Does AI communicate better than real doctors? If so, why is that?

The New York Times recently ran an article titled “Empathetic, Available, Cheap: When A.I. Offers What Doctors Don’t”, which should be very concerning to the medical profession as it emphasizes three things that they are often not. But probably won’t concern the real decision makers in healthcare – the corporate owners, “health systems”, insurance companies, and private equity. After all, their concern is solely making money, and they are doing just fine, thank you.

The article indicates that AI seems to be responsive to and nice to people, and seems to show respect, concern, and empathy; “seems to” is important, because these are computer programs, not people, and they don’t have any feelings. Nonetheless, people feel better when they are addressed with respect, concern, and compassion. Even if it is programmed and not real. The truth is that doctors and other actual people do not always do so, for a variety of reasons. And they don’t even have the chance to if the patient cannot contact them, which is so common as to be routine these days

For many years, I told medical students that, while they had worked very hard to master the language of medicine, learning idioms, jargon, eponyms, and acronyms so they could fit in and impress their seniors, residents and attending physicians, regular people would not understand them if they spoke like that. They had to be able to translate that back into their first language, English (or whatever their vernacular was). This is an important skill, for without it people (“patients”) won’t understand what you are saying, and won’t know what is going on with them. And that is important. It takes effort, and it takes intentionality – you must want the person to understand what you are saying. That’s is true even if what you are telling them is bad news, something that will make them upset or unhappy.

I thought about this after a recent conversation with a couple of current medical students. I made the points above, about the importance of communicating in a way people can understand, and observed that, in fact, often people did not understand. This was based on, among other things, the number of times I had to try to explain to my patients, as a family doctor, what their specialist was saying. And the number of times I had to try to figure out, as a family member or friend, what my family member or friend’s doctor had been telling them that led them come away with what seemed to be an incorrect understanding of the situation. I have even said “If you assume that no one ever understands anything their doctor tells them, you will be correct a distressing percent of the time”.

The students agreed, but when they gave examples from their experience, I became more concerned.

A surgeon I worked with was unable to get all of the cancer out, but when telling the patient used all kinds of technical and unfamiliar terms, like ‘clean margins’. It was like they were trying to not lie, but to obfuscate what they were saying by talking in words and phrases that were technically true but not meaningful to the patient. I was left, after the surgeon had gone, to try to respond to the patient who asked me ‘What did they just say?’”

Obviously, this should not be the job of the medical student, but of the surgeon. And while it is tempting to say, “Well, they’re surgeons; communication is not their strength” (and while, as a family doctor, I like to think we are better at it), most or all doctors are guilty of this sometimes. (It is also true that it is even harder when you have to acknowledge that the bad news may, in fact, be the result of something you did wrong, but this is a separate area.)

I have recently had experience with close family members who had complications during procedures. One, during an endoscopy, had their blood oxygen level drop and had to have a breathing treatment afterwards, receiving a new diagnosis of asthma. This was upsetting, but at least they were told everything. Another, in a much more concerning episode, had major lung surgery. After the surgery, they had terrible, persistent pain which was not adequately treated. Several months later, visiting another doctor (not the surgeon), they were told that their oxygen level had also dropped severely, as a result of having a pneumothorax, a serious, potentially dangerous condition where air gets into the chest cavity and can partially collapse the lung. More relevant, it can be terribly painful. This might explain why the nurses, following their pain-management algorithms, did not give the patient sufficient pain medication. It is still not clear if they were told their patient had a pneumothorax, but it is definitely clear that the patient, my family member, was not told. They should, of course, have been.

There are a lot of potential problems with AI providing people medical information, some of which are discussed in theTimes article. For one thing, it could be wrong. It doesn’t really know you, and part of the reason that you are consulting the medical AI (or real clinician) is that you don’t actually know either exactly what is wrong with you, or how to put it in terms that will get you the correct answer to your question even if the AI is capable of getting the correct answer. Of course, sadly, the same can be true of real doctors, especially when you don’t actually speak to them; the article leads with the story of a person who wanted advice on how to increase the protein in their diet, and received generic – and unhelpful – answers from the physician on line (presumably a “patient portal”). For all we know, they could have been AI produced.

