I have never met Dr. Joseph C. Kvedar of Partners HealthCare’s Center for Connected Health, Susannah Fox of Pew Research Center’s Internet and American Life Project, or Professor Andy Clark of Edinburgh University face to face in the real world. And yet they have all profoundly changed the way I think about health care’s most vexing problem: how are we going to take care of all these Baby Boomers who are starting to retire and get sick?
Kvedar nicely summarizes this supply and demand problem on one slide in a talk I watched on YouTube; he notes that there are currently 24 million Americans with diabetes, and the rate is increasing 8% every year. One in three Americans over 20 years old have hypertension, and Kvedar wonders where we are going to get all the doctors to care for these patients. His answer is we need to form trusting relationships with technology in a process he terms Emotional Automation. (http://e-patients.net/index.php?s=fox)
I had never heard of Kvedar or the Center for Connected Health until I saw a Fox twitter link to her blog post about robots, enchanted objects, and networks. (http://e-patients.net/index.php?s=fox) Fox and I follow each other on Twitter, so I read her blog, which included the embedded YouTube video of Kvedar speaking about Emotional Automation. In a way Fox is also responsible for me knowing about Professor Clark’s views on “embodied cognition” and “the extended mind.” One Sunday Fox noted in a tweet that my habit of aggregating the health care news every morning at 5:30 AM was helpful to her and the rest of my twitter tribe. That one pat on the back encouraged me months later to scour the New York Times blogs where I found Professor Clark’s Opinionator blog titled “Out of Our Brains.”
Can technology really solve the supply and demand problem in American health care? Can humans love and trust electronic devices made of glass, silicon and plastic? What can video games teach us about changing behaviors to cope with chronic disease? Should we think about what the explosion of cognitive prosthetics means for our understanding of the interplay between brains, bodies, and the real world where we live?
Many of us have already formed trusting, loving relationships with technology, but we have not really thought through the implications for health care. People love and trust their iPhones and tablet computers because they are extensions of themselves. “It is different now that we carry our second self with us. We think with the objects we love and we love the objects we think with.” So says MIT’s Sherry Turkle, the pioneering student of evocative subjects (http://ow.ly/3jjCG). Mark Rolston, chief creative officer of Frog Design, observes that people grieve when they lose a personal electronic device. “You are leaving your brain behind,” he says (http://ow.ly/3jjCG). I have blogged before about Lois Simmeth, 73, who lives in a Pittsburgh nursing home that provides her with a $6,000 harp seal robot to hold. “I love animals. I know you’re not real but somehow, I don’t know, I love you (http://ow.ly/21cj7).” Kvedar observes that humans find it easy and natural to anthropomorphize pet rocks and tomagotchis. He also states that most of us initially believe that a trusting relationship requires two human beings who interact face to face in the real world. (http://e-patients.net/index.php?s=fox)
Philosopher Roger Scruton is not buying my argument that trusting relationships with technology are possible:
“In real life, friendship involves risk. The reward is great: help in times of need, joy in times of celebration. But the cost is also great: self-sacrifice, accountability, the risk of embarrassment and anger, the effort of wining another’s trust. Hence I can become friends with you only by seeking your company. I must attend to your words, gestures and body language, and win the trust of the person revealed in them, and this is risky business…. When I relate to you through the screen there is a marked shift in emphasis. Now I have my finger on the button. At any moment I can turn you off…Of course I may stay glued to the screen. Nevertheless, it is a screen that I am glued to, not the person behind it.”
