Hacking the Human Mind, Pt. 2: Enter Reality
In the first part of this post, I discuss the concept of “hacking the human mind” in mythology and fiction. Ever since antiquity, many people have tried to improve the human mind and body. The information era has contributed the term “hacking” to the idea of human-improvement. More recently, pop culture has adopted the idea of hacking humanity and turned it into a ubiquitous plot device.
Snap Back to Reality
Whoops there goes Gravity
Hollywood has portrayed hacker-like characters as superhumans, shadowy villains or even honest-to-goodness sorcerers. However, hacker culture in real life is a far cry from its fictional portrayal. While wizards and sorcerers jealously guard their knowledge, real-world hackers are famous for sharing knowledge. (especially when they’re not supposed to)
Possibly thanks to the popularity of “hacking the human mind” as an idea, medical researchers have started to promote the so-called hacker ethic. This philosophy holds that decentralized, open-source use of technology can improve the world. Traditional medical research goes through multiple cycles of proposal, review and revision before anything happens. Successes are often published in closed-access journals while failures are often buried. The hacker ethos encourages freewheeling experimentation and open-source sharing among the scientific community.
Among its many innovations, hacker culture has given birth to the idea of medical hackathons. A “hackathon” is defined as an short duration (often just a weekend), high-intensity multidisciplinary collaboration. During the event, participants make “60 second pitches” to attract other people who might have special skills. For example, a physician with a good idea for telemedicine might go around trying to find a coder who knows about Internet security. Then they could come across a hacker with machine-vision expertise and use him to improve their cameras.
Although they occur too quickly to really polish a product or conduct clinical trials, hackathons generate numerous bright ideas that can be worked on later. In a way they are the ultimate brainstorm.
Heroes of the Brainstorm
Harder, Better, Faster, Stronger
Hackathons are undoubtedly coming up with lots of very good ideas. However, even the best medical ideas take a long time to implement. The only ideas that can be implemented immediately are very small pieces of provider-side software. (ie, enhanced changeover sheets for hospitalists) Anything that touches a patient requires a lengthy process of requests, reviews, and consents before it is ever used… and only then can you figure out whether it is effective.
As of 2014, the medical hackathon simply hasn’t been around long enough to show much of an effect. It’s a bit like a drug in Phase I-Phase II studies: everyone has great hope that it will improve things, but you can’t point to a major innovation that would not have been possible without the hackathon.
Integrating small-scale hackathon products into larger suites of medical software is a much tougher problem. Even the large-vendor EHRs (Epic, Meditech, Cerner) have difficulty communicating with each other, let alone with smaller pieces of software. The greatest problem in healthcare IT is that the so-called “HL7 Standard” isn’t really a standard.
Standard file formats exist so that they can be consistently read by everyone. A PDF looks the same on a PC, Mac, iPhone or Google Glass. A Kindle file (.AZW) is the same on a Kindle, PC or phone. Even medical imaging has a true standard format. Whether your CT scanner is a GE, Phillips, or Siemens, when you export DICOM images to another physician, the CT slices will show up exactly the same.
HL7 is not like that at all. In my personal experience, naively transferring documents between two pieces of “HL7-compliant” software results in loss or misinterpretation of some of the data. In order to fix this, you need a highly trained IT expert to create a specialized “connectivity interface”, or sometimes you pay big bucks to purchase such an interface. I am amazed that things are still so difficult in the year 2014.
In the field of traditional software design, hackers have benefited from the uniform interoperability of Unix (Linux) for many decades. As of today, healthcare lacks this important feature.
Maybe the hackers could come up with a solution for interoperability?
One of the promises of “medical hacking” has been the application of “Big Data” techniques to healthcare. Data analysis in healthcare has always been difficult and often inconsistently performed. Many medical students and residents can tell you about painstaking research hours spent on manual data-entry. Big Data techniques could turn ten thousand med student hours into five minutes of computer script runtime. Unfortunately, to this date Big Data has been much less successful in real life.
So far, the two Biggest Data medical innovations have been Google Flu Trends and 23andMe. GFT purports to forecast the severity of the flu season, region by region, based on statistics on flu-related Google searches. 23andMe was originally supposed to predict your risk of numerous diseases and conditions using a $99 DNA microarray (SNP) analysis. Far from being a home run for Big Data, both of these tools are more reminiscent of a strikeout, if not a pick-six.
GFT was billed as a Big Data tool that would vastly improve the accuracy and granularity of infectious disease forecasting. When first introduced in 2008, GFT’s flu predictions were more accurate than any existing source. However, every year it became less and less accurate, until it became worse than simply measuring how many flu cases happened two weeks ago. GFT’s performance degraded so badly, it was described as a “parable of traps in data analysis” by Harvard researchers.
23andMe offered SNP testing of the entire genome, used both for ancestry analysis and disease prediction. Prior to November 2013, the website offered a vast number of predictors ranging from lung cancer to erectile dysfunction to Alzheimer’s dementia to drug side effects. It was held up as an exemplar of 21st-century genomic empowerment, giving individuals access to unprecedented information about themselves for the low, low price of $99.
