Sunday, February 17, 2013

What will a Doctors Appointment in 2020 look like?

(This is a short story I wrote for my medical school's new medical humanities journal)

I was getting big, scratchin’ 300 pounds, so I thought I should probably lose some weight. I saw an ad for a new doctors’ office in town, so I thought, “What the hell?” I don’t much care for doctors, hadn’t been to one in years besides my cardiologist, but my insurance through work had just kicked in (first time I’d had good coverage in a while) so I figured it couldn’t hurt.

When I walk into the clinic the first thing I notice is the smell.  Smells good, clean, homey.  My eyes adjust to the room, and the next thing I notice is that every single person is holding one of them fancy tablets.  They’re all wearing headphones, mumbling, making smudges on the flat surfaces with rubber tip pens.  I walk up to the window to check in and the nurse (the only person back there behind the glass) hands me one too, with a bracelet that she asks me to slip on my left wrist.

I do, and she explains, “The bracelet will measure your vital signs. Our practice is participating in a pilot program to test new interactive medical software. The tablet is running an app that will guide you through the medical history and personal information gathering process, but should you need any help I’ll be more than happy to assist you!”

I grunt, sit down, and am surprised by how comfy the seat is. Plenty of room, even for my fat ass. I don’t know how to use these gadgets very well, and I worry about making a fool of myself.  I push my thumb in the box, and the app starts up.  It asks me if I’ve got a smartphone, I click yeah.  It tells me to bump my smartphone to the tablet, so I do, and the icon floats from the tablet on to my phone.  The pop-up says , “I have located most of the information I need from your phone.  May I use it?” I click sure and it brings up a form for my personal information, most of it already filled out including my meds, pharmacy, allergies, as well as my name, address, where I work, insurance information, even my picture!  It freaks me out.  I guess I was worried for the wrong reason.  That was too easy! But at least I didn’t have to type it all. So much for privacy.

After I finish with that page a questionnaire comes up.  It asks me to use a gauge to measure how strongly I agree or disagree with the following statements:
• I am healthy (Yeah no)
• I want to be healthy (That’s better)

Next is some legal mumbo jumbo. Usually I just click “accept” but the tablet’s got eye motion trackers, won’t let me scroll unless I read it. Goddamn lawyers.

At the end of that page it asks:
“Would you like to know the results of all the tests that will be run today, or only those that are pertinent to your treatment plan?”
That’s easy. Less is more. What are they gonna do with the rest of it? I wonder.

Now it asks me to fill in the blank:
“A doctor should______”

I cough a little. How the hell should I know?  Isn’t he the one went to school for eight years? it tells me that’s an invalid answer.  No shit.  So I put “Listen.” Not sure where that came from, but it sounds good.  The app does some fireworks, then the tablet goes transparent (just uses the camera I suppose to show the room in front of me), and some arrows point towards the direction of the far wall, where I see a big TV with my first name two spots from the top, and the status bar says I should be in to see the Doc in about fifteen minutes.  Not too shabby for such a stripped down outfit.

The fifteen minutes seem like five, and the nurse calls me back.  She looks too young to have gone to nursing school. She takes the gizmos and says “All your vital signs are normal except your blood pressure, which is high.”
“How high?” I ask.
 “170 over 100,” she says.  She shows me a curve, and I see a line in the red danger zone which marks where mine is.  She asks me how I’m feeling, and if my chest hurts. 
I say, “I’m fine,” a little put off. 

She leads me to the room and says she needs to take some blood, and my heart starts to go bump.  All of a sudden I remember why I avoid doctors.  I curse under my breath, roll up my sleeve and she turns around with a fat pen, giggles, and says, “All I need is a naked fingertip.” She takes my hand and says, “Just a little pinch.” I feel a shock on my finger.  Reminds me of how my grandpa used to check his sugar. She turns away.
“That’s it?” I ask.  She turns back around, nods, says the Doc will be in shortly, and bounces her cute lil’ rear out of there.

