Mayo Clin Proc, August 2001, Vol 76
Commencement Address
Digital Medicine: The Promise and the Peril
JORDAN J. COHEN, MD
T he Class of 2001! Wow. The very first doctors and
scientists to be minted in the new millennium. No
doubt you’re tired already of people telling you that. But
it’s hard for someone like me, who graduated from medical
school some 40 years ago, to resist the temptation to take
note of the new millennium and to marvel at the future you
have before you. Forty years ago no one had even dreamt,
let alone heard of such things as the Internet or handheld
computers or genes microarrayed on a chip. The world of
medicine and medical research that you are entering is so
vastly different from the one my classmates and I faced that
it literally boggles the mind.
Here’s an example. In our wildest dreams, we could
never have imagined a colleague by the name of Doctor
No. 117. According to an article in the Albany Times
Union, Doctor No. 117 at AmericasDoctor.com was the
sole person that a woman from Ohio named Ann Mann
trusted to give her advice when her granddaughter broke
out in a series of unexplained rashes. On the Internet, Mrs
Mann had a conversation, in real time, with a doctor she’d
never met—a doctor whose name, race, and gender she
didn’t even know. She logged on because she wanted to
talk to someone about her granddaughter’s illness. She
didn’t have to make an appointment, she didn’t have to take
her granddaughter out in the cold, she didn’t have to sit for
an hour or two in the doctor’s waiting room reading old
magazines, and she didn’t even have to pay a fee. And Mrs
Mann isn’t unsophisticated about medicine—in fact, she’s
a trained paramedic. Yet she chose to seek advice from
AmericasDoctor.com, one of a rapidly growing number of
Web sites where physicians, often anonymous, provide
medical information over the Net—no stethoscope, no
exam table—just a mouse and a keyboard. At some sites,
they even write prescriptions on-line.
I have to smile at how many words from that story have
been totally redefined since I graduated from medical
Adapted from an address at the commencement exercise of the Mayo
Medical School and Mayo Graduate School, May 19, 2001. Dr Cohen
is president of the Association of American Medical Colleges.
Address reprint requests and correspondence to Jordan J. Cohen,
MD, Association of American Medical Colleges, 2450 N St NW,
Washington, DC 20037.
Mayo Clin Proc. 2001;76:857-859
Commencement Address 857
school. A mouse used to be a little rodent with a tail, a
keyboard played music, “real time” was the only time there
was, and “on line” was where you stood to wait for a
haircut. Times certainly have changed.
Let’s consider another example: the e-medicine cabinet.
It won’t be in your bathroom tomorrow, but the new tech-
nology branch of Andersen Consulting has created a
“smart” medicine cabinet. It’s permanently connected to
the Internet; it keeps track of what medications you’re
supposed to take; it reminds you when you miss a dose; it
tells the pharmacy to refill your prescription when you’re
running low; and it even sets off an alarm if you try to take
your partner’s medication instead of your own. And that’s
not all. If its outside sensors detect a high pollen count, the
cabinet recommends medication for your allergies. What I
don’t know is whether it still has that little slot in the back
where you can put used razor blades!
As you know better than I, examples abound of fabulous
new devices powered by new information technologies,
and they are multiplying daily. The upshot of this fantastic
technological revolution is nothing short of transforma-
tional, both for the practice of medicine and for medical
research. No doubt about it. A profound and fundamental
transformation is under way, and you, the Class of 2001,
have the extraordinary privilege not only to experience it
firsthand but to shape its destiny.
The question your generation will have to answer is this:
Will the upside, the limitless potential of digital medicine to
improve the health of individuals and communities, tri-
umph? Or will the downside, the avalanche of impersonal
bits and bytes, submerge the ageless power of hands-on,
face-to-face medicine—the power to comfort the sick per-
son, to ease the burden of illness compassionately, to calm
the fears, to provide individualized advice in desperate
times, as only an experienced, empathetic, caring physician
can?
On the upside, the potential benefits of this digital trans-
formation to improve the health of individuals and commu-
nities are hard to overestimate. They are truly astounding.
