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.

Culture and Medical Culture: Understanding to increase benefit and reduce harm

Culture is often understood, at least by that culture that is in a majority in a given place, as a characteristic of others. That is, we are “regular”, they have a culture. The greater the disproportion between the dominant group and others in terms of numbers, the less diverse a community is, the more this – incorrect – assumption prevails. In the 19^th century, before the work of Bronislaw Malinowski and Margaret Mead, who actually spent time in the places and cultures they were studying,  cultural analysis of the world by anthropologists was often done “offline” by what have become known as “armchair anthropologists”. All European, they ranked cultures from least to most civilized, and guess what: European, and especially Western European, cultures were always at the top!

It should be needless to say that this was wrong. In addition to all the examples that can be given of other non-European cultures were far more advanced (think the Arab world for mathematics and science, China for all kinds of things), all cultures are different. They do not just have “strengths” and “weaknesses”, or areas in which one is “better”, but differences which have developed to serve the needs that existed where they lived. Weather, for a start, makes a difference in the types of crops grown or how housing is designed. In addition, of course, different cultures share many similarities. This allows for, for example, religious ecumenism, in which folks of different religions can come together based upon the values that they share. In the US today, we have seen great advances in understanding not only that differences between cultures do not mean one is better than another, but also that similarities between people usually exceed differences. Recently, we are seeing great strides against racism, sexism, jingoism, and all the other “isms” that promote hatred instead of understanding. Unfortunately, however, we also see a backlash from people who feel threatened by the idea that other people, whom they have disparaged and discounted, are indeed their equals. This has gone beyond attitudes; it has led not only to violence, but to legislation enshrining prejudice, hatred, and discrimination. I hope this will get better, but it might get worse first.

One way that we have on tried to address this issue in medical education has been discussions between small groups of students about how they see common phenomena in the world, in their communities, in families, and relationships. The more diverse a class is, the richer these discussions become and the more the students learn that what they think of as “regular” is in fact just as much a cultural belief as that of other people. Of course, this also can reveal assumptions that they may make about what is “normal” that are not normal for others, particularly regarding financial and socioeconomic issues. Or, for instance, whether the police are seen as your protectors or your persecutors.

This becomes an important entry point for examining medical culture, which certainly exists and carries its own beliefs and prejudices, as do most professions. These beliefs are no more, or less, “true” than sociocultural beliefs. Because medicine involves not only extensive interaction with other people who are not immersed in the culture but, even more, extensive power over the lives and health of those people, coming to grips with what you (and your teachers) believe because, well, we all believe it, rather than what is based in evidence, is important. This is more difficult because a big part of the socialization to a profession such as medicine is for a novice who is from outside that culture to learn the jargon, way of thinking, and indeed prejudices that characterize it, and this can have negative as well as positive results.

For example, our medical students usually enter perfectly capable of speaking English (and perhaps other languages) and conversing with others and communicating ideas and information. As part of becoming doctors, they learn new language, new terms, new acronyms, new meanings, and eagerly repeat them as evidence of their acculturation. Unfortunately, this can become an obstacle to communication with their patients, who do not speak this language. One example: a couple of sentences ago, I used “positive” and “negative” in their usual English senses of “good” and “bad”. However, when doing medical tests (lab, imaging, biopsies) a positive result is usually bad, and a negative result is good. But when a doctor, or student, informs a patient that their results are negative, it is common for the patient to react with fear, since this sounds like a bad thing. We urge them to say “normal”. Whew, that’s a relief!

Some other issues of medical culture are address in an Op-Ed by Robert Pearl in the Los Angeles Times of May 16, 2021, “How doctor culture sinks US health care”. A big part of Dr. Pearl’s critique in the distinct bias, not only in physician attitudes but in medical journal articles, towards intervention and procedures rather than prevention. This, he notes correctly, is very much tied to money, since physicians and hospitals and health systems (which are increasingly the physicians’ employers) stand to make much more money from them. Medical journals are more likely to print articles with positive (there is that word again!) results, demonstrating that a procedure had benefit, than negative results, demonstrating that, actually, compared to something – or nothing – else, something (or nothing) that was easier, cheaper, less interventive, and less dangerous, it had no better outcomes. Of course, anyone can see that knowing this information, that doing something is not worthwhile, is at least as important as knowing that something works well.

