A beginning or the end.

Saturday morning. Beginning of November. A new weekend. Will this in history be seen as the end of our prolonged sequence of largely similar weekends or the end of a settled life? Tuesday is the American presidential election. Public opinion polls are divided and the outcome is difficult to predict. Should the Democrats win (or even remotely look as if they might), the Republicans have indicated that they will contest the results of the election with assorted allegations of fraud interference and so on. Should the Republicans win and Trump becomes the president, from his uterances so far, we can expect that radical change is underway and the existing order of the last decades will be overturned.

Artificial Intelligence in Medicine (and every other traditionally human activity)

AI in Medicine From disdainful condescension to wide eyed breathless adulation of capabilities to doom ladened contemplation of real prospects? Is that a reasonable summary of the evolution of computing held by many(most?) outsiders in many (most?) disciplines? Yes. Certainly in Medicine See what computers can do! See how computers can help in daily practice! See how computers might manage (better?) if left in charge! The New England Journal of Medicine, an august (austere even) channel for publication of medical innovation has now an offspring NEJM AI "Monthly (12 issues/year) with continuous publication" Started January 2024. 21st Century innovation dissected in a 19th Century Medium disseminated by 20th Century Technology. Neat! For this is the issue of our time. How shall we live with our own unique creation, while extracting maximum benefit and, selfishly, leaving something for nimble minds to do?

Reform and Modernisation

Two terms regularly used to justify change and to claim a free pass not requiring evidence or justification of worth. Used by persons of widely differing stances from ultra conservative to extreme radical in their attitude to the status quo. In first encounter from any given source they are consequently all but worthless beyond denoting a desire for change and the suspicion of motives. Steve Pincus in [1688: The First Modern Revolution - Steven C. A. Pincus - Google Books](https://books.google.co.uk/books?id=Oc-uXxPXfmwC&printsec=frontcover&dq=pincus+1688&hl=en&newbks=1&newbks_redir=0&sa=X&redir_esc=y#v=onepage&q=pincus%201688&f=false) makes extensive use of modernisation in describing apparently approvingly, many of the facets for that time. Throughout there is the sense that modernity is good solely on some unstated axiomatic justification, but embedded in the notion that is consists of change which is approved of by contemporary or current elite opinion. Reform seems to have lost much of its suggestion of improvement and seems now no more informative then "change". The notion of betterment in human affairs is thoroughly dependent on a package of perceptions and attitudes each of such a contestable nature that "reform" begins in contention and ends in confusion. This degradation of the word seems well established by the apparent absence from the language of a single word expressing the opposite. Reform in short is change desired by the reformer and modernisation is the same but with heavier emphasis on the inevitable time dimension. "Evidence based reform" has the merit of guiding us to some description of the motivations behind the proposed action. A term bandied about willy nilly. What does it mean? Apart from the purely factual - pertaining to chronologically recent times, events, practices etc. It seem frequently to convey no more than a set of arrangements or changes of which the writer approves. Politicians are forever wanting to modernise by which they seem to mean no more than to make changes they prefer.

Atheism

This would seem to be the default condition of man, An evolving. ever more complex relationship with the environment and increasing powers of speculation as tot he nature of otherwise opaque experiences. Hence God. The prototypical version of a phrase common in my childhood. "A big boy did it and ran away" A force beyond my capabilities and understanding broadly human in basic features. And if one why not many? And if they are aware of each other and disagree? Hence Olympus, Zeus and all that. But there is only one hence western civilisation and its discontents. Perennially neurotically obsessed by the fragility of its own invention. Hence items such as this: ["God in Exile: Modern Atheism](https://www.abebooks.co.uk/servlet/SearchResults?tn=God+Exile:+Modern+Atheism)" Over a thousand pages of anguish seemingly written from a firm believers perspective. Available to read [here](https://archive.org/details/godinexilemodern0000fabr/page/n9/mode/2up)If you have the interest. Or Stamina. And pointless.

Healthcare costs.

It certainly does. We are fortunate in that the capabilities of healthcare have never been greater. With greater capability comes, sadly. greater cost. There is no free lunch. We must make provision for our future needs without prividing an undeserved income for the rich "investors". We need a community wide public healthcare insurance with the premiums determined by capability to pay rather than historic patterns of need. This, by any other name is taxation. Taxation of which we approve since we will alk likely one day require it's products. So. When any politician tells you that he/she will reduce taxation immediately demand to know which aspects of healthcare (or other necessary services) they will abolish. No ifs no buts. Tax cuts harm our wellbeing. Drive home the message. Today and every day.

Post Flexner

Flexner's model persisted in one form or another for about a century. Late in the 20th century however, using rationale to its limits and adding communal experience with the advent of Clinical Epidemiology, from the late 1950s onwards was not enough. In 1985 we saw the birth of EBM, Evidence Based Medicine; the notion that pride of place in a doctor's decision making should come from the products of well designed and constructed clinical trials addressing the situation in hand. Dr Guyatt from Canada has been given credit for leading this move though many others were actively involved. The products of individual trials were however disjointed and cumbersome for daily use. This led to the construction of guidelines addressing a growing range of clinical situations. They themselves, managed manually, had their own problems and, mercifuly, the arrival of the personal computer and all tht followed have resolved any residual issues. Now the physician has a full set of resources to assist individual decision making, succinct, authorative and able to be interpreted not only by doctors but by patients and a wide range of healthcare professionals. The Flexner physician no longer has a monopoly. And next came big Data an AI: which knows all the guidelines and can write new ones. Watch this space.

