13 Jul 2024

Singal, Jena: It’s not just hype. AI could revolutionize diagnosis in medicine

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The history of medical diagnosis is a march through painstaking observation. Ancient Egyptian physicians first diagnosed urinary tract infections by observing patterns in patients’ urine. To diagnose diseases of the heart and lungs, medieval doctors added core elements of the physical examination: pulse, palpation and percussion. The 20th century saw the addition of laboratory studies, and the 21st century of sophisticated imaging and genetics.

Despite advances, however, diagnosis has largely remained a human endeavor, with doctors relying on so-called illness scripts — clusters of signs, symptoms and diagnostic findings that are hallmarks of a disease. Medical students spend years memorizing such scripts, training themselves to, for example, identify the sub-millimeter variations in electrocardiogram wave measurements that might alert them to a heart attack.

But human beings, of course, err. Sometimes, misdiagnosis occurs because a doctor overlooks something — when the patterns of illness fit the script, but the script is misread. This happens in an estimated 15% to 20% of medical encounters. Other times, misdiagnosis occurs because the illness has features that do not match known patterns — they do not fit the script, such as when a heart attack occurs without telltale symptoms or EKG findings.

Artificial intelligence can help solve these two fundamental problems — if it’s given enough financial support and deployed correctly.

First, AI is less susceptible to common factors that lead doctors to make diagnostic errors: fatigue, lack of time and cognitive bandwidth when treating many patients, gaps of knowledge and reliance on mental shortcuts. Even when illnesses conform to scripts, computers will sometimes be better than humans at identifying details buried within voluminous health care data.

Using AI to improve the accuracy and timeliness with which doctors recognize illness can mean the difference between life and death. Ischemic stroke, for example, is a life-threatening emergency where a blocked artery impedes blood flow to the brain. Brain imaging clinches the diagnosis, but that imaging must be performed and interpreted by a radiologist quickly and accurately. Studies show that AI, through superhuman pattern matching abilities, can identify strokes seconds after imaging is performed — tens of minutes sooner than by often-busy radiologists. Similar capabilities have been demonstrated in diagnosing sepsis, pneumonia, blood clot in the lungs (pulmonary embolism), acute kidney injury and other conditions.

Second, computers can be useful for illnesses for which we haven’t developed the right scripts. AI can, in fact, diagnose disease using new patterns too subtle for humans to identify. Consider, for example, hypertrophic cardiomyopathy, a rare genetic condition in which the heart’s muscle has grown more than it should, leading to eventual heart failure and sometimes death. Experts estimate that only 20% of those affected are diagnosed, a process that requires consultation with a cardiologist, a heart ultrasound and often genetic testing. What, then, of the remaining 80%?

Researchers across the country, including at the Mayo Clinic and UC San Francisco, have demonstrated that AI can detect complex, previously unrecognized patterns to identify patients likely to have hypertrophic cardiomyopathy, meaning AI-driven algorithms will be able to screen for the condition in routine EKGs.

AI was able to recognize these patterns after examining the EKGs of many people with and without the disease. The rapid growth in health care data — including detailed electronic health records, imaging, genomic data, biometrics and behavioral data — combined with advancements in artificial intelligence technology has created a major opportunity. Because of its unique ability to identify patterns from the data, AI has helped radiologists to find hidden cancers, pathologists to characterize liver fibrosis and ophthalmologists to detect retinal disease.

One challenge is that AI is expensive, requiring large-scale data to train computer algorithms and the technology to do so. As these resources become more ubiquitous, that can make the associated intellectual property difficult to protect, discouraging private investment in these products. More generally, diagnostics have long been considered unattractive investments. Unlike their therapeutic counterparts, which see around $300 billion in research and development investment a year, diagnostics receive a modest $10 billion in private funding.

Then there’s the question of who pays for the use of AI-based tools in medicine specifically. Some applications, such as detecting strokes, save insurers money (by preventing costly ICU stays and subsequent rehabilitation). These technologies tend to get reimbursed more quickly. But other AI solutions, such as detecting hypertrophic cardiomyopathy, may lead to increased spending on costly downstream therapies to treat newly identified chronic illness. Although the use of AI may improve quality of care and long-term outcomes in such cases, without financial incentives for insurers, reimbursement and thus adoption may be slow.

Life sciences companies have on rare occasion agreed to subsidize development or reimbursement of AI-based diagnostics. This will help bridge the gap, but the federal government may need to play a greater role. Federal support for COVID diagnostics during the pandemic drove rapid development of critical tests, and the cancer moonshot project has helped drive R&D in screening and new treatments.

It is usually tough to marshal funding at the scale needed for new medical frontiers. But the National Academies of Medicine has estimated that tens of billions of dollars and countless lives could be saved from improving diagnosis in medicine.

