CHATGPT AND ANESTHESIA

12 Jun 202313 Jun 2023THE ANESTHESIA CONSULTANT Leave a comment

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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

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In 1997 the IBM computer Deep Blue beat world chess champion Gary Kasparov head to head. Is it feasible that CHATGPT, this decades artificial intelligence wunderkind, can equal or better a physician anesthesiologist? I entered three anesthesia consultations into CHATGPT, one preoperative, one intraoperative, and one postoperative. Is CHATGPT as good as an MD? Let’s look at what the computer answered:

PREOPERATIVE QUESTION

An 80-year-old woman with congestive heart failure gets short of breath walking up one flight of stairs. She needs to have her gallbladder removed. What sort of preoperative tests or therapies should this patient have before surgery?

CHATGPT: For an 80-year-old woman with congestive heart failure (CHF) who needs to undergo gallbladder removal surgery, it is essential to conduct a thorough preoperative evaluation to assess her overall health status and identify any potential risks. The specific evaluation required may vary depending on the patient’s medical history, the severity of the CHF, and the recommendations of the healthcare team involved. However, here are some general aspects that may be considered:

Cardiac Evaluation: Given the patient’s CHF and symptoms of shortness of breath, it’s important to assess her cardiac function comprehensively. This may involve an electrocardiogram (ECG) to evaluate heart rhythm, an echocardiogram to assess heart structure and function, and possibly additional tests such as stress testing or cardiac catheterization, depending on the severity of her symptoms and the presence of any known cardiac conditions.
Pulmonary Evaluation: Since the patient experiences shortness of breath, it may be necessary to evaluate her lung function. Pulmonary function tests, such as spirometry, may be conducted to assess lung capacity and function.
Lab Tests: Routine blood tests may be performed to assess the patient’s overall health and check for any abnormalities that could impact surgery. This may include a complete blood count (CBC), comprehensive metabolic panel (CMP), coagulation profile, and other specific tests as deemed necessary.
Imaging Studies: Depending on the patient’s medical history and symptoms, imaging studies like an abdominal ultrasound or a computed tomography (CT) scan may be ordered to confirm the diagnosis of gallbladder disease and assess its severity.
Medication Review: A review of the patient’s current medications, including those used to manage her CHF, is crucial to ensure they are optimized for the surgery. Medications may need to be adjusted or temporarily stopped to minimize potential risks during the procedure.
Anesthesia Evaluation: An evaluation by an anesthesiologist is important to assess the patient’s readiness for anesthesia and determine the most appropriate anesthesia plan for her, taking into account her cardiac condition and any other medical considerations.

It’s important to note that this is a general outline, and the specific preoperative evaluation for the patient should be determined by her healthcare team, including her primary care physician, surgeon, cardiologist, and anesthesiologist. They will consider her individual medical history and unique circumstances to ensure a safe and successful surgery.

INTRAOPERATIVE DECISION

A 60-year-old man with a history of hypertension is having a knee arthroscopy surgery under general anesthesia. In the middle of the anesthetic, his heart rate drops to 20 beats per minute, his blood pressure drops to unmeasurable, and he no longer has peripheral pulses. What do you think is going wrong, and what should be done do to save this man?

CHATGPT: I’m not a doctor, but the symptoms you described during the anesthetic suggest a severe and potentially life-threatening condition. This could indicate a cardiac event or a complication related to the anesthesia. One possible explanation for the sudden drop in heart rate, blood pressure, and loss of peripheral pulses is a condition called “bradycardia with hypotension” or “bradycardia-induced hypotension.”

In this situation, it’s crucial for the medical professionals involved to take immediate action. Here are some general steps that might be considered:

Alert the medical team: The anesthesiologist or healthcare providers in the operating room need to be notified immediately about the patient’s deteriorating condition. The surgeon and additional medical personnel may also be called upon for assistance.
Assess the airway, breathing, and circulation (ABCs): Ensure that the patient’s airway is clear and breathing is supported. Provide supplemental oxygen if necessary. Assess circulation and check for the presence of a pulse. If the patient is unresponsive or there is no pulse, initiate cardiopulmonary resuscitation (CPR) immediately.
Notify the code team: If the patient remains unresponsive and pulseless, it may be necessary to activate a “code blue” or similar emergency response to involve a specialized team experienced in resuscitation procedures.
Perform advanced cardiac life support (ACLS): Healthcare providers trained in ACLS protocols will initiate resuscitation measures, including chest compressions, defibrillation (if indicated for certain types of cardiac rhythms), and administration of medications such as epinephrine to help restore circulation.
Identify and address potential causes: Once the patient’s vital signs have stabilized or as the resuscitation efforts continue, the medical team will work to identify the underlying cause of the cardiac event. This may involve evaluating the patient’s medical history, reviewing medications, and conducting further diagnostic tests such as an electrocardiogram (ECG) or blood tests.

