Dr Robot, Mr Quintana and the Lords of the Rings

Have you read the news? Do you know what’s happened? In Social Media and WhatsApp chats, what do you think about what’s happened?

I had not heard, and neither was I particularly interested until I found myself watching the TV news: “Robot doctor tells the patient he’s going to die”. Even at this point, I had no particular emotions, but then I watched the scene recorded by the granddaughter of Ernest Quintana, 78 years, patient at a Hospital in Fremont, California, managed by Kaiser Permanente, an established and respected Health Maintenance Organization, which presents itself with these words on the homepage of their website:

Thrive your way. We’ll take care of the rest. There are many ways to live healthily. Also, when you’re a Kaiser Permanente member, many people work together to help you stay that way. Your doctor, specialists, and health plan are all part of one connected team — coordinating your care seamlessly, so you don’t have to. It’s how we do things faster, easier, and better — and help you live healthy your way. 

Despite this slogan, on March 9, a robot appeared in the hospital room where the patient Ernest Quintana was lying and through a video-link screen a doctor appeared in a remote place, to inform the patient You might not make it home, You have no lungs left. The granddaughter Annalisa Wilharm, who was present, knew he was very sick, but she and her family had no idea of the extent up to this point. The one-way conversation continued with the Remote-Control Doctor informing the patient, who was not conscious, There is a risk that your breathing is too weak…we don’t have an effective treatment, but I can give you comfort therapy, take off the oxygen mask and activate a morphine drip.

Since the patient could not hear or comprehend, the grand daughter had the difficult task of translating into easy words the bad news and, unwittingly, do the doctor a favour by obtaining from the patient the legal consent needed to take away the oxygen mask and move to palliative sedation (euphemistically called comfort therapy) through morphine administration. Quintana died the very next day and the family is still in shock.

Michelle Gaskill-Hames, senior vice-president of Kaiser Permanente Greater Southern Alameda County, called the situation highly unusual and said officials “regret falling short” of the patient’s expectations, but said that telemedicine and teleconsultation is very effective and We will use this as an opportunity to review how to improve the patient’s experience with tele-video capabilities.

There was no outright admission of error: “falling short” meant simply not being able to satisfy the client, with the event labelled “as an opportunity” to continue with a practice which appears to have significant problems. Ironically, better having two case histories, useful documentation to learn more.

Well, if at the beginning I was only interested in the facts, looking at the whole process, I now must admit my surprise and anger for many different reasons. To begin with, the use of a video-link with a Remote Doctor looked like a dystopic science fiction movie! It could have been 2001 Space Odyssey, in which the computer HAL 9000 had to inform the spaceship captain that he would soon be dead. Ironically, the style of language used by the doctor, in this case, is like one learnt from the 0-1 binary code with which Computers and Robots works: since active treatment is not working, we must move to “comfort therapy”. More telling than this would be the active question that doctors always ask; Do you understand me? A question almost impossible to ask if the doctor was not in the patient’s room, in his proximity, gazing at his face, hands, body and condition.

He would never have asked this “rhetorical question” for two main reasons: the first is that being physically there, he would have in his eyes and hands much more detail of the complex picture of the conscious status of the patient (doctor had in his hand simply an MRI lung image and not the patient’s brain image) and secondly, the fact that unless one does not have mirror neurons, as with those unfortunates who have Asperger Autistic Syndrome, a normal developed empathetic human being would never ask such a question. Poor granddaughter Annalisa tried to translate the doctor’s words but her fumbling words were those of someone “over her pay grade”: simply, your breathing will be stuck, no other words to add, to inform her grandfather. She was put in an awkward situation, through no fault of her own and one which is absurd, inhumane and dystopic.

The management of Kaiser Permanente makes the claim that many people work together to help you stay that way, healthy. Your doctor, specialists, and health plan are all part of one connected team. But in this case the patient was dying and “Your doctor” was somewhere lost in the space and in translation, and yet they continue to defend the quality of their telemedicine and televisits.