However, the inclination (or perhaps prejudice) among most physicians is to do something, to intervene; aside from making money, it makes them feel that they have skills, are justified, are important. Unfortunately, this is also an attitude quite prevalent among their patients, who want something done to help their problem – to cure their disease, or increase their lifespan, or improve the quality of that life, and in particular to ease their pain. But doing something does not always improve things, and can definitely increase the risk of harm. We need to know what works (and what doesn’t), and in what circumstances, and what the dangers are, and what the alternatives are, and their potential benefits and risks, and then have discussions together about what, in the specific circumstance a specific person is in, what would be the best choice for them.

This effort is likely to overlap with more traditional sociocultural and religious beliefs, which can have an influence on what a person thinks would be best for them. Communication around this requires care, and a real effort on the part of the medical professional to understand and to make their own thoughts clear and clearly expressed. This is even more complicated when, as is the case, physicians are from a pretty narrow slice of the American population, racially, culturally, and economically (and, again, a good argument for increasing its diversity). As in all situations where there is a power differential (and in medical care, the greater power lies with the physicians and health systems) it is incumbent on those with greater power to make the effort to understand those with less. And, at least as important, to not make decisions for and about people based on only your understanding – or worse, assumptions – about what they want, or are because of race, religion, gender, national origin, etc. Doctors, even when they are well-meaning (and all of them are not always) too often allow themselves to fall victim to the ecological fallacy, and confuse “condition X is more common in population Y” with “the patient is a member of group Y so probably has condition X”.

It is, of course, also very important to recognize that all interventions and procedures are not a bad idea; indeed, they are often the best treatment. And, also, that not everything sold as “preventive” is really so; plenty of tests and treatments called preventive are not proven to prevent anything. It is not easy to overcome prejudices and beliefs.

But understanding that we all have culture, and trying to not be bound by it and doing our best to understand that of others, is a good start.

Medical communication is indeed often "lost in translation"

I often write about the things that I believe make a big difference in the health of people. Some of these are access to the health system, particularly financial access in the US. The bizarre and inappropriate structure of the US health system in terms of overemphasis on high-tech, subspeciality care at the expense of adequate primary care is extremely important. I also believe that the “social determinants of health”, the characteristics of people’s lives that are not usually considered as part of the health system (socioeconomic status, environmental exposures, stress, education, housing, etc.) are major contributors to health.

I have also written about medicine in terms of recommendations for prevention and screening from different organizations (I tend to advocate for those from the US Preventive Services Task Force) and about treatments that are promoted but are often of minimal benefit and sometimes harm to people. Occasionally, I even venture into the area of medical research, trying to help folks understand how science progresses, and how there is rarely a “breakthrough” as big as the news media like to trumpet. As a medical educator, I am very concerned about how we train doctors, and have also frequently written on that topic.

Most of these themes are focused on “population health” rather than the management of individual patients with individual diseases, not because the latter is unimportant but because these issues are extensively addressed in many other outlets, and the ones that I have described are, I think, not as well understood both by the medical community and the general population. I believe that the almost exclusive emphasis in our country on treatment of individuals limits both our commitment to addressing population and system issues, and the resources available to do so.

However, sometimes there is an issue that is mostly about human behavior, something that could be changed, and would make a big difference in the healthcare experiences of most people. One of those I have touched on before (Medical schools are no place to train physicians, January 5, 2014), because I see it as a key part of medical education, is communication between health care providers and their patients. This was addressed in an outstanding “Opinionator” blog that appeared in the New York Times on February 9, 2014, "Lost in Clinical Translation" by Theresa Brown.

Ms. Brown is apparently a nurse, but what she discusses is at least as applicable to doctors and to other health professionals. Starting with a reference to the Gary Larson “Far Side” cartoon here, she gives excellent examples of failures of communication that were disturbing to patients, but did not, apparently, disturb the health professionals who, presumably, thought they were communicating as clearly as Ginger’s human owner does. One story is of her friend's husband, who a heart procedure called a “cardiac catheterization” to look for blockage in the arteries that supply the heart itself, which can cause a heart attack. (That description is, I hope, clear; when I told my residents, however, I just said “he had a cardiac cath”, which was very clear to them but would likely have mystified most patients.) As it turns out the test was completely normal, but this was not clear to the obviously very worried wife who understood almost nothing about what she was being told (for example, that he was being kept overnight in the intensive care unit because this is routine after such a procedure, not because his condition required intensive care!).

