Try to make him feel welcomed. Reigning Jeopardy! champion and IBM robot, Watson, is devouring the material in medical textbooks and journal articles in hopes of landing a job as a physician's assistant.

The trainee was sequentially presented the details of a fictitious patient: there’s an eye problem; vision is blurred; the family, living in Connecticut, has a history of arthritis. The trainee’s initial response was uveitis. More clues and the diagnosis was changed to Behcet’s disease until finally the trainee settled on Lyme disease. How sure was this seemingly hasty student of medicine? Seventy-three percent sure.

Medical trainees and doctors are not typically in the habit of quantifying their assessments with such Commander Data-like precision, but this trainee happens to share more qualities with the Star Trek android than the rest of the medical staff. Following its resounding victory on Jeopardy!, IBM’s Watson has been working hard to learn as much about medicine as it can with a steady diet of medical textbooks and healthcare journals. The mock case described above was part of a recent demonstration to the Associated Press showing just how much Watson has learned. The robot’s diagnosis was correct and it identified a link between symptom and cause that was “not common,” as one participating physician called it. After being told the patient was pregnant and allergic to penicillin, Watson suggested treating her with cefuroxine. Its human colleagues agreed. The demonstration was a success, and it is the hope of IBM and many medical professionals that Watson will one day soon lend doctors a helping hand as they perform their daily rounds.

The need for efficient use of medical information becomes more pressing as the amount of information amasses at an exponential rate. Dr. Herbert Chase, a Columbia University medical school professor, tells the Associated Press that it has been 30 years since doctors were last able to keep pace with the growing body of medical knowledge. With only so many hours in an often overwhelming day, doctors are hopeless to keep up with a body of knowledge that doubles every five to seven years. In addition to the struggles of keeping pace, the sheer volume of information presents a separate challenge to share that information effectively. Michael Yuan, a scientist that has worked with IBM, cites a 1999 study that found doctors field more than 1,100 questions a day and fail to answer 64 percent of them. The inefficient exchange of information leads to mistakes in any field. In the medical field, those mistakes could cost lives. A widely-noted–and hotly debated–report published in 2000 estimated that as many as 98,000 people die in a given year from medical errors occurring in hospitals. As the report notes, “that’s more than die from motor vehicle accidents, breast cancer, or AIDS.”

Now imagine Watson on the job. Never one to nap in the library, Watson’s database would be updated daily with the latest in research from potentially all online journals. The director of Health Informatics Center at the University of Southern California, Carl Kesselman, points out the need to track advances in genomics, specialized drugs, off-label uses, and the increasingly finer-grained classifications of diseases. Of course the physicians themselves can find the information, but the online searches would be labor-intensive and time-consuming. A physician’s assistant like Watson with realtime updates could simply be asked Jeopardy!-style questions to find answers or get second opinions. To make the interactions Jeopardy!-style, speech solutions developer Nuance is currently working with IBM to provide Watson speech recognition software customized with medical jargon. Doctors could query Watson’s database on the go by speaking into a handheld device.

Not to be confused with Sherlock Holmes' sidekick, Watson is named after IBM founder Tom Watson.

At this early stage in its medical education Watson understandably, still makes mistakes. A team of medical students are working with Watson to catch mistakes and try to identify what causes them.

Its knowledge is not limited to science. Watson can also keep an eye on complex treatment guidelines that are often updated so the physician doesn’t have to. It can access medical records as well. However, for access to be completely streamlined they need to be digitized. Unfortunately the medical record digitization seems to be a change hospitals are thus far slow to adopt. Progress is being made, however, by companies like Practice Fusion, a maker of electronic health records (EHR) systems. Combining the latest medical knowledge with the patient’s medical history would give Watson the best chance to catch those rare cases that doctors might be slow to diagnose or miss altogether.

A major break from previous practice is IBM’s plan to include patient blogs among Watson’s data set. Much as they do now on websites such as carepages.com, patients can share symptoms, drug efficacy, drug side effects, relevant family histories, etc. Like a medical wikipedia, the data cloud that amasses could be mined by Watson to pull out obscure relationships that would normally pass under the radar of doctors concerned only with their patients. For example, cross-reactivity between two types of drugs that aren’t taken together very often. In essence, Watson would be conducting its own studies without a priori goals or limitations.

But the data is anecdotal, you say? Dr. Chase agrees, but argues that doctors are already using anecdotal data when they take medical histories. The patients’ descriptions are anecdotal, and the doctors don’t listen any less.

To me the patient blogosphere is the most exciting of Watson’s resources. What sort of insights into medicine and disease will we gain simply by blogging about our own experiences? As Wikipedia shows us, there’s truth in numbers. A major challenge to mining those insightful gems is blogs that are easily understandable to Watson. It’s one thing for a doctor to have a one-on-one conversation with Watson and refine his query when he inevitably runs up against misunderstandings. But it’s quite another thing to glean underlying facts from thousands of blogs from all over the world. A universal format for the patients would help, perhaps including a basic list of yes or no questions.

C'mon, admit it. You can hear the heart beat: "boomp...boomp...boomp..."

A know-it-all robotic physician’s assistant that you can talk to from anywhere with a handheld device. Reminds me, again, of Star Trek, “Computer, across how many worlds has the epidemic spread?” (Yes, that’s two Star Trek references in the same blog!). But one company would argue that it is years ahead of IBM in bringing AI to the forefront of medical diagnosis support–and her name is Isabel. Isabel Healthcare’s founder Jason Maude’s named the database program after his daughter who as a child was misdiagnosed with chicken pox (instead, she had two rare chickenpox-related complications). Created a decade ago, the company’s mission is to decrease misdiagnoses, and it performs essentially the same functions as Watson: symptoms are entered and the computer sifts the database to produce a list of the most likely causes. Isabel asks questions that the doctor might not think to ask, indicates the gold standard treatment, and lists relevant medical literature.

