beauty of medical technology essay

Use of Technology in Healthcare Essay

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The modern health care industry is significantly transforming in terms of decision making, workflow, and information management. These changes are motivated by a federal policy focusing on building an electronic infrastructure that supports patient safety, service quality, and other healthcare initiatives. The National Strategy for Quality Improvement in Healthcare (further referred to as National Quality Strategy or NQS) has three primary purposes: to provide better and more affordable care and pursue healthy communities and populations (McBride & Tietze, 2018). Health information technology (HIT) is promoted as a critical element in this context. It implies the application of informatics as a tool for improving the health of populations served and the care delivered to them.

Several legislations have been implemented to achieve NQS goals. Most notable of them are the Affordable Care Act (ACA), the HITECH Act, and an incentive program for electronic health records (EHR) (McBride & Tietze, 2018). ACA was first implemented in 2009 to combat the uncontrollably escalating prices in the healthcare field (Zhao et al., 2020). The main idea is to manage the cost and simultaneously improve the quality of care services. An example of such control tools is the creation and support of accountable care organizations (ACO). These organizations supervise savings accounts for contracts at risk, which oblige the provider companies to fixate the rate of provided services.

Meanwhile, ACA establishes the general framework for qualitative performance evaluation. Its measures are systematized under five domains: patient and caregiver experience, safety, preventive health, at-risk population health, and care coordination (McBride & Tietze, 2018). To fulfill the requirements to be considered an ACO, organizations must implement sophisticated technology. In particular, ACOs require EHRs and health information exchange (HIE) data to be translated into actionable information representing comprehensive data management and extensive reporting capability. Consequently, HIT infrastructure is vital for advancement within the ACA healthcare delivery system.

The HITECH act holds responsibility for the promotion, adoption, and meaningful use (MU) of the HIT. It was implemented in 2009 with a focus on HIT support, college programs offering HIT training, and various grants supporting the research (Lin et al., 2019). In the context of HIT MU, HITECH developed three phases to accomplish the goals defined by the NQS. Each phase of MU emphasizes the technology it is designed to improve, which results in robust infrastructure and reliable outcomes (McBride & Tietze, 2018). Phase one focuses on implementing certified EHRs’ basic requirements, such as the ability to assess and report quality metrics and information exchange using electronic prescriptions. MU’s phase two targets consumer engagement (also referred to as “patient-centeredness”) and increases the assessing and reporting capacity of the data exchange concerning certified products. Phase three further expands the data exchange capacity requirement (more structured data, higher quality reporting) using HIEs at a more significant scope – within and across regions and states.

In the context of MU phases, the organizations that adhere to MU’s established standards are financially supported with payments from the EHR incentive program. In other words, the organization receives incentives when using a certified EHR and adhering to specific certified products’ criteria (McBride & Tietze, 2018). Starting in 2011, the incentive program extended over the years, with its timetable determined by the provider’s choice to either adhere to Medicaid or Medicare incentive programs. In the meantime, hospitals have access to both Medicaid and Medicare incentives; in many cases, these incentives can equate to millions of dollars.

Lin, Y. K., Lin, M., & Chen, H. (2019). Do electronic health records affect quality of care? Evidence from the HITECH Act . Information Systems Research , 30 (1), 306-318. Web.

McBride, S., & Tietze, M. (2018). Nursing informatics for the advanced practice nurse: Patient safety, quality, outcomes, and interprofessionalism (2 nd ed.). Springer Publishing Company.

Zhao, J., Mao, Z., Fedewa, S. A., Nogueira, L., Yabroff, K. R., Jemal, A., & Han, X. (2020). The Affordable Care Act and access to care across the cancer control continuum: a review at 10 years . CA: a cancer journal for clinicians , 70 (3), 165-181. Web.

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The Beauty of Medicine Discoveries

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Medical Technologies Past and Present: How History Helps to Understand the Digital Era

Published: 07 July 2021
Volume 43 , pages 343–364, ( 2022 )

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Vanessa Rampton ORCID: orcid.org/0000-0003-4445-8024 1 ,
Maria Böhmer 2 &
Anita Winkler 2

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This article explores the relationship between medicine’s history and its digital present through the lens of the physician-patient relationship. Today the rhetoric surrounding the introduction of new technologies into medicine tends to emphasize that technologies are disturbing relationships, and that the doctor-patient bond reflects a more ‘human’ era of medicine that should be preserved. Using historical studies of pre-modern and modern Western European medicine, this article shows that patient-physician relationships have always been shaped by material cultures. We discuss three activities – recording, examining, and treating – in the light of their historical antecedents, and suggest that the notion of ‘human medicine’ is ever-changing: it consists of social attributions of skills to physicians that played out very differently over the course of history.

Trends in the Development of Digital Technologies in Medicine

Donna Haraway: The Digital Cyborg Assemblage and the New Digital Health Technologies

Digital health—high tech or high touch.

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Human beings have their own goals and intentions, and products should help them to realize them in an optimal way. In many cases, though, these goals and intentions do not exist independently from the technologies that are used. [Technologies] do much more than merely function – they help to shape human existence. Peter-Paul Verbeek (2015, 28)

Introduction

A wide range of novel digital technologies related to medicine and health seem poised to change medical practice and to challenge traditional notions of the patient-physician relationship (Boeldt et al. 2015; Loder 2017; Fagherazzi 2020). A number of recent pieces have explored the ethical implications of this, asking, for example, whether new means of delivering ‘greater efficiency, consistency and reliability might do so at the expense of meaningful human interaction in the care context’ (Topol Review 2019, 22). Various contributions from patients, physicians, bioethicists, and social scientists have warned that computer technologies somehow stand between the physician and the patient and that there is a fundamentally human aspect of medicine that coexists uneasily with machines (e.g. Gawande 2018; Verghese 2017). As a remedy, recent contributions call for ‘clinical empathy’ not only as a desirable characteristic trait of future physicians, but even as a selection criterion for medical students (Bartens 2019). The role history plays in these discussions is striking. Commentators often assume that current concerns about how technologies may lead to the ‘de-humanisation of care’ (Topol Review 2019, 22) are the unprecedented products of technological, social, and cultural transformations in the late twentieth-/early twenty-first centuries. When the history of medicine is referenced, it is largely in one of the following ways: first, to emphasize that today ‘[w]e are at a unique juncture […] with the convergence of genomics, biosensors, the electronic patient record[,] smartphone apps, [and AI]’ (Ibid., 6), whereby the singularity of the digital era makes historical comparisons with antique predecessors seemingly irrelevant. Second, the history of medicine is used in a nostalgic manner to refer to past medical practices, seemingly grounded in the ability of a doctor to ‘liste[n] well and sho[w] empathy,’ as having a fundamentally human element that is threatened by the digital era (Liu, Keane and Denniston 2018, 113; see also Johnston 2018). With some notable exceptions (e.g. Greene 2016, Kassell 2016, Timmermann and Anderson 2006), historians of medicine have largely refrained from attempting to interpret recent digital developments within their broader historical contexts. The historicity of digital medicine in its various forms and the insights of the history of medicine for contextualising the patient-physician relationship in the digital era have yet to be fully fleshed out.

In this contribution, we draw on historical examples and the work of historians of medicine to highlight how all technological devices are ‘expressions of medical change’ (Timmermann and Anderson 2006, 1), and to show how past analogue objects shaped physician-patient relationships in ways that remain relevant today. Our focus is on Western European medicine since the early modern period. While acknowledging the profound differences between medicines in particular historical times and places, we argue, first, that patients and doctors have always interacted in complex relationships mediated by objects. Medical objects and technologies are not only aids for performing certain human tasks, but themselves have a mediating function and impact how physicians and patients alike perceive illness and treatment. We then contend, second, that history helps inform current discussions because it highlights the plurality of ways in which the physician-patient relationship has been conceived in different eras. In particular, the ability of the physician to listen well and show empathy seems to be not so much a historical constant but rather a social attribution of certain skills to physicians that played out very differently over the course of history. Both points help us to show that some of the hopes and fears related to digital technologies are not so entirely new after all.

We work through these hypotheses in relation to three activities in the clinical encounter that have been significantly affected by digital medical technologies, namely i) recording (Electronic Health Records), ii) examining (Telemedicine), and iii) treating (Do-It-Yourself medical devices). In each case, we begin with a specific contemporary technology and the debates around it before showing how a historical perspective can contribute to our understanding of them. First, we discuss electronic health records in the light of current criticisms which maintain that this technology cuts valuable time the doctor should be spending with the patient, thereby threatening an assumed core responsibility of the physician, namely listening empathetically to the patient. History shows that physicians have not always seen administrative record-keeping as foreign to their main work with patients; rather, it has been a formative part of their professional identity at different times. Moreover, the value that both physicians and patients ascribed to empathic listening has varied substantially over time. Second, in the case of examining, we start from the observation that current debates about telemedicine focus on the greater distance between patients and physicians this technology brings about. The historical perspective demonstrates that these debates are but one example of how changing examination technologies affect both physical distance and reciprocal understanding in the patient-physician relationship. Our examples illuminate that physical proximity in the medical encounter is a modern phenomenon, and that it did not always imply a meeting of the minds between physician and patient and vice versa. Finally, our third section on self-treatment demonstrates that Do-It-Yourself devices have the potential to challenge medical authority and, by giving patients more power, alter those power balances between physician and patient that are constitutive of an idealised view of the patient-physician relationship. Yet here too there are significant historical precedents for thinking of doctors and patients as but two players within complex networks of people and technologies, in which patients ascribe value to a multiplicity of relationships.

Record-keeping: computers and the administered patient

Electronic health records (EHRs), that is computer-based patient records, have transformed the way contemporary medicine is practiced (see, for example, Topol, Steinhubl and Torkamani 2015, 353). While the electronic recording of patient files by individual health care providers has become common practice since the 1990s, a central virtual collection and storage of all health data relating to an individual patient is a rather new development which is currently being debated and technically introduced in various states. This virtual patient file is of secondary order because it is fed with original electronic files derived from various primary recording systems (GP, clinic etc.), and it follows a population health surveillance logic rather than the logic of the treatment of individual cases. The main idea is that both patients and health care providers have access to a corpus of health documents, which is as complete as possible, to make diagnosis and treatment more efficient, more precise and safer for patients, and less costly for the health system. While patients may make use of this possibility on a voluntary basis and are asked to distribute access rights to providers, healthcare providers are obliged to cooperate and feed the system with relevant data (for a local example see current implementation efforts in Switzerland and its pitfalls as described in Wüstholz and Stolle 2020). One of the main premises of supporters is that EHRs will facilitate not only networking and interprofessional cooperation but also enhance communication between doctors and patients: they ‘provide health care teams with a more complete picture of their patients’ health [and] improve communication among members of the care team, as well as between them and their patients’ (Canada Health Infoway; see also Porsdam, Savulescu and Sahakian 2016).

Yet critical discussions surrounding the introduction of EHRs doubt exactly that. They suggest that the increasing documentation, virtual storage and sharing of sensitive patient data threatens an assumed historical core value of the doctor-patient relationship, namely the possibility of physicians establishing an intimate and ‘deeper connection’ with their patients (Ratanawongsa et al. 2016, 127). From the perspective of healthcare providers, professionals criticise the time-consuming nature of EHRs, arguing that this technology supplants the time the doctor has for direct communication and time spent ‘in meaningful interactions with patients’ (Sinsky et al. 2016, 753). That screens are coming ‘in between doctors and patients’ is a widespread notion (Gawande 2018). In addition, medicine’s increasing dependence on screens is perceived as undermining important social rituals, such as exchanges between physicians and other healthcare colleagues who used to discuss their cases in more informal ways (Verghese 2017). Last but not least, EHRs are seen as a major factor contributing to declining physician health and professional satisfaction because of their time-consuming data entry that reduces face-to-face patient care (Friedberg et al. 2013). This last point seems to be crucial as the digital interfaces of EHRs indeed require a maximum of standardisation, homogenisation and formalisation of recording styles that necessarily conflicts with more informal, individual recording techniques. On the one hand, doctors are forced to fill in fields and checkboxes that do not correspond to their own knowledge priorities, that is the things they would want to highlight in a certain case from the perspective of their specialty. On the other hand, they have difficulties in identifying relevant information when too much data on an individual patient has been entered by too many people. The desired interprofessional collaboration thus runs the risk of complicating instead of facilitating the making of a diagnosis. Surgeon Atul Gawande maintains that in the past, analogue documentation forced physicians to bring essential points into focus: ‘[d]octors’ handwritten notes were brief and to the point. With computers, however, the shortcut is to paste in whole blocks of information […] rather than selecting the relevant details. The next doctor must hunt through several pages to find what really matters’ (2018). Together, these points of critique suggest not only a certain fear that the increasing digitisation of patient records might disturb relationships that in the pre-digital era were based on professional intuition and meaningful, trust-building face-to-face communication. The critique also suggests that what is threatened is the meaning and satisfaction a physician takes from his/her recording work.

