The AI Will See You Now

Recently there was an article in the NY Post that touched upon a study from MIT where 300 people evaluated medical advice written by a doctor or by AI. Across the board, people rated AI-generated responses as more accurate, valid, trustworthy, and complete than those written by human physicians. This included advice that could lead to unnecessary or harmful medical actions.

There certainly is a place for AI in healthcare. I have personally used it to research and cross-reference treatment options for myself and our family. But I always take it with a bit of skepticism. As Ronald Regan noted, “trust but verify”!

What I’m seeing and worrying about is straightforward: low-cost, high-throughput clinics staffed by a single human and driven by AI triage and decision systems. Think of a MinuteClinic or PatientFirst where the first line of care is an algorithm housed in a robot that follows committee-driven best practices. A human clinician is present, but only to be called in for exceptions or higher-acuity cases. For many people this will feel like access – fast, cheap, and predictable. For those of us who value the art of healing, it feels like a narrowing of what medicine can be.

Certainly there are real benefits to standardized, AI-driven pathways: faster triage, lower per-visit costs, and consistent adherence to guidelines. For underinsured or uninsured patients, that can mean care they otherwise wouldn’t get. But efficiency is not the same as wisdom. Clinical judgment often depends on small, nonverbal cues, a patient’s tone over time, or a clinician’s memory of past visits. Algorithms excel at pattern recognition across large datasets; they struggle with nuance, context, and the messy individuality of human illness.

When care is reduced to algorithmic outputs, we risk losing the doctor-patient relationship that turns information into healing and where trust, empathy, and individualized judgment live. If AI becomes the default gatekeeper, deciding who needs a trained human provider and who does not, I believe we’ll see a two-tiered system.

·  A baseline, AI-delivered public option and

·  A premium, human-centered private option for those who can pay. 

In the end we arrive back at a point where we have a stratification that perpetuates inequities that today’s “healthcare for all” advocates complain about. Healthcare is not a right due to the fact it must be delivered by someone’s work (and you have no right to compel someone to work). Be skeptical when the politicians and influencers, be it Musk or Sanders, tell you that with AI lowering the cost of providing healthcare that we can offer a high-quality national healthcare delivery system. In the end, it’s almost always that you get what you pay for (or vote for).

Vaccination Vexations

With the approval of Moderna and Pfizer's vaccines for emergency use in December it was time for the state governments (and health care players) to get people scheduled for their two doses. This was hardly a big surprise - the Trump administration had said back in the summer that it was targeting late 2020 or early 2021 for them to be available, and the companies more or less supported that claim. Yet if the web sites out there are any indication the effort to register people to get their shot was a quick throw together. I speak from experience of trying to use them.

First up we have Baltimore County. I filled out the online form and hit submit, hoping that the next screen would let me pick a time, if available. I certainly expected that I'd get a confirmation email that registration was successful. But no, nothing. Crickets. A few days later on NextDoor I see a thread that apparently some people are getting an acknowledgement, but usually only after multiple attempts. Which I'm sure has led to multiple registrations by now, and likely making it challenging to determine just how many people are ready to get vaccinated. You have no way to see an estimate as to when you'll get it, nor any way to unregister should you manage to get the shot at some other venue. Overall a glitchy and not well thought out implementation.

The next award goes to Giant Pharmacy's attempt. Often when you click on their link to schedule an appointment you receive a screen telling you that you are in a queue. They're nice enough to given you the estimated time you'll be taken to the page to register for an appointment (anywhere from a couple minutes to half an hour in my experience), and your anticipation grows that you'll be able to set up an appointment. 

However, in all the times I've done this over the last two weeks, once you leave the queue you're told there's no vaccinations slots available and to please check back later. Clearly there were none available to begin with, so why make the person wait with false hope of being seen? Query your database and if OpenAppt == null, say that right up front. That's basic user experience design.

Then we have RiteAid's effort. The start page has you fill out a form to verify whether you are eligible, about 5 questions. Not a big deal except that you have to do that every single time, every day that you want to check. That's what cookies are for RiteAid - you can save some information on the user's browser so that they have a better experience. Look it up.

