Presentation on theme: "The Future of Emergency Medicine"— Presentation transcript:
1 The Future of Emergency Medicine Jonathon M. Sullivan MD, PhDWayne State UniversityDetroit Receiving Hospital
2 Purpose of this Lecture Put away your pencils, classThis won’t be on the testRaina Burke wouldn’t stop bugging meSullydog just wants to have funSome of us might actually learn something
3 Outline Science fiction vs. futurism How futurism (doesn’t) work Identifying trends:Technological trendsSociological and demographic trendsEconomic and political trendsGlobal trends (megatrends)Summary (how I failed to predict the future)
7 Science Fiction vs. Futurism “The difference between fiction and reality? Fiction has to make sense.”–Stephen King
8 Futurism Historical antecedents 19th century Comte's discussion of the metapatterns of social changeEarly 20th century systems science in academia,National economic and political planning:FranceSoviet Union and Eastern bloc countries.Emerged as an academic discipline after WWII
9 Futurism Two broad approaches: Increasing crossover American: “Quaterly Report/Bottom Line” mentalityapplied projectsquantitative toolssystems analysisanalysis of complex, large scale systems and the interactions within those systems.Identification of units, processes and structuresgame theory analysis and modeling—signficant $$$ appsEuropean: “What about our Great-Grandkids?” mentalitymore speculative and interested in long-term future of humanity, planetary systems, etcIncreasing crossover
11 Futurism An increasingly dismal science Wild cards (Asimov’s Mule) Butterfly effects (chaos theory)Uncooperative marketsUncooperative societies and electoratesSelf-organizing systemsSingularities – point at which f(x) = ∞; also describes historical or technological discontinuities:Advent of agriculturePrinting pressInternet9-11War, Famine, Plague, BushThe odd asteroid
13 Futurism The Delphi Method An explicit approach developed by the Rand corporation for Defense/Strategic planningUtilizes panels or pools of expertsHighly rigid methodology and information flowLousy track record
18 Enough CYA, Dog Step One In This Fool’s Errand: Identify Trends: Technological trendsSociological and demographic trendsEconomic and political trendsGlobal trends (megatrends)
19 Technological Trends Information Technologies Artificial Life, Genetic Algorithms, Cellular AutomataMolecular biology, proteomics, computational protein foldingArtificial organsMedical imagingMaterials science and nanotechnologyDrug delivery technologies for deep organ and organ-spec txsPoint-of-care testingResuscitative adjunts
20 Technological Trends: IT More than just data storage and collectionIncreasing penetration into EM is manifestPros: efficiency, safety, info availabilityCons: info overload, privacy concerns, infrastructure vulnerabilityImportant sub-trends:Decreasing processor sizeMoore’s lawWireless networksHIPAA considerations, security issuesNeural networks, diagnostic algorithms
21 Technological Trends: IT Question: does more information = better care?Available evidence casts grave doubt on such a presumptionSwan-Ganz CathetersQuestion: does increased information increase the resolution of the retrospectoscope?
22 Tech Trends: IT Information vs. Exformation As disorder in a system increases:The entropy of the systemincreasesthe amount of information “encoded” in the system
23 Tech Trends: IT Information vs. Exformation Work Information Entropy↑ Work“Value Added”
25 Tech Trends: IT Accelerating Acceleration Kurzweil:Human technological progress tends to accelerate over the course of historyIT accelerates the rate of acceleration of technological progressHave we passed the singularity?20 years ago, could we have predicted:Internet porn, PDAs, MyYahoo!, the Y2K scare, CIS, genetic algorithms?10 or so years ago we actually DID predict:The Internet would make everything perfect forever, dial-ups and Yahoo! would free China and N. KoreaLess paperwork for everybody! Yipee!A sudden return to neolithic civilization at midnight,(Cruz told me he was dissappointed when it didn’t happen)A better informed public and more honest politiciansThe Internet was going to change EVERYTHING!Network evolution: emergent and unpredictable
26 Trends: IT Oppos. Trend Overwhelming (Info Overload), low E/I Decreased EfficiencyUsed to enforce rigid protocolsSpawns non-pt-care “busywork”Cart > HorsePrivacy at RiskPulls physician FROM bedsidePromotes balkanized healthcareStreamlined information, hi E/IMaximizes efficiencyPromotes innovation and flexibiityMinimizes non-pt-care responsibilitiesTransparent ITMaximizes privacyPulls physician TO the bedsideIntegrates healthcare systemsI 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!
