Don’t Blame Burnout

BY SANJ KATYAL

It is hard to open a medical journal in any specialty without seeing an article on burnout. There are statistics, trends, and of course a myriad of causes detailed in these articles. A few even offer some sensible solutions – flexible scheduling, peer support, delegation of clerical work and an increased focus on personal well-being activities are steps in the right direction. 

I have previously written that “the absence of burnout does not equal wellness” just as the absence of disease does not imply health. We deserve more than simply the ability to function, we deserve to flourish. This is where a field such as positive psychology, or what many call the science of happiness, can offer some evidence-based guidance. 

What has become clear over the past few years is that many people are giving new buzzwords like burnout or moral injury too much credit for their unhappiness. Many of us are not well, either personally or professionally. It’s not as if we are joyful, peaceful and fulfilled at home and then suddenly begin to suffer only when we go to work. 

Our jobs, colleagues or even the draconian healthcare system are not to blame for our discontent. Many of us may feel burned out but it has little to do with our career choice. Not many of us are fulfilled. Not many of us are content. Not many of us are free of stress and anxiety. Most of us seem to be restless and want to feel better all the time. So we blame our jobs, our bank account, people around us, even the world, and call it burnout. Burnout, while a significant problem for some people is now conveniently being used by many to shift the blame away from ourselves. We are the problem. But the good new is that we are also the solution. It is our lack of understanding that causes us to feel perpetually discontent and  frantically chase happiness in various forms. It can only be understanding that will set us free. 

What is it that we have not understood? What are the questions deep within us that we never have the courage to ask?

Why are we not fulfilled? Why are we restless and anxious much of the time? Why do we crave distractions in phones, TV and alcohol?

What we don’t understand is that the discontentment and restlessness that many of us feel is the natural state of our minds. Our mind has evolved to protect us and is constantly searching for opportunities and avoiding threats. Look at how you spend your days, look at your thoughts – they will largely be seeking something pleasurable and avoiding something painful. We are all firefighters putting out fire after fire each day differing only in the size of the inferno. 

Our mind can never be satisfied because that would threaten its survival. This is why we take everything in our lives for granted. This is the reason we need gratitude journaling because our minds will make us forget how good we really have it. This process, called hedonic adaptation, ensures that we will take for granted stimuli in our lives that are constant so we can easily recognize new stimuli (potential threats) from old ones that fade into the background. The problem is that much of the things that fade into the background of our lives are the very aspects that make life worth living – our close relationships, health, and meaningful work. This is why “I’ll be happy when” syndrome exists. Look back on your own lives. Each stage of life was replaced by a new goal to achieve.  This also explains Impact Bias or the overestimation of how good or bad some future event will make us feel. In general, things are not usually as good or bad as we think they will be but our minds exaggerate this future “impact”.  Both phenomena of hedonic adaptation and impact bias serve as evolutionary wiring that motivates us to keep alert, active and never satisfied. 

But here is the crux of the issue – We are more than just the evolutionary wiring of our minds. 

Our minds will first and foremost always be concerned with self-preservation. Our minds are hard-wired to never be satiated because doing so would threaten its survival. Imagine not being constantly alert for food or predators in the wild? Imagine if we became satisfied with our situation and were no longer motivated to keep searching? We would not last long. Satisfaction is like kryptonite for the mind. 

Therefore, the essential nature of our mind is a state of visceral discontent – restlessness and a feeling of something always missing regardless of what we achieve. 

Since we believe we are nothing more than this evolutionary wiring, we also live in this state of visceral discontent.

Once discontent, we seek to feel better because most of the time we don’t feel the way we want to feel.

Here is another false step:

We search for satisfaction thru our minds which by their very nature can never be satisfied. 

So life becomes one chase after another. We think that this next goal or achievement will be the one that finally brings contentment. It certainly may give us a boost in happiness (pleasure) for a while until we get used to it and return to our baseline. 

Life, for most of us has become a series of trying to satisfy desires. But each desire brings fear, anxiety and ultimately more desire. We are anxious about the possibility of not getting what we want. If we get it, we are fearful of losing it. If it sticks around, it ceases to give us the same pleasure and we move on to a new desire. This is what fills most of our lives – fear, anxiety and endless desires.

There is some relief in this understanding. 

Our discontent is not our fault. It is not because we have not yet found the perfect job, partner, or meditation practice. It is not because we don’t have that new title or enough money to retire. It is not for a lack of working hard enough. Our discontent is simply our minds doing what they were designed to do – protect us. 

The only fault of ours is not understanding that we are more than simply the evolutionary wiring of our minds. 

Once we can see that most everything we do is coming from a place of dis-satisfaction of our mind, we can change the equation of our life. 

The default equation imprinted on us from a very early age is: DO-HAVE-BE. 

Our minds (and the collective mind of society) tell us that we are inadequate in some (or many ways) and must do something in order to have some result in order to be (feel) better. 

Consequently, everything we do becomes a desire to feel better in some way. We became physicians because it made us feel better at least for a little while. We keep trading time for more money than we probably need because it makes us feel better. We put pressure on our kids to achieve because it makes us feel better. 

Since all pleasures fade because of hedonic adaptation, any activity done as a desire to feel better will not provide what we are really craving – lasting satisfaction or permanent fulfillment. 

So what is a more effective equation to live by? 

BE – DO – HAVE

Start from a place of completeness and contentment apart from the endless discontent and desires of our minds. Eastern wisdom has implored us to realize this as our natural state of being. Then from this place, DO whatever you are moved to do without any need to boost our self-image or happiness level. Then HAVE whatever result may or may not come from this activity which was done solely for the activity itself. 

What does this mean on a practical level?

We have to earn a living. Earning what we need to live comfortably is effective and necessary. Most of us, however, use money as a surrogate for some future state of contentment. We feel if we make a lot of money, we can travel the world, retire early or finally relax and enjoy life. The truth for most of us is that if we cannot enjoy our leisure time now, we will not enjoy more of it later. There is no future state of contentment – there is only now. There is no future state of happiness – there is only now. Can we make this moment content by understanding that all of our discontent and unhappiness is simply the habit of our mind? Can we watch the wheels of the mind churn out thought after thought that either causes or attempts to relieve discontent?

As physicians, we can work to the best of our ability. If the environment is toxic, then we should leave it. Let us come to the job already content with who we are at our core. Don’t look to our jobs to fill a void within us. Don’t let our self-worth be at the mercy of titles, accolades or our bank account. 

On a personal level, imagine interacting with your children already complete in yourself. Our interactions with them will be more pure and effective if we don’t need them to make us feel better. Ironically when we no longer need them to achieve or succeed a certain way for us, they do so even more.  

There is something within each of us that we are called to do. Something that we woud pay to do. Something that we have no choice but to do regardless of any external recognition. For some, it may be taking good care of patients. For others, being a physician may simply be a useful and good career but not what they want to do forever. In their spare time, they may be writers, poets, painters, or musicians. Creativity for no reason other than the activity itself. They come to this creation already content, immersed without a care for the result. 

