BOOK

Deep Medicine
How Artificial Intelligence Can Make
Healthcare Human Again
Eric Topol
Basic Books, 2019

Recommendation
In lay terms, cardiologist Eric Topol describes advanced technologies and offers a
balanced view of artificial intelligence (AI) in medicine. Each chapter begins with
various miracles attributable to AI – for instance, rare disease identification and
the formulation of new drugs – and then describes AI’s shortcomings and likely
futures with respect to health care. Topol argues that the best outcomes stem from
collaboration between doctors and AI. He implores decision makers to leverage AI
immediately for routine health care tasks – chores that consume doctors’ time and
hamper their efforts to build trusting, caring relationships with patients.

Take-Aways
• To fix health care, Americans need big data, deep machine learning and,
most critically, human empathy.
• The United States today practices “unintelligent medicine.” It ranks a
distant last among OECD nations in terms of quality.
• The US health care system lags most other sectors in technology adoption.
• Though imperfect, AI that pulls from millions of cases and research
articles has already begun to aid doctors.
• AI and machine learning face formidable obstacles: opacity, bias,
hacking and the fear of job loss.
• AI could transform nutrition science to allow personalized, optimal diets for
everyone.
• AI will transform the mental health care field.
• For most people, remote care and virtual medical coaches could constitute
the bulk of health care.
• Soon, AI may do most health care work at least as well as humans at a small
fraction of the cost.

Summary
To fix health care, Americans need big data, deep machine
learning and, most critically, human empathy.
Over the past several decades, the US health system has grown more expensive
and less effective. In 2017, health care surpassed retail as the biggest business in
the United States and is its largest employer. Most patient complaints center on the
lack of personalized care. Doctors and nurses no longer have the time, interest or
empathy needed to build patient relationships.

The United States today practices “unintelligent medicine.” It ranks a

distant last among OECD nations in terms of quality.

The United States spends more money overall and more per capita than any OECD
nation. Unintelligent, or “shallow medicine” costs more and delivers less because it
replaces understanding the whole person with diagnosing via the latest widget.
The status quo leads to massive overprescribing of procedures and drugs.
Astonishingly, up to 33% percent of all medical procedures in the United States
turn out to be unnecessary. Prescribed drugs help only about 25% of the patients
who take them. Patients suffer stress and danger from false positives on tests,
unnecessary surgeries and wrongly-prescribed drugs.

Physicians learn early that speed equals more accurate diagnoses. They are told
that with experience, they will develop increasingly better pattern recognition,
allowing them to make the right diagnosis within minutes of seeing a patient. Yet
more than 12 million serious mistakes occur each year in diagnosing patients in
the United States. Second opinions randomly performed on 300 patients confirmed
only 12% of prior physician diagnoses. Doctors who claim 100% certainty in their
diagnoses are right only 60% of the time.

The US health care system lags most other sectors in technology

adoption.

AI experiments began in the mid-1930s, but true big data has been around only
since about 2010. Enormous quantities of data, places to store it and computers
capable of processing it have brought stunning advancements in AI. In 2017, for
example, AI surpassed human abilities in the most complex games and in image
and voice recognition. Using deep neural networks and reinforcement learning,
algorithms now teach themselves new things. AI in medicine lags significantly, yet
when doctors extract big data about an individual and run it through deep-learning
algorithms, practitioners can achieve miraculous insights.

“It’s no wonder we have an opioid epidemic when it’s a lot quicker and easier for
doctors to prescribe narcotics than to listen to and understand patients.”
When a seizure-stricken newborn entered the Rady Children’s Hospital emergency
room in 2018, doctors followed normal procedures, prescribed drugs and placed
the baby under observation. But he got sicker, risking imminent brain damage or
death. Fortunately, Rady is one of the world’s only facilities with rapid gene-
sequencing capabilities. Using a blood sample, its labs amassed 125 gigabytes of
genetic data, which they fed into a natural language processing (NLP) system.
In 20 seconds, the NLP identified 88 unique genetic patterns within the child to
produce a phenotype. A machine-learning algorithm sorted through millions of
known genetic types to find several hundred that can cause the seizures the boy
was suffering. The data, paired with the baby’s unique phenotype, immediately
found the culprit: a harmful but easily-managed gene, ALDH7A1, that occurs in
fewer than one in 10,000 people. All this took only a day and a half from the baby’s
arrival in the emergency room.

