Lost in the Signal

I finally got around to reading Bryan Caplan's The Case Against Education: Why the Education System Is a Waste of Time and Money.  In it, Dr. Caplan, an economic professor at George Mason University and self-avowed libertarian, argues that, aside from basic literacy and numeracy, our educational system serves less to educate and more as a way to signal to employers who might make good employees. 

Oh, boy, did this book make me think about our healthcare system. 

Credit: UCLA Health

Dr. Caplan's views on economic signaling are by no means out of the mainstream, although his application of it to education may be.  Think of it this way:

• how many of the courses you took in high school and college have actually proved useful to you in your career?
• Indeed, how much of what you learned in those courses do you still remember?

Dr. Caplan cities a raft of statistics to support his point-of-view, including ones about adults' dismal knowledge of most subjects after they graduate, how few college majors actually train many people for jobs in those fields, and even how the "learning to think/learning to learn" arguments are not well supported by data.

He believes that employers prefer people who get a college degree (or at least a high school diploma) because the degrees signal that graduates are "intelligent, conscientious, and conformist."  That is, if you are willing to endure the boredom of all those years of classrooms to the end, you're not only at least moderately smart but also are more likely to be willing to endure the tedium that their jobs will probably have.

E.g., if you are hiring and have two candidates with similar grades and courses, but one of them didn't finish a class in their senior year (and thus could not graduate) versus one who stuck it out for the diploma, how likely are you to risk hiring the dropout -- even though, in terms of what they supposedly learned in college, they were almost exactly the same?

Dr. Caplan notes from his own experience how many students search for easy courses and easy professors, and often fail to even show up for classes -- not behaviors one would do if trying to maximize their learning.  He argues that it has never been easier to find great education: you can audit classes for free at many universities, and take online classes from some of the world's best teachers.  But neither will be recognized by employers in their hiring. 

Dr. Caplan offers drastic remedies, such as cutting all government funding to education, making college more expensive, cutting most majors (he does like practical majors such as statistics or engineering), and more vocational training.  He also supports child labor, as he thinks it is better that kids at least learn how to work instead of wasting time in school.

I suspect Dr. Caplan staked out an extreme position to make a point, but that does not mean that his point doesn't have validity.  Most people would tend to support ever more spending on education -- free college for everyone! -- but, at some point, there have to be diminishing returns, and it is certainly possible that we have passed that point.  It's not like we're doing better on most measures of knowledge or skills. 

Credit: Lown Institute

We spend over a trillion dollars annually in government (federal, state, and local) support for education, which is more than we spend on defense but way less than we spend on healthcare.  As with education, most of us would probably acknowledge that healthcare is full of waste -- not just excess administration but also unnecessary/inappropriate care. 

Even worse, all that healthcare spending seems to buy us declining mortality increasing morbidity, and an array of quality outcomes that rival some third world countries.  Perhaps over-reliance on signaling is one of the reasons for this. 

For example:

Degrees: The gold standard in healthcare is the M.D. (or D.O.).  We look for it, we rely on it, we have faith in it.  And we expect physicians to spend more time in training than other countries, and spend more money on it.   

But we don't really know which medical schools (or residency programs) are better than others.  We don't know how individual physicians did in those programs.  We don't know the relationship between excellence in training and excellence in practice.   

Even worse, we don't know which physicians are good at what they do, much less who the best are.  Having a license or even board certification not only does not guarantee basic competence, it doesn't necessarily mean a physician isn't impaired, has lost their license elsewhere, or even has sexual assault charges. 

We like the degree signal so much that we're increasingly expecting nurses to have B.S.N.s (or Master's), and Ph.D.s for nurse practitioners, pharmacists, and physical therapists.   

Does any of this necessarily make healthcare professionals better?  How would we know?  Or are they just signals to reassure us?

Reputation: You know the Cleveland Clinic.  You know the Mayo Clinic.  You know the most prestigious medical institution in your region.  But you probably can't say why they are more prestigious, and they probably can't really prove that they should be.  

We base these views a lot on faith, on word of mouth, on anecdotes, on which have newer/fancier buildings, and, increasingly, on advertising.  On signals, in other words. 

Latest: We like the newest drug, even though it usually is (much) more expensive and may only offer slightly, if any, improved efficacy.  We like new tools like gamma knives or robotic surgery because, well, they are newer and must be better, expensive be damned.  We get MRIs even when CT scans or a simple X-ray might suffice.  

Given a choice between older treatments/technology or newer ones, who among us wouldn't prefer the latter, even when the latter has not demonstrated its superiority, especially in cost/benefit?  The fact that it is the latest is our signal that it must be better.