Find your own creative pursuit. Listen to the voice deep in your heart rather than the one in your head telling you to do more, achieve more, become more than you already are. As the Ancient Indian scriptures state, “You are already that which you are seeking”. 

Sanj is radiology’s spiritual advisor. He has written for THCB before.

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Designing (Healthcare) via Roblox

BY KIM BELLARD

Here’s a question: what medical schools are incorporating Roblox into their curriculum?  

Interested readers can get back to me, but in the meantime I’m guessing none.  At best, very few.  And instead of “medical schools” feel free to insert kind of “healthcare institutions/organization” that is interested in educating or training – which is to say, all of them.  By way of contrast, I was intrigued by the collaboration between Roblox and The Parsons School of Design. 

Perhaps you don’t know about Roblox, a creator platform whose vision is “to reimagine the way people come together to create, play, explore, learn, and connect with one another.”  As their website says: “We don’t make Roblox.  You do.” It claims to have almost 10 million developers using its platform, hosting some 50 million “experiences.”  

I first wrote about it in 2021, astonished that over half of American children used it, with some 37 million unique daily users. Today it has over 66 million unique daily users — some 214 million monthly active users.   The vast majority of the users – as much as 80% — are under 16, a fact Roblox is acutely aware of and is seeking to change.  

Parson and Roblox announced the collaboration last November.  “Partnering with Roblox offers Parsons students working in creative technologies an exciting opportunity to engage the complex intersection of visual culture and social structure, and to play with how we make meaning when we dress ourselves – in digital and physical worlds,” said Shana Agid, PhD, Dean of the School of Art & Media Technology.  The 16 week course culminated in a digital fashion showcase earlier this month.

“We as a university wanted to work on this project because we want to learn what skill set students need to be successful on this platform,” Professor Kyle Li said. “[Roblox is] also interested in shifting their audience from 12 and younger to 17 to 24. And I thought, ‘We have the perfect specimen to test all those things.” As The Verge reported, “The Parsons course is an extension of Roblox trying to prove that it’s a viable and legitimate tool for adult life.”  Roblox Founder and CEO David Baszucki is clear on this point: “Our goal is one platform, where age-appropriate experiences for every life stage can be found.” 

Most of the Parsons students had not used Roblox prior to the course, but learned how digital design brings both new opportunities and limitations to their fashion expertise. “Working in digital gives you so much freedom in terms of the structures you want to have,” one student told The Verge. Another student told The Wall Street Journal: “You can make crazier looks for less money in the digital world.  Fabrics are expensive.”

Digital fashion is nothing new, whether in Roblox, gaming, or other Metaverse iterations.  For example, designer Rebecca Minkoff recently launched a collection for Roblox, noting this about digital fashion: “I don’t think this is going to go away.” 

Other design schools, such as Drexel, Fashion Institute of Technology, Pratt Institute, Savannah College of Art and Design, offer courses in digital design/metaverse.  Epic Games just invested in a digital fashion company. And Roblox recently started letting creators make money from selling limited-run avatar gear. 

Now, I don’t care all that much about fashion generally, even less about digital fashion, but I am hugely interested in what appeals to younger generations and the inevitable movement to a more digital economy.  And, I have to note, Roblox is interested not just in an older audience but also in healthcare in particular. A few examples:

• Early last year Akili Interactive partnered with Roblox to offer EndeavorRx^®. its prescription video game treatment. Eddie Martucci, CEO and Co-Founder of Akili Interactive noted: “Roblox has changed how millions learn, work, connect and play, and we are excited to work together to further push the boundaries of our industries and continue to redefine the experience of medicine.” 
• Last fall Philips Norelco rolled out Shavetopia in Roblox, as part of its broader Movember program promoting men’s physical and mental health. “We launched Shavetopia to extend the social conversation around Movember beyond the physical world and into the digital world,” said marketing director Viestel da Silva. 
• Early this month Roblox Founder and CEO David Baszucki and his wife made a philanthropic gift to Stony Brook University so that biomedical engineer and neuroscientist Lilianne Mujica-Parodi can develop Neuroblox, a software program inspired by Roblox. The platform hopes “to open up a world of modeling possibilities for neuroscientists without training in computational sciences.” E.g., Roblox for neuroscientists. 
• The American Heart Association is allowing its Heart Hero characters to be used for 30 days in Roblox game Race Clicker.  AHA says: “This is an important opportunity for the American Heart Association to meet kids where they are to share the benefits of mental and physical health to help them grow to reach their full potential.”

And, of course, there are various health or health-related games and experiences offered on the platform.

—————

We’re failing our kids generally when it comes to their health.  We have a teen mental health crisis, fueled in no small part by social media. More than 40% of school-aged children have at least one chronic condition. The anti-vaxx movement, which was envigored but not started by COVID, could have devastating long-term impacts, particularly on children.  And, of course, our healthcare system’s fumbling efforts towards more digital tools and interfaces baffle, frustrate, and turn off young people.  

If healthcare thinks it is reaching young people through, say, Facebook, it is badly misreading its audience and badly underestimating how poorly Facebook protected patient data.  If it wants to reach young people, it’s got to be thinking about gaming, Raspberry Pi, Scratch, TikTok,– and Roblox.  

Think back to Roblox’s vision — “to reimagine the way people come together to create, play, explore, learn, and connect with one another.”  — and tell me which of those goals you wouldn’t want a healthcare organization to share.  Think about how Parsons is using Roblox to give its students new tools to approach fashion design, and tell me why medical schools and other healthcare institutions/organizations shouldn’t also be giving healthcare professionals similar tools to approach healthcare differently, like Dr. Mujica-Parodi is doing.  Think about how healthcare needs to be more relevant to young people and tell me why Roblox wouldn’t help.  

As I said before, I don’t know what a healthcare Roblox would look like.  But I sure hope someone starts to figure it out — soon. 

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

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Operation Searchlight: The American-supported Pakistani genocide you probably haven’t heard about

BY ANISH KOKA

On March 25th, 1971, the Pakistani army launched Operation Searchlight, a military campaign to brutally suppress a Bengali nationalist movement.

The roots of the genocide lie in the parting gift British rulers gave to the Indian subcontinent at the time of independence in 1947. British controlled India was separated into Hindu majority India and Muslim majority Pakistan. But because there were two dense non-contiguous Muslim majority areas in British controlled India, the muslim majority country of Pakistan was divided into East and West Pakistan.

East and West Pakistan were linked by religion, but little else. East Pakistan was culturally Bengali, and had much more in common with Bengali Hindus than Muslims in West Pakistan. While Bengalis took pride in their culture and language, West Pakistani’s looked down on the Bengali’s because it was deemed to be too influenced by Hindu culture. While Bengali muslims may have identified themselves with Pakistan’s islamic project, by the 1970s many in East Pakistan had given priority to their Bengali ethnicity over their religious identity, desiring a society more in accordance with Western principles of secularism and democracy. A growing opposition in East Pakistan strongly objected to the Islamist paradigm being imposed the West Pakistani state.

