Yesterday I saw this tweet from Enrico Coiera:
So I downloaded the editorial and noted these sections:
Through the Internet, the public has access to a growing supply of information on health and disease, often of variable quality and relevance. As a result, providing information on health will no longer be the exclusive remit of health care professionals.
Coiera, 1996, p. 3
And…
It is clear that the changing nature of information delivery brings with it enormous implications for the delivery of health care. There is a pressing need for dialogue within the profession to understand the impact of communication and information technologies on the provision of health care. Some sections of the profession are already actively experimenting with the technology. However, the implications of the Internet extend far beyond the technology itself. We should now, and with some haste, be examining its implications for the future of medical practice (my emphasis).
Coiera, 1996, p. 3-4
Reading the article today, it’s hard to recognise how prescient Coiera was when he made these claims in 1996. In retrospect it’s easy to map these ideas onto the present day and to draw a reasonably straight line from 1996-2021. Obviously, “the changing nature of information delivery brings with it enormous implications for the delivery of health care.” It’s hard not to see the changes over the last 15 years as a natural and inevitable progression. But there’s nothing inevitable about the direction that the development of any technology takes. Every feature of a technology is the result of a series of human choices that optimise the technology towards a value-laden outcome.
But even if it’s relatively clear that technology and it’s uses aren’t inevitable, it’s still difficult to see how some people can get it so wrong. Shortly after Coiera’s editorial was published in the BMJ a medical librarian wrote to the editor in response (this is the letter that Coiera is referring to in the opening tweet):
Coiera states that, as a result of the Internet, the provision of information on health will no longer be the exclusive remit of health care professionals. This statement is obviously false: other well known providers of information on health include grandmothers, busybodies, sick people, magazines, and libraries-and all of them have been around for much longer than the Internet. Other features of the Internet that Coiera identifies – accessibility, uncontrollability, lack of confidentiality, and variability with regard to the quality of information provided-apply equally well to the sources I have listed. There is nothing new here (my emphasis).
Due, 1996, p. 977
The really big impact of computing on information delivery, which was never so widely heralded as the Internet, resulted from a much more important innovation than a mere communications system. This was the introduction by librarians of computerised indexes (my emphasis) such as Medline, which provide access to information through the use of search tools based on multilevel thesauruses and boolean logic (neither of which can readily be used in a printed index). This occurred 30 years ago.
Due, 1996, p. 977
What struck me isn’t the fact that Due got it so wrong; no-one has a monopoly on making the wrong bet. The important takeaway for me is that Due wasn’t able to see outside his own paradigm. He honestly thought that the introduction of digital indexes was a “much more important innovation” than the internet, which he refers to as “a mere communications system”. He couldn’t see outside his world of medical libraries, to the extent that this “mere communications system” was insignificant alongside the introduction of digital indexes. He was completely unable to see that everything in his world was about to be disrupted.
It’s easy to focus on how spectacularly Due got this wrong but I shouldn’t need to point out that the same was true for almost every industry at the time, including music, news, advertising, travel, etc. We all find it difficult to see outside our own paradigms and so end up thinking that, while technology will surely disrupt those other people over there, we’re safe because we’re different. There is something essential about what we do that can’t be replicated more efficiently and more effectively by something else.
I’m thinking of this now because I’m in the middle of analysing a dataset that I collected in 2019, on physiotherapists’ perceptions on the introduction on AI into clinical practice (yes, I know it’s a bit late, but Covid). It’s striking how the aspects of clinical practice that I think are most vulnerable to automation (for example, clinical reasoning) are often the ones that my study participants believe is safe, because “we’re different”. Often they refer to something that I’ve been coding as the “Human element”, which they seem to be using as a shorthand for an ephemeral human quality that isn’t replicable by machines and algorithms. “We’re different”, is what they seem to be saying. I can’t help but wonder if we’re moving into the future with the same blinders that prevented Stephen Due from seeing the internet as more than “a mere communications system.”
We really need to figure out better ways to see outside of our paradigms.