From the perspective of patients, other concerns related to EHRs are more relevant, among them the safety of personal health data. But while notions of privacy – who has control over the data, who owns the patient history – are important for patients, a number of studies also show that patients perceive the careful digital documentation of their case as something positive (Assis-Hassid et al. 2015; Sobral, Rosenbaum and Figueiredo-Braga 2015). ‘Forced to choose between having the right technical answer and a more human interaction, [patients] picked having the right technical answer,’ reports Gawande (2018; see also Hammack-Aviran et al., 2020). It thus seems that as long as patients think EHRs are providing them with a higher quality of care, they readily accept EHRs and their doctors’ dependence on screens – hence adapting their expectations to technological change.

In order to scrutinize these purported threats and attitudes towards EHRs, the rich history of patient records provides a relevant historical backdrop. In studying patient records, historians have addressed exactly these issues: they have examined how the patient-physician relationship has changed over time and have used medical records to gain insights into how past physicians documented medical knowledge, how this influenced their perceptions of their professional identity, and their obligations vis-à-vis patients (Risse and Warner 1992). As a first step, it is important to see that even though EHRs pose new challenges because of their digital form, recording individual patients’ histories as part of medical practice and ‘thinking in cases’ as a form of epistemic reasoning are a historical continuum (Forrester 1996; Hess and Mendelsohn 2010). The patient history dates to ancient Hippocratic medicine when detailed medical records were written on clay tablets and handed down for centuries to preserve the esteemed knowledge of antiquity (Pomata 2010). Yet the content and form of medical records, as well as the practices producing them have changed remarkably over time (Behrens, Bischoff, and Zelle 2012). In Western Europe, physicians in sixteenth-century Italy re-appropriated the ancient practice and typically recorded their cases in paper notebooks, as part of a larger trend to systematize and record information (Kassell 2016; see also Pomata 2010). As Lauren Kassell notes, the records of early modern practitioners ‘took the form of diaries, registers or testimonials, often they were later ordered, through indexing or commonplacing, by patient, disease or cure, providing the basis for medical observations, sometimes printed as a testimony to a doctor’s expertise as well as his contribution to the advancement of science’ (2016, 122). The historical perspective reveals that the rationale for a particular type of medical record-keeping always developed in tandem with the technical capabilities for its enactment, changing ideas of how diseases should be recorded, as well as with the preferences of individual physicians (ibid. 120). Crucially, as the organization of these collections of patient histories changed, so too did medical knowing and normative ideas about the physician-patient relationship (Hess and Mendelsohn 2010; Dinges et al. 2016).

As shown above, current critical discussions about EHRs tend to evoke a medical past in which patients were given time to talk about their illness, doctors listened and engaged in meaningful interactions, and record-keeping did not interfere with these processes. Allegedly, there were few concerns over misuse of data as there was less data produced and fewer players in the game. How does this popular nostalgic view correspond to research findings in the history of medicine? To some extent, the context of ‘bedside medicine’ comes close to these ideas. This model of care remained dominant in Western Europe until the nineteenth-century. One of the main ways in which physicians generated medical knowledge at the bedside of patients was to conduct ‘verbal analysis of subjectively defined sensations and feelings’ by patients (Jewson 1976, 229-230), and these patient testimonials provided the details recounted in physicians’ notes (Fissell 1991, 92). This is partly because the early modern doctor-patient relationship was based on a ‘horizontal’ model of healing (Pomata 1998, 126-27, 135) and a legally binding ‘agreement for a cure’ (ibid., 25 passim), which gave considerable power to patients, placing them on ‘near-equal hermeneutic footing’ with doctors (Fissell 1991, 92). Physician and patron (patient) made a contract in which the mostly upper class-patient would only pay fees after ‘successful’ treatment; vice versa, doctors were not obliged to treat a patient but would rather take on patients whose potential cure, and ability to pay fees, could be foreseen. Patients’ verbal satisfaction and willingness to conduct word-of-mouth publicity for a practicing physician were key to his reputation at that time and influenced physicians’ relationships with their clients.

However, it is problematic to project today’s vision of a desirable empathic relation between doctors and patients back into the past. Although upper-class patients clearly had some power in their relationship with physicians, the dominance of patients’ speech in medical records as such should not be interpreted as proof that doctors cared about their patients in the modern sense of showing understanding. With respect to nineteenth-century bourgeois medicine, Roy Porter noted that flattery and attention in the medical encounter were calculated practices of physicians concerned to secure clients and that ‘solemn bedside palaver[,] a grave demeanour, an air of benign and unflappable authority’ were all part of the prized ‘art of never leaving without a favourable prognosis’ (1999, 672). In a similar vein, Iris Ritzmann has emphasized that eighteenth-century doctors were eager to adhere to a certain ‘savoir faire,’ that is rules of conduct that would allow them to obscure the fact that in many cases, their abilities to heal were very limited (1999). And in Paul Weindling’s assessment of German medical routines, physicians’ desires to satisfy the patient subjectively were even purely instrumental: ‘[s]ympathy with the feelings of the sick was an economic necessity owing to the competition between practitioners’ (1987, 409). In all these cases, the value ascribed to direct physician-patient dialogue was very different from today’s ideas about an empathic encounter between physicians and patients; an engaged bedside manner often had more to do with calculated support for an upper class and sometimes hypochondriac clientele.

Similarly, as concerns the careful documentation of a patient’s medical condition and history, historical evidence shows that doctors did not do it primarily for their patients’ needs but for purposes of professional standing. This was important at a time when physicians’ scientific authority still needed to be established. The fact that in many cases there were several physicians involved in the treatment of the same case made documentation and communication between physicians (and sometimes for the public) especially relevant – and especially conflictual. Eighteenth-century case histories reflecting the context of bedside medicine indeed suggest that doctors were sometimes eager to publish case histories of patients that would bespeak their ability to heal by highlighting the misfortune of their competitors in order to enhance their own reputation. This shows how misleading the popular nostalgic view of a past intimate and unbroken bond between physicians and patients is, and that analogue paper technology did not necessarily strengthen this bond but could also be used in ways that were not beneficial for patients. Unlike today, this was an era in which practices of record-keeping mirror multiple, local and highly individual ways of documentation; the formalisation and standardisation of patient files which 19 th -century hospital medicine would trigger was yet to come.

As hospitals and laboratories became important institutions for medicine in the century roughly between 1770 and 1870, they also changed the practices of record-keeping, as the customary interrogation of patients’ accounts of the course of their disease did not coincide with changing understandings of disease, scientific interests and cultural expectations (see Granshaw 1992). For instance, French anatomist and pathologist Xavier Bichat (1771-1802) dismissed note-keeping based on patients’ narratives as an obsolete method for knowledge-making. He observed in his Anatomie générale (1801), ‘you will have taken notes for twenty years from morning to night at the bedside of the sick [and] it will all seem to you but confusion stemming from symptoms that fail to coalesce, and therefore provide a sequence of incoherent phenomena’ (1801, xcix, our translation). The kind of medicine favoured by Bichat and like-minded physicians focused on gaining anatomical and physiological insights directly from the body, using both physical examination and remote techniques in the laboratory. One way in which record-keeping changed to accommodate these interests was in the use of a more technical language to describe the experiences and expressions of patients. Mary Fissell argues that with the rise of hospital medicine, ‘doctors begin to sound like doctors, and patients’ voices disappear’ because doctors interpret patients’ words and replace them with medical equivalents (1991, 99). More generally, historians have shown that during the nineteenth century, medical culture changed in a way that gradually diminished the importance of patient narratives in medical writing (Nolte 2009).

How did these changes in recording practices play out for patients in the medical encounter ? From the historical perspective, the fact that physicians adopted a more technical language in their interactions and records should not be taken as evidence for a loss of human interaction or as something that patients necessarily disliked. On the contrary, the more systematised and formalised type of record-keeping was considered state of the art and was in accordance with a rapidly growing belief in the natural sciences among both patients and the general public (Huerkamp 1989, 64). This is related to the emergence of a specific concept of scientific reasoning that, in turn, fostered a sense of ‘scientific objectivity’ that called for dispassionate observation and accurate recording (Daston and Gallison 2010; Kennedy 2017). By the end of the nineteenth century, academic physicians had managed to create such professional authority that the ‘horizontal model of healing,’ in which the physician courted his upper-class clients, was replaced by a vertical model, in which the patient subjected himself to the authority of the physician. A Berlin doctor advised his fellow colleagues in 1896 that they should communicate their medical prescriptions to patients in a way that ‘prevents any misunderstandings and so that no further question can be addressed to him’ (cited in Huerkamp 1989, 66, our translation). For patients, this growing scientific authority and paternalism meant very different things, depending on class and social status. While medical services became accessible to more people, in particular thanks to the introduction of obligatory health insurance for workers, lower classes often experienced medicine as an instrument of power rather than benevolence (Huerkamp 1989). But even for the well-to-do, who undoubtedly benefitted from newly developed medical techniques, in particular in the realm of surgery, the acceptance of medical paternalism, male rhetoric and heroic cures came with high costs. This is suggested, for instance, in a famous letter by the court lady and writer Frances (Fanny) Burney who underwent a mastectomy in 1811, a rare document offering a patient’s perspective on these matters (Epstein, 1986).

From the perspective of doctors at the turn of the nineteenth century, record-keeping was associated not only with professional obligations but also with personal fulfilment. In many European countries, physicians were asked to provide expert opinion for juridical and administrative regulations as the state was increasingly interested in tracking its population’s health (Ruckstuhl and Ryter 2017; Schmiedebach 2018). In her study of Swiss physician Caesar Adolf Bloesch’s private practice (1804-1863), Lina Gafner shows the extent to which he perceived medical practice documentation as constitutive of his professional role and self-understanding as a medical expert. Bloesch’s patient journal ‘constitutes one single gigantic research report’ (2016, 265) because it was key for allowing him to generalize from the experiences gained in his practice in order to produce knowledge to contribute to contemporary scientific discussions. Gafner notes that the ‘format he gave his journals [leads] us to assume that scientific or public health-related ambitions were part of Bloesch’s professional self-image’ (263). In contrast to this historical example, where patient care and journal keeping were combined in the light of professional ambition, it stands out that healthcare providers of today tend to see their administrative work as opposed to patient care, even as separate and conflicting tasks; it is assumed that for physicians ‘seeing patients doesn't feel like work in the way that data entry feels like work’ (Amenta 2017). This is probably related to the fact that many physicians experience the requirement of working with a given software as a limiting restraint, which they are not really able to control, while they experience working with patients as something they have learned to master. As Gawande admits: ‘a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me’ (2018). It thus seems that it is primarily the question of ownership that distinguishes past recording styles from today’s recording systems: it is difficult to individually appropriate something which is designed to harmonize if not eliminate individual recording styles.