I look around the room.  The walls are covered in some kind of plastic that doesn’t reflect the light very well.  There are no jars of supplies on the countertop, no flashlights with old telephone cords hanging on the wall behind me, no flickering fluorescents above, no obvious sign that I’m in a Doc’s office. I notice triangular solar panels in all the corners of the ceiling and another big flat screen on the wall next to me, covered with the same plastic film. I touch it. Reminds me of petting a sting ray at the aquarium as a kid, rough one way, smooth (almost slippery) the other.  The TV wakes up and starts flashing a commercial for hand sanitizer, as if to say, “Get your grubby paws off!” On the counter I notice a box the size of a lunch pail with a rotating holographic display of a naked man, hands at his sides, palms forward. There’s a rhinestone glove hanging on the wall next to it.  Kinky.  Hope I don’t need a rectal!

The screen is flashing some ad for a local gym. “You callin’ me fat?” I say out loud.  The ad is quickly over and changes to one about life insurance. God, the nerve!  A pop-up says, “The Doctor will see you now.” So I straighten up.  The door opens itself and in comes… Not the guy from the commercial.

“Hello, my name is Dr. Patel,” says a very attractive, dark, Asian woman wearing a white coat over a tight fitting pinstripe pantsuit.
“Um, I’m Hal.” I respond.
“Hello Hal!” She shakes my hand.  Her hand is smooth, but she has a firm grip. She takes the seat next to the table where I’m sitting and crosses her knees. Her shoes are worn on the bottom, but still got plenty of rubber left. Made for walking. She’s looking at me. Her eyes are framed by a thick, black coat of mascara to match her jet black hair. She’s stunning. Not good for my heart! 

“I had a chance to read your responses from our questionnaire.  Thanks for filling that out.”
I clear my throat. “Sure.”
“I just have a few more questions before we get started, OK?”
“What does ‘good health’ mean to you?”

I stroke my stubbled chin. Strange question.  And she doesn’t seem to be in any hurry, lets me sit there like an idiot for what seems like forever.

“To… to live to see your grandkids?” I ask with some hesitation.  
“Hum, alright. ‘To live to see your grandkids.’  And what role would you like me to play?”

Again, I’m stumped. Is this a game? What kind of place is this? I thought doctors were supposed to know what their job was.

“Just keep me alive!”
“I can do that,” she says with a smile. “So let’s get to it. What brings you in today?”
I shrug, slap my gut. “Ain’t it obvious? I wanna lose some weight.”
“Alright, you want to lose weight. Let’s write that down.  Computer!”

I reel back as she stands up, her raised voice still ringin’ in my ears.  The flat screen, which had gone the same color as the wall when she walked in, wakes up in a flash of color and graphics. I swallow hard. It takes me a second to get my heartbeat back to normal.   “Please show me Hal’s medical record.” A face appears, a balding older man with a grey goatee, thin white hair and glasses.

“Certainly, Doctor. And hello Hal!” the man says as he turns to me and nods.

“Hal, this is Howard,” says the Shedoc. “Howard is my scribe. He is an artificial intelligence, an AI,  like Siri. He can understand almost any question or command about your medical record, and I’ll be using his program during our visit today. Is that alright?”
I nod, not taking my eyes off the AI. He seems to see me too, and cracks a mischievous little smile. I look away.

“Howard, visit type is preventative health screening, and chief complaint is ‘I want to lose some weight.’” The face fades, and I see my words get typed into a large header at the top of the screen and from yards behind it, in TV land, I see templates rushing up, filling the remaining space. The doctor motions for me to join her in front of the screen, so I slide off the table and take a step closer. She reaches out and brushes two templates aside, they disappear off opposite edges of the screen. Using her pointer finger and thumb on each hand, she expands two rectangles onto the screen. I realize she’s not really touching it, just motioning. Then I remember the solar panels on the ceiling. “They must be motion sensors,” I think to myself.

