Google Is My New Hippocampus

August 6, 2011

A few days ago, upon awakening but before my brain was fully alert, I was reviewing the events of the previous few days in preparation for the new one.  At one point I tried to remember a conversation I had had with a colleague about three days prior, but I could not quite remember the specifics of our discussion.  “No big deal,” I thought to myself, “I’ll just Google it.”

Almost immediately, I recognized the folly of this thought.  Obviously, there is no way to “Google” the events of our personal lives.  But while impractical, the solution was a logical one.  If I want to know any fact or piece of information, I Google it online.  If I want to find a file on my computer, I use Google Desktop.  All of my email conversations for the last five years are archived in my Google Mail account, so I can quickly find correspondence (and people, and account numbers, and emailed passwords, etc) at the click of the “Search” button.  No wonder I immediately thought of Googling myself.

A recent article in Science claims that the permeation of Google and other search engines into our lives—and now onto our smartphones and other portable gadgets—has not only made it easier for us to retrieve information, but it has also changed the way we remember.  In their experiments, three cognitive psychologists from Columbia, Harvard, and UW-Madison demonstrated that we are more likely to forget information if we know that we can access it (e.g., by a search engine) in the future.  Moreover, even for simple data, we’re more likely to remember where we store pieces of information than the subject matter itself.

The implication here is that the process of memory storage & retrieval is rapidly changing in the Online Age.  Humans no longer need to memorize anything (who was the 18th president?  What’s the capital of Australia?  When was the Six-Day War?), but instead just need to know how to access it.

Is this simply a variation of the old statement that “intelligence is not necessarily knowing everything but instead where to find it”?  Perhaps.  An optimist might look at this evolution in human memory as presenting an opportunity to use more brain power for processing complex pieces of information that can’t be readily stored.  In my work, for instance, I’m glad I don’t need to recall precise drug mechanisms, drug-drug interactions, or specific diagnostic criteria (I can look them up quite easily), but can instead spend pay closer attention to the process of listening to my patients and attending to more subtle concerns.  (Which often does more good in the long run anyway.)

The difference, however, is that I was trained in an era in which I did have to memorize all of this information without the advantage of an external online memory bank.  Along the way, I was able to make my own connections among sets of seemingly unrelated facts.  I was able to weed out those that were irrelevant, and retain those that truly made a difference in my daily work.  This resulted, in my opinion, in a much richer understanding of my field.

While I’ve seen no studies of this issue, I wonder whether students in medicine (or, for that matter, other fields requiring mastery of a large body of information) are developing different sets of skills in the Google Era.  Knowing that one can always “look something up” might make a student more careless or lazy.  On the other hand, it might help one to develop a whole new set of clinical skills that previous generations simply didn’t have time for.

Unfortunately, those skills are not the things that are rewarded in our day-to-day work.    We value information and facts, rather than substance and process.  In general, patients want to know drug doses, mechanisms, and side effects, rather than developing a “therapeutic relationship” with their doctor.  Third-party payers don’t care about the insights or breakthroughs that might happen during therapy, but instead that the proper diagnoses and billing codes are given, and that patients improve on some objective measurement.  And when my charts are reviewed by an auditor (or a lawyer), what matters is not the quality of the doctor-patient interaction, but instead the documentation, the informed consent, the checklists, the precise drug dosing, details in the treatment plan, and so on.

I think immediate access to information is a wonderful thing.  Perhaps I rely on it too much.  (My fiancé has already reprimanded me for looking up actors or plot twists on IMDB while we’re watching movies.)  But now that we know it’s changing the way we store information and—I don’t think this is too much of a stretch—the way we think, we should look for ways to use information more efficiently, creatively, and productively.  The human brain has immense potential; now that our collective memories are external (and our likelihood of forgetting is essentially nil), let’s tap that potential do some special and unique things that computers can’t do.  Yet.


The Virtual Clinic Is Open And Ready For Business

July 9, 2011

Being an expert clinician requires mastery of an immense body of knowledge, aptitude in physical examination and differential diagnosis, and an ability to assimilate all information about a patient in order to institute the most appropriate and effective treatment.

