This is an essay I wrote in June of 2002. It was written as a response to a blog post that Dave Winer made, questioning why software professionals don’t get the respect they deserve. I’m posting it again here, because the only other copy on the Internet is hosted on a site that isn’t mine. It’s a long article, but I think it takes a good stab at answering the question.
Doctors vs. Geeks
I spent 3 years, from 1991 to 1994, working in the Texas Medical Center. It’s the largest medical institution in the world and at the time, it had the largest institutional information network in the world, too. It was an interesting confluence of geeks and doctors and an interesting time, right at the birth of the commercial Internet. I occupied a relatively senior position in the geek hierarchy and worked very closely on a daily basis with department chairmen, CIOs, CEOs, and world-renowned physicians from the various medical schools, teaching hospitals, universities, and clinics affiliated with the TMC.
I had been there little more than a month before I recognized something that I found more than a little disconcerting. Most of the medical professionals and quite a few of the PhDs as well held a high disdain for technology, specifically information technology. Oh, they liked things like video conferencing (for remote telemedicine applications), miniaturized electronics (for things like pacemakers, neural stimulators, etc.), and were always scheming new gadgets to make a particular surgery simpler or safer. But “mundane” technologies like cell phones, PDAs, pagers, the Internet, the Web, e-mail, and other sorts of information-related devices held little interest for them.
After a while, it became clear why. These professionals viewed their professions as the pinnacle of human learning, and the human body as the most complicated system possible. Yet, I watched them struggle to solve problems on a daily basis that someone with a rigorous training in logic-based problem solving could knock out in no time. Visualizing and producing solutions that led to better medical treatments, more effective experiments, more powerful drugs, or some other “system-related” result always seemed to be a matter of trial and error. Information systems were never applied to their best effect and the outcomes always seemed to be more the result of a random walk than a purposeful journey.
Oh, it wasn’t because the geeks didn’t try. Hundreds of us worked on things like better patient record systems, improved image analysis for pathology samples, simulations of various human organ systems, huge expert systems for patient diagnosis, better communications infrastructures for distance learning, telemedicine, and even remote surgery. The problem is that none of the geeks’ efforts stemmed from the worlds of physiology, endocrinology, nephrology, neurology, gastroenterology, cardiology, or any of the other dozens of -ologies that medical school students are inundated with. We were technology generalists and that high-level system view of information flow, system interactions, and design insight necessary to build a complex information system was completely at odds with the medical culture.
In this universe of academic medicine, specific knowledge ruled. Reductionists were czars. Questions like “how does this protein interact with that drug compound?” or “how do sodium channels in neurons affect neural capacitance?” always took precedence over more generalized questions like “is there a correlation between the bacteria load in a patient and the incidence of heart disease?” I watched doctors and PhDs who were experts in human physiology, who had studied the minute inner workings of the lining of the stomach, argue vociferously over something as simple as their belief that helicobacter pylori bacterium couldn’t be responsible for stomach ulcers.
Even when confronted with mountains of evidence that there was a relationship between a person’s genetic predisposition to infection by the bacteria and their incidence of stomach ulcers, these gentlemen refused to be convinced that their intimate understanding of acid production, gastric emptying, and other G.I. details wouldn’t provide the ultimate answer. Their inability to see the relationship between genetics, immune system, G.I. system, and other variables effectively blinded them to an obvious treatment for their patients’ ulcers — a simple antibiotic. Of course, this is common knowledge and treatment today. But 10 years ago it was something on the order of a holy war between believers and infidels, to be waged with new acid inhibitors, surgeries, and diets.
I think there are three fundamental issues that cause a great disconnect between geeks and doctors: culture, the nature of the systems they interact with, and “ease of use.”
Culturally, the medical profession and the information sciences seem superficially similar. Both require highly dedicated, technically astute individuals to spend years accumulating knowledge. The differences come from the way this knowledge is acquired and applied. Doctors draw on an enormous body of codified knowledge. Rules, relationships, anatomies, formulae, and procedures form a vast sea of information to be sorted, categorized, memorized, and retrieved on demand. It’s no wonder that some expert systems experience a higher diagnostic success rate than human physicians when confronted with complicated, obscure symptoms and pathologies. The amount of information to be managed and recalled in context is enormous.
I had the opportunity to watch an entering class of first year med students for their entire time at the University of Texas Medical School in Houston, through their third year and then their internships. It was an amazing transformation from wide-eyed idealist to detached, white-coated professional. I, personally, think the kids lost something important on the way to becoming doctors. The process involves replacing curiosity and the ability to ask questions with absolute certainty and the ability to make instantaneous decisions. After all, lives are at stake and hesitation or indecision can be fatal, or at least that’s what they’re taught. Add to that the fact that there are generally only one or two “accepted” ways to accomplish a particular medical outcome and it starts to become clear where the two cultures diverge.
