I recall being a young General Practitioner, setting out to make my way in the world, before guidelines were a thing. We had not heard of health automation and all medicine was personalized. I had purchased an established, full-time practice in a small provincial town and was juggling my time seeing patients, keeping on top of paper-work and balancing the books. While I was not new to General Practice (you may be relieved to hear), I was new to the business and the government funding processes.
This was before the days of a multitude of self-help guides, beseeching me to look deep and see what it was that I really wanted. I was a doctor and instinctively knew that I wanted to be in General Practice and that came with government funding. In practice, my priority was finding the best option for those who trusted me enough to help guide them through the vagaries of medicine. I quickly picked up on subtle cues – the confidence in the walk from the waiting room, the furrowed lines, the florid skin, the direct gaze, the odor, the interaction between parent and child. These cues helped to guide me towards a plan that supported healing. This is not to say that I did not write the patient’s name on the prescription pad as they were sitting down, a complaint often heard from those disgruntled. I did, and this bought me an extra minute to spend with the patient. On the flip side of this interaction, if I did not prescribe a pharmaceutical, the patient would often feel hard done by, with one or two wanting their money back!
Medical Guidelines & Unintended Consequences
Then came the Medical Guidelines. We were reassured that these were, in fact, just that – guidelines. We were not meant to use the flowcharts and the algorithms at all costs. As clinicians, these guidelines were there to help us make the correct clinical decisions with regards to diagnosis and treatment, but ultimately, the decisions and responsibilities were ours. In reality this was the start of health automation and the decline of personalized medicine.
Fast-forward twenty plus years. Guidelines are now not only instilled as “Best Practice” but there are penalties for those clinicians who do not follow them. These may range from disapproving tut-tuts from colleagues, to financial penalties to legal procedures with a risk of being summarily struck off the medical register. The process of formulating and instituting guidelines is somewhat murky and I discuss this briefly in my post on Citizen Science, but big pharma most certainly plays a part.
Junior doctors are surprised to see that I write my notes free-style and do not use a template of check-lists. That is how I was taught – observe, listen, examine, recognize a pattern that matches with a medical situation (diagnosis) and formulate a plan (treatment). I find the act of writing often helps this process. This is not to say that check-lists and guidelines have not been helpful to me, they have – a lot. I was, however, lucky enough to start off in medicine and in general practice before guidelines were rules. The art of medicine and the medical ritual were important parts of supporting healing. There was no health automation and medicine was automatically personalized.
It is interesting to note that along with the enforcement of guidelines has come a dramatic reduction in independence regarding how a doctor runs their practice. Most general practices now involve a never-ending cycle of programs, certifications, reporting and funding rounds with an ever-increasing bureaucratic health authority.
Have the guidelines helped? It is generally accepted that less medical mistakes have been made since their introduction. The health authorities take pride in providing a service where the outcome for the individual is the same no matter which doctor is seen.
It is my experience, however, that the public are more disgruntled with medicine, often choosing to trust influencers and bio-hackers with predictably mixed results. General Practitioners are over-worked and stuck between one-dimensional pharmaceutical protocols and patients who want a magic pill. It seems that the guidelines have leveled the playing field, lifting “poor” doctors up and leveling “good” doctors down.
In New Zealand, the incidence of chronic diseases is on the rise, while the medical industry consumes 10% of GDP. Covid-19 has normalized Telehealth. Telehealth is a benefit in certain circumstances of acute medicine but limited in the medicine of life, General Practice. There are less subtle cues, the conversation does not flow, and the paperwork increases with Telehealth. While current flow-charts may suggest a diagnosis to be confirmed by the clinician, the advent of personal wearables and health AI may soon fully take over diagnosing. Big tech companies are investing heavily in the health sector (e.g. Apple Health). It presently looks like health automation will reinforce the guidelines and soon there will be an avatar on the screen ticking the boxes, but the advent of consumer-held data is unpredictable, creating personal medicine opportunities for consumers.
Can Automation Provide Personalized Medicine?
What can a doctor with the best interests of their patients in mind do? The clock cannot be turned back and maybe even should not be. Humans are wired towards seeking simple solutions for complex problems, compounded by the notably poor assessment of long-term risk. Ideally medical interactions would include both subtle and subconscious clues, the rigor of checklists, and empowerment for both clinician and patient. We all know intuitively that health is not going to stay the same. Automation is definitely going to be commonplace driven by consumer-held data. However, automation of a sub-optimal process will only serve to multiply the current outcomes. The medical guidelines may have had unintended consequences and there is no point in speeding up something that does not work.
Personally, after almost giving up medicine, I have found my own way. I run a non-funded private medical clinic that provides for a modicum of freedom. I encourage patients to be an active part of the medical ritual. I use check-lists but my notes are still typed free-style. For myself, and hopefully for patients, the process has meaning, provides value, and supports healing and long-term health. However, I can see only a fraction of the number of patients I saw in the past.
Is automation able to assist? There are proxies for the overall state of an individual that can be automated (e.g. HRV), potentially providing some of the subconscious clues. More data may however serve to further overwhelm both patient and clinician.
A Unique Medical & Individual Algorithm
The clinic’s wearable initiative, Omic, has incorporated the concepts of personal history, situational awareness and physical metrics including HRV into a usable platform. The diagnostic and treatment engine in the platform collates thousands of data points into usable interventions and feedback for clinicians and patients.
Our aim is to reapply the collective wisdom of hundreds of years of medicine, combine this with the data from the individual and provide a cost-effective option for those seeking not just personalized interventions, but also wanting to rediscover the medical ritual.
We are dreaming big and we are making progress.