History | Medical Futures Lab

Apr 24 2014

Communication, Culture, Health, History, Humanity, Story

Trust the Knife

Last summer my father had a basal cell carcinoma removed. It was about a dime sized patch of skin just to the left of his nose. Although this form of cancer is rarely deadly it was still a sobering experience for my family especially considering we are all fair skinned and highly susceptible to skin cancer. Living in southern California does not help either. The surgery was successful and after one year and several cortisone shots one can barely tell my dad had a chunk of flesh taken out of his face.

My dad did however have one problem with his treatment process. It wasn’t the hospital facilities or the painful tending to his wound every night after the surgery. Instead his biggest issue with the whole experience was that his doctor rarely talked during checkups. During the whole process I remember him constantly bringing up how the doctor would come in the room, examine him and then most often leave without uttering a single word. When my dad tried to ask him how everything is going he would nod and mutter inaudibly under his breath. The only words the doctor ever said to my dad involved what he was going to do and that my dad had to make another appointment with his secretary. The nurse was responsible for informing him why they were doing surgery and providing background information on this form of cancer. My dad was really turned off by his doctor’s lack of enthusiasm and transparency. I was shocked that a doctor, whose job it is to form a bond with his or her patient and instill trust, would not share information face to face and instead use nurses convey reasoning for the treatment.

To me this kind of doctor seems to be of the old school type, those who believe you do what I say and everything will be okay. While many younger doctors focus on good bedside manner there remain many that practice old-fashioned principles. Granted my dad’s doctor is in his late seventies so he is most likely the byproduct of this archaic brand of practicing medicine. Nonetheless, this example draws attention to the necessity of doctor-patient communication. It is important not only that communication take place regularly but that the patient feels he or she is on a level playing field and can speak freely. The best way to ensure patient involvement is for the doctor to speak more often, using language that the patient can understand while having a pleasant and familiar tone. In this class we have learned a lot about how technology can enhance communication but it is vital we do not forget that quality care involves personal conversation that creates an atmosphere conducive to establishing trust.

Feb 26 2014

Electronic Medical Record, History

History of Medical Records Systems from 19th to 21st century on Connexions

Guest post by Olivia Banner

I’ve just posted A History of Medical Records on Connexions (a Rice University-based repository for online learning modules). By showing medical record systems from the nineteenth century through the present, this project illustrates how the physician/patient encounter has been recorded, and the accompanying text begins to tease out what we can learn from the forms such records have taken.

When we teach about the history of medicine, students often take it for granted that medical records sit outside of history: that it is obvious what a hospital or a doctor would want to measure and record about their patients. Yet that information has changed over time, and what a hospital or a doctor selects as significant enough to record tells us much about the needs of medical institutions as well as what goes on within the physician-patient encounter. In addition, the format for those records has undergone constant transformations due to the introduction of new technologies, or changes in institutional needs, etc., and their format reveals much about medical practice.

The project is still in progress, and the materials I have been able to gather have been limited by what archives have saved (and medical records, seen as the stuff of bureaucracy, are often not considered important for the historical record) as well as by concerns about privacy. Materials from Los Angeles and Boston archives will be added in future months. Nevertheless, what is included here will help us all learn more about the history of medicine as it moved from the analog to the digital age.

Sep 16 2013

History, Medicine

Louis Pasteur Visits Medical Futures Lab

Way back in 1895, a French physician by the name of M. Jeanne attempted to persuade his fellow doctors that big changes were coming to the field of medicine. As he wrote in the Concours Médical,

“It may not be too soon to look ahead into the future that the scientific revolution, brought about by the beneficent discoveries of the illustrious Pasteur and his school, has in store for the medical profession. […] Diagnosis, that primordial element of our art, will soon no longer be able to do without the microscope, bacteriological or chemical analysis, cultures, inoculations, in a word everything that may give our clinical judgments absolutely precise data. […] Let us go back to school, and prepare the ground for an evolution, if we are to avoid a revolution.”

We’re using Bruno Latour’s The Pasteurization of France (1984) – the source of the quote – in my graduate seminar, “Emergent Media: Technologies, Networks, Culture” at Rice University. Our focus is on the complex interplay between the emergence of new media technologies in different historical periods (past, present and future), the networks of commerce and creativity that fuel and arise from these innovations, and the cultural productions that result. While much of our reading looks forward at digital interfaces, we can learn a lot about contemporary evolutions and revolutions by looking back – and the bacteriological revolution was about as disruptive as they get. But the key point is that it was a revolution that came from outside of medicine, and it only gained momentum through an accumulation of forces, including professionals and the lay public, who all felt they shared a common goal.

In one hundred years, will we have a Louis Pasteur of digital medicine? Will the eventual embrace of digital tools seem as obvious then as the embrace of bacteriology seems to us now?

Latour argues that physicians in France finally joined the Pasteurians only after the development of the diptheria serum, which required the doctors’ services to diagnose the disease. By devising a serum that treated but did not prevent disease, the Pasteur group allowed doctors to keep their jobs and get on the bacteriology bandwagon without losing face. What will be the magic serum that allows medicine to join the digital revolution? Self-tracking? Personalized genomics? 3-D printing? Whatever it is, history tells us that it will only take over by making itself seem inevitable.

Apr 22 2013

Culture, Design, Electronic Medical Record, History, Medicine

EMRs and the Problems of Diagnoses, Part 2

Guest post by Olivia Banner.

“Schematic Flow Chart for DIAGNO II Computer Program,” Robert Spitzer and Jean Endicott, American Journal of Psychiatry 125, 7 (1969): 15.