27 Trends: Bioimaging Ultrasound More compact: every doc with a unitenhanced resolutioncontrast materialsexpanded utilization by EPsContinued evolution of computed tomographyMRIMagnetic resonance spectroscopy—more info about chemical and physical properties of a region than MRIMultinuclear imaging—tweak nuclei other than HInternal imaging
28 Tech Trends: Bioimaging The M2A capsule endoscopeminiature video camera, light source, batteries and a radio transmitter.Video images transmitted by radio telemetry50,000 images / seven-hour procedure.Data recorder: walkman-like device worn by the patientComputer workstation imaging software
29 Tech Trends Neural networks and pattern recognition Currently used to look for Osama bin Laden at the JFK airportSystems require mimimum processing power to “learn” complex patternsNever miss a pneumonia on CXR again
30 Tech Trends: TMSUses electromagnetic induction to set up currents in neuronal populationsAlready being used in neuropsychiatry and brain researchThis one could be a singularity
32 Tech Trends: Point-of-Care Testing “We got blind diabetics out there taking their own blood sugar, but JCAHOsays I’m not certified to do it.”- Rick Bukata
33 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 rheumatologyLong term effects are critical:Molecular adjuncts to resuscitationMolecular/genetic diagnosticsRapid protein repairEarly prevention of cell-death triggers
34 Tech Trends: Drug Delivery Organ/tissue-specific delivery systemsAbility to deliver engineered or recombinant proteins to tissues will be keyTargeted tissue delivery will be a major step forwardinnovations in interventional radiologyComputational protein foldingrecombinant proteins, eg, active group + targeting domainengineered virionsnanotechnologyengineered microorganismsantisense RNA technologiesmicelles, microspheres
35 Tech Trends: Materials Science New materials technologies will have implications for all areas of medicine:Prosthetic limbs, organs and jointsDrug development and delivery systemsMedical imagingEmerging technologies:Superconducting materials, esp ceramicsCompositesSelf-assembling layers/vapor depositionNanolithography and nanomatrices
37 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.
38 Tech Trends: Nanotechnology Engineering at the molecular and atomic levelProgress is explosive:nanomaterials: nanotubes, buckyballs, nanocompositeselementary nanocircuitsnanophotonics and nanolasersnanolithographyPreliminary work with ATP’ase-driven nanomotors hacked out of natural casettesHoly grails: kinematic replicators, rod logic, molecular-level quantum processors
39 Tech Trends: Nanotechnology Nanogears operating at room temp. Han and Globus, et al, NASA.
40 Tech Trends: Nanotechnology Carbon nanotube deposits carbon on a diamond matrix.
43 Tech Trends: Nanotechnology An example of an artificial microstructure created with carbonnanotube nanolithography
44 Tech Trends: Materials Science and Nanotechnology National Nanotechnology InitiativeInstituted during the Clinton AdminBush increased funding to $3.63 BIncorporates dozens of Federal agencies, including HHS and NIHAlready moving rapidly into the commercial sectorhydrogen sensorschip manufacturemanufacture of night vision and solar-power technologiestextiles
46 Tech Trends: Nanotechnology Implications for Emergency Medicine:Drug deliveryAntibiotics, antiviralstissue stabilization and repairDiagnostics and imagingMicrotelemetryThrombolysis“cell surgery”gene excision and repairArtificial tissues and organs
47 Tech Trends: Nanotechnology Challenges:New technologies always mandate new skill setsSome nanotechnologies will be biohazards; handling and regulationadverse reactions to nanomachinespotential for abuse: neo-protists, microexplosives, “Gray Goo” scenario
48 Tech Trends: Artificial Organs Continued progress with mechanical organs and tissues, especially pumps (hearts), tubes (vascular, ducts), joints, bone and muscle.New materials and processesA new generation of artificial tissues and organs, representing a confluence of several technologies
49 Tech Trends: Artificial Organs Here Be DragonsBiodegradable TissueScaffold(see “nanolithography”)Inoculate with tissue-specificcultured cells or stem cellsYa got ya kidney, there.
50 Tech Trends: Resuscitative Adjuncts Synthetic oxygen carriersHypothermiaReperfusion cocktailsCardiac, cerebral, renal, spinal cord, musclecaspase and calpain inhibitorsinsulin, growth factorsmitochondrial stabilizersfree radical scavengersthrombolytics post-arrest?Refinement of the EGDT approach
51 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.
52 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 problemsAlready being used to optimize “just in time” shipping strategies, flight plans, traffic volumes, etc.
