Watson Computer, M.D.

It was announced this week that Watson, the IBM AI computer system that defeated human counterparts Ken Jennings and Brad Rutter on Jeopardy a few months ago, was "hired" by Columbia University Medical Center for a new challenge - diagnosing complex medical conditions.

It really isn't that surprising.  Physicians go through complex algorithms to diagnose patients, just like computers running code.  "Tell me what brings you in today", or "How long has this been going on?".  "Can you describe the pain?".  "Where is the pain located?".  "Does the pain radiate or travel?".   Those of you who are my patients are used to me going through these "checkdowns", to use a sports analogy.  We decide which pieces of data are important, and which can be discarded.  After a few minutes of asking questions and getting quality answers, we have formulated a short list of possibilities, called a differential diagnosis.  A physical exam adds in more data, pinpointing the diagnosis or eliminating certain diagnoses from the list. Finally, if we are unable to make a diagnosis, we may order some tests, like blood work or an xray.  Then, 95+% of the time, voila.  The patient is diagnosed, treated, and improves (hopefully).

A computer can be trained to go through the same algorithms, go through the same checkdowns, per se, and order the same tests. And I am sure they can make the same diagnoses as well, maybe even pushing our 95% success rate.  Despite this, Watson and his computer brethren aren't going to take over medicine any time soon.

A computer cannot do a physical exam.  A computer can't (yet) tell inflection of voice, get a sense that the patient is in obvious discomfort, or understand certain human behaviors.  A good example is a 20 year old male coming in to see me with his parents.  20 year old males normally don't come to the doctor, much less with their parents.  This is a subtle yet important piece of information, one I obtain the moment I walk in the exam room.  It changes the way I approach the visit.

I am sure that Watson will be fantastic at helping diagnose really complex patients.  But for every day medicine?  Not yet.  The art of medicine, to efficiently, compassionately and correctly diagnose and treat a patient is something which requires a human to human interaction, between the doctor and the patient.  Nowadays, patients can research symptoms on the Internet to "diagnose" themselves.  The problem is that they can't do it correctly.  Patients call our office, wanting treatment for pink eye, but when we see them, they really have allergic conjunctivitis.  Or, a patient thinks they have heartburn, but after we evaluate them, we diagnose them with angina, a telltale sign of heart disease.

One of my famous teaching points is that common things are common, uncommon things are uncommon, and rare things are rare.  The vast majority of what we see is common.  Doctors don't need to memorize all the esoteric data that Watson has in its neural net to practice medicine, we just need access to it. This is why physicians shouldn't feel threatened by Watson getting his medical degree.  We should embrace these technologies because the practice of medicine is a gray science, with endless variables.  It's never black and white, and it constantly changes.  6.4 billion human machines, all similar, but none the same.  Systems like Watson can help us find patterns in disease presentation across different populations, allowing us to better diagnose patients.

My practice has used computers since 1997, when we transitioned from a paper to an electronic medical record (EMR) system.  Our information systems keep our patient data organized, remind us when patients are due for screening tests, tell us if we accidentally prescribe a medicine to someone who is allergic, and, most importantly, makes sure our notes are legible.  I can't imagine practicing medicine without these tools.  They are unbelievably useful.  I think every medical practice should adopt these technologies to improve patient care, despite the fact that implementation can be cost-prohibitive.

I am looking forward to seeing what Watson can do.  But, at the end of the day, Watson can have his massive trove of medical knowledge.  I'll take my smaller, more useful noggin, my Dell server with our patient database, and Mr. Grzyb's amazing mini-kolackys at Christmas time.  Watson doesn't know what he's missing.

Lowdown on our slowdown

2011 has been disturbingly slow.  Through April, the number of patients I saw in the office was 140 less than in 2010.  That may not sound like a lot, but it's about 2 patients a day.  Add that up over the entire year, and it's real revenue we have to do without.

