What Data-Driven Corporate Medicine Has Wrought
There is a woodcut you have probably seen, done in a late-Medieval style, depicting a young man sticking his head through the starry sphere and gazing, amazed, at the machinery of the Universe. This is how I feel when I read history. Like the shepherd in the woodcut, we inhabit history without grasping it. Even when we glimpse its workings, it takes a historian to make sense of what Terry we see.
I was reminded of this by a story a younger, computer-savvy doctor told me last year, about a time he caught a glimpse of the primum mobile of his world—and realized later that he had entirely missed its significance. The hospital where he works had adopted a new electronic medical record. Despite the description, the program wasn’t primarily a medical record. It was billing software, designed to massage medical information in ways that would yield the highest returns.
Neither of us was scandalized about this. It’s hard to blame a hospital for trying to get paid. What did scandalize my friend was when he found that with the right sequence of clicks this new program could display something called the “performance characteristics” of every one of his colleagues, listing (among other things) how long it took them to sign off on their progress notes. Many of his colleagues, like himself, he admitted, tended to be a little late.
Let me explain: to many doctors, chartwork is drudgery. Patients come first. To hospitals, progress notes are the quantum unit of production, what a hospital must have in order to bill an insurer. The kind of procrastination we were discussing was human enough, just the ancient push-pull between employer and employee. Seeing that procrastination laid out and anatomized for everyone to see: that felt a little scandalous—an indecent airing of private sins, probably a glitch in the program, but really nothing more.
But it was more than that: “I realized later that data represented the performance characteristics of everyone in the hospital down to the slightest detail. Suddenly we were all working for the machine.” What my friend had seen was more than an intrusive glimpse into his colleagues’ peccadilloes: it turned out to be the first stirrings of a vast machinery that was about to change his world. The quantity of data the machine could collect, the high-resolution analysis it enabled of the physician’s every minute, had shifted the balance. Blind to what might actually be going on within those minutes (where the doctor and patient might be discussing, say, a newfound cancer), the hospital focused simply on measuring them, dictating what care doctors could provide based on metrics and not on individual human needs. “It’s not like we didn’t have to meet standards before this,” my friend concluded sadly. “It’s just that they’re able to police us now so very, very closely.”
Blind to what might actually be going on within those minutes (where the doctor and patient might be discussing, say, a newfound cancer), the hospital focused simply on measuring them.
I thought about that woodcut, and that conversation, when I read the new second edition of Paul Starr’s The Social Transformation of American Medicine. Starr’s brilliantly incisive history charts the rise of medicine as a “sovereign profession,” one that, over the course of the 19th and 20th centuries, acquired the power and prestige to put itself above many of the forces constraining the rest of us in our daily lives.
The most concise picture I can conjure of the sovereignty Starr sketches would be the romanticized antics of Hawkeye and Pierce in M*A*S*H. Set at the apogee of the profession’s influence, the film and later television series suggest how doctors were exempt from most forms of institutional discipline. They bowed to their licensing boards and their draft boards, and that was it. Beyond that, according to Starr, American doctors could determine whom they saluted, whom they cared for, what they got paid, and how.
In the 2017 second edition, Starr adds an epilogue declaring the end of that sovereignty. He charts its decline and fall, largely under the weight of the insurance companies (government and private): Medicare, HMOs, and the Blues. But the story has continued past this epilogue. Events move so quickly now. We might read the final chapter of that fall written not on bureaucratic quadruplicate, but in binary: the transformation of medicine, through digital technologies, into a panopticon, in which the doctor becomes another worker, no more sovereign than any other cubicle-dweller, one more element in a system striving toward optimization of outcomes. That was what my friend had glimpsed, that day he peered into the works of the electronic medical record. Thanks to Starr, I’m beginning to understand what his story means—not just to one physician, but to all of us, doctor and patient alike.
If we are not inclined to sympathize too much with doctors in their loss of sovereignty—they remain, after all, well-paid cogs in the machine—the means by which the profession fell, and the forces that made those means so powerful, nevertheless affect us all. The world moves quickly, but this feels like a familiar story already: through information technology, capital amasses new forms of value to itself—forms composed of bits of information about everybody—and deploys this new wealth to shape the world to its advantage. Information technology enables corporations to squeeze the last quantum of value out of the resources—chiefly human—at hand. The medical profession has fallen into the same mill grinding up everybody in our era, in a world in which everything can be monetized, down to the smallest fragments of our lives.
Committed doctors will still find ways to give time to their patients, even beneath the full weight of the corporations’ pressure to “perform.”
In choosing to view physician “performance” (defined God knows how, but unlikely in a way that has anything to do with patients’ well-being) as a resource no different from any other commodity, the corporations now marketing health care to the public have given doctors reason to worry about who those corporations imagine should command physician loyalty. It’s hard to picture this disrupted world as one where the patient is supposed to claim the doctor’s allegiance. If the doctor-patient “encounter” is imagined as a line in accounts receivable, that makes it much harder for it to be honored as an episode in a relationship. What new chapter we are about to open in the history of medicine is difficult to foresee. But I wonder as well if the digital panopticon is really the end of the story.
The panopticon is never as perfect as the individual fears—or the corporation wishes—it to be. Orwell understood this, and this is why he gave Winston Smith his oddly shaped apartment, where—out of view of Big Brother’s all-seeing eye—he still could make his own moral choices. Committed doctors will still find ways to give time to their patients, even beneath the full weight of the corporations’ pressure to “perform.” They do so everyday because the structures of knowledge and power we inhabit are everywhere full of gaps.
Consider that woodcut, and its curious, daring shepherd breaking through the scrim that hides the workings of his world. And consider as well the most important fact about that woodcut. It’s a fake, not Medieval at all, but the work (most probably) of Camille Flammarion, the popularizer of science who first published it in the late 19th century. Most probably. No matter how complete we think our understanding—and in this I include also the corporations in their deployment of Big Data’s all-seeing eye—there are always gaps, fundamental flaws in the way we have framed the situation, things we have taken as fact that turn out, on examination, to be anything but—misprisions and misrepresentations suggesting the ultimate vulnerability of structures built on an unquestioning faith in the power of data. Compelling social histories like Starr’s help us see that the machine isn’t always what it presents itself to be.
