Published in The Skeptic, Volume 21, Issue 2 (2008)
Wendy Grossman examines how technology and treatment combine in the modern healthcare system.
I’VE SPENT the last couple of months interviewing people on the subject of ehealth. Mostly, these are companies who want to sell the NHS things – implantable medical devices that send patient data to doctors over a secure connection, the networking behind those connections, computerised management systems, and so on. The good news is that all of these companies are serious medical companies. So far, not one has proposed sending crystal vibrations across the Internet via synchronised concentration or proposed to supply home homeopathic remedy manufacturing kits.
Instead, the modern pacemaker has sensors and an internal processor to store the data the sensors collect, plus a wireless connection that lets the patient pass a mouse-like antenna over his chest to read the data, which can then be sent down an ordinary telephone line to a secure website. There, the doctor can read and assess it. The idea is a win all round: the patient doesn’t have to travel to the hospital, and the doctor can spend less time on routine visits and accordingly more on the patients who really need his time.
And that’s just one example. We’re talking hospital-supplied tablet computers that run video games as well as allowing hospital staff to show you your patient records and graphical pictures of your innards for discussion. We’re talking digital radiography, electronic patient records (with all the privacy issues those involve), turning pathology labs from a cottage industry into a modernised hub-and-spoke network of high-volume processors, and slapping barcodes or radio-frequency identification (RFID) tags on everything from patients to scalpels to reduce wastage, improve safety, and cut costs in the supply chain. If it all works it will be fabulous.
We’ve generally said that the growth of so-called alternative medicine has been fuelled by the increasing remoteness of today’s medical service. Personal relation- ships with doctors are becoming as rare as personal relationships with bank managers. The average GP’s practice has thousands of patients, only the unhealthiest of whom probably know their doctors at all.
Oddly enough, the remote monitoring techniques the ehealth companies are talking about as necessary to make the NHS’s resources cover the needs of the population could take this trend either way. Patients with devices that can be monitored remotely may in fact feel in closer touch with their doctors if they get frequent reports (even if those reports are automated) about their condition than they do now with two to four routine appointments a year. On the other hand, it’s also easy to imagine that patients will be getting their automated reports from service centres based in India, where the staff will be reading treatment instructions from scripts.
I’d gotten as far as this when Simon Singh handed me a copy of the new book he’s written with Edzard Ernst, Trick or Treatment? Alternative Medicine on Trial. And there, very helpfully, on page 65, as part of a discussion of the placebo effect and the importance of double-blind trials, they write about the Hawthorne effect: “It has been shown that the act of close monitoring can lead to a generally positive change in a person’s health or performance.”
It seems logical to think of the placebo effect as deriving from alleviating fear and anxiety and the key is trusting your doctor. Of course there are always physical causes, but it’s the rare condition that is improved by get- ting the patient to panic. Close monitoring seems like an obvious way to diminish patient anxiety in a lot of cases.
The IT-skeptics among you will already have spotted the bluebottle in the unguent: since when does IT work the way we’re told it’s going to? I would do these inter- views during the day and then wander the Web at night, finding the stories the vendors didn’t mention. For example, Choose and Book, the electronic system intended to give patients control over doctors’ appointments, entertainingly sent the wrong appointment details to 340 patients. Fun! (OK, be fair, that’s out of seven million appointments it’s made.) And that fancy new implanted defibrillating gizmo? A bunch of MIT guys discovered they could hack into the stream of data in transit. Dismiss the likelihood of this all you like; if your doctor is seeing you remotely, you are your data, and it had better be secured against tampering.
Of course, no one gets to open up someone’s chest and plonk in a medical device without regulatory approval. But as I understand it, what gets studied is the efficacy of the device itself – does it synchronize the chambers, or defibrillate, or whatever it’s supposed to do? As far as I’m aware, other than anecdotal evidence no one is comparing the outcome of remote monitoring versus traditional hospital appointments. Let’s leave aside my morbid fantasy that as resources get tighter some bean-counter will come in and point out that if patient data can be read and assessed remotely, it might as well be done in Bombay instead of Basingstoke. Can the placebo effect survive the Internet? P.S. I can highly recommend Singh and Ernst’s book. Good stuff.