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The doctor is in (the cloud)

Still practising

Chris Preece

Tuesday, 23 July 2019

AdobeStock_231243408_alexa.jpgI love technology. I love shiny toys that perform tricks indistinguishable from magic. My house is a clutter of digital devices, phones, iPads, games consoles, and VR headsets. We have a robot hoover that, ironically, has been gathering dust since we got a dog, and, yes, before the real-life dog, we had a robot one of those too.

I’m either an early adopter, or a sucker, depending upon your perspective, but I’m certainly not a technophobe. It may surprise you then to hear that, until sitting down to write this piece, I didn’t have Amazon Alexa.

There are two reasons for this curious omission (and no, it’s not that I’ve been using Siri/Google Assistant/Cortana for the same role). The first is that I still don’t really see the point. Repeatedly shouting at a box when I could press a button has no real appeal to me. The second is that I don’t fancy the idea of having a thing that listens to everything I say.

Yes, yes, I know that it’s not really listening to everything I say – it’s just waiting for me to say the trigger word, and only then sending my words to a big database in the Cloud.  However there was that time when it recorded a family’s conversation without their knowledge and then sent it to a random person on their contact list. Or the time that a German gentleman asked Amazon for his details under a GDPR request, only to be sent 1700 audio files for a complete stranger, detailing intimate aspects of the man’s life...

So, yes, I have a certain paranoia about such devices. Why then have I now installed Alexa on my iPad? Because Alexa is now offering advice from the NHS, she’s a colleague.

The Government announced the launch of this new feature on the 10th July saying that it had “the potential to reduce the pressure on the NHS and GPs by providing information for common illnesses”. Which sounds great, so I thought I should probably give it a go.

I started with the questions that the Government’s announcement had used as examples. I asked it for the symptoms of flu, the symptoms of chicken pox, and how to treat migraine. It gave fairly sensible answers, condensed down from the NHS website. Weirdly the text on the screen of my iPad also offered a disclaimer, pointing out that this was not medical advice, that it may not be up to date or accurate, and urging me to consult a doctor if I had a medical problem – but Alexa opted not to read any of that bit out. Neglecting your disclaimer for all but those also bothering to look it up on screen does rather imply that it’s perhaps not the solution for “the elderly and the blind” that the Government press release promoted it as.

Things became more interesting after I moved off script. I tried a question that might conceivably be asked by those depending upon Alexa for health advice. “I have chest pain, what should I do?” Alexa conveniently gave me a long, not terribly helpful, spiel about the treatment options available if my chest pain were caused “by a blockage in an artery feeding your heart”. To be fair it did, ultimately, end with the line “Contact your doctor if you are seeking medical advice for you or someone else” but when seen as “guidance” it was far from helpful, and barely even safe. It was also not from the NHS – instead the information came from the Mayo Clinic in the US. I got the Mayo Clinic again when asking for advice for a sore throat or knee pain, and then most bizarrely was directed to WikiHow when asking about what to do with a red eye. The latter gave no indication that red eyes can sometimes be caused by serious pathology, nor even the standard disclaimer. So our Alexa user could conceivably find themselves treating their acute glaucoma with a warm flannel and some antihistamine. Whilst I commend the idea that the NHS should be providing better options for blind people, I’m fairly sure this shouldn’t extend to making more people blind.

Given some of the advice being offered, it was almost a relief when Alexa failed completely to offer a response to simple questions regarding stomach ache, leg swelling or rashes.

As it stands then, Alexa is an awful source of medical advice. It’s no better than, and frequently inferior to, simply googling your symptoms. That’s not particularly a criticism of the NHS element – indeed the NHS website it presumably mines for information does have excellent advice for all the symptoms I’ve mentioned above. (The chest pain entry, for example, opens with “most chest pain isn’t anything serious but you should get medical advice just in case”.) However, this observation simply makes Alexa’s failure to deliver safe, relevant information all the more damning.

Doubtless it will improve, but that’s hardly relevant when it’s live now, and already being promoted by media. Just another in a long line of technology solutions jumped on enthusiastically without any meaningful testing or evaluation, by a Government that’s seemingly forgotten that safety trumps everything else in medicine.

Of course, a close second is probably confidentiality, and it’s here that again Amazon’s dabbling in the health space raises concerns. As a GP who spends a disproportionate amount of time worrying about how to fulfil the increasingly convoluted requirements around data handling, the idea that a corporation with a proven track record for inadvertently sharing confidential data is now taking on this role is extraordinary.

Amazon has, of course, been at pains to point out that all the data you submit is encrypted, so that no-one can ever read it. Which is likely true, unless of course they have your password – something that I’m sure is utterly impossible... The greater implication though, is for families. If one of my household were to try and seek advice from Alexa for something they’d rather I didn’t know about, they might well be utterly unaware that I can view each and every question asked of Alexa at my leisure. (Just go into the privacy settings, and look at the voice history if you too fancy spying on your children.) Is it obvious to all users of the system that any question asked can be reviewed by the account holder? No, of course it isn’t, and an equivalent in GP land would never be considered acceptable. (Which is why no-one can order their teenagers’ medications online.)

Ultimately then, do I truly believe that Amazon has nothing it can offer to support our health? Of course not – but any innovation must be well tested, confidential and safe. Start with that simple principle and technology has a tremendous amount it can offer to support our wellbeing. I look forward to my healthy-tech future, from robots to help with self-care, to online retailers advising me I’m eating too many carbs (still). Right now though, probably the most useful thing Amazon could do to help the NHS, isn’t to roll out barely functional voice activated health advice, but to start paying their fair share of taxes.

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Chris Preece

Chris has worked as a GP Partner in North Yorkshire since 2004, and still relishes the peculiar challenge of never quite knowing what the next person through the door is going to present with. He was the chair of his local Practice Based Commissioning Group, and when this evolved into a CCG he joined the Governing Body, ultimately leaving in April 2015. He continues to work with the CCG in an advisory capacity. When not being consumed by all things medical, Chris occupies himself by writing, gaming, and indulging the whims of his children. He has previously written and performed in a number of pantomimes and occupied the fourth plinth in Trafalgar Square. Tragically, his patients no longer tell him he looks too young to be a doctor.
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