Once you get the display of stores that are participating in COVID vaccinations you select one. And then it depends on your luck as to whether the "Next" button will be enabled. Some days it is, some days it isn't. On the days that it was enabled it always yielded an apology that no vaccines were available. So, like Giant, maybe do that check right after I give you my zip code? Or maybe use the ability to access my device location and warn me immediately that there's nothing available in my area right now? 

"Next" is disabled with no explanation of why

And, to complete the experience at RiteAid, if you do get the "sorry, try again later" message then they don't want you to navigate away, posting a warning alert that you may lose data. What data? That you don't have any vaccination appointment to offer me?

Having been a developer for a couple of decades now I know it can be challenging to get it right. It does require attention to detail and patience/perseverance at times. That's why it drives me nuts when you hear talking heads nonchalantly offer the advice that someone whose job has become archaic "learn to code." 😠 Horrible advice! Unless that person has an affinity and some passion for coding they will be terrible at it and hate their job - and their mediocre code will only serve up more end user pain. 

But beyond the slip ups of the developers - and we all mess up occasionally - this poor experience reflects that testing was completely inadequate. These are not subtle, hard to reproduce bugs. They're a cockroach strolling across the kitchen floor during your afternoon tea party bugs. Hopefully the management team responsible for these snafus will get the appropriate feedback and adjust their process to include better testing. Until then, good luck scheduling your COVID-19 vaccination appointment!

Weight Watchers Alabama Style

Have you heard about this? The state of Alabama has decided that in 2010 all of its employees will have to pay an additional $600 per year towards their healthcare premiums. Well, actually, it's only their fat employees that will have to cough up the money. That's right - they'll apparently be having a good ol' fashion Weight Watchers style weigh in right there at the state office building to make sure your BMI is acceptable. Nothing like a little financial incentive coupled with public embarrassment to get folks to drop those pounds.

If you don't know me I'll say in the interest of full disclosure that I'm not svelte. I've battled weight all my life and have found my greatest successes at Weight Watchers. Yet it's not empathy for these state workers that angers me about this new policy but rather the clear path that we're going to head down under the pretense of controlling health care costs. Once again we're on a slippery slope here. How about $750 annually if you smoke (we can draw blood to check up on you)? Maybe a grand if you have to be treated for a venereal disease since that implies you have unprotected sex (we'll just throw up some curtains around that scale).

The intent of motivating people to adopt a healthy life style is laudable but misguided in this instance. You do not need (want) a government entity trying to enforce this. It seems to me that what we really need is to put the patient back in charge of their healthcare. Insurance has insulated patients from the need to be good consumers, and that is a bad thing. Rather than the government or business trying to formulate financial penalties for imprudent behavior it seems that somehow we have to return to patients being consumers and reaping the benefits (or detriments) of their decisions.

Be Careful What You Wish For

It's a pretty fair statement to say that I've had an above average familiarity with American healthcare. Worked my way through school as a pulmonary technician at a local hospital, 20+ years a dentist, abstracting hospital charts for HICFA, working for BC/BS of Maryland (CareFirst), helping to create electronic document management for another major mid-Atlantic insurer, and not least being married to Deb whose been a nurse for 20+ years. I'm no expert by any means but I certainly have some experience compared to the average person.

Like just about everyone else I'm quite concerned about our American healthcare system. It is indeed suffering, but the simplistic rhetoric that I'm hearing in this election year is even more troublesome. This is a complex problem that will require reform in many arenas if there is to be any hope in not only maintaining the best health care delivery system but also improving it. Rather than creating the mother of all blog posts I'm going to try to create a series of posts, each addressing some facet of the solution or potential pitfall.

My first comment is one of great caution allowing government, especially at a federal level, to assume the role of gatekeeper. History shows us that we should expect a system that is bureaucratic and authoritarian - two attributes you do not want when you're seeking medical treatment. Many folks rail that we are backwards because we do not have a system of National Healthcare such as England. Yet look at what we see being reported from across the pond - cancer patients threatened with treatment termination should they attempt to acquire an additional anti-cancer drug which they're willing to pay for on their own. It is a classic and expected outcome of a bureaucracy attempting to apply rules. We'd fare no better - and in fact, we already do similar enforcement in Medicare where a physician and patient may not engage in any private contract or else the doctor will be barred from participating in Medicare for two years as a penalty.

So, tenet #1: Keep the gatekeeper keys to your medical care out of the hands of the government