WBUR's "Smarter health: How AI is transforming health care"

This a WBUR radio series starting today: In the first episode in our series Smarter health, we explore the potential of AI in health care — from predicting patient risk, to diagnostics, to just helping physicians make better decisions. It happens that I'm working on an essay regarding AI and the art of physical diagnosis by clinicians.

They offered to accept comments via their voicemail. Here's my submission:

Voicemail: 617-353-0683

Hello, My name is Bill Koslosky. I’m a retired physician and now a medical writer living in Omaha, Nebraska.

Once during my residency in general surgery, our team was assembled around a patient’s bed on morning rounds when the attending said, “Don’t just do something, stand there.” An obvious turnaround of a familiar phrase, but he wanted to make the point that as physicians in training we needed to sharpen our powers of observation when visiting with a patient. It wasn’t enough just to look at the notes and lab work in the chart. We needed to increase our abilities at physical diagnosis.

What comes to mind when we think of examples of powerful skills of observation and inference, is  Sherlock Holmes, the fictional Arthur Conan Doyle character. Doyle studied medicine and was awarded a medical degree. Doyle admitted that Holmes was partially modeled on his former teacher Joseph Bell, a Scottish surgeon and lecturer. As an exercise to illustrate this, Bell  would pick a stranger, and by observation, deduce his occupation and recent activities.

So while we anticipate increased powers of diagnosis through the use of AI, we shouldn’t minimize the art of close observation and physical diagnosis in the course of clinical practice.

Arthritis: Essential Terminology

 Being a medical writer, my primary focus is the language of medicine, which is the starting point for understanding the concepts and engaging the health care system, when necessary. I'll define these terms involving arthritis in the larger context of other diseases.

Arthritis - Inflammation of one or more joints. This is experienced by (Latin): pain (dolor), warmth (calor), redness (rubor) and swelling (tumor), the clinical symptoms of inflammation as they were defined in the first century AD by the Roman scholar Celsus. You could also include decreased function, as anyone with a sprained ankle can testify to as they used rest, ice, compression and elevation (RICE) to help with recovery. People with arthritis also report stiffness as a symptom.

Because joint inflammation is such a non-specific term, arthritis encompasses more than 100 conditions that affect the joints.

According to the CDC, the main types of arthritis are:

Osteoarthritis (OA) - This is the "wear and tear" condition involving damaged or worn down cartilage that prevents bone-on-bone abrasion with the normal working of the joint. It typically affects the hands, hips and knees, with age as a predisposing factor.

Rheumatoid Arthritis (RA) - Rheumatism, an ancient Greek word coined before the underlying process was known, relates to auto-immune disease, which means your body's mistakenly senses your normal tissue as foreign and begins an attack. There are various ways this can be started. In rheumatic fever, heart tissue can be damaged, sometimes resulting in deformed valves, when strep throat or scarlet fever is not adequately treated. The cause is infection with the Group A Streptococcus bacterium, which is important to diagnose early.

Gout or Gouty Arthritis is another disease first observed long before the mechanism was known. It was known as the disease of kings because it was believed to be associated with wealth which allowed an excessive diet of meat, seafood and alcohol, to the point where the painful toe wrapped in a bandage was a status symbol.

Gout is caused by the deposition of urate crystals, usually painfully noted in the base of the big toe. It may also cause tophi (chalky nodules), kidney stones, or kidney damage.

Fibromyalgia "is a condition that causes pain all over the body (also referred to as widespread pain), sleep problems, fatigue, and often emotional and mental distress," according to the CDC. It "affects about 4 million US adults, about 2% of the adult population. The cause of fibromyalgia is not known, but it can be effectively treated and managed."

Childhood Arthritis - Also called Juvenile Arthritis, the most common form is Juvenile Idiopathic Arthritis or Juvenile Rheumatoid Arthritis. The term idiopathic is used when the exact cause of the disease is not known, but cases are managed by Pediatric Rheumatologists. There are treatments, but in some cases there will be a long-term remission.

