The 35th Conference of the International Society for Quality and Safety in Healthcare (Isqua)

‘Heads, Hearts and Hands – Weaving the Fabric of Quality and Safety’

 

Ladies and Gentlemen :

 

  1. I am very happy to be here this morning at the opening of this international conference on Quality and Safety in Healthcare, or QSH. I find the theme of this conference to be very evocative, especially to a non-medic such as myself. The imagery of heads, hearts and hands, all working together to weave the complicated fabric of quality healthcare delivery, conveys effectively the multi-faceted nature of your endeavours in this field, as well as some of the challenges involved in combining these different skills and qualities.

 

  1. I want to speak to this theme today, but I want to situate these three components of head, heart and hands within the context of the disruptive state of the healthcare sector today. Transformative changes in the sector are being driven by the incredible technological advances that are currently taking place – in everything from robotics to genetics to AI – as well as by the changing nature of medical needs that is associated with increased chronic disease and aging populations. The impacts of these changes are still unfolding, with far-reaching implications for both the more mature healthcare systems of the advanced economies, and for those of the middle and upper-middle income countries of this region. We all face the same challenge of developing effective responses to the escalating medical needs of our populations, which maximise the potential offered by the new technologies.

 

  1. One key area of change of particular importance in relation to QSH, is the increasing attention that is being given to the more emotional dimensions of health and healthcare. This growing emphasis on the mental aspects of health contributes to both more effective diagnosis and understanding of ill-health, and better treatment and responses. The trend derives in part from our deepening knowledge of how mind-body connections work, due to advances in neuro-biology, as well as imaging and other areas. It is thus very much part of and dependent on the current wave of technological breakthroughs. Some of the potential applications of this growing understanding of the mechanisms of brain-body communication are highlighted by current research into placebo effects. In this field, brain-body pathways are being harnessed to trick the brain into responding to decreasing levels of medication in the same way. These approaches are already being applied in areas from pain relief to muscle performance to chronic fatigue syndrome.[1]

 

  1. Far more attention is now also being paid to the more emotional dimensions of healthcare responses and treatment. This has become necessary due to the central role of mental aspects in many chronic non-communicable diseases or NCDs, as well as the rise of mental health problems. This trend can be seen in the focus of much popular medical writing on the importance of the doctor-patient relationship, and on the crucial role that effective communication plays in improving health outcomes.[2] As the influential writer and surgeon Atul Gawande put it, ‘in this war against sickness, we begin not with genetic or cellular interactions, but with human ones.’[3] These insights have contributed to the gradual but decisive movement away from more traditional physician-based models, and towards far greater patient engagement and self-management of disease, both of course also central to promoting better quality and safety in healthcare.

 

  1. While perhaps not as headline-grabbing as bionic limbs or genetic editing, this growing interest in the more emotional dimensions of health is equally ground-breaking, and is very much part of the broader disruption and transformation that the sector is undergoing. For the remainder of the speech, I want to consider some aspects of the current wave of technological advance in the medical field, and some of the implications of the increasing attention being given to the mental dimensions of health and healthcare. While the former affects the skill-sets and the technical expertise of healthcare professionals, or their ‘hands’, the latter is closely related to the ‘heart’ component. Both of these in turn then shape the knowledge or ‘head’ aspects, contributing to an empathetic and informed approach to medical practice that effectively weaves together the three components.

 

  1. It can sometimes feel as if we are being bombarded with ever more amazing stories about the accelerating pace of technical change, as part of the fourth industrial revolution, or IR 4.0. In any number of areas, from flying cars to space travel, science fiction seems to be turning into science fact. But the actual rate at which technological advances are translated into real-life applications varies considerably in practice. Progress occurs in fits and starts, and while some innovations are adopted and developed, many others remain on the drawing board. Commercial factors are among the key drivers of this process, including potential returns and barriers to entry, along with regulatory and ethical challenges, and the failure of the technology itself to deliver the improvements necessary for commercial viability. Many anticipated breakthroughs, such as self-driving cars and personal assistant robots, have failed to fully get off the ground as yet, and real progress is not as inevitable or as exponential as we may expect.