But West Pakistan controlled the military, and formed much of the ruling elite after the partition in 1947. In a move designed to send a message to Bengali speaking East Pakistani’s , the founding father of Pakistan, Muhammad Jinna even made Urdu the national language of all of Pakistan, and branded those opposed as enemies of the State.

The predominantly Bengali East Pakistanis outnumbered West Pakistanis and chafed at control from Islamabad. It was little suprise then, that in the first general election, the Awami league, campaigning for more local control, under the leadership of Sheikh Mujibur Rahman won a majority of votes and demanded control of the government shift to East Pakistan.

The president of Pakistan at the time – General Yahya Khan and the leader of the dominant PPP party in the West Pakistan – resisted. They had no intentions of a transfer of power to Sheikh Rahman. Negotiations between the two sides broke down, and a disabling strike called by Rahman effectively shut down the East Pakistani economy.

Shortly after, West Pakistan launched Operation Searchlight. The goal ? To extinguish the nascent Bengali nationalist movement by killing or imprisoning its leadership, and even more importantly, destroy any possibility of a future nationalist movement. The Pakistani Armed Forces and supporting pro-Pakistani Islamist militias from Jamaat-e-Islami began an ethnic cleansing campaign that claimed the lives of 300,000 to 3 million people. The army also launched a systemic rape campaign of Bengali women, raping between 200,000 and 400,000 Bengali women.

One of the groups that were eyewitness to the atrocities was the American consulate stationed in Dacca, East Pakistan. Daily telegrams were sent to US President Richard Nixon, and National Security Advisor/Secretary of State Henry Kissinger about the brutality being carried out with American weapons supplied to Pakistan.

The systemic rape of Bangladeshi women was without precedent in the modern era. Australian doctor, Geoffrey Davis, was brought to Dacca by the International Planned Parenthood Federation (IPPF) and the United Nations.

His task?

Perform late term abortions, and facilitate large scale international adoption of the war babies born to Bangladeshi women. In an interview, Davis was asked why the Pakistani’s had to impregnate the women. “

“… so there would be a whole generation of children in East Pakistan that would be born with the blood from the West. That’s what they said.”

Arthur Blood was the American diplomat stations in Dacca and increasingly grew more horrified. His daily cables to DC became more urgent – but continued to be steadfastly ignored by Nixon and Kissinger.

Blood was particularly moved by the killing of a Hindu Bengali professor he had befriended on the very first night of the Pakistani operation.

Early in the crackdown, Dev was dragged out of his home, hauled to a field in front of the Hindu dormitory at the university and shot dead. There was no other reason that he was killed other than being a Hindu professor

Neighboring India was quickly deluged by millions of East Pakistani’s fleeing the Pakistani genocide, and quickly decided to prepare to launch a military operation. This would take time, and in the interim, India became active in support of the Bengali East Pakistan guerilla’s that called themselves the Mukti Bahini (Freedom fighters).

Tipped off to the looming Indian offensive, Pakistan launched a pre-emptive airstrike meant to neutralize the Indian airforce. This failed miserably, and thus started the formal war between India and Pakistan. The Indian strategy was primarily a defensive war on India’s Western border with Pakistan, and an all out Blitzkrieg on the East Pakistani front to liberate the Bengali’s.

The plan was masterminded by Major General Jacob-Farj-Rafael Jacob, the chief of staff of the Indian army’s eastern command who also happened to be a Sephardic Jew born in Calcutta.

Nixon and Kissinger, silent partners in the genocide to date, now sprung into action with a multi-pronged strategy to stop India.

1. Future POTUS George W Bush was sent to the United Nations to call for an immediate ceasefire (the only no votes came from the India friendly Soviet bloc) on the grounds India was violating the sovereignty of a neighboring nation.
2. Push Iran and Jordan to supply US arms to Pakistan with the understanding the US would replace the equipment during the next budgetary cycle
3. Push China to mass its troop on the Chinese border with India
4. Move a US carrier into the Bay of Bengal

Supplying arms to Pakistan without going through Congress was illegal because the Democrat controlled congress had been leaked the Blood telegrams and had cut off all further military aid to Pakistan. It didn’t matter to Nixon/Kissinger that what they were doing was illegal, or that involving China risked spreading the conflict.

China had a deep animosity to India, but reluctant to anger the Soviets demurred. The Soviets also moved their own aircraft carrier into the Bay of Bengal.

The Indian army destroyed the heavily outnumbered Pakistani army in rapid fashion, before any US machinations could bear fruit, and on December 16th, over 93,000 Pakistani troops surrendered, making it the largest surrender since World War 2.

In contrast to the atrocities meted out by the Pakistani army, India treated all Prisoners of War in strict accordance with the Geneva convention. It released more than 93,000 Pakistani’s in 5 months. The Pakistani’s were humiliated, and Bangladesh came into existence.

Anish Koka is a cardiologist. Follow him on twitter @anish_koka . Link to this story on twitter here.

Pakistan continues to dispute the events that transpired despite overwhelming evidence to the contrary. The US involvement is subject of a fantastic book by Gary Bass.

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The New Rules of Healthcare Platforms: APIs Enable the Platforming of Healthcare

BY VINCE KURATIS, BRENDAN KEELER, and JODY RANCK

Recent regulations have mandated the use of HL7 FHIR APIs (application programming interfaces) to share health data. The regs apply to healthcare providers, payers, and technology developers who participate in federal programs. Many incumbent healthcare organizations are viewing these mandates as a compliance burden. That’s short-sighted. We recommend a more opportunistic POV.

APIs facilitate the sharing of health data across different devices and platforms. By adopting APIs, healthcare organizations can transform themselves from traditional service providers into powerful platforms that can connect patients, providers, and other stakeholders in new and innovative ways.

This blog post is the fourth in the series on The New Rules of Healthcare Platforms. In this essay, we explore the many benefits of API adoption for healthcare organizations and the key considerations that must be taken into account when implementing APIs:

• Healthcare’s Data Inflection Point
• APIs Enable Platform Business Models
• Barriers, Challenges, Reality Check

Healthcare’s Data Inflection Point

Compared to other industries, healthcare generates a disproportionately large amount of data. According to RBC Capital Markets, “30% of the world’s data volume is being generated by the healthcare industry. By 2025, the compound annual growth rate of data for healthcare will reach 36%. That’s 6% faster than manufacturing, 10% faster than financial services, and 11% faster than media & entertainment.”

