Guest Editorial
Psychiatry, Technology, and the Corn Fields of Iowa
Harry Karlinsky, MD, MSc, FRCPC
This issue’s In Review section provides erudite overviews of 3 specific technologies and their current role in the field of psychiatry. Dr Rima Styra addresses the impact of the Internet—a powerful technology for accessing clinical and research information, obtaining online continuing medical education, and communicating with patients and colleagues. Dr Don Hilty and his colleagues offer a definitive review of how telepsychiatry in the form of videoconferencing can increase access to psychiatric care, particularly in remote communities with otherwise-limited health care resources. Finally, Dr John Luo focuses on the personal digital assistant (PDA) and its ability to provide information and decision support at the point of care. Aside from outlining the potential benefits of each technology, each review is also careful to cite potential limitations, such as the possible legal liabilities associated with the use of physician–patient e-mail, the dearth of cost studies within the telepsychiatry literature, and the security risks of the PDA.
Interestingly, despite their compelling opportunities, use of each of these technologies currently varies significantly. Access to the Internet, for example, has become widespread within psychiatry in relatively few years. According to survey results from the Canadian Medical Association’s 2003 Physician Resource Questionnaire, an impressive 88% of physicians now personally use the Internet (1). This survey also found that the PDA, introduced in its current format only in 1996, is experiencing similarly rapid adoption, with more than one-half of MDs under age 35 years now using this technology. In contrast, only a limited number of telepsychiatry programs and telepsychiatrists are currently active within Canada, despite the fact that telepsychiatry in Canada was evaluated as early as 1986 (2). Why do the adoption rates vary for these innovative technologies—or, to restate the obvious, getting psychiatrists to adopt a new technology, even if it has apparently obvious advantages, may be attended by varying degrees of difficulty: why?
One compelling set of explanations can be found in the field of “diffusion research.” This field of study examines how innovations “diffuse” or are adopted within a given system. Defined more formally, the diffusion of innovations is “the process by which an innovation is communicated through certain channels over time among the members of a social system” (3). The most influential paper within this interesting discipline may initially appear to be more than somewhat removed from the field of psychiatry. In 1941, Ryan and Gross interviewed each farm operator living in 2 small Iowa communities “to ascertain the process through which hybrid seed was absorbed” into the Iowa Corn Belt (4). The investigators’ questions included whether and how each farm operator had heard about hybrid corn; whether hybrid corn was now being planted; and if planted (or “adopted”), when and why. By way of background, the innovation of hybrid corn was one of the most important new agricultural technologies when it was made available to Iowa farmers, in 1928. Compared with the existing open-pollinated varieties it was designed to replace, its advantages included 20% greater yield, more drought resistance, and improved suitability to mechanical harvesting.
Ryan and Gross found that all but 2 of the 259 Iowa farm operators had adopted hybrid corn between 1928 and 1941. By 1933, however, only 10% of the Iowa farm operators had adopted the hybrid corn, despite its relative advantage over open-pollinated seed. The adoption curve then “took off,” with the rate rising rapidly to 40% by 1936. The rate then levelled off as increasingly fewer farmers remained to adopt the new idea.
Remarkably, this relatively simple study led to several profound insights that extend far beyond farming and new types of corn seed. One key observation was that farmers varied in terms of “innovativeness”—the degree to which a farmer was relatively earlier in adopting new ideas than other farmers. It is now apparent that the time at which individuals within a population adopt virtually any given innovation is continuous. This so-called “innovativeness dimension” can be usefully used to partition individuals into the following 5 adopter categories (with dominant personality attributes added in parentheses): innovators (venturesome), early adopters (respect), early majority (deliberate), late majority (skeptical), and laggards (traditional). Adopter distributions for a given innovation tend to approach normality; Figure 1 shows the approximate percentage of individuals included in each adopter category that would be applicable for most innovations.