“As machines get smarter and take on suitable tasks, humans might actually find it
easier to be more humane.”
AI is a powerful assistant to any open-minded, skillful physician. A data-driven
health system needs information about everyone at the aggregate and individual
level. It needs powerful AI algorithms to explore the data. It needs these tools for
their diagnostic capabilities and because they can relieve overburdened doctors
and nurses. This would free medical professionals to focus on the hardest
cases and spend more time with all patients.

Though imperfect, AI that pulls from millions of cases and research

articles has already begun to aid doctors.

Algorithms that provide whole-person diagnostics are accurate only 51% of the
time compared with 84% for physicians, but the gap will narrow quickly. Machines
excel at specific diagnoses. AI outperforms physicians in detecting skin cancer
and early Alzheimer’s. Facial recognition software can detect rare conditions in
children by comparing a child’s face with a database of faces of people suffering a
small range of diseases.

Algorithms help physicians estimate how much longer terminal patients might live.
The insights lead to a better quality of life for patients who can potentially spend
their remaining days at home, which cuts health care costs. Keeping people out of
hospitals reduces the rampant incidence of hospital-borne infections such as
sepsis, which kills about a quarter of all patients who die each year in US hospitals.
A large part of the problem comes down to overworked physicians and nurses who
make mistakes, a crisis that AI can ameliorate.

AI and machine learning face formidable obstacles: opacity, bias,

hacking and the fear of job loss.

Deep neural networks (DNNs) represent the vanguard of AI today. DNNs mimic the
human brain. Each of the multiple hidden layers processes a small part of an
overall problem, passing it up the layers until an answer emerges from the top
layer. How the machine arrives at the answer or recommendation remains a
mystery.

Doctors and hospitals face direct liability for outcomes. Machines used in
medicine must explain how they arrive at diagnoses and recommendations, a
hurdle that researchers haven’t yet cleared.
AI faces the problem of bias based on the data sets from which it learns and based
on the coders who develop them. AI is vulnerable to hacks, including the
unintended but well-publicized releases of millions of personal data records from
various private and government sources.

“The greatest opportunity offered by AI is not reducing errors or workloads or even

curing cancer. It is the opportunity to restore the precious and time-honored
connection and trust…between patients and doctors.”
In terms of many people losing jobs to AI, reliable opinion suggests that while
millions of jobs may disappear, even more will emerge.

For doctors whose work involves imaging and pattern recognition – for example,
radiologists, pathologists, ophthalmologists and dermatologists – some AI experts
have issued predictions of job loss. Algorithms regularly outperform physicians in
these fields – but only against narrow parameters, such as the ability to spot
pneumonia in X-rays or to see diabetic retinopathy in eye scans. Even here, AI is
performed mostly in laboratory settings, not in the real world. An AI typically does
one thing well, for instance, finding evidence of a specific condition; trained
physicians often consider dozens or more possibly related aspects when they
review scans.

Machines can assist rather than replace physicians. AI can spot anomalies,
relieve doctors of routine cases and double-check their work. NLP can transcribe
and tag patient conversations. Algorithms can aid oncologists in diagnosing cancer
and can help cardiologists in detecting heart conditions – including atrial
fibrillation, which affects almost one-third of Americans.

“Shockingly, up to one-third of medical operations performed are unnecessary.”

All this could reduce costs enormously. The average American radiologist, for
example, earns $400,000 annually and interprets between 50 and 100 scans daily.
Machines can interpret 260 million scans in 24 hours for about $1,000. As of 2019,
nearly 19% of US GDP (more than $3.5 billion, or $11,000 per person) goes to
health care each year, up from $800 per person – just 8% of GDP in 1975.

AI could transform nutrition science to allow personalized, optimal

diets for everyone.