Over the past 15 years, new regulations have driven digitization, data interoperability, and data sharing. The goal of regulations has been to liberate patient data that has previously been unstructured and trapped in patient silos. Venture capitalist Kahini Shah summarized these regulatory efforts in her article entitled Healthcare Data APIs – An Upcoming Multi-Billion Dollar Market?:

Recent regulation is forcing digitization, aggregation and transmission of medical records. Congress passed the HITECH Act in 2009, prompting the adoption of electronic health records. Before that medical records were paper based. Healthcare data is incredibly siloed, every American sees an average of 19 providers in their lifetime. Connecting these disparate electronic systems and having them exchange information is called interoperability. In 2020, the HHS and CMS implemented two rules that mandate patient access to their medical records and interoperability. These transformative rules give patients the right to access their data when they need and make it available via APIs. The interoperability rules state that there is no blocking – EHRs must allow data to be shared easily across different systems owned by different vendors.

Shah points out that many early-stage companies already “get” healthcare APIs. There are many companies connecting, aggregating, and transmitting medical records:

Healthcare data is at an inflection point. After a decade-long regulatory march, COVID accelerated the adoption of digital health technologies. Healthcare consumers are demanding the levels of service and responsiveness that they experience elsewhere. Will incumbent healthcare organizations latch on to the opportunities presented by APIs?

APIs Enable Platform Business Models

“APIs are at the basis of platforms business models on which ecosystems are built.”—Paolo Malinverno, Research Vice President, Gartner

The Strategic Value of APIs

APIs are becoming increasingly essential for achieving growth, driving innovation and gaining a competitive edge in today’s business landscape.

Deloitte explained why APIs must be viewed more broadly: “APIs have often been treated as tactical assets until relatively recently… Cut to today’s reality of digital disruption and diverse technology footprints. In many industries, creating a thriving platform offering across an ecosystem lies at the heart of a company’s business strategy”

Success with APIs requires a broader perspective on how technology can be used to support business objectives. Tiffany Xingyu Wang and Matt McLarty explained in their Harvard Business Review article entitled APIs Aren’t Just for Tech Companies:

Companies that have been most successful with APIs display common thinking patterns and practices, something we call the “ways of the API.” Following are three of the most impactful of these patterns.

1) The Unbundling Way: Dismantling and Rebuilding Business Capabilities Through APIs. Jeff Bezos published a corporate edict around 2002 mandating that from that point forward, all product teams were required to expose their data and functionality through APIs. Not only that, he insisted that teams were only allowed to communicate with each other through these APIs. It was an extreme step intended to promote team autonomy and product agility. It was a few years before the mandate took hold, but it created an unprecedented platform for growth….

2) The Outside-In Way: Designing and Developing with the API Consumers in Mind. Stripe entered a crowded payments market in 2010. Identifying mobile app developers as an underserved customer segment, Stripe focused on delivering the most useful and usable APIs possible. It worked. Stripe has close to 20% of the online payments market share (a number that’s growing), and the company is valued at over $100 billion. One of the pillars of their success has been an unwavering commitment to designing their products outside-in from the consumer’s perspective….

3) The Ecosystem Way: Cultivating a Digital Ecosystem with APIs. Borrowing another Clayton Christensen concept, Twilio envisioned the “value network” for mobile applications, the digital ecosystem within which apps would exist. By looking at the various stakeholders (app users, app developers, third-party service providers) and the value exchanges between them, Twilio identified a gap that could be filled — combining and accelerating carrier services — to the benefit of all ecosystem members.

Bezos’ 2002 decree described above has been widely quoted, but it’s not always explained in plain terms — that Bezos explicitly mandated the adoption of internal and external APIs at Amazon. He ended the mandate with: “Anyone who doesn’t do this will be fired. Thank you; have a nice day!”

APIs Can Support a Wide Range of Business Models

There are many potential uses for APIs. APIs: A Strategy Guide listed some of them:

• You need a second mobile app
• Your customers or partners ask for an API
• Your site is getting screen scraped
• You need more flexibility in providing content [and data]
• You have data to make available
• Your competition has an API
• You want to let potential partners test the waters
• You want to scale integration with customers and partners

It’s beyond the scope of this post to go into detail, but we want to give you a sense of the wide range of internal and external business models that APIs can support:

The graphic (above) is from Programmable Web’s 2020 Guide to API Business Models. Here’s a brief explanation:

The tree hierarchy attempts to logically organize API business models according to several groupings and sub-groupings. For your monetization conversations, it facilitates important questions like “Should this API be externally exposed outside of our firewall and, if so, should it be productized for consumption by the general public, reserved for partner use, or both?”

Benefits of APIs

More broadly, there are many benefits of adopting APIs in healthcare. Here are some of the most notable advantages:

1. Efficient interoperability and data sharing: One of the primary benefits associated with API adoption in healthcare is improved data sharing among healthcare providers, patients, and other stakeholders. APIs can enable seamless data exchange between different healthcare systems and disparate technology platforms, ensuring that all parties have access to accurate and up-to-date health information.

2. Increased patient engagement: By providing patients with access to their own health data via APIs, healthcare organizations can empower patients to take a more active role in their own health management. This can lead to improved patient outcomes and higher levels of patient satisfaction.

3. Innovation and scalability: APIs can enable healthcare organizations to more easily collaborate with third-party developers to create new digital health solutions. This can result in the creation of innovative new tools and services that can help improve patient care and reduce costs. Additionally, APIs can help healthcare organizations scale their operations more efficiently by leveraging the expertise of other organizations in the industry.

4. Increased Profitability: Boston University researchers examined The Impact of APIs in Firm Performance. They found that “API adoption – measured both as a binary treatment and as a function of the number of calls and amount of data processed – is related to increased sales, operating income, and decreased costs. It is especially tightly related to increased market value. In our preferred specification, binary API adoption predicts a 10.3% increase in a firms’ market value.”

A Healthcare Example — Patient-Facing APIs

Writing in the Journal of Medical Internet Research, Aaron Neinstein and his colleagues conducted interviews with 10 top health systems to gain insights into their approach towards patient-facing APIs. The objective was to understand the initial experiences of healthcare systems and identify insights that could be beneficial for policy and practice. Their key findings:

Our results suggest a reason for optimism about the prospects for patient-facing APIs and their impact on the US health care system…The health systems we interviewed all planned to increase the use of patient-facing APIs, and many stated that this was “the right thing to do.” Two use cases emerged as the strategic driving forces for health systems: the ability for the patient to create an aggregated longitudinal health record and better digital patient engagement.

Barriers, Challenges, Reality Checks

“Today, a firm without application program interfaces (APIs) that allow software programs to interact with each other is like the internet without the World Wide Web.” –Bala Iyer and Mohan Subramaniam, Harvard Business Review

Despite the benefits, APIs are not a foregone conclusion. There are many challenges to the widespread, ubiquitous adoption of APIs.

Realizing the Value of APIs Requires a Mindset Shift

We believe the biggest challenge to broad API adoption in healthcare is “mindset”. Healthcare moves slowly. The industry has been resistant to sharing data and assets. Deloitte explained the shift that is needed:

APIs can be a vehicle to spur growth, and even create new paths to revenue. Viewing APIs in this way requires a shift in thinking. The new integration mindset focuses less on just connecting applications than on exposing information within and beyond your organizational boundaries. It’s concerned less with how IT runs, and more with how the business runs.

