Jill LePore: Robots, Creative Disruption and the Global Economy

Maria New, MD

"Every age has a theory of rising and falling, o f growth and decay, of bloom and wilt. Every age has a theory of about the past and the present, of what was and what is,  a notion of time, a theory of history.
   Disruptive innovation as a theory of change is meant to serve both as a chronicle of the past and as a model for the future."
    --Jill Lepore The New Yorker, June 23, 2014. 

In the end, Lepore says "disruptive innovation" is blind to continuity, and fails as  a prophet. 

In his New York Times piece, "Fear Not the Coming of the Robots" Steven Rattner, argues the innovations in technology since the industrial revolution have displaced people, eliminated jobs, but the overall effect of putting telephone operators, typists, travel agents, gas station attendants and elevator operators out of work has been good because it has occurred in the setting of allowing consumers to do all these jobs themselves, better, faster and with little or no expense.

All this makes the Phantom look around his own world of physicians and surgeons and see the changes and wonder which are for the better and which are not.  Surgeons who grasped the importance of laporoscopic surgery by which a gall bladder or a colon can be removed through the use of fiber optic instruments through 4 puncture holes rather than through long incisions through layers of fat, muscle and peritoneum found themselves busier than ever, while those who cleaved to the notion that a beautifully done dissection down to a gall bladder is as much a work of art as a medical procedure, found themselves out of work.  This may be heartless, but it is progress.

On the other hand, the entry of women who are mothers into a profession has changed things, disrupting the value system which placed the patient first.  This system once valued self sacrifice, putting the patient ahead of your own needs, ahead of the needs of your family.  Now, doctors do not apologize for telling a patient they have to leave now, to take their children to the lake for the weekend. Someone who doesn't know you will take the next shift. I limit my commitment to your care. My kids come first.

And then there is the judgment about what it means to be good or to be the best. We are always told America has the world's best medical care. But the Phantom is currently skulking about the international meeting of 10,000 endocrinologists and he was stunned by the presentation of an Italian who showed videos of procedures using ultrasound to inject metastases from thyroid cancer, and successfully treat patients without surgery in the office. When an American asked, from the audience, if the Italian had any thoughts on why American doctors were so far behind  the Europeans in this area, the Italian shrugged, thought for a moment, likely considered the politics of his conjecture and finally said, "Well, you Americans do not have a national health system. We have only to show this procedure works, that it saves the system money and it is good for the patients and we get approval.  The primary consideration is what is good medicine. Here, it's always about who makes the profit."

Then, consider Maria New.  Dr. New is now in her late 80's. When she was in her late 30's she saw children at Cornell Medical school who had been born with "ambiguous genitalia."  A girl would have a clitoris so enlarged, it looked like a penis and her labia were almost fused. Dr. New suspected these girls had been exposed to high levels of male hormone in utero and she had a steroid lab at her disposal to test the blood of these girls and she quickly figured out the biochemistry.  In stages, with advances in technology, she was able to make the diagnosis and define the biochemistry in each patient within a week of birth, then on the day of birth, then months before birth, but only recently has technology allowed the identification of this problem in utero by simply drawing blood from the mother, and this can now be done so early in pregnancy, the problem can be prevented by treating mothers of affected daughters with simple medication--but only if you know the daughter  in utero has that diagnosis.

The problem for Dr. New is, the equipment needed to detect this disease, to allow treatment, costs almost half a million dollars and she cannot get a grant to do this.  Fortunately, an academic in Hong Kong offered to collaborate with her. He had the machine; she had the patients. 

She has to send her patients' blood from New York, by courier, to Hong Kong, where the studies are done within 24 hours.  She visited Oman, where they have two such machines in the hospital still in the boxes, unopened because they do not have a doctor in Oman who knows how to use them.  In New York City, Dr. New can only fill out forms and hope for fortune to smile upon her.

This is where we have come from the globalization of medicine, the aggrandizement of the  for profit motive in American medicine and the refusal of Americans to risk their best medicine in the world fora system of national health.

We have had disruptive innovation in American medicine and the results are decidedly mixed.  We are seeing advances, but they are coming from abroad. That is new. But is it progress?