I don't go as far as Professor Caplan and say that most of our healthcare spending is wasted and should be cut, but I do think we spend more than we should, and too much on the wrong things.  We'd get a bigger bang for our buck by investing more in public health and less in direct medical care. 

We've gotten lost in healthcare's signals, and aren't focusing enough on what they're actually supposed to be telling us. 

The End of Health Insurance

Paul Tullis has an interesting article in Bloomberg about how self-driving cars might kill auto insurance "as we know it."  After all, if human error is responsible for 90% of auto accidents, and those humans are taken out of the equation, what's left to insure?

Many people don't think much about autonomous vehicles, but Mr. Tullis reports that Michelle Krause, an Accenture insurance expert, says that their impact on auto insurance "...comes up in every strategic conversation" within insurers.

It made me wonder: what would it take to kill health insurance...as we know it?

I.U. professor Rodney Parker told Mr. Tullis: "Liability is likely to migrate from the individual to the manufacturer and the licensers of the software that drives the AV."  This means that, as David Ross Keith, an MIT professor, also told Mr. Tullis: "It’s foreseeable that insurance is a much less consumer-facing industry in the future."

The experts that Mr. Tullis talked to see closer relationships between auto makers and auto insurers; as for potential mergers between the two, Ms. Krause told him "those conversations are going on as we speak."

It makes healthcare mergers like CVS-Aetna or Cigna-Express Scripts look far-sighted.  After all, UnitedHealth's non-health insurance subsidiary, Optum, has already become a powerhouse for the company. 

CVS prototype Health Hub.  Credit: CVS

Let's think about what health insurance is for:

• Averting losses: Like every other form of insurance, health insurance was originally about protecting people against unexpected, catastrophic losses.  It still serves this purpose, and should you ever have the misfortune, say, to have a premature baby or to go through a long program of cancer treatments, you'll appreciate this aspect.  
• Budgeting: Americans somehow came to expect that their health insurance should protect them even against expenses that were moderate and predictable -- most notably, preventive care.  It's not that most of us could not afford these services, we'd just rather finance them via our health insurance premiums rather than budgeting them ourselves, which is a crazily inefficient way to do so.  
• Subsidization:  ACA instituted a program to subsidize cost-sharing for lower-income people via insurer payments (although the Trump Administration has been trying to end them).   As a result, health insurance has become the de facto mechanism to transfer money for health expenses to lower-income people not on Medicaid/Medicare.

I'll take these in reverse order:

Subsidization 

Health insurance is not the right mechanism to do wealth transfers.  It's not what it is designed for, and it is not what it is good at.  Such transfers are a social problem, and should be dealt with via the tax code and/or social welfare payments (as we do, for example, with payments for food or housing).   

Budgeting

It's a failure on our healthcare system's part, that we feel we need financial incentives to get preventive services.  Either we've failed to convince people that getting such services is in their best interests, or we've been promoting services for which that case is unclear.  Neither of these is good.  

We need to stop expecting health insurance help us budget for expenses that, in any other aspect of our lives, we'd be paying for ourselves.  

Averting losses

Even if we accomplished both of the above, health insurance would still probably not look too different than it does now.  Our healthcare system would still have catastrophic expenses, and we'd be looking for protection against them.  We'd still have networks, negotiated prices, and tensions between those who deliver health care and those who pay for it.

Credit: WSJ

We have to attack the root problem, which is not just the prices, but also the costs.  Some examples of how this can happen:

Virtual care will allow us to get advice and even treatment where/when we want it, and increasing reliance on A.I. rather than human expertise will both cut direct costs and, hopefully, unnecessary treatments.  

DIY health is a trend that has promise to greatly impact costs.  Whether it is hearing aids, insulin pumps, or "biohacking," we're starting to move away from reliance on expensive solutions from traditional healthcare sources to cheaper, even home-grown solutions.  

Robots, right now, fall within the "more technology, more expensive" ethos of our current healthcare system, but that cannot last.  Robots will get smarter and more versatile, we'll get better at building them, and they'll allow us to take costs out of healthcare in the way they've taken costs out of manufacturing. 

Hospitals, are, as I've stated previously, "19th century institutions operating under 20th century business models in the 21st century."  

We need to move to a future that is not institutional.  We need to move to prevention, to addressing root causes of health problems, and to delivering more care at home and in the community.  With better real-time monitoring, we can do this cost-effectively.

