I was asked this morning why I was at work; shouldn’t I be on strike? However, as I work for a University, I am a clinical academic; as a group weren’t balloted and hence we don’t have a legal right to strike. The reasons for NHS consultants striking are very well rehearsed and laid out in this open letter to Steve Barclay, Secretary of State for Health and Social Care, by the consultant body at University Hospitals Dorset. Do you agree with them?
Race to the Bottom
What the medical and healthcare community haven’t factored into their arguments is the current race to the bottom. The democratisation of knowledge, information technology, artificial intelligence (AI) and the commodification of healthcare and wellness means that the medical profession is not the only show in town. Plans are afoot to shorten medical school curricula, create medical apprenticeships, increase the number of physician assistants, increase the number of medical training posts and increase the use of technology to deliver healthcare. This means the era of highly-trained, highly-paid healthcare professionals is ending, and the erosion of pay and working conditions is the consequence of these changes. In short, the UK government is saying consultants will become dispensable. This position is dangerous because there is a time lag before these many changes embed into clinical practice.
Are neurologists dispensable?
The neurological examination and its interpretation will likely be done more efficiently using objective tests and AI algorithms than by a neurologist. Similarly, the ordering and interpreting of neurological investigations will be done better by AI.
AI is starting to help by doing some relatively simple tasks; for example, checking e-prescriptions for errors and drug-drug interactions. This happens in some healthcare systems but is not fully implemented in the NHS. Another is the automatic interpretation of blood results, such as flagging and querying diagnoses based on patterns in the blood results. Our electronic system doesn’t do this.
What about checking the retina? Most Clinicians have difficulty checking the optic disc for swelling or papilloedema swelling due to raised intracranial pressure. This is a critical finding that needs urgent medical attention. Data already demonstrates that AI is better than ophthalmologists in interpreting retinal images and flagging potential pathologies. Why has this not been adopted into routine NHS clinical practice?
Most neurologists will have little problem identifying an unmet need that AI could fill. The bigger issue will be getting the technology into the NHS workflow, which is still largely based on an antiquated Victorian model for delivering healthcare. I am unsure if the BMA (British Medical Association) and my colleagues realise that the Government’s reluctance to engage with us is their understanding of where healthcare is going.
Artificial Intelligence
I recall arguing with a colleague in the late 90s about the inevitable rise of machines and artificial intelligence (AI). He believed AI would never be as good as analogue or human intelligence. He is now a very distinguished Professor of neurology. Has he changed his position? It is virtually impossible not to pick up a newspaper or magazine without somebody opining on the same issue 25 years later.
The English love using the idiom ‘he, she or they can’t see the forest for the trees’. This doesn't seem right. Dare I suggest we flip the idiom to say they ‘can’t see the trees for the forest’ in other words focusing on the big picture means they have missed a fundamental insight from the details.
Here is the rub. To follow my arguments, I will take a reductionist approach and explain things in terms of information technology. You must understand Boolean logic and alternative numbering systems outside the decimal or base ten system, such as the binary and hexadecimal systems used in computer science. Or, for that matter, other numbering systems, e.g. the quinary or base five system, which was used by ancient tribes in South America. Historians tell us that base five and base ten systems dominate human history because of the fact that we have five fingers on each hand and ten fingers when we combine them.
The fundamental question is whether there is any difference between a binary code or base 2 (0,1), a ternary or triplet code (0, 1, 2) base 3, a quaternary code (0, 1, 2, 3) base 4, or our decimal system (0, 1, 2, 3, 4, 5, 6, 7, 8, 9) base 10 in terms of potential data storage?
Here is the maths:
Base 10: 610 + 610 = 1210
Base 2: 1102 + 1102 = 11002
Base 3: 203 + 203 = 1103
Base 4: 124 + 124 = 304
These statements are all equivalent to each other regarding their fundamental meaning (counting or simple addition). Because all these numbering systems capture and store the same information, what are the implications of this insight for how we define intelligent life or sentience (the capacity to solve problems and experience feelings and sensations)?
These debates are about the forest. If you look at the trees, you realise that biological life is based on a quaternary (base 4) DNA code translated into a triplet (base 3) RNA code that defines how proteins and other molecules are formed, processed or metabolised, i.e. biological life. From a reductionist perspective, biological life is a relatively simple code (information) that creates the analogue complexity we see around us.
Why would digital life be any different? Digital life may be based on a binary code (base 2), which will evolve into something as complex as biological life given sufficient time and selection pressure. Digital life or algorithms will eventually develop the necessary complexity to become sentient if it has not done so already and to complete almost all tasks we do at present, including the practice of medicine. However, few people want to accept this. Why? Isn’t it obvious? Many algorithms I interact with daily have the murmurings of early sentience and are clearly superior to humans at doing specific tasks.
You might want to catch up with Blake Lemoine, a Google engineer who claimed that LaMDA, one of Google’s AI engines, was sentient if you missed it. Sadly, Google fired him for seeing the ‘trees for the forest’.
Downstream of the issue of sentience is mortality. Evolution has built into biological life, ageing and death. These features are essential for evolution. Blade Runner, my favourite movie from 1982 about biological clones or replicants, has a lesson embedded in the storyline; as sentient digital beings emerge, we should make sure they age and are mortal. Knowing you can live forever would be too depressing for any sentient to comprehend.
“I’ve seen things you people wouldn’t believe… Attack ships on fire off the shoulder of Orion… I watched C-beams glitter in the dark near the Tannhäuser Gate. All those moments will be lost in time, like tears in rain… Time to die.” Roy Batty; a replicant portrayed by Rutger Hauer in Blade Runner.
Do androids dream of electric sheep? Do AI engines dream? Do they have the capacity to experience feelings and sensations? Can artificial intelligence algorithms fall in love? For me, the answer is obvious. And when it comes to the management of MS, the answer is also obvious. It is only a matter of time before I become obsolete and digital algorithms and robots take over my role as a neurologist to help people with MS to manage their disease. Maybe you disagree? On the flip side is that by the time this dystopian view of neurology and medicine emerges, we may have licensed EBV vaccines that prevent MS. Dare I dream?
Whoever wins this strike or a negotiated compromise is reached, it won’t stop the rise of the robots. We should be asking how soon robots will be competent in helping you manage your MS without input from a trained neurologist. Or maybe I am wrong; you don’t want to help from a robot in managing your MS?
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General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust. The advice is intended as general and should not be interpreted as personal clinical advice. If you have problems, please tell your own healthcare professional, who will be able to help you.
NHS strikes: implications for the future management of MS