On the other hand, geeks have relatively little codified knowledge to draw on early in the learning process. Culturally, geeks learn by doing. They take a few relatively simple tools and techniques that they learned in school and apply them, generally in an iterative process of learning, until the desired result is achieved. It would be impossible to try and memorize all the possible ways to implement a given information system. There are as many different techniques as there are individuals. This seems incredibly untidy to a scientist. There’s no “right” answer. And geeks learn by sharing, which is something that is culturally abhorrent in the world of academic research. In the highly competitive world of research grants, tenure, and “publish or perish,” the incentive to share has been all but removed. So it seems that these two worlds are culturally at odds from the start.
Couple that with the fact that the human body is an enormously complicated system. It’s clear that we don’t really understand it all that well. People still get sick and die. Surgeons still use knives to chop off parts of a sick body, internists still mix chemicals into humans to correct specific problems, and neurologists still treat the brain as a relatively fragile piece of meat to be poked, shocked, and chemically treated into proper function. It’s not that surgeons, internists, and neurologists aren’t extremely capable, well-educated, and talented individuals, because they are. It’s that they started with a system they knew absolutely nothing about and no tools beyond their five senses to uncover its secrets. It’s only recently that technology and science have advanced to the point that things are significantly different for doctors than they were 500 years ago.
Geeks started with nothing. No complex systems, no unknown processes, no mysteries of life. Information science sprang into being at most in a period of 75 years. Everything in a geek’s universe, including his tools, the systems he builds on, and the things he creates were all the product of other geeks. Geeks are the ultimate controllers of their universe because they created it, which is a luxury not yet afforded the medical profession. It means that geeks can have ultimate knowledge of any of their system. One day, that will also be true for the medical profession. Once the human body is completely understood, it will cease to be the most complicated system we know of. Geeks will simulate it. That will by definition be a more complicated system. But it isn’t the case now and that is where the biggest dichotomy comes from between geeks and doctors. Doctors deal with a mostly unknown system with emergent behaviors. There are virtually no information systems complicated enough to exhibit emergent behaviors yet. To a doctor, that means what geeks do is inherently less difficult.
My years in the TMC taught me that doctors tended to downplay the value created by geeks. It seemed too easily understood and easy to master. Realities aside, piling up centuries of arcane knowledge seemed inherently more valuable to them than something that they considered mostly a trade. This is crux of the third element, “ease of use.”
In the medical world, the user is the system (i.e., the patient). The doctor’s work product is hopefully an improved system. But the problem is the user. The user has little knowledge of the system, isn’t sure when or if it’s broken, and is actually fearful of the process of modifying or using the system. It’s not a user-friendly system or process and the user’s life is literally at stake. All knowledge of the system and how it is supposed to work is held by doctor, putting the user at a serious disadvantage and placing the medical professional in an unnaturally superior position of total control.
In the geek’s world, systems are specified by and used by the users. I’m talking about complex systems built by teams of developers, spanning large physical infrastructures and not relatively simple desktop applications created by one or two engineers. Military command and control systems, large telecommunications infrastructures, complex avionics systems, and large multi-user operating systems all fall into this category. While they may be too complicated for the user to create or maintain themselves, the process of specifying and using them isn’t inherently fear inducing. Geeks actually strive to serve the user and minimize the difficulty of using the system, hiding the complexities of the technology from the user. The intent is that the user is in control.
This desire to place the user in control results in an apparent oversimplification of geek-produced technologies and provides the users with an illusion of simplicity. The measure of a good information system is always its unobtrusiveness and ease of use. Nobody considers what transpires when they make a cell phone call, for example. But this is one of the most complex interactions of technology the average person performs on a daily basis. Understanding the intricacies of how the call is placed and possessing the knowledge to actually engineer such a system is certainly exceeds that necessary to extract an appendix.
So why do medical professionals place themselves in an intellectually superior position, and why do geeks adopt a diminished role? The answer seems obvious, that doctors deal with the lives of people and geeks just deal with bits of technology that make lives easier. That was certainly how several doctors and PhDs related it to me. And that probably would be the end of it if it were true.
Unfortunately, geeks have done too good a job of simplifying what they do for users, hiding the complexities of the systems they build, and their ultimate value to society. I think the reality is that doctors keep individuals’ physical infrastructure functioning and geeks keep society’s infrastructure functioning. How many people would lose their lives tomorrow if the telephone system stopped working? if the avionics in all 747s failed? if the GPS guidance system in a cruise missile failed? if the computer systems running the nation’s power grid failed? Don’t kid yourself. Geeks do a job that is likely far more important to the safety and welfare of a larger number of people than the medical profession does. They just do it in a quiet, unassuming way that doesn’t require elevating individual accomplishment. And people do take it for granted. That should be a tribute to the geeks for a job well done.
One day, the medical profession will have eliminated all of the mystery surrounding the human body. When that day comes, doctors as we know them will likely cease to exist. Medicine will just become one more system for the geeks to model and implement. Until then, people are going to continue to elevate those who keep them alive and continue to overlook the others who merely simplify their lives, even if they don’t know who’s who.