The Power of Medical Experts’ Distance From Technology

Hanna Zeavin’s The Distance Cure: A History of Teletherapy, and Jeremy A. Greene’s The Doctor Who Wasn’t There: Technology, History, and the Limits of Telehealth, are both histories of technology and medicine that question the centrality of the expert as the deciding factor in the success or failure of medical technologies. In Zeavin’s book, the expertise of the psychologist is largely eroded by approachable, amateur forms of counseling and mental health intervention by telephone—such as volunteer-staffed mental health and suicide crisis lines, and even programmatic, computerized forms of “therapy” by phone, text, or terminal link.

In Greene’s book, generations of mostly white, male, middle class internists alternately adopted, developed, and derided technologies that repeatedly promised to “revolutionize” their craft (and repeatedly failed to do so). Greene’s narrative charts multiple forms of twentieth century telecommunications technologies and the medical instruments built around and with them, ultimately showing a cyclical history where each iteration of medical tools based in communication technologies had a promising start and then either a precipitous decline or a long, grinding aftermath of unintended consequences accompanying their integration into U.S. medicine.

In Greene’s work, much of the lack of success of the technologies in question is due to expert pushback, and the successful technologies that do become widespread noticeably contort both medical professionals and patients into a new framework of care with different expectations. As a result, Greene’s history is in some respects a flipside to Zeavin’s. The doctors in Greene’s history largely prevail in pushing back against communication-enabled medical technologies that they feel will erode their field, the patient experience, or—most critically—their claims to professional expertise. In Zeavin’s history of teletherapy, however, the experts are largely absented by the technology, continually squeezed out or bypassed by amateurs with telecommunications devices that “meet people where they are” when they are in crisis or even in need of routine mental health help.

The juxtaposition of these two books creates a fascinating speculative history of medical expertise and its interaction with technological change, specifically in the form of medical tools that are enabled by telecommunication. Zeavin’s book centers the technology to explain how medical professionals failed to adequately keep up with the demands of all of the many patients and potential patients in need of expensive or otherwise inaccessible mental health help. In discussing the apotheosis of the amateur, programmatic tele-therapist model, Zeavin highlights the 20th century computer programs (ELIZA and others) that allowed “patients” to talk to a “computerized therapist” that aimed to “allow for computer programs and eventually Internet-delivered therapies with no expert oversight…further subtracting the therapist from the therapeutic scene” (158). Zeavin also describes a doctor who, overwhelmed with cases, created a “Therapeutic Learning Program” with the aid of a computer in the 1980s, in order to try to systematize and routinize psychological care that could be delivered in group settings. In many ways, this attempt at systematization and classification of people’s similar complaints and concerns is at the heart of all forms of medical care, but, on the other hand, it also shows what the doctors pushing back against technology (in Greene’s history) feared when they derided the “heartless assembly-line medicine” (220) that could potentially come to pass with computerization of some of the tools of their trade. While Greene’s book sympathetically centers the viewpoint of medical professionals as they alternately adopted and fought against changing technologies meant to democratize medicine and revolutionize their field, it nonetheless points out how their investment in the inequitable structures of U.S. medicine made them as much a part of the problem as any of the failed technologies under discussion.

Paradoxically, Zeavin’s history, which decenters the expert and makes the case for the amateur and even automated forms of distance therapy as meaningful and appropriate in many situations, is the history that—through leaving the chair of the medical expert largely unoccupied—creates a hole that seems like it can only be filled by medical expertise, rather than by more technology. Meanwhile, Greene’s history, whose title alludes to “the doctor who wasn’t there” centers medical experts to a much greater extent, and shows how their enmeshment in white supremacist systems (everything from segregated hospitals to racist experimentation on Black and Indigenous populations) helped hold off technologies that might have produced more equitable outcomes and decreased the gap in care between marginalized populations and patients who were white, middle class, relatively wealthy, and within driving distance of major cities.

Taking a figurative page from Zeavin’s history, Greene relates that the “annihilation of space” (24) that the telephone promised was not an annihilation of culture, nor of class, race, gender, or any of the categories that today still limit people’s access to modern high quality healthcare or sometimes prevent their being cared for at all. This is because, as Zeavin concisely puts it, the telephone, or cable modem, or text message is not merely a means of conveyance but a nonhuman partner in the therapeutic encounter: “the therapist-patient dyad, reconceived as a triad, provides a unique site for examining these current concerns about what media add to human relationships and what they subtract” (5). As Green concludes, “the medium of care is not neutral”(243), and the “standard white, middle-class patient who was all too often the assumed user of medical technology” (139) figures into the history of medicine as a key factor limiting the transformative potential of these supposedly “revolutionary” technologies.

The stories in these two books also powerfully convey how historiographical choices shape our understanding of “what happened” in the case of medical technology. Zeavin recounts the difficulty of finding archives for writing her book—a book that is in essence about the ephemeral, technologically-mediated relationships between people seeking mental health support. “It may be that the most troubling work I did in this project was wading through the call logs of a suicide hotline in which the names, addresses, and phone numbers of those contemplating suicide and undergoing other kinds of crisis evaluation were plainly written,” Zeavin relates. “I doubt very much that anyone calling a suicide hotline in the 1970s thought that in giving their information to a counselor, it would end up in an archive that was publicly accessible within their lifetime, if ever” (23-24). Greene’s narrative about the recurrent “overextended promises of utopian social engineering” (134) coexists with a discussion about unwanted and unwarranted surveillance as a side effect of greater technological connectivity.

As a result, these histories are all the more relevant to contemporary concerns and debates about the role of technology in medicine. Particularly in a post-Dobbs landscape where many people rightly fear their bodily autonomy may be compromised by technologies that record or report information about them, and may live in states with little or no access to certain kinds of healthcare, the lessons of Zeavin’s and Greene’s histories are remarkably similar: technologies that promise transformation will never match the power of community care models that can meet patients where they are—and technologies that can help in this pursuit will often be rejected by those in power who see this transformation of care as an unacceptable erosion of their privilege to determine what medicine should look like.

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