The Future of Emergency Medicine Jonathon M. Sullivan MD, PhD Wayne State University Detroit Receiving Hospital

Purpose of this Lecture Put away your pencils, class This won’t be on the test Raina Burke wouldn’t stop bugging me Sullydog just wants to have fun Some of us might actually learn something

Outline Science fiction vs. futurism How futurism (doesn’t) work Identifying trends: Technological trends Sociological and demographic trends Economic and political trends Global trends (megatrends) Summary (how I failed to predict the future)

Science Fiction vs. Futurism

Science Fiction vs. Futurism

Science Fiction vs. Futurism

Science Fiction vs. Futurism “The difference between fiction and reality? Fiction has to make sense.” –Stephen King

Futurism Historical antecedents 19th century Comte's discussion of the metapatterns of social change Early 20th century systems science in academia, National economic and political planning: France Soviet Union and Eastern bloc countries. Emerged as an academic discipline after WWII

Futurism Two broad approaches: Increasing crossover American: “Quaterly Report/Bottom Line” mentality applied projects quantitative tools systems analysis analysis of complex, large scale systems and the interactions within those systems. Identification of units, processes and structuresgame theory analysis and modeling—signficant $$$ apps European: “What about our Great-Grandkids?” mentality more speculative and interested in long-term future of humanity, planetary systems, etc Increasing crossover

Futurism

Futurism An increasingly dismal science Wild cards (Asimov’s Mule) Butterfly effects (chaos theory) Uncooperative markets Uncooperative societies and electorates Self-organizing systems Singularities – point at which f(x) = ∞; also describes historical or technological discontinuities: Advent of agriculture Printing press Internet 9-11 War, Famine, Plague, Bush The odd asteroid

Futurism Anticipatory thinking (futures) Backcasting (eco-history) Causal layered analysis (CLA) Environmental scanning Scenario method Delphi method Future history Monitoring Backcasting (eco-history) Back-view mirror analysis Cross-impact analysis Futures workshops Failure mode and effects analysis Futures biographies Futures wheel Relevance tree Simulation and modelling Social network analysis Systems engineering Thinklets Visioning Trend analysis Morphological analysis Technology forecasting If you can’t dazzle ‘em with prophecy….

Futurism The Delphi Method An explicit approach developed by the Rand corporation for Defense/Strategic planning Utilizes panels or pools of experts Highly rigid methodology and information flow Lousy track record

Identify opposing trends and extrapolate p p Extreme Scenario  Extreme Scenario  Extreme Scenario 1 Extreme Scenario 1 Extreme Scenario x Extreme Scenario x ↑t, p p p

And Voila! A Stunningly Accurate Prediction Emerges!

Identify opposing trends and extrapolate You want fries wit’ p dat? I’d like to thank the Nobel Academy… My Wife The Match

Trend Trend Trend ?

Enough CYA, Dog Step One In This Fool’s Errand: Identify Trends: Technological trends Sociological and demographic trends Economic and political trends Global trends (megatrends)

Technological Trends Information Technologies Artificial Life, Genetic Algorithms, Cellular Automata Molecular biology, proteomics, computational protein folding Artificial organs Medical imaging Materials science and nanotechnology Drug delivery technologies for deep organ and organ-spec txs Point-of-care testing Resuscitative adjunts

Technological Trends: IT More than just data storage and collection Increasing penetration into EM is manifest Pros: efficiency, safety, info availability Cons: info overload, privacy concerns, infrastructure vulnerability Important sub-trends: Decreasing processor size Moore’s law Wireless networks HIPAA considerations, security issues Neural networks, diagnostic algorithms

Technological Trends: IT Question: does more information = better care? Available evidence casts grave doubt on such a presumption Swan-Ganz Catheters Question: does increased information increase the resolution of the retrospectoscope?

