MEDICINE’S SHAMEFUL SECRET: AI HAS NO ALGORITHM FOR FEELING EMPATHY

By Douglas Ratner, MD

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After forty years in clinical medicine, I have retired (still writing medical thrillers) but eager to share some brutally honest evaluations about a field that I love, Medicine. A profession that allowed me every day to make a difference in people’s lives but whose disturbing fault lines today present themselves all too often for me to remain quiet. My observations hopefully will generate honest discussions about its merits and just as important, potential solutions.

? My roles over the years have varied from teaching, practicing medicine, chairing a department of medicine, promoting one of the first population health efforts, training over 500 residents in Internal Medicine, and chairing a commission on disease management, all forging my perspective on our present day healthcare problems.

Today I speak of matters of the heart! We are at a crossroads in medicine when it comes to public trust worsened by a pandemic where science was twisted in many cases for political gain. Therefore, it is not surprising that confidence in medicine is eroding though this process was set in motion years before by the ‘corporatization’ of medicine. The result: more people are seeking out less conventional voices of “authority” that align closer to their beliefs.1

Distrust, however, leads to lives lost. (unvaccinated complications, decreased cancer screenings and adoption of preventive measures.)2 But just as noteworthy, where has the warmth, the caring gone, which many of us older physicians have concluded is the source of true joy in Medicine? “The humanity,” as Dr. Eric Topol often laments. Yes, though it can be an exciting time with the advent of Artificial intelligence, what is next? “Artificial Warmth?”

Undoubtedly, AI will continue to be part of an emerging paradigm but it cannot replace a hand at the bedside, the eye contact, the understanding between clinician and patient. Recently I sought to clarify a personal medical issue by seeking out a fresh perspective from a highly thought of subspecialist and found myself struck by the lack of warmth, the hurried few minutes to talk which further exacerbated a sense of isolation.

“The world is becoming lonelier and there’s some very, very worrisome consequences,” spoke Dr. Jeremy Nobel, the architect for an initiative called “Project Unlonely.” A Harvard study found that 43% of young adults reported that no one in the past few weeks had “taken more than just a few minutes” to ask how they were doing in a way that made them feel like the person “genuinely cared.” 3

Furthermore, it is estimated that over half of the elderly population feel this way according to many experts. In the UK, physicians screen for loneliness, a positive but do they inadvertently contribute to same by an almost mechanical approach to this problem?4 ?I recall vividly an elderly patient of mine who insisted on seeing me every month like clockwork. When I informed her that we could space out the visits, she broke down sobbing. Why? Because our monthly appointments offered far more than medical advice. They provided a sense of caring and a hedge against isolation and true loneliness. “Someone of substance who makes me feel less alone, a friend,” she added embarrassingly. As far as the clinical manifestations of loneliness, one simply needs to point out the malady called, ‘Takotsubo Cardiomyopathy,’ an oftentimes lethal consequence seen in these scenarios.

This overall lack of true empathy amidst a world seemingly filled with hatefulness and cruelty has led to another area of deep concern centering around our two-tiered system of care, one for the haves and one for the have-nots. Poverty (the family’s 2022 poverty threshold is $35,801 or below) afflicts all races and sadly, these human beings, the ‘have nots’ have become devalued by so many in our society and yes, many providers, if they are being honest with themselves. In my experience, most will object strenuously and attack this message as untrue. However, the proxy marker for respect has become tied to one’s type of insurance as there remains a stark difference in behavior from providers shown those suffering from the malady, “hypoinsurancemia” (Medicaid or no insurance at all). Disrespect of a human being is heart breaking on its own but when it leads to catastrophic results that simply does not occur at such an alarming rate with wealthier patients, it is obscene! Some examples I have witnessed which I warn you, are disturbingly true:

An African American woman with a raging overactive thyroid where medicines failed to suppress who desperately needed to be treated with radioactive isotope was given an appointment at the University Hospital (our distressed hospital had run out of the expensive isotope). The University Hospital would not accept her for four months despite arduous protestations from myself. She died a week later of a malignant arrythmia after I attempted to reassure her when she inquired meekly, “Is this problem going to kill me?” She knew the score.

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Another low income patient after sustaining a fall required neurosurgery. The patient later recalled smelling alcohol on the surgeon’s breath but dared not say anything for fear of being rejected as a patient. He is now a quadriplegic.

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Two African American teenagers tragically died soon after delivering their babies. Why? After delivering their healthy babies, they both complained of persistent headaches but were given short shrift. Their headaches were due to persistent cerebrospinal leaks from their epidurals that required a simple ‘blood patch’, a straightforward bedside procedure. Both women did not receive this beneficial step. They subsequently died from brain herniations as a result of their ER physicians either believing they were ‘drug-seeking’ or simply unaware of this potential complication. Placing doubt upon this latter explanation is the fact that the second woman succumbed only a month after the first one.