This sort of thing happens a lot. Daily. Hourly. There are many reasons for poor communication to occur between health professionals and patients. Some are that people, when they are scared and sick and in a strange place, have difficulty listening to strange words and understanding unfamiliar concepts. They may have to be told again and again, just as, I tell my students and residents, we all had to study to pass exams even though we'd be "told" everything once, in the lecture. But there are a lot of other things that are our fault, and can be remedied by different behaviors.

One, we – doctors, nurses, and other health professionals -- are very comfortable in the hospital, and we take it in stride; it is our "briar patch" and we're at home, but for patients and families it is a scary place full of thorns. I ask doctors and nurses to think about they would feel if they had to go to court, as witness or defendant or plaintiff, and look at how easily the attorneys comport themselves. It is a good reminder of how patients feel in a hospital.

Two, we speak "medical" fluently. We have such familiarity with both words and concepts that we assume that they mean something to regular people (which is, by the way, the correct English term for "patients" and "patients’ families"). But usually they don't; words that mean very different things sound a lot the same; even if people have heard them before they usually have only a vague idea of what they mean, and the difference between "is" and "is not" is, while obviously very significant, not always clear to folks. I point out, just for an easy one, how often we use "negative" when we are describing a normal test. We should ALWAYS use "normal" or "not normal". "Negative" sounds bad. "Positive" (which is often bad) sounds good!

Three, we often use obfuscating words, unnecessarily medical words when regular ones will do fine, and use lots of modifiers and adverbs that make what we are saying even more unclear. The use of such modifiers ("probably", "likely", "potentially", 'possibly") may make what we say more technically accurate, but can obscure the message. Similarly, we are often uncomfortable giving bad news, and when we use such modifiers we may think we are lightening the load a bit for the patient, but really we are being more unclear. When we hide behind medical words, we are protecting ourselves from having a long and perhaps difficult discussion; completely subconsciously, I'm sure, we expect that maybe they won't understand, and thus won't ask hard questions. Also we tend to speak in the third person, kind of distancing both ourselves (first person) and the patient (second person) from what we are saying. All these are illustrated by thinking about how a statement like "The biopsy result showed that the tumor was probably malignant" conveys a very different (and probably incomprehensible) message than "you have cancer".

It is a lot to think about, but the good part is that these behaviors can change. We just have to want to, and work at it.

NOTE: The Medicine and Social Justice blog will appear less often than it has, intermittently or maybe not at all, for some time. I am on sabbatical and will be engaged in writing a book, more or less on the themes described in the first two paragraphs of this piece, the themes that have been the subject of this blog.

Evaluating the Communications Skills of Potential Medical Students: Looking at the "Whole Person"

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As US medicine is becoming increasingly seen as more impersonal and technological, there is an unsurprising reaction among the people it serves. While Americans unquestionably value the benefits of high-tech interventions (at least for themselves and their loved ones – maybe not so much for others), they also want doctors who will listen to them, understand them and care about them. There is a definite sense that technical skill is great but the decision about how and to whom to apply that skill requires understanding the person, not just the disease and the potential intervention.

Most people are not in a good position to evaluate physician skill on a technical basis. Most studies on this topic have found that in general people assume quality – they assume the knowledge and skill of their doctors, and of the hospitals in which they practice. This is why hospitals and practices often compete on the basis of “hotel” services -- is there a nice lobby, is the place modern and impressive, are the rooms big, is the food good -- as well as issues such as “are complaints addressed”. When people are unhappy with their medical provider, doctor or hospital or other, it is usually because they had a bad outcome or because they didn’t get the “service” that they wanted. All of us can relate to that, but these are not always the result of “bad medicine” being practiced. Not getting the service you wanted may be medically appropriate if that service was not indicated or even potentially harmful. The bad outcome may be because the provider didn’t do a good job, but it could just as well be because there was inherent risk in both the procedure done and the underlying disease that it was intended to treat. Indeed, it  may be that the potential benefits of the procedure were oversold and the risks minimized; when people are suffering they are often likely to look at potential benefits and not so much at risk. It is therefore the job of the provider to make clear what the benefits are most likely to be (not just “best case scenario”). A cure? How often? An improvement? How much? A longer life? How long? And in what condition? And what are the risks? And costs? This, of course, gets back to communication.