Tech Trends: IT Information vs. Exformation As disorder in a system increases: The entropy of the system increases the amount of information “encoded” in the system

Tech Trends: IT Information vs. Exformation Work  Information  Entropy ↑ Work “Value Added”

Tech Trends: IT Accelerating Acceleration Kurzweil: Human technological progress tends to accelerate over the course of history IT accelerates the rate of acceleration of technological progress Have we passed the singularity? 20 years ago, could we have predicted: Internet porn, PDAs, MyYahoo!, the Y2K scare, SETI@home, CIS, genetic algorithms? 10 or so years ago we actually DID predict: The Internet would make everything perfect forever email, dial-ups and Yahoo! would free China and N. Korea Less paperwork for everybody! Yipee! A sudden return to neolithic civilization at midnight, 12-31-1999 (Cruz told me he was dissappointed when it didn’t happen) A better informed public and more honest politicians The Internet was going to change EVERYTHING! Network evolution: emergent and unpredictable

Trends: IT Oppos. Trend Overwhelming (Info Overload), low E/I Decreased Efficiency Used to enforce rigid protocols Spawns non-pt-care “busywork” Cart > Horse Privacy at Risk Pulls physician FROM bedside Promotes balkanized healthcare Streamlined information, hi E/I Maximizes efficiency Promotes innovation and flexibiity Minimizes non-pt-care responsibilities Transparent IT Maximizes privacy Pulls physician TO the bedside Integrates healthcare systems I am Dr. Borg. Your files will deleted within 29 minutes. I may contain malicious programs. If you wish to continue, hit “pay.” Hmm…650 delinquent charts, an expiring license and a transfer from Providence. There. All done. Back to patient care!

Trends: Bioimaging Ultrasound More compact: every doc with a unit enhanced resolution contrast materials expanded utilization by EPs Continued evolution of computed tomography MRI Magnetic resonance spectroscopy—more info about chemical and physical properties of a region than MRI Multinuclear imaging—tweak nuclei other than H Internal imaging

Tech Trends: Bioimaging The M2A capsule endoscope miniature video camera, light source, batteries and a radio transmitter. Video images transmitted by radio telemetry 50,000 images / seven-hour procedure. Data recorder: walkman-like device worn by the patient Computer workstation imaging software

Tech Trends Neural networks and pattern recognition Currently used to look for Osama bin Laden at the JFK airport Systems require mimimum processing power to “learn” complex patterns Never miss a pneumonia on CXR again

Tech Trends: TMS Uses electromagnetic induction to set up currents in neuronal populations Already being used in neuropsychiatry and brain research This one could be a singularity

Tech Trends: Point-of-Care Testing

Tech Trends: Point-of-Care Testing “We got blind diabetics out there taking their own blood sugar, but JCAHO says I’m not certified to do it.” - Rick Bukata

Tech Trends: Biomolecular Medicine Comprises several fields: Genomics, proteomics, computational protein folding, molecular genetics, molecular immunology, computational protein folding, etc. Short-term effects on EM probably moderate, compared to disciplines like oncology, hematology and rheumatology Long term effects are critical: Molecular adjuncts to resuscitation Molecular/genetic diagnostics Rapid protein repair Early prevention of cell-death triggers

Tech Trends: Drug Delivery Organ/tissue-specific delivery systems Ability to deliver engineered or recombinant proteins to tissues will be key Targeted tissue delivery will be a major step forward innovations in interventional radiology Computational protein folding recombinant proteins, eg, active group + targeting domain engineered virions nanotechnology engineered microorganisms antisense RNA technologies micelles, microspheres

Tech Trends: Materials Science New materials technologies will have implications for all areas of medicine: Prosthetic limbs, organs and joints Drug development and delivery systems Medical imaging Emerging technologies: Superconducting materials, esp ceramics Composites Self-assembling layers/vapor deposition Nanolithography and nanomatrices

Who is this Man? Dr. K. Eric Drexler

Tech Trends: Nanotechnology You’re going to feel a little prick now… Note: This is NOT a nanomachine! Note: You should NEVER say this to a patient.

Tech Trends: Nanotechnology Engineering at the molecular and atomic level Progress is explosive: nanomaterials: nanotubes, buckyballs, nanocomposites elementary nanocircuits nanophotonics and nanolasers nanolithography Preliminary work with ATP’ase-driven nanomotors hacked out of natural casettes Holy grails: kinematic replicators, rod logic, molecular-level quantum processors

Tech Trends: Nanotechnology Nanogears operating at room temp. Han and Globus, et al, NASA.

