Do you remember the 1998 movie You've Got Mail, starring Meg Ryan and Tom Hanks? I saw it on cable recently. Ryan's character runs a small bookstore in New York. Tom Hanks owns a megastore, which moves into Ryan’s neighborhood. He and Meg Ryan fall in love with each other over the (then relatively new) Internet, Microsoft Outlook acting as Cupid. The small store bites the dust, but the two find true love.
Only 14 years old, yet quaint beyond belief: how rapidly things change. The technology is so last decade. What self-respecting potential dater would fail to peruse a Facebook entry, and where are the Tweets and text messages and smartphones? And really, would Meg Ryan’s character think of Hanks as anything other than a creepy Internet stalker? And would you really forgive someone who destroyed your livelihood?
The megastore is clearly modeled on Border's, which did indeed demolish legions of small bookstores in the 1990s. I walked by a boarded-up Border's at the Indianapolis airport recently. The Internet didn't bring Borders a love note, but rather Amazon and Kindle. The company failed to adjust, and it disappeared. Joseph Schumpeter’s creative destruction at work, a less efficient organization replaced by a more efficient (read: fewer actual jobs) organization. Barely a decade after being portrayed as an unstoppable juggernaut, it was on the ropes.Meanwhile I still have a neighborhood bookstore. I don’t know how long it will last. Maybe all bookstores are doomed by the Internet and its progeny. I hope not. Maybe I am old-fashioned, but I love the feel of a book in my hand, enjoy turning pages, browsing to see if the work engages my interest. Even more, I like wandering through the stacks at my local library or bookstore and coming across a new author I’ve never seen before. My friends tell me that they can do the same thing on Amazon, but somehow it just doesn’t seem the same. All right, I am old-fashioned.
At ASCO, and in oncology practices throughout the United States, we wrestle with the effects of the digital revolution. Trying to guess the future of technology is something of a fool’s errand, but we’ve already seen tectonic shifts related to the digital era. And we know it will proceed apace, as Moore’s Law continues its inexorable march.
Take medical research. If I want to see where a trial with a new agent is being performed, I go to clinicaltrials.gov and there it is. It is, not infrequently, being performed in Beijing or St. Petersburg or Warsaw. Partly this is due to the fall of the Iron Curtain and the triumph of globalization, but a major factor in the success of clinical trials outsourcing is the ability of contract research organizations to push information across the globe in microseconds using agreed-upon international data standards.
The end result is both more rapid clinical trials (a good thing) and fewer American clinical researchers (a bad thing). I got an email the other day from a medical oncologist in private practice I have known for many years, a solid citizen who has always placed patients in trials because it was the right thing to do. After thirty years, he and his group are shutting down their research office and letting their full-time research nurse go. His email said, “What a shame—we can’t afford to do it anymore.” What a shame for all of us.
And access to that research has been totally transformed as well. I used to spend hours in my medical library digging through Index Medicus, something that dates me as a seriously old guy. Now I do a PubMed search, then go online to my medical school library and download the PDF file for an article. Months go by without me ever entering my medical school library. If it disappeared as a physical structure, I would survive its loss with equanimity. Will there be only one central medical library, located perhaps in Bangalore or Shanghai, ten years from now?
Will medical journals even continue to exist in a paper format? I would guess not. If they do still exist, they will need to be serving some other purpose than they do today. For medical societies such as ours, our flagship journal is an important part of our identity as well as an important source of advertising revenue. What happens when the advertisers no longer believe that they can reach their target audience in a paper format? We may find out sooner than we wish.
Some of the current trends in cancer care, particularly the transition from small independent practices to large corporate (frequently hospital-based) medicine, seem forced and artificial to me. Very Tom Hanks megastore, if you will. But the medical megastores are not inherently efficient, nor are they immune to the effects of the digital revolution. How long before they become the new Borders, and what will replace them when that day comes? And what will happen to all of us Meg Ryan types, when Tom Hanks’ megastore crashes and burns, undercut by some new technology? Will the megastore’s owners be thinking of us when they go into the dustbin of technologic history?
Planning for this branching tree of medical futures is complicated as much by politics as it is by economics and technology. Many of the trends in health care are driven by decisions made in Washington (and sometimes Bethesda), and those decisions are often made independent of changes in technology. Nor are they always rational in economic terms, as political persuasions have hardened into political ideology bordering on theology, often abetted by special interest lobbying.
So we keep working, as a society and as individuals, confident only of the fact that our patients will still require our services for the foreseeable future. We try and be prepared for whatever comes, knowing that Hippocrates’ profession has outlasted every corporation and every technologic innovation. And maybe things will work out for Tom and Meg, though I wouldn’t depend on it. Anyways, I preferred Sleepless in Seattle.