Filling the Gaps

Thank you for publishing the heartbreaking personal story by Cathryn Delude, who tried to find the right care to honor her mother’s wishes. Her story is, tragically, one of many. We continue to fail to recognize the dying process as it transpires in our health care systems. Even when someone is well-informed about the choices they may need to make for a loved one, our policies and culture in health care thwart even the most passionate advocate. Fortunately, a different set of skills and knowledge are entering medical education with the growth of palliative medicine fellowships and integrated end-of-life curricula in residencies and medical schools. This change, however, will take at least a generation to change the culture.  

While the Medicare Hospice Benefit is an important part of providing the best care at the end of life, people still fall into gaps where hospice care may not be able to reach. To truly make a difference, we need to see better integration of social and health care services for people with advanced illnesses, more research into accurate prognostication so that we can better utilize the right resources, and most important, we need to hear more stories like this, so we improve on our mistakes before they befall another person.

CHRISTIAN T. SINCLAIR  // Assistant Professor of Palliative Medicine, University of Kansas Medical Center, Kansas City, Kans.

The Algorithmic Doctor

Back in 1970, William Schwartz predicted that automated diagnostic support would soon come of age in the practice of medicine because medical knowledge was outstripping human cognition capacity. Whether he was right then can be debated. Today, it is much harder to argue that the landscape has changed. With tens of thousands of clinically known relevant genetic variants and the ever-finer diagnostic distinctions made possible by precision medicine, even specialists can’t reliably make the best diagnoses and prognoses without computational support. 

There will be an interesting market competition to determine whether that automated intelligence function will come in through the medical establishment or whether it will come externally through commercial services. A much more interesting question, however, is whether a new generation of health care consumers, powered by Internet searches and with a far greater stake in their own health care, will be the drivers and recipients of comprehensive and up-to-date decision support. Perhaps in the future, you or your health proxies will first consult with the Consumer Reports–vetted Dr. Marcus Wellmate-9000, version 5.0, to determine the best course of treatment to precisely address the health issues you are facing.

ISAAC KOHANE // Co-Director, Center for Biomedical Informatics, 
Harvard Medical School, Boston, Mass.