The science of diet and nutrition has become wholly inconsistent over the decades.
Unfortunately, randomized controlled tests (RCTs) – the gold standard in research
– rarely occur in nutrition studies. Getting a random sample of people together,
policing their diets and measuring the results for years at a time isn’t practical. The
result is one-size-fits-all dietary advice, which might work only for the nonexistent
average person.

AI has made inroads. Nutrigenomics, for example, connects diet with an

individual’s genome. Data from sensors and stool-sample analysis help identify a
person’s gut microbiome and have yielded valuable insights about which foods
might work best for specific individuals. These techniques remain unproven but
auger well for the future of AI in enabling individualized diets.

AI will transform the mental health care field.

Mental health issues plague almost one-third of Americans, and most never receive
treatment. Worldwide, depression as a work disability causes the most lost
employee time. At 120 suicides daily, suicide accounted for more deaths in 2017 in
the United States than car accidents, AIDS, war and homicides.

“It is essential that we upgrade diagnosis from an art to a digital data-driven

science.”
Many randomly-controlled experiments show that people disclose more
information to chatbots designed for mental health therapy and that these tools
draw people who claim the technology helps them. Algorithms based on a host of
markers, including voice patterns, keyboard entry, facial patterns, and other
biometrics have diagnosed depression and other mental health issues at accuracy
rates equaling or surpassing those of physicians and, in some cases, psychiatrists.
Human professionals who use algorithms and machines make the best providers.
In the case of psychiatry, recent advances suggest a mental health care revolution
would take place soon if professionals and decision makers embraced these fast-
improving tools.

For most people, remote care and virtual medical coaches

could constitute the bulk of health care.

In St. Louis, Missouri, the new $300 million Mercy Hospital Virtual Care Center
might be a harbinger of the future; it’s a medical facility without beds. Whether
they are at home or in an intensive-care unit elsewhere, patients receive the close,
unhurried attention they crave from caregivers. Mercy Hospital provides live,
distanced interaction between patients and caregivers as well as
automated remote monitoring, the intensity of which differs depending on the
patient’s condition.

Voice-recognition and NLP technologies, including home tools like Alexa and
Cortana, portend a future in which everyone will have a virtual medical coach.
Your coach will know everything ever published about medicine. It will have
access to all your data, will understand you holistically and will monitor your
health continually. It will perform diagnoses based on your voice, sleep patterns,
retina scanning, your answers to questions, and more, and it will order kits for
advanced testing. It will connect and interact with the broader medical
community to confer and to book appointments.

Soon, AI may do most health care work at least as well as humans at

a small fraction of the cost.

With demand for health care services increasing and costs spiraling, an
international race to lead the world in AI medicine is underway. The United
States, Canada, France and the United Kingdom have contributed the most so far,
but India and China have accelerated their pace. China, which has no data privacy
protections for citizens and massive shortages of health care professionals, will
spend what it takes to dominate the field and may soon take the lead.

“It will soon be obvious that half our tasks can be done better at almost no cost by AI.
This will be the fastest transition humankind has experienced, and we’re not ready
for it.” (AI expert Kai-Fu Lee)”
For medical and other advanced research, AI’s ability to process staggering
amounts of data almost instantly makes it increasingly indispensible. Much health
care work involves data entry, crunching and analysis. AI may soon do most of the
work. By around 2030 or so, it may evolve into a true partner. In a century, it may
do almost everything.

The best part of the future depends on access to a vast range of personal data –
including accurate electronic health records (EHRs) dating back to birth or earlier
for every person as well as entire genome information, regular gut microbe data,
urinalysis, blood pressure, accurate smartphone EKGs, and so on. The closest data
sets currently available – that is, EHRs – contain incomplete and often erroneous
data.

AI-enabled coaches remain a distant dream. In the meantime, medical

professionals must leverage AI in order to slow down and better engage with
patients.

About the Author

Eric Topol, MD, is a world-renowned cardiologist, executive vice president of
Scripps Research, founder of a new medical school and one of the top 10 most-
cited medical researchers. He also wrote The Patient Will See You Now and The
Creative Destruction of Medicine.