenuate them, in some cases swiftly and dramatically. We see, for example, a rapid attenuation of the nursing shortage as robot aides invade hospitals, long-term care facilities, and homes. See, for example, “Blood-Processing Robots” and “Humanoids in the OR” below.

Reference: Reece, Richard L., M.D. (2003). “Eight New Directions for 2004.” HealthLeaders News, July 9.

Robot Solution to Staffing Shortage

Parata Systems joins a half-dozen or so major automated pharmacy manufacturers targeting retail pharmacies. Its $185,000 robotic system can dispense, cap, label, and sort 240 prescriptions an hour. The 12 square foot dispensing unit small enough to find room in the smallest pharmacies, yet is claimed to fill prescriptions twice as fast as its competitors.

The unit contains 252 cells to hold pills. When it receives an order, the appropriate cell opens and the pills are ejected by forced air into a bottle. It then attaches a cap, prints and affixes a label, and deposits the bottle in alphabetical order of patient last name into a tray. One pharmacy that tested the machine for over a year found it effectively did the work of two pharmacy technicians and enabled the existing pharmacists to spend more time on other tasks.

Only about two percent of pharmacies have installed automated systems, the company claims, but hopes to close a deal on 1,000 systems for an unnamed large national drugstore chain.

Reference: Fisher, Jean P. (2003). “Robot filling the gap.” News & Observer, July 30.

Here Now: Blood-Processing Robots

A $2 million (including $650,000 of building remodeling) robotic blood processor installed in a Memphis hospital processes about 1,000 tubes a day, including blood delivered from outside physician offices and clinics, and could process 400 an hour. Each bar-coded sample undergoes 15-16 individual tests. The system precludes human error, notes Scott Shepard in the Memphis Business Journal, and frees up medical technologists to pursue “something more interesting than stand before a centrifuge all day,” as well as eliminating the overtime the hospital had been paying them.

The system delivers results ten minutes faster for patients in the Emergency Department, and has reduced the time taken for routine morning inpatient tests from two hours to 75 minutes, making the blood work results available to physicians in time for morning rounds.

To the extent there is a growing shortage of medical technologists, who could complain about their replacement by uncomplaining, harder-working, faster, more accurate, less error-prone, and ultimately cheaper machines?

Reference: Shepard, Scott (2003). “Robotic blood processor gives Methodist an edge in diagnostics.” Memphis Business Journal, July 25.

Humanoids in the OR

NASA has conducted tests to evaluate the use of “robonaut” aides for astronauts performing EVA (extravehicular activity) tasks. The tests involved a whole team of robots — dexterous humanoid robots, ground-controlled robots, free-flying robots, giant crane robots — backing up the astronaut in assembling an aluminum truss, installing electrical cable, and decontaminating the astronaut’s spacesuit of a corrosive chemical, such as the ammonia used in the International Space Station’s cooling system.

Besides eliminating the need for a second astronaut to be always present for backup and support, the robonaut teams will help reduce the large proportion of EVA time spent by astronauts in setting up and closing up — preparing instruments, managing tethers, and so on. NASA says the technology could be ready for International Space Station jobs in three to four years.

The humanoid robonauts used in the tests had hands dexterous enough to use the same tools astronauts use, including ratchet wrenches, retractable tethers, and socket caddies. In the future, NASA says, “a Robonaut could work like a nurse in an operating room, where an EVA crewmember, like a doctor, would ask the nurse for a particular tool and have it placed in his or her hand.” To which we would naturally wonder when a robonaut will actually be a nurse in an operating room, handing instruments to the surgeon and taking care of the closing.

If all procedures in the OR went off like clockwork, without the slightest unpredicted hitch, then of course clockwork automatons could safely be entrusted to handle most of the work. But any setting involving humans always carry the potential for unpredictable events, so clockwork robots would not do as nurses in the OR.

For almost a decade, teams at MIT, Michigan State, and other research centers have been developing robots that learn like a human baby. Michigan State’s SAIL (Self-organizing Autonomous Incremental Learner) is endowed with a “developmental program” that gives it curiosity and other attributes necessary to real learning. SAIL, said its developer, interacts with the real world “like a baby interacts with his doctors, his father, his mother,” and from those interactions it gains “a sense of the outside world.” SAIL has already “learned tasks like navigation, identifying and sorting objects, even some speech,” according to Technology Review editor Rebecca Zacks.

References: NASA (2003). “‘Spacewalk squad’ joins humans and robots.” News release posted July 6 at spaceflightnow.com; Zacks, Rebecca (2003). “:Teachable Robots.” Technology Review, July/August.