Prescription drugs are one of the biggest pain points for consumer healthcare spending.  Part of this looks a lot like greed, such as seemingly exorbitant increases for previously affordable drugs (e.g., insulin), part of it is the U.S. not negotiating prices as other countries do, and part of it reflects the long pipeline for drug discovery and development.  The former two are more price issues than cost ones, but the latter one is one 21st century technology can help address.

Credit: Chemistry World

For example, we are already in the era of 3D printed prescription drugs, and this will rapidly advance, even to the point of printing your own drugs at home.  This will have huge impacts on manufacturing and distribution costs.

We are also early in the era of using artificial intelligence to aid the drug development process.  A.I. can sort through vast amounts of data to identify likely combinations and monitor side effects, among other things.  The FDA is encouraging such uses.  Novartis, for example, sees itself as a data company, according to Business Insider, seeing A.I. as its "next great tool" in drug development.  

Long story short: take the big costs out, as is possible, and the need for health insurance goes away, or greatly lessens.

We shouldn't accept the status quo; not in how care is delivered, not in how much care costs, and certainly not in how it is financed.  If auto insurers are discussing merging with automakers, Apple is thinking about its post-iPhone era, Ikea wants to become the "Amazon of furniture," and Amazon's own future may be more about cloud computing than retail, then certainly health insurers should be looking to a very different future. 

Virtual Docs.for All!

There are lots of big ideas being pushed these days, in partly reflecting the run-up to the 2020 elections.  There is the Green New Deal that aims to move the U.S.to a "secure, sustainable future," including (but by no means limited to) moving away from fossil fuels by 2030.  In healthcare, there's the evergreen "Medicare for All," which didn't secure Bernie Sanders the 2016 Democratic nomination but which is popping back up (although skeptics point out it is more like Medicaid for All). 

We'll see how either of those play out, especially with our divided, hyper-partisan elected officials, but instead I'll propose something that is potentially more achievable: let's ensure that every American -- at least, those with access to a smartphone or computer -- has access to their own virtual physician (both human and A.I.).

Baidu's Melody.  Creit: Baidu

Healthcare reform in the U.S. in recent years has tended to be about improving the number of people with health coverage (even ACA left some 27 million without coverage) or using more "value-based" payment mechanisms, which have yet to really shake-up our fee-for-service system.

We are a long way from getting consensus on covering everyone, or on revamping the methodologies for the incomes of all healthcare professionals/organizations, but virtual care for everyone is something we can achieve now, at a reasonable cost.

Andy Kessler, writing in The Wall Street Journal, says "it's time to fire your doctor!"  He lists many of the ways consumers can use technology to track their own health, as well as seek medical advice through "several smartphone-based platforms now function like Uber for doctors."  (He is quick to note though, that when you're really sick you'll still want a specialist).

Mr. Kessler points out: "Doctors don’t scale, so the real future of medicine is digital diagnosis...The revolution is coming.  But not from your doctor."  

Credit: Accenture

A.I. has been looming for healthcare for a few years now, with uneven results.  Babylon Health, for example, pitched its chatbot in the U.K., but ran into concerns from physicians about the advice it was giving.  In China, Baidu has been using its chatbot (for both consumers and doctors) for a couple years.  China views A.I. as an essential component of its future healthcare system.  

Meanwhile, A.I. continues to get better. A new study (from China, not surprisingly) demonstrated an A.I. that was highly accurate in diagnosing several common diagnoses.  It's accuracy rate challenged the highest accuracy rates of human physicians.  The thing to remember, as Mr. Kessler noted in his article, is that "The best doctor sees one patient at a time, but a clever piece of code can be used by countless people." 

Studies have also found that A.I. can detect heart disease and lung cancer more accurately than human physicians, and in diagnostic imaging.  There have already been FDA approved AI tools for ophthalmology and stroke detection.  

Healthcare Bot use Credit: Microsoft

In a recent Insights, Forbes cites study that indicate private sector investment in healthcare will reach $6.6b by 2021, with AI generating potential U.S. annual savings of $150b by 2026 (Accenture) or $269b (McKinsey).   IBM (Watson) and Google (Deep Mind) have invested heavily in A.I. for healthcare, and Microsoft just rolled out its Healthcare Bot Service to help spur creation of chatbots and A.I. personal assistants.  

As for virtual care from humans, it is not entirely clear that virtual visits do replace in-person ones, nor are most physicians involved in providing them, but the promise remains.  Kaiser Permanente, which has also long been an advocate of using A.I., claims over half of all visits are virtual.  Many, perhaps most, large health plans/employer health plans give their members the choice of virtual visits.   