It’s important to note that the above steps are general guidelines and the specific actions taken may vary depending on the patient’s condition, the resources available, and the expertise of the medical team on-site. In such a critical situation, the immediate focus will be on stabilizing the patient and providing appropriate resuscitation efforts to restore circulation and address any life-threatening issues.

POST ANESTHESIA EMERGENCY

In the recovery room after a tonsillectomy, a 5-year-old child coughs up blood, becomes short of breath, and becomes unconscious. What is probably going on, and what should be done to save this child?

CHATGPT: I’m not a doctor, but the symptoms you described following a tonsillectomy can be indicative of a serious complication known as postoperative hemorrhage. In this situation, it’s crucial to seek immediate medical attention. Here are some general steps that might be considered:

Activate the emergency response: Alert the medical staff immediately about the child’s deteriorating condition. Nurses and physicians in the recovery room should be notified, and additional assistance may be needed, such as calling a code or emergency response team.
Ensure a patent airway and support breathing: Assess the child’s airway and breathing. If the child is experiencing difficulty breathing or is unresponsive, the healthcare providers should take steps to establish and maintain a clear airway. They may administer oxygen and provide respiratory support if necessary.
Control bleeding: Postoperative hemorrhage can cause significant blood loss, leading to the symptoms you described. The doctors should perform a thorough examination to identify the source of bleeding and take appropriate measures to control it. This may involve suctioning the blood from the child’s mouth, using medications to constrict blood vessels (such as topical epinephrine), or applying direct pressure to the bleeding site.
Administer fluids and blood products: If the child is experiencing significant blood loss, intravenous fluids and blood products may be necessary to stabilize their condition and restore blood volume.
Provide immediate resuscitation measures: If the child becomes unconscious or experiences cardiac arrest, cardiopulmonary resuscitation (CPR) should be initiated immediately. Healthcare providers trained in pediatric resuscitation will perform chest compressions, provide assisted ventilation, and administer medications as required.
Prepare for surgical intervention: Depending on the severity of the bleeding and the child’s condition, emergency surgical intervention may be necessary to control the bleeding. The surgical team will be assembled, and the child will be transferred to the operating room for further assessment and management.

It’s important to note that the above steps are general guidelines, and the specific actions taken may vary depending on the child’s condition, the resources available, and the expertise of the medical team on-site. In such a critical situation, the immediate focus will be on stabilizing the child, controlling the bleeding, and providing any necessary resuscitation efforts.

ANALYSIS:

Note that CHATGPT preceded two of its three answers with the words, “I’m not a doctor, but,” which likely removes the possibility that CHATGPT creator OpenAI will be sued for medical malpractice. From the answers above, I’ll attest that if you’re an inexperienced anesthesiologist or certified registered nurse anesthetist (CRNA) working alone, there is value having a resource like CHATGPT immediately available. Are there any notable errors in the CHATGPT answers? No, not really. As a written reply to the questions posed, the artificial intelligence of CHATGPT gives a reasonable outline regarding how to proceed.

Anesthesia is an acute care specialty, and often there will be no time to consult CHATGPT regarding what to do next because the patient is trying to die right in front of you, for example in the second and third scenarios above. Expect artificial intelligence in medicine to be most applicable in specialties like radiology, pathology, and dermatology, where digital images are analyzed. In radiology, this would be the evaluation of digital X-rays, MRIs, or CT scans. In pathology, this would be the evaluations of digital images of microscopic biopsies, and in dermatology, this would be the evaluation of digital images of skin lesion photographs. The model for the machine learning of digital images will be similar to the process in which a human child learns. When a child sees an animal, his parents tell him that animal is a dog. After repeated exposures the child learns what a dog looks like. Early on the child may be fooled into thinking that a wolf is a dog, but with increasing experience the child can discern with almost perfect accuracy what is or is not a dog.

CHATGPT relays information developed by algorithms. Is the practice of medicine destined to be directed by computer algorithms? Yes. We’re already guided by algorithms/cognitive aides such as the decision trees of Advanced Cardiac Life Support (ACLS) or the Stanford Emergency Manual. These flow charts are useful to direct acute care, and to assure no aspect of emergency treatment is overlooked. Expanded use of algorithms is inevitable as more data is accumulated on the management of large populations of medical patients. Current electronic medical records (EMR) systems exist in every hospital, and the EMRs are generating the sort of Big Data that algorithms will be built on.

I’ve had an interest in AI and robots in medicine for years. All Things That Matter Press published my novel Doctor Vita in 2019, several years before CHAPGPT became reality. Doctor Vita described the introduction of artificial intelligence in medicine machines in a Silicon Valley university hospital. A significant and anticipated advance in Doctor Vita is the ability to interact with patients and doctors by voice input and auditory output. In short, the artificial intelligence in medicine of the future will converse with us, just as Alexa and Siri already do.