What has become abundantly clear is that the availability of
information is the key to overcoming virtually all of the
barriers we now face to improving personal and public
health. Think about it. If we could always get the right
857 © 2001 Mayo Foundation for Medical Education and Research
858 Commencement Address
information to the right place at the right time for the right
person to use, there is no reason why we couldn’t
• kindle widespread adoption of healthy lifestyles,
• maximize people’s adherence to proven preventive
practices,
• make much more timely diagnoses,
• render far more accurate prognoses,
• select the most appropriate treatment every time for
each individual,
• eliminate the unaccountable variations we now see in
practice patterns across the country,
• improve dramatically patients’ compliance with medi-
cal advice, and
• reduce by orders of magnitude the alarming number of
errors the system now produces.
And providing the right information to the right place at
the right time for the right person is precisely what the new
technological tools that will be at your disposal are increas-
ingly able to do. Both for physicians and for patients. Not to
mention the revolutionizing impact of computational biol-
ogy on the creation and translation of basic research find-
ings for the benefit of people.
Given the facts already on the ground, it’s not too diffi-
cult to foresee some of the major changes in the way
medicine will be practiced in your lifetime. I realize the
hazards of forecasting. As Yogi Berra once said, “Predict-
ing is risky business—especially about the future.” Yogi’s
caution notwithstanding, let me make 10 really safe fore-
casts. Really safe, because most of these 10 futures are
already here in some places.
1. Every individual will maintain a lifelong electronic
file of comprehensive health information and will person-
ally, or through a designated surrogate, authorize access to
appropriate providers of that portion of the information
needed to deal with current problems.
2. Individuals will maintain their own personalized
medical Web pages to which their doctors and others, as
directed, will post relevant information and reminders tai-
lored to the patients’ specific needs and desires.
3. Doctors and patients will routinely communicate via
e-mail and via televisits, reducing substantially the hassles
now associated with making and keeping routine office or
clinic appointments.
4. Using sophisticated on-line devices, individuals
will monitor their own health status at home as frequently
as necessary to maintain health and to comply with physi-
cian-prescribed or self-selected disease management
programs.
5. Individuals with all manner of acute and chronic
diseases and disabilities will routinely access Internet sites
to join virtual communities of similarly afflicted people for
support and to share experiences and advice.
Mayo Clin Proc, August 2001, Vol 76
6. Many patients with stable chronic illnesses will
choose to maintain a cyber-relationship via the Net with a
respected source of specialized expertise, wherever in the
world it may reside, to meet their needs for ongoing moni-
toring and updated advice.
7. Minimally invasive, robotically mediated microsur-
gery, powered by advanced information technologies, will
greatly reduce the now unavoidable trauma, pain, and long
recovery times associated with gaping surgical incisions and
with surgeon’s big hands mucking around inside the body.
8. Confidential access to automated psychiatric con-
sultation and advice will overcome the reluctance many
people feel about seeking help for common and often dis-
abling mental and emotional disorders.
9. Decision support systems will automatically and
immediately integrate individual patient information with
relevant and updated medical literature, enabling physi-
cians routinely to base their decisions, both in the hospital
and in their offices, on the best available evidence.
10. Reliable information systems will undergird all the
complex processes of care, greatly minimizing the risk of
error by reducing reliance on memory and safeguarding
against fatigue and unavoidable distractions.
How soon will these and other miraculous transforma-
tions be commonly available? To quote cyberspace guru
Bruce Sterling, “I used to think that cyberspace was 50
years away. What I thought was 50 years away, turned out
to be only 10 years away. And what I thought was 10 years
away ... it was already here. I just wasn’t aware of it yet.”
With last year’s momentous transition from the second
to the third millennium, we not only have crossed an irre-
versible temporal threshold, we have crossed a threshold of
irreversible, fundamental transformation in the way doc-
tors interact with their patients and in the way their patients
interact with them and with the rest of the health system.
How could there be a more exciting time to begin a career
in medicine?
But so far, I’ve spoken only of the awe-inspiring upside
of this transformation. Is there also a dreaded downside to
digital medicine that could vitiate its benefits? The answer,
I’m afraid, is yes; that is, if we allow ourselves—and our
patients—to be lulled into the misguided notion that the
doctor-patient relationship is based on nothing more than
the transfer of information.
To be sure, as I’ve just emphasized, much of what
modern health care and modern science are all about is,
indeed, the transfer of information. And to be sure, one of
the time-honored roles doctors have played is to convey
specialized information to their patients, information that
was otherwise inaccessible to them.
