
Can a Computer Replace Your Doctor? - mp4box
http://www.nytimes.com/2014/09/21/sunday-review/high-tech-health-care-useful-to-a-point.html
======
tst
Atul Gawande wrote about 'non-human' tools in medicine [0]. He advocated using
checklists but he has also written about other tools. One I remember was a
flow chart to predict some sickness. It outperformed humans solidly.

The biggest problem with checklists, flow charts and software (one older
example is MYCIN [1]) is adaption. If the medical practitioners don't want the
systems they are going to fail. He also writes a lot about that in the book.
He tried to introduce it into hospitals but the professionals often ignored
the lists or just checked the boxes without actually checking the condition.

I personally imagine that a practitioner with a good system works the best or
like Frederick P. Brooks said [2]:

> If indeed our objective is to build computer systems that solve very
> challenging problems, my thesis is that IA > AI that is, that _intelligence
> amplifying_ systems can, at any given level of available systems technology,
> beat AI systems. That is, a machine _and_ a mind can beat a mind-imitating
> machine working by itself.

[0]:
[http://en.wikipedia.org/wiki/The_Checklist_Manifesto](http://en.wikipedia.org/wiki/The_Checklist_Manifesto)

[1]: [http://en.wikipedia.org/wiki/Mycin](http://en.wikipedia.org/wiki/Mycin)

[2]: [http://www.cs.unc.edu/~brooks/Toolsmith-
CACM.pdf](http://www.cs.unc.edu/~brooks/Toolsmith-CACM.pdf)

~~~
mashmac2
Average Is Over by Cowen (2013) has this exact same thesis - for the next 100
years, human + machine > AI.

[http://en.wikipedia.org/wiki/Average_is_Over](http://en.wikipedia.org/wiki/Average_is_Over)

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danso
What I would like to see more in these discussions is the possibility of using
computers for triage in medicine...too often, these kinds of "will computers
replace us" discussions focus on the computers doing _everything_...but how
about a computer being trained to do as much of the "mechanical" work of a
doctor's judgment as possible? Leaving the humans to focus on the 5%

An example I have in mind is Apgar's score, an almost stupidly simple index of
a newborn's baby health, but a system devised by an anesthesiologist who
realized that doctors' traditional method of judgment (check to see if the
baby is crying "weakly") left many babies at risk of dying needlessly.
[http://en.wikipedia.org/wiki/Apgar_score](http://en.wikipedia.org/wiki/Apgar_score)

I think if the profession stopped worrying about "replacing" doctors and
rather, augmenting them, I think the discussions would be more beneficial.

~~~
yummyfajitas
Doctors are expensive. Computers are cheap. The more we can replace doctors,
teachers, taxi drivers and other baumol workers with machines, the more
consumer surplus is generated.

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Ygg2
I don't think that is true, by not paying doctors, teachers, taxi drivers,
etc. the less consumers there are.

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jiggy2011
The surplus provides money for the consumers to spend on other things.

~~~
Ygg2
Consumers can't consume if they don't have the money. Every time you fire
someone and he can't get job for time X, you are reducing overall consumption
during that time X.

Instead the money if concentrated in fewer hands and there is an upper limit
to what a human can consume (e.g. a single rich person can't eat more than
hundred middle class people).

~~~
jiggy2011
If someone is spending less on healthcare, they will instead direct that money
into buying perhaps restaurant meals. More demand for restaurant meals means
that prices and profit margins in that industry will go up which will cause
more restaurants to open, who will in turn employ more chefs and waiters
causing their wages to go up and causing them to buy more things (like
healthcare).

~~~
Ygg2
I don't think healthcare expenditure would have reduced cost, because health
is not a negotiable goods.

If anyone becomes permanently unemployable, he will become poor. If there is
demand for restaurant meals, prices and profit margins will increase and
poorer people will be unable to afford it.

Each person that becomes poor, is another consumer less and the rest of people
will become richer. Once you have waiters/chefs that have super high wages,
they'll be automated and removed permanently from their job. Repeat until
there are only few producers/consumers and the rest are living on a fringe.

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infra178
I despise this attitude that people go to the doctor to figure out what is
making them sick. Most of time, when people visit general practice doctors,
they already know what's wrong with them. But we have to wait hours or days
for an appointment, drive through traffic, sit in a waiting room for hours,
and pay a bunch of money so that some jerk can spend five minutes typing our
symptoms into his laptop.

I get it: they're gatekeepers to prevent people from abusing or misusing
medicines. But wouldn't it be better to allow people access to medicine based
on objective measurements taken over a long period of time rather than making
people interview for it?

When I'm sitting in a waiting room, I'm thinking about what I need to say and
do to convince the doctor that I'm sick. If I'm polite and smile is he going
to believe me when I tell him I'm in pain? If I don't have a fever is he going
to believe I had one two hours ago? I know that he gets paid whether he treats
me or not and that he knows every treatment is a potential lawsuit if he makes
a mistake. He has every incentive to play it safe and find some reason to
avoid treating me.

The other day, I read an article about a woman in Houston. Emergency room
doctors avoided treating her for a stroke because her boyfriend mentioned that
she has occasionally smoked marijuana. Classifying her as a drug user allowed
them to just give her some Zoloft, push her out the door, and collect the
check. She'll never be the same again. And this happened in one of the best
hospitals in one of the best medical centers in the world. The problem is
systemic.

