Let Robots Prescribe Medicines?

Dr. Amos-Google

Dr. Amosbot

I wonder if we should just let robots prescribe certain medications like opioids and benzodiazepines now that I’ve just read the story about a California physician on trial for second-degree murder for prescribing the alprazolam that some patients accidentally overdosed on while misusing them.

They overdosed and died, yes. Was the physician a bad-to-the-bone murderer? That’s debatable, at the very least. But it is critically important to ask ourselves, as a society, how to safely prescribe certain drugs and who should prescribe them.

By the way, alprazolam is not a painkiller, as the article seems to imply, initially. It’s an anxiolytic which, for some patients, can become addictive. On the other hand, it can be a very effective anti-panic agent although it probably should not be prescribed on a long-term basis for most anxiety sufferers. And there is also the well-known potential lethality of legitimate painkillers like opioids, another class of drugs associated with high accidental and intentional overdoses.

There’s no doubt bad doctors are out there and a recent story drives that point home in no uncertain terms, saying “Hospital are dangerous places” where patients are “killed” and “Doctors and hospitals are doing a poor job of policing themselves…”

Physicians are apparently also doing a poor job in clinics all over the U.S. A small percentage are primary care physicians (but remember, the vast majority of them are hard-working, outstanding doctors), which prompts a couple of questions:

  1. Should we be allowing psychiatrists only to prescribe these drugs?
  2. Should we be letting robots prescribe these drugs?

I can tell you that psychiatrists are in high demand and short supply, as pointed out in the article at the link, the author citing statistics indicating many psychiatrists are aging out–60% of them are 55 years old and up, me included. The number of psychiatrists will likely continue to shrink, influenced by stigma and the perception that we’re paid less (true), which won’t help the average medical school and residency graduate manage the huge educational loan debt they’ve accumulated. While the Affordable Care Act (ACA) may be exacerbating the situation by increasing the population of patients covered by insurance, there’s another population that’s aging in–the baby boomer geezer generation with their increasing medical challenges. That may be an even bigger problem and there’s only one solution I can see.

These geezers need to stop getting older, immediately if not sooner!

I can also tell you that Maintenance of Certification (MOC) will not ensure safer patient care. It might ensure early retirement for a growing number of doctors who don’t have time for trivial, time-wasting, irrelevant exercises in medical minutiae.

I wondered if there is a political solution to the problem, until I read this article. Note that Donald Trump has nearly nothing to say about mental health issues…I’m just sayin’. And if you vote for me, I promise…

So let’s go back to my original speculation, which is whether or not we should let robots prescribe potentially dangerous drugs. I was going to say that this approach might get rid of the emotional side of prescribing for most physicians:

Patient: Doctor, I’m in so much pain and it makes me very anxious.

Dr. Robot: No.

Patient: But Doctor, I just broke my leg in two places and I’m so anxious I can barely breathe!

Dr. Robot: No.

Patient: I think I’m going to faint and…

Dr. Robot: No.

Maybe not. In fact, some futuristic multimillionares like Martine Rothblatt are bankrolling the production of robots who retain that human element of emotion, like Bina48, an android which seems almost as sentient and vulnerable as the flesh and bone person on whom it (she?) was modeled at Martine’s behest.

OK, so maybe a little creepy…and maybe we don’t want that much feeling in the clinic when a cold-blooded addict travels hundreds of miles to connive a trusting physician into prescribing a controlled substance. We need a Goldilocks Robot Doc, somebody not too cold and not too hot.

Hey, it’s not so far-fetched; bots can be bellhops–maybe they can also pass pills in hospitals. Still, it makes me think of Douglas Adams’ video game bots in Starship Titanic back in the Windows 95 era (it didn’t play well on our PC either).

While I think it’s possible that tying 30% of a hospital or clinic administrator’s salary to safer prescribing might work–there are a lot of administrators out there who might be bad to the bone.

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Comments

  1. Jim,

    As you probably know this topic is one of my favorites and I lecture on it about 20 times per year. You propose an interesting paradigm because I would speculate that machine prescribing would closely emulate suboptimal human prescribing. The reason is that they both follow highly flawed algorithms of the general sort: “I am here to help patients” -> “Prescribing medication for a specific diagnosis or at the patient’s request for that diagnosis is helping patients” -> therefore I am going to prescribe this medication.

    Those algorithms follow oversimplified and flawed logic and ignore a number of high-risk scenarios. They also minimize the decision-making step that requires the physician to say why a medication in contraindicated or why they will never prescribe it. There are many scenarios that distinguish competent prescribers from incompetent ones and I have diagrammed a few in this bubble diagram:

    http://real-psychiatry.blogspot.com/2014/04/overprescribing-bubble-diagram-explained.html

    Regulators that are quick to blame physicians for overprescribing seem to not understand that this problem is widespread and encompasses plenty of non-psychiatric medications – antibiotics being the best case in point. They also seem to think that a CME exercise in rote learning will make competent opioid and benzodiazepine prescribers. I think that any senior medical student could pass one of those exams. I don’t think all psychiatrists are perfect prescribers of addictive medications, but we can teach insights into how to avoid errors and how to examine the interpersonal and unconscious aspects of prescribing that lead many physicians to prescribe medications that they are uncomfortable writing. I have a few posts on my blog about the issue if anyone wants to look at additional details:

    http://real-psychiatry.blogspot.com/search/label/overprescribing

    George

    Liked by 1 person

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