The first phase of the project will be a simple bookkeeping function: storing information about the patient and his treatment and displaying it on command on a teletype, or a cathode-ray tube (essentially, a TV screen), whenever the physician requests it. A hypothetical example of such a display is shown on the next page.
Here the computer is summarizing intravenous (Ringers) and oral fluid intake, urine output, and weight change over a five-day period. This achievement will not be very exciting to anyone who has not spent half an hour going through a patient's chart attempting to extract this information- which the computer can provide in milliseconds.
FLUID TOTALS INPUT: 1300 OUTPUT: 447 «T. CHANGE: +.8
YESTEBDAX 8/1/68
Bill 200/300 -/SO 60/126 81
10AM 800/600 100/160 76/200 81.6 800P
6111 100/2600 -/TOO ZOO/1200 7AM 72/2576 60/750 100/1300 FLUID TOTALS INPUT: 3325 OUTPUT: 1300
82 82 BT. CHANGE: +1
1/31/68 300(200)/3200 1/30/68 3000(-I/3000 1/89/68 4200 (100)/4300
1100 1000 900
B,P
But the second stage is rather different. It is called "computer-generated treatment regimen," and what it means is that the computer will itself advise future therapy, which the physician is free to accept or ignore.
Another hypothetical example, for a new patient admitted to the unit:
ADMISSION DATE T
05/08/69 ADMISSION TIMEN^ 11.22AM ADMITTING DOCTOR'S INITIALS… KRD PATIENT'S NAME… SMITH, JOHN BIRTH DATE… it/20/65 UNIT NUMBER… 1234567
THIS UNIT NUMBER IS ALREADY ASSIGNED.
TRY AGAIN OR USE TEMP. UNIT NUMBER… 123456 LOCATION… SBI WEIGHT (LB OR KG?)… 20 KG HT (IN OR CM?)… 110 IN/CM? CM^ BURN DATE T TIME SAM TOTAL PERCENT BURtT… 16
PERCENT 1ST DEGREE… 0
2ND DEGREE… 9^
2ND-3RD DEGREE… 27
BURN SURFACE COMPUTEoTo BE
0.27 SQ METERS TREATED PREVIOUS TO EW
ew therapy
N/S
. 0
ye? enter totals (ml) l!c~ringers… 200 plasma…? blood, urine.. 0~ vomitus
SUGGESTED INITIAL REPAIR AND MAINTENANCE 1440 ML RINGERS BEFORE 4.00 PM 05/08/69 RATE: 315 D/M PED (80 AD) 1640 ML RINGERS BEFORE 8.00 AM 05/09/69 RATE: 100 D/M PED
SUGGESTED INITIAL REPAIR AND MAINTENANCE 1440 ML RINGERS BEFORE 4.00 PM AT A RATE OF 310 D/M (PED)
1640 ML RINGERS BEFORE 8.00 AM ON 05/09/69 AT A RATE OF 100 D/M (PED)
Now this is not really so ominous. The suggestions for therapy are actually based on principles that come from John Crawford, chief of pediatrics at the Burns Unit. In essence, they represent (assuming no error in the program, and no variables that he would take into account but the machine does not) his therapeutic program were he personally treating the patient.
Thus the computer is at best as clever as a single clever man, and at worst considerably less astute than that one man.
Once in use, the MGH burns project will be analyzed by doctors, and adjustments made to refine the program. And as the program improves, it may become more and more difficult for a physician to ignore the computer's "advice."
In the future, it may be possible to have a computer monitor the patient and carry out therapy, maintaining the patient within certain limits established by physicians-or even by the computer itself.
The major consequence, indeed the avowed aim, of computer therapy in any form will be to reduce the routine work of patient care done by doctors. Other elements of that care are already disappearing; nurses have taken over several of these, and technicians have taken over others. Thus, during the week, the MGH has routine blood samples drawn by technicians and routine intravenous maintenance-starting IV lines and keeping them running-done by specially trained IV nurses. These programs were quite radical a few years ago, when doctors thought nurses constitutionally incapable of dealing with intravenous lines or drawing blood from a vein. But a startling consequence of this new specialization of nonphysician health personnel has been better care, in certain areas, than the physician himself could deliver. Even if doctors don't believe this, the patients know it well. On weekends, when the IV nurses and the blood technicians are off duty, the patients complain bitterly that the physicians are not as skilled in these tasks.
As for the special skills still reserved to physicians, such as lumbar punctures and thoracic and abdominal taps, it is only a matter of time before someone discovers that these, too, can be effectively delegated to other personnel.
It would thus appear that all the functions of a doctor are being taken over either by other people or by machines. What will be left to the doctor of the future?
Almost certainly he will begin to move in one of two directions. The first is clearly toward full-time research. The last fifteen years have seen a striking increase in the number of hospital-based physicians and the number of doctors conducting research in governmental agencies. This trend will almost surely continue.
A second direction will be away from science toward the "art" of medicine-the complex, very human problems of helping people adjust to disease processes; for there will always be a gap between the illnesses medicine faces and science's limitations in treating them. And there will always be a need for people to bridge that gap.
Physicians moving in either direction will be helped by a new freedom from the details of patient care; and physicians now emotionally attached to those details, such as those doctors who religiously insist on doing their own lab work, are mistaking the nature of their trade. Almost invariably, they would do better spending their time talking with the patient, and letting somebody else look at the blood and urine or count the cells in the spinal fluid-especially if that person (or machine) can work more rapidly and accurately than the physician himself.
One can argue that this presages a split among physicians, between those with a scientific, research orientation, and those with a behavioral, almost psychiatric, orientation. That split has already begun and some bemoan it. But, in reality, art and science have rarely merged well in a single individual. It is said that Einstein would have starved as a cellist, and it is certainly true that the number of doctors in recent years who have been both superb clinicians and excellent laboratory researchers is really quite small. Such men certainly can be found, and they are always impressive-but they are distinctly in the minority. In fact, the modern notion that the average physician is a practitioner of both art and science is at best a charming myth, at worst a serious occupational delusion.
In the final analysis, what does all this mean for the hospital and for the patient in the hospital? One may look at the short-term possibilities, as represented by the burns treatment program.
It will reduce the mundane work of ward personnel, both doctors and nurses, and leave them more time to spend with the patient. For doctors, it should mean more time for research as well. And for the patient, that should ultimately be a good thing.
Furthermore, as an extension of the hospital, a computer program offers quite extraordinary possibilities. Any hospital in the country-or even any doctor's office-could utilize the program, by using existing telephone lines. A community hospital could plug into the MGH program and let the computer monitor the patient and direct therapy. As a way to utilize the innovative capability of the hospital, and its vast resources of complex medical information, this must surely represent a logical step in 2,500 years of evolution. And for the patient, that, too, should ultimately be a good thing.