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.

Free speech, religious belief, and facts: how does it affect health?

The massacre at the French magazine Charlie Hebdo was shocking and horrible, as are the massacres and atrocities that occur regularly with less immediacy to those in the West, such as those committed by Boko Haram in Nigeria. The most positive result was the massive outpouring of support for free speech, for being able to say and print what you want even if it offends people. And, I would add, particularly if it offends the powerful, which Charlie Hebdo also did. More than a million in the streets of Paris saying “Je suis Charlie” (“I am Charlie”), with more than 40 heads of state in attendance, even if they didn’t actually lead the march, but were photographed together on a protected side street. And even if many of them sponsor severe repression of free speech in their home countries. 

The inclusion of Israeli Prime Minister Benjamin Netanyahu was particularly problematic given the violently repressive policies of his government, but given that the companion attack was on a kosher supermarket where four Jews were killed, the symbolism was important even if a lightning rod for (largely just) criticism of Israeli government policy. Less appreciated was the message from Netanyahu that French Jews should all come to Israel, and more appreciated were the sentiments of French Prime Minister Manuel Valls that ‘France Without Jews Is Not France’, and the demonstrators, most of whom were not, who carried signs that said “Je suis juif” (“I am Jewish”).

But the necessary condemnation of terror, and moves to avert it, along with the necessary condemnation of anti-Semitism and the conflation of Jews with the actions of the government of Israel (or the conflation of Islam with the actions of Islamic terrorists) does not solve the problem of communication, that people see “truth” so differently. I don’t know that I can offer much more insight into the conflict of seeing truth through the lens of religious doctrine (and of course some people and groups’ interpretation of religious doctrine) and a “liberal” concept of the value of free speech. I was interested in the perspective of Maajid Nawaz, a British Muslim who became a radical Islamist at 16, served 4 years in an Egyptian jail where his readings changed his perspective and later founded Quilliam, an anti-jihadist think tank in London, expressed on NPR’s Fresh Air. Asked by host Terry Gross how he saw himself as the same person, given his loss of relationships including family and friends since his “conversion”, Nawaz spoke about commitment to justice. He said it was the blatantly unjust treatment of Muslims that motivated him to fight as an Islamist, and the same commitment to justice that makes him oppose terrorism. Ideologically, I think that this is a good start.

 Most countries, including France and the US, have a mixed relationship with free speech. In the US (which I know much better), many people not only support free speech for positions that they agree with but also positions that they can tolerate listening to. Of course, however, true support for free speech means support for speech you abhor, hate, despise, think dangerous. Not, of course, the same as action (“your free speech stops just short of my nose”), but certainly includes free assembly and demonstrations to express views. If one’s religious views include opposing anyone’s right to criticize your religion (or, even more, as illustrated by the Inquisition or ISIL’s massacres of Yazidis, not adopt your religion), you are clearly endorsing a society antithetical to free speech. And, of course, with the grossly immoral series of US Supreme Court decisions that money is speech and that corporations are people who can exercise that “speech”, the entire concept of free speech in our country is perverted.

Closer to home, and closer to the usual themes of this blog, health and social justice, we see again how beliefs not only threaten free speech but threaten our ability to act as an honorable and just society because groups of people see things so differently. The reasons given are many: our social isolation from groups of people unlike us (residential segregation by race and class and age and educational level), our ability to receive “customized” news, where what we watch on TV or find on the Internet is that which agrees with what we already believe. When people hold views based on their faith, it may be difficult or even unreasonable to expect to change it; this is what “faith” is. However, when people hold views that are not religious and are demonstrably wrong in the face of the facts, and those beliefs are held as firmly as those that are religious, and those beliefs threaten the core well-being of other parts of our society, we would hope that they could change.

I have often written about the Social Determinants of Health. These are the conditions of people’s lives that make them more vulnerable to illness, less likely to be able to prevent it through both health screening and living in places and circumstances in which prevention is possible. For example, not near areas of high pollution, not in poor quality cold housing, not in no housing. To have shelter, and decent food, and the opportunity for education for themselves and their children. All the things that characterize their lives and come before their access, or lack of access, to the health system comes into play. If we are to improve the health of the American people, we must not only provide equitable access to health care geographically, financially, and socially (with language access and caring and actual interest in people’s health) but also address those social determinants that disadvantage so many in the pursuit of their health.

 

And then I read the results of a survey by the Pew Research Center that says a majority of well-to-do Americans think that poor people “have it easy”. Widely reported, including by the Washington Post which leads with “There is little empathy at the top”, and CNN, which reports “54% of those with the greatest financial security believe that ‘poor people today have it easy because they can get government benefits without doing anything in return’…Only 36% of the wealthiest say ‘poor people have hard lives because government benefits don't go far enough to help them live decently.’" I want to say this is unbelievable, but I have to believe it is true that they think this. I am, nonetheless, aghast that they could think this. What world do they live in? Is it really true that their only contact with poor people is on TV news, Fox News at that? Have it easy?

Would they want to test that? Live like poor people for a while? Even knowing that – unlike real poor people – they could return to their comfort in a month or a week, would they be able to tolerate it? Not being able to pay their bills, not have heat, not have decent or sufficient food, not be able to afford the doctor, not be able to take off work without losing pay to go to one even if they had health insurance? I think – I know – that if they did they would feel differently about it being easy to be poor. But while there is great value to “walking a mile in someone else’s shoes”, there is a way to know what is going on without even doing that. It is called opening your eyes, looking at the facts.

Even when they are uncomfortable, even when they challenge your beliefs, or more importantly your sense of self-entitled comfort. To not do so is part of no one’s religion. This is the responsibility of free people.