Bad Directions

I love the GPS analogy for health care.  Patients need a GPS for their health, showing them the reality of their past, present, and future health.  The analogy has not only shown me how I want to give care for my patients, it has also given me insight into the pitfalls of automated medical care.
Way back in the days when GPS was new, the rental care company Hertz advertised \”NeverLost,\” a GPS on your dashboard (if you forked out the extra money for it).  I was asked to give a talk in Oregon, and decided I would try out this cool new technology (since others were picking up my bill).  While I found it overall very useful, there were a couple of times it didn\’t work as advertised.

  • I needed a sweatshirt, so  I used the NeverLost for directions to a Wal-Mart.  It worked!  It gave me flawless directions to a Wal-Mart store…in Las Vegas (over 1000 miles away).  I stopped at a gas station and they told me that there was actually a Wal-Mart 1/2 mile down the road.
  • Then, when I was trying to get to Crater Lake, \”Never Lost\” repeatedly directed me down dirt roads, some of which had trees fallen across their path.  NeverLost was quite perturbed when I didn\’t follow its direction, nagging me to make an immediate u-turn back toward the tree in the road.


Lest you think this is a problem unique to the early days of GPS, let me tell you about a more recent (and more expensive) GPS mishap.  While in Northern Michigan on vacation I asked for directions using the GPS on my phone.  It directed me down another dirt road, complete with deep ruts for tires which made my car scrape its underside on a dirt-rock potpourri, doing damage to my catalytic converter and costing me several hundred dollars.  (I have subsequently decided to ignore all dirt road directions).

In a recent article on the Health Care Blog, John Goodman speculates on the replacement of doctors (and nurses) with devices and software.

Clearly lot of primary care can be delivered without doctors. But how much do we really need the nurse? If a nurse can type in my answers to questions and follow a decision tree, why can’t I do that myself? If the nurse’s advice is largely read off a computer screen, why can’t I read the advice myself?

What about the hands-on activities? Patients can already take their own blood pressure. In fact you can do it yourself inside the CVS pharmacy. If the health care system were not so dominated by third-party payer bureaucracies, I suspect my iPhone would already have a stethoscope app. If my iPhone can easily identify a piece of music playing in a local bar, how hard would it be to create an app that interprets stethoscope sounds? As for the ENT observations, couldn’t an app do that as well?

The article recounts a visit to a MinuteClinic in which Goodman\’s care was menu-driven and automated, prompting him to muse about the people taking his money to do a task that he could do without them.  This makes me nervous since he is, to some degree, saying I can be replaced by a computer.  Forget about \”to some degree,\” he finishes with a flourish:

Finally, there is the matter of the prescription my nurse e-mailed to the pharmacy. If she is just following a protocol, why do we need the nurse? Why can’t I do it myself? Or more precisely, why can’t I authorize the computer to mail in the prescription the same way the nurse does?

Here’s my prediction: Within five years we’ll all have MinuteClinic decision trees on our personal laptop computers.

Wow.  Is he right?  I used to think MinuteClinics would hurt my business, but having my patients completely avoid care altogether seems a legitimate threat to the future of my primary care.

The outcry from primary care physicians on this is inevitable, as Goodman threatens the very heart of the our business model. The only way I am paid is when my patients come to my office in person, so I bring patients in for whatever care possible.  Patients using smart phones and computers to avoid my office seem to spell my doom as a PCP.  Should we arise as PCP\’s and defend this turf?  Or would that amount to holding on to an outdated business model, much as the record industry held to its monopoly on music distribution with the advent of digital music?


But I think Goodman is right that the direction toward this is inevitable, and so, instead of mimicking the music industry and trying to argue for an outdated model, we should carve out a new role in patient care  This role addresses the weaknesses of MinuteClinics, computerized care, and GPS devices.  My GPS follies underline two important facts about directions given by technology:

1. Technology can give bad directions.

For a GPS, this becomes apparent when facing a tree in the road or a bill from your car repair shop  Consequences of bad medical directions may be  much more serious, raising expense and even causing injury or death.  But bad directions doesn\’t keep me from using a GPS; instead, I use the GPS as part of the solution, not the whole.  The best directions come from mixing GPS directions with knowledge of people who know the roads and can give directions from personal experience.