Psoriatic Arthritis - This is associated with Psoriasis, "a skin disease that causes red, itchy scaly patches, most commonly on the knees, elbows, trunk and scalp." It can also cause thick, pitted fingernails. "Psoriatic arthritis is similar to rheumatoid arthritis (RA) in symptoms and joint swelling (inflammation). But it tends to affect fewer joints than RA," reports John Hopkins Medicine.

This post will serve as a primer for the most important terms, but in future posts I'll go more in depth about diagnoses and treatment options.

"The World's Fastest Indian" - Part of Anthony Hopkins' Aging Trilogy

 Now, on Amazon Prime Video you can watch the 2005 film "The World's Fastest Indian." starring Anthony Hopkins. The blurb: "The story of New Zealander Burt Munro, who spent years building a 1920 Indian motorcycle -- a bike which helped him set the land-speed world record at Utah's Bonneville Salt Flats in 1967."

The film is set in 1967, with Burt as 68 years old. The gist of the film is that his quest to set a motorcycle land speed record was viewed as more self-delusional than improbable, but with his charm folks eventually came to his aid, and he succeeded. He was beset with newly-diagnosed angina, and had a chronic case of benign prostatic hyperplasia, which is only worth noting for the remedy given to him by a Native American man.

I consider this the first of what I call Hopkins' aging trilogy of films, continuing with "King Lear," and "The Father," for which he won the Best Actor Academy Award.

Artificial Intelligence & Longevity Report from MIT AgeLab

 This is a report produced by the MIT AgeLab entitled AI and longevity: Consumer and expert attitudes toward the adoption and use of artificial intelligence. 

They describe this report as "research into consumer and expert views about the intersection of AI

and the longevity economy." It follows from the book The Longevity Economy: Unlocking the World's Fastest-Growing, Most Misunderstood Market by Joseph F. Coughlin, the founder and director of the AgeLab.

The John A. Hartford Foundation: "Dedicated to Improving the Care of Older Adults"

 The John A. Hartford Foundation Web site has a number of excellent resources.

Their Dissemination Center has links to relevant publications such as: May 26 "GIA Webinar: Conveying Empathy from a Distance - Using E-empathy in Goals of Care Conversations," "National Collaboratory to Address Elder Mistreatment Mentorship Program," and "Generations Journal Article: The Positive Impact of Public Health Engagement in Healthy Aging During the COVID-19 Pandemic."

With this last link I discovered The American Society on Aging's (ASA) Generations Journal, and the ASA's Conference On Aging 2022 April 11–14, 2022 | New Orleans, LA. The theme is Advancing Economic Security. 

"Antidotes to Ageism" Video, and the Need for Better Patient Agency

The organization Changing the Narrative in Colorado in partnership with the Boulder County Area Agency on Aging, created a 16-minute video: "Antidotes for Ageism: A brief guide to creating inclusive care in an ageist society."

"Ageism is a real problem everywhere, including in healthcare. It isn’t just wrong; it has impacts on our health, lifespan and economy."

You can download their "Guidelines for Age-Inclusive Communication," as a .pdf file. This document includes a reference:  "Research by FrameWorks Institute shows that certain terms are often associated with – and reinforce – negative stereotypes about older people that result in stereotyping and discrimination."

UPDATE, Thursday, May 12, 2022: I'm watching the video now, which begins with a definition of "ageism," as "Stereotypes (how we think), prejudice (how we feel), and discrimination (how we act) towards others, or oneself, based on age."

Maybe policing thoughts and feelings is attempted by raising awareness, but this is not always the case. Minds and hearts are reluctant to change, especially when ageism has been pervasive implicit bias in Western culture for at least 200 years(?) Better to approach the problem with enhancing the agency of those affected.

One interviewee states, "My goal is to change the way we think about growing older." Another promotes volunteerism, which seems to be a step down from more ambitious and personal pursuit such as starting a company.

