Sweet Dreams: The ­Future of Medicine

I’ve told my friends that I know we won’t time travel in the future because the first thing I would do is return to the past to tell myself that it’s going to happen. That was a great after-dinner conversation until …

During a recent lunch hour, I was sitting on a park bench at our medical school campus, frustrated by the third prior-authorization denial of the morning, when the smell of sulfur tickled my nose, a quick breeze blew through my hair, a sound like a clap of thunder startled me, and, as if an elevator opened in front of me, a person looking a lot like my father stepped through a crack in space and said, “There will be time travel in our future!”

I was most surprised. I stood up next to myself and stared. I actually touched my — or, rather, I should say, his so you can keep us apart — forehead and noted the deep wrinkles of laugh lines and sorrows. It was me, or more precisely will be me. We sat down, chuckled together and talked.

He wouldn’t answer questions about my future, my children’s lives, my friends — something about avoiding paradoxes and becoming my own grandfather. So, we were stumped. What could my older me say about the future?

“Well, I suppose I could tell you about the future of medicine!” he exclaimed.

“Aren’t you concerned I could mess it up?” I asked.

“As if you have any power to change the current or future state of medicine?” he harrumphed. “Of course, I’m not concerned.”

“You have a point,” I said and shrugged. “So, what does the future hold for health care?”

He thought with eyes squinted. Finally, he announced, “I can tell you that universal coverage passed in the U.S. Congress.”

“You’re joking? The liberals finally pushed it through?” I asked, jaw hanging.

“Of course not! The business community rose up en masse when they realized that, instead of corporations paying a trillion dollars in health care costs per year, all U.S. citizens could be covered, as other first-world countries have done, at a huge savings to them. Individual taxes went up, but we pay nothing for health insurance and have no out of pocket costs. Three trillion dollars in health care savings the first decade! Not only that, the administrative costs burdening doctors’ offices dropped like a rock overnight.”

“Wow,” I exclaimed. “I never thought that would happen. Did Bernie live to see the day?”

“They rolled him out to wave at the crowd,” he affirmed. “In the first year, many of the racial disparities in care disappeared as all people had equal coverage,” he affirmed. “There was evidence that would result back before 2020, when the Affordable Care Act Medicaid expansion states provided improved care to people of color and those in poverty.”(1,2)

“Did the government take over the hospitals?” I asked.

“Nope,” he shook his head, “they left them alone. Universal coverage was only about ensuring all citizens had insurance.”

“But what about free enterprise? Competition in the market place?” I retorted.

He snorted. “Once all the public held the same ‘currency,’ ” he said, making air quotes, “health systems became truly competitive, regardless of their location and payer mix.”

“Didn’t health care costs keep rising?” I asked naively.

He laughed. “No, it was exactly as Anderson kept telling us back in the day: ‘It’s the prices, stupid!’ Having one large payer doing the negotiating ensured high-value care was provided at affordable prices.”(3)

“So, what else you got in that brave new world?” I prodded, elbows on my knees, and eager. He placed his hands behind his head, and leaned back.

“Let’s see,” he pondered. “Artificial intelligence … that’s been a game changer,” he said, pointing his finger at my chest and nodding.

“You mean robot doctors?” I asked, eyes wide.

He looked at me with disdain. “I mean the ‘deep learning’ kind of AI that helps with diagnosis and treatment.(4) My smartwatch app listens to patient encounters, tracks symptoms and signs, and spits out a prioritized differential diagnosis with an evidence-based workup and treatment plan individualized for the patient. The diagnostic accuracy is much higher than any physician could develop alone. At first it was off-putting, and my patients looked askew when they heard the app talking to me in the exam room. A decade later, patients expect it.”

“I’m not sure I’d feel comfortable with that kind of intrusion,” I added, eyebrows furrowed.

“You won’t. I wasn’t,” he demurred. He raised an eyebrow. “More problematic is AI radiology and pathology. Even in your days, computer-based radiology and pathology were more sensitive than the human ability to find problems.(5) That trend continued, and the specificity only improved with time. There are very few radiologists and pathologists in practice anymore. They exist in our future mainly to characterize anomalies and oddities.”

I stroked my chin. Should I alert our medical students so they make informed decisions about career choice? Or would that be meddling with the future?

“And then, you’ll be glad to know we don’t enter data into EHRs anymore,” he smirked.

“Great Osler’s ghost!” I exclaimed.

“Instead, we have a video camera in the room, recording the visit. It parses into an electronic document the history, the exam, the diagnoses, and the treatment plans discussed. It creates a relatively short note, since,” he smiled continuing “with universal coverage, nobody is concerned about documenting for payment reasons.”

My excitement was growing.

“Tell me about the pharmaceutical industry. Have you tamed the beasts yet?” I asked expectantly.

He nodded, and stuck his bottom lip out. “It’s better. Universal coverage gave Americans one strong bargaining partner for Big Pharma. The Food and Drug Administration, which sits under the executive branch of government, finally limited the patentability of inconsequential changes in “me, too” medicines, stopped extending patents, and put more resources into reviewing generic drugs — all to increase their availability. They also got tough on new devices.”

We both leaned back against the park bench and looked up into the wild blue yonder.

“Wow,” I said after a minute, shaking my head slowly, not taking my eyes off the white billowing clouds set in the sky, “it sounds like a great place to practice medicine.”

“It truly is,” he nodded, then looked over at me. “But, now you have to get back to the clinic and see your patient.” He grabbed my arm and shook me. I pushed his hand away. He seemed very insistent and shook me more. I looked over at him.

“Dr. Beasley,” he said with a woman’s voice, “please wake up and come back inside. Ms. Jones is waiting to be seen.”

Suddenly, I awoke and looked up at my nurse, who scowled.

“Wait! Where did I go?” I asked with a start, looking behind and underneath the park bench for my older me, as my nurse put her hands on her hips and tapped her toe, impatiently.

References

1. Daw JR, Sommers BD. Association of the Affordable Care Act dependent coverage provision with prenatal care use and birth outcomes. JAMA. 2018;319(6):579-87.

2. Swaminathan S, Sommers BD, Thorsness R, et al. Association of Medicaid expansion with 1-year mortality among patients with end-stage renal disease. JAMA. 2018;320(21):2242-50.

3. Anderson GF, Reinhardt UE, Hussey PS, Petrosyan V. It’s the prices, stupid: why the United States is so different from other countries. Health Aff (Millwood). 2003;22(3):89-105.

4. Hinton G. Deep Learning — A technology with the potential to transform health care. JAMA. 2018;320(11):1101-2.

5. Jha S, Topol EJ. Adapting to artificial intelligence: radiologists and pathologists as information specialists. JAMA. 2016;316(22):2353-4.