Unfortunately, in many practice settings these days, such expertise is not highly valued.  In fact, these age-old skills are being shoved to the side in favor of more expedient, “checklist”-type medicine, often done by non-skilled providers or in a hurried fashion.  If the “ideal” doctor’s visit is a four-course meal at a highly rated restaurant, today’s medical appointments are more like dining at the Olive Garden, if not McDonald’s or Burger King.

At the rate we’re going, it’s only a matter of time before medical care becomes available for take-out or delivery.  Instead of a comprehensive evaluation, your visit may be an online questionnaire followed by the shipment of your medications directly to your door.

Well, that time is now.  Enter “Virtuwell.”

The Virtuwell web site describes itself as “the simplest and most convenient way to solve the most common medical conditions that can get in the way of your busy life.”  It is, quite simply, an online site where (for the low cost of $40) you can answer a few questions about your symptoms and get a “customized Treatment Plan” reviewed and written by a nurse practitioner.  If necessary, you’ll also get a prescription written to your pharmacy.  No appointments, no waiting, no insurance hassles.  And no embarrassing hospital gowns.

As you might expect, some doctors are upset at what they perceive as a travesty of our profession.  (For example, some comments posted on an online discussion group for MDs: “the public will have to learn the hard way that you get what you pay for”; “they have no idea what they don’t know—order a bunch of tests and antibiotics and call it ‘treated'”; and “I think this is horrible and totally undermines our profession.”)  But then again, isn’t this what we have been doing for quite a while already?  Isn’t this what a lot of medicine has become, with retail clinics, “doc-in-a-box” offices in major shopping centers, urgent-care walk-in sites, 15-minute office visits, and managed care?

When I worked in community mental health, I know that some of my fellow MDs saw 30-40 patients per day, and their interviews may just as well have been done over the telephone or online.  It wasn’t ideal, but most patients did just fine, and few complained about it.  (Well, if they did, their complaints carried very little weight, sadly.)  Maybe it’s true that much of what we do does not require 8+ years of specialty education and the immense knowledge that most physicians possess, and many conditions are fairly easy to treat.  Virtuwell is simply capitalizing on that reality.

With the advent of social media, the internet, and services like Virtuwell, the role of the doctor will further be called into question, and new ways of delivering medical care will develop.  For example, this week also saw the introduction of the “Skin Scan,” an iPhone app which allows you to follow the growth of your moles and uses a “proprietary algorithm” to determine whether they’re malignant.  Good idea?  If it saves you from a diagnosis of melanoma, I think the answer is yes.

In psychiatry—a specialty in which treatment decisions are largely based on what the patient says, rather than a physical exam finding—the implications of web-based “office visits” are particularly significant.  It’s not too much of a stretch to envision an HMO providing online evaluations for patients with straightforward complaints of depression or anxiety or ADHD-like symptoms, or even a pharmaceutical company selling its drugs directly to patients based on an online “mood questionnaire.”  Sure, there might be some issues with state Medical Boards or the DEA, but nothing that a little political pressure couldn’t fix.  Would this represent a decline in patient care, or would it simply be business as usual?  Perhaps it would backfire, and prove that a face-to-face visit with a psychiatrist is a vital ingredient in the mental well-being of our patients.  Or it might demonstrate that we simply get in the way.

These are questions we must consider for the future of this field, as in all of medicine.  One might argue that psychiatry is particularly well positioned to adapt to these changes in health care delivery systems, since so many of the conditions we treat are influenced and defined (for better or for worse) by the very cultural and societal trends that lead our patients to seek help in these new ways.

The bottom line is, we can’t just stubbornly stand by outdated notions of psychiatric care (or, for that matter, by our notions of “disease” and “treatment”), because cultural influences are already changing what it means to be healthy or sick, and the ways in which our patients get better.  To stay relevant, we need to embrace sites like Virtuwell, and use these new technologies when we can.  When we cannot, we must demonstrate why, and prove how we can do better.

[Credit goes to Neuroskeptic for the computer-screen psychiatrist.  Classic!]


Is Weiner Really Such A Bad Guy?