For those who aren't aware, here is an overview of my medical practice.  It is located in Naperville, IL, an upper middle class suburb southwest of Chicago, with a population of 160,000.  We have in excess of 6000 active charts (patients seen in the last 36 months), with a demographic breakdown of 20% pediatrics, 60% adults, and 20% Medicare (or patients aged 65+).  It is, in my opinion, what the prototypical family practice should look like.

Our office hours haven't changed at all. We are open Monday, Tuesday, Wednesday, and Friday 8 to 5, Thursday 11 to 8 pm, and Saturdays 8 am to 12 pm 2 out of 3 Saturdays.  We haven't decreased our support staff, so wait times on the phones are < 5 minutes, and typically < 2 minutes if you don't call between 8 and 9 am.

So the question is, why are our numbers down?  I have a number of theories.

First, pharmacy run clinics.  There is one located in the Walgreens up the street from our office.  These clinics are staffed by nurse practitioners, with evening and weekend hours.  Patients are choosing these clinics, paying a premium (usually around $75) for the "convenience" of walking in without an appointment, even if there is an hour or two wait.

Second, time off of work.  We have seen a significant increase in requests for appointments after 5 pm.  Patients simply won't take off work to come in when we have appointments.  What is amazing is that my Thursday evenings, when I work until 8 pm, are rarely booked out.  Same thing for our Saturdays.  People want to be seen on their way home from work (between 5 and 6 pm), or not at all.  My staff offers multiple appointments to these types of patients, with no luck.  They want to come in when they want to come in.

Third, out-of-pocket expenses.  Deductibles have risen to the point where people are choosing to "wait and see" when they get sick.  These acute care visits are the ones we've seen decrease - colds, coughs, headaches, etc.  These are the bread and butter visits of most primary care offices.  Higher deductibles, high unemployment, high fuel prices,  higher food prices; all of these have made patients think twice about what and how much they can/want to spend on healthcare.

Lastly, mediocre flu seasons.  We used to be able to bank on the January to March window to give us a healthy bump in visits because of influenza.  Not any more.  The H1N1 outbreak of 2009 changed everything (for reasons unknown).  Since that outbreak, we've had 2 straight uncharacteristically slow flu seasons, and thus, less sick visits.

We are coming into the busy, school physical time of our work year.  I am beginning to worry that the nurse-run, deep discount school physical clinics put on by companies like the Visiting Nurses Association are going to further dent our appointment base.  I'm going to post a blog at a later time about the real risk of these bogus school "physicals", which are really just appointments to complete forms for school.

It may seem counterintuitive, but these are the times when I am happy I own my practice.  I can't imagine what it's like for physicians who are "owned" or are part of large mega-groups when their numbers go south. The factors that have caused this decrease in patient visits aren't going to improve any time soon, and if we continue to see a deterioration in our visits, I have the ability to make adjustments in my overhead, unlike employed physicians.

Here is hoping (tongue-in-cheek) for a nice outbreak of influenza sometime soon.

Welcome!

I set up this blog in late 2009 with the idea that I wanted to start to write about healthcare. Well, I guess I wasn't ready at the time. In the 18+ months since I set up this account, there has been an avalanche of healthcare issues that have dominated the headlines, from the sweeping healthcare bill passed by Congress to rising insurance premiums. It's been a slow few weeks at the office, so I figured, heck, stop procrastinating and start writing.

I would like this blog to both educate and entertain. Healthcare is a massive, intimidating beast. I am going to try and pull back the Curtain of Oz for you, telling stories about the challenges, frustrations and joys of what it's like to practice medicine in today's world. Delivering high quality care to the masses is not easy, I can tell you that, but it's something I think is going to make for some good reading.

I am looking forward to your comments and replies. I will be enlisting the guidance of my fellow bloggers, so be patient with me if I make a mistake or two with blogging protocol. Don't be shy to share your opinions. That is how we, together, will make this work.

Thanks for taking a few minutes out of your week to follow along. Here we go...