It would be much better – some of us would say essential – for doctors to communicate fully and honestly with their patients, using language that they can understand, even when the news is not good. And for them to be there, being, well, patient, while their patient tries to formulate questions, and answer them. But there are a lot of reasons that they don’t, or can’t.

A part of it may be that they are poor communicators, or uninterested in having their patients understand everything, especially if it could be embarrassing or take a lot of time. But AI doesn’t have that problem. It is not paid by the patient, and it has no set number of people it has to see in a given amount of time the way that real clinicians do. These actual clinicians often work in hamster-wheel conditions (time spent not only seeing patients but having to do electronic charting aimed at maximizing profit via upcoding as much as possible) which are not the fault of the doctor, but of their employers who are interested in “throughput” to make as much money as possible. Saliently, procedures are relatively well reimbursed but spending the time necessary to talk to a person to be sure that they completely understand what is going on is not. Of course, this is also part of the reason that there are fewer students entering primary care and more are entering better-paid procedure-based specialties.

Having a health care system that valued, and paid for, communication would be good. It would have to start with a system designed to maximize the health of our people, not corporate profit. Yes, there would still be some doctors who communicated poorly, and even made poor medical decisions, but those could be dealt with as individuals, rather than having them intrinsically encouraged by the system.

Doctors could and should do better, and maybe there is a place for AI. But there is no place for profit in healthcare.

Continuity of care? Hospitalists? Who calls the family?: Corporate control makes health care worse.

I was recently talking with a friend who was still (justifiably, IMO) furious at her local hospital. Last year her husband, 90, was admitted for an attack of diverticulitis. While hospitalized, he suffered a heart attack on a Sunday morning and was transferred to the Intensive Care Unit. The treatment was fine – indeed now, at 91, he is quite improved – but her complaint was that no one called to tell her! She found out when she went to visit him in the hospital that afternoon. I am sure that virtually any adult presented with this scenario would say “of course, as soon as possible, call the family!” Can you imagine that they didn’t?

Sadly, I can. It reflects a lot of issues in the medical care system. One that my friend identified was the hospitalist system, where the doctor who is responsible for the care of a person in the hospital is not their regular physician, but someone employed by the hospital (usually an internist or sometimes a family doctor). In itself this can be an issue, which I will discuss below, but the bigger problem she identified was the frequent change in who this responsible physician was, different on the weekends, and at night, and almost impossible for her to get to know. Indeed, she was not certain if the doctor she talked to later that day, the one who told her, not apologetically, that they were “trying to figure out what to do with him” (as if this was an excuse for not calling the wife of an 90-year-old patient to tell her that he had a heart attack) was the actual hospitalist or a resident working with them. If you don’t know the attending physician du jour, or even know who they are, it is hard to be sure. I might add that my friend is a highly educated and well-insured person. When they suffer such indignities, and they do, it is certainly far worse and more frequent for people who are not.

Why would doctors not want to call the family of a person in the hospital, especially but not only if they are old and frail and suffer a particular acute life-threatening event, as soon as possible? Is it imaginable that they do not? Why would they not want – insist upon – the family knowing who the responsible physician is? Do they just want to be anonymous, not to be bothered?

Maybe, sometimes, but I do not think that this is the primary reason. Think about it. You are the “hospitalist”, a hospital-based physician tasked with responsibility for the care of lots of people (“patients”) who you didn’t know before they were admitted. On top of that, you are not the weekday hospitalist, but the one covering for them on the weekend, a weekendist if you prefer (I sure don’t!). Maybe you are even the nocturnist, the night-time hospitalist. In any case, you have a list of patients to see, and to get to know, and maybe you come into the hospital in the morning to see them all (which, of course, has to be one at a time, someone first, someone last) when all of a sudden you hear from the nurses that one of them has had a heart attack. Maybe someone you have seen already, maybe not, maybe it is the afternoon, and you have already left the hospital. You tell them, the nurses and the residents working with you, to begin their well-practiced routine of treating an acute myocardial infarction (MI, heart attack) and give other instructions, including to call cardiology, and tell them to call you back. Do you specifically instruct them to call the family? Do you think that would be obvious to them? Does it even occur to you? Is it someone else’s job? Whose?