June 25, 2011

I don’t use this blog as a platform for political opinions or broad social commentary, but the Anthony Weiner “sexting” fiasco has raised some issues in my mind.  And I guess, in a roundabout way, it actually does pertain to psychiatry and medicine, so I figured I’d share these thoughts.

Unless you’ve been exiled to the Gulag for the last month, you probably know that Weiner, a Democratic New York congressman, was forced to resign from his post after the outcry over lewd photographs he sent to women from his Twitter account.  He left his office in disgrace and is apparently entering rehab.  (Maybe I’ll write about the wisdom of that move in a different post.)

The thing is, Weiner was a generally well-liked Congressman and was reportedly a leading candidate to run for mayor of New York in 2013.    He had many supporters and, until the “Weinergate” scandal broke, was seen as a very capable politican.  One might argue, in fact, that his sexual exploits had no effect on his ability to legislate, despite the vociferous (and at times rabid) barbs levied upon him by pundits and critics after the scandal became public.

Now, don’t get me wrong.  I am not condoning his behavior.  I am not saying that we should ignore it because “he’s otherwise a good guy.”  In no way should we turn a blind eye to something that shows such poor taste, a profound lack of judgment, and a disregard for his relationship with his wife.

But does it require the sudden unraveling of an entire political career?  Weiner has done some bad things.  But do they make him a bad congressman?

Some of the same questions arose during the recent flurry of stories about doctors who speak for drug companies.  As ProPublica has written in its “Dollars for Docs” series, some doctors have earned tens of thousands of dollars speaking on behalf of companies when they are also expected to be fair and unbiased in their assessment of patients, or in their analysis and presentation of data from clinical trials.

This is, in my opinion, a clear conflict of interest.  However, some of the articles went one step further and pointed out that many of those doctors have been disciplined by their respective Medical Boards, or have had other blemishes on their record.  Are these conflicts of interest?  No.  To me, it seems more like muckraking.  It’s further ammunition with which critics can attack Big Pharma and the “bad” doctors who carry out its dirty work.

Now I don’t mean to say that every sin or transgression should be ignored.  If one of those doctors had been disciplined for excessive or inappropriate prescribing, or for prescription fraud, or for questionable business practices, then I can see why it might be an issue worthy of concern.  But to paint all these doctors with a broad stroke and malign them even further because of past disciplinary action (and not simply on the basis of the rather obvious financial conflicts of interest), seems unfair.

The bottom line is, sometimes good people do bad things.  And unfortunately, even when those “bad things” are unrelated to the business at hand, we sometimes ruin lives and careers in our attempts to exact justice.  Whatever happened to rehabilitation and recovery?  A second chance?  Can we evaluate doctors (and politicians) by the quality of their work and their potential current conflicts, rather than something they did ten or twenty years ago?

(By the way, there are some bad—i.e., uninformed, irresponsible—doctors out there who have no disciplinary actions and no relationships with pharmaceutical companies.  Where are the journalists and patient-advocacy groups looking into their malfeasance?)

In our society, we are quick to judge—particularly those in positions of great power and responsibility.  And those judgments stick.  They become a lens through which we see a person, and those lenses rarely come off, regardless of how hard that person has worked to overcome those characterizations.  Ask any recovered alcoholic or drug addict.  Ask any ex-felon who has cleaned up his act.  Ask any “impaired professional.”  (In the interest of full disclosure, I am one of those professionals, whose “impairments” stemmed from a longstanding mental illness [now in remission] and affected none of my patients or colleagues, but which have introduced significant obstacles to my employability for the last five years.)  And ask any politician who has had to surrender an office due to a personal failing like Weiner’s.

Come to think of it, ask any patient who has been given a psychiatric diagnosis and whose words and actions will be interpreted by her friends, family,  doctors, or boss as part of her “borderline personality” or “bipolar” or “psychosis.”  It’s hard to live that down.

When evaluations matter, we should strive to judge people by the criteria that count, instead of the criteria that strengthen our biases, confirm our misconceptions, and polarize us further.  If we are able to do so, we may make it easier for people to recover and emerge even stronger after making mistakes or missteps in their lives.  We also might get along with each other just a little better.


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