It’s fitting that this year’s ACOG meeting was held in New Orleans, because navigating the 2013 ASCCP Pap Smear Management Guidelines presented there feels like trying to make my way through the Mississippi bayou. The guidelines include 18 different algorithms encompassing almost any combination of pap and HPV abnormality we docs are likely to encounter among our patients. But all tributaries lead to the same place, where we achieve optimal reduction in cervical cancer with minimal harm.
Cervical cancer prevention is a process with benefits and harms. Risk cannot be reduced to zero with currently available strategies, and attempts to achieve zero risk may result in unbalanced harms, including over treatment. …optimal prevention strategies should identify those HPV-related abnormalities likely to progress to invasive cancers while avoiding destructive treatment of abnormalities not destined to become cancerous. Adopted management strategies provide what participants considered an acceptable level of risk of failing to detect high-grade neoplasia or cancer in a given clinical situation.
I’m not even going to try to spell out everything in the guidelines, which come from the American Society of Colposcopy and Cervical Pathology (ASCCP), except to say that they represent further movement away from aggressive screening and treatment of pap smear abnormalities, especially in younger women, in whom treatment carries small but real childbearing risks. The guidelines are increasingly reliant upon HPV testing to determine who and how often to screen, and when to treat. They also acknowledge the role of testing for HPV 16 and 18 as a way to be sure that those women with adenocarcinoma of the cervix (which is less likely to show up as cancer on a pap smear) are identified and treated.
In my post, I talked a bit about the marketplace-driven IT innovations in healthcare, and medicine as seen through the eyes of the IT entrepeneurs. I questioned just how much of what doctors do today can really be replaced by algorithms, particularly the doctor-patient relationship.
I then asked if Khosla was right and answered myself – Maybe. I stated that we were in the midst of a huge disruption in healthcare, and reflected on how I was already seeing signs of that disruption in my current practice. And while I still did not see anything changing too much just yet, as far as the future Khosla predicted? I wasn’t so sure.
I then stated that if there is a revolution in healthcare, we docs needed to make ourselves a part of it now. I urged my fellow physicians to become involved, in order to be sure that what happens in the IT-driven healthcare future actually improves our patients’ health beyond what we are doing today.
It’s a completely legitimate concern, and, I believe, an extremely important one. As an example, I cited the evolution of the EMR – a system that has created high hopes and caused huge disruption at enormous cost, even as we continue to struggle to find conclusive evidence that EMR use actually improves patient outcomes.
There’s a big discussion going on in the health tech community about a controversial keynote speech given by Vinod Khosla at the Health Innovation Summit (HIS), in which he stated that 80% of what doctors do could be replaced by machines.
If you’re a doc like me who has no idea who the heck Vinod Khosla is (he’s a venture capitalist and co-founder of Sun Microsystems), why he’d be a keynote speaker at a healthcare event and what the heck HIS is, well, that’s the point of this post. You see, there are a whole lot of folks like Khosla out there – investors, entrepreneurs, tech types – who are attempting to redefine healthcare according to their own personal vision. Where we see a healthcare system in crisis, they see opportunity – just another problem with a technological solution. Computer-driven algorithms are the answer to mis-diagnosis and medical error, IPhone apps can replace physician visits, video connectivity can increase access.
Where we see illness and distress, they see a market.
And what business folks like to call disruption in the marketplace. Think about what happened to downtown small town USA after the first shopping mall opened. Or what happened to movie houses when Netflix started offering DVD rentals online. Or where all the independent bookstores went when the first Borders opened up, and what happened to Borders when the Kindle hit the market.
Out with the old, in with the new.
If Khosla is right, the we docs in our offices and hospitals are the old downtown department stores, the bookstores and the bricks and mortar businesses in an online revolution. We’re replaceable. At least most of us.