Hospice by computer?

The Atlantic this week published a provocative article entitled “The Computer Will See You Now.”  Using the supercomputer Watson as a starting point, the author explored the mind-bending possibilities of e-care.  In this near future, so many aspects of medicine will be captured by automated technology that the magazine asked if “your doctor is becoming obsolete?”

The IT version of health includes continuous medical monitoring (i.e. your watch will check all vital functions), robotic surgery without human supervision, lifelong personal database with genetic code core and intensive preventive care modeled for each person’s need; all supervised by artificial intelligence with access to a complete file of medical research and findings.  The e-doctor will never forget, never get tired, never get confused, never take a day off and will give 24/7 medical care at any location, anywhere in the world, for a fraction of the cost. Perfect care, everywhere, at every moment, for a pittance.

While the transformation for doctors seems clear, a shift from being at the core of medicine to being what the article described as “super-quality-control officers,” what intrigues me is not how doctors will change (retire); the real question is how patients will adapt to this new healthcare world?  Particularly when experiencing extreme or life threatening illness, will patients accept that family, friends and a pumped up Ipad are enough?

150 years ago doctors had little actual healing to offer, so what they gave was themselves at the bedside.  In our romantic memory of that time, patients expected professional compassion, gentle wisdom and personal support.  With the medical revolution of the past century, doctors now have a great deal more true care to offer.  However, that focus on science has resulted in patients expecting professional distance, fragmented communication and, no matter what passion a physician may hold in his heart, a lack of effective compassion at the bedside.

This next step in health evolution may completely remove the human provider from care and thus a vital question must be whether patients fighting extreme illness will trade human imperfection for computerized perfection?

It seems bizarre to consider a world where a patient dying of cancer, on hospice, would receive care supervised by machine.  But, once we trusted our hard won dollars to a person called a banker, thought the self-checkout-line at the market was insulting, actually shopped at stores, traveled in airplanes flown by men, bought or sold stock certificates representing value, could read a map and predicted the weather by the color of the sunset, not by satellites flying far above the sky. Once, the couple I saw get engaged on bended knee by the fire, spent the rest of the night dreaming and staring into each other’s eyes, not texting on smart phones.

Perhaps the privacy, freedom and quality promised by the e-hospice-doc, means its organic ancestor is doomed as the dinosaur.  Patients will get perfect care at home with the one’s they love, and avoid physician office waits and emergency room indignities, comforted by computer screen reassurance and synthetic GPS-like voice.  But, on that day, when that first patient dies with dignity, gently and quietly supervised by monitor’s glow, I will wonder whether doctors are the only thing that has become extinct.