 

  1. In the medical sector however, some of the hype is being realized, and technological advances are making it out of the lab and into our everyday lives, with real benefits for our health. Tipping points, or the crossing of thresholds that trigger breakthroughs and significant change, are being reached in a number of areas. This in turn propels further growth, as changes in one field bolster those in another, and as costs are gradually driven down. This process can be seen with genetic sequencing, where progressive cost reductions mean that full genetic mapping has now become accessible to anyone. Further advances such as genetic editing, with its enormous life-saving potential, are also entering mainstream medicine through the CRISPR technology. Impressive advances are currently being experienced in areas as diverse as AI, Virtual Reality or VR, and robotics; in neuro-science, genetics and other areas of biology; in diagnostic imagery, laser surgery, and 3D printing; and in connected devices and wearables, and the ‘Internet of Things’, among others. All these are spurred by, and dependent on, the continued progress of technological ‘enablers’ such as internet speed and data-processing capacity, and nano-technology.

 

  1. These various advances are together contributing to the coming era of ‘precision medicine’, in which healthcare responses will be fully customised to individual needs, and will focus primarily on prevention and management. Movement in this direction is evident in areas such as precision oncology, which treats cancer according to its genetic profile rather than where it manifests. Genomic testing is already a standard part of cancer treatment in the US. According to Harvard geneticist, George Church, ‘By 2040, 1 billion people will have their whole genome sequenced, and get constant updates of their immunomes and biomes.’[4] These developments are set to revolutionise healthcare, as potential health problems will either be identified early and corrected, or will be managed in as tailored, and thus effective, a way as possible.

 

  1. The progress occurring in the concrete application of technological advance in the medical sector reflects the primacy of commercial viability and the profit motive in driving the adoption and application of technological change. The potential markets for these various innovations are huge, and substantial funding is available from various sources. While the deep-pocketed pharmaceutical and technology giants are able to back highly exploratory investigations, venture capital is also strongly attracted to the immense potential future returns, despite the high risks. The giant tech and pharma companies are thus playing a key role in driving technological development in the sector, although small and agile start-ups are also very much part of the picture.

 

  1. Government and academic funding of research also of course still plays an important role, and more purely scientific and humanitarian motivations do remain paramount across much of the medical field, including its more cutting-edge elements. The commitment to an open-source approach that prevails in some areas also helps to push forward the real-world application of technological advances. This can be seen in the wide dissemination of key technological enablers that occurs via the cloud. By promoting the spread of IT techniques, such as those related to machine learning, this freedom of access helps to generate further innovation and application. Conceptual advances, also crucial for pushing forward progress, are disseminated in a similarly democratic way. So despite the leading role of the private sector in driving innovation and the practical application of technological advances to healthcare, many other factors are also involved in the process.

 

  1. One area that is currently experiencing significant progress is AI. Its applications in healthcare seem to be developing faster than in other sectors with equally enormous potential for the technology. AI is already being used in diagnostics in China, both in specialised areas including skin disease and some cancers, as well as more broadly. One leading Chinese tech company has developed a diagnostic tool that covers the 700 most common diseases presented in 90% of medical cases.[5] AI is starting to be used in responses and treatment as well, and may prove to be particularly useful in the management of the symptoms and chronic aspects of NCDs. This includes through the delivery of reminders to patients about both the more medical aspects of their treatment, including taking medication and attending appointments, and the more lifestyle-related areas of diet and exercise regimes. The issue of ‘adherence’ is of course a key factor in the management of many of the risk factors and symptoms of NCDs, from blood sugar and blood pressure, to diet and exercise, and smoking and alcohol consumption.[6]

 

  1. Amazon’s virtual assistant, ‘Alexa’, powered by deep learning and equipped with the latest voice recognition tools, is currently being developed to play just this type of role in relation to diabetes. In partnership with pharma company Merck, the overall aim is to create innovative ‘digital consumer solutions’ for people living with this and other chronic diseases. These will build on and go beyond the current generation of wellness apps, which have themselves become very widely used to manage everything from diet and exercise to sleep and meditation.

 

  1. Such developments highlight the interesting way that technological advances are meshing with the growing awareness of the importance of patient engagement and self-management of their own health issues. Devices and wearables, powered by the Internet of Things, and able to monitor and respond to health conditions in real-time, will play a key role in this area.[7] The Apple watch is already being equipped to monitor changes in heart-rate using an ECG, while measurement of blood sugar is not far off. The aim is again to improve management of NCD risk factors, and to tap the vast potential market in this area. So-called ‘digiceuticals’ are another interesting innovation, based on the same approach of using greater measurement and monitoring of symptoms to develop more customised responses. Early trials with lung cancer patients, which used subjective reporting to monitor and adjust responses to treatment, showed positive impacts on life expectancy in this very difficult to treat disease. [8]

 

  1. The development of some of the tools of precision medicine is thus already fairly advanced, with key technical and conceptual elements already in place in some areas. The symptoms and risk factors that can be tracked and ameliorated in this way affect hundreds of millions of people globally, contributing to substantial disability and countless premature deaths. Progress in this area thus has the potential for hugely positive impacts, and can play a crucial role in addressing the global public health crisis created by the inexorable rise of NCDs. The continued evolution of precision medicine, and its extension to the masses, will be a central element of future healthcare efforts. Complementary advances in devices and wearables, the Internet of Things, neurobiology, and a host of other areas, will only boost progress further.