In a previous post, I wrote about Ted Gup’s critique of the current rush to organize human differences into diagnostic categories, which he published on the heels of the CDC’s recent report that 11% of U.S. children are currently diagnosed with ADHD (see “Diagnosis: Human”). It’s interesting to consider this critique in light of the DSM’s history, and in light of projects to automate diagnoses using computers, all of which produces some intriguing questions about the future of EMRs.

Some readers may already be familiar with the vagaries of how the DSM has treated “homosexuality” over the years: it wasn’t until 1986 that editors completely removed it from the DSM.

This is only one among many examples of how the DSM mirrors cultural attitudes toward the groups of “symptoms” it classifies as psychiatric disorders.

In the late 1960s, one of the DSM’s previous editors, Robert Spitzer, developed a computer program intended to automate diagnosis. Called DIAGNO, the program was envisioned for use during intake at psychiatric facilities. Spitzer’s basic premise was that, since clinicians employ a decision tree to arrive at a differential diagnosis, and software code also uses decision trees, a computer program could be equally if not more precise than humans at determining diagnoses. DIAGNO went through three versions as Spitzer fine-tuned it over the years, aiming for a program that could one day skip the clinical encounter altogether.

As far as I’ve been able to figure out, DIAGNO remained a dream that was never implemented; however, it’s interesting to note that Spitzer was building on other researchers’ programs to automate recommendations for which drugs to use to medicate specific disorders. One of these was used in the late sixties at the University of Texas Medical Branch in Galveston. (Please comment if you have any additional information on DIAGNO’s implementation!) The dream of automating diagnoses lives on, however, whether in technologies intended for use in the home such as SCANADU, which would diagnose medical conditions, or those for use in clinical settings. In the latter category we could include a fascinating project that attempts to integrate findings from cognitive science to help automate psychiatric diagnoses, so that diagnoses can be reached through a computer program analysis of a patient’s narrative (see Cohen et al., “Simulating Expert Comprehension”).

I wonder what Ted Gup would say about this latter effort. In this dream of a future where diagnoses are automated, his narrative about his suffering might, when analyzed by software, be diagnosed as a condition suitable for treatment. Do we want this future where computers can diagnose? What happens when EMRs are based on diagnostic categories that can’t reflect the particular exigencies of their historical moment that drive the diagnosis?

How does automating diagnoses occlude broader cultural debates about the diagnoses themselves? And how can we, as educators, best alert our students to these problems, even as we search for more efficient ways to implement new digital technologies into clinical practice?

Apr 17 2013

Culture, Electronic Medical Record, Health, History, Medicine

EMRs and the Problems of Diagnosis

Guest post by Olivia Banner.

I’ve been thinking a lot about how to draw the attention of physicians and medical students to debates over the diagnoses that they often accept as self-evident, particularly because these diagnoses are intricately interwoven into electronic medical records.

As we try to develop better EMRs, can we integrate into them an understanding that diagnoses reflect the cultural and social meanings about human characteristics that circulate in their historical times?

These questions became particularly relevant when I read a reaction to the recent CDC release about ADHD, which is now diagnosed in 11% of U.S. children. In a New York Times Op-Ed piece (“Diagnosis: Human”), Ted Gup, a fellow of the Edmond J. Safra Center for Ethics at Harvard University, described a set of personal experiences that made him critical of the current rush to affix psychiatric diagnoses to characteristics that are perhaps simply part of what it is to be human. When his son displayed qualities that other eras might have labeled “rambunctious,” our era stepped in with a diagnosis of ADHD, for which his son received, in lieu of talk therapy, the standard treatment: amphetamines.

At the age of 21, his son was found dead of a lethal mix of medication and alcohol. Gup views the death as a logical outcome of his son’s experience, where medication was not only the accepted tactic to address those qualities society labeled as a “disease,” but was also used as part of a culture of success, where, particularly among college students, amphetamine use is rampant. As further evidence of why the ballooning of diagnoses is a problem, Gup offers up the example of his own grief, an all-too-human and understandable response to losing his son – and which, according to the latest edition of the DSM, is diagnosable under the category of depression, and therefore treatable with medication.

Gup’s impassioned critique led me to consider how diagnoses are integrated into EMRs.

As we attempt to develop EMRs that can be “meaningfully used,” is there any way they might reflect broader cultural debates over the meaning of particular diagnoses?

In my next post, I’ll return to these questions in light of ongoing attempts to develop computer programs that could automate diagnosis, both for medical and psychiatric conditions. Let me know what you think.

Medical Futures Lab

Category Archives: History

Trust the Knife

History of Medical Records Systems from 19th to 21st century on Connexions

Guest post by Olivia Banner

Louis Pasteur Visits Medical Futures Lab

EMRs and the Problems of Diagnoses, Part 2

Guest post by Olivia Banner.

This is only one among many examples of how the DSM mirrors cultural attitudes toward the groups of “symptoms” it classifies as psychiatric disorders.

How does automating diagnoses occlude broader cultural debates about the diagnoses themselves? And how can we, as educators, best alert our students to these problems, even as we search for more efficient ways to implement new digital technologies into clinical practice?

EMRs and the Problems of Diagnosis

Guest post by Olivia Banner.

As we try to develop better EMRs, can we integrate into them an understanding that diagnoses reflect the cultural and social meanings about human characteristics that circulate in their historical times?

As we attempt to develop EMRs that can be “meaningfully used,” is there any way they might reflect broader cultural debates over the meaning of particular diagnoses?

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