Healthcare organizations need to adopt a discipline for creating APIs strategically, rather than making point connections on a project-by-project basis.

Financial Incentives are Misaligned

The gradual shift towards value-based care and payments has been ongoing for decades, yet its pace has been slow. This is largely due to the misalignment of financial incentives, particularly under the prevalent fee-for-service reimbursement model.

Under fee-for-service, incentives for data sharing are minimal. Historically, providers have considered data as their proprietary asset. There is no direct financial reward for sharing data, and APIs and other data-sharing ecosystems, like Carequality and TEFCA, are often perceived as burdensome compliance requirements rather than opportunities for improving patient care and business operations.

Will New Regs Be Enforced?

As previously noted, much of the momentum toward API adoption in healthcare has been spurred by federal regulations In 2022 Troy Bannister, former CEO of Particle Health, posed the question of whether there will be resources and an appetite to vigorously enforce these regulations:

So far, no real fines have been issued against violators, and honestly, I don’t know where they’d even start. I don’t know a single hospital, practice or clinic adhering to the rule today. How do we feel, as a country, about a system of government that creates rules, laws and policies but allows entire industries to ignore them completely—either directly through abstinence or indirectly through lobbied, hyper-specific loopholes?

Healthcare Lags in Attracting Developers

Despite the increasing digitization of healthcare, the industry has struggled to attract top-tier software developers. Compared to sectors like finance and media, healthcare has been slower to adopt technology, often due to complex regulations and the necessity to comply with multiple standards. The intricate nature of EHRs, the diversity of integration capabilities, and the technical density of healthcare standards present significant challenges to developers. Coupled with this, the industry’s fragmentation and inconsistent pace of technology adoption may deter developers who could otherwise drive innovation.

Data Privacy and Security Issues

A big challenge of API adoption in healthcare is ensuring the appropriate protection of sensitive health data. Maintaining confidentiality and security of patient health data is paramount, and ensuring that healthcare organizations remain in compliance with privacy regulations can be a major hurdle.

Data Quality is Inconsistent

EHRs have built on differing data models, vastly limiting their ability to exchange data that is “understood” by other EHRs. For example, a recent JAMIA study reported only 22-68% interoperability across EHR platforms.

The United States Core Data for Interoperability (USCDI) is a standardized set of health data classes and constituent data elements for nationwide interoperability of health information technology (IT) systems. The USCDI sets a minimum standard for the data elements that must be shared to support patient care and facilitate access to health IT.

However, the USCDI has limitations. It does not cover all of the necessary data elements required for patient care or research. It only focuses on structured data, which can exclude important clinical information that is not captured in a structured format. Lastly, the USCDI is not a comprehensive data set.

Limitations of the FHIR API

Implementing and utilizing the FHIR API requires advanced technical knowledge and infrastructure. The FHIR API only provides a standard format for exchanging specific types of health data, meaning not all data elements may be available through the FHIR API.

Conclusion

The API economy is growing and changing rapidly, with new business models, tools, and strategies being developed to meet the needs of patients, healthcare organizations, and developers. As APIs become more ubiquitous across industries, they are reshaping the way businesses grow and innovate.

It’s time for healthcare to join the thriving API economy.

Vince Kuraitis, JD, MBA, is a health care consultant and primary author of the e-CareManagement blog, where this post first appeared.

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THCB Gang Episode 125, Thursday May 25

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday May 25 at 1PM PT 4PM ET are Olympic rower for 2 countries and DiME CEO Jennifer Goldsack, (@GoldsackJen); medical historian Mike Magee (@drmikemagee); and writer Kim Bellard (@kimbbellard);

The video will be below. If you’d rather listen to the episode, the audio is preserved from Friday as a weekly podcast available on our iTunes & Spotify channels

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Can AI Part The Red Sea?

BY MIKE MAGEE

A few weeks ago New York Times columnist Tom Friedman wrote, “We Are Opening The Lid On Two Giant Pandoras Boxes.” He was referring to 1) artificial Intelligence (AI) which most agree has the potential to go horribly wrong unless carefully regulated, and 2) global warming leading to water mediated flooding, drought, and vast human and planetary destruction.

Friedman argues that we must accept the risk of pursuing one (rapid fire progress in AI) to potentially uncover a solution to the other. But positioning science as savior quite misses the point that it is human behavior (a combination of greed and willful ignorance), rather than lack of scientific acumen, that has placed our planet and her inhabitants at risk.

The short and long term effects of fossil fuels and carbonization of our environment were well understood before Al Gore took “An Inconvenient Truth” on the road in 2006. So were the confounding factors including population growth, urbanization, and surface water degradation. 

When I first published “Healthy Waters,” the global population was 6.5 billion with 49% urban, mostly situated on coastal plains. It is now 8 billion with 57% urban and slated to reach 8.5 billion by 2030 with 63% urban. 552 cities around the globe now contain populations exceeding 1 million citizens.

Under ideal circumstances, this urban migration could serve our human populations with jobs, clean air and water, transportation, housing and education, health care, safety and security. Without investment however, this could be a death trap. 

Clean, safe water is fundamental to maintaining the health and productivity of these city dwellers. Investment in water infrastructure, according to the OCED, delivers a 3 to 1 return on investment. So the money should be easy to find. But it’s not. And it’s not for a lack of science or technology. It is an issue of priorities. For example, American citizens manage to find 16 billion a year to spend on bottled water, almost always no better, and occasionally worse, than common tap water.

Robin Wall Kimmerer, in her novel “Braiding Sweetgrass,” writes:  “Among our Potawatomi people, women are the Keepers of Water. We carry the sacred water to ceremonies and act on its behalf. ‘Women have a natural bond with water, because we are both life bearers,’ my sister said. ‘We carry our babies in internal ponds and they come forth into the world on a wave of water. It is our responsibility to safeguard the water for all our relations.’”

When it comes to planetary health, that is the kind of respect, common sense, and imagination we need to yield quicker and better results than AI. Planetary health requires well ordered priorities and shifts in human behavior like the recent trend away from huge, dangerous and disruptive hydroelectric energy projects like the Three Gorges Dam in China. Humans now rely on hydroelectric projects for 16% of the world’s energy. That’s good in that it is renewable and lowers carbon emissions. But its’ effect on the environment, displacing humans and animals with dam construction, and playing a role in catastrophic disasters when dams fail, has drawn criticism.

In response, a simple solution called “pumped storage” is rapidly supplanting huge dam projects. The system is simple – two reservoirs, one high and one low. When energy use is low, water is pumped into the upper reservoir. When demand is high, water is allowed to flow into the lower reservoir through turbines that generate needed energy. Places like China, which has been all in on hydropower, has switched 80% of their future projects to “pumped storage” because it is fast, safe and effective, and can “provide a flexible backup for wind and solar.” The key insight is that the reservoir system acts as a battery, storing potential energy ready to go, on demand, without adding the additional cost of storage.