~~~
conformal
your characterization of visits to the doctor is spot on: they are gatekeepers
to medication and treatment and they have a warped incentive structure that
biases them to under-treat anyone they don't "believe".

on top of what you describe, i find most doctors to be biased towards "i know
better than you" behavior. i have found that being an intelligent person makes
dealing with doctors especially difficult since you need to be strategic to
convince them and at the same time appear to not know too much about your own
health problems. i have had incompetent resident doctors argue with me just
because i know more about my illness than they do, and their ego is such that
they cannot admit to themselves or me that they are wrong.

any technology that leads to me spending less time interacting with doctors is
a huge win.

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ThomPete
This is what stood out for me actually:

 _"... At the Mayo Clinic’s Transform symposium this month in Rochester,
Minn., I heard Eric Dishman, a general manager at Intel, explain how he had
used data to individualize his own cancer care. More than a decade ago, when
he was only partly responding to chemotherapy for a rare kidney cancer, he
used a step monitor to help figure out what provoked his pain and then worked
with a physical therapist to treat it. More recently, scientists were able to
analyze the genetic sequence of his tumor, identifying a medicine for
treatment. He is now cancer free..."_

~~~
spartango
If you find the work in cancer interesting, it's worth looking into a few
commercial outfits that are doing this type of testing:

* Genomic Health ($GHDX) with OncotypeDX

* Foundation Medicine ($FMI) with FoundationOne

Both of these companies have tests on the market that analyze tumor genomes
(sequencing or microarray-based) and provide information to oncologists to
better treat their patients. Information like drug efficacy and tumor
aggressiveness (requiring chemo-/radiotherapy).

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jostmey
As someone who has been in and out of the US medical system, I strongly agree
with the opening statement by Dr. Wadhwa.

In my experience there are a lot of incompetent and immoral doctors. As a
patient I need a trusted opinion, for I myself have not spent the last ten
years in training to become a doctor. So who or what can I turn to? The
medical system in this country feels too badly broken. I need another option.

~~~
DanBC
Cochrane Collaborations review the research amd perform meta analysis to tell
us what does or doesn't work.

The English NICE recommend treatment based on cost effectiveness.

The "friends and family" test should be used by all English hospitals and that
might give you some information.

I'm not sure how you find out whether a particular surgeon is an incompetant
butcher.

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plg
"Can a Computer Replace Your Doctor? "

only if it's pre-programmed to be > 40 min late for each appointment

~~~
parennoob
Seriously, what is the cause for this in American medicine? Every time I go in
for something simple, I have to go through about 3 layers of administrative
people before even a nurse practitioner sees me. I'd be really glad if I could
interact with a computer-based system in the mean time.

~~~
bavcyc
The doctor starts on time. Patient one requires slightly more time than
scheduled...repeat for other patients. Also doctors have other tasks than
seeing patients: reviewing lab work (part of seeing patients?), pharmaceutical
sales reps, signing paperwork, etc.

Automation would be nice, but not sure how you could remove all the time sinks
in US Medicine.

/not a doctor, just observations as an end user.

~~~
fnordfnordfnord
and some patients miss appointments, and nobody plans to be ill so there are
last-minute "squeeze-me-in" appointments, etc. etc. Some practices manage this
much better than others though.

~~~
cscharenberg
I think that is the more interesting question: why don't practices get better
over time at managing this? There are places I go: hair salon, doctor, the vet
that are always 30 minutes behind. As a one-off that makes sense, but as a
pattern stretching over years it means they don't adapt to account for this.
If, on average, appointments take 2 minutes longer than they think then change
the appointment times to account for that. Do _something_.

It annoys me, as a process-oriented thinker, that so many offices never get
better at handling average daily volumes.

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fnordfnordfnord
Easily, definitely. I've never had a primary care physician that couldn't have
been replaced by a "Dr Kiosk™"; which would almost certainly have been
superior in nearly every way.

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melipone
It can certainly replace an optometrist. I really don't trust those doctors
with binary search (better/not better) :-)

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final
Of all mainstream professions (including software developers) medical doctors
have the highest average IQ. They understood very well how dangerous for their
mortgages and standard of living a computer doctor can be. The MD lobby in US
have fought tooth and nail since the 1980s to stall advance in this area.

