What do the Air Force and family medicine have in common? AI

This year, I did a lot of reading about current and future applications of artificial intelligence (AI) in health care - for example, how it will reduce the grunt work of selecting future physicians; become a required competency in medical education; provide relief from overflowing primary care electronic in-baskets; and provide clinical decision support for treating patients with depression. I've read pessimistic commentaries about chatbots and large language models being a "Pandora's box" and more optimistic pieces arguing that generative AI can overcome the "productivity paradox" of information technology: that is, it won't take decades to see large gains in health care quality and efficiency, as we haven't seen with implementation of electronic health records. Meanwhile, regulatory authorities are still struggling to catch up to ensure the safety of AI products without discouraging technological innovation. (And while I was retrieving these articles online, Microsoft Bing's AI-enabled search engine kept trying to take over writing this blog post.) But the most interesting article that I read about AI this year had nothing to do with health care. It was about the U.S. Air Force.

"AI brings the robot wingman to aerial combat," declared the science fiction-sounding headline of this August 2023 New York Times story. It discussed the XQ-58A Valkyrie, a pilotless "collaborative combat aircraft" described as "essentially a next-generation drone." Eying a seemingly inevitable armed conflict with China over the disputed island of Taiwan, U.S. Air Force war planners hope that these robot wingmen (wingAIs?) will not only be far less expensive to produce than conventional piloted warplanes, but also spare the lives of many human pilots who would otherwise be shot down by China's vast antiaircraft apparatus. Why expect our flying servicemen and women to become casualties while performing exploits of derring-do when a fearless AI can complete the same mission at a fraction of the risk?

Military AI raises ethical dilemmas, of course. Behind every drone attack on suspected terrorists is a human being who has judged (rightly or wrongly) that the target is indeed a wartime adversary and fair game. But "the autonomous use of lethal force" - the idea that AI could be making kill decisions without any human signoff - makes many people uneasy. The Pentagon, naturally, dodged a reporter's question about whether the Valkyrie aircraft could eventually have this capability.

Similarly, I could imagine that in the next decade or two (before the end of my career) AI could be developed to perform many of the basic functions of a physician assistant in primary care: ordering recommended screening tests and vaccines, titrating medications for hypertension and diabetes, and deciding whether or not to prescribe antibiotics or antiviral drugs for patients with acute respiratory illnesses. Physician supervision would probably consist of reviewing charts and signing off on them at the end of a clinical session rather than double-checking the AI's decisions in real time. Would that mean that AI would be autonomously practicing health care? Sure it would. Would this application be easier or harder to adjust to than formations of armed Valkyries using machine algorithms to identify enemy personnel and shooting to kill?

My favorite public health and health care books of 2023

This year's annual list of my favorite reads includes two works of fiction and eight real-life narratives about cancer, the history of medicine, rural family practice, and urban street medicine. As usual, I have listed them alphabetically by title rather than in any order of preference. For more great titles, feel free to peruse my lists from 2022, 2021, and 2015-2020. Other than the occasional free book to review for Family Medicine, I don't receive anything for reading or sharing them.

**



1. Chasing My Cure: A Doctor’s Race to Turn Hope into Action, by David Fajgenbaum



2. From Whispers to Shouts: The Ways We Talk About Cancer, by Elaine Schattner

3. Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine, by Jim Downs



4. The Masters of Medicine: Our Greatest Triumphs in the Race to Cure Humanity’s Deadliest Diseases, by Andrew Lam



5. Medicine and Miracles in the High Desert: My Life Among the Navajo People, by Erica Elliott



6. The Other Dr. Gilmer: Two Men, A Murder, and an Unlikely Fight for Justice, by Benjamin Gilmer



7. Rough Sleepers: Dr. Jim O’Connell’s Urgent Mission to Bring Healing to Homeless People, by Tracy Kidder



8. Take My Hand, by Dolen Perkins-Valdez

 

9. That Time I Got Cancer: A Love Story, by Jim Zervanos

 


10. 2060, by Richard Young

Will the high price of gene therapy for sickle cell disease put this cure out of reach?

On December 8, 2023, the U.S. Food and Drug Administration (FDA) approved Casgevy, the first gene therapy utilizing clustered, regularly interspaced short palindromic repeats (CRISPR) for the treatment of sickle cell disease in patients 12 years and older. Mimicking a protective mutation that causes fetal hemoglobin (HbF) to persist into adulthood, Casgevy uses the CRISPR-Cas9 enzyme to edit a patient’s own blood stem cells to intentionally disable a DNA “brake” on HbF production. The modified stem cells are transplanted back to the patient and result in the production of high levels of HbF, preventing the sickling of red blood cells and eliminating or greatly reducing future painful vaso-occlusive (VOC) crises. In an ongoing single-arm trial—initial results were published in 2020—29 out of 31 treated patients had no severe VOC episodes for at least 12 consecutive months during the 24-month follow-up period.

The approval of Casgevy, which has a list price of $2.2 million for the single course of treatment, had been anticipated for months. However, the number of the estimated 100,000 Americans affected with sickle cell disease who will be able to afford it is unclear. Although the lifetime medical costs associated with sickle cell disease average $1.7 million, insurance companies may be unwilling to pay the exceptionally high up-front cost of this curative therapy. Compared with standard of care, one analysis found gene therapy to be an equitable strategy for U.S. patients per distributional cost-effectiveness analysis standards. Obstacles in addition to cost include needing to undergo chemotherapy and being hospitalized for months until the patient’s immune system recovers.

