Josh Briscoe

@jbriscoe.bsky.social

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Hospice and Palliative Care Physician #MedPsych #MedSky #HAPC #Bioethics Writing @ Notes from a Family Meeting: https://familymeetingnotes.substack.com

Dr. Paisley’s brow furrowed. “I will say, it looks like you’re spending about an average of three minutes per encounter on non-clinical chatter. Hmm. The weather, patient vacations. Of course, of course we want our patients to feel welcome, but…” A pie chart grew on the wall. “If you reduce that to just one minute, you’ll be able to see seven more patients in a day! Goodness, look at that. Three minutes of non-clinical puts you in the bottom 10th percentile. Friendly, but inefficient!”
The PPP is grounded on the presumption that a patient with the capacity to make a decision is given information and they yield a response. It treats the patient as a machine, which is why we believe a machine could so easily replace them.2 But that’s not how decision-making works. It’s laden with emotion and values. It’s fraught with negotiation. Most people aren’t sitting at home pondering their...
I’m amazed anyone could believe that once an AI scribe saves a clinician time, administrators will leave the reclaimed time untouched. If a clinician could see 14-16 patients in a day without an AI scribe (already a number too high for primary care and most sub-specialties), surely they could see 20-25 patients with an AI scribe. The encounters become shorter because what is expected isn’t human connection but a technical service rendered ever more efficiently by other tools in the AI suite. That reclaimed, unbillable time shouldn’t be given back to those 14-16 patients because presumably those encounters are already optimized. It should be given to 6-9 other patients who can be seen today instead of next week. This isn’t good for the clinicians but the encounter isn’t about them. They are parts in the machine, and may soon be expunged by AI anyway. Ironically, neither is it good for the patient who finds themselves treated as a bureaucratic client, a machine, or an animal, depending on the flavor of dehumanization their condition warrants.
Dr. Paisley’s brow furrowed. “I will say, it looks like you’re spending about an average of three minutes per encounter on non-clinical chatter. Hmm. The weather, patient vacations. Of course, of course we want our patients to feel welcome, but…” A pie chart grew on the wall. “If you reduce that to just one minute, you’ll be able to see seven more patients in a day! Goodness, look at that. Three minutes of non-clinical puts you in the bottom 10th percentile. Friendly, but inefficient!” An item popped up on Winston’s to do list at the bottom right hand corner of the wall: Complete efficiency module #151.
This woman upon admission to the intensive care unit had a health status of 5. Today, as the resident gives updates to the patient’s husband, the woman’s health status is a 6, because all else is unchanged apart from the kidney function. In no way should the conversation highlight that things are “better.”
Our work flows from our beliefs, however inchoate, about the good life. Our work also shapes what we take to be the good life. It shapes our life anyway. We might not see it right away, but that’s why Crawford invites us into a closer reading of our lives and work
I’m not sure anyone predicted the EMR would be so quickly and completely co-opted for non-clinical interests, chiefly to be used for billing and coding. After that there are medicolegal uses of documentation. Trailing, frail and almost forgotten, are the actual clinical uses of documentation. The EMR is already used as a form of surveillance, though it is a blunt instrument as it depends on the clinicians’ honesty and thoroughness in being their own clerk. “If you don’t document it, it didn’t happen.” Understood in a certain way, that’s just not true: the patient really did receive a thoracentesis whether it was documented or not. You really did palpate their abdomen whether it was documented or not. But in another way, in the way that administrators, lawyers, and billers care about, it absolutely did not happen if it wasn’t documented. The note doesn’t just reflect reality. It is reality. When EMRs were first being broadly deployed in the United States, clinicians were encouraged to adopt them and demonstrate “meaningful use” - e.g., writing electronic orders. There were some incentives that went along with this. Now, as far as I know, there aren’t any more carrots. There are only sticks, ranging from polite reminders to addend or update documentation to accord with coding rules all the way to temporary banishment from the EMR if you’re delinquent on certain forms of documentation.