Figure 1 The approximate percentage of individuals included in each of the 5 adopter categories (from 3, Figure 7.2, p 262)
Another key observation by Ryan and Gross was that different types of communication channels played greater or lesser roles at various stages in the innovation-diffusion process. In brief, Ryan and Gross found that salesmen were more important channels for earlier adopters, whereas neighbours were more important for later adopters. As Rogers later summarized,
The 2 rural sociologists intuitively sensed what later diffusion scholars were to gather more detailed evidence to prove: that the heart of the diffusion process consists of interpersonal network exchanges and social modeling between those individuals who have already adopted an innovation and those who are then influenced to do so. Diffusion is fundamentally a social process (3).
The relevance of these findings quickly became evident in other disciplines, including medicine, and indicated how new medical ideas are adopted by doctors. As one early example, Columbia University investigators analyzed factors influencing the prescription of the new antibiotic tetracycline by physicians in 4 Illinois cities. In addition to obtaining results that strikingly parallelled those of Ryan and Gross, these researchers also established the importance of opinion leaders within the medical community—individuals now definable as early adopters respected by their colleagues. Although advertisements and pharmaceutical salesmen increased awareness and knowledge of the new antibiotic, a respected peer’s subjective evaluations and personal experiences of the new antibiotic were crucial to convincing typical doctors to prescribe it for their own patients (5).
Let’s return to technology and psychiatry. It is perhaps now apparent that the variables determining the rate at which psychiatry adopts new technologies—like the Internet, PDAs, or videoconferencing—are complex and extend far beyond their perceived attributes. Different psychiatrists vary in their degree of innovativeness; how psychiatrists learn about a technology will influence their decision to adopt it. Other variables also influence the rate of adoption, including whether the decision to adopt is optional, collective, or imposed. It is not surprising that the decision to implement a telepsychiatry program within a health care bureaucracy will evolve more slowly than individual psychiatrists’ voluntary decisions to begin using an innovation such as the Internet or PDAs.
Even potential users’ perceptions of the innovation’s perceived attributes is a complex matter that extends beyond relative advantages over other technologies or existing processes. Attributes of an innovation also comprise issues of complexity, trialability, and observability (3). The relatively slow diffusion of videoconferencing within psychiatry is therefore likely also related, first, to its perceived complexity and, second, to the difficulty an individual psychiatrist might have in obtaining expensive equipment to use on a trial basis, or even in observing its use by others. Innovations can also be compatible or incompatible with individual values and beliefs, thereby affecting the rate of adoption. For example, psychiatrists who strongly value interpersonal interactions with patients will likely be slow to adopt telepsychiatry if they perceive it, accurately or not, to be an impersonal technology that interferes with communication and the establishment of a therapeutic alliance.
In conclusion, it will be fascinating to observe the introduction of future innovative technologies within psychiatry. It will be just as fascinating to observe how these new technologies diffuse within our personal clinical practices and health care systems. New elements introduced by the Internet already include Web-enabled digital health records, personalized “Ask the Expert” information services, and e-therapy. Other information and communication technologies—virtual reality, the Tablet PC, wireless connectivity, interactive voice-response systems, continuous speech recognition, and natural language processing—each of which has advantages and disadvantages, are now being used by innovators and early adopters. As William Gibson stated, “The future is here. It’s just not widely distributed yet.”
References
1. Martin S. More than half of MDs under age 35 now using PDAs. CMAJ 2003;169:952.
2. Dongier M, Tempier R, Lalinec-Michaud M, Meunier D. Telepsychiatry: psychiatric consultation through two-way television. A controlled study. Can J Psychiatry 1986;31:32–4.
3. Rogers EM. Diffusion of innovations. 4th ed. New York: The Free Press; 1995.
4. Ryan B, Gross NC. The diffusion of hybrid corn in two Iowa communities. Rural Sociology 1943;8:15–24.
5. Coleman JS, Katz E, Menzel H. Medical innovation: a diffusion study. New York: Bobbs-Merrill; 1966.
Author(s)
1Clinical Professor and Director, Continuing Medical Education and Professional Development, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
Address for correspondence: Dr H Karlinsky, Department of Psychiatry, 2250 Wesbrook Mall, University of British Columbia, Vancouver, BC V6T 1W5
e-mail: harryk@telus.net
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