“This box,” she points to one at the bottom, “will be our clipboard, where we’ll keep information temporarily. This,” points to one on the side “will be our problem list, where we will put your medical concerns that need to be addressed.” She looks me in the eye as she says this, likes she’s not at all impressed with this touch-no-touch big screen TV.

“Howard,” the face comes back, “Please populate the problem list.” The AI turns his face to the other side of the screen, and I see four or five items appear, words I don’t know with numbers after each one. I don’t dare interrupt, but she must have read my mind. “These are codes we use in medicine for billing purposes. This code is for your high blood pressure and this for your obesity.  The others are from past illnesses and surgeries.”

“Mmhmm,” I mumble.  When she said “your obesity” I felt like somebody punched me in the gut. I never thought of myself as obese before. My grandpa, now he was obese! Old man couldn’t get himself off the couch for the last five years of life. That’s not me!

“Howard, please show me Hal’s timeline.”  The templates and boxes fade, and in appears a grid with a thick red line across the screen, dotted randomly by points that grow tentacles with thought bubbles on the ends and fly off in all directions as they rotate slowly around the red line like a rotisserie.

“There are some pretty large gaps here in your record, Hal, from the time you were 12 to 18, and here again from age 21 to 30. What can you tell me about your health during those times?”
I tell her I don’t remember nothin’ from when I was a kid, except for a broken arm at 15, and that my family didn’t have insurance, and I spent my twenties in and out of jail…

“In what state were you incarcerated?” interrupts the AI. His voice squeaks then goes deep, grindy. Startles me.
“Here. Uh, this one.”
“I am searching for your records now.” A pause. “Yes, here they are.” All of a sudden there are so many dots in my twenties that they run together. My lifeline looks more like a rolling pin.
“You saw the doctor often in jail?” It wasn’t really a question.
“Sure. Every week. All there was to do.”
“I understand. In between sentences were you ever hospitalized or had surgery?”  she asks.
I think for a minute.  “Yeah, once in ’09. Car crash. ‘Bout broke my goddamn neck.”
“I have located those records also!” sings the genie in the TV.

She asks me more questions about my sauce and smokes, about the meds I take, and digs out of me that this is the first time I’ve been to see a regular doc in about 5 years.
“All this must seem very strange.” She gestures toward the screen.
“It’s different.” Too different! Things change too fast to keep up with nowadays.

“Thank you, Howard. Please update the problem list. We will now proceed to the physical exam.” The screen returns to the boxes. More red words and numbers. She smiles and motions with her arm for me to have a seat back on the table.  I sit, glance at the clock, and realize I’m tired even though I was only standing for 5 minutes. It wasn’t that exciting.

“Are you alright?” she asks.
“I’m fine,” I say, catching my breath.
“Very well.” She goes on, “To begin, I’d like to ask some general questions about your health in the last week.” She pauses, and I nod for her to go on. She’s standing close to me now. My eyes are at the level of her chest, and I realize I’m staring. It’s hard not to.

“Have you had any fevers, sweats, or chills?”
“Unexpected changes in weight?”
“I wish!”
 She laughs, just once, and then she chokes it back. I don’t mind. In fact I want to hear it again. She puts her hands on my head, and chills run down my neck and chest. It has been so long since somebody touched me. When I open my eyes, I see her pulling out what looks like a phone from her coat pocket. She asks me to look directly ahead and a bright light pierces into my right eye, then my left.

“Have you had any changes in vision?”
“Hum! Now you ask!” Another laugh. When the black dots fade I see two pictures of red, spidery veins on the screen.
“What are those?”
“Your retinas, and they appear normal except for some new vessel growth here around the disk, something we call neovascularization, which is an early sign of diabetes.”  I see the words she just said show up under the images. The last word, diabetes, stands out. That’s what Gramps had. Diabetes. Obesity. He died in his early sixties, a mess: pissing his pants in front of the TV, smellin’ like a dumpster. Had a heart attack. Slumped over, like he slept. The day was half over before we figured it out…

She keeps talking. All I’ve got to say is, “No.” She’s in my ear now. A picture of my greasy ear drum appears on the TV.
“Can you hear this?” A rumbling sound.
“Tell me when you can no longer hear it.” The pitch goes up, gets shrill like a dog whistle, then it’s gone.
 “Alright.” She does the other ear. She takes off the little plastic funnel, and says, “Please open your mouth, stick out your tongue and say ‘Ahh.’” I do much more than that! But this time, she only smiles. Charm is wearin’ off. I glance over at the TV again and notice the words are still churning out. It must be watching her and taking notes.