Tom Chatfield and I are betting Scruton is not addicted to World of Warcraft or WoW as it is fondly called by its 12 million monthly subscribers who pay over $1 billion annually to play this Massively Multiplayer Online (MMO) video game. Chatfield in his book Fun Inc.: Why Gaming Will Dominate the Twenty-first Century (New York: Pegasus Books, 2010) describes the WoW social experience as friendly and accessible to both beginners and experts. The story of how Adam Brouwer’s orc warrior Mogwai after 4,500 hours of play became the leader of the guild Adelante with 20,000 gold pieces and the two most powerful weapons in WoW is instructive for those of us who do not play MMO games. Although Brouwer thinks he could sell Mogwai for $10,000 on e-Bay for real world money, his obligations and allegiances to his fellow players won’t allow him to cash out. “The strange thing about Mogwai is that he doesn’t just belong to me. Every item he has got through the hard work of twenty or more other people. Selling him would be a slap in their faces. When I started, I didn’t care about the other people. Now they are the only reason I continue.” (Chatfield)
Video games have much to teach us about how to motivate humans to self manage their chronic diseases, and they offer a research tool for large-scale studies of human behavior. Researchers are interested in why video gamers become so absorbed and focused and are able to easily achieve the state of flow usually associated with master musicians and champion athletes (http://ow.ly/3pgbZ). “Gamers are engaged, focused, and happy. How many employers wish they could say that about even a tenth of their work force?” says Edward Castronova of Indiana University (http://ow.ly/3pgbZ). How many doctors wish they could say that about a tenth of their patients managing their chronic illness? A recent Harvard Business Review article concluded “the best sign that someone’s qualified to run an internet startup may not be an MBA degree, but level 70 guild leader status” in a MMO video game. (Chatfield)
Nicole Lazzaro of the player experience and research company XEODesign has identified four key characteristics of video games that may help explain why the typical American has spent 10,000 hours playing computer games by the age of 21. “Hard fun” entails pursuing a goal that gets more difficult with each level of play and requires the player to use sophisticated strategies and be rewarded for progress. “Easy fun” entails sheer enjoyment of the game and satisfying the player’s need for curiosity and mystery. “Altered states” refers to player reports that video games changed how they felt inside by clearing the mind, eliminating boredom, changing their sense of time, and experiencing a sense of achievement. “The people factor” is important to gamers because they develop relationships with others. Remote interactions with fellow players from all over the world are increasingly taking place through microphones, speakers, and real time conversations as well as in-game interactions. (Chatfield)
These learnings from video games can and are being incorporated into strategies to motivate patients to change behaviors to prevent and live with chronic disease conditions. Managing a chronic condition is full of failures manifested by high blood sugars and unexpected increases in body weight. Chatfield believes “One of the most profound transformations we can learn from games is how to turn the sense that someone has ‘failed’ into the sense that they ‘haven’t succeeded yet.’” (http://ow.ly/3pgbZ) Carnegie Mellon University’s Jesse Schell has described a system of awarding points for everything we do in real life in order to reward healthy behaviors. Lucy Bradshaw of Maxis explains, “You could strive to get the 10-stroke tooth brushing achievement, for instance, and then somehow you would collect all those points and utilize them.” (http://ow.ly/3pgjn) Dr. Jane McGonigal of the Institute for the Future plays the online Chorewars game in which she and her husband earn real rewards by doing chores in their San Francisco apartment. (http://ow.ly/3pgbZ) Anne McLaughlin of North Carolina State University’s Gains Through Gaming Lab says, “To make something into a game, you have to have a goal. You have to create the game. It’s more than just measurement…I know we keep talking about blurring the lines between gaming and reality, but I think it does that, and when it’s for a good cause it’s great.” While some think this is great, even the moderator of the South by Southwest Interactive Festival found it “rather ominous and spooky.” (http://ow.ly/3pgjn)
Video games also offer a research tool for understanding the real time interactions of complex systems involving people. Emergency triage and epidemic management are just two areas where game theory can reproduce complex systems and try out different strategies. Blitz Game Studios is developing a triage game that takes place in an interactive three-dimensional world. One physician favorably compared this approach to the traditional large-scale emergency training with volunteers covered with fake blood. “A virtual world can simulate the noise, the chaos, everything. You could assess, for example, the exact percentage and degree of someone’s burns from
the way they looked in a game.” Most importantly such a game allows participants to try out different approaches and see if they work. Epidemiologist Nina H. Fefferman at the 2008 Games for Health Conference stated that studying thousands of people in games could model the unpredictable human behavior in epidemics. (Chatfield) Castronova says, “One reason that policy keeps screwing up – think Katrina – is because it never gets tested. In the real world, you can’t create five versions of New Orleans and throw five hurricanes at them to test different logistics. But you can do that in virtual environments.” (http://ow.ly/3pgbZ) Chatfield observes, “Game technologies excel at nothing so much as scoring, comparing and rewarding progress.”