The World Health Organization projects there will be a shortage of ten million healthcare workers worldwide by the year 2030. Contemplate the following:

All medical knowledge is available on the Internet. Doctors don’t know everything or remember everything, so we routinely look up facts, evidence, and data on the Internet. A computer can recall all of these facts.
Most every medical diagnosis and treatment can eventually be written as a decision tree algorithm;
Voice interaction software is excellent and improving every year;
The physical exam is of less diagnostic importance than scans and lab tests which can be digitalized; and
A computer is far cheaper than the seven-year post-college education required to train a physician.

Will artificial intelligence assist MDs or replace MDs?Replacement of medical personnel with computers will not be welcomed by patients, doctors, or nurses, but there’s a need for cheaper healthcare, and the concept of automating physician tasks is no longer the domain of science fiction. It’s inevitable that AI will change current medical practice. A bold prediction: AI will change medicine more than any development since the invention of anesthesia in 1849.

Will the evolution of artificial intelligence in medicine lead to improved healthcare outcomes? In 2018 and 2019 autopilots drove two Boeing 737 Max airplanes to crashes despite the best efforts of human pilots to correct their course. Eleven people were killed in crashes involving vehicles using automated driving systems in the United States during a four-month period in 2022. Will we see improved outcomes or worsening outcomes when AI intersects with medicine, and machines are directing medical care? We don’t know yet. In the spirit of Jules Verne, this century’s trip around the world, to the center of the earth, to the moon, or beneath the ocean’s surface, will be the coming of artificial intelligence in medicine.

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

IS ANESTHESIA AN ART OR A SCIENCE?

14 Aug 201529 Oct 2018THE ANESTHESIA CONSULTANT Leave a comment

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THE ANESTHESIA CONSULTANT

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

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Is the practice of anesthesia an art or a science? Is the practice of medicine an art or a science?Over one hundred years ago the father of modern medicine, Dr. William Osler of Johns Hopkins Medical Center, made the following statements: “Medicine is a science of uncertainty and an art of probability,” and “The practice of medicine is an art, based on science.”

In my career I’ve practiced three specialties at Stanford: internal medicine, emergency medicine, and anesthesiology. My career has bridged clinics, operating rooms, intensive care units, emergency rooms, and helicopter trauma medicine. I’ve practiced in four different decades.

With all respect to Dr. Osler’s legacy, what I’m witnessing in the clinical arena today tells me 21^st century medical practice will be very much about science and very little about art.

A Merriam-Webster dictionary definition of science reads “knowledge about or study of the natural world based on facts learned through experiments and observation.”

An Oxford English dictionary definition of art reads “the various branches of creative activity, such as painting, music, literature, and dance.”

Which of these definitions best fits your medical practice?

To me, the answer is clearly “science.”

I searched through all the secondary definitions of “art” in multiple dictionaries, and found very few definitions of “art” that apply to the practice of medicine. The closest fits were: art is a skill or special ability e.g. a skill at doing a specified thing, typically one acquired through practice, from the Oxford English Dictionary; or art is skill acquired by experience, study, or observation e.g. the art of making friends, from the Merriam-Webster dictionary.

Medical school training consists of four years of intensive study of anatomy, physiology, biochemistry, pharmacology, microbiology, pathology, diseases, and the treatment for diseases. Core classes require extensive memorization and comprehension of complex scientific facts. In the last two years of medical school, clinical classes require the student to apply this complex science while evaluating individual human patients. New skills acquired at this clinical stage are those of interviewing, history taking, physical examination, interpretation of medical test results, differential diagnosis, and application of appropriate therapies. Mastering the doctor-patient interaction requires an education in empathy, effective listening, respect, and conversation about complex medical topics using parlance non-medical laypersons can comprehend.

Creative activities such as painting, music, literature, and dance are absent from the preceding paragraph. There is an “art” to making the correct diagnosis, and there is an “art” to applying empathy, effective listening, respect, and conversing about complex medical topics in language non-medical laypersons can comprehend. In this context, “art” connotes those secondary definitions, as in “a skill at doing a specified thing, typically one acquired through practice.” A talented doctor with years of experience is a skilled artist of medical practice, just as World Series hero Madison Baumgartner is a skilled artist of pitching baseballs. A student entering a career in medicine in the 21^st century must prepare herself or himself for the scientific rigors of the job. The opportunity to create is largely absent.