Yet even as Bloesch and contemporaries embraced the administrative tasks associated with medical note-taking as an opportunity to become a medical expert, other nineteenth-century physicians had different views of its value. But their criticisms of record-keeping were not motivated by the inherent value they saw in interactions with patients. Rather, their critiques were linked to a notable shift during the nineteenth century as scientific interest, triggered by administrative requirements as well as different disease conceptions and methods (e.g. in epidemiology research), changed its focus from the individual case study to population studies (see Hess and Mendelsohn 2010). In Nikolas Rose’s words, ‘the regularity and predictability of illness, accidents and other misfortunes within a population’ became ‘central vectors in the administration of the biopolitical agendas of the emerging nation states’ (2001, 7). Bound up with a new emphasis on tabulation, as well as ‘precision and reliability,’ various German-speaking hospitals instigated a new tabular format designed to enable physicians to compile their observations of patients into ward journals organized into columns and, eventually, generate an annual account of the course of disease (Hess and Mendelsohn 2010, 294). Yet in response some physicians rejected what they saw as excessively confining recording requirements. Volker Hess and J. Andrew Mendelsohn describe how the chief physician at a Berlin clinic ranted about the ‘inadequacy of our [tabular] journals’ and their inability to produce medical knowledge (295). While Mendelsohn and Hess themselves remark that such tabular ward journals were very ‘far from the patient history as observation, as prose narrative’ (293), the physicians’ rejection of the use of columns to record cases was not motivated by a concern to recover patients’ own narrations of their ailments or the feeling that record-keeping prevented them from properly attending to their patients’ needs. On the contrary, these physicians were concerned with producing an annual disease history and were frustrated that ‘the ultimately administrative format’s own rigid divisions blocked the writing of a synoptic history’ (296). Rather than recovering a face-to-face encounter with patients, they were interested in finding a recording format that would allow them to present a more compelling and sophisticated general description of disease, relying on mass information.

The current consensus among historians of medicine is that we should neither conceive medical records as ‘unmediated records of experiences of illness and healing’ (Kassell 2016, 126) nor as disentangled from the medical encounter itself. Rather, ‘processes of record-keeping were integral to medical consultations’ because ‘as ritualised displays and embodied knowledge, case books shaped the medical encounters that they recorded’ (122; see also Warner 1999). In relation to how ‘computerization’ is shaping contemporary medical encounters, three main points are of note. First, physicians have not always seen time spent writing and recording patient histories as in competition with interacting with patients themselves. At various times in history, the careful documentation of individual cases was perceived as a fundamental resource for generating medical knowledge and time spent doing so as part of the self-identity of physicians. Against the repudiation of digital record-keeping by today’s physicians, historical evidence shows that to the extent that physicians saw record-keeping as coinciding with their overall knowledge objectives, they accepted and even embraced it. This is linked to a second point, namely that prolonged time spent listening to the patient talk was not historically seen as evidence of good medical practice. For example, in an era when listening at length to patients was associated with the obsequious physician catering to the ego of the upper-class patient, the sober inscription in a nineteenth-century casebook noted that ‘too much talking showed that little was wrong’ with the patient (Weindling 1987, 395). Finally, patients too accepted administrative work by doctors as a sign of expertise and not necessarily as something that reduced the doctor’s attention to them. While the power balance changed in favour of doctors and ascribed less epistemic value to patients’ words, this was not necessarily negatively received by patients. History therefore shows that we should not view technological changes as isolated from the broader medical culture surrounding them but rather as shaping and co-constructing this culture. Today’s fear that the introduction of EHRs might change the communication and relation between physicians and patients for the worse tends to blame technology for a broader cultural and medical change of which it is just one tiny aspect, that is the growing belief in data and the logic of gaining stratified knowledge to provide relevant information about any one patients’ condition. Given that patients’ expectations exist in a dynamic relationship with how physicians learn, make decisions and interact with them, EHRs are themselves bound up with creating new conditions for the physician-patient relationship.

Examining: telemedicine and the distant patient

A further way in which digitalization has influenced the medical encounter is that it has emerged as the new virtual consulting room, thereby radically transforming the settings and procedures of physical examination. Although most people still go to ‘see the doctor,’ medical encounters today no longer have to take place in physical spaces but can occur via telephone or internet – what is broadly referred to as telemedicine, literally healing at a distance (from the Greek ‘tele’ and Latin ‘medicus’) (Strehle and Shabde 2006, 956). According to the World Health Organization, as a global phenomenon, telemedicine is more widespread than EHRs with more than half of responding member states having a telehealth component in their national health policy (WHO 2016). In the context of the COVID-19 pandemic, telemedicine has been overwhelmingly seen as ‘[a]n opportunity in a crisis’ and has further gained in popularity (Greenhalgh et al., 2020; see also Chauhan et al., 2020). A senior NHS official cited by The Economist called the widespread adoption of remote care (viz. telemedicine) a ‘move away from the dominant mode of medicine for the last 5,000 years’ (2020, 55). In the virtual examination room, patients can ask a physician for a diagnosis, a prescription and a treatment plan and send information about diseased body parts via digital media. When inquiring about the health conditions of their patients from a virtual consultation room, physicians sometimes need to ask their patients for certain practices of self-examination and self-treatment (Mathar 2010, section III). Advocates of telemedicine emphasize that there is no risk of mutual infection, advantages of cost savings, convenience, and better accessibility to medical care generally and for people living in rural and remote areas in particular. In Switzerland, for instance, the Medgate Tele Clinic promises to ‘bring the doctor to you, wherever needed’ (2019) while the U.S. Doctor on Demand characterizes itself as ‘[a] doctor who is always with you’ (2019). Patients, meanwhile, appreciate the greater availability of physicians, less travel time and better overall experience (Abrams and Korba 2018). However, telemedicine also raises various critical questions about the effects of physical distance on the physician-patient relationship. In particular, can the quality of the examination and diagnosis be high enough if a physician only sees his/her patient via screen but cannot smell, palpate and auscultate him/her? Furthermore, how can a trusting doctor-patient relationship be established virtually and at a distance? (see Mathar 2010, 13). While some of these critiques are based on the assumption that a fitting medical encounter between physician and patient should be a ‘good, old-fashioned, technology-free, dialogue between physician and patient’ (Sanders 2003, 2), we show below that all encounters inevitably ‘pass through a cultural sieve’ (Mitchell and Georges 2000, 387). Not only has the perceived need for the physical proximity of physician and patient varied substantially over history, but historical physicians and patients have not seen physical distance as preventing them from achieving emotional understanding. Whether physical examinations took place in-person or remotely, at each point in history doctors relied on their knowledge and its applications, that is a cultural lens through which s/he gazes on, over or into the human body. Regardless if examined remotely or closely, changes in examination procedures always challenge the established sense of the emotional bond between patient and physician, which therefore needs to be defined anew.

The standard physical examination as we know it today was considered less important in Europe up to roughly 1800 because of the conventions governing the relationship between physician and patient/patron, and also because of the conventions governing the relationship between male doctor and female patients. Many physicians considered physical examination morally inappropriate and saw it as dispensable for making a diagnosis. Physicians of upper-class patients generally considered their task more to advise than to examine and treat (Ritzmann 1999, 203). From his close analysis of a casebook by a seventeenth-century English physician, Stanley Joel Reiser concludes that the ‘maintenance of human dignity and physical privacy placed limits on human interaction through touch’ (1978, 4). Given the desirability of maintaining physical distance, physicians relied on and developed other sources of knowledge than their own sense of touch. The physical examination was ‘the method least used’ by the seventeenth-century physician who rather favoured ‘the patient’s narrative and [his] own visual [outward] observations’ of the patient’s body. In her study of a manuscript authored by a surgeon-apothecary of the same historical period, Fissell singles out blood-letting as one ‘of the few occasions on which a professional […] might routinely touch a patient’ and notes that it was necessarily ‘transformed into a careful ritual, one which attempted to compensate for the transgressive nature of the encounter. The blood-letter's courteous attention to returning the patient to his or her un-touched status underlines the mixture of courtesy and technique which made good medical practice’ (1993, 23). In ways now unfamiliar to us, manners and morals interacted to make physical examination and touching patients an ancillary part of the desirable patient-doctor encounter at that time.

Regular in-person physical examination as a routine practice and diagnostic technology is a rather recent development that came along with a new anatomical understanding of disease during the course of the nineteenth century, namely that diseases can be traced to individual body parts such as organs, tissues and cells, rather than unbalanced bodily humours (Reiser 1978, 29). It was at this time that the doctor’s examination skills no longer depended on the patient’s word and the surface of the (possibly distant) body, but started relying on what the doctor could glean from the patient’s organic interior (Kennedy 2017). In order to ‘get’ to the physical conditions of the body’s interior, a number of instruments were developed to facilitate the new credo of examination. The most famous example of such a nineteenth-century examination technology is the stethoscope, invented by French physician René Laennec (1781-1826). ‘By giving access to body noises – the sounds of breathing, the blood gurgling around the heart – the stethoscope changed approaches to internal disease,’ wrote Roy Porter, ‘the living body was no longer a closed book: pathology could now be done on the living’ (1999, 208). Crucially, technologies like the stethoscope brought the physician and patient into the examination room together but by providing physicians with privileged access to the seat of disease did not necessarily bring them closer in terms of understanding. Doctors now heard things that remained unheard to the patient, and this provoked a distancing in terms of illness perceptions. In Reiser’s account, the stethoscope ‘liberated doctors from patients and, by doing so, paradoxically enabled doctors to think they helped them better. […] Listening to the body seemed to get one further diagnostically than did listening to the patient’ (2009, 26).

The result is visible in the resistance surrounding some examination technologies that allowed physicians to delve into the body’s interior in order to gain new anatomical and pathological insights but that proved too transgressive for some existing physician-patient contacts. The vaginal speculum, introduced into examination procedures in Paris in the early-nineteenth century, may have fitted well with physicians’ new commitments to empiricism and observation. But at the time of the speculum’s introduction, female genital organs, in contrast to other organs, were regarded ‘as so mysterious and so sacred that no matter how serious the disease that afflicted them might be, it was no justification for an examination either by sight or touch’ (Murphy 1891, cited in Moscucci 1990, 110). Although the speculum was in line with pathological disease concepts and close, interior observation, moral considerations continued to undermine its suitability in the clinical context. At a meeting of the Royal Medical and Chirurgical Society, chronicled in the Lancet , commentators associated the speculum with both female and physician corruption, and the loss of moral virginity and innocence caused by its insertion into the body (Anon. 1850). In Margarete Sandelowski’s estimation, the vaginal speculum ‘required physicians not only to touch women’s genitals, but also to look at them, and thus imperiled the relationship male physicians wanted to establish with female patients’ (2000, 75). Here was a case in which technology challenged the socially accepted relationship between (male) physicians and (female) patients of a particular class because its application demanded increased physical closeness, and therefore was seen as undesirable and transgressive. As Claudia Huerkamp notes, it took a long time to establish a specific ‘medical culture’ in which the physical examination of female parts by a male physician was not perceived as breaking a taboo (1989, 67).

In other instances, the use of the speculum and the unprecedented access it provided to women’s anatomy mirrored existing power structures. The first uses of the speculum were justified in reference to and tested on the most vulnerable members of society. Deirdre Cooper Owens (2017) has demonstrated that in the U.S., racist arguments helped to defend the speculum’s application and experimentation on black, enslaved women as they were deemed to have a particularly ‘robust’ constitution, high tolerance of pain, and so on. Medical men such as James Marion Sims, who by his own account was the inventor of the speculum, combined his privileged access to enslaved women’s bodies with intrusive forms of examination in order to gain new knowledge crucial for the emerging field of gynaecology. This was also true for Irish immigrants in the U.S. (Owens 2017) and in the case of prostitutes in France and Germany, where the speculum was used as an instrument of the medical police (Moscucci 1990, 112). Prostitutes were screened using this new instrumentation as supposed carriers of venereal disease, whereas male clients did not need to undergo any screening. This highlights how intrusion into the body in the name of more accurate examination was frequently bound up with power and control, especially of marginalized groups.

Even as the seat of disease became increasingly associated with specific locations inside the body, this coexisted with the notion that medicine could still be conducted ‘at a distance.’ The example of the telephone demonstrates how tele-instruments worked alongside close examination devices that adhered to the principle of disease as located in particular interior body parts. In fact, the potentiality of the telephone for the medical profession was apparent from its invention in 1876; 4 as Michael Kay notes, the first inter-connected users were doctors, pharmacists, hospitals and infirmaries (2012). Practitioners used the technology, which enabled the clear transmission and reproduction of complex sounds for the first time, to improve existing instruments, or to devise entirely new examination methods. For instance, in November 1879, the Lancet published the case of an American doctor who, when phoned in the middle of the night by a woman anxious about her granddaughter’s cough, asked for the child to be held up to the telephone so that he could hear it (Anon. 1879). A group of physicians predicted in 1880 that home telephones would allow a new specialty of long-distance practitioners to ‘each settle themselves down at the centre of a web of wires and auscult at indefinite distances from the patients,’ potentially replacing the traditional stethoscope (cited in Greene 2016, 306). The telephone was also lauded for its potential to uncover foreign objects lodged in patients’ bodies, for example by acting as a metal detector (see Kay 2012). In line with the belief that a ‘good examination’ required a physician having access to the body’s interior in order to discover the seat of disease according to the localisation principle, the telephone was seen as an extension of the doctor’s ear that could improve examination and diagnosis.