In the “old days”, when someone’s family doctor took care of them even when they entered the hospital, it was almost certain the family would be called. The doctor knew the person, often had been seeing them for years, and knew the family. They knew, of course, that the family would want to know, and felt it to be their responsibility to inform them. This changed with the creation of hospitalists as a separate specialty, and has accelerated with the corporate takeover of medical care and the dramatic increase in physicians as employees of corporations (most often hospitals, sometimes physician-owned groups, sometimes for-profit, often owned by private equity). Different physician roles have been identified, such as caring for people in the office (and very rarely at home), in the hospital, in nursing homes. While these roles had always existed, often the same doctor filled the different roles for their patients; now different doctors would. The delivery system, which had been patient-focused (“I’m your doctor and take care of you wherever you need care”) became provider-focused (“We, as the providers of care, will develop a system that works efficiently for us; unfortunately for you, that means you will not have the same doctor all the time”).

Actually, there were many good reasons for this change. It is not easy, was never easy, to be a “full-spectrum” family doctor, to see people in the office both with appointments and as walk-ins, to do home visits for those who were ill and found it difficult (from age or disease) to get to the office, to see people in nursing homes and in the emergency room, and make “rounds” on and care for your patients in the hospital. And, often, get up in the middle of the night to deliver a baby. It was tough on the doctor, and tough on their families, as many books and films have depicted. In addition, these family doctors had (and have) much lower incomes than most specialists, including those who do shift work where they know exactly which hours they will work. Plus, as more and more things could be cared for in an outpatient setting (we will leave, for now, whether this was always a good idea), the people admitted to the hospital were sicker and often required more specialized knowledge that a physician who focused only on hospital medicine could better stay up on.

But there were also bad reasons, many of them stemming from the movement of physicians from self-employed to employees, increasingly working for hospitals and even for corporations that had no health professionals in charge. This corporate model, based on the industrial concept called “scientific management” or “Taylorism”, focused on increasing efficiency as the most effective way to generate maximum profit. It is more efficient to have some doctors who stay in the hospital all the time and some doctors who care for people in the outpatient setting (“ambulists”, another term that fortunately hasn’t caught on), and others who care for people in nursing home or even in their own homes. This not only reduces travel time, but allows more people to be scheduled (“speed up”) and provides the basis for further increasing the number of patients seen and concomitantly decreasing the time spent with each (see "Direct primary care" not the answer for our health system. Beware "Project 2025"!, July 9, 2024),

The problem is that this is not always the best for the patient. Yes, it is good to have people who are expert and current on the care of people in the hospital (“inpatients”) to take care of you, just as, when you need one, it is good to have experts in an organ (cardiologists, nephrologists, pulmonologists, etc., and various types of surgeons if you need surgery). But it is also good if the person taking care of you knows something about who you are, or at least your medical history. If they have never seen you before you show up in the hospital, they have nothing to compare your current situation with: are you worse? A lot worse? Better? About the same? And, by the way, if someone actually knows you – your family would almost certainly get a call!

Is it possible to have most of the good with little of the bad? The continuity (sometimes called “primary care”) clinician – family doc, internist, pediatrician, family or adult or pediatric NP – can delegate the key medical decisions to hospital experts but stay as the leader of the team. The leader, not the pain-in-the-neck “local doctor”. The professional who can fill their role as the one who cares for the whole person, not as the subspecialist for only one disease or organ. The one who cared for the patient before admission and will continue to do so afterward, not as the hospitalist for whom the patient was essentially born the day of admission and will disappear the day of discharge. Someone who can provide context and understanding and, believe it or not, continuity!

Of course, we’d need more primary care clinicians, not fewer as is the current direction in which we have been and continue to be heading (Incredible (Terrible) Shrinking Physician Supply, Health Justice Monitor, Sept 7, 2024). This would decrease efficiency, perhaps, but increase effectiveness. And while it might cost more money (thus lower profits for the corporations) it might actually save money for the overall system by having historical memory of the person when they go from home to hospital to home, and not change almost daily each time a new doctor is in charge.

Worth thinking about!

Pro tip: If you have to be admitted to the hospital, or have a heart attack, try to do it on Monday, or at least Tuesday. Do not wait for the weekend!

