Peter J. McDonnell, MD, is director of the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of 

Peter J. McDonnell

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"We can only be said to be alive in those moments when our hearts are conscious of our treasures."

 "I feel a very unusual sensation-if it is not indigestion, I think it must be gratitude."

Articles

Dr. McDonnell focuses on what gifts ophthalmologists have received in their profession.

Ophthalmic gifts for which to be thankful

"There are worse things in life than death. Have you ever spent an evening with an insurance salesman?"

Later, I realized that my father's treatment of salespeople was influenced by my grandfather. An orphan who came to this country by himself at age 12, my grandfather never went to college, but made a living by selling insurance. I also found out that, as a general surgeon, my dad frequently had sales representatives ("sales reps") from drug and device companies visit the clinic that he oversaw as medical director. Although he was busy, he told me he always made some time to listen respectfully to the visitor, and it annoyed him when the other surgeons did not do the same. 

Those memories came to mind when I was speaking with some friends (male and female) who used to be sales reps for pharmaceutical companies. The conversation turned to what it was like to interact with physicians in that role. Some of the anecdotes that came out were frankly hard to listen to: outrageously rude and dismissive behavior, unwelcome sexual overtures (both verbal and physical), inappropriate requests for quid pro quos in which the sales representative would provide some financial reward to the physician in return for prescribing behavior. Sometimes, the reps left a doctor's office feeling completely humiliated, without knowing where to turn for support. 

Having grown up as the only brother of five sisters and now being the father of two daughters, I find the idea that some male physicians regularly feel free to accost female sales representatives sexually is particularly outrageous. Those doctors are apparently well known by the female reps because they have a consistent pattern of behavior. 

Those stories made me wonder if sales reps are disgusted with all physicians. "Not at all," my friends assured me. From the perspective of most sales reps, the vast majority of physicians are intelligent, professional, and pleasant to interact with. 

A Web site for pharmaceutical salespeople is 

. Visit it sometime and read a message board where reps describe some of their experiences with physicians (

									http://www.cafepharma.com/boards/showthread.php?t=109619/

). Among the "outrageous behaviors" recounted: doctors screaming at reps because the free lunch being provided wasn't to the physician's taste; written sales aids being ripped up and thrown at the rep because the doctor "was having a bad day"; female reps being groped. Pretty sobering stuff. 

Does spending life in school and medical training, followed by a highly paid position with all the prestige accorded physicians explain why some physicians would be so arrogant? Does being busy in clinic, as most physicians are, justify treating salespeople like dirt? Even if it is only a modest fraction of doctors who behave so inappropriately, no doubt those very negative interactions are particularly memorable. 

By the way, there is also a lot of juicy gossip on 

, although some of it strikes me as being a bit mean-spirited. 

 director of The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of 

. He can be reached at 727 Maumenee Building, 600 N. Wolfe St., Baltimore, MD 21287-9278 Phone: 443/287-1511 Fax: 443/287-1514 E-mail: 

From the perspective of most sales reps, the vast majority of physicians are intelligent, professional, and pleasant to interact with. Some however, are not and include outrageously rude and dismissive behavior, unwelcome sexual overtures (both verbal and physical), and inappropriate requests for quid pro quos in which the sales representative would provide some financial reward to the physician in return for prescribing behavior.

Most sales reps say physicians are pleasant

“I think, therefore I am.” -Rene Descartes

As you know, artificial Intelligence (AI) has been getting a lot of attention these days in the lay press, in our science journals, and in movies. Recently, the FDA granted its approval to an AI/machine learning approach to the analysis of retinal photographs to screen for diabetic retinopathy based upon data suggesting that the approved AI approach may actually be superior at detecting retinal disease than relying on a human diagnostician.

From recent conversations, I learned that AI commonly evinces strong feelings, positive and negative:

- A medical school dean told me that he thinks AI will streamline the diagnosis of most medical illnesses. He believes this will make the career path of primary care physician much less interesting in the future, and he is encouraging his own child to consider becoming an ophthalmologist.

-  IBM thinks its Watson computer will improve the outcomes of cancer therapy, improving patient care while generating a revenue stream for the company.

- A physician friend worries, like the famous physicist Stephen Hawking, that AI will be an existential threat to the human race. This vision of a dark future includes autonomous lethal devices taking human life.

- Another physician friend sees AI as a friend and servant of humans. Autonomous vehicles, for example, will make travel ever safer, eventually dramatically reducing traffic fatalities.

All this attention has caused me to look into the field of philosophy of artificial intelligence and what it means to think.

In 1950 mathematician Alan Turing wrote a paper entitled “Computing Machinery and Intelligence” that began: “I propose to consider the question, ‘Can machines think?’” Turing conceived the test that today bears his name.

The Turing test says that a machine will have exhibited intelligence equivalent to a human when a human, sitting at a keyboard and typing back and forth with an unseen correspondent, cannot tell after several minutes whether the responses are those of a machine or another human. So far, no wonder of computing technology has yet passed this test.

One AI test involved a machine analyzing performances of famous comedians. After, the machine was tasked with writing its own jokes.

The results are laughable. While curious and perhaps interesting, these computer-authored jokes are more devoid of humor than the least funny human-authored jokes you have ever heard. Most of my friends believe that computers today can think to some degree, and in the future with certainty will be able to mimic human thought and conversation.

“If they can think,” I asked, “does that also mean they are alive?”

Isn’t that what Descartes had in mind with his famous quote? My friends would not make this leap. The consensus was thought, and life are not synonymous. For example, a machine might be capable of thought but not be alive in the same way that a single-celled organism, like Staphylococcus, might be alive but not capable of thought. Machines are demonstrating more capability to perform tasks like interpreting x-rays or detecting diabetic retinopathy without human oversight.