 

  1. It seems almost paradoxical that at the same time as these astounding high-tech leaps forward are occurring, the very ‘low tech’ improvements associated with the growing understanding of the mental and emotional dimensions of health are having an equally transformative effect. The trend towards a greater appreciation of these aspects is closely linked to the changing nature of medical needs in the modern world. The rise of NCDs and massive aging is associated with increasingly complex and chronic symptoms and risk factors, many of which have predominantly or strongly mental and emotional dimensions. Effective treatment of such conditions must take these aspects into account.

 

  1. The relationship between health provider and patient, and the very way in which treatment is dispensed, is now being recognised as a key factor in shaping health outcomes. The experiences and needs of patients themselves are increasingly being put at the heart of the entire process, with more effective communication widely seen as one of the most important aspects. This is contributing to the development of a very different approach to healthcare than the traditional, paternalistic model of the past, and one that views treatment as a partnership between patient and healthcare provider, in which self-management also plays an important role. This is necessary both from an ethical point of view, and because it contributes to better outcomes. More and more studies are demonstrating the enhanced outcomes that result from increased attention to emotional aspects of health. According to one writer on this area, ‘research bears out that how caregivers present and administer treatment has a powerful effect on clinical outcomes.’ [9] This is the case across the whole gamut of healthcare areas from childbirth, to pain relief and other chronic complaints, to palliative end of life care.

 

Ladies and Gentlemen

 

  1. Technological advance is itself a central element of our growing understanding of the mental and emotional aspects of health, as discussed, and some of the most promising current developments combine both high and low-tech aspects to great effect. But this trend towards the humanisation of healthcare goes beyond technological advance. Better outcomes are achieved through the very non-technical means of more active engagement by patients, and more effective communication between patients and healthcare providers. As described by one writer, ‘even as doctoring appears to be dominated by technology, the human, affective relationship is at the very center of responsible practice.’ This growing recognition of the central role played by these aspects serves to underline the continued importance of healthcare professionals. It suggests that alongside the precision measurement of symptoms and fine-tuning of responses that AI and devices will deliver, in the fast-approaching future there will still be a role for so-called ‘human medics’ to deliver this all-important human touch.

 

  1. So while technological advances can contribute substantially to strengthening the technical capabilities of medics, greatly enhancing what our hands and heads are capable of, the emotional aspects of healthcare, that lie at its heart, cannot be so easily replicated by machines. And so while we must invest in AI, in devices, and in the other cutting-edge technologies that are transforming the sector, at the same time, we must not neglect the human elements of healthcare, and must continually strive to build our capacities in this area as well.

[1] Jo Marchant (2016) ‘Cure : a journey into the science of mind over body ‘

[2] Including Danielle Ofri, (2017) ‘What Patients Say, What Doctors Hear’; Atul Gawande, (2008) ‘Better : Notes on a Surgeon’s Performance, (2018), ‘Being Mortal : Medicine and What Matters in the End

[3] In Better (2008)

[4]‘Tomorrow’s World’, Declan Butler, Nature Vol 530, 25th Feb 2016, p.399

[5] http://www.thestar.com.my/tech/tech-news/2018/07/02/china-counts-on-ai-to-find-a-cure-for-its-ailing-health-care-system/

[6] Ofri, (2017), chapter 4

[7] ‘Advances in technology are reshaping healthcare: what will the future hold’. MIMS, 21st February 2018

[8] FT Weekend 25/26th August 2018, p.10, ‘Breakthrough software fights disease’

[9] Ofri (2017), p.74

 

In The News:

https://www.thestar.com.my/news/nation/2018/09/25/sultan-nazrin-dont-neglect-human-elements-in-healthcare/

http://www.sinarharian.com.my/nasional/jangan-abai-elemen-insan-dalam-penjagaan-kesihatan-1.883591

 

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