In this context, reactions to the increased physical distance between physician and patient varied. The benefits of using a telephone instead of the more traditional speaking tube, which allowed breath to pass from one speaker to another, when communicating with patients with contagious diseases were recognised very early (Aronson 1977, 73). A testimonial letter, written by the Lady Superintendent at the Manchester Hospital for Sick Children in 1879, stated: ‘[The recently installed telephone] is of the greatest value in connection with the Fever Ward, enabling me to always be in communication without risk of infection’ (cited in Kay 2012). Yet some physicians worried that telephone technology had effectively ‘shrunk’ perceived social distance between them and the working classes, making them liable to be overly contacted by the general public. As one doctor complained in the Lancet in 1883: ‘[a]s if the Telegraph and the Post Office did not sufficiently invade and molest our leisure, it is now proposed to medical men that they should become subscribers to the Telephone Company, and so lay themselves open to communications from all quarters and at all times. […] The only fear we have is that when people can open up a conversation with us for a penny, they will be apt to abuse the privilege […] ’ (cited in Kay 2012) . Not only were doctors concerned about the telephone invading their ‘leisure,’ they worried that they might be overrun by the public, and their medical expertise would be needlessly exploited. Because of the inherent fear of doctors that an excessively frequent use of the telephone could flatten the social order and their standing within society, it is not surprising that the public use of the telephone came under critical medical scrutiny. This is visible in the way that telephones themselves came to be seen as seats of infection. At the end of the nineteenth century when most telephones were for public use (Fischer 1992), the British Medical Journal cautioned there was a need to curtail ‘the promiscuous use of the mouth-pieces of public telephones’ (Anon. 1887, 166). In general, the use of the telephone was informed by insights from bacteriology, which transformed individual disease ‘into a public health event affecting communities and nations’ (Koch 2011, 2), and placed new emphasis on the need to keep potentially infectious bodies as well as social classes at clear distance from one another (see Peckham 2015).

In relation to the pitfalls of today’s telemedicine and the fundamental questions of physical distance and emotional rapprochement in the medical encounter, these historical findings demonstrate that what was perceived as the ‘normal’ setting and procedure of medical examination could change remarkably within a rather short time. Before the nineteenth century, close physical examination generally played a less prominent role while patients’ illness accounts had a greater weight in the medical encounter. Indeed, in some contexts physical distance was seen as the prerogative of good medical practice. Post-1800, by contrast, is characterized by the standardisation of physical close examination, but also by the introduction of new technologies into the patient-physician relationship that themselves challenged socially-accepted degrees of physical closeness. However, this does not necessarily mean that such technologies disturbed a former unbroken bond, rather, various technologies became players in the game and could (or not) be appropriated by patients and doctors alike. Technology did not simply affect the physician-patient relationship, rather, existing societal and moral understandings influenced how technologies came into being and how they were used (Peckham 2015, 153). Our historical examples suggest that rather than seeing telemedicine as something fundamentally new and potentially threatening because it seemingly undermines a personal relationship, it may be more useful to acknowledge that technologies and cultural understandings always govern the degree of physical closeness and distance in medical encounters, and that this has had manifold implications for the emotional doctor-patient bond. The success of telepsychotherapy during the Covid-19 pandemic is perhaps a case in point. Even as it is unique among medical specialities because of the extent to which it considers the human relationship as fundamental for healing, psychotherapy via phone or video link has increased dramatically during the public health crisis, and also had good results (Békés and Aafjes-van Doorn 2020). This points not only to how physician-patient closeness and emotional understanding can exist in times of physical distance, but also to the constantly variable ways in which both the cultural imagination and experience of distance manifest themselves (Kolkenbrock 2020).

Self-treatment: do-it-yourself medical devices and the expert patient

The third field of digital medicine that we would like to put into historical perspective is one of the fastest growing fields of eHealth, namely do-it-yourself (DIY) health technologies. Such technologies broadly refer to the mobile devices that ‘now allow consumers to diagnose and treat their own medical conditions without the presence of a health professional’ (Greene 2016, 306). Silicon Valley firms sell ‘disintermediation,’ that is the possibility of cutting out middlemen – physicians – and allowing consumers to better control their health via their devices (Eysenbach 2007). Significant private investments have been driving these changes which, in the forms of smart devices and wearable technologies, often imply purchasing a product (e.g. a smartphone) and related applications and tools (see Greene 2016; Matshazi 2019). The website Digital Trends 2019 ranking of ‘the 10 best health apps’ range from Fitocracy, a running app that allows you to track your progress and that promises a fitness experience with a ‘robust community of like-minded individuals’, to Carbs that transfers the meals you have eaten into charts of calories, to Fitbit Coach that promises you the experience of having a personal trainer on your smartphone (de Looper 2019). 5 Health systems have bought on and increasingly ask patients to observe and monitor themselves with the help of these technologies, and in some cases, the use of apps to measure blood pressure, pulse and body weight such as Amicomed and Beurer HealthManager are closely connected to the possibilities of sharing one’s data remotely with a physician. In terms of reception, the delegation of tasks to digital devices is associated with patients having new options and new knowledge of their own health. In the estimation of one hospital CEO, this dramatic ‘democratization’ of technology and of knowledge signals ‘a true coming of age of the patient at the centre of the healthcare universe’ (Rosenberg 2019). In the words of chronic patient and patients’ rights advocate Michael Mittleman, while there may be benefits for patients when technologies take over certain tasks that were previously the prerogative of physicians, such technologies nevertheless pose a fundamental challenge to the ‘golden bond’ that previously characterized the patient physician-relationship, for example in the age of the house call (conversation with the author, 2019). It is clear from these statements that DIY devices – because they suggest that the more beneficial relationship is that between the patient/consumer and his/her devices – challenge previous assumptions about the inherent value of the physician-patient relationship as well as the balance of power between those two actors (see Obermeyer and Emmanuel 2016).

Both the notion that patients inherently benefit from circumventing physicians and taking their health into their own hands, as well as the idea of a close, almost familial bond that characterized the physician-patient relationship prior to contemporary DIY practices can be nuanced if we acknowledge that do-it-yourself medical practices have a long and varied history. As Roy Porter has noted, in the eighteenth-century, ‘ordinary people mainly treated themselves, at least in the first instance[,] “medicine without doctors” [was] a necessity for many and a preference for some’ (1999, 281). Only in the nineteenth-century did the medical profession establish a monopoly in health care and have the official power to determine what was ‘health’ and ‘sickness’. In the previous centuries, local and pluralistic ‘medical markets’ embraced far more providers of health services and their varied tools, including barbers, surgeons, quacks and charlatans, so that patients chose among the options that most convinced them or that were affordable to them (Ritzmann 2013, 418). But patients also had the option to help and treat themselves using the means at their disposal – Fissell argues that a person who fell ill in 1500 and still in 1800 almost always first sought medical treatment in a domestic context: ‘[h]e or she relied upon his or her own medical knowledge of healing plants and procedures, consulted manuscript or printed health guides, and asked family, neighbors, and friends for advice’ (2012, 533). As Fissell points out, the enormous diffusion and importance of self-therapy at the time meant that the ‘boundary between patients and practitioners was hard to pin down’ (534). While current depictions of an idealised interaction between physician and patient assume a physician who through his/her knowledge examines, advises and treats the non-knowing patient, history shows that the presumed boundaries between the expert and lay person are far more blurred than is usually assumed.

The presumed novelty of a de-centralised market for DIY devices that potentially threatens the dual relationship between physicians and patients can be put into perspective when considering historical examples. Due to a fairly unregulated medical market in the early modern period, competition was high and the business of medicinal recipes lucrative. In this context, profit-motivated apothecaries benefited from offering new recipes made from exotic products: as of the fifteenth century European pharmacies stocked many wares with medicinal properties – including spices, elements such as sulphur, and plants, for examplemastic and sundew – and these were bought by people who gathered and dealt in medicinal plants (or ‘simples’) and other apothecaries, who made them into medicines. In the wake of the European voyages of discovery, the range of products became ever wider and more expensive, and apothecaries were a very profitable business branch for a long time (Ehrlich 2007, 51-55). King and Weaver have used evidence from remedy books in eighteenth-century England to show how families purchased recipes for remedies, and resold both the recipes and the medicines they brewed to other local people (2000, 195). Until the nineteenth century the medical market flourished and was accessible and lucrative for many participants, while the demand for ‘medical’ services was high, particularly in towns and cities. Access to the technologies of healing – whether domestic medical guides or healing herbs – allowed patients to control their health and treatments according to a wide range of scientific explanations. In contrast to other European countries that meanwhile had developed some restrictions for apothecaries and their suppliers, in Britain the market-place was remarkably varied in the light of the free-market principle caveat emptor (let the buyer beware). ‘In English conditions,’ wrote Porter, ‘irregulars, quacks and nostrum-mongers seized the opportunities a hungry market offered’ (1995, 460). In these conditions of market-oriented healing, both patients and healers alike believed, sometimes fervently, in the effectiveness of the remedies on offer. Moreover, the network of relationships in which such transactions took place was remarkably fluid, with patients using the services of several health professionals in succession or simultaneously.

In the following centuries, medical practice and science would change dramatically due to the rise of academic training as a prerequisite to enter the medical profession, a development seen across Europe, as well as the integration of physicians into national health agendas. A growing belief in science and a paternalistic ideal of the academic physician attributed to him the sole power over medical practice and technologies. It became more difficult for other healers to participate in the health market, and the knowledge of the self-treating patient was diminished as well. As part of the attempt to counteract competition from non-educated or apprenticed healers, in the United Kingdom only registered doctors could hold various public posts, such as public vaccinator, medical officer and the like (Bynum 2006, 214). Yet ‘alternative’ medicine, a term that contained all those healers not licenced and accepted by the respective medical registers, continued to satisfy patients’ needs, although to a lesser extent. In Weindling’s assessment of the prospects of university-educated physicians to attract clients in nineteenth-century Berlin, ‘[f]ierce competition from a range of unorthodox practitioners must be assumed’ (1987, 398). The popularity of hydropathic doctors and water cures, mud-bathing and vegetarianism are but some examples of how alternative medicines co-existed alongside official ones and were increasingly popular treatments even though they did not meet the contemporary academic criteria of standards regarding safety and efficacy (Ko 2016). Thus patients often looked beyond qualified physicians to other practitioners, and their own sensibilities played a considerable role in which relationships they chose to develop.

A look into twentieth-century history shows that DIY practices were integrated into official medicine as well (Timmermann 2010; Falk 2018). The significant rise of chronic diseases and life-long treatment, for instance, required the co-operation of patients in the form of self-tracking and observation of their bodies since it could not be done by medical experts alone. In the first decades of the twentieth century, DIY methods and technologies for measuring blood pressure or sugar became particularly vital, transforming the roles of ‘patient’ and ‘doctor’ and relationship between them. Examining the history of self-measuring blood pressure, Eberhard Wolff notes that patients doing so in the 1930s required both patience and training, and also were pushed into a more active and participatory role during medical treatment: it was not the doctor anymore but the patient who produced and controlled relevant data that were decisive for further medical decisions and treatment (2014, 2018). With the rise of the risk factor model in mid-twentieth century – the identification of factors in patient’s behaviour and habits that were suspected of contributing to the development of a chronic disease – DIY practices grew ever more important and so did its technologies. From this moment, the idea of preventing disease shifted towards individual, possibly damaging behaviours such as smoking and diet that could trigger a number of different diseases. As a consequence, the patient received more responsibility in order to live up to the new credo of maintaining his or her personal health (Lengwiler and Madarász 2010). Optimizing a personal healthy life style hence did not necessarily occur in direct consultation with a doctor but rather in conjunction with health products available on the market. In the words of sociologist Nikolas Rose, in the course of the twentieth century:

[t]he very idea of health was re-figured – the will to health would not merely seek the avoidance of sickness or premature death, but would encode an optimization of one’s corporeality to embrace a kind of overall “well-being” … It was this enlarged will to health that was amplified and instrumentalized by new strategies of advertising and marketing in the rapidly growing consumer market for health (2001, 17-18).

