at a time like this you want to talk about me
WHY DO YOU THINK I WANT TO TALK ABOUT YOU
because you share my feelings about that damned computer
WHAT DOES THAT SUGGEST TO YOU
that, of course, you hate computers too
YOU THINK I HATE COMPUTERS TOO
why not, they're hardly human, are they
PERHAPS THAT'S WHAT WE ARE HERE TO FIND OUT
no computer could converse as you can, for example
OH
i can't understand how anyone could be fooled by a mere machine
CAN'T YOU REALLY
no, after all, there is nothing creative about a computer program
YOU ARE BEING NEGATIVE
i am convinced i am correct
ARE YOU WORRIED TO HAVE BEEN CONVINCED YOU ARE CORRECT
no, not in the least, not at all. not even a little
YOU ARE BEING NEGATIVE
you said you agreed with me, didn't you
IS THAT WHAT YOU HEARD ME SAY
why don't you try to dissuade me - computers diddle with numbers that 'sail
YOU WISH ME TO TRY TO DISSUADE YOU
you can't
YOU THINK I CAN'T
for example, could a computer in conversation like this raise a new topi c
YOU SEEM TO HAVE AVOIDED SPEAKING OF YOUR PARENTS ALTOGETHER
precisely as you just did YOU THINK I JUST DID
yes, and that's what shows the difference between a man and a computer
I SEE
This kind of interaction is suggestive, at least, of the ways computers can be utilized in the future. And as the hospital reaches out into the community, these may be increasingly important. According to Jerome Grossman of the MGH Computer Sciences Laboratory, "A large part of history-taking is directed toward finding out how sick a person really is. The first question is always whether a patient needs to see a doctor at all. That's the biggest decision doctors make over the phone now-talking to the patients, trying to decide whether they're sick enough to be seen now, or whether it can wait. The patients want to know the same thing, so they spend all night or all weekend trying to get hold of the doctor, who's off duty, or out of town, or something…
"In the near future, when the home computer and television set is practical, you're going to be able to plug right into the hospital computer without ever leaving your home. The computer will flash questions on the screen, like 'Do you have a cough?' and you answer by touching the screen with your finger at the appropriate place. We've just developed a screen like this. It doesn't require any special gadgets or light pens or anything, just your finger. Touch the screen, and the information is recorded. Eventually, the computer will flash back some directions, like 'Come to the hospital immediately' or 'Call your doctor in the morning' or 'Have a check-up within six weeks,' or 'Someone will come on the screen, if further classification is necessary.' So there you have it. That first big decision-who needs to be seen-is settled by the computer, without ever having required the doctor's presence."
The idea is interesting not because it is an imminent practical development-it is not [What is imminent is the use of computer stations to take a portion of routine history and to advise the doctor on further tests. Such consoles are already in use experimentally in the MGH medical clinics and in certain private doctors' offices] -but rather that it represents a further extension of the hospital into the community-not only into clinics via TV, but into the homes of many individuals, via computer. One can argue, in fact, that those who predict the hospital's role as "primary physician" or "first-contact physician" is declining are wrong. It will, ultimately, increase with the use of computers.
Automated diagnosis is one thing; automated therapy, quite another. It is probably fair to say it is feared equally by both patients and physicians. It is also important to state firmly that the following discussion is largely speculative; automated diagnosis is in its infancy, but automated therapy has hardly been conceived. Its modern forerunners are the monitoring systems that check vital signs and the electrocardiogram. These monitors are not computers at all, in any real sense; they are just mechanical watchdogs, about as sophisticated as a burglar alarm.
At the present time, there are serious problems facing anyone who wishes to automate the therapy of even a circumscribed class or category of patient. To automate the therapy of all patients, with the full spectrum of disease, would be an enormous undertaking. Whether or not it is done will depend largely upon the demand for it, which in turn depends upon the availability of physicians. In assuming that it will be done, at least to some extent, I have also assumed that the shortage of physicians in this country will increase in the foreseeable future, necessitating a practical change in the doctor's functions.
Partially automated therapy is already desirable. The reasons are twofold. First, modern therapy makes necessary an enormous amount of paperwork; one hospital study concluded that 25 per cent of the hospital budget was devoted to information processing. The usual hospital systems for collecting, filing, and retrieving information consume great quantities of time for nearly everyone working in the hospital, from the physician who must spend time thumbing through the chart, to the nurses who must record routine data, to the personnel who work full time in the chart-record storage rooms. One consequence of the present methods, aside from the expense, is the number of
errors that occur at various points along the line. And the possible advantage of putting all data through computers is the ability to check errors. For instance, if medications are ordered by the physician through a computer, that computer can tirelessly review orders for drug incompatibilities, inappropriate dosages, and so on.
The second reason comes from experience with present monitors in intensive-care units. These monitors "watch" the patient more carefully than any group of physicians could; the patient's condition is sampled continuously, rather than just during rounds. Such monitoring has already changed many ideas about the nature of disease processes [One example: the incidence of cardiac arrhythmia following myocardial infarction is now suspected to be virtually 100 per cent; it is thus an almost certain consequence of heart attack- this is useful information since the arrhythmia are the most common cause of sudden early death from heart attack.] and it has renewed consideration of therapy at intervals. For example, most drugs are now given every six hours, or every four hours, or on some other schedule. But why not continuously, in an appropriate dose? And in that case, why not have a machine that can correct therapy on the basis of changes in the patient's condition?
Seen in this light, automated therapy becomes a more reasonable prospect. It will require adjustment, of course, by both doctors and patients. But that adjustment will be no more severe than in other sectors of society.
In the past fifty years, society has had to adapt to machines that do mechanical work-in essence, taking over functions of the musculoskeletal system. It is now quite accepted that almost nobody does anything "by hand" or "on foot," except for sport or pleasure. But what is coming is what Gerard Piel calls "the disemployment of the nervous system," in a manner comparable to the disemployment of the musculoskeletal system. Man has accepted the fact that there are machines superior to his body; he must now accept the fact that there are machines in many ways superior to his brain.
The image of the patient, lying alone in bed, surrounded by clicking, whirring stainless steel is certainly unnerving. It is easy to agree with the doctors who fear automation as leading to depersonalized care, and the computer, as psychologist George Miller notes, as "synonymous with mechanical depersonalization." But that is probably because we are so unfamiliar with them, and, in any event, man has found ways to personalize machines in the past-the automobile is a baroque example-and there is no reason to think he cannot do it in the future.