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.