The common misguided belief is that clinicians are ‘colorblind’ and that race or other characteristics don’t effect care.? Really? Additionally, we have deluded ourselves into thinking that our safety net facilities (ie. FQHC’s, etc) suffice. They do tremendous work but are limited in their offerings due to financial shortcomings. Most subspecialists refuse to make themselves available because of poor reimbursement. Tragic.

Providers, please don’t dismiss this reality! Personally, I have always been acutely aware that minority patients demonstrate an unusual level of “thankfulness” for my care delivered. Eventually I realized that they were simply unaccustomed to being treated with the dignity such fellow human beings so richly deserve.

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What about the professional pride in collaborating with other professionals on the phone or in person regarding a patient’s care? A routine occurrence in years past but difficult to maintain when only seven minutes allowed per office visit. A cog in the Relative Value Unit (RVU) payment system. Personally, I have had to intercede repeatedly with serious medical issues involving family and friends due to poor history taking, sketchy documentation, and poor clinical acumen on the part of their physicians. This is nothing short of appalling (ie costochondritis diagnosed as gallstones, sciatica rather than kidney stones, viral gastroenteritis instead of renal failure, etc.) Based on the CDC.gov website, medical error is the third most common cause of death in United States after heart disease and cancer. Or to put it another way, there are 18 million diagnostic errors each year in United States, and “nearly every person will experience a diagnostic error in their lifetime.”5

Early in my career when I began devising disease management programs that were especially geared towards the underserved and more to the point, the poorest in our society, I received a rude awakening. I approached the school district where the hospital I worked at was situated. An urban area that was riddled with the ravages of hypertension, diabetes, and morbid obesity. Appearing before the school board, after being welcomed warily, I proceeded to describe a school project where we would raise money to build a six foot character similar to “Big Bird’ that had two heads, one with good health habits and one with unhealthy ones. I had already met with a former employee of Jim Henson who was building his own company of characters similar to the muppets. I then mentioned that since the African-American population (the school district was overwhelmingly populated by minority students) disproportionately suffered from hypertension, diabetes, and kidney disease, it was imperative to try to make a significant difference there. What ensued initially flabbergasted me but in retrospect educated me as well. The school board chairwoman upbraided me for singling out the black population to which I replied, “We Jews have our Tay-Sachs and so forth…” Though my statements were entirely factual, the perceived intent was erroneously labeled ‘racist’ in nature when indeed, I was only trying to help, my clumsiness in expressing myself notwithstanding.

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That we are a nation with large, disquieting problems is clear.

One of the benefits of being responsible for delivering healthcare to people of every ethnic group and educational level is realizing that there is far more in the human condition that we share with each other than issues or qualities that divide us. Believe me, I have seen this first hand.

?Furthermore, we have been so consumed, even overwhelmed, by platitudes or gaslight solutions that appear to demonstrate progress but in actuality, achieve little or none. Being one of the first to identify the “health-related social needs” (HRSN)? such as housing and food insecurity while structuring a ‘Community Health Trust, ‘ ?where community services were made available to the poor, has overshadowed these other issues. Unfortunately, such a focus appears today to “limit progress,…a state in which every person has a fair and just opportunity to be as healthy as possible,”8 ?by ignoring the issues cited here.

Many physicians in fact confide that they are struggling and “had their entire persona change.” ?Caught between the Hippocratic Oath and the “realities of making a profit from people at their sickest and most vulnerable,” a new term has been coined, aptly termed ‘moral injury’ by some.6

Others adamantly describe that they have become “instruments of betrayal.”7 Strong words.

Unfortunately, idealism has given way to disillusionment. One way to reverse this dangerous trend is to start “caring’’ in the truest sense of the word. Tolstoy wrote, ”If you feel pain you are alive, if you feel other people’s pain, you’re a human being.” “Despite groundbreaking advancements in science, technology, and disease treatments, this is not the golden era of fulfillment.”9? AI will never out-care human doctors, “the secret sauce. The gift of time.”10? We shouldn’t continue to delude ourselves for our patients deserve better.

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*The author’s newest medical thriller, The Caducean Choice, will be available soon on Amazon, his sixth book.

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1&2. Daniela J. Lamas, Patients Are Losing Trust in Doctors. Medicine Suffers, NYT, April 24, 2024.

3 &4,Adriana Rodriguez, Americans are lonely and its killing them. How the US can combat this new epidemic., USA Today, December 24, 2023.

5. Natalie McGill, Americans will experience at least one medical diagnostic error in their lifetime, report says, The Nation’s Health 45(9) E50, November/December 2015.

6&7.Eyal Press, The Moral Crisis of America’s Doctors, NYT Magazine, June 15, 2023.

8. Alicia Fernandez, M.D., etal. Keep Your Eyes on the Prize-Focusing on Health Care Equity, NEJM, May 16/23, 2024.

9.Robert Pearl, M.D., Clinical burnout in the U.S.: New data, surprising insights. Breaking the Healthcare Rules Newsletter, Nov.27, 2023.

10. Eric Topol, M.D., Topol Charts AI Path to More Accuracy in Medicine, Sept. 3, 2021, Vol. LXX!!!, No. 18, NIH Record.