Artificial intelligence offers a path toward that. It should complement, rather than replace, the human expertise that already saves so many lives. The future of medical diagnosis doesn’t mean handing over the keys to AI but, rather, making use of what it can do that we can’t. This could be a special moment for diagnosis, if we invest enough and do it right.

Gaurav Singal is a computer scientist and physician at Harvard Medical School and was previously the chief data officer of Foundation Medicine, a cancer diagnostics company. Anupam B. Jena is an economist, physician and professor at Harvard Medical School and co-author of ” Random Acts of Medicine: The Hidden Forces That Sway Doctors, Impact Patients, and Shape Our Health” and the Random Acts of Medicine Substack. They wrote this column for the Los Angeles Times.

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13 Jul 2024

David Brooks: The deep source of Trump’s appeal

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There was an extraordinary story in Politico this week. A group of Democratic officials and union leaders told journalists that Donald Trump was competitive in New York state. In 2020, Joe Biden won New York by 23 points. But now, Democratic Manhattan Borough President Mark Levine said, “I truly believe we’re a battleground state now.”

If New York is anything remotely like a battleground, then Trump is going to win this election in a landslide. What is going on?

The proximate answer of course is that many voters think Biden is too old. But that doesn’t explain why Trump was ahead even before the debate. It doesn’t explain why Trump’s candidacy is still standing after Jan. 6. It doesn’t explain why America is on the verge of turning in an authoritarian direction.

I’ve been trying to think through the deeper roots of our current dysfunction with the help of a new book by James Davison Hunter titled “Democracy and Solidarity: On the Cultural Roots of America’s Political Crisis.” Hunter, a scholar at the University of Virginia, is (in my opinion) the nation’s leading cultural historian.

He reminds us that a nation’s political life rests upon cultural foundations. Each society has its own way of seeing the world, its own basic assumptions about what is right and wrong, its own vision of a better world that gives national life direction and purpose. Culture is the ocean of symbols and stories in which we swim.

American culture, Hunter argues, was formed within the tension between Enlightenment values and religious faith. America was founded at the high point of the Enlightenment, and according to Enlightenment ideas: a belief in individual reason, that social differences should be settled through deliberation and democracy, that a free society depends on neutral institutions like the electoral system or the courts, which will be fair to all involved.

But over the centuries many Americans have also believed that America has a covenantal relationship with God — from Puritan leaders like John Winthrop on down. The Bible gave generations of Americans a bedrock set of moral values, the conviction that we live within an objective moral order, the faith that the arc of history bends toward justice. Religious fervor drove many of our social movements, like abolitionism. Religious fervor explains why America has always had big arguments over things like Prohibition and abortion, which don’t seem to rile other nations as much. As late as 1958, according to a Gallup poll, only 18% of Americans said they would be willing to vote for an atheist for president.

Each generation, Hunter continues, works out its own balance in the tension between Enlightenment liberty and moral authority. In the 20th century, for example, the philosopher John Dewey emerged as the great champion of Enlightenment values. He believed that religion had been discredited but that a public ethic could be built by human reason, on the basis of individual dignity and human rights. He had great faith in the power of education to train people to become moral citizens. (Dewey’s understanding of education remains influential in the United States.)

Theologian Reinhold Niebuhr thought this was naïve. He believed that Dewey underestimated the human capacity for sin. He believed that you can’t use science to answer questions about life’s ultimate purpose and meaning. He dismissed the idea that with just a little more schooling, we would be able to educate people out of racism and selfishness, or that secularism can address life’s deepest problems. “The religious ideal of forgiveness,” Niebuhr wrote, “is more profound and more difficult than the rational virtue of tolerance.”

Dewey and Niebuhr differed, but they both thought it was important to build a coherent moral order; they both believed there was a thing called the truth; they both believed that capitalism preyed on the vulnerable. In other words, across their differences they both operated within the cultural framework and tension that had long defined America.

And over the decades, most Americans lived with one ear attuned to the doctrine of Dewey and the other ear attuned to the doctrine of Niebuhr. If you want to see these two traditions within one person, look at Martin Luther King Jr. He used a Christian metaphysics to show how American democracy could live up to both Enlightenment and divine ideals.

Unfortunately, Hunter notes, this fruitful cultural tension died with King. Starting in the 1960s, America grew less religious. Those who remained religious were told to keep their faith to the private sphere. American public life became largely secular, especially among the highly educated classes, producing what the First Things editor Richard John Neuhaus called “the naked public square.” By 2020, 60% of Americans said they would vote for an atheist for president.

