Medicine is awaiting its own Photoshop

by reestheskin on 05/10/2020

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My experience is limited, but everything I know suggests that much IT in healthcare diminishes medical care. It may serve certain administrative functions (who is attending what clinic and when etc), and, of course, there are certain particular use cases — such as repeat prescription control in primary care — but as a tool to support the active process of managing patients and improving medical decision making, healthcare has no Photoshop.

In the US it is said that an ER physician will click their mouse over 4000 times per shift, with frustration with IT being a major cause of physician burnout. Published data show that the ratio of patient-facing time to admin time has halved since the introduction of electronic medical records (i.e things are getting less efficient). We suffer slower and worse care: research shows that once you put a computer in the room eye contact between patient and physician drops by 20-30%. This is to ignore the crazy extremes: like the hospital that created PDFs of the old legacy paper notes, but then — wait for it — ordered them online not as a time-sequential series but randomly, expecting the doc to search each one. A new meaning for the term RAM.

There are many proximate reasons for this mess. There is little competition in the industry and a high degree of lock-in because of a failure to use open standards. Then there is the old AT&T problem of not allowing users to adapt and extend the software (AT&T famously refused to allow users to add answering machines to their handsets). But the ultimate causes are that reducing admin and support staff salaries is viewed as more important than allowing patients meaningful time with their doctor; and that those purchasing IT have no sympathy or insight into how doctors work.

The context is wildly different — it is an exchange on the OLPC project and how to use computers in schools, but here are two quotes from Alan Kay that made me smile.

As far as UI is concerned — I think this is what personal/interactive computing is about, and so I always start with how the synergies between the human and the system would go best. And this includes inventing/designing a programming language or any other kind of facility. i.e. the first word in “Personal Computing” is “Person”. Then I work my way back through everything that is needed, until I get to the power supply. Trying to tack on a UI to “something functional” pretty much doesn’t work well — it shares this with another prime mistake so many computer people make: trying to tack on security after the fact …[emphasis added]

I will say that I lost every large issue on which I had a firm opinion.

Crime pays but leave it off the CV

by reestheskin on 23/07/2020

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Whenever I have looked at the CVs of many young doctors or medical students I have often felt saddened at what I take to be the hurdles than many of them have had to jump through to get into medical school. I don’t mean the exams — although there is lots of empty signalling there too — but the enforced attempts to demonstrate you are a caring or committed to the NHS/ charity sector person. I had none of that; nor do I believe it counts for much when you actually become a doctor1. I think it enforces a certain conformity and limits the social breadth of intake to medical school.

However, I did do things   work outside school before going to university,  working in a variety of jobs from the age of 14 upwards: a greengrocer’s shop on Saturdays, a chip shop (4-11pm on Sundays), a pub (living in for a while 😃), a few weeks on a pig-farm (awful) and my favourite, working at a couple of petrol stations (7am-10pm). These jobs were a great introduction to the black economy and how wonderfully inventive humanity — criminal humanity— can be. Naturally, I  was not tempted😇. Those in the know would even tell you about other types of fraud in different industries, and even that people actually got awarded PhDs by studying and documenting the sociology of these structures (Is that why you are going to uni, I was once asked).

On the theme of that newest of crime genres — cybercrime — there is a wonderful podcast reminding you that if much capitalism is criminal, there is criminal and there is criminal. But many of the iconic structures of modern capitalism — specialisation, outsourcing and the importance of the boundaries between firm and non-firm — are there. Well worth a listen.


  1. See below  for a long aside on this point.

I think there is a danger in exaggerating the role of caring and compassion in medicine. I am not saying you do not need them, but rather that I think they are less important that the technical (or professional) skills that are essential for modern medical practice. I want to be treated by people who know how to assess a situation and who can judge with cold reason the results of administering or withholding an intervention. If doctors were once labelled priests with stethoscopes, I want less of the priest bit. Where I think there are faults is in the idea that you can contribute most to humanity by ‘just caring’. The Economist awhile back reported on an initiative from the Centre for Effective Altruism in Oxford. The project labelled the 80,000 hours initiative advises people on which careers they should choose in order to maximise their impact on the world. Impact should be judged not on how much a particular profession does, but on how much a person can do as an individual. Here is a quote relating to medicine:

Medicine is another obvious profession for do-gooders. It is not one, however, on which 80,000 Hours is very keen. Rich countries have plenty of doctors, and even the best clinicians can see only one patient at a time. So the impact that a single doctor will have is minimal. Gregory Lewis, a public-health researcher, estimates that adding an additional doctor to America’s labour supply would yield health benefits equivalent to only around four lives saved.

The typical medical student, however, should expect to save closer to no lives at all. Entrance to medical school is competitive. So a student who is accepted would not increase a given country’s total stock of doctors. Instead, she would merely be taking the place of someone who is slightly less qualified. Doctors, though, do make good money, especially in America. A plastic surgeon who donates half of her earnings to charity will probably have much bigger social impact on the margin than an emergency-room doctor who donates none.

Yes, the slightly less qualified  makes me nervous.