The best comment was by someone who said "each year brings more confidence, having more experience in life, ability to take more risks, and to venture into areas I probably wouldn't have done at a younger age. The fact is fighting ageism is about changing your own mind first, and the most compelling agent for change is serving as an example.

Interestingly enough, with advancing research into artificial intelligence and the race to mimicking human thought and decision making, the problem of bias must be approached. Bias is a given when you use a computational approach for decision making. Human decision making is even more complicated and harder to analyze and correct. Daniel Kahneman's "Thinking, Fast and Slow," and his work in the psychological study of human decision making was recognized with a Nobel Prize.

With healthcare, there isn't the same urgency in treating older adults or using more involved therapies, perhaps underestimating the possibility of a good result. It's the "I don't want to push things you don't want to do" attitude. Too often, when clinicians are approached with this problem, it comes down to using the excuse that "it's the system." This makes it easy to absolve responsibility.

The video suggests that older adults are subjected to more unnecessary clinical tests. But this can be debated that some developing chronic conditions are associated with age such as metabolic syndrome. Older adults have been excluded from clinical trials, again with the belief that this will lead to more robust results. And, for this reason, the data don't exist for treatments such as vaccines.

Then we have elderspeak. It's entirely appropriate to speak out when you're subjected to this.

Wrong assumptions: depression is not a normal part of aging. Sexuality is not to be discussed. Other factors such as ethnicity, gender identity, socio-economic status, lifestyle choices etc., are similarly ignored.

The worst realization is that poor delivery of health care is not causally limited to ageism or any other type of social prejudice. Doctors and nursing are forced to sit in front of a computer to capture codes and not observe the patient as a unique individual--they have be reduced to a series of check boxes for more efficient billing. Clinicians are increasingly experiencing burnout, and the patients become more burdensome as the monolithic healthcare system is untouchable. Predictions are being made that costs healthcare in the US will rise significantly due to the burden of the evolving Covid-19 pandemic.

My antidote for ageism, and all the other various implicit biases, as well as the many systemic failings of the US healthcare is agency. The much-discussed patient-centered model is elusive. It's up to each individual person who interacts with the healthcare system had better be prepared to do his or her homework. You can keep a daily journal of medications taken, blood pressure readings, moods, etc., to make it easier to get proper recognition of your particular health needs by presenting these in your clinic visit.

Ageism is not going away anytime soon. Work to improve your agency first.

May Events for Older Adults

The Health Insurance Counseling and Protection (HICAP) is presenting "Medicare Fraud: Detection and Prevention." This Zoom event is happening tomorrow, May 11. You can register here.

There's another virtual event occurring on May 16, 2022: National Council on Aging, NCOA Connect, 5th Annual Older Adult Mental Health Awareness Day Symposium, May 16, 2022.  The OAMHAD Symposium will take place from 10:00 am until 5:00 pm EST. OAMHAD Symposium Agenda.

 The Administration for Community Living (ACL), HHS, is designating May 2022 as #OlderAmericansMonth.

"Every May, the Administration for Community Living (ACL) leads the nation’s observance of Older Americans Month (OAM). In 2022, ACL will be focusing on aging in place – how older adults can plan to stay in their homes and live independently in their communities for as long as possible. The 2022 theme is Age My Way, an opportunity for all of us to explore the many ways older adults can remain in and be involved with their communities." You can tag your Tweets to @ACL.gov with #AgeMyWay, along with submitting your ideas for participating.

As I mentioned in a previous post, May is also Arthritis Awareness Month. The CDC has a Web page entitled "Arthritis Awareness Month: Expanding Interventions for Arthritis."

UPDATE: I found another Zoom Webinar, this one produced by Janine Vanderburg, featuring the 16-minute film "Antidotes for Ageism: A brief guide to creating inclusive care in an ageist society," followed by a discussion. Sign up here for the May 12, 1 p.m. CDT event.