At the same time, science and reason failed to produce a substitute moral order that could hold the nation together. By 1981, in the famous first passage of his book “After Virtue,” philosopher Alasdair Macintyre argued that we had inherited fragments of moral ideas, not a coherent moral system to give form to a communal life, not a solid set of moral foundations to use to settle disputes. Moral reasoning, he wrote, had been reduced to “emotivism.” If it feels right, do it. In 1987, Allan Bloom released his megaselling “The Closing of the American Mind,” arguing that moral relativism had become the dominant ethos of the era.

In other words, Americans lost faith in both sides of the great historical tension, and with it the culture that had long held a diverse nation together. By the 21st century it became clear that Americans were no longer disagreeing with one another; they didn’t even perceive the same reality. You began to hear commencement speakers declare that each person has to live according to his or her own truth. Critics talked about living in a post-truth society. Hunter talks about cultural exhaustion, a loss of faith, a rising nihilism — the belief in nothing. As he puts it, “If there is little or no common political ground today, it is because there are few if any common assumptions about the nature of a good society that underwrite a shared political life.”

Was there anything that would fill this void of meaning? Was there anything that could give people a shared sense of right and wrong, a sense of purpose?

It turns out there was: identity politics. People on the right and the left began to identify themselves within a particular kind of moral story. This is the story in which my political group is the victim of oppression and other groups are the oppressors. For people who feel they are floating in a moral and social vacuum, this story provides a moral landscape — there are those bad guys over there and us good guys over here. The story provides a sense of belonging. It provides social recognition. By expressing my rage, I will earn your attention and respect.

In public discourse, identity politics is more associated with the left. Progressivism used to be oriented around how to make capitalism just; but now in its upper-middle-class form, it’s oriented around proper esteem for and inclusion of different identity groups.

But as Hunter notes, Donald Trump practices identity politics just as much as any progressive. He tells the story of how small-town, less-educated Christians are being oppressed by elites. He alone is their retribution. That story resonates with a lot of people. In the 1950s, Billy Graham assumed that his faith was central to American life. By the 2020s his son Franklin considered himself a warrior under siege in an anti-Christian culture.

The problem with this form of all-explaining identity politics is that it undermines democracy. If others are evil and out to get us, then persuasion is for suckers. If our beliefs are defined by our identities and not individual reason and personal experience, then different Americans are living in different universes and there is no point in trying to engage in deliberative democracy. You just have to crush them. You have to grab power and control of the institutions and shove your answers down everybody else’s throats.

In this climate, Hunter argues, “the authoritarian impulse becomes impossible to restrain.” Authoritarianism imposes a social vision by force. If you can’t have social solidarity organically from the ground up, then you can impose it from top down using the power of the state. This is the menace of Trumpism.

Democrats are not immune to this way of thinking. In a 2019 survey Democrats were more likely than Republicans to admit to occasionally thinking that we’d be better off as a country “if large numbers of the opposing party in the public today just died.” Democrats were more likely than Republicans to believe that their opponents were “evil” and “un-American.”

But in this world, in which politics is seen as a form of total war, Biden looks obsolete. In a nihilistic pseudo-authoritarian world, he’s still one of those old-fashioned liberals who reveres the Constitution and his Catholicism. The ideals that animate him and that he uses to give poetry and lift to his speeches fail to inspire millions of American voters. A plurality of voters believe that Biden’s age is a bigger problem than Trump’s authoritarianism because they just don’t see the latter as that big a problem.

The core question in Hunter’s book is: Can you have an Enlightenment political system atop a post-Enlightenment culture? I’d say the answer to that question is: Over the long term, no.

The task, then, is to build a new cultural consensus that is democratic but also morally coherent. My guess, and it is only a guess, is that this work of cultural repair will be done by religious progressives, by a new generation of leaders who will build a modern social gospel around love of neighbor and hospitality for the marginalized.

But the work of building that culture will take decades. Until then, we, as a democracy, are on thin ice.

David Brooks writes a column for the New York Times.

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13 Jul 2024

Today in History: July 13, Live Aid concerts

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Today is Saturday, July 13, the 195th day of 2024. There are 171 days left in the year.

Today’s Highlight in History:

On July 13, 1985, the “Live Aid” benefit rock concerts were held simultaneously in London and Philadelphia, raising millions for famine relief in Ethiopia.

Also on this date:

In 1793, French politician, physician and journalist Jean-Paul Marat was assassinated by Charlotte Corday, who stabbed him to death in his bath.

In 1863, deadly rioting against the Civil War military draft erupted in New York City. (The insurrection was put down three days later.)

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Today in History: July 10, the Battle of Britain begins in World War II

In 1923, a sign consisting of 50-foot-tall letters spelling out “HOLLYWOODLAND” was dedicated in the Hollywood Hills to promote a subdivision (the last four letters were removed in 1949).

In 1930, the first FIFA World Cup began in Uruguay.

In 1960, John F. Kennedy won the Democratic presidential nomination on the first ballot at his party’s convention in Los Angeles.