We shouldn’t hide behind the belief that a patient’s mere choosing means they “accept the risks.” Patients are vulnerable. Trade-offs are necessary. Choosing isn’t a means of defying or defending one’s vulnerability, but should be recognized as a fragile act carried out in the context of that vulnerability. Trade-offs come with the territory.
Dr. Paisley’s brow furrowed. “I will say, it looks like you’re spending about an average of three minutes per encounter on non-clinical chatter. Hmm. The weather, patient vacations. Of course, of course we want our patients to feel welcome, but…” A pie chart grew on the wall. “If you reduce that to just one minute, you’ll be able to see seven more patients in a day! Goodness, look at that. Three minutes of non-clinical puts you in the bottom 10th percentile. Friendly, but inefficient!” An item popped up on Winston’s to do list at the bottom right hand corner of the wall: Complete efficiency module #151.
illness is the abnormality that reveals what is normal
Given the time pressures on clinicians, AI documentation is an unstoppable tsunami, a wave that will wash over our work lives, with no way of turning it back. Perhaps there will be technical “fixes” to help the virtual AI creature in my exam room better sort the wheat from the chaff, or learn my charting preferences. What is less likely is that primary care physicians will be able to regain control over our relationships and the means of production of our notes without a fundamental shift in the balance of power — a concerted move away from a corporate-controlled, transactional, assembly-line model toward a more patient- and clinician-centered redesign of primary care.
All experts were at one time novices; all masters were once newbies. Every one who wants to learn the craft will grapple with inexperience. The technical mindset, on the other hand, is probably held with ambivalence.2 Sure, it’s good to be efficient, maybe it’s sometimes necessary to be reductionistic, and perhaps we can trick ourselves into believing we’re amoral, and all this might require trading off warmth and compassion. Some clinicians might willingly make that trade, but many do without knowing it. A virtue-based frame of moral development could respond to both challenges. For the inexperienced, it could help orient education not toward knowledge acquisition for its own sake, which is not the purpose of the clinical encounter, but toward restoring and sustaining health. For those captured by the technical mindset, this frame helps enliven and humanize their practice of medicine by orienting it toward something more meaningful than efficiency for its own sake. A virtue-based frame can help clinicians attend to the moral landscape of the clinical encounter, sustain presence amidst distraction, and care well for their patients, colleagues, and themselves. It also acknowledges that the clinicians themselves, not just their tools, are part of the healing process of the clinical encounter.
Today’s AI mirrors tell us what it is to be human, what we our- selves care about, what we find good, or beautiful, or worth our attention. It is these machines that now tell us the story of our own past, and project our collective futures. They do so without living even one day of that history, or knowing a single moment of the human condition. What happens to a person, or an intel- ligent species, when they stop telling their own story? What do we lose when self-knowledge and self-determination yields to the predictive power of an opaque algorithm?
The cover of the children's book "If You Give a Mouse a Cookie," featuring a mouse holding a cookie.
The fox's struggle to reach the grapes mirrors our ongoing efforts to include older adults in clinical trials. Much like the fox's fruitless leaps, our attempts to create meaningful, inclusive research in geriatric oncology often fall short of their goal. Even when older adults are included in trials, the outcomes measured frequently do not align with what matters most to them.
The lesson for those who would seek their healing from machines (or the Machine) is to behold how easily technology slips between humans, promising to enhance their relationships. Instead, it modifies them. It sets the tone. It frames the questions. It shapes the vision. For health and medicine, does that matter? Only to the extent that we believe people are more than machines themselves.
Consider how impressive a boundary this is - someone can have literally tens of thousands of fans for doing popular writing in a field, and the amount of extra status it gives them in the field is within a rounding error of zero. Only your reputation within the priesthood matters.
Not only are we prone to error, but we’re prone to evil. This state should temper our expectations for any technology that claims to be an enhancement because the object being enhanced (the human) as well as the one enhancing (the human) are so limited.
