👋 Hi All. It’s a Good Friday for some medical news. Here’s what we got:

• 🇺🇲“Make America Healthy Again”

• 😟 AI Just Beat Doctors on Empathy.

• 🤔 Which Methotrexate Side-effect To Focus On?

• 🦾 Robotic Boost for NHS

INTERNATIONAL HEALTH NEWS

🇺🇲”Make America Healthy Again”

Can you hear that? Silence. 

No controversy, scandals or mistakes from the NHS this week. How are we to get our fix now? Let’s turn our attention to “the land of the free”. Trump always has something for us.

This week the Trump administration has proposed massive cuts to the federal health programmes. The plan was revealed in a leaked 60-page “passback” document. 

Massive means massive. The National Institute of Health(NIH) will lose 40% of its budget. Going from $47 billion to $27 billion. They must have taken a leaf out of the UK’s book(CCG’s => ICB’s), as they are also condensing 27 institutions into just 8. 

So long agencies for minority health, nursing, chronic disease prevention, HIV work and rural hospitals 👋. Instead, they get a shiny new “Administration for a Healthy America”(AHA). The CDC also gets a 44% haircut, wiping out established programmes tackling obesity, heart disease, smoking and domestic HIV efforts.

This change will hand Health Secretary RFK jr a $500 million pot for “Make America Healthy Again” projects. Although I think $500 million won’t make much of a dent in their 40% obesity rate. Meanwhile, the FDA is now being treated like an early start-up. They’re ability to review drugs and devices would now hinge on its own fee collection alone. 

The administration frames it as restoring "proper federalism" and cutting “woke ideology” from government. Critics, however, warn it’s a short-sighted hack job that could gut rural health services and skyrocket future Medicare and Medicaid costs.

Will Congress go for it? Hard to say. They torched Trump’s last big NIH cuts. But if it goes through, rural America and public health could be in a pickle.

RESEARCH UPDATE

😟 AI Just Beat Doctors on Empathy.

The new Black Mirror just released. The season overall was pretty mid. Not been the same since they americanised it.

But I really loved that episode where the patient opened up to a super empathetic doctor, only to find out at the end… the doctor was an AI the whole time?

Wait, that wasn’t an episode? Ohh… that was actually real life.

Another AI vs Doctor study just dropped in Nature. And this time the LLM isn’t just smarter than doctors, it’s also apparently more empathetic. And there goes that “human connection" moat we thought we had. 

Introducing AMIE(Articulate Medical Intelligence Explorer). This is a custom LLM which has been trained and optimised for diagnostic dialogue. This includes history-taking, differential diagnosis, management and escalation. The researchers are trying to give GP’s a run for their money, by pitting the AI against primary care providers.

Method: This was an OSCE style RCT. They took 159 case scenarios from the UK, Canada and India, from a multitude of specialties. They compared the performance of the AI to 20 board-certified primary care physicians. The performance was then evaluated by patient-actors and then specialist physicians. 

The consultations were conducted over text-message(which obviously isn’t how things go down in real life).

So…the AI beat the physicians in a variety of clinical domains. Across accuracy, information acquisition, differentials, we only matched it on escalation recommendations. But how on earth is it more human than us?

Really, the patient-actors rated it on politeness, attentiveness, rapport building, honesty, comfortability. We lost in all domains.  

So is it time to hang up the boots and leave the game before the game leaves us? No. Why? Because the study has some issues.

1. Doctors don’t talk in text: Unless you’re trying to get a Viagra prescription from Superdrug, we don’t communicate over text. This unfamiliar text-chat interface handicapped the physicians. Additionally, the AI had been trained to be good in this environment, unlike the physicians

2. Read between the lines: Patients don’t tell you everything. The intricacies of non-verbal communication were not, and cannot be explored in this study

3. It’s a simulation: The simulated environment had an array of limitations. Assumes an underlying disease state (as OSCEs always have a diagnosis), thus neglecting patients who are really just fine. No space for the worried well. 