53 Social and Demographic Trends Your patient’s getting older:
54 Social and Demographic Trends Your patient’s getting older:
55 Social and Demographic Trends Your patient’s getting more complex:
56 Social and Demographic Trends Your patient is smarter (maybe)Patients have more access to medical informationLess trusting of doctorsMore likely to ask questionsWe treat them like customers, they act like customers
57 Social and Demographic Trends Your patient speaks Urdu. How’s your Urdu?Actually, he/she probably speaksSpanishChineseFrenchGermanTagalogVietnameseItalianKoreanRussianPolishNotwithstanding all the rhetoric, America will become increasingly polyglot in the next century.More important is the issue of cultural diversity.
58 Social and Demographic Trends Your Patient Does T’ai Chi and smokes Tigoba RootNew Age Freaks from Royal Oak will rock your worldUse 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 unresolvedIncreased immigration affects this trend
60 Economic and Business Trends: Apocalypse Now 114 million ED visits annuallymore than 1 for every 3 people in the United States16 million per ambulance.EDs have become preferred setting for many patientsSeen as an djunct to community physicians ("go to the ED for some labs")(recent growth in ED use driven by patients with private healthinsurance)
61 Economic and Business Trends: Apocalypse Now Between 1993 and 2003:population grew 12 percenthospital admissions increased 13 percentED visits rose 26 percentDuring the SAME PERIOD:United States lost 703 hospitals198,000 hospital beds425 hospital Eds"mainly in response to cost-cutting measures and lower reimbursements by managed care, Medicare, and other payors.” (Institute of Medicine)
63 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
64 Economic and Business Trends: Apocalypse Now Overloaded EDsWaits of hours or days for inpatient beds.Ambulance diversion daily problem in many cities.EMS fragmented and disorganized45 million uninsured Americans.System is ill prepared to handle large-scale emergenciesnatural disaster (more common)Influenza pandemic (more likely)Acts of terrorism (imminent)
71 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 WHOworse than Chinacomparable to Iraq.Euro Itchy and Scratchy:Have far fewer uninsuredGet more bang for their health care buckHave comparable waiting times and rationingAchieve comparable patient satisfactionTake it up the butthole on taxes, but don’t seem to mind
72 Universal Coverage: the Worst Possible System Would require new taxes and at least some increase in Federal bureaucracyPeople who hate it:DoctorsHMOs, insurance cosBig PharmaConservativesin powerLibertariansTrial LawyersThe publicOppos. TrendCurrent trends in American healthcare are unsustainableOther systems have huge problems, but still work better than oursPeople who want it:DoctorsProgressives & LibsHate AmericaEmployersThe public
73 Oppos. Trend EM takes up more slack for a sick healthcare system More uninsuredFew social support systemsLack of regionalization and nationalization“Highest bidder” technologies crafted to make money, not senseEM becomes MORE DIVERSIFIED and LESS FOCUSED“I’m doing a fellowship in Emergency Podiatric Acupunture!”EM loses its academic momentumIncreasing loss of hospitals and academic centers makes EM a “red-headed stepchild”EM seen as an economic drain on govts, med schools and hospitalsEM not well integrated in local and national disaster/antiterro planningEM integrated into a comprehensive national healthcare strategyInnovated technologies selected and deployed to maximze patient care and departmental readinessEM becomes MORE FOCUSED and LESS DIVERSIFIEDIt’s called “EMERGENCY MEDICINE”EM’s academic momentum continuesMore academic chairsMore NIH fundingMore translational researchNew areas of investigationStabilization of hospitals and medical centers stabilizes the standing of EdsEM seen as crucial to the success of local, regional and national health care systems, both operationally and financiallyEM a keystone element in disaster planning
74 “What are your predictions, Sullydog?” You haven’t been listening.
75 Okay, fine. Predictions the next 10-20 y Technological innovation will proceed apacesignificant deployment of nanotech, TMS, AI, neural nets, etc.Biotech from SingaporeEmergency Medicine will continue its current academic trajectoryResuscitology, heart failure, stroke, sepsisSystems analysis, GAs, ITPhysician wellnessCreation of new National Institute for acute/emergency/trauma medicine (as recommended by IOM)
76 Okay, fine Predictions for next 10-20 y IT will streamline our workflow and help put us at the bedsideIncreasing deployment of neural nets and AI-like systems to improve diagnosis and tx and reduce errorsContinued refinement and evolution of CQIAppearance of more explicit multidisciplinary team approach to EM
77 Okay, finePredictionsEDs will continue to pick up the slack while America gets her s**t togetherEPs and EDs will continue to do more primary careBad for Emergency MedicineBad for Primary CareBad for patientsPublic health mandates (funded vs unfunded)?Overcrowding will continue for the foreseeable future
78 Okay, fineIncreasing regionalization and nationalization of health care systemsDriven less by public health concerns than disaster / terror preparednessWhat 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