She asks me to unbutton my shirt. I bite my tongue, and do as she says. She pulls out a small probe, like a lip balm tube, and says “I’m going to place this on your chest to listen to your heart and lungs.” She places it against my chest with her right hand, and stares at the phone in her left.  I hear whooshing—my heartbeat—I see a dance of blue and red on the small screen. She twists the probe, like she’s turning a car key, and then moves it around in all directions like she’s tenderly stabbing me in the heart.  
“Any chest pain? Palpitations? Shortness of breath?”
 “No.” I lie.
She moves to the other side of my chest, haves me breathe in and out through my mouth, all the while twisting and turning the probe this way and that.
“No shortness of breath?”
“Nope.”  Not why I came in.  Next she holds it up to my neck, one side, the next.

“Now I’d like to listen to your abdomen.” I start to lie down, but she stops me. “That won’t be necessary.” She presses the tube into the center of my gut. I suck in. “Try to relax” she says. She moves it up under my ribs on either side. I can’t help but tense up. She eases off. Another round of questions.
“No... No… No…”

“Ok. We’re done with this!” She puts the tube back in her pocket. I exhale. She starts tapping on the phone and talking without looking up. “Not long ago these ‘studies’ [she air quotes] used to be ordered outpatient and would take days, even weeks, to get back to the physician, and when they did eventually get back to us we didn’t know what to do about it most of the time.”

“What changed?”

She smiles, puts her phone away, looks me in the eye and says, “Let me show you.”

She walks over to the box with the naked man on top, puts on the glove, and walks back. Here we go, I think to myself and the bumping starts again. But she turns to the TV instead of askin’ me to bend over. My buttcheeks relax, and I slump with a sigh.

The genie pipes up. “Virtual rendering is complete. Would you like to view the model now?”
“Yes, thank you Howard.” A 3D image of a torso appears. Looks familiar, but at least twice as fat as me.
“Please prepare echogenic visceral cross sections of these regions for the transducer.” She draws a circle with the gloved hand over the model of my upper belly and my heart. The layer of skin becomes transparent, a thick layer of yellow fat, then the muscles and bones fade away and I see the plumbing. I see the same thing floating in the air above the box! She walks back over to it, reaches into the box with the gloved hand, and I see fingertips appear inside the hologram fondling the tubes. Her fingertips!

“What the hell is that thing?!” It comes out like a cough.

“This is a force transducer that converts the ultrasound image obtained during the exam into a model that I can feel using this special glove. Pretty neat, huh?” I’m speechless. I get it, but I don’t at the same time.

“This method allows me to feel the density of your liver, the thickness of your coronary arteries, and the amount of fat around your pancreas without having to cut you open—better for both of us!” She’s not showing off, she’s genuinely giddy. I can tell this is her favorite part of the job. It’s almost cute, but then I remember that those are my guts, and seeing her fingers digging and pinching ‘em gives me the heebie-jeebies.

She turns to me, holds out the glove and says, “Wanna try?” I feel sick, an acid burp bubbles up and burns through my nose.
“No thanks.”
She shrugs. “Howard, please add the following diagnoses to the problem list.” The box with the red words comes back. “AFLD, nodular cirrhosis of the caudate lobe, chronic pancreatitis with fibrosis, metabolic syndrome, and coronary atherosclerosis of the LAD.” The words tumble onto the list, each with a number. It’s all Greek to me.

