unsrsly (u/unsrsly) - Readit News

unsrsly commented on “AI promised to revolutionize radiology but so far its failing” statmodeling.stat.columbi... · Posted by u/macleginn

nanidin · 4 years ago

I have very little experience with the existing medical establishment, so forgive me if I've imagined a scenario that is not relevant. I would like to be able to go to have a scan done, receive the scan data, then have the choice of submitting that to a radiologist of my choice or to an AI service of my choice that can read and recommend next steps. It seems like such a scenario is stifled by the existing way of doing things.

My experience with getting a sonogram was that the sonogram wasn't that expensive, but getting it read was hugely expensive. I understand that there are issues of liability, but it's really frustrating that I'm saddled with a high deductible healthcare plan where access to useful medical stuff is stuck behind 3-4 digit costs. Want antibiotics, inhalers, ADHD meds - all of which are pretty cheap in generic form? Pay $100 to the doctor for the privilege. People have very little agency in this system.

I guess at the end of the day I'd like to see open data (I'm able to get the images/data from all kinds of scans & diagnostics), and some kind of transparent system for submitting my data for diagnosis or analysis. There may be caveats & waivers, but I'd be willing to pay $10 to an AI service to tell me "You definitely need to consult with a radiologist based on the data presented" before I pay a radiologist orders of magnitude more to tell me that everything looks OK.

unsrsly · 4 years ago

You're making some very interesting and valid points. You've correctly identified that when receiving bundled services you lose the ability to negotiate or comparison shop on the basis of price. This is unfairly combined with a legal presumption that when the healthcare system generates a bill, the bill is valid until proven otherwise. Now, although we probably need more physicians, I don't think the limited supply of physicians is the primary reason for this situation - it's more due to increasing market concentration of health insurers on one side and hospital systems on the other, leading to regional monopolies that don't compete on price. In fact, with the decline of private practices and the rise of hospital systems, physicians receive less than 10% of all healthcare revenue. I can see that you'd like to unbundle your healthcare and regain control over prices, and I think that's a very reasonable thing to want.

unsrsly commented on “AI promised to revolutionize radiology but so far its failing” statmodeling.stat.columbi... · Posted by u/macleginn

nanidin · 4 years ago

I’m not sure, but it removes the conflict of interest (and subsequent gatekeeping) created by radiologists who don’t want technology to automate away some of their work.

unsrsly · 4 years ago

There's a lot to unpack here! In the USA, the ABR regulates human radiologists via board certification. Medical technology is traditionally regulated by the 510K, PMA, and de novo pathways at the FDA. Of course, these products still have to demonstrate value in order for major stakeholders (hospitals, radiology practices) to purchase them. And using these products does not absolve the ordering doctor, the radiologist, or the hospital of legal liability for misdiagnosis. In fact, IANAL and this is a somewhat novel area of the law, but any AI product that functions as a drop-in replacement for a radiologist might be held liable for misdiagnosis that leads to harm. These liabilities could become quite large for a product deployed at scale (a single misdiagnosis causing death can lead to a settlement in excess of 10 million dollars). In summary, there's quite a bit more to the issue than simple "gatekeeping." It might be appealing to blame radiologists for these issues, but there's a much larger system at work that's designed to ensure quality and safety for patients. This is not AdTech - lives are at stake and people can get hurt. Now, this definitely comes with a cost to innovation, but it's going to take more than just a few MD's to reinvent the economics and law of computers practicing medicine on people.

unsrsly commented on Machine learning is booming in medicine, but also facing a credibility crisis statnews.com/2021/06/02/m... · Posted by u/Ice_cream_suit

BiteCode_dev · 4 years ago

Unless the AI can talk tot the patient to get some context, it's going to be taking decisions with only very partial information, no matter how good it is.

Still, I'm thinking that as it improves, it's going to show that doctors are not that good at their job on average, and that's going to be fun to watch.

unsrsly · 4 years ago

> Still, I'm thinking that as it improves, it's going to show that doctors are not that good at their job on average, and that's going to be fun to watch.