According to Rose, by such developments, ‘selfhood has become intrinsically somatic – ethical practices increasingly take the body as a key site for work on the self’ (18). But he also argues that by linking our well-being to the quality of our individual biology we have not become passive in the face of our biological fate. On the contrary, biological identity has become ‘bound up with more general norms of enterprising, self actualizing, responsible personhood’ (18-19). By considering ourselves responsible for our own biology as key to our health, we have come to depend on ‘professionals of vitality’ (22) whether they be purveyors of DIY devices, genetic counsellors, drug companies or doctors.

With respect to contemporary debates over DIY practices, some have argued that they allow both doctors and patients to be ‘experts’ and call for ‘a relationship of interactive partnership,’ not only because patients today are often informed but also because ideally they know best their own bodies and ailments (Kennedy 2003). Against this idealising assessment, the historical perspective makes us aware that while self-help and self-treatment have been an important dimension of past medical cultures, it appears that historically, patients have not relied as much on a face-to-face empathetic encounter with any one physician as today’s debates suggest. Moreover, today as in the past, the mere existence of markets for medical devices influences how consumers/patients decide whether to resist or embrace the various possibilities of self-treatment as well as their relationships with those who provide it. As Porter has argued, purveyors of ‘alternative’ medicines rationalised their therapeutic effects in ways that differed from official scientific methods and using arguments that likewise changed over time. Depending on the perspective of whose model of evidence users deemed most credible, the co-existence of diverse models for practicing medicine must be assumed throughout history and despite nineteenth-centuries attempts to eliminate unorthodox medicines (Timmermann 2010). The result was a diverse network of fast-changing relationships in which no single one was ascribed the ultimate power to heal. Reflecting on this history, historian of medicine and physician Jeremy Greene has stated that contemporary DIY devices therefore appear ‘neither wholly new nor wholly liberating’ (2016, 308). Our analysis corroborates Greene’s, in that it shows how those who use new DIY technologies may free themselves from their traditional relationship of dependence on physicians, while also creating new relationships with those actors who produce apps or conduct marketing. Yet our study also suggests that there is no one ethical conclusion about whether DIY or physician-dominated care is a better way of living up to a more humane medicine. Ethical arguments and the grounds on which we are supposed to resolve them are complex and variable. As seen in these historical examples, they have changed profoundly over time with each technology and medical concept challenging and refashioning the doctor-patient bond anew. Furthermore, there is no such thing as a ‘timeless’ doctor’s healing presence, or even medical expertise, or an ill person/patient. As shown above, as health and illness are defined, redefined and challenged throughout history, this process creates both expert and patient, as well as shapes the relationship between them.

An oft-heard concern about ‘computerization’ in medicine is that digital objects are changing human interactions. While various representatives from the tech side are optimistic about the effects of increasingly dynamic and intelligent objects in the medical encounter, some patients and physicians are more skeptical and see their social relationships as disturbed by new technologies. ‘Doctors don’t talk to patients’ is the most common complaint the CEO at a Montreal hospital recounted hearing from current patients (conversation between the author and Lawrence Rosenberg, 2019). Fears that increasing digitization of medicine will disturb the relationship that can potentially make the patient ‘whole’ again are not without foundation (King 2020). However, without a clear baseline for assessing changes we have limited scope for drawing conclusions about present day realities or long-term trends. Given the appeal of using the past to suggest a more ‘human’ but lost era of medical practice, a less nostalgic but more sophisticated understanding of the past as provided by historical research would serve us well. In this sense, history can counteract a characteristically modern myopia, namely, as intellectual historian Teresa Bejan has put it, our ‘endearing but frustrating tendency to view every development in public life as if it were happening for the first time’ (2017, 19).

As we saw in the examples dealing with record keeping, examining and self-treatment, trends that consider the patient as an object – a diseased lung, or a malfunctioning heart valve – and the concomitant use of technologies to record, examine and treat physical symptoms were necessarily in tension with patients’ own accounts of how they became ill and of the symptoms they experienced. In fact, concerns about the loss of meaningful personal contact in the medical encounter are incomprehensible without reference to a historical trend dating back to the beginning of the nineteenth century which seems to undermine the patient’s perspective by focusing on increasingly specialised processes within the body. Yet neither before nor after that time is there an unmediated patient’s voice that we are able to recover: the medical record as historical source has its own distinct material history, and patients’ expectations were always bound up with broader societal views about acceptable standards of healing. The historical perspective also shows that we should not take for granted the linear narrative of the technological as adverse to human relations and reducing empathetic understanding in the medical encounter – to paraphrase Lauren Kassell, the digital is not just the enemy of the human (2016, 128). Rather, it makes us aware that our understanding of the doctor-patient relationship and of its role in healing are themselves historically contingent. The idea of ‘a friendly, family doctor “being there”’ and the association of medicine with a ‘desirable clinical relationship’ (as opposed to e.g. perfect health) is an idea that has played out very differently in the course of history (Porter 1999, 670). There were times in which listening to patients was bound up with completely different expectations from both sides, and there were times in which physical examination was not seen as an indispensable part of medical practice. Moreover, while the monopoly of the physician in matters of health care and the focus on the (exclusive) healing potential of the clinical relationship is of relatively recent origin, we have seen that the popularity and economy of DIY devices has a much longer history, one that resists a linear account of DIY devices as something purely liberating. Hence, in contrast to idealised and simplified historical narratives that lament the loss of human relationships, more sophisticated accounts should acknowledge that medical objects and technologies are not the strange and disturbing ‘other’ in the medical encounter but rather integral players therein. As Frank Trentmann has put it, ‘things and humans are inseparably interwoven in mutually constitutive relationships’ (2009, 307). While the authors of a recent study suggest that ‘the traditional dyadic dynamics of the medical encounter has been altered into a triadic relationship by introducing the computer into the examination room’ (Assis-Hassid et al. 2015, 1), it seems more likely that the dyadic relationship has never existed.

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Vanessa Rampton received funding from the Branco Weiss Fellowship – Society in Science.

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1 We rely on a definition used by science and technology scholars whereby the term ‘technology’ operates on three levels (see Bijker, Hughes and Pinch 2012, xlii). First, there is the physical level, referring to tangible objects such as a smartphone, wellness band, or stethoscope. The second level of meaning concerns activities or processes, such as 3D printing or creating X-rays. The third level refers to knowledge people have in addition to what they do, for example the knowledge that underpins the conduct of a surgical procedure. This approach shows the extent to which specific tools and techniques, knowledge, and rationales for intervention are intricately bound together. Our use of the term ‘digital,’ that is involving computer technology, in relation to medicine ‘includes categories such as mobile health (mHealth), health information technology (IT), wearable devices, telehealth and telemedicine, and personalized medicine’ (U.S. Food and Drug Administration).

2 As a rule, while systematic reviews of telemedicine generally portray it as effective as in-person consultation or promising, evidence is limited and fast-evolving (Ekeland, Bowes and Flottorp 2010; Kruse et al. 2017; Lee et al. 2017).

3 In Germany, legislators have reacted to these concerns by limiting video consultation to cases in which physician and patient have physically met before, and primarily using it for monitoring the course of disease, including chronic ones, or the healing of an injury (Heinrich 2017).

4 Scottish-born US inventor Alexander Graham Bell was the first to be awarded the U.S. patent for the invention of the telephone in 1876 (Fischer 1992).

5 Interestingly, and probably most important for their users, nine out of ten among the ranked apps are available as free downloads ( https://www.digitaltrends.com/mobile/best-health-apps/ , June 16, 2019).

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Rampton, V., Böhmer, M. & Winkler, A. Medical Technologies Past and Present: How History Helps to Understand the Digital Era. J Med Humanit 43 , 343–364 (2022). https://doi.org/10.1007/s10912-021-09699-x

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Beauty might not necessarily be the first word that comes to mind when we think about research, but as Dr. Brandon Vaidyanathan’s work highlights, it plays a crucial role in the flourishing of scientists.

Vaidyanathan is an associate professor, chair of the department of sociology and director of the Institutional Flourishing Lab at The Catholic University of America. His research examines the cultural dimensions of religious, commercial and scientific institutions. Currently, Vaidyanathan leads Work and Well-Being in Science , the largest cross-national study investigating factors that affect the wellbeing of scientists.

While there isn’t an official term that describes this research field just yet, Vaidyanathan feels inclined to call it “aesthetics in science”: “There is a very recent and growing body of work in philosophy and sociology that looks at how aesthetic factors (e.g., beauty, awe, wonder and other aesthetic emotions) shape scientists and the practice of science,” he says.

In this interview with Technology Networks , Vaidyanathan describes what is meant by “beauty” in science, how it can be studied and the implications of such research.

Molly Campbell (MC): Can you talk about how you became interested in this research field?

Brandon Vaidyanathan (BV): I was drawn to research this area because in qualitative research interviews with scientists for a previous project, our team was surprised to hear them regularly bring up “beauty” as a key motivating factor. There is also new research that is raising concerns about how the pursuit of “mathematical beauty” in physics can be a source of bias that is derailing scientific progress.

MC: Can you talk about the current research landscape exploring the role of beauty in science, and what actionable insights it offers?

BV: My project Work and Well-Being in Science is the largest international study on the aesthetics of science. We surveyed several thousand scientists in 4 countries and also conducted 200+ in-depth interviews.

One key insight is that aesthetic factors are a major source of motivation for scientists to pursue their careers in the first place.

Our team finds that most scientists see science as an aesthetic quest – a quest for the “beauty of understanding,” which is the pleasure gained from discovering the hidden order or inner logic underlying phenomena they study.

We also find that aesthetic experience is very strongly associated with well-being among scientists. This is especially important in light of considerable research pointing to a mental health crisis in science. Our work underscores the need to preserve the intrinsic motivations and joys of doing science and address the obstacles to it (such as institutional pressures and toxic leadership) that scientists face.

Read Vaidyanathan’s published work on exploring aesthetics in science:

Aesthetic experiences and flourishing in science: A four-country study
Individual differences in scientists’ aesthetic disposition, aesthetic experiences, and aesthetic sensitivity in scientific work
Beauty in biology: An empirical assessment

Besides this project, the work of Cambridge philosopher Dr. Milena Ivanova highlights the importance of aesthetics in scientific experiments in her books and articles. Prominent scientists such as Nobel Prize winner Frank Wilczek and Oxford biologist Richard Dawkins have written books about aesthetics in science ( A Beautiful Question: Finding Nature's Deep Design and Unweaving the Rainbow: Science, Delusion and the Appetite for Wonder ). Sabine Hossenfelder published a bestselling book on the negative aspects of mathematical beauty in physics.

MC: Can it be challenging to explore the role of beauty in science?

BV: The challenge to survey research in this area is that it is increasingly difficult to get a high response rate for surveys – even with financial incentives in place, most people don’t want to take a survey, and mail servers often filter out survey invitations as spam. It is also difficult to get elite populations (e.g., scientists) to participate in research. We think increased dissemination of our results and awareness of our findings can help motivate scientists to continue participating in research so we can learn how to improve well-being in the scientific community.

MC: Are there any specific research methodologies that you view as integral to the progression of this field?

BV: So far the work that has been done is either philosophical, historical or sociological (through interviews and surveys). Longitudinal survey work would be important in order to assess causal mechanisms. More experimental and even neuropsychological work could also benefit this field in helping us understand how aesthetic experiences affect scientists and their relevance to scientific practice.

Dr. Brandon Vaidyanathan was speaking with Molly Campbell, Senior Science Writer for Technology Networks.

About the interviewee:

Dr. Brandon Vaidyanathan is associate professor, chair of the Department of Sociology and director of the Institutional Flourishing Lab at The Catholic University of America. He holds bachelor’s and master’s degrees in business administration from St. Francis Xavier University in Nova Scotia and HEC Montreal respectively, and a PhD in sociology from the University of Notre Dame. Dr. Vaidyanathan's research examines the cultural dimensions of religious, commercial and scientific institutions, and has been widely published in peer-reviewed journals. His current research examines the role of beauty in science and other domains of work.