“I’m sorry for the medical jargon. Basically what I found is evidence of liver dysfunction, inflammation in your pancreas, and hardening of the arteries that keep your heart alive. These are all consistent with your history of alcohol use, a fatty diet, and a family history of diabetes and heart disease.”

Holy Shit! Is she talking about me?

 “Howard, please access Hal’s vitals and blood results and combine his Framingham score with the Seattle heart failure model to compute a 10 year survival curve with a 90% confidence interval.”
“Certainly Doctor… With no improvement in Hal’s health status, the natural course of his disease will most likely end in death in the next ten years; in other words, the probability that Hal will be alive in 10 years with no improvement in his health is approximately 45%. Most likely cause of death is stroke, second most likely cause of death is heart attack.” She turns to me slowly, and asks, “Do you have any questions?”

She doesn’t touch me, but I’m in pain. The words slice through me. I feel numbness replace the ache.
I’m checkin’ out.

My mind is blank. My mouth hangs open. I see nothing.



I heard what he said. It shouldn’t surprise me. I saw the whole thing, saw everything she did. It is me they’re talking about. My body! Right?

The room comes back into focus. I look away from her, to the box of red words, to the list. A death sentence written in a language I can’t even read!

I shouldn’t have come.

“How are you feeling right now… emotionally?” Her voice is quiet. Sounds far away.

“How do I feel?” You just told me I’m gonna die! How do you think I feel?

I see Gramps, before he got sick—strong, laughing, leaning over to give Grams a kiss. I remember the look on her face the day we buried him, the same questioning look she had every day he was sick that seemed to always ask “why.”
That’s not me. I don’t wanna die! There’s got to be a way out. There’s always a way out!

“What can I do? What are my options?”

“You want to change?” She’s not smiling. Her look is challenging, straight in the eyes.

 It’s game time. “Yes.”

“What are you willing to do?”


“Good.” Her lips part and she smiles, big and beautiful. “Howard, please add another 10 minutes to my visit with Hal. He and I would like to discuss a treatment plan to improve his chances of survival.”

“By what factor, Doctor?”

“How about we double it? Bring it up to 90%?” She’s asking me. I jerk my head up and down.  She shouts, “Therapeutic target is 90%!”

“Input received… Accessing decision analysis program Delta Rho… building individualized decision web for Hal… Rendering is complete!”

“Show me the web Howard.” She is standing stiff, moving slowly. She puts the glove back on. She is in another world, in TV land. The status bar at the bottom says COMPLETE and in comes a flashing point, lines shooting out from it in all directions and branching, more points, more branches! The image shrinks to make room on the screen for the new branches. One line veers off to the right, becomes a deep red, then goes out of sight. Another turns yellow, then goes straight up to the top.  The perspective starts to change. I look over at her and see that she is holding her gloved hand out in front of her like a priest during a blessing, and she is slowly extending it straight out.  As she moves, the view changes. A small flick of her finger erases an entire branch, the red one.

We get close enough to one of the points to see that it is labeled, “Immediate intervention: Compatible statin therapy+35% total cholesterol reduction+ moderate exercise+ compatible diet= 65% 10 year survival.” She reaches out and the node lights up a bright green.

“This is our approach, Hal, uh, I mean Howard.” She snaps out of it, turns to me, “Sorry!”

“That’s alright,” I say.

“Well, as you can see these interventions will get you most of the way there; however, we are still pretty far from our goal of 90%. This is where you come in. I’m going to put your resolve to the test.”

“I’m listening.”

“Before we go any further, I need to know how committed you are to making the changes listed here. Howard will build reminders into the calendar on your phone, he will send you a shopping list every week for your diet, and he can negotiate with your insurance company to pay for a gym membership and even reduce your premium if you are following the plan and losing weight. But, if you don’t, your rates will go up, and they will go up twice as fast if you start to gain weight! Do we have a deal?”

“You drive a hard bargain!” Got me where it hurts

“From one to ten, how committed are you to this course of action?” she asks.

“Hum… I’d say an eight.”

“Why eight? Why not nine?” She’s puttin’ on the pressure.