So, what do we need Watson for?

IBM executives point out that Watson is much faster than Isabel and much better at understanding terms that it hasn’t memorized from a textbook. Watson would know, for instance, that “difficulty swallowing” is “dysphagia.”

Watson has a ways to go before it makes the grade. IBM estimates that they are still a couple years away from making a marketable Watson. Doctors, IBM execs say, should not feel threatened by their fast learning student. The clinician’s role is to practice medicine and Watson’s role is to support the clinician, to act as a library. I have to admit, I’m skeptical. Medical students are a pretty ambitious lot. It may just be that beating two of the world’s best at Jeopardy! on primetime television isn’t enough for Watson. Maybe its done playing games and wants to contribute in a meaningful way to society.

Or, maybe Watson just wants to be called Doctor.

[image credits: modifed from Asset Protection Law Journal; Wikipedia; scoreforsale.com]
image 1: modified
image 2: Tom Watson
image 3: sickbay

Can you spot which hand Emily Fennell was born with, and which was recently attached? Hint: the bandage is the only real give away.

The latest recipient of a hand transplant is coping well in Los Angeles. On March 5th, Emily Fennel, age 26, received a donor right hand to replace the one she lost nearly five years earlier in a car accident. Now, more than six weeks later, she once again has two working hands and is on the road back to a normal life. In the weeks and months ahead, Fennel will continue to undergo occupational therapy – picking up small objects and relearning how to use her right hand. Doctors think she’ll one day have as much as 60% of the functionality of her original limb. You can see Emily discuss her condition before and after the transplant in the videos at the bottom. With more than a dozen cases in the US, and over 40 worldwide, these transplants are slowly becoming a more common procedure…but seeing doctors attach a new hand to Emily’s arm still seems utterly incredible!

In order to transplant the new hand onto Fennel’s arm, surgeons had to connect 23 tendons, 2 bones, 2 arteries, and at least 3 nerves. The connection was made along a skewed ellipse, rather than a circle like a bracelet. This was to ensure that scar tissue didn’t create a ring at the wrist that would impair movement or healing. While Fennel is reportedly adjusting well to the transplant, at this point in the recovery process she has no feeling in the attached hand. The connected nerves grow slowly (~1 millimeter per day) and so it will take many more weeks or months before she can receive sensations from the new limb. This numbness, however, has not stopped her from training to rebuild atrophied muscles in her arm and dexterity in her hand.

Hand transplants are extraordinary works of surgical finesse, but they come with a high price. Fennel will have to spend the rest of her life on immunosuppressant drugs to keep her body from rejecting the donor tissue. Those medications increase risks for high blood pressure, liver damage, kidney damage, cancer, and body wide infections.

Despite these dangers, Fennell is not alone in pursuing hand transplants at UCLA. The UCLA Hand Transplantation Program is still seeking prospective patients for the procedure, and while eligibility is limited, and the screening process rigorous (involving medical and psychological tests), I’m sure many will pursue entry into the program. Especially as the first success, Fennell, seems very happy with the results of her transplant.

The general field of transplants has become increasingly bold in the past few years, which has paid off with remarkable successes. We’ve seen several double hand transplants, as well as full face transplants. With stem cells, we’ve seen new organs grown inside patients using nothing more than their own cells and a donated ‘scaffold’ of the organ. Combined with Emily Fennell’s recent surgery, these accomplishments paint a picture of a field of medicine that is accomplishing tasks that would have seen impossible a few decades ago. In the next few years, some of these surgeries could become almost common.

That’s assuming, of course, that they don’t get replaced by something better. While Fennell decided that prosthetics weren’t the right solution for her amputation, others have chosen that route. We’ve seen how not only are robotic limbs becoming more adept, the most advanced prototypes are able to provide sensory feedback. As hand transplant surgeries improve in the years ahead, so too will these robotic alternatives. How long until they become as good as the biological versions? Fennell was able to find a near perfect match for her missing hand, but what about all the amputees who aren’t so fortunate? Whether it’s due to hopes of augmentation (eventually robotic limbs will surpass biological ones, even if takes fifty years) or a limit in opportunity, I think prosthetics will continue to be a strong solution for amputees even as hand transplants improve. If I had to weight the risks of immunosuppressant drugs versus the comfort of having a biological hand…I’m not sure how I would decide.

The beautiful thing is that patients can decide. We have options for amputees that simply weren’t available a generation ago. Advanced robotic hands or waiting for a biological replacement – these are both pretty amazing options. Someday in the future we’ll probably be able to add ‘grow a new hand from your own stem cells’. Fennell’s success with her new limb is another sign that we live in an extraordinary age. Medical technology keeps improving, and as it continues on its accelerated trajectory there may soon be no injury that we cannot repair, no tissue that we cannot replace, and no one that we cannot help.

I love medical science.
…Now check out the videos below to see the incredible procedure:

*note: If videos do not appear below, please refresh your browser.

This first video is a brief overview of Fennel’s story, with a focus on the most recent updates on her condition. Her recovery is amazing.

In this extended video you get to see even more of Fennel’s backstory and recovery from the operation:

This final video focuses on the surgery itself, which took place March 4th and 5th over 14 hours.

[image credit: UCLA Health System/Ann Johannson Photography]
[video credits: LA Times, UCLA Health System]
[sources: UCLA News, LA Times]