What (connected) doctors?
In the US, doctors now have their own version of Instagram. The application, Figure 1, passed one million subscribers in 2016. Students, residents and doctors use it to share pictures and opinions and have private discussions. While this platform is, in practice, restricted to relatively complex cases, it does bring together a vast community and encourage exchanges. While Figure 1 is still seen as something of a toy, the Canadian start-up behind it has big plans. To that end, it has developed a private, secure messaging application and public forums, and offers the opportunity to occasionally consult with “leading specialists.” But is that changing the scope and essence of medical practice?
More or less extensive networks of connected doctors
Doctors are increasingly connected and find themselves at the heart of several networks: professional networks and networks shared with patients. In France, 60% of private practice doctors have at least one type of software, and most have a smartphone and download apps for professional use. But very few (2%) use networks shared with patients, according to 2015 data from the French Medical Board They mainly use pharmaceutical databases, for their own information. So doctors just aren’t an interactive bunch? Maybe they don’t have the right tools. There are few options for professional exchanges, like Figure 1. A few similar initiatives do exist, including Santé Connect, but none of them has been as successful.
Applications that connect practitioners and patients have been the most successful in recent years. While in 2015, doctors had to content themselves with answering web users’ questions via the hashtag #DocTocToc, they now have more options, like MesDocteurs or Push Doctor. Both websites offer patients a way talk to doctors and get medical advice by video, for a fee. MesDocteur has requested authorization from the Medical Board to switch from offering advice to consultations, during which doctors could write prescriptions. More and more doctors are on board: “It’s a way to reassure patients, but also to direct them to specialists, reduce congestion in GP practices and emergency rooms, and avoid the dangers of self-medication,” explains geriatric orthopaedic specialist Charles-Louis Buccafusca.
Practitioners who might otherwise feel that these applications are being forced on them and replacing them have found their place in this paradigm. However, these applications do lack the legal framework and the attendant security and privacy guarantees needed to convince the profession as a whole. Going further, could this change be symptomatic of a new way of practising medicine, which could be partly remote and offer a partial response to the growing issue of medical deserts in certain regions of France, and even more so in under-equipped countries?
The DMP, an ideal information network that is far from a reality
The biggest network which should be developed around doctors is still an information network that would give them a better overall view of patient care, to enable better cooperation and ultimately higher quality care. In France, the difficult roll-out of the DMP (personal medical record) forms a stark contrast with the ebullient chaos of healthcare apps and platforms. These online health records still have not been implemented over a decade after the original deadline. Reality soon caught up with the initial enthusiasm. GPs in particular had high hopes for them. They saw the DMP as a way to escape their professional isolation. But the program was designed without their input, and is often incompatible with their software, hard to use, and too slow to actually be used during consultations.
In short, the DMP has already cost over 500 million euros for just 600,000 records created, most of which are empty or have extremely limited content. As Jean-Paul Hamon, president of the French Federation of Physicians, notes: “You have a series of documents that pile up. What we need is a summary. Unfortunately, no one does that other than primary care providers.” Sociologists Alexandre Mathieu-Fritz and Laurence Esterle, authors of a study on the implementation of the programme in Picardy, observed that in the regional hospital, DMPs are systematically created and filled in by receptionists rather than doctors, who neither read them nor make entries in them. Private practitioners, on the other hand, are forced to manage DMPs on their own time. The sociologists found that those who tried to do so spent entire evenings on them.
When faced with the same issues, the British equivalent of the DMP, the Summary Care Record, was restricted to the bare minimum, mainly the information required for emergency treatment. The French authorities are nothing if not persevering, and decided to give the DMP a second chance along with a new name - “dossier médical partagé” or “shared medical record” Nine departments are currently testing this new and improved version. The key new features: patients can create their own file, and France's national health insurance provider automatically fills in the records for the past 12 months at the end of the year. Objective: nationwide use in 2019.
Standardised data managers?
By reviving the old fantasy of a record centralising each patient’s full medical history, digital has produced “idealised” tools which are a poor fit for reality and leave practitioners to struggle with an ever-increasing amount of managerial work. Today, digital translates to vast amounts of new information to process.
“These products (connected devices) will generate even more data to process. A lot of doctors feel that they aren’t paid to deal with that,” says lawyer Pierre Desmarais. A 2016 study by Philips and Ipsos shows that 59% of French professionals have received data from connected devices from their patients and that 66% think that connected healthcare technologies will increase their workload by swamping them with useless data.