Knee-jerk over reliance on scientific inventiveness lets us all off the hook. Before we give a green light to the next batch of dot-come gazillionaires, we’d be smart to ask two questions: What makes sense? and What’s best for the health of all Americans?

In fairness to Tom Friedman, he warns about putting all our eggs in the scientific basket without tightening regulations that support “scaled sustainable values.” Yet his final words do little to encourage confidence based on past history and performance. As he puts it, “God save us if we acquire godlike powers to part the Red Sea but fail to scale the Ten Commandments.”

Mike Magee MD is a Medical Historian and author of “CODE BLUE: Inside the Medical-Industrial Complex.”

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What Can We Learn from the Envision Bankruptcy?

By JEFF GOLDSMITH

Envision, a $10 billion physician and ambulatory surgery firm owned by private equity giant Kohlberg Kravis Roberts, filed Chapter 11 bankruptcy on May 15.  It was the largest healthcare bankruptcy in US history.   Envision claimed to employ 25 thousand clinicians- emergency physicians, anesthesiologists, hospitalists, intensivists, and advanced practice nurses and contracted with 780 hospitals.  Envision’s ER physicians delivered 12 million visits in 2021, not quite 10% of the US total hospital ED visits.

The Envision bankruptcy eclipsed by nearly four-fold in current dollars the Allegheny Health Education and Research Foundation (AHERF) bankruptcy in the late 1990’s.   KKR has written off $3.5 billion in equity in Envision.   Envision’s most valuable asset, AmSurg and its 257 ambulatory surgical facilities, was separated from the company with a sustainable debt structure.  And at least $5.6 billion of the remaining Envision debt will be converted to equity at the barrel of a gun, at dimes on the dollar of face value. 

KKR took Envision private in 2018 when Envision generated $1 billion in profit, in luminous retrospect the peak of the company’s good fortune.   Envision’s core business was physician staffing of hospital emergency departments and operating suites.    In 2016, then publicly traded, Envision merged with then publicly traded ambulatory surgical operator AmSurg.  This merger seemed at the time to be a sensible diversification of Envision’s “hospital contractor” business risk.   

Indeed, Envision’s bonus acquisition of anesthesia staffing provider Sheridan, acquired by AMSURG in 2014,  helped broaden its portfolio away from the Medicaid intensive core emergency room staffing business (EmCare), which required extensive cost-shifting (and out of network billing) to cover losses from treating Medicaid and uninsured patients.   It is clear from hindsight that where you start, e.g. your core business, limits your capacity to spread or effectively manage your business risk, an issue to which we will return.

The COVID hospital cataclysm can certainly be seen as a proximate cause of Envision’s demise.

The interruptions of elective care and the flooding of emergency departments with elderly COVID patients, which kept non-COVID emergencies away, damaged Envision’s core business as well as nuking ambulatory surgery. By the spring of 2020, Envision was exploring a bankruptcy filing.  An estimated $275 million in CARES Act relief and draining a $300 million emergency credit line from troubled European banker Credit Suisse temporarily staunched the bleeding.  But the pan-healthcare post-COVID labor cost surge also raised nursing expenses and led to selective further shutdowns in elective care and further cash flow challenges.  

While one cannot fault KKR’s due diligence team for missing a global infectious disease pandemic, with hindsight’s radiant clarity, there were other issues simmering on the back burner by the time of the 2018 deal that should have raised concerns.  Two large struggling investor owned hospital chains,  Tenet and Community Health Systems, began divesting marginal properties in earnest in 2018, placing a lot of Envision’s contracts in the pivotal states of Florida and Texas at risk.

More importantly,  there were escalating contract issues with  UnitedHealth, one of Envision’s biggest payers,  as well as increasing political agitation about out-of-network billing, which provided Envision vital incremental cash flow.  These problems culminated in a United decision in January 2021 to terminate insurance coverage with Envision, making its entire vast physician group “out of network”. 

The United dispute coincided with a skillfully managed public policy initiative laying out the scope and indefensibility of Envision’s cost shifting strategy.  The assault began with a 2016 study covertly assisted and guided by United  by a prominent Yale health policy analyst.  This study ignited a firestorm of press criticism and was followed by an aggressive lobbying and PR campaign funded by United and other large commercial payers  aimed at restricting balance billing by firms like Envision. 

This campaign culminated in the Dec 2020 Congressional passage of the No Surprises Act, which effectively ended balance billing and subjected thousands of Envision’s out-of-network bills to an arbitration process. NSA went into effect in January 2022.   Ironically, days prior to its Chapter 11 filing, Envision won a $91 million judgment from an arbitration panel against United for out-of-network billing disputes from 2017-2018.  If this judgment survives the inevitable challenges, the proceeds will end up repaying Envision’s creditors.  

A significant longer term threat to Envision’s bargaining power was the proposed Federal Trade Commission prohibition on non-competes for its physicians. Non-compete clauses in employment contracts forbid employed physicians from working for others (e.g. local hospitals, in-market physician groups or competing multi-market staffing firms)  in the same community for a period of years.  Outlawing non-competes would remove a major leverage point for physician staffing companies- the threat of terminating an unfavorable hospital contract and forcing the hospital to cover its ERs and ORs from out-of-the market docs.

If historical FTC precedents hold, non-profit hospitals and systems, a major client group for Envision, would be exempt from the FTC mandate, tipping the bargaining balance decisively their favor.  Hospital systems already vastly outstrip staffing firms in physician employment.  Asymmetrical restrictions on physician non-compete clauses in employment contracts would pose an existential threat to the many private-equity based physician enterprises, as well as Optum Health’s huge and rapidly growing physician group.   

Strategically, the Envision bankruptcy raises anew the question of whether there are economies of scale, and investment returns to scaling, in healthcare. Certainly the conventional wisdom argued that large firms like Envision had the ability to recruit and retain clinicians across vast geographies, and negotiating power with the large insurers that increasingly dominate key insurance sectors like Medicare Advantage and Managed Medicaid.  

Envision’s demise strongly suggests that the power balance-both political and economic- has tipped decisively in the direction of payers like United.  Rising interest rates, the increasing scarcity of clinicians as workaholic baby boom vintage docs and deepening financial challenges for the ultimate customers of many of these companies, namely hospitals, suggest that we may have reached an inflection point in the viability of many private equity physician care models, with their 4-7 year holding periods and a succession of owners.   Current owners might find it increasingly difficult to exit their positions.

Looking beyond private equity, the evident diseconomies of co-ordination and concentration of business risk in the large healthcare rollups may argue against the type of consolidation that created Envision in the first place. This problem is likely to haunt many of the putative healthcare “disrupters” such as CVS and Amazon that are busily and extravagantly overpaying for clinical assets in search of the holy grail of “integration” and market dominance.