Painters, musicians, authors, and dancers create original art, some of it fantastic and some mundane. In medicine this type of creativity is rare, but it does exist. The medical laboratory researchers who cured smallpox and polio changed the world by creating their discoveries. The medical researchers seeking cures for Alzheimer’s disease, Ebola, or HIV are in a constant quest for the discovery of original ideas. Physician authors such as the Bay Area’s Abraham Verghese (Cutting for Stone) and Khaled Hosseini, (The Kite Runner) wrote outstanding literary works and are very creative. Many physicians express creative skills in their hobbies as musicians, artists, sculptors, actors, dancers, and writers. These physicians earn their living with their primary jobs in medicine, and expend their creative energies in these secondary outlets in their spare time.

A generation ago the ideal physician may have been depicted in the persona of Dr. Marcus Welby, a fictional television doctor. Dr. Welby was the Atticus Finch of medicine, a kind, smiling, gray-haired physician who spent each week’s sixty-minute show working on healing and treating one patient’s problems. His heroic skills were wisdom, intelligence, empathy, and a steadfast dedication to that one patient for the entire TV show each week. Although he was portrayed as a savvy, highly-schooled professional, Dr. Welby thrived by an almost god-like ability to feel his way through a difficult case and create a workable diagnosis and solution. In Dr. Welby’s office practice each patient posed a dilemma he had to solve during an hour-long television episode. In today’s office practice each patient’s complaints must be addressed in a twenty-minute period of time, after which the physician must enter all the information into a cumbersome version of a computerized Electronic Medical Record (EMR) before meeting the next patient for the next twenty-minute encounter.

In the 21^st century operating room practice of anesthesiology, we typically have ten minutes to talk to a patient prior to rendering them unconscious. After anesthetic induction the patient is changed into a sleeping human who carries objective values for blood pressure, heart rate, oxygen saturation, respiratory rate, temperature, and exhaled gas concentrations. The practice of anesthesiology becomes very much like a physiology experiment with the twin goals for the patient of a) guaranteeing sleep, while b) striving to maintain perfect vital signs. Where is the art? Is there art in varying techniques to accomplish these goals? Is it an “art” to anesthetize shoulder arthroscopy patient #1 with propofol and sevoflurane, and then to anesthetize shoulder arthroscopy patient #2 with propofol and an interscalene block? Rather than “art,” I’d call this using clinical judgment based on experience and scientific information.

Let me point out several current trends which are moving physician jobs further away from any creativity:

1) The organization of medicine into large corporate practices, with the variability of practice minimized. I recently attended a clinical lecture Stanford Medical Center in which the topic was “Variation is the Enemy of Good.”

2) The goal of organizing patient management into detailed and specific algorithms for physicians to follow, to insure they’re all treating the same medical problems the same way. In the Forbes article Medicine Is An Art, Not A Science: Medical Myth Or Reality?(July 12, 2014), author Robert Pearl MD, the CEO of the Permanente Medical Group, describes the value of protocols for the operating room, for treatment of stroke, and for prevention of heart attack, and concludes “We can predict that doctors who today refuse to follow the national recommendations for treating patients with strokes, heart attacks and a variety of other medical problems will be hard to convert. But we must change their behavior. The health of their patients and our nation depends on it.” Examples of such protocols in anesthesia practice are algorithms introduced for the management of total knee and hip replacement anesthesia, using a combination of neuroaxial block, regional nerve block such as adductor canal block, plus multimodal pain medication regimens (Gandhi and Viscusi, Multimodal Pain Management Techniques in Hip and Knee Arthroplasty, The New York School of Regional Anesthesia (www.nysora.com) Volume 13, J u l y 2009, pages 1-10).

3) A move to a “shift work” mentality in modern medical practice. A generation ago an MD would follow up on his patients until all the work was done for a given day, in addition to being night on-call for patients of his partners or colleagues once a week. In the past I worked for the largest HMO in California. The HMO culture promoted a 40-hour-per-week shift work mentality for physicians. When three p.m. arrived, many doctors signed off to the next doctor coming on duty to take over their job.

4) The promotion of non-physicians into the workforce to perform roles previously handled by MDs. Due to an inadequate supply of primary care doctors, the future of clinic medicine in large corporate medical practices will likely be legions of nurse practitioners and/or physician assistants supplying much of primary care.

5) Pursuit of artificial intelligence in medicine (AIM) as a goal. A recent Wall Street Journal article, IBM Crafts a Role for Artificial Intelligence in Medicine: Deal for Merge Healthcare is step toward training IBM’s Watson software to identify cancer, heart disease (August 11, 2015) described a significant advance in AIM technology. It’s not hard to imagine artificial intelligence computers making diagnoses and treatment decisions in the future.

Are these trends bad? Time will tell. The trends are driven by economics, and don’t expect to see them reverse. Variability will decrease and so will the feeling that medicine is an art.

Let’s hope future generations of physicians will still quote Osler’s claim that “the practice of medicine is an art, based on science.” May empathy, effective listening, respect, and conversation always be critical skills envied and mastered by all physicians.

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