What medicine is for: Staying human in the age of AI

In a previous column on how artificial intelligence is on the verge of dominating large workflows in healthcare without a human being “in the loop,” I warned that the very nature of healthcare is now up for cultural grabs. The bean counters and efficiency mongers are demanding the use of AI in ways that threaten the profession itself.I detailed several recent examples, but here’s another one: the health system giant Kaiser Permanente is using AI to evaluate everything from a nurse’s productivity to her empathy and tone of voice. The result, some nurses said, was a fundamental change in the nature of the care they offered. One nurse nervously watched the clock as she stayed on the phone to care for someone experiencing suicidal ideation. Another cut short a conversation with a newly diagnosed terminal patient.Happily, nurses are pushing back in defense of their vocation to care for a fellow human being. They circulated petitions, went on strike, and picketed using the tagline, “Trust nurses, not AI.” The state of California, too, is resisting. Yesterday, for instance, Gov. Gavin Newsom (D-CA) signed AB 1979 into law. This bill insists that healthcare professionals must maintain independent professional judgment and that autonomous AI may not perform licensed medical work apart from a human being. It also places health chatbots under California’s medical confidentiality law and requires that patient messages written by AI be identified as such.Pushing in quite a different direction, however, is a federal administration easing oversight of AI in healthcare. In January, the Food and Drug Administration made more room for clinical decision-support software, and this past July, the FDA and the Centers for Medicare & Medicaid Services joined the White House Science Office for a closed-door demo day for several AI healthcare companies showcasing what they can do.One might think that time saved by super-efficient AI would be given back to the human relationship between healthcare practitioners and patients in the form of more time for interaction. But that is not what is happening. Most often, the bean counters put physicians at the service of making more money by seeing more patients.Christina Farr recently pointed out that “about 75% of health-system IT and informatics leaders say the revenue cycle is their top area for AI.” The New York Times recently reported that AI is driving healthcare costs up, not down, at least in part because AI helps describe patients with “more complicated conditions and adding a secondary diagnosis.” In turn, hospitals “were paid an average of nearly $12,000 more per case.”As Bishop Conley of Lincoln, Nebraska, mentioned at his homily at the opening Mass of the annual meeting of the Catholic Medical Association a few weeks ago, the use of AI is accelerating the growth of “structures of sin” in our healthcare system.In my previous column on this topic, however, I did promise to follow-up my criticism with a vision of healthcare that incorporates clinical uses of AI. The most powerful case for doing so comes from a focus on justice for the most vulnerable, who have limited access to healthcare. The American Association of Medical Colleges predicts a shortage of 86,000 physicians by 2036. This is on top of an already acute shortage for the underserved, especially in rural areas.If we want Americans to have access to primary care, mental healthcare, and geriatric care, there is a case to be made that — if current trends continue — it will be delivered by AI, or it will not be delivered at all. Thus, the controversial plan that Dr. Ezekiel Emanuel laid out recently in the Journal of the American Medical Association for incorporating autonomous AI into healthcare workflows (again, without a human in the loop) seems like it may be the only thing that makes it possible for our most vulnerable neighbors to get what they need.But is such an outcome worth it if we must fundamentally change the nature of medicine itself by turning it into something that isn’t human?In a powerful talk on AI in medicine given at Benedictine College recently, Dr. Kristin Collier of the University of Michigan School of Medicine offered story after story demonstrating the power of human connection and relationship in the healthcare encounter. In one case, a patient of hers with heart failure gets hospitalized, almost like clockwork, several times a year. Every workup comes back negative, but she, as this man’s primary care physician who got to know him so well over many years, knows why: his wife leaves to visit her sister and, with no one around to cook, he eats processed food and his sodium spikes.Collier worries that clinical workflows run by autonomous AI would erode this essentially human part of the experience. Indeed, it would accelerate the process of dehumanization that has been underway for some time. She notes that an intern comes into the job able to describe her vocation by focusing on a human relationship, saying something like, “I want to take care of people with diabetes.” When she becomes a fellow, however, the language changes: “I want to take care of diabetics.” Finally, as an attending physician, she describes her work by saying, “I manage diabetes.”The AI revolution has provided many “it is a time for choosing” moments about who we want to become as a culture. In healthcare, the following choice lies before us quite directly: Will we push back against a system already tempted to erase human relationships? Collier notes those called to medicine almost always want to care for people: someone’s mother, their sister, their best friend. Those pushing for a shift toward autonomous AI often have a good goal in mind, such as expanding access to medical services for those who do not have them, but we simply must not undermine the very nature of healthcare itself to produce good outcomes.But what do we do with massive questions of lack of access for the vulnerable? The solution must be to build new healthcare institutions, which train more physicians and other healthcare practitioners in an art that focuses on in-person, human encounters.Happily, this is now starting to happen. More medical schools are being created, including many in the osteopathic tradition. Such new DO schools are in vogue now in large part because they are far less expensive and complicated to create, but it is also true that their particular philosophy addresses the current AI challenge in interesting ways. Physicians trained in this tradition receive hundreds of additional hours of training, with physical touch as a central part of the exam. This helps identify somatic dysfunction and stimulate the body’s natural healing capacity, but it also builds — through communication and informed consent — trust, security, and a profound physical presence and connection. It builds a distinctly human relationship.Significantly for those focused on care for the whole person, the osteopathic tradition describes the human being as “a unit of body, mind, and spirit.” The Catholic Church built what became this country’s healthcare infrastructure, but with the current shortage on the horizon, and the very nature of the practice of medicine on the chopping block, the church is getting back into the game.TRUMP TO HAVE DINNER WITH ANTHROPIC CEO DARIO AMODEI AT WHITE HOUSE: REPORTWhen Collier was speaking at Benedictine, the founding dean for their coming school of medicine said, “We are building the school she is calling for.” I’m close to another project to create a new Catholic DO school, this one coming from the Franciscan Health Alliance. The cavalry is coming.Can authentic healthcare use AI as a tool? Absolutely. But the case I’ve made here insists that the burden of proof must fall on those wanting to implement it. Such tools must demonstrably return time and attention to human encounters. They must not erode a clinician’s judgment or skillset. And they must never put at risk the essential experience of a (literal) human touch.