Parenting medical disruptors

rebel-without-a-cause-2Popularized telemedicine — that is, teleconferencing with a physician over one’s smartphone — worries many critics because it assumes patients can be evaluated without a physical exam.  The critics are right that those with a financial interest in “disrupting” health care typically minimize the trade-offs.  Convenience and lower cost are trumpeted, while risks of misdiagnosis and mismanagement are waved off.  The concerns of practicing physicians are dismissed as self-serving and illegitimate.  Common sense supplants expertise; repudiation of experts, or perhaps a rebellion against them, lies just under the surface. Startup culture celebrates and sometimes handsomely rewards brash Big Thinkers who don’t let a few practical matters, like the fact that diagnosis isn’t always a slam dunk, impede progress.  Steven Jobs wasn’t the only one with a reality distortion field.

The tension between professionalism and commercialism isn’t new or limited to medicine.  Misgivings by medical personnel about “Dr. Google” and smartphone telemedicine parallel misgivings by attorneys about do-it-yourself wills and divorces, and by CPAs about at-home tax return software.  In each domain professionals lament the erosion of quality, and their inability to provide it, while business disruptors revel in expanded markets.

It’s also well accepted that providing high quality products or services, and wide availability at the same time, is an elusive challenge.  Usually it’s one or the other.  Although the marketplace accommodates fine dining and fast food, the fiduciary role of doctors, attorneys, accountants, and banks separates these fields from the restaurant business.  Banking is a prime example: no amount of convenience or access make up for uncertainty about the safety of one’s money.  And while profit, or making a living, motivates professionals as much as it does the businesspeople who aim to unseat them, only the former maintain longstanding traditions and ethical codes to put their patients or clients before profit.  The stale charge that heel-dragging professionals are financially self-serving applies far more to the gung-ho disruptors themselves.  Medical care has always been about high quality and wide availability, which is why health care reform is genuinely hard.  Trading away quality for availability or expediency is simply cutting corners.  We could have done that all along.

Smartphone telemedicine doesn’t currently allow physical examination.  There are a range of scenarios (“use cases”) where this makes little difference, and many others where it matters a lot.  But technology is a moving target.  It’s a safe bet that remote examination technology will improve, gradually putting this concern to rest.  Criticism of telemedicine is not about what it someday may become — “Star Trek” style holodecks with virtual physicians? — but about today’s enthusiasts getting ahead of themselves.  That is, selling science fiction, not science.  This creates a peculiar dynamic: innovators speak in vague but urgent tones of our shiny future and the need for traditionalists to step aside for progress, while critics walk a tightrope between condoning exploration and improvement, and at the same time keeping everyone safe.  This resembles nothing so much as parental oversight over a teenager.  Like good parents, professionals must step aside to allow entrepreneurs to try new things, learn from their mistakes, and yes, ultimately make the world better than they found it.  But we can’t be negligent either.  Some cool new toys are risky, some daring adventures bring unanticipated danger.  It’s no coincidence that the language of “disruption” sounds adolescent, and that pushback from the disruptors sounds like a teenager complaining that his or her parents are old-fashioned, uncool, and self-interested.

There’s a direct parallel in my specialty.  For over 35 years, advocates of a neurobiological approach to psychiatry have oversold what we actually know.  From now-discredited “chemical imbalances” to current talk of circuitopathies, neurobiology enthusiasts dismiss humility (and occasionally honesty) as old-fashioned and uncool.  This began with an Oedipal victory over Papa Freud in the 1970s, was codified into DSM-III in 1980, celebrated as the Decade of the Brain in the 1990s, and has shaped the NIMH and psychiatric research ever since.  Neurobiology has become the dominant paradigm, a matter of faith.  But aside from a limited range of scenarios (“use cases”) involving addiction and bonafide brain injury, it’s vaporware so far.  We psychiatrists are told to think neurobiologically, and to educate our patients using the language of brain circuitry — even though it’s often an educated guess, and even though it doesn’t actually change our treatment.

Surely time is on the side of the innovators.  It’s a safe bet we’ll learn much more about the brain, gradually discovering the causes of at least some disorders we currently call psychiatric.  Thoughtful criticism of neurobiological psychiatry is not about what it someday may become.  It’s about today’s advocates getting ahead of themselves, selling wishes and half-truths as established science.  Neurobiology disruptors speak in vague but urgent tones of our imminent bright future and a need for the older generation to step aside for progress.  Meanwhile, critics play the parental role, walking a tightrope between encouraging exploration and improvement, while keeping everyone safe with care for the brain and the mind.

It’s not easy parenting adolescents.  Sophomoric self-righteousness, know-it-all smugness, and knee-jerk rebellion can be irritating as hell.  Suddenly, adults are idiots and “just don’t understand.”  The young resist all guidance and veer toward obvious trouble.  It’s nerve-wracking to hang back and watch this happen; to refrain, except in extreme circumstances, from wagging a parental finger and chiding, “you have a LOT to learn!”  And all these challenges grow in complexity when the “adolescents” are actually adults, sometimes even colleagues, and when professional expertise and decades of hands-on experience invite only suspicion, not authority or respect.  Even if our concerns are dismissed as the bloviation of myopic dinosaurs, we still hope our colleagues, business counterparts, and larger society grow up fast enough to see past the seduction of disruption and rebellion.  We need to weigh the real trade-offs we face.


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