Up, Please

 When I think of elevator operators, I think of health care.

Now, it’s not likely that many people think about elevator operators very often, if ever.  Many have probably never seen a elevator operator.  The idea of a uniformed person standing all day in a elevator pushing buttons so that people can get to their floors seems unnecessary at best and ludicrous at worse. 

But once upon a time they were essential, until they weren’t.  Healthcare, don’t say you haven’t been warned. 

Elevators have been around in some form for hundreds of years, and by the 19^th century were using steam or electricity to give them more power, but it wasn’t until Elisha Otis debuted the safety elevator that they came into their own.  New engineering techniques such as steel frames made skyscrapers possible, but safe elevators made them feasible; no one wanted to climb stairs for 10+ stories. 

Those generations of elevators weren’t quite like the ones we’re used to.  The speed and direction had to be controlled manually, the elevator had to be carefully brought to a stop at a floor, and the doors had to be opened and closed.  Managing all this was not something that anyone wanted to entrust to passengers.  Thus the role of the elevator operator.

But, of course, technology evolved, allowing for more automation.  According to elevator engineering expert Stephen R. Nichols: 

Elevator buttons were introduced in 1892, electronic signal control in 1924, automatic doors in 1948, and in 1950 the first operatorless elevator was installed at the Atlantic Refining Building in Dallas. Full automatic control and autotronic supervision and operation followed in 1962, and elevator efficiency has steadily increased in other ways.

Elevator operators gradually transitioned from being mechanical operators to concierges, helping passengers find the right floors and making them more comfortable.  A 1945 elevator operators strike in New York City had a crippling effect.  As Henry L. Greenidge, Esq. wrote on Linkedin, “The public refused to go near the controls despite having watched the operators work the levers numerous times. The thought that a layperson could operate an elevator was simply an outrageous thought.” 

Within five years, as Mr. Nichols pointed out, the first operatorless elevator debuted, and within two decades the profession of elevator operator was almost extinct.  Indeed, a 2016 paper by economist James Besson found that, of 271 occupations that existed in 1950, “In only one case—elevator operators—can the decline and disappearance of an occupation be largely attributed to automation.” 

So, what does this have to do with health care? 

For most of the time we’ve had medicine, we’ve replied on experts, such as physicians, to guide us in our health.  To paraphrase Mr. Greenidge, the thought that a layman could manage their own health was simply an outrageous thought. 

It’s no longer such an outrageous thought.  People have access to an enormous amount of information – of varying degrees of quality – and an array of DIY options.  No one is likely to do their own cardiac catheterization anytime soon, but, for example, people with diabetes have done amazing DIY, including artificial pancreas.  If you haven’t heard of synthetic biology or biohacking yet, you will.  They’re like putting buttons on elevators, giving the “passengers” more direct control. 

Add artificial intelligence to the mix, well -- it’s a different healthcare system.

Right now our health care experience is like going into a strange skyscraper.  There’s a directory, of sorts, but it’s very hard to read and not intended for us to read it.  The “elevator” we get onto has buttons, but the numbering system might as well be Greek.  We need elevator operators, in the form of health care professionals, to tell us where we need to go, on which floors, and to press the right buttons for us. 

It’s not an experience intended for us to self-manage, or designed for us to make it easy to do so.  The technology is available, but not embraced.  Our healthcare experiences have not, like elevators, become fully automated, but it’s a future we should anticipate.

Mr. Greenidge was drawing the parallels of elevator operators not to healthcare but to self-driving cars, but some of the parallel applies to healthcare nonetheless.  For example: “In both instances automation was available during the periods in which human operation was popular. Additionally, there were safety concerns from a skeptical public who hadn't quite accepted the technology yet.”

Similarly, Mr. Nichols is interested not in elevators per se but in the physical-human and digital interfaces.  He writes:

Many of the challenges in modern passenger experience involve providing intuitive interactions and behavior solutions, and these can largely be achieved through new technologies and the application of connected and Internet of Things (IoT) technologies from other industries (Gulan et al. 2016). Digital interaction technology such as smartphones, wearables, video analytics, and other sensors, as well as advances in physical-human interfaces (e.g., touchscreens instead of buttons), will greatly improve intuitive behavior.

Technologies can be combined and introduced to lower anxiety and increase convenience and efficiency. Ensuring that passengers feel safe, trust equipment reliability, reduce or eliminate their wait time, get to their destination faster, and travel in a secure, comfortable, personalized space is of paramount importance to elevator technology well beyond the early physics-based problems.

We should be applying all that to healthcare as well.  Improving intuitive behavior, increasing convenience, ensuring we feel safe, having a comfortable, personalized space – isn’t that the health care system we want?

AI in healthcare is going to give people more autonomy.

Back in 2008, Audrey Boguchwal, then a student at Columbia University and now a Product Manager at Autodeak, wrote:

…the best elevators are the ones we notice the least. They transport us safely and efficiently to our destinations and we rarely think about them. It is only when an elevator is broken, or too slow or too fast that it becomes present in our lives.

So it should be with healthcare.  Our best experiences should be the ones we notice the least.  They get the job done efficiently and unobtrusively.  Unfortunately, in healthcare, too often something is broken, or moves too slow or too fast.  We’re too aware of them.

I’m not saying healthcare professionals are gong the way of elevator operators, but we should be designing a healthcare system in which we need fewer of them and in which we can do more on our own.