“Well, I’ve tried to do this before, and it always starts off well, but you know how it is… The road to hell…” I look down at my feet, squeamish, embarrassed, but it’s the truth.

“Alright, why an eight instead of a seven?” she asks it in a kinder way, almost like she’s impressed.

“Cause it’s what I want. That’s why I came in here.” For the first time I feel like I can look her in the eye. I’ve laid it all out. I got nothing left to lose. This is me.

“I know you can do it Hal, and I’m going to do all I can to help you succeed.” She lays her hand on my shoulder. I feel emotions breaking to the surface. It’s uncomfortable. I swallow, blink, wipe my nose with the back of my sleeve. “But there’s something else I need you to do—you’ve got to give up the tobacco, for good. Let me show you why.”

She turns again to the wall.  “Howard, what are Hal’s chances of survival if he stops smoking as of today?”

“Including tobacco cessation to decision model… 10 year survival with current parameters is approximately 90%!” She looks right at me. She doesn’t say anything. She doesn’t have to. It’s my call.

“I’ll do it.”

“Good! And what about your wife?”
How did she know about the Mrs.?!

“Er, what about her?”

“Will she support you in this? And by that I mean will she help you with the diet, exercise program, and most importantly will she stop smoking, too?” I hadn’t thought of that.

“I don’t know.” I honestly don’t.

“Let’s ask her, shall we? Howard! Please call Hal’s wife for me, Jane, isn’t it?” She cocks an eyebrow. She’s relentless!

“Connection is secure.”  The PA crackles, I hear my wife’s ring tone.

“Mrs. Watson?”
“Hello, this is Dr. Patel, your husband’s physician.”
“Oh God! Is he alright?”
“Yes, yes. We have just discussed his health and have agreed on a comprehensive treatment plan to make sure you and he get to enjoy your grandkids!” She smiles over at me.
“Oh. That’s… that’s great.”
“But Mrs. Watson, I would like to ask if you are willing to work with Hal and I to make this happen. Can we count on you?”
“What do you mean? Of course I want to help! Why wouldn’t I?”
“Hal is going to start eating better, exercising, and he is going quit smoking. And to be successful, he needs our help with those things—yours and mine. Are you willing to quit smoking as well?”


“I suppose. I mean… Yes. Of course.”
“Wonderful! I will email you the details, and please feel free to write back or call with any questions. We are still accepting patients, and I would be happy to be your physician as well, should you need one.”
“Oh, well, thank you!”
“Goodbye now!”
“Ok, goodbye!”

I laugh out loud! I can’t believe what just happened. Never in my life have I seen somebody with balls that big! And on a woman to boot!

If I wasn’t a married man…

“Well Hal, our time is coming to a close. Before I say goodbye, I just want to quickly summarize our visit today.” She pauses for my nod. “We put together a timeline of your life and medical history, identified your major medical concerns, and seeing the real probability that you would not be around for your grandkids we came up with a plan to improve your chances—double  them—which  includes: 1, adding a medication to your daily regimen to lower your cholesterol; 2, an individualized diet with automated support; 3, an exercise program and financial incentive to lose weight; and 4, immediate tobacco cessation. Are you with me?”

Wow! We did all that? We did, didn't we?

“I’m with you, Doc.”

“Alright, I’d like to see you again in two weeks to follow up on your progress. And in the meantime, I want you to know that I’m here for you if you have questions or concerns. The app on your phone will help you reach me and give you access to everything we discussed today regarding your treatment plan.”


“I’ll see you next time!” She shakes my hand. The door opens itself, and out she goes.

I sit there for another minute, gather my things and step out into the day. I had forgotten what a beautiful day it was! Or maybe, I just didn't notice it before. I reach for my smokes, then stop.

Wait! What did I just agree to? What the hell just happened?


  1. Jordan -

    That was a great story. I am curious, how much of this is in the research pipeline today?

  2. Just about all of it, except for the decision analysis software and interactive medial AI (although IMB's Watson is pretty nifty).

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