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ratpik
Atul Gawande's checklist manifesto emphasizes the need for processes while
solving complex problems like surgery. A doctor can forget to wash his hand
while a machine cannot forget. So that is a place where computer assisted
techniques make sense just like the case of flying a plane where the autopilot
can take care of most things except when things go wrong and humans have to
take over. I don't think anyone with adequate experience in healthcare and
technology would make wild claims about replacing doctors with machines. There
are plenty of places where machines can aid doctors and simplify processes at
scales thereby letting doctors focus on more complex things. That's how the
automobile industry evolved and so will healthcare. But doctor's will always
be needed. They would just be doing different things or existing things in a
different way.

There are plenty of people in this part of the world (Eg. India) where people
are just getting to the point of trusting a ATM machine with cash withdrawal.
Assuming machines become better than doctors at asking patients the right kind
of questions, knowing when they are lying or just not able to communicate
their problem, there is still a significant barrier and probably a generation
of cultural changes that would make it acceptable to have a machine as your
primary care giver. Diagnostics have been using complex technology for a
while, so there is no doubt about technology improving the decision making
process. However diagnosis is just one and probably a small part of the
healthcare process. Actually improving the patients health requires following
a treatment plan and adherence to lifestyle and medical processes. Most people
just fail to comply due to behavioral reasons. This is where technology and so
call 'AI' can play a role. By understanding individual human behavior patterns
and guiding people to do small changes that would improve their health
outcomes. We have been working on fixing this problem for people with chronic
conditions like diabetes at
[http://www.janacare.com](http://www.janacare.com).

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6d0debc071
I would most certainly trust a well programmed computer to replace my doctor.

The examples given in the piece seem more to do with not taking a single
measurement as an absolute diagnosis. Which I'd never program a computer to do
anyway...

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grondilu
Personally I'd compare it to meteorology. Meteorologists used to interpret
images from satellites and I suppose they made predictions based on a bit of
science, but also a lot of heuristics. Now (still a supposition, I'm just a
layman about this) computers do most of the heavy work. Yet meteorologists
still exist : their work consists in choosing the computer, operating it,
understanding the output and other stuff like that. You can't just give a
supercomputer to someone and expect him to predict the weather. It's still a
job for an expert.