Medical AI is trained on labels generated by doctors. Can you explain how it will exceed the performance of doctors on average? Are you assuming that the labels will be generated by the "top x%" of doctors? If so, how will you identify those individuals? Or is there some other mechanism you're expecting to improve the performance?

unsrsly commented on “AI promised to revolutionize radiology but so far its failing” statmodeling.stat.columbi... · Posted by u/macleginn

nanidin · 4 years ago

> Further, Radiologists standards of practice are driven partly by their board (The American Board of Radiology) and the supply of labor is also controlled by them (The American Board of Radiology) by way of limited residency spots to train new radiologists.

Perhaps it is time to found the American Board of Computational Radiology (or Medicine)? There seems to be a chilling effect on tech innovation in the medical space in the US. On recent trips to the dentist, it seems like most of the cool new tech is coming out of Israel.

unsrsly · 4 years ago

Interesting, how would the standards of the Board of Computational Radiology be set? Is the implication that the current standards are too high?

unsrsly commented on “AI promised to revolutionize radiology but so far its failing” statmodeling.stat.columbi... · Posted by u/macleginn

jollybean · 4 years ago

Family member worked on a board of a hospital, they raised charitable donations to buy more powerful software for the radiologist.

The radiologist can now work 10x faster and still bills the hospital the same amount.

The Doctor's Guild is exceedingly powerful.

I really wish Wallmart or Amazon would get into providing healthcare services on the long tail - a lot of common stuff.

I sounds odd but both those companies are built around ripping margins out of the value chain and not keeping much for themselves.

Ok, maybe not either of them ... but something like that: The 'Walmart of Healthcare' that revolutionizes cost.

Also - there are enough Medical Practitioners who would work there. Enough of them do care about patient outcomes, cost etc..

unsrsly · 4 years ago

There is zero chance the software allowed the radiologists to work 10x faster... what?

unsrsly commented on “AI promised to revolutionize radiology but so far its failing” statmodeling.stat.columbi... · Posted by u/macleginn

TuringNYC · 4 years ago

>> seismic interpretation here

Strong disagree here. Lets put aside the math and focus on money.

I dont know much about seismic interpretation, but I know a lot about Radiology+CV/ML. I was CTO+CoFounder for three years full time of a venture-backed Radiology+CV/ML startup.

From what I can see, there is a huge conflict of interest w/r/t Radiology (and presumably any medical field) in the US. Radiologists make a lot of money -- and given their jobs are not tied to high CoL regions (as coders jobs are), they make even more on a CoL-adjust basis. Automating these jobs is the equivalent of killing the golden goose.

Further, Radiologists standards of practice are driven partly by their board (The American Board of Radiology) and the supply of labor is also controlled by them (The American Board of Radiology) by way of limited residency spots to train new radiologists.

So Radiologists (or any medical specialist) can essentially control the supply of labor, and control the standards of best practice, essentially allowing continued high salaries by way of artificial scarcity. WHY ON EARTH WOULD THEY WANT THEIR WORK AUTOMATED AWAY?

My experience during my startup was lots of radiologists mildly interested in CV/ML/AI, interested in lots of discussions, interested in paid advisory roles, interested in paid CMO figurehead-positions, but mostly dragging their feet and hindering real progress, presumably because of the threat it posed. Every action item was hindered by a variety of players in the ecosystem.

In fact, most of our R&D and testing was done overseas in a more friendly single payer system. I dont see how the US's fee-for-service model for Radiology is ever compatible with real progress to drive down costs or drive up volume/value.

Not surprisingly, we made a decision to mostly move on. You can see Enlitic (a competitor) didnt do well either despite the star-studded executive team. Another competitor (to be unnamed) appears to have shifted from models to just licensing data. Same for IBM/Merge.

Going back to seismic interpretation -- this cant be compared to Radiology from a follow-the-money perspective because seismic interpretation isnt effectively a cartel.

Happy to speak offline if anyone is curious about specific experiences. DM me.

unsrsly · 4 years ago

Interesting, can you give an example of a radiologist hindering progress? You make an interesting point about radiologists setting practice standards - what alternative do you propose? You may also want to consider that radiologists don't determine practice standards in a vacuum - they have to serve the needs and expectations of their clinical colleagues.

unsrsly commented on The Trouble with Brain Scans nautil.us/issue/98/mind/t... · Posted by u/dnetesn

ska · 4 years ago

I don't really know what you are responding to here.