Rock Health's 2018 Digital Health Consumer Adoption survey found continuing increases in the percentage of consumers using such services: 75% have used at least one telemedicine channel.    

If we think about it, it is crazy that when we have a health problem, the thing we are expected to do is to call our doctor for an appointment, then drive there (or to the ER/urgent care) to find out what is wrong.  This is why we end up sharing our germs with a room full of other sick people, waiting for our turn to be seen, and worrying the whole about what might be wrong and is going to happen to us (not to mention how much it will cost). 

There are too many unnecessary visits, resulting in too many unnecessary tests/procedures.  Everyone agrees on the problem, but few healthcare professionals think they are the problem.  They're just as happy to have those in-person visits, regardless of the time and money they cost their patients.  That is not putting the patient first, and that is not patient-centered care.

In most cases, the first step should be an AI-based triage to determine what is most likely to be wrong, if I need to communicate with a human physician immediately/virtually, or if I need to seek in-person care -- and, if so, from whom/where, taking into account any health plan network restrictions. 

The U.K's National Health Service reportedly pays Babylon Health about $80 per patient annually, which would equate to around $26b.  That sounds like a big number, but it's probably more like a CHIP-sized bargain.  It's much cheaper than Medicare-for-All or the ACA premium subsidies.  The cost could most likely be reduced by economies of scale, tougher competitive bidding, and, most substantially, passing off costs by requiring health plans to cover it. 

Such coverage would also let the U.S. set the standard in "licensing" AI for healthcare and end the crazy-quilt licensing of human telemedicine physicians we have now.  Both would be boons for the U.S. healthcare system. 

We're already (finally) getting more worried about China's efforts in A.I. -- as demonstrated by President Trump's recent A.I. order -- and this initiative would help us keep pace with their A.I. healthcare efforts.

Giving everyone access to a virtual physician is a good thing to do.  It's the right thing to do.  And it's not only something we can afford to do; it's something we can't afford not to do. 

Let's Stop Healthcaresplaining

You've probably heard of "mansplaining," usually used to describe men explaining something to women in a condescending and/overconfident manner, and often on a topic that the woman knows more about than that man.  Well, healthcare has its own version of that, which I'm calling "healthcaresplaining."

 Healthcare (and health) is complicated.  Healthcare can often be confusing, even scary.  Life and death decisions sometimes have to be made in milliseconds, with no time for discussion or debate.   All those are reasons why many -- especially healthcare professionals -- are adamant that patients aren't and never will be "consumers." 

That's an example of healthcaresplaining. 

The 21st century is a complicated time.  We are surrounded by, and dependent on, technology that we don't really understand and that most of us would be at a loss to repair.  That's why we have the Genius Bar and the Geek Squad. 

It's not just the technology; many aspects of our lives are based on rules and processes that we also don't understand.  As a result, we delegate many of those aspects to "experts."  Something is gained, to be sure, but something is lost too.

For example:

• If you are arrested or otherwise get involved with the judicial system, you almost certainly will hire a lawyer (even if you are one yourself);
• If you have or hope to have significant income/assets, you probably have a financial planner and a tax accountant;
• If you buy a house, you usually use a realtor;
• If you have health issues, you are likely to have a physician, and other healthcare professionals.  

The legal, financial services, tax, real estate, and healthcare systems have each evolved to the point that laypeople don't expect -- and aren't expected -- to understand them.  They and other parts of our lives are growing increasingly more complicated, making us ever-more dependent on those experts.

The thing is, this state of affairs is not preordained.  It doesn't have to be this way.  The truth is that this complexity serves the professions that revolve around it.  Lawyers draft the laws, tax professionals design the tax code, and healthcare professionals create the operating structures of our healthcare system.  

A good example of this are the new requirements for hospitals to list "prices."  Instead of promoting transparency, they reveal the convoluted charge structure behind hospital bills.  They use terminology most people don't understand, is at a granular level most won't actually get charged at, and reflects gross charges rather than negotiated prices.  It's like looking at the SKU of every item used in making an automobile and trying to figure out what you'll pay for the car.

Credit: Caitlin Hillyard/KHN illustration; Getty Images

ICD-10, CPT, RBRVS, HCPCS, ICF, NDC, DSM -- these are all examples of systems that are used in healthcare to describe your condition and/or treatment, in an effort to diagnosis and bill.  They are all monstrously complex and growing moreso.  

We can keep making them more complicated.  There are reasons why we do.  That doesn't mean we should.  

Instead, we should be looking for ways we can stop disintermediating people from the things they are trying to do.  We should be helping people be their own experts, rather than relying on more, and more specialized, experts.