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Medical technology can increase life expectancy. Is it a blessing or curse?

In recent years, the development of advanced medical technology has sparked a hot debate over the impact of increasing life expectancy. Some people claim that people are living in a healthier life thanks to the advanced medical treatment. Whereas, others believe that long longevity puts an extra burden on the society. In my opinion, despite some drawbacks, the fact that medical technology has improved human’s life shall not be ignored.

Over the past years, governments from different countries have paid attention on bringing healthcare to every citizen, which allows more people to be benefit from the usage of medical technology, including advanced medical treatment in cancer, diabetes and asthma. Through these technologies, people today are living a healthier and longer life. Eventually, population aging becomes a phenomenon that gives young generation more opportunity to spend time with their elders. Thus, medical technology has brought positive impacts to human’s life.

In contrast, population aging stated above also puts economic pressure on young generations and increases the problems associated with generation gap. Government also need to expand age care facilities and policies to enhance the rights of elders, which leads to extra funds from the tax. From this point of view, increasing life expectancy is becoming a burden for the whole society.

In conclusion, there is in deed both positive and negative impact from increasing life expectancy. However, it is almost impossible to neglect its benefits to everyone in the society the drawbacks shall be well handled.

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Essay evaluations by e-grader

Grammar and spelling errors: Line 1, column 240, Rule ID: SENTENCE_FRAGMENT[1] Message: “Whereas” at the beginning of a sentence requires a 2nd clause. Maybe a comma, question or exclamation mark is missing, or the sentence is incomplete and should be joined with the following sentence. ...anks to the advanced medical treatment. Whereas, others believe that long longevity put... ^^^^^^^

Transition Words or Phrases used: also, however, if, so, thus, well, whereas, in conclusion, in contrast, in my opinion

Attributes: Values AverageValues Percentages(Values/AverageValues)% => Comments

Performance on Part of Speech: To be verbs : 8.0 10.5418719212 76% => OK Auxiliary verbs: 3.0 6.10837438424 49% => OK Conjunction : 5.0 8.36945812808 60% => More conjunction wanted. Relative clauses : 6.0 5.94088669951 101% => OK Pronoun: 10.0 20.9802955665 48% => OK Preposition: 39.0 31.9359605911 122% => OK Nominalization: 10.0 5.75862068966 174% => OK

Performance on vocabulary words: No of characters: 1369.0 1207.87684729 113% => OK No of words: 245.0 242.827586207 101% => OK Chars per words: 5.58775510204 5.00649968141 112% => OK Fourth root words length: 3.95632099841 3.92707691288 101% => OK Word Length SD: 2.81179760075 2.71678728327 103% => OK Unique words: 148.0 139.433497537 106% => OK Unique words percentage: 0.604081632653 0.580463131201 104% => OK syllable_count: 432.0 379.143842365 114% => OK avg_syllables_per_word: 1.8 1.57093596059 115% => OK

A sentence (or a clause, phrase) starts by: Pronoun: 1.0 4.6157635468 22% => OK Article: 2.0 1.56157635468 128% => OK Subordination: 0.0 1.71428571429 0% => More adverbial clause wanted. Conjunction: 0.0 0.931034482759 0% => OK Preposition: 8.0 3.65517241379 219% => Less preposition wanted as sentence beginnings.

Performance on sentences: How many sentences: 13.0 12.6551724138 103% => OK Sentence length: 18.0 20.5024630542 88% => OK Sentence length SD: 47.0816991041 50.4703680194 93% => OK Chars per sentence: 105.307692308 104.977214359 100% => OK Words per sentence: 18.8461538462 20.9669160288 90% => OK Discourse Markers: 6.53846153846 7.25397266985 90% => OK Paragraphs: 4.0 4.12807881773 97% => OK Language errors: 1.0 5.33497536946 19% => OK Sentences with positive sentiment : 7.0 6.9802955665 100% => OK Sentences with negative sentiment : 5.0 2.75862068966 181% => OK Sentences with neutral sentiment: 1.0 2.91625615764 34% => More facts, knowledge or examples wanted. What are sentences with positive/Negative/neutral sentiment?

Coherence and Cohesion: Essay topic to essay body coherence: 0.261194740839 0.242375264174 108% => OK Sentence topic coherence: 0.0996622299398 0.0925447433944 108% => OK Sentence topic coherence SD: 0.0966906197584 0.071462118173 135% => OK Paragraph topic coherence: 0.157498936196 0.151781067708 104% => OK Paragraph topic coherence SD: 0.0757525131412 0.0609392437508 124% => OK

Essay readability: automated_readability_index: 14.3 12.6369458128 113% => OK flesch_reading_ease: 36.28 53.1260098522 68% => OK smog_index: 8.8 6.54236453202 135% => OK flesch_kincaid_grade: 12.7 10.9458128079 116% => OK coleman_liau_index: 15.14 11.5310837438 131% => OK dale_chall_readability_score: 9.3 8.32886699507 112% => OK difficult_words: 74.0 55.0591133005 134% => OK linsear_write_formula: 11.5 9.94827586207 116% => OK gunning_fog: 9.2 10.3980295567 88% => OK text_standard: 9.0 10.5123152709 86% => OK What are above readability scores?

--------------------- Rates: 77.7777777778 out of 100 Scores by essay e-grader: 70.0 Out of 90 --------------------- Note: the e-grader does NOT examine the meaning of words and ideas. VIP users will receive further evaluations by advanced module of e-grader and human graders.

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‘Patients like mine’ technologies must rest on solid evidence

By Saurabh Gombar June 21, 2024

Among three rows of people painted in blue watercolor, all facing the right side, one person in the top row, third from the left, is depicted in orange and looking to the left — first opinion coverage from STAT

V endors of electronic health records and other health technology platforms have begun to publicize and demonstrate “patients like mine” capabilities, which insert analytics distilled from EHR data into the physician workflow to guide clinical decisions. While these implementations could be helpful, simple analytics must not be passed off as evidence, and care must be taken to rigorously implement and vet these tools to avoid the negative clinical and cost outcomes associated with incorrect care decisions.

At its core, the “patients like mine” concept is simple: The outcomes of similar patients for each care choice being considered are made available to a health care provider, as if she or he asked “What happened to similar patients for whom the same choice was made?”

Vendors are exploring “patients like mine” as a way to evolve the EHR from its historically passive role in the clinical workflow toward a more active one. To date, the limited active roles for EHRs have centered mostly on alert-driven clinical decision support (CDS) that nudged or enforced providers to comply with guidelines or processes explicitly approved by the health system. This form of clinical decision support has been shown to broadly improve clinical outcomes and process quality . But when implemented incorrectly, it can also lead to disastrous consequences .

As a physician and informatics researcher, I have long believed in the tenets of evidence-based medicine established across the last half century, and have sought to build technology that integrates reliable precision evidence into the care provided for everyone. Yet with more and more of this work being driven by the tech and investment communities, I have grown increasingly concerned that the core methodological tenets the medical community relies on are being stepped over, creating risks for patients, unexpected costs to the health care system, and increasing liability risk for medical professionals.

The medical community’s process for generating and implementing evidence for care is well established and fueled by clinical trials, observational research, and meta-analyses backed by agreed-upon methodologies and peer review. Findings are summarized into guidelines, and extensive training reinforces health care professionals’ ability to identify trusted sources of evidence and use the best evidence available to them.

Despite the rigor and volume of standard clinical evidence, it alone is not enough to meet the needs that precision medicine requires. In some specialties, less than 20% of daily medical decisions are supported by quality evidence. Technology can play a critical role to rapidly create observational evidence sourced from similar patients and enable the use of that evidence at the bedside. Big tech and large EMR players have begun developing “patients like mine” technology and their PR machines are building excitement about the promising future.

Any evidence-providing technology, however, needs to ensure that the standards of transparency, data quality, and methodological rigor are being met. Regulations already hold life sciences companies, which also have large financial incentives in clinical evidence, to high standards when it comes to how they generate and communicate evidence for their products.

Automating “patients like mine” is risky and can cause harm

Let me pose a simple scenario that occurs thousands of times a day across the nation: a patient comes to their primary care physician with uncontrolled high blood pressure despite six months of attempted control on low-dose losartan, a common first-line drug in the angiotensin II receptor blocker class of blood pressure medicines. The EHR identifies 10,000 “similar” patients and displays for half a dozen possible blood pressure therapies their expected changes in blood pressure after six months along with their five-year heart attack risk. The physician sees that blood pressure appears best controlled with hydrochlorothiazide (another common blood pressure medicine in the class of thiazide diuretics), and the five-year heart attack risk is lowest by a few percentage points, and so adds it to the existing treatment regimen, and sends the patient on their way.

The addition does indeed help control the patient’s blood pressure. But 12 months later, the patient sees his doctor because of pain and swelling in his big toe. He is diagnosed with gout, a condition that thiazide diuretics increase the risk of. The patient now needs expensive chronic management for a painful and debilitating ailment that could have been avoided by taking a more evidence-based approach of either adjusting the dose of losartan or adding an alternate medication.

If recommendations like the scenario I described are built into clinical workflows, it will play out hundreds of times across the country.

What went wrong in that instance, and how can it be prevented?

First, the EHR automatically defined “similar” without the physician adding important clinical criteria for their patient. Because “similar” can be defined in any number of ways, understanding what is the physician asking is essential for correctly defining “similar.”

Second, patients can be “similar” at different points in their clinical journeys; making sure “similar” patients are at the same decision point is essential. In the hypertension scenario, a patient could have uncontrolled blood pressure any number of times over the course of their life and, if all such points are included, the most intense treatment regimen will likely show the best outcomes — but such a regimen will also likely come with the most adverse events. Using an appropriate methodology to identify the decision point, as well as to match patients on demographic and clinical characteristics related to their outcomes, is necessary to produce reliable clinical suggestions.

Third, by providing only simple analyses of the percentage of patients with controlled blood pressure or 5-year heart attack risk, and not confidence intervals around the point estimate, “patients like mine” fails to convey uncertainty in the prediction.

Fourth, these methodological issues are compounded by messy EHR data which should be cleaned prior to preforming predictive tasks.

Five steps to correctly get to evidence for “patients like mine”

To correctly generate evidence from observational data like that extracted from the EHR to guide therapy for “patients like mine,” the following criteria must be met:

Use proper statistical methodology. Appropriate statistical methodology that controls for confounders in observational data is essential to drawing conclusions from real-world data.

Standardize data quality evaluation. Datasets used for predictive purposes need to be cleaned for purpose and each time a cohort of patients is created for a “patients like mine” analysis the cohort needs to be assessed as being statistically powered to answer the clinical question being asked .

Standardize definitions of clinical concepts. A condition like diabetes can be defined in many different ways from looking at diagnostic codes, medications, lab values, and a combination of these over time. Definitions must be transparent to allow providers to know if their patient meets the criteria.

Regulatory grade transparency and auditability. Any recommendation made by a “patients like mine” system should be traceable, including source data, methods, and code used to implement the analysis. Such “patients like mine” tools are to be regulated as medical devices in guidance released by the FDA in late 2022.

Convey information and visualization to providers. Providers need to be given enough information to contextualize a recommendation and determine if their patient is appropriately represented in it.

While I remain excited and enthusiastic about the potential of bringing precision evidence to care for everyone, and believe that “patients like mine” approaches are an integral way to improve decision-making, I believe it is imperative to stick to sound methodology and transparency when generating evidence. Implementing dashboards with superficial analytics without understanding the underlying clinical scenario will lead to worse outcomes for patients and higher costs to an already overburdened health system.

Saurabh Gombar, M.D., Ph.D., is the chief medical officer of Atropos Health, which creates real-world evidence for health systems and life science companies, and an adjunct professor of medicine at Stanford School of Medicine.

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The Grand Challenges of Medical Technology

New developments in medical technology span the breadth of the healthcare environment providing new solutions for therapies, diagnostics, and imaging. Healthcare is a billion dollar market which drives the development and progression of healthcare technologies to the clinic. The innovative approaches which involve novel tools and technologies form the basis for this translation. Exciting areas highlighted by this new Journal, such as Cardiovascular Medtech, Nano-Based Drug Delivery, Medtech Data Analytics, Pharmaceutical Innovations, Regulatory Affairs and Regenerative Technologies represent key examples where step changes in healthcare solutions are being addressed. In each one of these sectors and across sectors, there are major challenges which we can identify.