They are late to the party and will be compelled to “pay up” to get the national market presence they seek.  CVS recently paid $18 million per physician to purchase boutique Medicare Advantage provider Oak Street Health.   

In 2012, financial strategist Nassim Nicholas Taleb, who predicted the 2008 financial crisis, argued in his Anti-Fragile: Things that Gain from Disorder,  that prospering in this modern economy requires nimbleness and the ability to rapidly adjust business strategy in the face of uncertainty and rapid market shifts.  He argued that many mergers seeking scale and leverage actually made organizations more fragile and, thus, prone to tipping over, as Envision did. 

What a wise colleague once suggested large healthcare organizations need is “optionality”- the ability quickly to adjust one’s holdings and business models to take advantage of economic cycles, regulatory and political changes and growth potential.  To have optionality is to be “anti-fragile”. 

UnitedHealth Group, a vast healthcare conglomerate spanning health insurance, care delivery, pharmaceutical benefits management and business intelligence and services has optionality, along with more than $2 billion a month in cash flow to fund it, and is anti-fragile.   Envision- with its heavy reliance on a single financial leverage strategy and a dominant customer type- was not. United’s optionality and long-game patience rather than its scale per se may be its biggest strategic asset.   Envision is United’s first major scalp.  There will be many others. 

Jeff Goldsmith is the President of Health Futures, Inc, one of Americas leading health futurists, and regular on THCB Gang.

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SPM-Creative Learning Exchange, Portland, OR (& virtual), July 16

As you may know I am on the board of the Society for Participatory Medicine (SPM) which is trying to promote a new partnership between patients and the health care system.

On June 16 at 8am-1pm PST SPM is hosting a Creative Learning Exchange in Portland, OR at OHSU. The topic is Advancing Health Equity Through Participatory Medicine and there’ll be patients, clinicians and other leading crucial discussions about how to move health equity forward.

If you are in Portland please come join the meeting and if you can’t get there, it will be broadcast online. (There’s a nominal cost for tickets but no one will be turned away if they can’t afford it) Click here to find out more.–Matthew Holt

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AI is Bright, But Can Also Be Dark

BY KIM BELLARD

If you’ve been following artificial intelligence (AI) lately – and you should be – then you may have started thinking about how it’s going to change the world. In terms of its potential impact on society, it’s been compared to the introduction of the Internet, the invention of the printing press, even the first use of the wheel. Maybe you’ve played with it, maybe you know enough to worry about what it might mean for your job, but one thing you shouldn’t ignore: like any technology, it can be used for both good and bad.  

If you thought cyberattacks/cybercrimes were bad when done by humans or simple bots, just wait to see what AI can do.  And, as Ryan Health wrote in Axios, “AI can also weaponize modern medicine against the same people it sets out to cure.”

We may need DarkBERT, and the Dark Web, to help protect us.

A new study showed how AI can create much more effective, cheaper spear phishing campaigns, and the author notes that the campaigns can also use “convincing voice clones of individuals.”  He notes: “By engaging in natural language dialog with targets, AI agents can lull victims into a false sense of trust and familiarity prior to launching attacks.”  

It’s worse than that. A recent article in The Washington Post warned:

That is just the beginning, experts, executives and government officials fear, as attackers use artificial intelligence to write software that can break into corporate networks in novel ways, change appearance and functionality to beat detection, and smuggle data back out through processes that appear normal.

The outdated architecture of the internet’s main protocols, the ceaseless layering of flawed programs on top of one another, and decades of economic and regulatory failures pit armies of criminals with nothing to fear against businesses that do not even know how many machines they have, let alone which are running out-of-date programs.

Health care should be worried too. The World Health Organization (WHO) just called for caution in use of AI in health care, noting that, among other things, AI could “generate responses that can appear authoritative and plausible to an end user; however, these responses may be completely incorrect or contain serious errors…generate and disseminate highly convincing disinformation in the form of text, audio or video content that is difficult for the public to differentiate from reliable health content.”

It’s going to get worse before it gets better; the WaPo article warns: “AI will give far more juice to the attackers for the foreseeable future.”  This may be where solutions like DarkBERT come in.

Now, I don’t know much about the Dark Web. I know vaguely that it exists, and that people often (but don’t exclusively) use it for bad things.  I’ve never used Tor, the software often used to keep activity on the Dark Web anonymous.  But some clever researchers in South Korea decided to create a Large Language Model (LLM) trained on data from the Dark Web – fighting fire with fire, as it were. This is what they call DarkBERT. 

The researchers went this route because: “Recent research has suggested that there are
clear differences in the language used in the Dark Web compared to that of the Surface Web.”  LLMs trained on data from the Surface Web were going to miss or not understand much of what was happening on the Dark Web, which is what some users of the Dark Web are hoping.  

I won’t try to explain how they got the data or trained DarkBERT; what is important is their conclusion: “Our evaluations show that DarkBERT outperforms current language models and may serve as a valuable resource for future research on the Dark Web.” 

They demonstrated DarkBERT’s effectiveness against three potential Dark Web problems:

• Ransomware Leak Site Detection: identifying “the selling or publishing of private, confidential data of organizations leaked by ransomware groups.” 
• Noteworthy Thread Detection: “automating the detection of potentially malicious
  threads.”
• Threat Keyword Inference: deriving “a set of keywords that are semantically related to threats and drug sales in the Dark Web.”

On each task, DarkBERT was more effective than comparison models.  

The researchers aren’t releasing DarkBERT more broadly yet, and the paper has not yet been peer reviewed.  They know they still have more to do: “In the future, we also plan to improve the performance of Dark Web domain specific pretrained language models using more recent architectures and crawl additional data to allow the construction of a multilingual language mode.”

Still, what they demonstrated was impressive. Geeks for Geeks raved:

DarkBERT emerges as a beacon of hope in the relentless battle against online malevolence. By harnessing the power of natural language processing and delving into the enigmatic world of the dark web, this formidable AI model offers unprecedented insights, empowering cybersecurity professionals to counteract cybercrime with increased efficacy.

It can’t come soon enough.  The New York Times reports there is already a wave of entrepreneurs offering solutions to try to identify AI-generated content – text, audio, images, or videos – that can be used for deepfakes or other nefarious purposes.  But the article notes that it’s like antivirus protection; as AI defenses get better, the AI generating the content gets better too.  “Content authenticity is going to become a major problem for society as a whole,” one such entrepreneur admitted. 

When even Sam Altman and other AI leaders are calling for AI oversight, you know this is something we all should worry about. As the WHO warned, “there is concern that caution that would normally be exercised for any new technology is not being exercised consistently with LLMs.”  Our enthusiasm for AI’s potential is outstripping our ability to ensure our wisdom in using them. 