Tech Trends: Nanotechnology Carbon nanotube deposits carbon on a diamond matrix.

Tech Trends: Nanotechnology Carbon Nanotube Microarray for Chip Cooling (JPL)

Tech Trends: Nanotechnology

Tech Trends: Nanotechnology An example of an artificial microstructure created with carbon nanotube nanolithography

Tech Trends: Materials Science and Nanotechnology National Nanotechnology Initiative Instituted during the Clinton Admin Bush increased funding to $3.63 B Incorporates dozens of Federal agencies, including HHS and NIH Already moving rapidly into the commercial sector hydrogen sensors chip manufacture manufacture of night vision and solar-power technologies textiles

Tech Trends: Nanotechnology

Tech Trends: Nanotechnology Implications for Emergency Medicine: Drug delivery Antibiotics, antivirals tissue stabilization and repair Diagnostics and imaging Microtelemetry Thrombolysis “cell surgery” gene excision and repair Artificial tissues and organs

Tech Trends: Nanotechnology Challenges: New technologies always mandate new skill sets Some nanotechnologies will be biohazards; handling and regulation adverse reactions to nanomachines potential for abuse: neo-protists, microexplosives, “Gray Goo” scenario

Tech Trends: Artificial Organs Continued progress with mechanical organs and tissues, especially pumps (hearts), tubes (vascular, ducts), joints, bone and muscle. New materials and processes A new generation of artificial tissues and organs, representing a confluence of several technologies

Tech Trends: Artificial Organs Here Be Dragons Biodegradable Tissue Scaffold (see “nanolithography”) Inoculate with tissue-specific cultured cells or stem cells Ya got ya kidney, there.

Tech Trends: Resuscitative Adjuncts Synthetic oxygen carriers Hypothermia Reperfusion cocktails Cardiac, cerebral, renal, spinal cord, muscle caspase and calpain inhibitors insulin, growth factors mitochondrial stabilizers free radical scavengers thrombolytics post-arrest? Refinement of the EGDT approach

Tech Trends: AL, GAs, CAs How’s this for sci-fi…. You will use artificial life forms to plan for staffing and maximize ED patient flowthrough.

Tech Trends: AL, GAs, CAs Genetic Algorithms a form of Artificial Life that uses principles of natural selection and fitness to evolve solutions to complex problems Already being used to optimize “just in time” shipping strategies, flight plans, traffic volumes, etc.

Social and Demographic Trends Your patient’s getting older:

Social and Demographic Trends Your patient’s getting older:

Social and Demographic Trends Your patient’s getting more complex:

Social and Demographic Trends Your patient is smarter (maybe) Patients have more access to medical information Less trusting of doctors More likely to ask questions We treat them like customers, they act like customers

Social and Demographic Trends Your patient speaks Urdu. How’s your Urdu? Actually, he/she probably speaks Spanish Chinese French German Tagalog Vietnamese Italian Korean Russian Polish Notwithstanding all the rhetoric, America will become increasingly polyglot in the next century. More important is the issue of cultural diversity.

Social and Demographic Trends Your Patient Does T’ai Chi and smokes Tigoba Root New Age Freaks from Royal Oak will rock your world Use of alternative medicine is increasing: in 2002, 36% of Americans had used some form of alternative therapy in the past 12 months (NIH data) Many issues of safety, efficacy and regulation remain unresolved Increased immigration affects this trend

“Apocalypse is boring.” -Bruce Sterling

Economic and Business Trends: Apocalypse Now 114 million ED visits annually more than 1 for every 3 people in the United States 16 million per ambulance. EDs have become preferred setting for many patients Seen as an djunct to community physicians ("go to the ED for some labs") (recent growth in ED use driven by patients with private healthinsurance)

Economic and Business Trends: Apocalypse Now Between 1993 and 2003: population grew 12 percent hospital admissions increased 13 percent ED visits rose 26 percent During the SAME PERIOD: United States lost 703 hospitals 198,000 hospital beds 425 hospital Eds "mainly in response to cost-cutting measures and lower reimbursements by managed care, Medicare, and other payors.” (Institute of Medicine)

