We have Artificial Intelligence (AI) bots to collate our ailments and scour the web for solutions, genetic tests to personalize our care, wearable monitors to collect our data, pharmacists to prescribe and dispense our medications and consultant physicians and allied professionals to provide our care.
Why then, do we need family doctors at all? Has the family doctor become a redundant relic from an idyllic past? In the era of ever-proliferating knowledge that exceeds the cognitive capacity of any human, isn’t a family doctor kind of like an abacus or sundial: a once essential creature now replaceable by sophisticated data, devices and care specialists?
Let’s explore the development of three areas that will affect the future of primary-care delivery and the value that family doctors can bring.
- Monitoring devices
Devices that collect our data have democratized health data, making it more accessible and prolific – the devices are owned and operated by patients. We have bed sensors, fall sensors, continuous glucose monitors, smart thermometres and personal diagnostics from our cell phones and smart watches. Smart watches can measure our sleep (indirectly through movement parameters), heart rate, arrhythmias, blood oxygen levels, blood pressure and much more. It’s barely hyperbolic to state that some of our wrists will be continuously monitoring vital signs from the day of birth until the last breath. Let’s not get bogged down on whether this is ‘good’ or ‘bad’ because, as with most tools, it could be either. For example, for those with Type I diabetes, continuous glucose monitoring has been revolutionary, empowering patients and their medical team to manage diabetes with higher precision, thus improving safety and reducing long-term complications. On the other hand, for someone prone to anxiety, knowing one’s heart rate every moment can provide unhelpful, counterproductive biofeedback.
For those with undiagnosed Paroxysmal Atrial Fibrillation (PAF), continuous heart-rate monitoring combined with evolving ECG technology could increase detection. While this technology so far has significant false positive and false negative rates, it may prove useful with further development. Since PAF increases the risk of thromboembolic stroke and effective medications are available, we may see a decline in strokes as a result. However, the medications are not benign and may cause serious bleeding. Patients with PAF need a trusted advisor to differentiate PAF from similar conditions, rule out underlying reversible causes, guide a careful comparison of the risks and benefits of treatment, decide on a course of action and provide monitoring and follow up going forward. Family doctors fill this role every day.
Also, what should patients do if their blood-pressure monitor says their blood pressure is high? Some end up in emergency departments, but for the vast majority follow-up with the family doctor to confirm the diagnosis, rule out underlying reversible causes, set personalized blood-pressure targets and begin management make for much more effective and efficient for the patient and health-care system alike.
- AI and bots
Family doctors are already using dashboards like CareCanvas to optimize preventative care, thoughtful antibiotic and opioid usage and primary-care research. There are bots that answer questions, diagnose medical conditions and give actionable recommendations. Izzy, Eva, Florence, Eliza and Molly are already here. They are multilingual, can have a friendly conversation so you don’t have to type, can remind you to take your pills, can listen (without judgment) and advise in Cognitive Behavioral Therapy and, if needed, connect you to a doctor. In fact, many people feel more comfortable being open with a bot than a human. In Japan, there are physical robots that will care for you, providing comfort and ongoing personal support.
There are bots that can look into patient medical records for rare diseases and genetic conditions, and can ensure no recommendations from guidelines are missed. There are bots that can review your cadence, your genome, your microbiome (using stool samples) and sociography (how you use social media) to diagnose medical conditions. There are algorithms that use “predictalytics” from large data sets to anticipate schizophrenic episodes or hypoglycemic attacks. The next big step is health-care kiosks that can collect health information and clinical measurements, and allow for patient self-check-in, telemonitoring and teleconsultation.
So, what’s left for the family doctor and physicians in general? As it turns out, quite a lot. According to Eric Topol, author of Deep Medicine, doctors with patterns like radiologists and pathologists may be able to shift their practice to be more patient facing. They could spend more time counselling patients on the nuances of the results and less on creating the report. Other doctors like family doctors can benefit from AI support while serving as a trusted advisor for patients. We all know we can watch a YouTube video that clearly explains how to upgrade the electrical wiring or plumbing in our homes, but in cases like these when the risk of any error is considerable, having a trusted professional to plan and guide the work allows us all to sleep easier.
- Practice-scope expansion
There is a family-doctor shortage in Canada. While initial steps are being taken to correct this, much is still to be done. It will take years to reverse course on mistakes from years past. Creating and retaining family doctors is a complex interplay between factors such as adequate training opportunities, attractive working conditions and team-based supportive practices. In the meantime, we have Band-Aids.
We have a deep respect for the knowledge base and professionalism of our colleagues on patients’ medical teams, such as pharmacists. We have observed, as you may have, ubiquitous Ontario Ministry of Health public service announcements “Don’t go down the internet rabbit hole, talk to your pharmacist (or nurse).” True, with 2 million (and climbing) Ontarians without a family doctor, many patients feel trapped in a bizarre alternate reality like the White Rabbit in Alice in Wonderland. However, there are at least three ways in which these distributed commercials oversimplify or underappreciate why the family doctor must be at the centre of patients’ medical care:
a. They are blind to the differential diagnosis
Although most red eyes are caused by something benign such as viral, allergic or bacterial conjunctivitis, some are not. Some are caused by sight threatening problems such as acute angle closure glaucoma, foreign body or other problems deep within the eye. Following the management plan for the benign problem will work just fine nine times out of 10, but sometimes it will cause harm.
b. They ignore Choosing Wisely
Choosing Wisely is a campaign designed to encourage health-care professionals to consider the value of diagnostic tests and treatments. The goal is reducing the unnecessary use of resources and avoiding unintended harms. An example of harm from a test would be wasted emotional energy worrying about a concerning result that ultimately proves to be a false positive. In the red-eye example, sometimes the best advice does not involve prescribing a medication at all.
c. They fail to consider deprescribing
Sometimes the best treatment is to get rid of medications or treatments that aren’t working or are causing harms.
There are many changes coming to the practice of medicine. New technologies and practices will disrupt how care is delivered. With thoughtful work, change will be for the better. Some doctors may feel threatened by this, but it is our belief that doctors, specifically family doctors, are more relevant than ever. As Patch Adams is believed to have asked, “At what point in history did a doctor become something more than a trusted and learned friend who visited and treated the ill?”
Humans need trusted advisors. In sickness or in health, family doctors have the privilege of serving that role, from the beginning until the end.