Telemedicine and teleconsultation are extraordinary tools for guaranteeing patient monitoring, especially in a home care setting or for specific purposes in hospital, but not for replacing core visits, in which there are crucial moments requiring communication in the diagnosis and decision-making process which require an alignment between doctors and patients. It is nowhere more important than in the physical encounter between carers and patients during end of life care. Technology can be used in certain moments, to guarantee the correct administration of medication, to avoid human errors with samples in the laboratory and in certain phases of surgery, but also in these cases it has been shown that the human eye as supervisor is always necessary to observe, perceive, understand, reflect and react to what is happening. Telemedicine implies distance and loss of empathy due to the remoteness of the doctor and distant too was the management of the patient with the choice of language, taken from business customer satisfaction.

There are many studies which now show the Machiavellian, Psychopathic, or Narcissistic Behaviour of people who reach top management positions: the dark side in organizations to date. Machiavellianism is characterized by manipulative actions and a lack of concern for others. Psychopathy reflects a combination of thrill seeking and lack of remorse. Narcissism, however, appears to be primarily driven by self-enhancement tendencies, common in someone who does not listen. The answer provided by the top management of Kaiser Permanente is a blend of all these mindsets and lifestyles. Here, we find ourselves in an odd situation. Notable the doctor’s interruption after 35 seconds of patients’ speak is what we called a not empathic encounter, however here we are far beyond any possible imagination, at the bedside a patient is dying and the Carer HUMAN TOUCH is extinguished, leaving the person lonely together with their whole family.

This is why this event is and will remain, a paradigmatic mal-practice didactic case, to be used by everyone in health care who wants to learn to become not a good carer but simply a normal carer.

A few days ago, I was reading an essay on Tolkien, the author of the Lord of the Rings, which tried to summarise in a few lines the vastness of the literary works of the English novelist during the first half of the XX century. The main message of his works is not, as somebody could easily guess, the fight between Good and Evil, but the fight between natural forces and those of industrialization and the creation of machines(today we would call them robots). The machine’s ability to corrupt is visible not only in warfare and military conquest but also in everyday life, as it can remove something innately human and transform it into something dull and enervating. The dire implications of the machine are captured in Tolkien’s Orcs: these creatures do not come to exist naturally but are bred by an evil power out of the slime of the earth. They are deformed and ugly creatures, whose hands are sometimes replaced with weapons. They seem to hate everyone, even themselves, and they take pleasure only in destroying and defiling. Tolkien suggests that they make no beautiful things, perhaps because they cannot recognize beauty. They care only about efficiency and conquest, to which they are driven by evil masters who rule through fear. On the other hand, we have the Ents, in J. R. R. Tolkien fantasy world, who closely resemble trees.

They are talking trees and appear in The Lord of the Rings as ancient shepherds of the forest and allies of the free peoples of Middle-earth. Ents are an old race, belong to the most ancient natural realm and they will fight against the loss of souls produced in the Earth by the Orcs and their chiefs. Death is such a natural embedded delicate moment that it should be honoured, mourned and supported with the respect given by the natural cycle of life and passing by: this is what humanities teach. Now as ever before, we have to get back to the Ents and their strength to oppose to the dumb revolution when robots –the Orcs- are used to replace human beings in very delicate matters.

Maria Giulia Marini

Epidemiologist and counselor in transactional analysis, thirty years of professional life in health care. I have a classic humanistic background, including the knowledge of Ancient Greek and Latin, which opened me to study languages and arts, becoming an Art Coach. I followed afterward scientific academic studies, in clinical pharmacology with an academic specialization in Epidemiology (University of Milan and Pavia). Past international experiences at the Harvard Medical School and in a pharma company at Mainz in Germany. Currently Director of Innovation in the Health Care Area of Fondazione ISTUD a center for educational and social and health care research. I'm serving as president of EUNAMES- European Narrative Medicine Society, on the board of Italian Society of Narrative Medicine, a tenured professor of Narrative Medicine at La Sapienza, Roma, and teaching narrative medicine in other universities and institutions at a national and international level. In 2016 I was a referee for the World Health Organization- Europen for “Narrative Method of Research in Public Health.” Writer of the books; “Narrative medicine: Bridging the gap between Evidence-Based care and Medical Humanities,” and "Languages of care in Narrative Medicine" edited with Springer, and since 2021 main editor for Springer of the new series "New Paradigms in Health Care."

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