Therapists are now using digital worlds with autonomous, virtual humans to help patients work through social anxiety, drinking, gambling, post-traumatic stress, and agoraphobia. (http://www.nytimes.com/2010/11/23/science/23avatar.html) Such therapists can discuss the patient’s feelings at the very moment that the virtual bartender asks the alcoholic if he wants to order another drink, and different coping techniques can be practiced time and time again in virtual situations that are experienced as real. One such patient said, “I just think it’s a fantastic idea to be able to experience situations where you know that the worst cannot happen. You know it’s controlled and gradual and yet feels somehow real…the great thing about it [is]…you get to practice.” (http://www.nytimes.com/2010/11/23/science/23avatar.html) USC psychologist Albert Rizzo has helped veterans with post-traumatic stress by using a virtual Humvee scenario that recreates ambushes by insurgents. “We can control the intensity of experience, and then work on the patient’s response,” breaking the association between reminders of the ambush and the panic the patient has been dealing with months later. (http://www.nytimes.com/2010/11/23/science/23avatar.html) In a USC study, people with social anxiety confessed more of their personal flaws, fears and fantasies to virtual figures programmed to be socially sensitive than to live therapists conducting video interviews. (http://www.nytimes.com/2010/11/23/science/23avatar.html)
Kvedar, who first introduced me to the concept of Emotional Automation, cites Karen the virtual wellness coach/avatar who gets her human walkers to exercise more and the Boston hospital patients who prefer a robot discharge planner to a human one as examples of humans learning to trust technology. And why shouldn’t the patient prefer the robot that is not in a hurry, does not talk down to the patient, and encourages the patient to ask the same question over and over again. The busy human discharge planner may in this setting be less effective than the avatar. (http://e-patients.net/index.php?s=fox)
The term avatar comes from Sanskrit and is usually translated as incarnation or descent to describe the process in which a higher spiritual being (Rama or Krishna, for example) takes on mortal flesh. It is now commonly used to describe a player’s presence within a video game. (Chatfield) Palo Alto Research Scientist Nick Yee, PhD has described the Proteus Effect, how our video game avatars change how we behave in virtual environments and in real life. In several papers, Yee demonstrated that players given more attractive or taller avatars disclosed more personal information and bargained more aggressively than unattractive, shorter avatars. Yee also showed that the person’s perceptions of their own attractiveness persisted outside of the game environment to affect their participation in real life online dating. Yee believes that providing users with “fit, athletic avatars in exergames may encourage longer and more engaged exercise sessions than if they were provided with normal-looking avatars or avatars that were modeled from their own bodies.” (http://www.healthgamesresearch.org/our-publications/research-briefs/the-proteus-effect)
Finally, what does all this do for our understanding of the interplay between brains, bodies, and the real world where we live? Professor Clark who works in “embodied cognition” and “the extended mind” fields of philosophy argues that a wire-free interface that links our brains to our notepad or iPhone should count as providing support for our cognitive processing. (http://ow.ly/3pgqK) Basically, I think he is saying that some of the activity that enables us to think occurs outside of our brain. He cites studies that show that hand gestures may play an active role in our ability to think; when research subjects were prevented from using hand gestures, they perform poorly on tests of mental abilities. He provocatively notes “evolution and learning don’t give a jot what resources are used to solve a problem. There is no more reason, from the perspective of evolution or learning, to favor the use of a brain-only cognitive strategy than there is to favor the use of canny (but messy, complex, hard-to-understand) combinations of brain, body, and world.” (http://ow.ly/3pgqK)
I have never spoken to Kvedar, Fox, or Clark face to face in real life, and yet they have indirectly convinced me that patients in the future will trust and use technology to prevent and treat illness in ways that we are just starting to understand and envision. The supply and demand problem of taking care of retiring Baby Boomers will include robots, avatars, video games, and physicians.
Kent Bottles, MD, is past-Vice President and Chief Medical Officer of Iowa Health System (a $2 billion health care organization with 23 hospitals). He was responsible for the day-to-day operations of a large education and research organization in Michigan prior to his work with in Iowa with IHS. Kent posts frequently at his new blog, Kent Bottles Private Views.