With the man and the boy together in this apocalypse, we see something only that relationship could show us: what it means for one to care for the other even as the other cares for them in return. The Road shows us that at the end of all human ingenuity, when every tool has failed, two people might carry each other along in love. That’s what we need: a willingness to bear with our companions as we accompany them in love, even when it feels like we’re wandering in a wasteland. It’s something only humans can share. It can’t be manufactured or sold, it’s not novel or flashy, and it can’t be distilled into a five-point plan. Instead, maybe the robot apocalypse will give us eyes to see one another for the first time in a long time.
By declaring that it is in fact appropriate to cause the death of a particular kind of patient who meets prespecified eligibility criteria, physician-assisted death necessarily denies that it is unconditionally good for that person to exist. If the goodness of that person’s existence is only conditional, then they do not have intrinsic value. And if the goodness of some people’s existence is conditional on the desirability of their lives to them, then this is true for all of us. Hence the goodness of existence is conditional for all of us, and none of us have intrinsic value. In this way, support for physician-assisted death forces us to deny that people have intrinsic value. It remains to us only to have extrinsic value, whether to ourselves or to anyone else. And since mere extrinsic value is a lesser and conditional form of value in comparison to intrinsic value, physician-assisted death detracts from human value. It devalues people.
— Is this a technology that actually empowers users with agency to accomplish the work they choose for themselves? — Or, is this a technology that will entrap users in systems which create new forms of dependency and diminish self-directed agency? — Will this technology generate an experience of real-world competency, or will it undermine the possibility of such an experience by promising to automate essential and meaningful labor? — What implicit values will this technology bring into an existing social ecosystem? How will it erode the existing values that animate the institution or group it seeks to serve? — In designing/adopting this technology, are we merely evangelists for a soulless gospel of optimization and efficiency? — Because computerized systems excel at generating data of varying degrees of quality and usefulness, will this technology introduce measures and metrics into spheres of life where they do little good and mostly induce unnecessary anxiety and competitiveness? — What versions of “modernized poverty” will this technology introduce into communities and sectors of society which are already under-resourced and inadequately supported? — Will this technology introduce new social divisions and promote disabling hierarchies in the social ecosystem in which it is deployed? — If the technology fails or if it is discontinued, will it leave its users worse off than they would have been had the technology never been introduced in the first place?
I sometimes hear health-care professionals speak of the benefit of physician-assisted death for patients in terms of the relief of fear and anxiety for patients prior to their death. By offering them control of the timing and manner of dying, some patients feel a sense of relief and freedom. These are undoubtedly important benefits, benefits that could also be largely achieved through assurance of high-quality palliative care through the dying process. What is striking about the notion of benefit here is that it is entirely accrued prior to the administration of any actual intervention. It is the anticipation of death, not the actual death, that is the means of this benefit. To evaluate the benefit of a treatment based on how a patient feels _before_ receiving it rather than based on how they feel _after_ receiving it is, to put mildly, very unusual.
The uncertainty of death is of particular importance and relevance for practicing health-care professionals. The uncertainty of death should make the use of death as a remedy for suffering entirely off limits. No responsible doctor or nurse can administer a drug whose effects are completely unknown to them. Because doctors and nurses have no idea what it’s like to be dead, causing a patient’s death in order to render them better off is akin to starting a patient on experimental therapy and then never following up to see what happens to them. Those who provide assisted death are acting out of blind faith in their own conception of what it is like to be dead. In the absence of medical evidence according to the usual standards, this seems deeply irresponsible.
This loss of intrinsic value and this reliance on our own will to assert our extrinsic value creates huge problems for our self-worth. I might demand respect from others, but what basis do I have to merit respect from myself? My own value is at bottom a matter of sheer choice. Such an arbitrary basis for human value is incredibly thin and cannot withstand any of the pressures that tempt us to devalue ourselves—we have little response to anything that leads us to doubt our self-worth, our significance, or the meaningfulness of our existence. Certainly we cannot look to others for reassurance of our value—what authority do they have to recognize value in us if we do not recognize it in ourselves? If I am the sole basis for determining my value, then I have no real cause to assign myself any value. In making ourselves the source of our own value, we undermine any basis for actually being valuable.
