Walter Bradley Center director Robert J. Marks continued his podcast discussion with anesthesiologist Richard Hurley in “Good and bad algorithms in the practice of medicine” (May 19, 2022).

An algorithm is “a procedure for solving a mathematical problem (as of finding the greatest common divisor) in a finite number of steps that frequently involves repetition of an operation.” (Merriam–Webster) We most commonly think of algorithms in connection with computers because that is how programmers instruct them. Algorithms, Dr. Marks points out, can either sharpen or derail services, depending on their content.

Before we get started: Note: Robert J. Marks, a Distinguished Professor of Computer and Electrical Engineering, Engineering at Baylor University, has a new book, coming out Non-Computable You (June, 2022), on the need for realism in another area as well — the capabilities of artificial intelligence. Stay tuned.

This portion begins at 01:59 min. A partial transcript and notes, Show Notes, and Additional Resources follow.

Robert J. Marks: Google driving instructions are algorithms. When I’m told to go to someone’s place, I’m supposed to go two miles on the freeway, turn left at the 7-11, go a couple blocks, turn right on Oriole Street, et cetera. So those are step-by-step procedures to get me from point A to point B.

Computers can only do things which are algorithmic. Every computer follows a step-by-step procedure for doing something. If something is non-algorithmic, it is not computable. One of the things that we’ve shown at the Bradley Center is that creativity, nuance, and insight are human characteristics that are non-algorithmic. You cannot write a computer program to do them.

And if you remove creativity, nuance, and insight and other criteria from making decisions, you are really stifling the degree to which you can interact. We’re going to talk about how algorithms stifle — and also enhance — the practice of medicine. Our guest today is Dr. Richard Hurley, a medical doctor who is board certified in anesthesiology and pain medicine…

Robert J. Marks: You’ve mentioned to me the onslaught of technology in your field.
Could you comment on that? One of the things you mentioned was a suture device for deep wounds.

Richard Hurley: The spine surgery that I do is predominantly implanting spinal cord stimulators. Basically it’s two very sophisticated wires that are put into the epidural space. It’s tunneled up into the mid portion of the spine. And when you turn it on, patients feel tingles in their lower back and legs. And for some patients that is excellent pain relief. But you don’t even have to feel the stimulation in order to get relief.

The biggest problem we had with this is that in active patients — and even non-active patients if they fell or whatever — the leads would move. They would either fall down or to the right or to the left. And so then you’d have to operate on them again and fix it. I didn’t have as much trouble as other people did. But I still had some, what we call “migration of the lead.” And so there was a group … that developed a product called Fixate.

It’s a device that allows you to suture a wire deep into a wound. And you don’t even have to get your fingers down into it. When you pull up on it and tighten up, it would cinch it down. And it’s amazing. Once a lot of people started using this, the lead migration and re-operations went way down. t’s just a simple device that’s available to anybody that wants to use it.

Robert J. Marks: That’s interesting. So there are other technological advances. I understand that robotics is now being used for a lot of operations. And all of this is going to be algorithmic.The physician either uses this as a tool or, if it’s unmanned, it does it on its own.

Richard Hurley: I’m not as familiar as a lot of other people are but … some guys are using it for knee replacement, for any abdominal or pelvic surgery. And the list, it keeps increasing daily. But the advantage is, is that you don’t have to have large wounds. You can do everything through a small incision. And so recovery time is better. Overall the results have been just as good if not better.

A robotic surgery device stitches a grape back together:

Some of the advantages of robotic surgery:

Robert J. Marks: One of the things that I wanted to talk about is the application of algorithms. Not necessarily in the practice of medicine, but in the constraints, which are put onto medicine by insurance companies and stuff. Could you talk to that? …

Richard Hurley: If you look at medical algorithms, it’s a visual road map to help guide you in your decision-making. That helps you plan for and evaluate your care. It’s to help to remove the uncertainty. It makes the decision-making much more accurate. And it’s developed by physicians for either physicians or other healthcare providers. It’s evidence-based, and it’s data-driven.

Now health insurance companies use algorithms for prior authorizations to determine the medical necessity for hospital admissions, prescriptions, surgeries, and procedures.

Robert J. Marks: So this really constrains your practice, doesn’t it?