Digitisation is also leading to a form of standardisation. In hospitals, digitisation is well under way. The IT equipment issued to all employees, from nurses’ aides to nurses, lab techs and doctors, as well as secure sharing of databases between establishments are significantly simplifying information sharing among practitioners and continuity of care for patients, whose records are now shared. But for some hospital staff, these tools are leading to standardisation of practices and can be used to assess or even control the care prescribed, something which is often viewed as a form of surveillance.
Remote medicine: doctors who provide more care?
Responsiveness, mobility, cooperation... Telemedicine, too, offers plenty of promise: addressing the future disappearance of “family doctors,” responding to the expansion of medical deserts, improving care for chronic diseases, and more. But how will it affect doctors and the way they practice?
To take just one example, in Cameroon, Gabon, India and Nepal, the Cardiopad, a touch screen tablet equipped with electrodes, allows patients to perform their own complete electrocardiogram (ECG). The results are then sent and processed within 20 minutes according to Himore Medical, the company behind the device. In countries with a severe lack of doctors and healthcare structures (Cameroon has just 31 cardiologists and a total population of nearly 18 million), as well as countries with harsh climates and patients in remote areas like Canada and Australia, this type of device can provide wider access to care. And that’s not its only advantage. In France, on an experimental scale, remote expert consultation programs are providing a new type of professional cooperation. Thanks to video conferencing and connected devices, geriatric specialists at Gabriel-Pallez hospital in Paris can consult a cardiologist from George Pompidou hospital with no need for their patients to make the trip. Specialists and primary care providers use video conferencing to share their expertise: one explains what to do, while the other shares his or her knowledge of the patient. Because consultations are now easier, they have become more frequent and micro-collectives have been formed through the pilot programme.
But does this increased collaboration come at the expense of patient-doctor dialogue? Decreased privacy, and to a lesser extent the inclusion of third parties in a one-on-one conversation, seem to be the negative aspects of telemedicine - if that conversation ever existed in the first place. The presence of a resident is often inevitable and patients have to talk loudly, even when it comes to things that are hard to say. In Quebec, one hospital created two remote units so that patients with kidney failure would have easier access to their nephrologists. Some doctors regret the lack of a human connection and the opportunity for patients to confide in them. But not all. Some are happy with the focus on the technical medical procedure: with this remote approach, they can focus on the area to treat thanks to careful observation of the bodies of digitised, impalpable and partial patients. In this case, patients may well be the ones feeling cheated, as they find themselves facing a truncated doctor who doesn’t always appear on the screen, who may be inaudible or not interact much. To ensure that the programme can operate without a serious loss of human contact, residents in the remote units have to fill in the gaps created by this form of medicine by screen.
Connected medicine and AI: augmented doctors?
Yet another issue: if interprofessional collaboration isn’t always easy, what about “collaboration” with artificial intelligence (AI)? Hospitals are just starting to test Big Data and AI solutions like IBM’s Watson or DeepMind from Alphabet (Google), on a small scale due to costs, and with significant difficulties since their IT infrastructure and databases aren’t up to the task. Super computers offer interesting potential for diagnostic assistance, particularly in oncology where they can facilitate detection or resolution of problematic cases, like that of a Japanese patient on whom chemotherapy never worked. Watson, IBM’s AI solution, solved the case in just ten minutes by detecting an anomaly in her bone marrow, when the case had baffled doctors for months.
Improvements to machines and their analytical tools are turning these artificial intelligence solutions into increasingly promising allies for doctors. Monitoring, prevention, treatment modification, diagnoses based on massive data: the expected improvements in practice and quality of care are essential. But how can doctors change the way they work to accommodate their new “virtual partners”? If AI develops the way its proponents predict, will doctors be restricted to a patient interaction focused role? Or will a new “smart” organisation develop, enabling fruitful human-machine collaboration? It is difficult to tell at this stage.
Doctors will doubtless have to change their practices to address the challenges (and negative effects) of telemedicine, the disintermediation encouraged by certain applications and digital devices, and the fact that patients are more aware. But how, and what resistance will arise? What place will there be for the human advantage that robots, and digital technologies in general, can never replicate?