4. Examinations[strikethrough]: AMIE can’t do examinations, all its investigations were reported by the system. Which is good for clinicians (for now). Until they fit GPT into a stethoscope…

So before you change your Linkedin profile to “former doctor, future barista”, remember that real life medicine isn’t the clean back and forth that an OSCE simulates. Until an AI can navigate a jam packed Monday morning with a toddler screaming in one room and a patient who should have really gone straight to A&E at reception, we’ve still got the advantage 💪.

RESEARCH UPDATE

🤔 Which Methotrexate Side-effect To Focus On?

So you have prescribed methotrexate for your patient with rheumatoid arthritis. Appropriate. It has been a favourite for decades. Problem is, it’s got all these pesky side effects. Mucositis, myelosuppression, pneumonitis, fibrosis popping up everywhere. It’s not exactly the friendliest of drugs.

Because of that, it demands constant monitoring. The blood tests, including FBCs, LFTs and U&Es, behave like toddlers. Leave them unchecked for too long and you can guarantee they are up to no good. But which one should you really be losing sleep over?

In a study published in Arthritis Research & Therapy, researchers conducted a retrospective analysis to assess methotrexate's impact on kidney and liver-related adverse reactions in RA patients.

They looked at 10,319 adverse drug reaction reports where methotrexate was the suspected culprit. Outcomes were categorised as either fatal, meaning the patient died, or non-fatal, which included life-threatening events, prolonged hospitalisation, disabilities and so on.

So what did they find? Out of those ten thousand cases, 1,082 were liver-related, 365 were kidney-related and 67 involved both. On paper, liver toxicity was more common. But when it came to deaths, the kidneys were leading the funeral procession. Among kidney-related side effects, fatalities occurred in 21.1 percent of cases compared to only 5.8 percent with liver toxicity. Suddenly, the liver looks like the least of your worries.

Here are the additional takeaways:

• Longer methotrexate use meant more kidney problems. Patients with kidney reactions had been on methotrexate for a median of 16.2 months, compared to 9.9 months for liver issues.

• Older and overmedicated was a bad combo. Liver-related deaths were more common in older patients who were also stacking up comedications like corticosteroids, acetaminophen and metamizole.

• Highest mortality in mixed disease. Patients with both liver and kidney involvement had the highest death rates, especially if they were mixing in NSAIDs, acetaminophen or metamizole.

In their own words, the authors put it plainly:

"Because drug management in patients with RA using methotrexate is a complex matter, precise and standardised recommendations on when and how frequently renal function needs to be tested to detect early signs of renal impairment might be helpful to prevent fatal outcomes."

TLDR: Whilst LFTs are important for monitoring, maybe do not let the kidneys feel left out.

MEDTECH/NHS NEWS

🦾 Robotic Boost for NHS

We’ve got more robots now. This time to assist us, not replace us.

NICE approves 11 robotic surgical systems to be used for soft tissue and orthopaedic surgeries. But there’s a catch: they’ll only be used on a probationary basis while the NHS figures out if they’re actually any good.

Five of the systems will be used for soft tissue procedures like hernia repairs, tumour removal and gallbladder surgeries.The other 6 will specialise in orthopaedic surgeries like knee and hip replacements.

NHS directors are betting big that this tech will make surgeries faster, more accurate, and maybe even less traumatic overall. Leading to shorter hospital stays, fewer complications and quicker recoveries. Hopefully.

“Robot-assisted surgery is crucial to the future of high-quality healthcare,” said Professor Sir Stephen Powis, NHS national medical director. 

This is all well and good, but each system will cost between £500,000 and £1.5 million. Additionally availability will be limited to specialist centres for the time being. Likely resulting in disparities between the north-south of the UK.

NICE has given the providers of the tech 3 years. If they live up to expectations, a wider rollout will be considered. If not... well, they’ll quietly unplug them.

NICE also notes that this is a huge boost to surgeons, as console-based solutions means that the physical demands of procedures will be reduced. Though I think my ortho consultant would grumble that the profession’s gone soft.

Handover Over 🫡 

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A week of firsts for The Handover

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