The business of America...or is America a business?

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“The business of America,” President Calvin Coolidge said, “is business.” His only famous quotation (after all, the guy’s nickname was “Silent Cal”), it is almost a mantra guiding the actions of Presidents, and Congresses, and state legislatures, since. It can be seen almost as a tautology, recognizing that successful businesses are essential to the economic success of the entire country, and the world. Pursued to perversion, with governments not just facilitating the success of business but doing anything businesses want, with no respect for the balance between business success and negative impact, however, it can have terrible results for society -- for many people, or, as in the recent implosion of the economy, for all people. Completely abandoning all regulation of financial derivatives, the housing market, etc., was predictably a bad idea. But, of course, those predictions were not heeded.

And are not being heeded. On the heels of the enormous public bailouts, absent any requirements that the financial industry actually do anything to help Americans (like, say, lend them money), we continue to see further deregulation. The Supreme Court will soon decide on whether to permit corporations, not just the individuals who own and work for them, to contribute to political campaigns. Many folks think that the conservative majority will say “yes”, based on the legal fiction that corporations are people, and therefore have First Amendment rights to freedom of speech.

Of course, corporations are not people, and the “founding fathers” who wrote both the Constitution and Bill of Rights had absolutely no intention of considering them as such. Indeed, given their experiences, most were quite suspicious of – often hostile to – corporations, which is why the Constitution provides for state control of them. This was because, as stated in an interesting discussion by Jan Edwards on the “Third World Traveler” website, “State governance was closer to the people and would enable them to keep an eye on corporations. In the eighteenth century, corporations had very few of the powers that we now associate with them. They did not have limited liability. They did not have an unlimited life span. They were chartered for a limited period of time, say 10 or 20 years, and for a specific public purpose, such as building a bridge. Often a charter would require that, after a certain amount of time, the bridge or road be turned over to the state or the town in which it was built. Corporations were viewed differently in early America. They were required to serve the public good.” Things, however, have changed, and this is apparently an area in which the “strict constructionists” on the Court are a little less strict.

Would this make a big difference? Well, perhaps conceptually it would, but corporations are already able to use their money to have great influence over policy. This includes the donations to candidates by the people associated with them, but more often and in greater amounts to the soft-money PACs to which they contribute. On the health care front, the New York Times recently ran an article (December 29, 2009) unfortunately titled Health Lobby takes fight to the states (I say unfortunately because, as the article makes clear, it is the lobby for the health care industry, not lobbyists for our health!) that looks at efforts in state legislatures to not participate in any health reforms that eventually pass Congress. The rationale for opposing the changes that would prevent insurance companies from denying coverage to people because of pre-existing conditions, and at least potentially extend coverage to the majority of the uninsured, is, according to author David Kirkpatrick, is based “on the grounds that it tramples individual liberty”. This is eerily reminiscent of the first point in Andy Borowitz’ December 17 piece, Senate Unveils CompromiseCare: “Under CompromiseCare (TM), people with no coverage will be allowed to keep their current plan”. Except that was intending satire; I don’t think that the 42 Florida Republican legislators pushing this plan meant to be self-satirical (but, hey, who knows?)

More interesting, and bringing this back to the influence of corporations on policy, Kirkpatrick notes that those 42 co-sponsors “…were almost all recipients of outsized campaign contributions from major health care interests, a total of about $765,000 in 2008, according to a new study by the National Institute on Money in State Politics, a nonpartisan group based in Helena, Mont.” Amazing. The suggestion is that these wealthy corporations are buying votes. A reader might conclude that these legislators, and so many others, are corrupt scuzzbuckets. But it is, probably, coincidental.

Maybe. After all, in our current political culture it takes money to get elected, money to get the word out on your positions, money to get the word out smearing your opponent, to buy radio and TV time. And it is a known fact that very rich people and corporations give much more money to politicians than poor and working people. So why would we think that they wouldn’t have an influence on the votes of these legislators, or those in Congress? Whether it is a matter the legislators “paying their donors back”, or simply of those donors funding the election of candidates who really believe in the issues important to them -- such as corporate personhood, or that trying to ensure that people get health care coverage tramples on their individual liberty. Or maybe those candidates just care more about that individual corporation than are about those cheap poor people who don’t make campaign contributions. OK, they’re corrupt scuzzbuckets.