What, then, does this say about the value of those who receive assisted death or who are potentially eligible for assisted death in comparison to those who are not eligible? Those for whom existence is deemed optional cannot possibly have the same value as those for whom existence is deemed essential. And if the existence of some persons is regarded as optional, then they do not have unconditional intrinsic value. Indeed, since existence could become optional for any of us (if we were to develop a serious disability or chronic illness, then we would become potentially eligible for assisted death), this would imply that nobody really has unconditional intrinsic value. As we have seen, if something has intrinsic, inherent, and unconditional value, then it is always good that it exists. If it is not always good that it exists, then it cannot have intrinsic, inherent, and unconditional value. Instead, if we have any value at all, that value would have to be extrinsic and conditional and dependent on some “valuer.”
Once you have reduced the concept of human intelligence to what the markets will pay for, then suddenly, all it takes to build an intelligent machine — even a superhuman one — is to make something that generates economically valuable outputs at a rate and average quality that exceeds your own economic output. Anything else is irrelevant.
. Either Ethicists, clinicians, and the courtsmust concede to the philosophical and political pressures driving the negative viewand remain neutral with respect to moral-metaphysical claims, which would requirepermitting Jehovah’s Witnesses and Christian Scientists to deny their children medi-cal treatment, or they must admit that these moral-metaphysical worldviews arerationally insufficient to warrant risking the deaths of children, which would requireconceding that ethicists have some ability to demarcate the boundaries of ethicallyacceptable options in the clinic.
Diekema’s claim that Jehovah’s Witnesses and Christian Scientists would violatethe harm principle in the cases he presents is not a conclusion that can be drawnfrom the harm principle as he formulates it, but one already presupposed by the met-aphysic he smuggles in. To demonstrate this, a flip test can be applied to Diekema’seight requirements. Suppose Diekema finds himself as a clinical ethicist in a societywhere ninety-five percent of people subscribe to the Jehovah’s Witness religion. Insuch a situation, how might Diekema’s questions fare if a parent requested a bloodtransfusion for their child? By requesting the intervention (in this case, a bloodtransfusion), are the parents placing their child at a significant risk of serious harm?Is the harm imminent, requiring immediate action to prevent it? Can the state inter-vention be generalized to all similar situations? Would most parents agree that thestate intervention was reasonable?24 In this hypothetical Jehovah’s Witness society,would not all these questions be answered in the affirmative? Following Diekema’sharm principle, the state would refuse to honor parental requests for blood transfu-sions for their children.Diekema’s harm principle thus leads to an opposite result when the metaphysicof those deploying the principle is changed. The substantive guidance of the harmprinciple comes from the metaphysic of those deploying it, not from the formulationof the harm principle itself.
A table describing the function of war metaphor in patient narratives pulled from a paper by Monica Bodd, et al.
Magic was, is, and always will be the attempt to predict how the hidden forces of nature will behave and to harness that power for one’s own use. This is the muttering of an ancient magus to curse his enemies, the “secret power” of the physician to diagnose disease by palpating a pulse, and the microscopic work of chemistry to lower blood glucose, kill cancerous cells, or cure an infection. The history of medicine and the history of magic are one. This is also why medicine’s history of development doesn’t track exactly with the structure of scientific revolutions. Medicine isn’t science.
Clinicians are eager to help those who suffer, and yet sometimes all we can do fails to alleviate suffering because suffering is more than a medical phenomenon. Eventually, all we can do will fail to help folks live longer and better. In the face of such failure, ASE is an attempt to wrest back control, for both the clinician and the patient. But death is unwieldy. We’ll hurt ourselves and others with it. The bloom may look like compassion, but its odor is poisonous. Death can’t be a goal of care.
Clinicians might declare “victory” when they’ve improved the surrogate marker of their particular disease or organ, but they’ve actually been playing a different “game” than one that benefits their patient. This maybe has happened because they’ve taken on an end for the sake of the means - they’re more enamored with the techniques of their work and the ends supplied by those techniques (“metrics”), than the more nebulous, harder-to-measure state of health of their patient which originally piqued their altruism.