As I posited, there is research interest and a few people doing it clinically. Your links support this. What they don't support is the idea that this is typical clinical practice.

unsrsly · 4 years ago

For those interested, here's a nice Tweet and video from a neurosurgeon at the Mayo clinic in Arizona demonstrating the use of both fMRI and intraoperative motor mapping: "Preoperative and Intraoperative mapping help with selection, safety and strategy."

https://twitter.com/BernardBendokMD/status/13785056756894556...

unsrsly commented on The Trouble with Brain Scans nautil.us/issue/98/mind/t... · Posted by u/dnetesn

scotty79 · 4 years ago

> Awake cortical mapping

She had that too.

> This is why fMRI is often used as a planning step before awake cortical mapping during the actual surgery.

That must have been the case.

I guess surgeons were trying to do whatever was in their power to not damage her speech center. Right after operation she had a few brief seizures when she lost ability to speak for a minute or two, but as the damage healed they quickly stopped.

unsrsly · 4 years ago

That must have been scary, but I'm glad she had a good outcome.

unsrsly commented on The Trouble with Brain Scans nautil.us/issue/98/mind/t... · Posted by u/dnetesn

ska · 4 years ago

> I'm not on the outside of medicine.

Fair enough, I didn't mean to suggest you were I was speaking more generally but worded that poorly.

My comments come from systems supporting thousands of clinical neurooncological procedures (i.e. tumor resections) in planning and execution with very little interest or utilization of fMRI beyond a handful proponents and their sites. Quite literally barely on the radar of most of the neurosurgeons apart from occasional papers, and some of them are quite negative about it also.

I could have an inaccurate picture of the breadth of clinical practice, and it's certainly a couple years out of date, but I would be very surprised to find a huge upsurge of usage outside research had happened.

It is certainly the case that the articles claim of "transformation" hasn't happened in that space.

If the article had instead claimed that some of the trickiest cases tend to have fMRI done (true, surgeons will take all they help they can get trying cases that otherwise might be inoperable) or that they are a feature of high profile academic sites (also mostly true) I wouldn't have objected.

unsrsly · 4 years ago

I respect your experience, and I'll concede that fMRI for pre-surgical planning in neurooncology is used at only some centers. If you worked mainly in neurooncology you may have missed some of the uses of fMRI for epilepsy surgery. Thanks for the discussion.

unsrsly commented on The Trouble with Brain Scans nautil.us/issue/98/mind/t... · Posted by u/dnetesn

ska · 4 years ago

> "Functional magnetic resonance imaging has transformed medicine."

This is not even close to true. The clinical impact of fMRI is very constrained. I've met many clinicians who have completely written it off at this point. Others that remain interested but find it mostly impractical and error prone. The only people I've met who seem to have any significant investment in it as a technology are cognitive scientists, and that's a ways from medicine.

> It allows non-invasive mapping of a patient’s brain regions to enable more accurate, precise neurosurgery,1"

Approximately nobody does this. fMRI isn't really even on the radar for most neurosurgeons. It's only recently that even detailed structural information (e.g. DTI) has got some real traction, let alone functional info. Note commercial vendors have had clinical packages on the scanners for (nearly? I forget who shipped DWI stuff first) a couple decades now. No such thing exists for fMRI, at minimum you need to buy a 3rd party processing system and may need a research key on your scanner.

Some researchers are interested in this; that's a long way from transforming anything.

> " as well as validating pharmacological effects of potential drugs on human brains.2"

There is perhaps a bit more promise here, but it's still way into the research only end. In the 15 years since the referenced paper was published, not much of this "promise" has been realized as far as I know (but this is further from my wheelhouse)

unsrsly · 4 years ago

> No such thing exists for fMRI, at minimum you need to buy a 3rd party processing system and may need a research key on your scanner.

This is not the case, for example see the GE BrainWave software.

https://www.gehealthcare.com/products/advanced-visualization...