History of the future?

History might aspire to describe the future. Knowing and understand the past and change through time who better than historians to write histories of the future which are the crucial guides to current action An attempt from 1976! "The Post Physician Era: Medicine in the 21st century." by Jerrold S Maxmen. https://archive.org/details/postphysicianera0000maxm "In fifty years [[Healthcare/Doctors]] will be obsolete, replaced by computers and a new breed of healthcare professional called 'the medic' " Two years to go! Nearly there. 

AI Guidelines for Clinical Care

We consult professional healthcare when we have experiencees we cannot understand, tolerate or resolve. The clinician listens to our account, makes a physical examination and often orders further special clinical investigations. But which ones and in what order? Guidelines exist but are too complex for current clinicians. AI will navigate them with ease. Clinical investigations in future would be most effectively utilised if selected and sequenced by AI . The Electronic Health Record will comprehensively record the patient details, the outcomes of previous similar consultations and initially at least "suggest" useful next steps. 

End of an Era

An era is coming to an end. Bracketed by the Flexner Report of 1910 and the arrival of Artificial Intelligence in Healthcare, medicine depended daily on the doctor being well schooled in bioscience and charged with delivering good decisions based on rationale, existing agreed best practice, personal and communal experience and respecting the patient's preferences and the healthcare system's capabilities and limitations. At the outset this was as good as it might be. But it wasn't that good. Existing best practice was no more than a consensus view with little evidence to support it. Personal experience was seldom recorded and relied on the recall of the practitioner who had few numerical data to help and whose recall of outcomes would be partial and most likely selective. Rationale, rooted in a thorough grasp of best scientific knowledge seemed the key redource yet has subsequently been shown to be an unreliable source of effective guidance. The capabilities of the system to deliver were by modern standards extremely limited. The patient's preferences were of course available and could be respected but limited by the aforementioned fragile contributions. Now we have robust evidence on best actions in an increasing range of situations, with AI to carry and dispense the data and guide non science based practitioners.

Evidence and Psychotherapy

In 1980 Smith Glass and Miller published this book: The Benefits of Psychotherapy https://archive.org/search.php?query=external-identifier%3A%22urn%3Aoclc%3Arecord%3A1244213270%22

They were supportive despite recognising small effect sizes.

In 1983 Prioleau Murdock and Brody published: An analysis of psychotherapy versus placebo studies - a scrutiny of a subset of the former's data. They wrote "It was concluded that for real patients there is no evidence that the benefits of psychotherapy are greater than those of placebo treatment."

We are still engaging in this. More to benefit the therapists than the patients?

After Flexner

We have seen how Abraham Flexner structured his view of medical education's future predicated principally on  the idea that doctors possessed of a fair grounding in assorted scientific disciplines would on clinical occasions be best able to derive and deliver a useful response for the patient. That was an implementation of the principle of rationale, the notion that, having considered what we know, we believe that this is likely to be a useful response.  While it is an integral part of current medical practice it is incomplete.  The second stage that was addressed in the years following the  Flexner report is the quantitative measurement of our past activities. We need to  know or have a record of what clinical decisions were made and recorded and what their outcomes were. Thee task was then to construct the methodologies and implement them to review past performance to discover successes and failures and to use that as an additional dimension of future practice. The idea that we should rely only on the individual experience of the clinician was to be supplemented by the accumulated communal experience of past activity. This activity was known as clinical epidemiology and was growing as we added the third element.

Forthcoming Election in UK

Stirring times. Polls suggest major change in government. Yesterday the Daily Telegraph, a resoundingly Tory newspaper had portentous headlines. In England it proclaimed "Tory Wipeout" and in Scottish editions "SNP Wipeout". It carried two constituency maps of the UK with the constituencies coloured by current or poll projected post election party. The current map is largely blue for the Tories in England and Yellow for the SNP in Scotland. On the map based on poll projections of the outcome of the election on 4th July Both Blue and Yellow are much reduced in a large swathe of Red for Labour. We shall see.

A New Flexner

 In 1910 Abraham Flexner, who was not a doctor, published his massive report on the education of doctors for the Carnegie Foundation in response to a growing concern at poor quality doctors being produced.  This triggered major change and perhaps intuitively recognised the core routes for doctors to produce useful advice for patients. These are three in number and presented in order  of increasing efficacy (and, at the time, decreasing accessibility)

Rationale "What should be worthwhile"

Experience "What has seemed to be worthwhile in previous similar situations"

Evidence "What has on average been shown to be worthwhile in controlled studies of similar situations "

In 1910 a programme of education could only be  securely based on  the first of these.  There was no structure to gather and analyse and disseminate clinical experience and no established methods of clinical science to mount prospective inquiry.  

There was however a burgeoning biody of bioscientific findings such that suitably armed a doctor could construct a logical argument to support specific conclusions in a given clinical situation. Such conclusions had no guarantee of being correct but we're likely better than what had gone before. 

Flexners report was widely adopted and this model of clinical practiced dominated unchallenged until 1985.