Continue Learning and Do No Harm

Continue Learning and Do No Harm 150 150 IEEE Pulse
Author(s): Nancey Trevanian Tsai

In this issue of IEEE Pulse, we explore the human interface of the microscopic with global systems. The parallels are as a Fibonacci fractal: Human beings are a scaffolding upon which microbiomes live, much like populations that live in the varying climates and geographies of the planet. As we advance technology for humanity, it is worth considering the impact of that interface.

As a physician, I take an oath to “Do no harm” to the patient. However, a simple phrase as such begs questions such as, “Harm, in what context?” Do I treat the kidney in spite of the heart? Do I treat the person in front of me with methods that may have adverse consequences to the next patient? Do I use heroic, short-term measures that have opposing long-term consequences? Can I trust my training, my understanding of treatments to be the correct paradigm as I engineer technologies to streamline the process? We can learn from our own microbiome as the different flora coexist mostly peacefully with other populations elsewhere on and in the same person.

The gut flora is not one population: The stomach is highly acidic and has enzymes that breakdown the food we consume. The small intestines are more neutral, swimming with binding agents to assist with uptake of nutrients to be sorted, resorbed, or evacuated via the large intestine. Each serves a purpose to preserve the human in which it lives. The flora in each section clearly has to be different to survive in its environment. Furthermore, the diversity of the flora keeps any single organism from dominating the area. Dominance of a single organism creates a pathological state. In fact, we call overgrowth of any single species, “an infection.” When we treat an overgrowth, such as Candida albicans which causes thrush, we inadvertently kill other symbiotic fungal species that keep bacteria in balance in other areas. In the reverse, many can attest to the fungal infection that inevitably follows after a few days of antibiotic treatment for sinus or bladder infection. Development of specie-specific antibody therapies to target the overgrowth decreases the malaise from the treatment.

The human is occasionally infected with viruses, many leaving their genetic footprint in our cells. In return, however, some of these particles offer protection against cancers or other pathological state. In the short term, the immune system ramps up to fight the invasion. Viral particles have the ability to hide in certain cell types and re-emerge, causing long-term pathology. For example, individuals are commonly infected with the Epstein-Barr virus (EBV) in high school or college. The initial infection with this type of herpesvirus leads to mononucleosis, or “Mono.” We tend to think of this as a benign disease, as most people recover after a few weeks, and it is rare for a person to rupture their spleen during that initial infection. However, EBV is suspected to be involved in the development of myocarditis, chronic fatigue syndrome, and a host of other autoimmune diseases, such as lupus and multiple sclerosis. In this sense, we have known about “long EBV” decades before “long COVID” and have lived with it without much existential panic. On the other hand, there are known oncolytic (onco = cancer, lytic = bursting) viruses that confer protection to its host. Other bacteria have either developed antibiotic resistance or have long growth periods. Mycobacteria species, such as that which causes tuberculosis, grows over weeks and months, which means treatments often last for a year or longer. Phage therapy seeks to treat these conditions more effectively with fewer side effects.

We seek to have a symbiotic relationship with our microbiome, and even the invaders that occasionally decide to take up residence. They produce cofactors vital to life, such as vitamin B12, produced through fermentation of microorganisms in our gut. Those cofactors not only keep us alive, but also affect our moods, our drive, and many aspects of our mental health. Conversely, dysphoria and other mental and emotional states can affect our physiology. Depression often manifests as a loss of appetite, loss of interest in pleasurable activities. We are just starting to understand the effects of climate and environmental change to our physical and mental health. There are the changes reactive to events, such as anxiety, post-traumatic stress disorder (PTSD), and suicidal ideation after natural disasters. In sports medicine, we are aware that the brain works 20%–30% less efficiently with each 1 °C increase of the temperature of the cortex. Employees who are ill are simply less effective for the same reason. As our environment changes, we are also affected by sequela, some of which are only starting to be identified.

Climate is not singular, just as our microbiome is not a singular population within our bodies. There are micro- and macro-climates which are affected by barometric pressure, temperature gradients, wind, and other vector effects. We instinctively know that the plants in the tundra are adapted differently than those in the desert. However, when humans intervene, insisting that Las Vegas and Phoenix need to have golf courses, we change the landscape. The previously barren land is now irrigated through technology, and that same technology lowers the water table, thus requiring more technology to maintain the new landscape. This is not new. Humans have been introducing new species that become invasive when there are no natural predators. Who knew that Australia could be overrun with rabbits? (Come see them in Sydney at the 2023 EMBC!)

We also introduce chemical species, through manufacturing, through drug discovery, and through energy management. Many of these changes help us to create creature comforts in the short-term, but what of the long-term effects? What is the relationship of golfers in Phoenix to the puffin population near Iceland? How much of the pharmaceuticals leaked to the water cycle am I responsible when I prescribe an antidepressant for my patient? How far does my “Do no harm” pledge go? It is likely there are natural divisions between areas of the earth as there are between the stomach, small and large intestines. It can be all too easy to oversimplify and exaggerate generalities, which is treating the ego’s need to understand rather than genuinely working through the complexities of a large system.

Artificial intelligence (AI) has no ego. It merely identifies what “is” and compares it to other metrics that have demonstrated outcomes. It does not assume meaning or emotion, and it has no attachment to any “story.” Clinicians—indeed, all persons—are unaware of their blind spots, occasionally defending them vehemently. At the same time, the lived experiences and ability to heal through storytelling can be of enormous benefit to another. The shared context, the scope of the impact to a person’s self-identified meaning, are the cornerstone of traditional therapy. Ideas and emotions are also infectious, occasionally leaving residual DNA that confers long-lasting benefit.

This issue of IEEE Pulse features a psychotherapy tool using AI to improve clinical effectiveness and efficiency. Some are concerned that AI will replace humans in the therapy role, when they figure out how it can pass the Turing test. There are still limitations to AI that prevent it from being more than an augmentative tool. The August 2022 IEEE Spectrum had a short article on the current limitations of AI, as represented by DALL-E 2. In short, AI struggles with scope and a human context. It also does not possess the sense of gravitas as to the brevity and preciousness of life, the impact of events that shape the lens through which each of us think, feel, and act. However, it is a useful tool for those blind spots, gently nudging us to use better words to convey empathy and draw out the issues that need attention from that person in front of us.

In the end, the context of “Do No Harm” has a context. While it is important to consider the broader implications of any prescription, it is hubris to think my influence extends much beyond the human in front of me. Then again, it is also important to be mindful that small amounts of DNA can substantially alter the health of an organism as I choose between treatments.

Do no harm and leave a small footprint.