To read the newspapers, the whole practice of medicine suddenly has been transformed from the learned profession it used to be into a high technology, beset on all sides by scientific hubris. And complaints about this perceived change are heard everywhere. There is too much science, it is claimed. Doctors are unable to deal at first hand with their patients, it is said, because of the sheer mass of machinery required for medical care. There is, it is asserted, such a high technology needed for health care that no society can cope with the cost. If it continues, medicine will be done in by its own scientific success.

It was in 1967 that the first patient went from Tunbridge Wells to the Brompton Hospital for pacemaker implantation. The recipient was a typically robust female octogenarian and while the eminent cardiologist was engaged in his task, she tapped him on the shoulder. “Young man” she said, “how many of these operations have you done?” He replied, somewhat modestly, “About 300,” expecting her to compliment him on his expertise. Instead, she said “Well, if you've done that many you should know to keep your patient's feet warm. Cover them up!” This anecdote aptly illustrates the contention implied in my title that a new and somewhat disruptive dimension in the form of technology has entered the field of medicine, a view which has attracted considerable support from various quarters (14; 16).

Instruction of medical students in the use of technologic procedures in clinical medicine has emerged in recent years on a more or less piecemeal basis. Individual technologies are introduced as the teaching hospital acquires the requisite equipment and personnel; as experience is gained by faculty and attending staff some sense emerges of the indications, contraindications, risks, accuracy, and usefulness of a procedure, which then is transmitted to housestaff and students. Instruction is likely to occur on a case-by-case basis, supplemented occasionally by conferences or formal presentations, generally oriented around major innovations, such as computerized transaxial tomography or magnetic resonance imaging. As relevant clinical literature appears, it is used to reiterate and expand the available information base of trainees, but to a considerably greater extent for housestaff than for students. Ultimately what emerges is a pattern of use, a gestalt, for each technology, reflecting the synthesis of the available information and clinical experience with the procedure in the particular institution. In view of the enormous number and variety of technologies available, the task of the student or house officer in acquiring even basic familiarity with those in common use is formidable. A coherent approach to instruction in the use of technologic procedures is required. Students need, and medical faculties must find, a way to provide intellectual systems for incorporating technologies into the clinical armamentarium in a manner that permits them to be maximally useful.

Pressures to contain health care costs have challenged physicians to be more discriminating in the use of medical technology. Particularly important is the need to apply diagnostic technology selectively since the costs of diagnostic tests and procedures may account for as much as one quarter of total hospital costs and a smaller but substantial proportion of ambulatory care costs.

During the past two decades a great deal has been learned about the role of physicians in generating medical costs and about ways of changing physicians' behavior so as to reduce those costs (8;10;19;30;34). Unfortunately, very little is known about how cost reductions affect the quality of care.

A common criticism of high technology is that therapeutic objectives are sometimes secured at too high a price in loss of quality of life. Certainly some interventions serve only to prolong life that is already of unacceptable quality to the patient (some rescues in intensive care and salvage surgery for cancer). Others leave the patient with less good quality of life than he enjoyed before treatment, either because the crisis that called for rescue had lasting effects (incomplete recovery from severe head injury) or because the intervention itself had inevitable adverse effects (mastectomy, laryngectomy, colostomy). Yet some life-extending technologies can improve dramatically the quality of a patient's life (renal and heart transplantation), while others are directed primarily at improving quality of life (hip replacement and coronary bypass surgery). When the ultimate result of technological intervention is improved quality of life or a reasonable extension of life of quality, then some temporary impairment of life's quality may be justifiable. The problem is to discover in which clinical circumstances the benefits expected from high technology are both great enough, and are also likely enough to be realized, to justify the resources that have to be expended by society and the inevitable burdens that have to be borne by the patient (11).

The problem that I will discuss in this essay is marvellously illustrated in the title given to me by the editors. The word “interface” is itself part of the jargon of technology, the technospeak needed by those who develop, use, and discuss functions, things, and relationships that had not existed previously in the human world. They must make up new words to describe new realities (and, unfortunately, allow new and ugly words to obscure old ones). An “interface” presumably describes the way in which one electronic system contacts another so that the first energizes the second. In the old world of human experience, an “interface” is impossible. The face of one human being is visible to another; two faces, smiling or frowning at each other, communicate. The mind behind one face can interpret the movements of another. Never does one human face interpenetrate or merge with another.

A rapid development in health care delivery has been the increasing use of technology. Technology will continue to transform medical practice and all health care workers are involved with technology by accident or design. This has resulted in technology dominating many health policy decisions (4).

The title which I have been given suggests that in my particular consideration of technology the emphasis should be not on professional attitudes, but on public attitudes, and what might be done to inform and if necessary improve them. At first glance, a sensible approach might be to conduct some kind of survey among “the public” to discover what proportion of people hold particular attitudes towards technology. With little in the way of regret, I shall foreswear that approach, not because I am unacquainted with such surveys, but because I perhaps know them too well. If you ask a completely unloaded question, such as “What is your view of medical technology?”, you will probably get answers, but you will not be able to determine how much they are preconditioned by how much the person knows, and in particular how any recent experience of medical investigation has turned out. That in turn may owe more to the nature of his problem than to the skill with which investigations have been selected and performed. On the other hand, if you ask loaded questions, such as “Is medical technology free of risks?,” you will bias the proportion of replies, and still find the answer no easier to interpret.

In considering the allocation of resources for health it is necessary to make a distinction between the provision of public and environmental health services and the provision of medical care by physicians and surgeons for those patients who seek treatment.

Since the early days of medical computing, medical computer researchers have envisioned how computers could benefit medical research and practice and have deplored the inability of medicine to take full advantage of the computer's power. They, and others, have analyzed the causes for the medical computing “lag.” These analyses identify a wide range of difficulties that the introduction of computers into medicine faced, and continues to face.