Probably the biggest underlying global challenge which requires a new “mind set” is maintaining a high quality of life for our aging populations. Across the globe, people are living longer and requiring new solutions to address life as an aged citizen. Regenerative technologies and robotics are highlighting a new era of how we maintain a healthy life through a millennial lifespan. Soft robotics and tissue engineering provide potential reparative solutions. New innovative technologies can help to maintain healthy lives in our aging populations by addressing major chronic and acute clinical conditions. Scientific disciplines in biology and molecular approaches have revealed the potential for new drugs and treatments, however, there are still significant gaps in the enabling technologies and supporting medical technology devices which need addressing. Recent viral pandemics such as COVID 19 have demonstrated clearly the need for new medical technologies to fight disease such as portable ventilators and respiratory assistive devices useable throughout the world in developed and underdeveloped countries. These future technologies require the skillsets of a diverse academic base crossing many scientific and engineering communities. In addition, to bring new approaches to the clinic, many facets of the field must be determined and defined to the standards and rigor of the scientific, regulatory and clinical communities. With the increase in innovative technologies and regenerative therapies aiming for the clinic, there are key challenges in delivery systems, metrology, quantitative and computational modeling, data throughput, multimodal approaches for the characterization of disease and treatments, physiological and biochemical monitoring of clinical treatments and tools, technology integration and automation.

What Are Examples of the Major Challenges We Face in the Med Tech Sector?

Over the past 10 years, the scale of healthcare therapies is reducing with “nanotechnologies” providing exciting opportunities. Examples of nanotechnologies include drug delivery systems with smaller and more targeted approaches, nanomagnetic solutions with nanoparticles for imaging and treatments such as hyperthermia in cancer. The ability to modify materials rapidly at small length scales using techniques such as laser direct printing and other 3D printing modalities provides opportunities for unique capabilities in the fabrication of medical devices ( 1 ). Techniques such as laser and 3D printing provide opportunities for processing a broad spectrum of advanced medical devices, such as drug delivery devices, stents, patient-specific prostheses, biosensors, and regenerative technologies ( 2 ).

Biomedical Complexity

Coping with the complexity of tissues and organs alongside the issues of multi morbidity in patients requires new approaches in targeting and specificity of drugs and other medical devices. Design for additive manufacturing (DfAM) aims to utilize the complexity of human systems for the development of medical devices. DFAM provides enhanced performance in our ability to generate biomaterials with complex geometrical designs at the micro-scale ( 3 ). New nano—drug release strategies allow localized delivery to provide specific solutions to regions and organs in the body ( 4 ).

Personalized and Bespoke Medicine

Stratification of patient populations is presenting a new era of personalized medicine. How we stratify patients requires new tools and diagnostic capabilities ( 4 ). How we tailor treatments to improve efficacy requires autologous and synthetic treatments. Repurposing existing drugs and new multi model drug designs require innovations in computational and in silico tools ( 5 ). The pharmaceutical industry is having to rethink how next generation drugs are developed and delivered enabling more personalized approaches within populations.

Early Diagnostics

Early screening for disease prevention rather than end stage treatment of degeneration has been proposed as a key solution for us to tackle long term conditions ( 6 ). New advances in the treatment of chronic disease require early identification often prior to detection of major symptoms. A disease which illustrates this challenge is Osteoarthritis where treatment is often given when the joint has completely failed and requires replacement. Early interventions which can arrest the degeneration of the joint would eradicate the need for these major surgeries. New diagnostic and imaging techniques are being developed which support early screening programmes.

Precision and Robotic Surgery

Surgical procedures in cardiovascular, opthamology and other major organs are evolving and improving with clinically validated protocols. Precision surgical tools combined with robotics and virtual surgeries provide the supporting technology advances in this area. New technologies have reached the clinic in minimally and non-minimally invasive, transluminal endoscopic, and single site surgeries ( 7 ).

Rehabilitation and Assisted Devices

Innovations in assisted devices are building mobility in our physically impaired populations. Advances in materials, electronics and designs are revolutionizing our ability to support and mobilize this community. The role of tissue mechanics and mechanotransduction has been identified in rehabilitation and provides a future area for new forms of rehabilitation regenerative therapies ( 8 ).

Stem Cells for Regeneration and Therapy

Stem cell therapies and regenerative medicine require significant support in the form of enabling technologies to reach the clinic. To deliver regenerative medicine therapies involves scalable production and application of standardized clinical grade biotherapies. The delivery is underpinned by effective supply chain capabilities combined with manufacturing and sourcing ( 9 ). These enabling technologies such as bioreactors for growing cells and biomaterial systems are identified within a new field termed regenerative medical technologies. In addition, novel diagnostics which monitor cell performance and efficacy are required to support regulatory approvals ( 10 ).

The Regulatory Environment and Standardization

New challenges include how to assess advances in therapies using health technology assessments which are tailored for new fields such as gene therapy or cell therapies. The expansion of medical technology in our hospitals has not kept pace with patient safety. Assessments and safety requirements play an important role in protecting against risk of failure. Evidence suggests that pioneer entrants in medical technology may take significantly longer than follow on products which can be related to novel assessments and lack of regulatory guidelines in some cases ( 11 ).

Finally, large databases of patient data are being captured in hospitals which if accessed provide wealth of information about disease treatment and prevention. Handling data sets and analysis of data has become a major growth area of interest globally ( 12 ). Mobile medical technology is expanding with multiple diagnostic and monitoring platforms using mobile app systems which can require new ways of approaching data analytics.

Conclusions

To tackle these challenges, the Med Tech field needs to work as a community celebrating their new high quality approaches and integrating them across organ sectors. This new journal, Frontiers in Medical Technology, will provide a forum for these disparate communities to come together and publish their articles in an open access format for dissemination. Reaching out to the clinician, clinical scientist, academic, engineering and commercial worlds, we aim to provide an on-line forum for high quality pier reviewed publications which spearheads new innovations in a global field and demonstrates their relevance in a clinical setting.

Author Contributions

The author confirms being the sole contributor of this work and has approved it for publication.

Conflict of Interest

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

This work was supported by an Advanced ERC grant Ref: DLV 789119, an EPSRC Healthcare Discipline Hopper Award Ref: EP/R013209/1 and the MRC UK Regenerative Medicine Platform Ref: MR/R015635/1.

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Elektrostal

Our editors will review what you’ve submitted and determine whether to revise the article.

Elektrostal , city, Moscow oblast (province), western Russia . It lies 36 miles (58 km) east of Moscow city. The name, meaning “electric steel,” derives from the high-quality-steel industry established there soon after the October Revolution in 1917. During World War II , parts of the heavy-machine-building industry were relocated there from Ukraine, and Elektrostal is now a centre for the production of metallurgical equipment. Pop. (2006 est.) 146,189.

40 Facts About Elektrostal

Written by Lanette Mayes

Modified & Updated: 01 Jun 2024

Reviewed by Jessica Corbett

Elektrostal is a vibrant city located in the Moscow Oblast region of Russia. With a rich history, stunning architecture, and a thriving community, Elektrostal is a city that has much to offer. Whether you are a history buff, nature enthusiast, or simply curious about different cultures, Elektrostal is sure to captivate you.

This article will provide you with 40 fascinating facts about Elektrostal, giving you a better understanding of why this city is worth exploring. From its origins as an industrial hub to its modern-day charm, we will delve into the various aspects that make Elektrostal a unique and must-visit destination.

So, join us as we uncover the hidden treasures of Elektrostal and discover what makes this city a true gem in the heart of Russia.

Key Takeaways:

Elektrostal, known as the “Motor City of Russia,” is a vibrant and growing city with a rich industrial history, offering diverse cultural experiences and a strong commitment to environmental sustainability.
With its convenient location near Moscow, Elektrostal provides a picturesque landscape, vibrant nightlife, and a range of recreational activities, making it an ideal destination for residents and visitors alike.

Known as the “Motor City of Russia.”

Elektrostal, a city located in the Moscow Oblast region of Russia, earned the nickname “Motor City” due to its significant involvement in the automotive industry.

Home to the Elektrostal Metallurgical Plant.

Elektrostal is renowned for its metallurgical plant, which has been producing high-quality steel and alloys since its establishment in 1916.

Boasts a rich industrial heritage.

Elektrostal has a long history of industrial development, contributing to the growth and progress of the region.

Founded in 1916.

The city of Elektrostal was founded in 1916 as a result of the construction of the Elektrostal Metallurgical Plant.

Located approximately 50 kilometers east of Moscow.

Elektrostal is situated in close proximity to the Russian capital, making it easily accessible for both residents and visitors.

Known for its vibrant cultural scene.

Elektrostal is home to several cultural institutions, including museums, theaters, and art galleries that showcase the city’s rich artistic heritage.

A popular destination for nature lovers.

Surrounded by picturesque landscapes and forests, Elektrostal offers ample opportunities for outdoor activities such as hiking, camping, and birdwatching.

Hosts the annual Elektrostal City Day celebrations.

Every year, Elektrostal organizes festive events and activities to celebrate its founding, bringing together residents and visitors in a spirit of unity and joy.

Has a population of approximately 160,000 people.

Elektrostal is home to a diverse and vibrant community of around 160,000 residents, contributing to its dynamic atmosphere.

Boasts excellent education facilities.

The city is known for its well-established educational institutions, providing quality education to students of all ages.

A center for scientific research and innovation.

Elektrostal serves as an important hub for scientific research, particularly in the fields of metallurgy , materials science, and engineering.

Surrounded by picturesque lakes.

The city is blessed with numerous beautiful lakes , offering scenic views and recreational opportunities for locals and visitors alike.

Well-connected transportation system.

Elektrostal benefits from an efficient transportation network, including highways, railways, and public transportation options, ensuring convenient travel within and beyond the city.

Famous for its traditional Russian cuisine.

Food enthusiasts can indulge in authentic Russian dishes at numerous restaurants and cafes scattered throughout Elektrostal.

Home to notable architectural landmarks.

Elektrostal boasts impressive architecture, including the Church of the Transfiguration of the Lord and the Elektrostal Palace of Culture.

Offers a wide range of recreational facilities.

Residents and visitors can enjoy various recreational activities, such as sports complexes, swimming pools, and fitness centers, enhancing the overall quality of life.

Provides a high standard of healthcare.

Elektrostal is equipped with modern medical facilities, ensuring residents have access to quality healthcare services.

Home to the Elektrostal History Museum.

The Elektrostal History Museum showcases the city’s fascinating past through exhibitions and displays.

A hub for sports enthusiasts.

Elektrostal is passionate about sports, with numerous stadiums, arenas, and sports clubs offering opportunities for athletes and spectators.

Celebrates diverse cultural festivals.

Throughout the year, Elektrostal hosts a variety of cultural festivals, celebrating different ethnicities, traditions, and art forms.

Electric power played a significant role in its early development.

Elektrostal owes its name and initial growth to the establishment of electric power stations and the utilization of electricity in the industrial sector.

Boasts a thriving economy.

The city’s strong industrial base, coupled with its strategic location near Moscow, has contributed to Elektrostal’s prosperous economic status.

Houses the Elektrostal Drama Theater.

The Elektrostal Drama Theater is a cultural centerpiece, attracting theater enthusiasts from far and wide.

Popular destination for winter sports.

Elektrostal’s proximity to ski resorts and winter sport facilities makes it a favorite destination for skiing, snowboarding, and other winter activities.

Promotes environmental sustainability.

Elektrostal prioritizes environmental protection and sustainability, implementing initiatives to reduce pollution and preserve natural resources.

Home to renowned educational institutions.

Elektrostal is known for its prestigious schools and universities, offering a wide range of academic programs to students.

Committed to cultural preservation.

The city values its cultural heritage and takes active steps to preserve and promote traditional customs, crafts, and arts.

Hosts an annual International Film Festival.

The Elektrostal International Film Festival attracts filmmakers and cinema enthusiasts from around the world, showcasing a diverse range of films.

Encourages entrepreneurship and innovation.

