# Algorithms in medicine: where they help… and where they don’t

Director of the Walter Bradley Center Robert J. Marks continued his podcast discussion with the anesthetist 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 (such as finding the greatest common divisor) in a finite number of steps that frequently involves repeating an operation”. (Merriam Webster) We most often think of algorithms in relation to computers, because that’s how programmers teach them. Algorithms, Dr. Marks points out, can either fine-tune or derail services, depending on their content.

Before you begin: To note: Robert J. Marks, professor emeritus of computer and electrical engineering, engineering at Baylor University, has a new book coming out You not calculable (June 2022), on the need for realism in another area as well – the capabilities of artificial intelligence. Stay tuned.

This part starts at 01:59 min. A partial transcript and notes, View Notes and additional resources follow.

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

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

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

Robert J. Marks: You told me about 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 spinal surgery that I do consists mainly of implanting spinal cord stimulators. Basically, these are two very sophisticated wires that are placed in the epidural space. It is hollowed out in the middle part of the spine. And when you turn it on, patients feel tingling in their lower back and legs. And for some patients, it’s great pain relief. But you don’t even have to feel the stimulation to get relief.

The biggest issue we had with this is that in active patients – and even non-active patients if they were falling or whatever – the leads were moving. They would fall either downwards, or to the right, or to the left. And then you’d have to operate on them again and fix that. I didn’t have as much trouble as the others. But I still had some, what is called “lead migration”. And so there was a group…that developed a product called Fixate.

It is a device that allows you to suture a thread deep into a wound. And you don’t even have to put your fingers on it. When you pull on it and squeeze it, it will tighten it. And it’s amazing. Once lots of people started using it, lead migration and re-operations dropped significantly. It is just a simple device which is available for anyone who wants to use it.

Robert J. Marks: It’s interesting. So there are other technological advances. I understand that robotics is now used for a lot of operations. And it will all be algorithmic. Either the doctor uses it as a tool or, if there is no staff, he does it on his own.

Richard Hurley: I’m not as familiar as a lot of other people but… some guys use it for knee replacement, for any abdominal or pelvic surgery. And the list continues to grow day by day. But the advantage is that you don’t need to have big injuries. You can do it all through a small incision. And therefore the recovery time is better. Overall, the results are just as good if not better.

A robotic surgery device sews up a grape:

Some of the advantages of robotic surgery:

Robert J. Marks: One of the things I wanted to talk about is the application of algorithms. Not necessarily in the practice of medicine, but in the constraints imposed on medicine by insurance companies and others. Could you talk about it? …

Richard Hurley: If you look at medical algorithms, it’s a visual roadmap to guide you in your decision making. This helps you plan and evaluate your care. This is to help eliminate uncertainty. This makes decision making much more accurate. And it’s developed by doctors for doctors 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 of hospitalizations, prescriptions, surgeries, and procedures.

Robert J. Marks: So that really limits your practice, doesn’t it?

Richard Hurley: Yes, because their prior authorization is supposed to reduce health costs. But they claim to save money by refusing health services deemed experimental or unnecessary, even if those care, drugs, or procedures are FDA-approved or approved by the Centers for Medicare and Medicaid Services.

Robert J. Marks: Is it correct? I was talking to a friend [who] has launched a new seniors service that can monitor seniors in their homes. And make sure they’re okay, that they’re moving. And then there’s a lot of data mining, which comes out of that, where how often they go to the bathroom, for example. How long they sleep. And you can monitor all of this from their technology.

But he said his big hurdle was getting Medicare and Medicaid approval. And he also said – and I want to check your take on this – that insurance companies would usually be part of that and agree to cover that cost if Medicare and Medicaid did. But you say that’s not necessarily true. Is it correct?

Richard Hurley: …they won’t approve anything that’s not FDA approved…if it’s a drug. If it’s a procedure, there’s all kinds of things they have to do to get it done. But even then, many procedures and devices must be approved by the FDA. But insurance companies, private insurance companies — just because Medicare does it, they don’t have to.

Often they are actually behind the eight ball. They have other agendas. A perfect example is a new drug that may have a strong indication, approved by the FDA. But before I can write a prescription for it, I have 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, patients got better. And then if they fail, you can order this new drug which could cost 100 times more than the old drugs.

Robert J. Marks: I see. So the drug companies probably want everything to be insurance approved. And then the insurance company comes in and makes all the rules. To what extent do pharmaceutical companies stifle your practice of medicine?

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

Now that number may have decreased. And I probably shouldn’t give you an exact number.

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

Richard Hurley: The threshold is so high and it’s so difficult and it takes a long time. And often, nurses or doctors have to go to their insurance company to get approval.

And I have the same problem with the things I do. And so it’s hard. Now over time these drugs will become cheaper and insurance companies will use them and then they will fight something else.

Robert J. Marks: I see. We talked about algorithms, nuances, insight and things like that. It seems that with a doctor, you have this nuance. You have this view of patients. And you should have that flexibility to prescribe what you think is appropriate. Yet I feel like the 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 am an interventional pain physician. So I agree that we should approach the patient. Certainly, from a conservative point of view, you should not embark on the most expensive treatment for modalities on day one. You have to get to know the patient.

Next: The challenges of medical care when insurance algorithms take precedence

Opioids: The high is brief, the death toll is horrendous. Fentanyl has medical uses, for example, in open-heart surgery where the patient is on life support; otherwise, it’s a one-way trip off-planet. Anesthesiologist Richard Hurley explains to Robert J. Marks how fentanyl affects the brain and why the street version is so deadly.

and

What anti-opioid strategies could actually reduce the death toll? Anesthesiologist Dr. Richard Hurley discussed with Robert J. Marks the value of cognitive behavioral therapy – reframing the issue. Life expectancy in the United States is falling due to deaths from opioids, although the problem is now mainly with illicit drugs, not those prescribed by a doctor.

## Show Notes

• 01:59 | Presentation by Dr. Richard Hurley
• 02:10 | Do surgeons pay fees for procedures?
• 02:59 | Coffee and calamari
• 04:45 | Spine surgeries
• 07:31 | Algorithms in Medicine
• 12:40 | Are pharmaceutical companies interfering with the practice of medicine
• 19:26 | How can the current system be fixed?