I want a T-shirt that says Artificial Intelligence Isn’t.
I spent a very long twenty minutes on a Zoom this week with a surgeon-turned-tech-entrepreneur from Stanford, who was trying to persuade me that the new software he’s developing is going to save primary care. Artificial intelligence is better than humans at making diagnoses, he tried to tell me, and then he showed me some (very biased) data to support his contention. We can keep people out of emergency departments, he said, if busy primary care clinicians connect patients to a robot or a chat process that would let them describe their symptoms. Then the AI-fired robot would tell them whether they needed to go to an Emergency Room, stay home, go to see their doctor, go to urgent care, or do something else. Most people who use the emergency room don’t get admitted to the hospital (true), so the bot will help keep the people who don’t need to be there out of the ED, according to my ex-surgeon friend.
Help! I don’t know where to start addressing how crazy this is. I come from a world where people have primary care doctors and other clinicians who are humans, and who are on call at night to answer their questions and address their urgent worries. Even if it is true that AI can make accurate diagnoses (which seems possible from written descriptions of a person’s problem) it is not true that AI knows how to talk to human beings who are sick, to hear what is worrying them, and to help them sort out what to do in a way that actually helps them. AI can create human-sounding voices. AI can evaluate complaints. But no AI has either true empathy or the personal responsibility for getting things right, understanding that real humans aren’t always logical. And no AI can build a relationship with a patient over time and know that person’s family or community. AI can be helpful in primary care by creating visit notes, so primary care clinicians can spend more time listening to patients and not clicking boxes on a computer. But no AI can ever have empathy or true authority or can make anyone feel truly safe.
I want to talk to human beings, not machines, not even smart ones. During the day and should I get sick at 3 am. Especially if I’m sick at 3 am.
Re: lacking intelligence. This week saw dueling press releases from the Governor and the Attorney General about Rhode Island’s primary care crisis, which I’ve been writing about here for two years and working on for forty years. The good news is that both the Governor and Attorney General are paying attention. The bad news is the unnecessary sniping. The Governor made a few helpful proposals that were mostly too little and too late and built his process around asking overworked primary care clinicians to take more patients, forgetting that when you beat a dying horse, it dies — forgetting that adding more patients to clinicians who are overworked will burn more of them out — and do it faster.
Both the Governor and the AG labor under the hallucination that just paying primary care clinicians and practices more will fix the problem. Nope. That will generate more money for administrators and push the cost of health care up, although some doctors might be able to afford better cars as they are burning out. And it might keep large practices run by those administrators from losing money and going belly up, so it might help stabilize the mess we are in. But it won’t fix anything by itself.
The central problem is our acute shortage of primary care clinicians. We need hundreds more than we have. If we push up salaries to attract them from Massachusetts and Connecticut, Massachusetts will just push up salaries to entice them to stay. We need to quadruple the number of residencies to train primary care folks; we need a major investment in scholarships with obligations and loan repayment programs; we need pathway programs in middle schools and high schools to get people to apply to nursing, medical and other health professional schools; we need coaching programs to help them through a ridiculous application process and about ten more interventions to fix the workforce shortage – and even all of that, if we started it tomorrow, won’t have a major impact for at least three to five, and more likely ten years.
What can we do now? There are a bunch of things we might try, but I’m not sure anything will work fast enough to fix the mess. We should move to a monthly payment per person, instead of billing by the visit. We should change EMRs or just use AI to eliminate the need for clinicians to sit at their computers and click boxes. We should reduce demands insurance companies and pharmacy retailers make for preauthorization and for clinicians to deal with their formularies — eliminating all of this garbage, not just reducing it 20 percent. And get rid of all the paperwork that comes from the government itself. Think of how much work we generate for pediatricians and other child health clinicians when schools require notes from doctors for kids to stay out of school. Think of the worker’s comp forms and the forms that need to be filled out for someone who is ill to keep their electricity or water. We should work hard to call back retired clinicians and have them be the teachers of residents and nurse practitioners, so the younger people can spend their time seeing patients. We should encourage and support people who are burning out to set up direct primary care practices, which don’t take any insurance and let clinicians have reasonable lives, rather than quit. Direct Primary Care will reduce the number of patients each clinician sees, which will be hard on the population. But it is better than losing those clinicians from Rhode Island all together.
For now, I think we have to set realistic expectations. People with a primary care doctor, NP, PA and practice should hope and pray that their clinicians can continue to practice and that those practices stay intact. ERs are going to be busy and sometimes overwhelmed. People moving to Rhode Island are going to have a very hard time finding a primary care practice. And the cost of health care is going to keep rising.
Like the Washington Bridge mess, we could have prevented all this. It’s crazy that we didn’t.
