The Doctor Who Wasn't There: Technology, History, and the Limits of Telehealth

The Doctor Who Wasn't There: Technology, History, and the Limits of Telehealth

Jeremy A. Greene

University of Chicago Press, 2022

In The Doctor Who Wasn't There: Technology, History, and the Limits of Telehealth, Jeremy A. Greene takes us on a journey of technological innovations in medicine. Specifically, that of what he calls “communication technologies,” from the late 19th through the early 21st centuries. His thesis, that these innovations must be viewed within their political, social, and economic terroirs, is laid out in temporal sequence. From the telephone to the radio, then television, and finally mainframe computing, the paths of successes and failures are laid out in this succinct and easily read history.

The women and men who fostered innovation figure prominently in this tale, as a reminder that it is humans who drive change. For Greene, “the medium of care is what we demand it must be”, (p. 252) and successes and failures hinge on the favorable coalescence of political will, finances, and professional support. In addition, for the patients and their providers, “who gained and who lost power in this exchange was determined….by a series of conscious decisions…” (p. 108). Corporate device firms, and the “medical-industrial complex,” as Arnold Relman, the former Editor-in-Chief of the New England Journal of Medicine called it (p. 230) are touched on throughout the volume, as agents of change as well.

Alexander Graham Bell launches the parade of progress when he invents the telephone, permitting 24/7 access to the physician, as well as “telephone diagnosis”—of, among other things, “laryngitis stridulus” (p. 14). Inevitably, the benefits of more rapid and easy care are balanced against the strain this places on the medical professionals who are literally at the beck and call of their patients. These professionals meanwhile incur medicolegal risks and find themselves burning out over time. Greene notes that the telephone reinforces an asymmetric power dynamic between physician, nurse, and patient, while exacerbating social inequities in healthcare access.

Once wireless technology arrives, devices such as Norman “Jeff” Holter's mobile cardiac monitor highlight the conflict between the good—remote monitoring capabilities—and the bad—the possibility of “transparent and continuous surveillance” of private citizens for their personal health information, as well as the specter of “medical hacking”-the illegal extraction of data from private devices. Another radio-dependent technology, the pager, “a gilded cage,” (p. 103) tightens the bond—or what Mort Weinberg, of the Motorola corporation, referred to as “an electronic leash” (p. 99) between patients and their providers, as well as between health care institutions and their providers. Samuel Shem (the pen name for psychiatrist Stephen Bergman) famously satirized the loss of physician autonomy in his novel, The House of God (p. 100). It allows patients to seek aid at any hour of the day and from any distance from the physician, including outerspace through remote monitoring of astronauts, and so both the role and the responsibilities of the physician are changed forever. Radio-paging adds to this idea of a “doctor-on-demand,” which may have improved patient access to care, but also engenders a sense of physician resentment and increases burnout.

Television—starting in the late 1940's—and accelerating in the 1960's, brings remote diagnostics and therapeutics to a new level, applied by pioneer Reba Benschoter for mental health services, and then further developed by the physician Kenneth Bird, credited with introducing the term “telemedicine”. Television's benefits of access, such as permitting community health clinics in disadvantaged communities and mobile care vans, and the additional benefits of permitting higher levels of diagnostic complexity and improved physician-patient communications, are possible despite the inherent limitations of not being able to touch or to smell. Providers today may find some solace in that our predecessors also had to deal with the “eye contact conundrum” (p.132) through which if one looks at the image of the patient's eyes, to the patient it seems that one is averting one's gaze, while if one looks into the camera, then one does not easily see the patient's image. Again, Greene notes that telemedicine amplifies asymmetrical power dynamics (p. 129): one poignant example is the sarcastic characterization of the physician's image as “The Face of God” when transmitted by a large television placed above the heads of viewing patients and staff. This problem is solved by moving the television from pedestal to floor.

Initial data privacy concerns with telemedicine have not limited its application or patient satisfaction. A survey study conducted in 2020 by the American Medical Association and COVID-19 Healthcare Coalition reports overall satisfaction with telehealth visits by both patient and physician.¹ Of the 2007 patient respondents, 79% were very satisfied with the care received during their last telehealth visit, and 84% were confident that their personal information was secure and private during their visit. Of the 1594 provider respondents, 73% reported that they would continue telehealth for chronic disease management.¹ Telemedicine's importance today is seen in achieving access during the COVID-19 public health emergency reaching underserved populations—those in rural areas or in so-called “medical deserts.”² Challenges of telemedicine are seen in the creation of viable business models for large-scale telemedicine entities and in the establishment of regulatory standards for tele-health-delivered care.^3,4

The boon of mainframe computing, microprocessors, and “big data” analytics reshaped data storage, and gathering, in medicine. Importantly, Vladimir Zworykin, one-time vice president for research at RCA, “believed that physicians would only truly begin to appreciate mainframe computing once they could see the benefits….in day-to-day clinical work.” (p. 199). This litmus test can be applied throughout the volume, for it is the coalescence of provider acceptance, funding, and the alleviation of disparities of care, which determine the successful integration of any given technology into medicine. Underlying these principles is the primacy of the people managing the technology: to date, machines have not been shown to replicate the empathy, and complex decision making, evidenced by human providers.