Some experts have recently called for an Intergovernmental Panel on Information Technology – including but not limited to AI – to “consolidate and summarize the state of knowledge on the potential societal impacts of digital communications technologies,” but this seems like a necessary but hardly sufficient step.  

Similarly, the WHO has proposed their own guidance for Ethics and Governance of Artificial Intelligence for Health.  Whatever oversight bodies, legislative requirements, or other safeguards we plan to put in place, they’re already late.   

In any event, AI from the Dark Web is likely to ignore and try to bypass any laws, regulations, or ethical guidelines that society might be able to agree to, whenever that might be.  So I’m cheering for solutions like DarkBERT that can fight it out with whatever AI emerges from there.  

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor

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Asking Bard And ChatGPT To Find The Best Medical Care, I Got Truth And Truthiness

BY MICHAEL MILLENSON

If you ask ChatGPT how many procedures a certain surgeon does or a specific hospital’s infection rate, the OpenAI and Microsoft chatbot inevitably replies with some version of, “I don’t do that.”

But depending upon how you ask, Google’s Bard provides a very different response, even recommending a “consultation” with particular clinicians.

Bard told me how many knee replacement surgeries were performed by major Chicago hospitals in 2021, their infection rates and the national average. It even told me which Chicago surgeon does the most knee surgeries and his infection rate. When I asked about heart bypass surgery, Bard provided both the mortality rate for some local hospitals and the national average for comparison. While sometimes Bard cited itself as the information source, beginning its response with, “According to my knowledge,” other times it referenced well-known and respected organizations.

There was just one problem. As Google itself warns, “Bard is experimental…so double-check information in Bard’s responses.” When I followed that advice, truth began to blend indistinguishably with “truthiness” – comedian Stephen Colbert’s memorable term to describe information that’s seen as true not because of supporting facts, but because it “feels” true.

Ask ChatGPT or Bard about the best medical care and their answers mix information you can trust with

Take, for example, knee replacement surgery, also known as knee arthroplasty. It’s one of the most common surgical procedures, with nearly 1.4 million performed in 2022. When I asked Bard what surgeon does the most knee replacements in Chicago, the answer was Dr. Richard A. Berger. Berger, who’s affiliated with both Rush University Medical Center and Midwest Orthopaedics, has done over 10,000 knee replacements, Bard informed me. In response to a subsequent question, Bard added that Berger’s infection rate was 0.5 percent, significantly lower than the national average of 1.2 percent. That low rate was attributed to factors such as “Dr. Berger’s experience, his use of minimally invasive techniques and his meticulous attention to detail.”

With chatbots, every word in a query counts. When I changed the question slightly and asked, “What surgeon does the most knee replacements in the Chicago area?”, Bard no longer provided one name. Instead, it listed seven “of the most well-known surgeons” – Berger among them – who “are all highly skilled and experienced,” “have a long track record of success,” and “are known for their compassionate care.”

As with ChatGPT, Bard’s answers to any medically related question include abundant cautions, such as “no surgery is without risk.” Yet Bard still stated flatly, “If you are considering knee replacement surgery, I would recommend that you schedule a consultation with one of these [seven] surgeons.”

ChatGPT shies away from words like “recommend,” but it confidently reassured me that the list it provided of four “top knee replacement surgeons” was based “on their expertise and patient outcomes.”

These endorsements, while a stark departure from the search engine list of websites to which we’ve become accustomed, are more understandable if you think about how “generative artificial intelligence” chatbots such as ChatGPT and Bard are trained.

Bard and ChatGPT both rely on information from the Internet, where individual orthopedic surgeons often have a high profile. Specifics about Berger’s practice, for instance, can be found on his website and in numerous media profiles, including a Chicago Tribune story relating how athletes and celebrities from all over the country come to him for care. Unfortunately, it’s impossible to know the extent to which the chatbots are reflecting what the surgeons say about themselves versus data from objective sources.

Courtney Kelly, director of business development for Berger, confirmed the “over 10,000” surgical volume figure, while noting that the practice placed that number on its website several years ago. Kelly added that the practice only publicized an overall complication rate of less than one percent, but she confirmed that about half that figure represented infections.

While the infection data for Berger may be accurate, its cited source, the Joint Commission, was not. A spokesperson for the Joint Commission, which surveys hospitals for overall quality, said it doesn’t collect individual surgeon infection rates. Similarly, a Berger colleague at Midwest Orthopaedics who was also said to have a 0.5 percent infection rate had that number attributed by Bard to the Centers for Medicare & Medicaid Services (CMS). Not only couldn’t I find any CMS data on individual clinician infection rates or volumes, the CMS Hospital Compare site provides the hospital infection rate only for a combination of knee and hip surgeries.

In response to another question I asked Bard, it gave the breast cancer mortality rates at some of Chicago’s largest hospitals, albeit carefully noting that the numbers were only averages for that condition. But once again its attribution, this time to the American Hospital Association, didn’t stand up. The trade group said it does not collect that type of data.

Digging deeper into life-and-death procedures, I asked Bard about the mortality rate for heart valve surgery at a couple of local hospitals. The prompt reply was impressively sophisticated. Bard provided hospital risk-adjusted mortality rates for an isolated aortic valve replacement and for mitral valve replacement, along with a national average for each (2.9 percent and 3.3 percent, respectively). The numbers were attributed to the Society of Thoracic Surgeons (STS), whose data is seen as the “gold standard” for this kind of information.

For comparison purposes I asked ChatGPT about those same national mortality rates. Like Bard, ChatGPT cited STS, but its death rate for an isolated aortic valve replacement procedure was much lower (1.6 percent), while the mitral valve death rate figure was about the same (2.7 percent).

Before dismissing Bard’s descriptions of the care quality of individual hospitals and doctors as hopelessly flawed, consider the alternatives. The advertisements in which hospitals proclaim their clinical prowess may not quite qualify as “truthiness,” but they certainly select carefully which truths to tell. Meanwhile, I know of no publicly available hospital or physician data that providers don’t protest is unreliable, whether from U.S. News & World Report or the Leapfrog Group (which Bard and ChatGPT also cite) or the federal Medicare program.

(STS data is an exception with an asterisk, since its performance information on individual clinicians or groups is only publicly available if the affected clinicians choose to release it.)

What Bard and ChatGPT are providing is a powerful conversation starter, one that paves the way for doctors and patients to candidly discuss the safety and quality of care and, inevitably, for that discussion to expand into a broader societal one. The chatbots are providing information that, as it improves, could finally trigger a public demand for consistent medical excellence, as I put it in book examining the budding information age 25 years ago.

I asked John Morrow, a veteran (human) data analyst and the founder of Franklin Trust Ratings how he would advise providers to respond.

“It’s time for the industry to standardize and disclose,” said Morrow. “Otherwise, things like ChatGPT and Bard are going to create pandemonium and lessen trust.”

As author, activist, consultant and a former Pulitzer-nominated journalist, Michael Millenson focuses professionally on making health care safer, better and more patient-centered.

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