In 1973, former presidential aide Alexander P. Butterfield revealed to Senate Watergate Committee staff members the existence of President Richard Nixon’s secret White House taping system.

In 1999, Angel Maturino Resendiz, suspected of being the “Railroad Killer,” surrendered in El Paso, Texas.

In 2013, a jury in Florida cleared neighborhood watch volunteer George Zimmerman of all charges in the shooting of Trayvon Martin, the unarmed black teenager whose killing unleashed furious debate over racial profiling, self-defense and equal justice.

In 2018, a grand jury indictment, sought by special counsel Robert Mueller, alleged that the Russian government was behind a sweeping conspiracy to interfere in the 2016 U.S. presidential election.

In 2020, Washington’s NFL franchise dropped the “Redskins” name and logo amid pressure from sponsors; the move followed decades of criticism that the name and logo were offensive to Native Americans. (The team was eventually renamed the Commanders.)

Today’s Birthdays:

Game show announcer Johnny Gilbert (TV: “Jeopardy!”) is 96.
Author and Nobel laureate Wole Soyinka is 90.
Actor Patrick Stewart is 84.
Actor Harrison Ford is 82.
Singer-guitarist Roger McGuinn (The Byrds) is 82.
Rubik’s Cube inventor Erno Rubik is 80.
Actor-comedian Cheech Marin is 78.
Actor Daphne Maxwell Reid is 76.
Sportswriter and talk show host Tony Kornheiser is 76.
Actor Didi Conn is 73.
Actor Gil Birmingham is 71.
Singer Louise Mandrell is 70.
Former boxing champion Michael Spinks is 68.
Actor-director Cameron Crowe is 67.
Comedian Tom Kenny is 62.
Actor Ken Jeong is 55.
Singer Deborah Cox is 50.
Actor Aya Cash is 42.
Former St. Louis Cardinals catcher Yadier Molina is 42.
Actor Colton Haynes is 36.
Actor Steven R. McQueen is 36.
Soul singer Leon Bridges is 35.
Actor Hayley Erin (TV: “General Hospital”) is 30.

13 Jul 2024

Twins fall to Giants; home run streak snapped in loss

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SAN FRANCISCO — Joe Ryan grew up in nearby Marin County, going to games as a kid to root on the San Francisco Giants at Oracle Park.

But his return to the ballpark as a major leaguer didn’t go quite to plan. Ryan gave up five runs — matching a season-high — and was hurt early by his defense in a 7-1 loss on Friday night at Oracle Park to the San Francisco Giants.

“Kind of from the start, we could have done some things differently,” manager Rocco Baldelli said. “I’m not saying that it all would have worked out if we did the opposite of what actually, the way it played out. We could have played better today. Could the game, in the middle of the game, have been a 3-3 game? Based on the way the game went, absolutely.”

It started almost immediately when Matt Wallner dove at a sinking liner off the bat of leadoff man Jorge Soler, but he was unable to catch it. As the ball bounced to the wall, Soler raced to third. He came around to score when the very next batter, former Twin LaMonte Wade Jr., hit a sacrifice fly.

An inning later, Brooks Lee made a low throw that Willi Castro at second base had to lean down to catch. Castro then lost the ball upon the transfer, and the Twins (53-41) were unable to turn what potentially could have been an inning-ending double play. That kept the inning alive, allowing two more runs to score in the inning.

Ryan gave up another run in the fifth and walked two batters to lead off the sixth. One of those inherited runners scored.

“They had a good plan tonight. Put some good swings on it,” Ryan said. “We didn’t play good defense and that’s usually how it shakes out. Got some extra long innings. Don’t get to go as deep into a game because of that and I just gassed out a little quicker.”

After his departure, Josh Staumont gave up a pair of runs in the seventh inning, sinking the Twins into an even larger hole. They were the first earned runs he had given up all season and they came in his 20th outing.

The Twins’ offense, meanwhile, was held to just a run despite plenty of hard contact. It was, notably, not a home run, meaning their bid to put themselves atop the record books fell just short.

Heading into Friday, the Twins had homered in 28 straight games, which had moved them into a tie for second place on Major League Baseball’s all-time list, behind just the 2019 Yankees, who accomplished the feat over 31 straight games.

“It’s probably one of the harder places to homer in,” Baldelli said of Oracle Park. ” … The streak was going to end at some point along the way. There’s no way to keep that going for an entire season. It was pretty impressive while it lasted though.”

Carlos Santana’s sixth-inning double brought home Carlos Correa for the Twins’ only run of the night against Giants (46-49) pitching.

“It was a game where we didn’t play our cleanest baseball today, we didn’t have good enough at-bats, we didn’t do enough,” Baldelli said. “Joe has been sharper previously, more so than he was today, we’ll have to get over it and just kind of move on from this one.”