Richard Hurley: Yeah, because their prior authorization purportedly is to reduce healthcare costs. But they claim to save money by denying health services that are considered to be experimental or unnecessary, even if that care or drug or procedure is FDA-approved or approved by the Centers for Medicare and Medicaid Services.

Robert J. Marks: Is that right? I was talking to a friend [who] has a startup of a new service for senior people that can monitor old people in their houses. And just make sure that they’re okay, they’re moving around. And then there’s a lot of data mining, which comes from that, where how many times they go to the rest room, for example. How long they sleep. And you can monitor all of this from their technology.

But he was saying that his big hurdle was to get approval by Medicare and Medicaid. And he also said — and I want to check your viewpoint on this — that the insurance companies would usually become a part of it and agree to cover this cost if Medicare and Medicaid did that. But you’re saying that’s not necessarily true. Is that right?

Richard Hurley: … They’re not going to approve something that’s not FDA-approved… if it’s a drug. If it’s a procedure, then there are all kinds of things that they have to do to get that done. But even then, many procedures and devices have to be FDA-approved. But insurance companies, private insurance companies — just because Medicare does it, they’re not obligated to do that.

A lot of times they are actually behind the eight ball. They have other agendas. A perfect example is, a new drug that comes out that may have a strong indication, FDA-approved. But before I can write a prescription for that, I’ve got to use all the old drugs that were never approved for that particular diagnosis or problem. But we knew that if you used them off label, the patients got better. And then if they failed those, then you could order this new drug that might cost 100 times more than the old drugs.

Robert J. Marks: I see. So the drug companies probably want to have everything approved by insurance. And then the insurance company comes in and they make all the rules. To what degree do the drug companies stifle your practice of medicine?

Richard Hurley: Well, to give you an idea, just recently, in the last three years, we’ve seen a number of pharmaceutical companies produce drugs that are called CGRP inhibitors, which are known to be fantastic drugs for migraine. These drugs are given intramuscularly and they last about two months. It’s been tremendous in terms of relief of patients who suffer from migraine. You’ve got to have 15 migraine attacks per month before they’ll approve that drug.

Now that number may have gone down. And I shouldn’t probably give you a exact number.

Robert J. Marks: But there is a threshold that’s…

Richard Hurley: The threshold is so high and it’s so hard and it takes a lot of time. And a lot of times the nurses or physicians have to go to their insurance companies to get this approved.

And I have the same problem with the things that I do. And so it is tough. Now over time, those drugs will become cheaper and then insurance companies will use them and then they’ll be fighting something else.

Robert J. Marks: I see. We talked about algorithms and nuance and insight and things of that sort. It seems that with a physician, you have this nuance. You have this insight into patients. And you should have this flexibility to prescribe what you think is appropriate. Yet, I get the sense that insurance companies kind of stifle that creativity and your practice, if you will, in medicine. Do you agree?

Richard Hurley: I do. I totally agree. In pain medicine, I’m an interventional pain physician. So I do agree that we should approach the patient. Certainly, from a conservative standpoint, you shouldn’t go into the most expensive treatment for modalities from day one. You got to get to know the patient.

Next: The challenges of medical care when insurance algorithms rule

You may also wish to read Dr. Hurley’s thoughts about addiction:

Opioids: The high is brief, the death toll is ghastly. Fentanyl has medical uses in, say, open heart operations where the patient is on life support; otherwise, it is a one-way ticket off the planet. Anesthesiologist Richard Hurley tells Robert J. Marks how Fentanyl affects the brain and why the street version is so deadly.

and

What anti-opioid strategies could really lower the death toll? Anesthetist Dr. Richard Hurley discussed with Robert J. Marks the value of cognitive behavior therapy — reframing the problem. Life expectancy in the United States is decreasing due to opioid deaths, though the problem is now primarily street drugs, not medically prescribed ones.

Show Notes

• 01:59 | Introducing Dr. Richard Hurley
• 02:10 | Do Surgeons Pay Royalties for Procedures?
• 02:59 | Coffee and Calamari
• 04:45 | Spinal Surgeries
• 07:31 | Algorithms in Medicine
• 12:40 | Do Drug Companies Interfere With the Practice of Medicine
• 19:26 | How Can the Current System Be Fixed?

Additional Resources

• Dr. Robert J. Marks
• Podcast with Dr. Richard Hurley on opioid addiction: Exercising Free Won’t In Fentanyl Addiction: Unless You Die First

Podcast Transcript Download