The problem was, 23andMe never bothered to submit any scientific evidence of accuracy or reproducibility to the Food and Drug Administration. The FDA sent a cease and desist letter, forcing them to stop marketing their product as a predictive tool. They’re still selling their gene test, but they are only allowed to tell you about your ancestry. (not any health predictions) This move launched a firestorm, with some people arguing that the FDA was overstepping or even following “outdated laws“.
However, the bulk of the evidence suggested that 23andMe simply didn’t give accurate genetic info. Some molecular biologists pointed out the inherent flaws in SNP testing, which make it impossible for 23AndMe to be usably accurate. Others pointed out that even if accurate, most of the correlations were too weak to have any effect on lifestyle or healthcare. The New England Journal of Medicine concluded that the FDA was justified in issuing a warning, and that “serious dialogue” is required to set standards in the industry. Other commentators were “terrified” by 23andMe’s ability to use your genetic info for secondary studies. After all, how can 23andMe sell genetic tests for $99 when other companies charge thousands? Obviously they didn’t plan to make money from the consumers; instead, 23andMe hoped to make money selling genetic data to drug companies and the rest of the healthcare industry.
In the end, that is my biggest misgiving against medical Big Data. Thanks to social media (this blog included) we have already commoditized our browsing habits, our buying habits, our hobbies and fandoms. Do we really want to commoditize our DNA as well? If so, count me out.
Doctoring the Doctor
Damnit Jim, I’m a doctor, not a hologram!
Another big promise of the “hacker ethos” in medicine is that it could improve physician engagement and enthusiasm for technology. Small decentralized teams of hackers could communicate directly with physicians, skipping the multi-layered bureaucracy of larger healthcare companies.
Many healthcare commentators have (falsely) framed the issue of physician buy-in as a matter of technophobia. Doctors are “stuck in the past“, “Luddites in white coats”, and generally terrified of change. The thing is, it’s just not true. Just look at the speed at which new medical devices are popularized – everything from 4DCTs to surgical robots to neuronavigation units, insulin pumps, AICDs and deep brain stimulators. If physicians saw as much of a benefit from electronic health records (EHRs) as we were supposed to, we would be enthusiastic instead of skeptical.
I believe that EHR would be in much better shape today if there had never been an Obamacare EHR mandate. No one ever improved the state of the art by throwing a 158-page menu of mandates at it. Present-day EHRs care much more about Medicare and other billing rules than they do about doctor or nurse usability.
Back on subject, I do believe that medical hacking has the potential to get physicians more involved in technological innovation. So long as physicians are stuck dealing with massive corporate entities, we can provide feedback and suggestions but they are very unlikely to be implemented. Small-scale collaborations empower doctors with the ability to really change the direction of a project.
Now, not every medical hack will result in something useful. In fact, a lot of hacks will amount to little more than cool party tricks, but some of these hacks will evolve into more useful applications. Some easily-hackable projects may involve documents or files produced by older medical technology. During residency I worked on a research project involving radiation treatment plans from a very old, non DICOM-compliant system. We quickly discovered that the old CTs were not usable by modern treatment planning software. Fortunately, one of the physicists on our research team was familiar with DICOM. He coded a computer program that inserted the missing DICOM headers into the old CT images, allowing us to import old CTs without any problems.
Introducing more hackers to medicine can only increase the number of problems solved by astute coding.
What Happened to Superpowers?
Paging Dr. Manhattan…
The addition of hacker culture to medicine certainly has a lot of potential to improve the everyday practice of medicine. But what happened to the idea of “hacking the human mind” in order to develop super-strength and speed?
On a very rudimentary level, “hacking the mind” improves physical performance every time an athlete grows a beard for the playoffs or wears his college shorts under his NBA uniform. But true hacking should be more sophisticated than mere superstition!
Biofeedback is a common pre-game ritual for various athletes that could be construed as a minor form of “hacking the mind/body”. Dietary habits such as carb loading could also be considered a mild form of hacking. For less legal mind-body hacking you could always turn to performance enhancing drugs.
Speaking of drugs, there’s a long-held belief that people high on drugs (mostly PCP, sometimes meth or bath salts) gain superhuman strength. While the evidence is mostly anecdotal, there’s a plausible medical explanation. The Golgi tendon reflex normally prevents muscles from over-exerting themselves, and it can be suppressed in desperate situations (the “mother lifts a car off her child” scenario). It’s reasonable to assume that some drugs could have a similar effect.
It’s also reasonable to assume that military physicians have spent decades (the entire Cold War for sure) trying to produce a super-strength drug with fewer side effects than PCP. The fact that our entire army doesn’t have the physique of Captain America suggests that those efforts were unsuccessful. Granted, this doesn’t rule out the existence of a super serum that only worked on one guy ever.
Evolutionarily speaking, it is highly implausible that humans would have tremendous physiological potential locked behind some mental gate. If the human body had such great power, our prehistoric ancestors would have needed every ounce of it to outrun or outfight angry lions and hippos and crocs. It would make no sense for humans to have a mental block on our strength. Unless removing that mental block led to instant death or infertility, the first caveman to lose his mental block would be evolutionarily favored over the rest of proto-humanity. Therefore, it’s very unlikely to think that human performance can be “magically” improved with drugs, meditation or other techniques.
So let’s cap off this long ramble with a little teaser on evolution and human strength. This National Geographic feature suggests that early humans directly traded muscle strength for brain power.
What is wrong with this argument?