On the whole, medical students have not been selected for communication skills. Sure, admissions committees value them, but they are not “make or break” the way test scores are. Most medical school faculty have a variation on the (true) story I heard from a colleague; the interviewer, a high tech physician, wrote on the applicant’s interview form “Great scores, zero interpersonal skills. Admit.” Unfortunately for the applicant, arguably more fortunately for his/her future patients, those interpersonal skills were so poor s/he finally failed out when s/he moved from the test-taking years to the actual patient care years.

A new medical school in Roanoke, VA, the Virginia Tech Carrilion School of Medicine, is formally integrating assessments of communication skills into its admissions process, as described in the NY Times July 11, 2011, New for Aspiring Doctors, the People Skills Test. The particular method that they are using is the “Multiple Mini-Interview”, or MMI, in which applicants have a series of 8-minute discussions with an interviewer who presents them with a problem – an ethical issue, a values conflict, a team dynamic – and looks for how well the interviewee is able to approach the problem, to think about, and to express their concerns. There is no “right answer”; “Candidates who jump to improper conclusions, fail to listen or are overly opinionated fare poorly because such behavior undermines teams.” This is not the traditional model for selecting doctors, who are classically opinionated, the “boss”, and so sure of themselves as to often be accurately characterized as arrogant. The article indicates that many other medical schools are looking at this system, originally developed at McMaster University in Ontario, Canada, or another similar one.

Of course, there was a response to this article and not all of it was positive. Most of the letters published in the Times on July 18 were critical in one way or another. Several were from physicians, but I will not mention the specialty for fear of feeding stereotyping (if you are interested in knowing, following the link above). While one writer set up a straw man to attack: “Charm won’t save a patient’s life,” which confuses (presumably on purpose) the ability to communicate and work with others as “charm”, other letters suggested that their authors had familiarity with the specific test, the MMI. They perceived flaws in the test, suggesting that it might overselect extraverts compared with introverts and be disadvantageous for the applicant “…with less ‘real world’ experience or an applicant with fewer resources who may have less experience navigating ethical discussions,” or that it “may ‘weed out’ talented applicants who have the compassion and capacity for great “people skills” but have not had the time or opportunity to nurture them.”  Another worried “that the stressful mini interviews might screen out not bullies, but mildly awkward people who would be fine when dealing with real patients and nurses.”

Another writer was generally supportive, but worried that “…while speed ethics tests are at best an intriguing experiment, at worst they are the latest gimmick”. This person suggested that “Medical schools might try looking at the whole person.” Of course, “looking at the whole person” is exactly what Virginia Tech Carilion and other medical schools are trying to do, whether using the MMI or other methods of assessment. They are trying to get instruments to measure that “whole person” beyond the ability to score well on multiple-choice tests, which have, after all, long been the cornerstone for deciding who gets into medical school. Our “charm” writer suggests that the answer is to “select brilliant students, and then cultivate their social skills.” Of course, all the data suggests that “brilliance” aside, it is much easier to teach knowledge and technical skill (the whole point of the medical education experience) than it is to teach social skill, as demonstrated by the elegant work of Dr. Robert Sade and colleagues, “Criteria for the Selection of Medical Students”[1], published in the Annals of Surgery in 1985.

Much other research has demonstrated that the traditional methods of selection (high test scorers, mostly from privileged backgrounds) predict success in the first two years of test-based education but not at all in the clinical years or in practice. MMI also has a research basis; Dr. Harold Reiter, the McMaster professor who developed it says “…candidate scores on multiple mini interviews have proved highly predictive of scores on medical licensing exams three to five years later that test doctors’ decision-making, patient interactions and cultural competency.”  

Perhaps the MMI is not the best tool for assessing communication and teamwork skills, but it is a good one, and those are important skills. Those skills, as Dr.Sade identified, are among those we should be selecting for. If the applicant has “less ‘real world’ experience”  but has “…not had the time or opportunity to nurture them,”  maybe it is important for them to do that and find out if they are capable before they are accepted to medical school.

The correlations we will ultimately need to have to see if our methods of medical student selection are good or not will not be with performance on multiple choice tests. They will look longer term at specialty choice, practice location and at the benefit to the health of the patients they care for. Most important will be the overall health of our population. In the meantime, we should at least accept medical students who have the basic interpersonal skills to communicate effectively with another human being.

[1] Sade RM, et al. Criteria for selection of future physicians. Ann Surg. 1985 February; 201(2): 225–230