Wise physicians in the future will harness that technology, freeing them up to do what highly-trained humans can do best (like stand-up comedy and injecting bevacizumab). My own view is that AI will be an overall force for good, but there is no reason why it will not be misused by some for criminal or malevolent ends.

Director of the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of Ophthalmology Times. 

He can be reached at 727 Maumenee Building 600 N. Wolfe St. Baltimore, MD 21287-9278
Phone: 443/287-1511
Fax: 443/287-1514
E-mail: pmcdonn1@jhmi.edu

Whether we like it or not, artificial intelligence has arrived

Do machines think?

During a recent conference, I had the chance to get together with three colleagues from around the world. It was after 5 p.m. The lectures were over. We were sitting in a cafÃ© enjoying the fruity adult beverage for which the host country is justly famous.

I don’t like to brag, but my ophthalmologist friends are fabulously successful (by any measure) and extremely intelligent and respected physicians. They live thousands of miles apart. Among the four of us seated at the table, six languages were spoken. All of them read and publish in the English language ophthalmology journals. We alternated back and forth between two languages as we sipped our cocktails and this truth serum began to flow through our veins.
	 

Somehow the topic of adenovirus conjunctivitis came up. I asked each of my colleagues how they treated that condition. What I heard surprised me.

One of my colleagues is impressed with the literature supporting a role for povidone iodine. He treats patients presenting with EKC with that agent, then has them escorted from his office while staff carefully wipe down everything the patient might have touched while present. He is careful to avoid the use of steroids, having been taught that they prolong the course of the disease. He believes his therapy shortens the course of the disease substantially.

Another colleague has a very different regimen. He gives every patient a topical nonsteroidal agent plus an intramuscular injection of a potent and long acting steroid. He believes his approach maximizes patient comfort and reduced redness and swelling. Patients can function and are grateful to have few symptoms.

My third colleague gives supportive therapy only, recommends transmission precautions, and reserves topical steroids for only the very severely affected patients.

Over a second delicious beverage, we discussed why it is that ophthalmologists who read the same papers in the same journals have such widely varying approaches to the management of a very common eye problem.

Not everyone gives the same credence to the same publications. Some ophthalmologists train with professors who are vehemently opposed to the use of corticosteroids while others had professors who used steroids frequently.

One colleague told an amusing story; his professor forbade the use of steroids by residents for patients in the university clinic but used them liberally in his private practice.

“I have to keep my private patients comfortable and happy,” he confided to his junior colleague.

The variation in practice among very well trained ophthalmologists frequently surprises me, given that we all acknowledge the importance of scientific evidence to guide our practice and read the same journals.

I dream of a future time when every patient with a certain problem receives the same effective treatment based upon the most current scientific knowledge, no matter which doctor he or she happens to see.

Why it is that ophthalmologists who read the same papers in the same journals have such widely varying approaches?

Evidence-based ophthalmology

"When I was younger, I hated going to weddings. It seemed that all of my aunts and the grandmother types used to come up to me, poking me in the ribs and cackling, telling me, 'You're next.' They stopped [doing] that . . . after I started doing the same thing to them at funerals."

									http://www.jokesaboutweddings.com/

My good buddy, an ophthalmologist, attended a wedding with his family a few years ago. The blissful couple had written their own vows, which reportedly were quite lengthy, and the ceremony was being videotaped. The couple expounded on their love for each other, going into considerable detail about how it was deeper than the deepest ocean, higher than the highest mountain, etc. After quite some time of this, my friend's son yelled out from the quiet audience, in an annoyed tone, "Yeah, yeah, yeah!" This commentary is captured on the wedding video, preserved for all time. 

Thirty percent of ophthalmic procedures are unnecessary? That was news to me. "This character has no idea what she's talking about," I thought. The American Academy of Ophthalmology already projects a likely undersupply of ophthalmologists to care for the aging baby boomers, people with diabetic eye disease, and everybody else who will need eye care a decade from now. We have been thinking that we would be hard-pressed to keep up with the demand for our services. But, in fact, it now turns out that the wonks (or at least this wonk) have revealed that about a third of what we do is really unnecessary. Who knew? 

Wedding vows was the other, unrelated news item of the program I was watching. Traditionally, vows were given to the couple by a minister or other official. But increasingly, tradition is being thrown out of the window and couples are concocting their own vows. That is a big responsibility, however, because the words written for wedding vows are meant to be extremely weighty and eternal (unlike the drivel I write in my columns). As a result, online wedding vow ghost authorship services will shoulder this important burden for the bride and groom. 

The connection, of course, is obvious. If the policy wonks who might come to control health care in the United States demand a 30% reduction in procedures, and with ophthalmology being such a procedure-oriented specialty, a lot of ophthalmologists will be looking for something to do. Forced to stay out of the operating room, they could devote their talents to penning vows, such as "Our love is like a red, red retinal arterial macroaneurysm" and "My respect for you is greater than the largest chalazion." 

Because so many ophthalmologists are good writers and some have senses of humor, this scenario could work out really well for couples tying the knot. But if you end up writing vows in a few years, have mercy on the young boys being forced to attend the ceremony, and keep them short. 

 director of the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of 

He can be reached at 727 Maumenee Building, 600 N. Wolfe St., Baltimore, MD 21287-9278 Phone: 443/287-1511 Fax: 443/287-1514 E-mail: 

One "policy wonk" suggests that physicians are performing too many procedures (about 30% too many), and that if they no longer perform unnecessary procedures, money will be freed up to reform the health care system.