In the past, my patients relied entirely on me for all of their medical direction.  They were largely in the dark about care, and could not get information from any other source.   So I ended up giving them turn-by-turn directions, nagging them whenever they chose to go another route.  The Internet changed everything, giving them access to both factual information and advice. Is that really a bad thing?  Do I really want to tell my patients things they could read on their own?  Do I really want to force them to come to my office for things they could get without me?  Why not instead take on the role of the friendly local who knows the roads better than the GPS?

2. Technology can give directions that lack perspective.

I recently saw a woman in the office who got an antibiotic for \”bronchitis\” (i.e. A loose cough, likely caused by a virus) from another physician.  Two days after starting her antibiotic she developed severe diarrhea and abdominal cramps.  She was a sick pup, presumably with colitis caused by Clostridium Difficile, a nasty bug that likes to take over the colon when other bacteria are killed off by broad-spectrum antibiotics.  Experience tells me that she probably would have gotten over her \”bronchitis\” without any antibiotic, sparing her the pleasure of abdominal cramps and near-dehydration (not to mention the joy of Flagyl, the nasty antibiotic I had to prescribed for her colitis).

The other physician was addressing her immediate concern, the loose cough, not considering the big picture of her health.  This is like the GPS sending me to Las Vegas to buy a sweatshirt at Wal-Mart.  Technology (and the MinuteClinic) doesn\’t have to live with the consequence of its advice.

So what should primary care be in this post-GPS era?  I think primary care has made itself far too small: becoming the treaters of coughs, the followers of protocols, and the keepers of the patient record.  In truth, I would gladly give up these mundane jobs, and fear my professional societies will fight for my right to hold on to them.  Primary care physicians are not simply \”non-specialists;\” we have a unique position in care – one that is growing in its importance with impending reform.

  1. We have a long-term relationship with our patients.  We know them as well as anyone, and so can give advice based on that personal knowledge, and will be by their side with the consequences of their medical decisions, good or bad.
  2. We have a unique position of communication.  We can explain the GPS results, keeping them out of danger and explaining the best path to everyone\’s goal: lots of birthdays.
  3. We are neutral.  I don\’t get paid more (like the specialist, drug company, or hospital) when my patients utilize our system.  I don\’t benefit when my patients get sick.  I want to keep them around for a long, long time, caring for their children and grandchildren.

Instead of fighting this change in direction, let\’s embrace the chance to go down a new road.  It seems like a much better direction to me.

3 thoughts on “Bad Directions”

  1. Interesting that you used the antibiotic example. I’m on two antibiotics for ten days for diverticulitis. I’m not sure that I needed the antibiotics. After an x-ray that caused me to get totally cleaned out I was feeling better each day. It was over a week later before I started taking the antibiotic.

    It was the trust I have for the PCP after several years of seeing him and what I read online about diverticulitis that caused me to decide to start the treatment.

    I’m sure that I had a point to make when I started this, but I can’t remember what it was. 🙂

  2. Over reliance on algorithms is indeed dangerous. Our role as physicians is to mediate between the knowledge base and the patient, and technology is a useful tool, but as yet far from replacing us. However it is important that we do not develop a negative view of technology and think of an us versus them ideology. It is a useful tool for us and our patients, and it will improve their knowledge which will make our job both more challenging, but also more interesting. Think of it as an intellectual exercise when discussing diagnosis and treatment with a well informed patient.

  3. My husband , a PhD, in EE and Physics, with two other PhD colleagues,all directionally challenged, got NeverLost on a rental car when going to a conference in a strange city, After a time, they finally realized they had been navigating around and around in a large square- NeverLost couldn’t tell the difference between Street and Drive.( It is now known as NeverFound)As for Primary Care- we are sometimes the ONLY ones who are getting the big picture. A lot of time is spent picking up the phone as Traffic Control- explaining (nicely) to a specialist that they are, well , lost……

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