Elektrostal supports aspiring entrepreneurs and fosters a culture of innovation, providing opportunities for startups and business development .

Offers a range of housing options.

Elektrostal provides diverse housing options, including apartments, houses, and residential complexes, catering to different lifestyles and budgets.

Home to notable sports teams.

Elektrostal is proud of its sports legacy , with several successful sports teams competing at regional and national levels.

Boasts a vibrant nightlife scene.

Residents and visitors can enjoy a lively nightlife in Elektrostal, with numerous bars, clubs, and entertainment venues.

Promotes cultural exchange and international relations.

Elektrostal actively engages in international partnerships, cultural exchanges, and diplomatic collaborations to foster global connections.

Surrounded by beautiful nature reserves.

Nearby nature reserves, such as the Barybino Forest and Luchinskoye Lake, offer opportunities for nature enthusiasts to explore and appreciate the region’s biodiversity.

Commemorates historical events.

The city pays tribute to significant historical events through memorials, monuments, and exhibitions, ensuring the preservation of collective memory.

Promotes sports and youth development.

Elektrostal invests in sports infrastructure and programs to encourage youth participation, health, and physical fitness.

Hosts annual cultural and artistic festivals.

Throughout the year, Elektrostal celebrates its cultural diversity through festivals dedicated to music, dance, art, and theater.

Provides a picturesque landscape for photography enthusiasts.

The city’s scenic beauty, architectural landmarks, and natural surroundings make it a paradise for photographers.

Connects to Moscow via a direct train line.

The convenient train connection between Elektrostal and Moscow makes commuting between the two cities effortless.

A city with a bright future.

Elektrostal continues to grow and develop, aiming to become a model city in terms of infrastructure, sustainability, and quality of life for its residents.

In conclusion, Elektrostal is a fascinating city with a rich history and a vibrant present. From its origins as a center of steel production to its modern-day status as a hub for education and industry, Elektrostal has plenty to offer both residents and visitors. With its beautiful parks, cultural attractions, and proximity to Moscow, there is no shortage of things to see and do in this dynamic city. Whether you’re interested in exploring its historical landmarks, enjoying outdoor activities, or immersing yourself in the local culture, Elektrostal has something for everyone. So, next time you find yourself in the Moscow region, don’t miss the opportunity to discover the hidden gems of Elektrostal.

Q: What is the population of Elektrostal?

A: As of the latest data, the population of Elektrostal is approximately XXXX.

Q: How far is Elektrostal from Moscow?

A: Elektrostal is located approximately XX kilometers away from Moscow.

Q: Are there any famous landmarks in Elektrostal?

A: Yes, Elektrostal is home to several notable landmarks, including XXXX and XXXX.

Q: What industries are prominent in Elektrostal?

A: Elektrostal is known for its steel production industry and is also a center for engineering and manufacturing.

Q: Are there any universities or educational institutions in Elektrostal?

A: Yes, Elektrostal is home to XXXX University and several other educational institutions.

Q: What are some popular outdoor activities in Elektrostal?

A: Elektrostal offers several outdoor activities, such as hiking, cycling, and picnicking in its beautiful parks.

Q: Is Elektrostal well-connected in terms of transportation?

A: Yes, Elektrostal has good transportation links, including trains and buses, making it easily accessible from nearby cities.

Q: Are there any annual events or festivals in Elektrostal?

A: Yes, Elektrostal hosts various events and festivals throughout the year, including XXXX and XXXX.

Elektrostal's fascinating history, vibrant culture, and promising future make it a city worth exploring. For more captivating facts about cities around the world, discover the unique characteristics that define each city . Uncover the hidden gems of Moscow Oblast through our in-depth look at Kolomna. Lastly, dive into the rich industrial heritage of Teesside, a thriving industrial center with its own story to tell.

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The winners and losers in the 2024 New South Wales budget

Graphic image showing three illustrations of people beside a 'winners and losers' sign, with a map of NSW in the background.

NSW Treasurer Daniel Mookhey has vowed not to impose austerity on the state despite the NSW budget remaining in deficit for the next four years.

With an $11.9 billion write-down of GST revenue blowing a hole in the budget there are no large-scale cost-of-living sweeteners for households.

These are some of the biggest announcements that could affect you.

Winner: Social housing

Icon drawing of different size buildings ranging from skyscraper to house.

The government is making a $6.6 billion investment in what is being billed as the largest state-based investment in social housing in NSW history.

Of this, $5.1 billion will go to building 6,200 new homes and replacing 2,200 homes in disrepair.

Half of these new homes will go to women escaping domestic violence.

There will be $1 billion spent repairing 33,500 existing social homes.

The government has already announced that essential workers are being looked after this year with a $650.1 million injection of funding to house key workers like nurses, paramedics, teachers, allied health care workers, police officers and fire fighters.

This scheme will provide 400 homes for essential workers in Sydney and 500 for health workers in regional areas.

Neutral: Cost of living

An illustration of one $2 coin balancing against another.

NSW residents hoping for a cash injection to help with cost of living will be disappointed with this budget.

Last year, the government announced new $250 energy rebates, toll and daycare relief.

There are no new rebate measures in this year's budget.

This year, the scheme that saw eligible seniors, university students and apprentices in regional areas receive $250 prepaid travel cards will wind down.

Instead, Mr Mookhey will rely on a helping hand for GPs in the form of payroll tax rebates, with the expectation that bulk-billing GP appointments will be easier to find.

Winner: Housing supply

Icon drawing of three multi-story townhouses.

The government has promised to deliver 21,000 new homes by releasing surplus government land.

The homes will be built by a mixture of government agencies and the private sector.

The government agencies will get first choice of the sites to deliver social, affordable and essential worker housing.

Other sites will be developed in partnership with the private sector but the government has not said how the sites will be allocated.

Forty-four sites have been identified.

Most are located in Sydney but the exact locations have not been revealed.

The government is also spending $520 million to speed up the planning system.

Councils will be incentivised to meet and beat their housing targets with a $200 million sweetener to help councils deliver roads, parks and community facilities.

Loser: Property investors

An illustration of a house with a Hill's Hoist washing line beside it.

Land tax thresholds will be increased for the 2024 land tax year and then maintained at that level.

The halt in indexing will mean people who own investment properties and holiday homes will need to pay land tax once their property values exceed $1.075 million.

These measures are expected to deliver an additional $1.5 billion in budget revenue over the next four years.

Foreign investors will now have to pay a 9 per cent duty surcharge, up from 8 per cent, and a 5 per cent land tax surcharge, up from 4 per cent on residential properties.

These two measures will raise $188 million in additional revenue.

The new land tax threshold, together with a strong property market has delivered $4.1 billion more in revenue for transfer duty and $5.6 billion in land tax.

Winner: GPs and patients

The government is helping to increase bulk-billing for patients by continuing with a GP payroll tax rebate at clinics that meet a bulk-billing threshold.

Past unpaid payroll tax liabilities for GPs will also continue to be waived until September.

This will cost the budget $189 million and aims to reduce financial pressures on GP practices so they don't pass on additional costs to patients.

RACGP NSW and ACT chair Rebekah Hoffman welcomed the government exempting GPs from retrospective payroll tax.

"This gives GPs across NSW certainty that they can continue to operate and keep their doors open for patients, without fear of being hit with a huge tax bill that will shut them down."

Winner: Public transport

Icon drawing of train and bus side by side from the front.

More than $22 billion has been allocated to building and improving public transport.

The centrepiece item announced earlier is $2 billion to Labor's election commitment to construct Stage 2 of the Parramatta light rail.

The 12-kilometre project will link the Parramatta CBD with Sydney Olympic Park, via Camellia, Rydalmere, Ermington, Melrose Park and Wentworth Point, with 14 new stops and three new river crossings.

The government will also invest $447 million to keep 55 Tangara trains on the tracks for 12 years longer than originally planned. The move is necessary to keep services running until a new fleet of trains is constructed.

Around $17 million has been set aside for the Future Fleet Program to revive the state's domestic train manufacturing industry.

Winner: Western Sydney Airport

The new Western Sydney International Airport will get $1 billion for roads linking to the site at Badgerys Creek.

They include a four-lane upgrade to Elizabeth Drive, the next stage of construction on Mamre Road, and four lanes along part of Mulgoa Road.

More than $10 million will also be invested in Appin Road to build a stronger connection from Wollongong and the South Coast to Campbelltown and the Western Sydney airport precinct.

"Our investment in roads in this region, in lock-step with the Federal Government, will provide industry the assurance to co-invest and get development moving. We are transforming and building the roads and the jobs will follow," Mr Mookhey said.

Loser: GST revenue

An illustration of a map of Australia that shows New South Wales highlighted.

As previously flagged, NSW will be $11.9 billion worse off owing to reduced Goods and Services Tax (GST) income.

Rather than 92 cents from every dollar of GST paid in the state, NSW will now only get 87 cents in the dollar.

Mr Mookhey said the Commonwealth Grant Commission's decision had cost NSW more lost revenue than the COVID-19 pandemic.

"For every dollar that Victoria will give to the smaller states next year, NSW will give upwards of four," he said in his budget speech.

He said the government would absorb the $11.9 billion hit to the bottom line, but it would lead to deficits over the four years of forward estimates.

Without the cut, treasury estimated NSW would have returned to surplus next year.

Neutral: Women

As in previous years, the budget includes a gender equality statement.

The government highlights several measures that proportionately benefit women, including $5.1 billion in social housing and $528 million for crisis accommodation and homelessness support services.

There is $245 million for domestic, family and sexual violence services, including $48 million for specialist workers and $45 million to improve bail laws and justice system responses.

The government has allocated $131 million for family support in the form of maternal and child health programs.

But there are no women-specific health packages or initiatives that directly address gender inequality, as there was in last year's budget.

These included programs to improve women's participation in the workforce, facilities to encourage women to play sport and more funding for breast cancer nurses and sexual assault nurse examiners.

The budget papers highlight that there is still an 11 per cent gender pay gap favour of men in NSW and a 6.2 per cent NSW public sector gender pay gap.

Winner: School students

Icon drawing of two books with broad brimmed hat sitting on top, and apple on left side.

The government has announced $8.9 billion in funding for building new schools and upgrading existing ones.

The government will spend $3.6 billion on schools in Western Sydney, though all apart from a new public school and high school at Box Hill have previously been announced.

More than 60 new schools are being delivered in Western Sydney.

Existing schools will benefit from $1.08 billion for maintenance, $200 million more than last year, including $600 million for school maintenance, $150 million for disability access and safety and $200 million for small upgrades and refurbishments.

Regional students will also benefit, with $1.4 billion allocated to building new and upgraded schools in regional areas.

To ensure regional schools have teachers, the Priority Recruitment Support Program will be expanded.

It allows regional schools with long-standing vacancies to offer a $20,000 recruitment bonus and a $8,000 relocation package.

Winner: Hospital patients

Hospital patients will benefit from $3.4 billion of spending on upgrading NSW's hospitals and health facilities.

Nearly $1 billion will go to rural and regional capital works projects, including in Eurobodalla, Temora, Moree, Cessnock and Shellharbour hospitals, with $265 million to Port Macquarie Hospital.

Nearly $48 million will go to the Ryde Hospital upgrade.

Around $480 million will be spent on easing pressure on emergency departments, by expanding access to virtual health delivered by Healthdirect, urgent care clinics and emergency department short-stay units.

NSW hospitals will also benefit from $274 million being spent on recruiting 250 healthcare workers for new and upgraded hospitals, including Prince of Wales, Tweed, Bowral, Sutherland, Wentworth, Cowra, Cooma, Glenn Innes and Griffith hospitals.

Health Minister Ryan Park said new hospitals needed staff to adequately run them.

"We need a fully staffed healthcare system that is responsive and well-resourced, because when we back in our health workers, we improve patient outcomes, and that's exactly what we're doing."

Winner: Flooded communities

Illustration of river with low water and dead tree

The government is spending $3.3 billion to help communities affected by floods to recover by repairing local and state roads.

More than $630 million goes to delivering new and safe housing in the Northern Rivers and Central West, including $525 million to support voluntary buy-backs, raisings, repairs and retrofits.

There is also $207.3 million available for emergency responses, including more firefighters and $2.4 million for the state-wide Disaster Response Legal Service.

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