Media stories abound describing how technology is going to change health care. We’ve heard about robots that can undertake complex surgery and care for older people, and chatbots that claim to outperform GP trainees. So I’ve been wondering whether a robot might replace me as a GP.
If I think about it, rather than a robot, I've come up with a wall with five features:
- A screen: something like a bank machine, into which people can tap personal information.
- A couple of holes: into which different bits of anatomy (arm, finger) can be inserted to check out ‘biometrics’ (blood pressure, blood oxygen level) or deposit body fluids to be tested in a giant, invisible pathology machine.
- A tube that people can blow into to check for strep sore throat, stomach bugs or various cancer markers.
- One of those whole body scanners you see in airports, which can check organs and spot early signs of cancers and other undesirable masses.
- And a kind of vending machine, like the ones that sell sweets on station platforms, through which a summary of personal risk factors, wellness targets, prescriptions, medications and various forms of advice and treatment are issued.
At the end of the wall, if it can’t sort out all your needs, a door opens into an oasis of professionally organised calm, where a living GP will examine whichever body parts need further attention and co-design a treatment plan.
How real is this wall?
Every feature described above is already in use, although not generally consolidated into an e-health wall. AskmyGP and eConsult offer the front-end computer triage. Fitbits and other wearables are clocking our risk factors, and smart toilets exist to monitor urine for signs of diabetes. GPs have biometric monitors in waiting rooms and near-patient testing kits in consulting rooms.
There are already breath tests for strep sore throat, and various cancer makers and artificial intelligence programmes are generating lists of possible diagnoses. Total body scans are used for health checks in the private sector, and for cancer staging and more in the NHS, while robotic dispensing and e-prescribing are also well established.
So what will I be doing if the wall does all of that?
With all this technology, will people still need to see a real doctor, and what will that doctor have to offer?
Looking through a financial lens, until the cost of a total body scan drops substantially, if any organ needs to be examined, you will have to be seen in person. Taking a wider perspective, there are at least five areas in which professional judgement provides stiff competition for computers.
First, doctors recognise patterns in ways that robots cannot credibly do (yet!). They make different clinical decisions when faced with two children with similar physical signs (such as high fever, flushed and coughing), if one sits passively in its mother’s lap and the other skips into the consulting room giggling. Likewise for two adults with sciatic back pain – one of whom sits down swiftly, without wincing, while the other lowers gingerly into a chair.
Second, doctors can de-medicalise. Drawing on a deep knowledge of a patient, their social and family context, they can try to manage health anxieties that affect around 10% of patients, spot the social determinants of disease (which would take numerous computer questions to identify), and steer patients towards non-medical resources – including their own inner assets and those of their family and community – to manage symptoms.
Third, GPs are sometimes the expert mediators of public health policy. Drawing on the pattern recognition that comes from the experience of comparing many patients, they can moderate the use of powerful opiates for pain or decide that antibiotics may not be necessary (at least in the short term, without reassessment).
Fourth they can provide decision support for dilemmas about investigation and treatment. Should an asymptomatic man have a PSA test? Should a 60-year-old woman with moderate arthritis that limits functional ability request a hip replacement? Yes, there are decision support programmes that exist, but they can be laborious to complete, and even after using them, many people still want a more nuanced face-to-face conversation.
Finally, in some situations, doctors empathise. This role is highlighted by many as a key aspect of general practice and it’s not always easy. Well intentioned words may not feel empathic to patients, particularly if they touch on difficult public health issues like obesity. But I don’t think that a computer yet exists (except perhaps in the film Her) that can do this well.
Not yet time to retire
So I don’t think my job will be replaced by a robot or a wall, but I am clear that it will change.
Patients arriving with lists of possible diagnoses will become the norm. Test results will be delivered electronically, saving the need for follow-up consultations. Remote monitoring technologies will let me call in patients with long-term conditions at the point they deteriorate, not because my annual recall system requires them to come in.
But there will be stresses too. Easy access via Skype will encourage the worried well to seek reassurance about common symptoms – further stoking demand that GPs already struggle to meet. Some patients will demand treatments they discover on the internet that may not be available through the NHS, and tense consultations will follow. I will need to learn new skills, such as analysing and interpreting data.
At present, I relish the prospect of being assisted by technology and dread the stresses it may cause in almost equal measure, so the implementation challenge – covered in my next blog – will be to introduce digital technologies to general practice in ways that deliver net benefits to patients and to staff.
In the meantime, I will keep trying to persuade patients to register for our online services, which many seem strangely reluctant to do. For despite all the hype about how technology will change the face of health care, there remains a large cohort who really quite like a trip to see the GP!
Rosen R (2018) "Will a robot replace me as a GP?", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/will-a-robot-replace-me-as-a-gp