Economic and BusinessTrends Apocalypse Now

Economic and Business Trends: Apocalypse Now EDs are the principal sources of care for 45 million uninsured Americans. Hospitals have little financial incentive to prevent ED overcrowding. "The ED often serves as primary care provider, a role for which it is not optimally designed.“ Increasing unavailability/reluctance of consultants

Economic and Business Trends: Apocalypse Now Overloaded EDs Waits of hours or days for inpatient beds. Ambulance diversion daily problem in many cities. EMS fragmented and disorganized 45 million uninsured Americans. System is ill prepared to handle large-scale emergencies natural disaster (more common) Influenza pandemic (more likely) Acts of terrorism (imminent)

Economic and Business Trends

Economic and Business Trends

Economic and Business Trends

Economic and Business Trends

Economic and Business Trends

Economic and Business Trends

Economic and Business Trends Overall United States health care performance ranked 37th (WHO) Far below the average of developed nations. Health care “level” ranked 72nd in the world by WHO worse than China comparable to Iraq. Euro Itchy and Scratchy: Have far fewer uninsured Get more bang for their health care buck Have comparable waiting times and rationing Achieve comparable patient satisfaction Take it up the butthole on taxes, but don’t seem to mind

Universal Coverage: the Worst Possible System Would require new taxes and at least some increase in Federal bureaucracy People who hate it: Doctors HMOs, insurance cos Big Pharma Conservatives in power Libertarians Trial Lawyers The public Oppos. Trend Current trends in American healthcare are unsustainable Other systems have huge problems, but still work better than ours People who want it: Doctors Progressives & Libs Hate America Employers The public

Oppos. Trend EM takes up more slack for a sick healthcare system More uninsured Few social support systems Lack of regionalization and nationalization “Highest bidder” technologies crafted to make money, not sense EM becomes MORE DIVERSIFIED and LESS FOCUSED “I’m doing a fellowship in Emergency Podiatric Acupunture!” EM loses its academic momentum Increasing loss of hospitals and academic centers makes EM a “red-headed stepchild” EM seen as an economic drain on govts, med schools and hospitals EM not well integrated in local and national disaster/antiterro planning EM integrated into a comprehensive national healthcare strategy Innovated technologies selected and deployed to maximze patient care and departmental readiness EM becomes MORE FOCUSED and LESS DIVERSIFIED It’s called “EMERGENCY MEDICINE” EM’s academic momentum continues More academic chairs More NIH funding More translational research New areas of investigation Stabilization of hospitals and medical centers stabilizes the standing of Eds EM seen as crucial to the success of local, regional and national health care systems, both operationally and financially EM a keystone element in disaster planning

“What are your predictions, Sullydog?” You haven’t been listening.

Okay, fine. Predictions the next 10-20 y Technological innovation will proceed apace significant deployment of nanotech, TMS, AI, neural nets, etc. Biotech from Singapore Emergency Medicine will continue its current academic trajectory Resuscitology, heart failure, stroke, sepsis Systems analysis, GAs, IT Physician wellness Creation of new National Institute for acute/emergency/trauma medicine (as recommended by IOM)

Okay, fine Predictions for next 10-20 y IT will streamline our workflow and help put us at the bedside Increasing deployment of neural nets and AI-like systems to improve diagnosis and tx and reduce errors Continued refinement and evolution of CQI Appearance of more explicit multidisciplinary team approach to EM

Okay, fine Predictions EDs will continue to pick up the slack while America gets her s**t together EPs and EDs will continue to do more primary care Bad for Emergency Medicine Bad for Primary Care Bad for patients Public health mandates (funded vs unfunded)? Overcrowding will continue for the foreseeable future

Okay, fine Increasing regionalization and nationalization of health care systems Driven less by public health concerns than disaster / terror preparedness What is the role of EM in govt surveillance of the public? Gradual integration of hospital systems and IT networks (this will be rough and slow going) Gradual evolution of single payer system(s) Probably 50 of ‘em, regulated by Feds (carrot-stick) Hospitals, pharmaceutical co.s, PGs, etc, continue to be operated on entrpeneurial models

CONGRATULATIONS TO THE CLASS OF 2006!