  • Social media sites like Facebook et all have crept into our lives and given us "friends" to interact with online, while our real life friendships are the ones we depend on in times of great sadness and/or great joy. Sure a like or comment on Facebook is nice, but a phone call or hug is much better. A good doctor's voice of reason or caring hand will never be replaced and for me will always be needed.
    • James Salwitz, MD
      My gut tells me you are right, but when I see that couple, deeply in love, sitting in a romantic corner of the restaurant by the fireplace, both on the own cell phones, I wonder about the future of human connection. jcs
  • alyce
    May we always have Doctors as caring as you. No machine is ever going to replace a kind voice and a gentle touch and feeling from a living breathing human Doctor.
  • Bridget Ryan
    As a former nursing home chaplain, the warm glow of anything, including a soft night light, at the time of death would have been welcome to indigent elders warehoused in an institution. For too many, dying is a very lonely business, and that includes the hospital setting where check-ins are scheduled. Hospice is better, but there are no certainties of watchful presence there either. Sadly, physicians are most often rushed and the kindness they imagine they give is just a brief moment. As a Boomer slipping into my senior years, I wonder how we will all make this romantic notion of a well-tended death a reality, and frankly, I am not optimistic about the prospects for myself, either! A caring community is the answer, and that takes time, commitment, and presence.
  • I have always viewed technology as enabling all of us to focus on what we can do best and improving the way we do things. In health care, yes, more electronic monitoring and more algorithms (e.g., Watson) should make improvements, but at the end of the day, I want a human to explain the implications to me and make that human connection. And I don't consider myself a luddite when it comes to tech!
    • James Salwitz, MD
      I suspect we will have to remind the techies that at the end of the day, people,compassion and a gentle touch still come first. I agree... knowing you work, your name and luddite certainly do not belong in the same sentance, Take care, jcs
  • "However, that focus on science has resulted in patients EXPECTING professional distance..." Jim is this a typo? Did you mean to write "experiencing". It seems to me that patients still expect physician empathy, communication with peers, and compassion! I remember when in college (a time long long ago in a galaxy far far away...) We were studying philosophy. We were discussing that a major challenge for mankind in dealing with the rapid growth of technology would be "how to spend our free time". Because of technology, we all would have to work less and less... I guess some future predictions are better than others!
    • James Salwitz, MD
      Unfortunately, I was deliberate in my choice of "expecting", as apposed to "experiencing" or even "desiring." It seems to me that so many patients I meet are astonished when a doctor shows them a little humanity, let alone real compassion, that I think patient's expectations have fallen. I am certain that patient's still want, desire and even beg for physician empathy... but what they expect is a pale second. I am still looking for that bounty of free time. Thanks very much for the comment, jcs
  • D Someya Reed
    How would you program "normal" for variables that are derived from an aggregate of all data taken in by individual facilities (i.e, hospitals, etc.). How would you program for the potential billions of exceptions of what may be normal for one person yet abnormal, even fatal, for another. Cost effective and mass marketing go together but not custom installation particularly on a global scale. What do you do when the power goes out or the batteries run dry even for a moment...that one critical moment? I'm not saying it won't happen but we do have a tendency more and more to leave a lot of issues out of the equation to deal with in versions 2, 3, 4...
    • James Salwitz, MD
      I think big data is our best chance of adjusting for individual variation. By that I mean, if a single doctor has only seen a particular patient variable a couple times, having access to national data base where that variable will have been seen thousands of times is the only chance that doctor has of giving really good personal care. I must admit I start bouncing off the wall when the power does go out. On the other hand I take a deep breath and remember how often every day we used to "lose" charts. Redundancy is key. jcs
  • D Someya Reed
    I remembered this post as I was reading Michio Kaku's book 'Physics of the Future.' Michio Kaku, for those unfamiliar, is a theoretical physicist, professor of theoretical physics, futurist and media personality. This came to mind as I read about the hundreds of millions of lines of code necessary to program the common sense known by a six year old into artificial intelligence (AI). He quotes Hans Moravec, former director of the AI lab at Carnegie Mellon: "To this day, AI programs exhibit no shred of common sense - a medical diagnosis program, for instance, may prescribe an antibiotic when presented a broken bicycle because it lacks a model of people, disease, or bicycles." I think we are very far away from true AI that can even begin to approximate humanity. With that in mind, I think we will be making, and have to make, a massive shift in society in order to ultimately accept this level of change whether it is realized by society or not. Your basic question, Hospice by computer?, will be done in violation of many of the current foundation beliefs of hospice. Even the basic tenet of no one deserves to die alone will be compromised. If you die with a not yet sentient computer by your side will you not be dying alone? Would a sentient one make it any different? This technology is likely to come some day but not for the benefit of people but for the cost savings. Maybe one day all things humans do (for work and pay) will be replaced by machines. But then you have to ask yourself how much value will money have when no one has any to spend? How much value will learning and skills have when no one needs them? Just as your romantic couple...how much value does real conversation have when texting "I love you" is done across a restaurant table?
    • James Salwitz, MD
      Are we moving further apart or closer together? Are we shallow enough that an intelligent manikin that says the "right" things at the perfect moment, every time, will be enough? Perhaps the most cost effective strategy will be to eliminate people altogether. Now that will save dollars. jcs
      • D Someya Reed
        You're right. That will save dollars but can we really call it progress if it costs us who and what we are? I think technology has become just another source of instant gratification. A letter that took weeks to deliver by Pony Express is now down to a little over 100 characters or a text message over a romantic dinner with abbreviations and icons because we've become too impatient to spell out the words (or even say them). Don't get me wrong, It's amazing to think what we may be capable of one day...get cancer, take "a" pill...break a leg, zap it and you're on the move again, no down time. But then, such as with 3D printers now, we may start creating anything we need, maybe even food, in our own homes. If interactive, holographic technology is invented we'll never really need to leave them. Or, very Star Trek-ian, if transporter technology is invented how long do you suppose it will be before the first person says, "OK, I'll be right there but I can only give you three seconds." I do like technology. I don't want to trade it for everything that makes me a caring, feeling human being. For another take, watch the film, 'Idiocracy.' Over the top stupidity but it does make its point.

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