I don’t know why, at my age and my at least moderate knowledge of history, I continue to be amazed by this. After all, one of the most corrupt Presidential administrations was that of Warren G. Harding, whose vice-president (and successor) was ol’ Silent Cal himself. I think there are a lot of Americans who actually think that their elected officials should work on their behalf, not on that of a monied corporate elite; they were responsible for the election of Barack Obama to the Presidency. Perhaps they thought that was enough, and now they could go back to watching TV, or playing on line at Facebook and Foursquare.

But they have to stay involved, because the powerful have the resources to keep coming back. If the people can defeat them once, they will try again. If the folks who voted for Obama do not keep working, inertia will lead to control staying with those who can afford to buy politicians. We cannot allow our country to be sold to the highest bidder
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Not "Special Interests": The Wealthy and Powerful

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One thing a blog might do is to provide connections between seemingly disconnected news stories. I have tried to do that, as well as focus primarily on medicine and health issues, but also with an emphasis on the social justice implications (or at least that is my attempt). I will make that effort here.

On July 31, 2009, the New York Times has a lead article titled “Big banks paid billions in bonuses amid Wall St. Crisis” by Louise Story and Eric Dash (http://www.nytimes.com/2009/07/31/business/31pay.html?_r=1&hp). I have often made clear my feelings about those big bankers and financiers (that they should have all their money taken away and either be put in prison or in surplus FEMA trailers), but apparently the bankers do not share that opinion. The information for this story came from NY Attorney General Andrew Cuomo, and reports that “At Goldman Sachs, for example, bonuses of more than $1 million went to 953 traders and bankers, and Morgan Stanley awarded seven-figure bonuses to 428 employees. Even at weaker banks like Citigroup and Bank of America, million-dollar awards were distributed to hundreds of workers…. ‘If the bank lost money, where do you get the money to pay the bonus?’ said Mr. Cuomo." Good question; apparently the answer is either directly (from our deposits or loan payments), or indirectly (from TAFP funds), from you and me. “Some compensation experts questioned whether the bonuses should have been paid at all while the banks were receiving government aid.” You can add some non-compensation experts, like me, to that group.

On the health reform front, we are treated to news reports that President Obama’s popularity has slid to 53% with only 42% approving and 47% opposing their understanding of the President and Congress’ health plans (NPR July 28, 2009, and widely reported). I have been following the health reform debate pretty closely and I am not sure I understand what the President’s health reform plan is; even the ones that are proposed variously in the House and Senate keep changing, and are hard to tell even with a scorecard, such as that offered by the Kaiser Family Foundation website, http://www.kff.org/healthreform/upload/healthreform_sbs_full.pdf.
Thus, there is a possibility that most of the Americans surveyed for this report also may not have a clear understanding. One of the reasons, of course, is the reporting in the media, which is always interested in conflict, as it sells better, and in the case, at least, of much of TV news – the source of most Americans’ information – frequently biased. One source of bias, even among less egregious offenders than Fox, is the constant parade of Republicans, a group whose contribution to the health debate has been limited to attacks and scare tactics.

The Republicans, of course, have no plan; it is a lot easier to shoot arrows at the Democratic proposal – any proposal – than themselves offer an actual plan that might be criticized. And, of course, it would be torn to shreds, since the only values that the Republicans share on health care is making sure that the wealthiest are protected in their wealth, that insurance and pharmaceutical companies make out like bandits, and that there be no government sponsored health plan, which effectively means not only would the currently uninsured be left out, but the currently underinsured and scared would be at even more risk.

The President has said the right things: Everyone must be covered. Costs must be controlled. There is no “null” option, the alternative is to continue things as they are and see massive growth in health care costs combined with more and more uninsured and underinsured people getting less and less health care that they need resulting in worsening health status for Americans. But the health plans being proposed by the Congress with the support of the White House are second rate (that is to say, they will not cover everyone and save money the way that a single player plan would). However, the big mistake is that the Congress has not supported the President’s play. Committed to repeating the mistakes of the Clinton health plan, they insist on compromises to try – absolutely without hope of success – to get bipartisan support. This is a mistake, as the Republicans have no credibility and are worthy of no respect or attention; this is, after all, the party of Alabama Senator Jeff Sessions, who voted against the confirmation of Sonia Sotomayor in the Judiciary Committee the same day because she has a judicial philosophy that is not consistent with the American ideal of Blind Justice. I suppose Sessions – whose own Supreme Court nomination faltered on the fact that he was tied to the Ku Klux Klan – has managed to pull the sheet over his own eyes.