But is that all doctors do? Certainly not. And I know
that’s not all you’ve been taught to do. First of all, doctors
Mayo Clin Proc, August 2001, Vol 76
with the skills the MDs among you have acquired are not
passive conduits of information. Doctors deal not with
generic classes of abstract patients but with unique indi-
viduals. As a doctor, you will be expected to gather all the
relevant facts about one particular individual at a time;
analyze and sift those facts to extract the nuggets of real
meaning; synthesize those nuggets into a coherent repre-
sentation of that patient’s reality; and, most important,
make a discretionary judgment about the best course of
action for that one unique person. Discretionary judgment!
That’s a term I’d ask you to remember.
Arguably, discretionary judgment is the most complex
task of which the human brain is capable. Certainly it is the
task for which physicians, the most highly trained of health
professionals, are uniquely qualified—the product of keen
intelligence, years of arduous schooling, and still more years
of hard-won experience. Discretionary judgment—the abil-
ity to make fine distinctions among alternative possibilities,
to draw valid conclusions from a unique set of circum-
stances, to combine intelligence, reason, understanding, and
intuition to discern the likeliest path to a successful outcome.
Discretionary judgment cannot be digitized.
But even that’s not all that real doctors do. We know that
when people get sick they want someone to care for them—
to care for them as human beings. Which means more,
much more than having someone provide accurate infor-
mation on a computer screen. It means yielding to the
security of a human relationship. It means tapping into the
genuine concern of a trusted professional, not tapping into
an anonymous chatroom. It means experiencing direct
physical contact with someone who cares, someone we can
rely on and in whom we can entrust our well-being. I hope
you’ll always remember Francis Weld Peabody’s most
famous admonition: “The key to the care of patients is
caring for the patient.”
Caring, like judgment, cannot be digitized.
I concede that people who “grow up digital”—as most
of your patients will have done—may be more comfortable
operating in cyberspace than previous generations were,
and they may even have a preference for health information
delivered by bits and bytes. But growing up digital does not
mean growing up in silicon. Evolution has taken eons to
refine our human sensibilities, to hardwire our instincts, to
attune our complex natures to harmonize with the vicissi-
tudes of the natural reality in which we live. A mere gen-
eration of immersion in the virtual reality of electronic
communication cannot eradicate our need, especially when
we are ill, for human contact, for a trusting relationship,
and for a caring physician.
So, this fundamental transformation of medicine, of
which you are now privileged to be a part, holds the promise
of untold benefits for humankind—for unprecedented in-
Commencement Address 859
sights into the complexity of basic biologic processes, for the
relief of human suffering, for major improvements in the
quality of medical services, and for the enhancement of health
for everyone. But those benefits will be realized, undimin-
ished, only if you and your colleagues are able to deepen the
roots of our profession’s timeless ethic of service to people.
What are those roots? They are communication, respect
for the individual, compassion, honesty, and, above all, car-
ing. These roots, admittedly, are already straining under the
extraordinary pressures of today’s competitive health care
system. Especially pressures on time. I would remind you,
however, that the winds of change are blowing more strong-
ly than they ever have. And they are sweeping away many of
the mundane chores that now require vast amounts of human
effort. Information technologies are transforming those
chores into automated processes. In their place will be time.
My plea for you is to use that time wisely for strengthen-
ing the human bonds that technology cannot possibly
forge. Take that time to listen to your patients. Listen for
sure to their complaints, but not just to their complaints.
Listen also to their stories; get to know them as people.
Listen hard for what scares them. Understand their dreams
and their disappointments. Teach them how to live
healthier lives. Be alert for opportunities to counsel, to
comfort, to encourage. No Web site can ever hope to do
that. That’s what doctors do. And that’s what you can do to
ensure that the quintessential nature of the doctor-patient
relationship endures.
As Bruce Springsteen wrote: “I ain’t lookin’ for prayers
or pity. I ain’t comin’ ’round searchin’ for a crutch. I just
want someone to talk to, and a little of that human touch.
Just a little of that human touch.” And I’ll take my leave
with the words of another of America’s great philoso-
phers—this one is a doctor, as well—none other than Dr
Seuss. Here is what that good doctor has to say in his last
textbook, Oh, The Places You’ll Go:
Congratulations!
Today is your day.
You’re off to Great Places!
You’re off and away!
You have brains in your head.
You have feet in your shoes.
You can steer yourself
any direction you choose.
You’re on your own.
And you know what you know.
And YOU are the guy
who’ll decide where to go.
And as you go, let me say: Take care. Be caring. And
good luck.