In Africa and India, which are home to most of the world’s population living with sickle cell disease, many patients die in childhood because of lack of access to standard-of-care treatments. For example, hydroxyurea, which reduces the frequency of VOCs and prolongs survival, was approved by the FDA in 1998 but remains unavailable to most patients. Experts recently proposed expanding the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) to provide hydroxyurea therapy for $67 per person to sickle cell patients in sub-Saharan Africa at a total cost of less than $100 million per year. That modest budget would barely begin to meet the needs of those potentially eligible for gene therapy, even if they were able to travel to one of the only three centers for bone marrow transplants in Nigeria, Tanzania, and South Africa.

**

This post first appeared on the AFP Community Blog.

As goes college, so goes health care?

My oldest child is applying to college this year. He is an outstanding student and likely to be offered significant scholarships, so my wife and I are not concerned about him (and us) being able to afford the tuition to the college he ultimately chooses. Tuition and fees at U.S. colleges actually increased at a lower rate than general inflation from 2022-23, breaking a 20-year trend that saw tuition increases for private and out-of-state public schools far outpace concurrent rises in incomes and costs of living. As a result, college has become less and less affordable, particularly for students who end up relying mostly on loans and rack up gigantic debt loads even if they don't complete their degrees.

But college-educated adults earn a lot more money than those without college diplomas, so going to college still makes economic sense, right? Maybe not. A few months ago, a New York Times Magazine story by Paul Tough (whom I've quoted previously on my blog) discussed "the new economics of higher ed." He cited the work of three researchers at the Federal Reserve Bank of St. Louis who found that looking at wealth accumulation rather than income, college graduates born in the 1980s or later had little advantage over their peers who didn't gradate from (or even start) college, with Black and Latino college graduates worse off than White college graduates. Data on postgraduate degrees was even more bleak: there seemed to be no wealth advantage at all.

Millennials with college degrees are earning a good bit more than those without, but they aren’t accumulating any more wealth. How can that be? ... The likely culprit, [one researcher] said, was cost: the rising expense of college and the student debt that often goes along with it. Carrying debt obviously diminishes your net worth through simple subtraction, but it can also prevent you from taking important wealth-generating steps as a young adult, like buying a house or starting a small business. And even if you (or your parents) were able to pay your tuition without loans, the savings you used are gone when you graduate, and thus are no longer available to serve as a down payment on a starter home or the beginning of a nest egg for retirement.

Fueled by skyrocketing tuition costs, total student loan debt more than tripled from $500 billion in 2007 to $1.6 billion today, and in an even more stunning statistic, "among student borrowers who opened their loans between 2010 and 2019, more than half now owe more than what they originally borrowed."

It's possible that demographic trends will act to moderate tuition costs in the future; as the pool of students finishing high school shrinks, colleges may need to keep tuition increases low to compete financially. For the sake of my pocketbook (my high school senior son is the oldest of four children), I certainly hope so. But reading about higher education made me think about another sector where costs and fees have been rising exponentially while the return on investment is middling and the quality of the product remains opaque: health care.

Since 1980, the U.S. has spent more on health care as a percentage of its gross domestic product than any other country in the world; today, nearly 1 in 5 dollars generated by the American economy goes to the purchase of health care. Yet average life expectancy stopped rising in 2010 and plummeted during the first two years of the COVID-19 pandemic, far more than in comparable countries where the average resident lives 5-6 years longer than we do. Further, U.S. men now are expected to die 6 years earlier than women, the widest gender gap in nearly 30 years, according to a recent study in JAMA Internal Medicine. The biggest drivers of this gap were deaths from COVID-19 and drug overdoses, which medicine can prevent with highly effective interventions: vaccines, medications to treat opioid use disorder, and the opioid reversal agent naloxone.

It's not that patients aren't enthusiastic about prevention. We spend $35 billion per year on largely worthless over-the-counter dietary supplements. According to a recent analysis of data from the National Ambulatory Medicare Care Survey, the proportion of primary care visits "with a preventive focus" increased from 12.8% in 2001 to 24.6% in 2019. But the services doctors provide at those "wellness" visits - mammograms, PSA tests, colorectal cancer tests, and CT scans for lung cancer - generally don't help people live longer and often lead to unintended harms. While discrete medical services don't save lives, we know that having a relationship with a primary care physician does. Good luck getting in to see one, though, when the pay gap between primary care and subspecialists discourages medical students from becoming family physicians, and the percentage of health care dollars invested in primary care nosedived from 2013 to 2020.

Will the U.S. eventually reach a "breaking point" when, like college today, people realize that they are being fleeced by a self-perpetuating sick care system and demand greater value for their money? Such as sending more of the trillions of dollars spent on health care toward primary care? Some states are starting to recognize the wisdom of increasing primary care spending, but progress has been slow. Our country would do well to heed this advice that I've adapted from food writer Michael Pollan: Get real health care. Not too much. Mostly primary care.