Disruption doesn't show on the tip of the iceberg

Joan Escarrabill

By chance, a couple of years ago, I found some images of Gediminas Pranckevicius, a Lithuanian graphic designer. Some of these images present a (small) upper part in which he describes familiar scenes, but the rest of the image (the lower part) is very complicated. The metaphor is automatic: there is (extraordinary) life in the submerged part of the iceberg.

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Disruptive changes take place in the submerged part of the iceberg that, in a short time, change the image of the visible surface. Taxi is a service that is changing in a profound way. The digital press also gives us some clues. In New York, it appears that there are ten times more alternative taxis than conventional taxis, which has caused a decrease in the income of taxi drivers (by almost 30%), a reduction in the value of licenses and a negative impact on traffic due to the large number of vehicles that circulate without passengers. It's a significant problem from many points of view, and the most impressive thing is that these profound changes have taken place in less than five years.

When this situation extends to the world of healthcare and the impact of digitisation –or technology in general– is discussed, many colleagues say that the disruption in the healthcare field will never be so radical or so rapid.

Many health professionals believe that these disruptive changes will not occur in the world of health. Maybe not. However, rifampicin was introduced in 1973, and anti-tuberculosis sanatoriums closed in 1981. Brain CT cornered the EEG, and the macrolides eradicated Helicobacter pylori and brought selective vagotomy to the showcase of history. Another example is the irruption of laparoscopic surgery. All of these changes spread in a short time. If this is not disruption, perhaps we should revise the definitions.

Health organisations continuously worry about the future. The approaches are usually reliable and highly argued, and the proposals aim to adjust the needs to the capacity (economic and human) to solve the pending challenges. The national strategy for primary care and community health (ENAPISC) is one of these approaches to the future. These conceptual frameworks are necessary, but the critical question is: are they sufficient? Are we talking about the tip of the iceberg (what is evident) or the invisible nine-tenths?

It seems that there are many elements below the pianist in Pranckevicius's image. I would dare to identify three:

a) The perspective of citizenship. There are good proposals for citizen participation that have given rise to AQuAS (2015) and the framework for citizen participation in health (Department of Health, 2017). Nevertheless, it is crucial to think about how the citizen perspective will incorporate into the transformation models of the health system. Do we health workers and citizens say the same thing when we talk about integration? Does integration include time management and information flow in the real world? It is vital not to make assumptions when we talk about the interests of citizens.

b) How will data (the extensive use of data) influence the design of services? Ping An Good Doctor, is a Chinese healthcare platform (with more than 200 million users) that combines mobile technology and artificial intelligence to offer healthcare services. It has installed 3 square metres booths that offer health diagnoses without health professionals and immediate access to essential drugs (One-Minute Clinic Booths). A video by Dr Jay Davisson discusses some exciting ideas about artificial intelligence taking on the role of a healthcare professional. Technology will offer answers that we cannot even imagine. Moreover, I do not enter to value its "quality".

c) The logical consequence of the irruption of the world of data and artificial intelligence leads us to the question of to what extent the machines will carry out work that we humans now do or to what degree the intimate interaction between the human being and the machine healthcare practice will change. There are some troubling answers in Mark O'Connell's book To Be a Machine. Will machines (technology) compensate for the fragility of the human body? Do we have to start thinking about cyborgs?

Perhaps, in the end, if we want to foresee the future, we would have to ask the reverse question: what jobs will the machines not do? Some authors say that humans still have more empathy, creativity and intuition at least for now.