Unfortunately, too many of the Democrats, as well as Republicans, are in the pockets of the lobbyists of wealthy billionaires and the huge companies, especially insurers and pharmaceutical companies but also large hospitals and hospital chains who stand to lose a great deal of money if we enact real health reform. After all, if there is “waste” in this system – and I think most informed people believe that there is – it is going into someone’s pocket. I call “waste” all those billions – hundreds of billions – of dollars spent on “health care” that is not spent on health care at all but insurance company profits and bloated administrative structures that are designed (on the insurance company side) to not pay, and (on the provider side) to try to get the insurance companies to pay. And the enormous mark-ups for certain drugs, such as cancer chemotherapy drugs. If we save all this money, certain companies won’t make it, and they are lobbying like heck to keep their piece of this huge, bloated, tasteless pie.

To call these “special interests” is, on the face of it, accurate, but deceptive because the term is without meaning. It has been developed and put forward precisely to hide the influence of wealthiest and most powerful corporations by conflating them with much smaller and weaker groups as “special interests”. Let us be clear: the influence of the Health Insurance Association of American or PhARMA is not the same as that of, say, those seeking rights for the transgendered. Or even of labor unions. These groups are powerful in our lives outside government all the time – hey, that is the problem, that the health insurance companies deny us coverage if we have pre-existing conditions, won’t insure us if we don’t work for a big company and don’t have the money to pay, makes us pay huge deductible and coinsurances, and still won’t pay the bills all too often. The one area of society that should be responsive to the needs of the people and not big corporations is our elected government, but the fact is that those companies have bought Congress too. After all, they have to run again and that requires a lot of money and it is a proven fact that wealthy individuals and corporations contribute a lot more money than poor and middle-class people. (What is it with those poor folks? Why don’t they contribute more to their congressmen?)

Which, of course, brings us back to the beginning of this piece. The problem facing health reform is the same problem facing reform of the financial and banking system. Money talks. Even after the gigantic disaster perpetrated by the banks and financial houses, the one that took down YOUR retirement, as well as, coincidentally, the entire US and world economy, they still have way more power than you do, and Congress is still feeding their interests. My last blog post addressed the “Tragedy of Meaning”, and how we like to explain suicide by people (like Adolph Merckle) as their reacting to bad events rather than because they suffer from depression. The best argument for that is in the first paragraph of this piece – of all those financial leaders who brought this ruin on all of us who are not committing hara-kiri but are demanding, expecting, and getting huge payoffs. The position being put forward that some of them are not the same individuals who were in charge before is nonsense; they have the same values, beliefs, and arrogance.

What can regular people do? We can be clear that we need a health reform plan that 1) covers everyone, every single one of us, 2) covers our needed services based on evidence, 3) doesn’t pretend that choice of insurance companies is the same as choice of doctors or hospitals. And that makes for every one of us to have access to all of the proven preventive and treatment modalities for the diseases we have or might get. And to write that email or make that phone call to our congressman daily if we have to. Start, for example, with urging them to vote for the Weiner Amendment in the House, which will come to the floor in September, that calls on the House to replace the current, flawed, patchwork HR 3200 health bill with HR 676, the Improved and Enhanced Medicare for All Bill, which will put us all in the same program (Medicare, the most popular government program in history) and at the same time revise payment structure to encourage what is GOOD for us rather than what is PROFITABLE for providers.

If the President and the Congress would just take the lead in not only saying, but proposing a plan, that would cover everyone and pay for it using the dollars currently wasted on both insurance company profit and the huge administrative infrastructure necessary to run that system; to say and propose a plan that says “we want health and health care for the American people and do not care a whit for the insurance industry”, the American people would be behind it.

Time to send that email.

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