Medicine could become kind of like this.

~~~
electromagnetic
Extending the metaphor. A computer might not predict a perfect storm
developing because the model isn't perfect. Without the human there to see it,
you miss something disastrous.

A doctor would be the same thing. Sometimes things just don't follow the rules
we expect them to. Medicine is full of instances where diseases cause obscure
complications. I mean the series House MD is based on these, there wouldn't be
a show without thousands of these instances.

I think taking human error out of mundane doctoring would be great, and
allowing people to specialize into the more complex areas where creativity is
as much a part of the diagnosis as anything else then I think we would greatly
benefit.

What's sad is if you read many of the cases used in the show House, the
patients IRL died. The condition was found in the autopsy, because the doctors
just kept following routine.

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smanuel
It can, but not now. Maybe in 10 - 15 years (or more). The numerous available
online (mobile apps) symptom checkers are a good indicator of the current
state of how a computer can solve your health/medical issue. Computers need a
lot more systematic data which is currently not available.

A blod post on this topic: [https://medium.com/@iamhealee/you-should-use-
symptom-checker...](https://medium.com/@iamhealee/you-should-use-symptom-
checkers-and-you-should-never-trust-them-ce09188efefc)

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niix
Stuff You Should Know did a great podcast on this awhile back.
[http://www.stuffyoushouldknow.com/podcasts/computers-
replace...](http://www.stuffyoushouldknow.com/podcasts/computers-replace-
doctors/) Pretty interesting stuff.

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wyager
Well, most of the doctors I've had throughout my life have been completely
impersonal, so a computer can't really be any worse in that regard.

The one glaring exception was the doctor I had in Mexico, where the medical
care is fantastic and inexpensive.

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EGreg
I was looking forward with amusement to reading such an article. Mainly
because I realized that all the arguments the doctor would make would come
down to decision making. He could pose vague rhetorical questions ("do you
treat the MRI or the patient?") but at the end of the day it's about
collecting data, analyzing it, making a decision (about diagnosis etc), and
informing the patient. All the things that he discusses, therefore, are about
justifying a human doing it instead of a computer. A human currently has the
advantage in certain "soft" undefinable aspects of decision making, which we
can call intuition. But if this is eventually formalized into a algorithm
whose performance can be measured and quantified vis a vis human doctor
performance, it will be like computer image recognition. In some cases it will
be obvious that the computer has erred, but for the majority of cases it will
be able to notice things humans don't, because of the sheer amount of
collective experience around the world as well as correlations that humans may
not have been able to detect.

(I should pause here and note the danger of confirming nontestable theories
though, as Karl Popper once wrote, " _Once, in 1919, I reported to him a case
which to me did not seem particularly Adlerian, but which he found no
difficulty in analyzing in terms of his theory of inferiority feelings,
Although he had not even seen the child. Slightly shocked, I asked him how he
could be so sure. "Because of my thousandfold experience," he replied;
whereupon I could not help saying: "And with this new case, I suppose, your
experience has become thousand-and-one-fold."_"
[http://www.stephenjaygould.org/ctrl/popper_falsification.htm...](http://www.stephenjaygould.org/ctrl/popper_falsification.html))

Go back and look at all the arguments the doctor makes. Once you remove the
vague handwaving, you're still left with the basic question: what are you
measuring, analyzing and deciding? Can computer aided methods do it better and
more accurately, and in the areas they can't, why not, exactly? - and can this
be improved? If so, it's a matter of time.

I am not saying a computer can replace a nurse's bedside manner or a doctor's
ability to make the final call but computer aided medicine would seem to be as
superior to regular medicine as computer aided chessplaying has long been
shown to be superior to both grandmasters and computers alone.

Even the maxim he quoted, that doctors should only measure things that may
affect the diagnosis or treatment, is a heiristic not unlike the chess
heuristics that guide grandmasters' thinking. But how often does a tactical
line or particular "hidden" property of a position override that heuristic?
And similarly, a computer can help uncover hidden correlations that a simple
human rule may miss. After all, medicine thought for millennia that washing
hands was just a ritual with no medical benefit until bacteria were
discovered.

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fizwhiz
Are there any startups working on technologies to aid prognosis in a non-
trivial way?

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goshx
Please someone make it happen.

------
Gatsky
Agree that technology enabling better health care delivery is a great thing
and still completely under-delivered. But as for technology replacing
doctors...

I think in general it is misunderstood what doctors actually do... ie that
they perform some kind of analysis to produce some kind of output. What they
actually do, is take responsibility for the well being of a complete stranger.
There are certainly a number of doctors that don't understand this, and have
some other kind of agenda like making money, getting through another day
etc... but ultimately, a doctor's 'special' role is to take responsibility.
This is not really measured or paid for or even expected, but I would say that
the success of a healthcare system relates to how much it helps or interferes
with this process. People don't really get this, because there are very few
jobs like this, and we are used to not having anyone take responsibility for
anything. Government and business are masters of diluting responsibility in an
ocean of bureaucracy. Accountability/transparency are not a substitute for
responsibility either.

I don't know how a computer is going to take responsibility for my health, or
my child's health. It seems a frankly ridiculous idea to me, like replacing
the world's violinists with robots.

There is probably a role for a 'computer' to deal with nuisance (as in,
currently a nuisance for the person who has to take time off work, go to a
medical centre, wait for the doctor) medical problems like routine blood
tests, rewriting a script, routine screening. These jobs are already being
taken on by non-doctor health practitioners like physician assistants, nurse
practitioners. This is a reimbursement issue really, and it can be done
because:

1\. There is strong evidence base for the activity (eg doing a pap smear for
pre-cancerous cervical lesions, or vaccinating a baby).

2\. It is easy to measure the success or failure of the outcome (eg the pap
smear is done, or not done).

3\. There is a very small risk of legal action. (so that the intervention can
be indemnified in such a way that it is still economically viable).

Much of medicine is not like this however. There is not a clear evidence base.
There are not easy to measure outcomes. The consequences when things go wrong
can be significant for the patient and the doctor/treating team. Health
systems are already ruined by an irrational focus on optimizing the wrong
thing eg surgical waiting times, time to hospital discharge, profits, so lets
not make the problem worse with technology that is apparently better at the
outcome we've decided to apply to the cornucopia of human disease and
dysfunction.

Disclaimer: I'm a doctor (in Australia). I'm sorry for the waiting times. The
truth is, I don't have the skills to invent an adaptive appointment queuing
algorithm. Isn't that an engineering problem?

edit: clarity

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uhmduhhh
I can give the answer without reading the article: No, it can't. Next time you
have a heart attack or cancer or a broken bone, see how much your laptop or
your iPhone can help you.

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Balgair
No.

Betteridge's Law of Headlines states: Any headline that asks a question can be
answered with No.

~~~
DanBC
I'm guessing you're getting downvotes from people who are sick and fucking
tired of reading the same trite comment quoting betteridge.

~~~
Balgair
Perhaps the title should be changed then. If it has become something that is
so well known and reviled, even when pointed out, then maybe we should change
that. Perhaps a script that edits these titles out? I think Betteridge's law
is true maybe 80% of the time (sorry no data here). If so, then thats enough
to just screen out the bait titles.

