Digital doctors

Sir William Osler, arguably the greatest physician of the 20th century, said this about being one’s own doctor: “A physician who treats himself has a fool for a patient.” The idea that the digital revolution in medicine will allow patients to manage their own medical care is naive (“Doctor You”, February 3rd).

Doctors and surgeons devote seven or more years of their lives acquiring the knowledge, judgment and experience that allows them to be qualified to care for patients. In fact it takes all these years to be able to do just three things: make a correct diagnosis, arrive at a prognosis and apply the correct treatment. Your presumption that, without medical training and experience, anyone can play app roulette, surf the net and become his own doctor, is folly.

FREDERICK HOLMES
Professor emeritus of medicine
University of Kansas Medical Centre
Kansas City, Kansas

The root cause that explains why IT has failed to transform the delivery of medical care is the information “disorder” deeply embedded within mainstream medical practice and in new alternatives to that mainstream. The only remedy is to define generally accepted standards of care for managing clinical information (patient data and medical knowledge). These standards are missing from medicine. As a rough analogy, imagine an economy operating without broad-based accounting principles for financial information. The effects would be crippling. That is where the health-care industry is now.

Medical records have always been plagued by disorder, both paper and electronic. To bring order, support tools that aid clinical decisions should be designed to identify the required patient data and couple that data with medical knowledge, rather than being based on algorithmic and probabilistic standards.

LINCOLN WEED
Underhill, Vermont

H.L. Mencken once said, “For every complex problem there is an answer that is clear, simple, and wrong.” Medical apps help people who are mostly young and mostly well and who want to consult a doctor quickly. They exclude those who suffer a greater burden of ill health. Simple IT answers exist at the expense of the more complex and expensive patients who must continue to rely on their traditional general practices for health care. Those practices will have less income if they lose young, healthy patients to apps, but will have to do more work caring for the complex cases.

The research evidence does not suggest that this new service results in better access or better quality care with fewer costs. Doctors want innovations that will improve the workload and workforce crisis in the National Health Service, rather than fake innovations that make the crisis worse.

TERRY KEMPLE
Former president
Royal College of General Practitioners
Bristol

“Doctor You”? A catchy phrase for your leader, but it would be better if we had a movement based on “Doctor with You”.

DAVID CUMBERLAND
Kuala Lumpur

* The concept you praised in your leader on digital health includes one danger: the dilution of medical responsibility. Sharing medical data with the patient is a basic civil right, it’s no wonder that Sweden is the first country to legislate it. But at the end of every medical process, there is a decision to be taken regarding the best course of action. The patient lacks the medical education and the accumulated medical experience to make such decision. His doctor has.

Transferring the burden of medical decision to the patient and his or her family may be comfortable for healthcare providers and even to the medical team, but it is wrong, both morally and professionally. The patient should only have one decision to make: which doctor does he or she trusts.

EPHRAIM SNEH
Former Israeli minister of health
Herzliya, Israel

* I am a retired doctor, and share your enthusiasm for the potential impact of digital technology on medical practice. However, new technology will only be successful if it enhances rather than diminishes our experience with the health system. A worried friend of mine recently asked me to interpret a section of the report he got back from a brain scan. Fortunately, the section of the report that caused him concern referred to age-related changes, not a tumor. Reading results that suggest abnormal pathology can be frightening. Patients should get access to their medical records, but they should first be discussed with a medical professional.

BARRY PERLMAN
New York

* Lost in the technological babble is the central pillar of medicine: the interaction between doctor and patient. When my health-care provider introduced medical software years ago I immediately experienced a jarring change. The doctor no longer faced me in the examination room. He sat at a computer desk with his hands on the keyboard, mostly looking at the screen when asking me questions. Elsewhere in the hospital, nurses would frequently come into the room and go to the computer without a glance at the patient. It was obvious that these health-care professionals were now accountable for filling in the blanks in the software at the expense of interacting with the patient. If data could create more genuine doctor/patient time instead of eroding it, that would be the magic bullet.
LYMAN LYONS
McFarland, Wisconsin

Europe’s migrant crisis

Although Charlemagne touched on some criticisms of Italy’s intervention in Libya’s migrant crisis, they were swiftly brushed under a carpet threaded with niceties about Marco Minniti, the Italian interior minister (February 3rd). Organisations such as Amnesty International do not “hate” Mr Minniti. Rather, many of us are deeply troubled by the effect of his policies. Italian and European co-operation with Libya means that tens of thousands of people are trapped in a country where they face horrific human-rights violations.

The Libyan government is refusing to take the steps necessary to overhaul its rotten migration-management system. These steps must include ending the detention and abuse of refugees and migrants and recognising the status of the UN. The fact that Mr Minniti and his fellow European ministers of interior are not making their assistance to Libya conditional upon such measures speaks volumes about their priorities. It also makes such co-operation unlawful. We should focus on resettling refugees out of Libya and bringing stability to a divided country. Europe must do much more to protect the women, men and children trapped in Libya. By closing its doors it is abandoning them to a wretched future.

MATTEO DE BELLIS
Amnesty International
London

Gun demographics

How many more?” (February 17th) stated that the shooting at the Marjory Stoneman Douglas school in Florida “was merely America’s 18th school shooting this year”. To many people that might sound like it was the 18th where someone killed, or tried to kill, students. In fact, the figure of 18 comes from an anti-gun group and counts any incident where a gun was fired on or near school property, including accidental discharges and one incident where a veteran with PTSD shot himself in a school’s parking lot when the school was closed.

MICHAEL BEARD
Portland, Oregon

It is unlikely that a generation raised on lockdown drills, with access to phone footage of gun rampages and a waning interest in hunting, will grow up parroting the National Rifle Association’s rhetoric as enthusiastically as today’s political leaders. Change is coming.

JOAN MAHER
West Bradford, Pennsylvania

An Olympic effort

One issue that remains taboo when it comes to doping in sport (“Whatever it takes”, February 10th) is the use of criminal sentences to combat it. The traffickers of the banned substances are punished, but in most countries the athletes face no criminal charges. This is unfair. In October 2015 the World Anti-Doping Agency issued a statement opposing the criminalisation of doping in sport. One of its reasons was that the system of sanctions, including the right to appeal to the Court of Arbitration for Sport, is sufficient. Well, obviously, it is not.

OLEKSANDR OVCHYNNYKOV
Strasbourg

Another way to fight doping in addition to the ones you listed is retesting. This allows for the storing of blood or urine samples taken from athletes who are tested in order to retest it once detection methods have improved. The deterrent effect is that a doped athlete takes the risk that his result will be disqualified long after his performance at the Olympics, or any other tournament he competes in, up to two years after the sample was collected.

SARKIS HOMBERGER
Geneva

A government in distress

A little over a year ago you nicknamed the British prime minister “Theresa Maybe” (January 7th 2017). After her subsequent disasters, I think a more apt moniker would be Theresa Mayday (“A sea of troubles”, February 3rd).

JAVIER SEMPERE
Madrid


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