By MARILYN M. SINGLETON M.D., J.D
Some pundits blamed algorithmic trading for the stock market’s recent wild ride. “Algo-trading” relies on computers programmed to follow defined instructions for placing trades. For example, the computer buys 50 shares of stock when its 50-day moving average goes above the 200-day moving average. Period. Algo-trading was popularized as a systematic approach that removes human emotion, intuition or instinct from the transaction.
Advanced medical algorithms are becoming the next best thing. Their intended purpose is to improve and standardize decisions made in the delivery of medical care, enabling multiple levels of health care practitioners to use the same “thought” process.
A medical algorithm can be a list of risk factors for various conditions, such as heart disease, or a simple calculation such as BMI (body mass index) utilizing height and weight to determine ideal numbers. Many algorithms are flowcharts with a binary decision tree: if BMI is greater than 25, do this; if not, do that. Newer algorithms based on machine learning, a form of artificial intelligence that simulates how humans learn, can analyze and diagnose radiology images or pathology slides or predict the actual risk of developing certain conditions.
Some of these advances are extraordinary and will likely add to our medical armamentarium. But they do not exist in a vacuum. Concomitant with the flow chart revolution, patients complain that when barely a nanosecond has passed since the physician’s first “hello,” they are handed a DNR form.
Yes, it is a good thing for a physician to know about a patient’s desires at what could be the end of his life. But it is unsettling when the 35 year-old “provider” cheerfully encourages a patient to fill out the form, crowing that she signed her DNR form. The patient is thinking, “you’ll feel a lot different about it at 65 than you do now.” Unfortunately in today’s healthcare delivery factories, when illness strikes “your” doctor may be a previously unknown-to-your hospitalist whose sole knowledge about you, the human being, is lab tests, x-rays, findings on physical exam and a form you signed 10 years ago. Your family relationships, religious views and the like are not his purview. When death is actually walking down your street you want to know and trust those in charge of your life.
In a recent case, a toddler was declared brain dead by one hospital, but apparently showed signs of life. His mother sought but failed to stop the removal of her child from life support. After the plug was pulled, she challenged the constitutionality of California’s Determination of Death Act which effectively takes away life-and-death decisions from parents. The Act provides that a person is dead when, in accordance with accepted medical standards, either the body or the brain has irreversible cessation of all function. A federal court dismissed the case, reasoning that the State cannot be held responsible for its determination-of-death laws, because doctors have “broad and legitimate discretion” to end patients’ life support.
Less obvious but nonetheless devastating, is the power Medicare, Medicaid and insurers exercise over life and death through pre-authorizations and denials of claims. In a lawsuit against Aetna for denial of benefits which the patient alleges “almost killed him,” Aetna’s medical director admitted under oath that he never looked at patients’ medical records when deciding whether to approve or deny care.
If physicians have the power over life and death, “if you like your doctor, you can keep your doctor” takes on added significance as more states adopt physician-assisted suicide laws. Even in Belgium where euthanasia is legal, its proponents are increasingly uncomfortable with the speedy approval of psychiatric patients’ requests to die. Discomfort turned to outrage when a dementia patient was euthanized when there was no evidence that the patient had asked to die.
As independent physicians we want to use the best advances to help our patients but we do not want medicine to devolve into paint-by-the-numbers. We dread the day when “algo-medicine” devoid of human emotion, intuition or instinct will say Sell! (to the mortician) when the patient hits 70? Buy! If the baby has no problems discerned on prenatal ultrasound?
If you want to ensure that your doctor has your back, run – don’t walk to a direct primary care practice (DPC). Tell your congresspersons to add the 1-page Primary Care Enhancement Act (HR 365 / S 1358) to upcoming “must pass” legislation. This will allow patients to use Health Savings Accounts (HSAs) to pay for DPC. Your life could depend on it.
Dr. Singleton graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.