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.
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.
> 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?
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.
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."
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.
I'm not on the outside of medicine. Significant practice variation exists, but complex neurosurgical conditions are usually managed at academic centers and fMRI is used for planning in neurooncology [1] and epilepsy surgery [2].
Awake cortical mapping has much better resolution than fMRI, and it avoids image registration issues, but it requires a great deal of planning and patient motivation. If it turns out that the language center is on the opposite side from the area of the surgery, then awake mapping might not even be necessary. This is why fMRI is often used as a planning step before awake cortical mapping during the actual surgery.
Thank you for sharing your story. Although fMRI has low resolution, it can be very useful for surgical planning in certain clinical scenarios. For example, to determine hemispheric dominance: "Although the estimated percentages are of some debate, language is the purview of the left hemisphere in approximately 95% of right-handed people and 70% of left-handed people ... At MSKCC, language lateralization mapping is most often requested in right-handed patients with left hemispheric lesions, left-handed patients with left or right hemispheric lesions, or right-handed patients with right hemispheric lesions and signs or symptoms of aphasia." [1]
fMRI is used to plan procedures that put eloquent cortex at risk. For example, tumor resections. Typically, fMRI is used for initial planning (whether the tumor is in the dominant hemisphere, how to approach the tumor). Then, in the actual surgery, function is confirmed using awake cortical mapping (e.g. stimulating different cortical areas with a bipolar electrode while the patient performs language tasks).
"All Cell Press and Lancet journals are part of the UC agreement. For these top journals, UC’s shared funding model — where the libraries share the cost of open access publishing with authors — will be phased in, with all Cell Press and Lancet journals integrated no later than 2023, midway through the four-year agreement."
"a limited number of societies that partner with Elsevier for their publishing have chosen to exclude their journals from transformative agreements, so their journals are not eligible for either reading, publishing, or both under the agreement. A list of these exclusions will be available soon and linked from this page."
IANAL but HIPAA compliance comes from following certain policies and procedures (e.g. for encryption and account provisioning). These rules are necessary but not sufficient to guarantee security. As for cameras in hospitals, I have only seen these pointed at beds in specific scenarios (e.g. epilepsy monitoring) but obviously it is important to keep these video feeds secure.
I certainly agree with you. Part of the core MR game is to flirt with right wing talking points but keep on playing both sides to get attention. This is really unfortunate and distracting when it comes to something like covid that is already so politicized. Their actual analysis of the pandemic has been hopelessly naive and lacking in rigor. If there's one good contribution they've made, it's been pointing out the ways in which certain regulations have hindered the response without adding value. Otherwise, it's only good for the links.