For example, it used to be that the "expert" in buying a car was the car salesperson.  You might try to negotiate with him/her, but there was a huge information asymmetry.  The internet has largely leveled that; the car salesperson still has the edge, because he/she does it every day, but it is at a least a fairer negotiation.

Or there are products like TurboTax, which uses software to let you replicate the tax experts.  Input a few numbers and it can produce your returns, even file them.  In financial services you can go online to buy and sell stocks, bonds, and mutual funds, using various tools to help you pick the best ones for your risk profile, all without any intervention of a financial planner.   

Similarly, there are now services that let you skip using a realtor, allowing you to view/list property online and using an attorney to oversee the paperwork -- all at a substantial discount over a realtor's commission.

Then there's healthcare.  Despite the massive amounts of health information available on the internet -- sometimes referred to as Dr. Google -- in receiving healthcare services we are nowhere near even the parity we might feel with a car salesperson in buying a car.  We don't know enough and we understand less.    

Indeed, healthcare is going the other direction, with calls for "social prescribing" or "exercise prescribing" as examples of the healthcare system trying to take its influence further into our daily lives.  It is true that much of our health happens outside the healthcare system, but that doesn't mean they should become part of it.

Instead of being cowed by healthcare professionals' expertise, we should be thinking of this great quote:

Otherwise, it's just healthcaresplaining.

Previously, I wrote that healthcare has to "do simple better."   I still believe that, but it is necessary, not sufficient.  It needs to make more things -- a lot more things -- simple.  

Tom Vanderbilt had a great article in The Atlantic about "reverse innovation" in healthcare.  Reverse innovation is "taking a technology or solution born of the resource constraints in developing countries and adopting it in wealthier ones."  Some call this "popsicle-stick" thinking.  

As he concludes:

But, in a country like the U.S., faced with spiralling health-care costs and access-to-care issues, where innovation typically leads to more expensive and sometimes unnecessary technologies, it may be time for medicine, still often dominated by a closed, guild-like mentality, to think more inventively. Home Depot might not be a bad place to start.

Healthcare could use "reverse innovation" in so many ways, in the broadest sense of the term.  We should be looking to make the healthcare system simpler.  We should be using language that ordinary people understand.  We should make encounters with the healthcare system less scary, and certainly less frustrating.  We should treat us like our health is our business.  We should help make health our business, and us the experts.

This kind of change will come from both purposeful design and the availability of self-service tools like AI, and it is inevitable -- although neither quick nor easy.  

Enough healthcaresplaining: we are not stupid; it is the healthcare system that is stupid.  

We Don't Need No Stinking Batteries

Quick: how many different power cords and chargers do you have for your various devices?

E.g., for your PC, smartphone, tablet, e-reader, or smartwatch.  And how much time do you spend actually charging them, or looking for somewhere to charge them?  It's likely that the answers are well in the more-than-I'd-like range. 

All that may be changing, due to something called rectennas.  More importantly, they may be what truly make the Internet-of-Things (IoT) possible.

Rectenna image.  Credit: Christine Danilo, MIT

Healthcare is quite enamoured about the possibilities of IoT -- not just wearables but smart pills, ingestibles, even tiny robots swimming around our bodies fixing problems.  We'd be able to track and address in real-time or near-real time what is happening with our bodies.  It is truly exciting.

For example, these elastic robots can actually change their shape based on their surroundings:

The researchers who developed them tested them specifically to mimic what it would be like to navigate through blood vessels with varying circumference and viscosity.  The lead author, Selman Sakar, noted: "if they encounter a change in viscosity or osmotic concentration, they modify their shape to maintain their speed and maneuverability without losing control of the direction of motion."

Pretty impressive.

The problem with many IoT devices, though, is similar to with our other devices: what happens when the battery runs low?  It's not easy to get a charger into our gut to repower smart pills, and for anyone worried about the ecological risks posed by computer or smartphone batteries, well, imagine tiny versions of those toxic batteries floating around in your body.

We'll need sensors to track the damage done by our other sensors' dead batteries.

Not with rectennas.  Rectennas are powered by Wi-Fi signals, like the kind you use in your house or at Starbucks to get internet access.  This is not a new concept, but what is new is that MIT researchers have been able to harvest enough power to make them useful, in a device only few atoms thick.

The research -- with the catchy title Two-dimensional MoS₂-enabled flexible rectenna for Wi-Fi-band wireless energy harvesting -- appeared in Nature.  MIT Professor and paper co-author Tomás Palacios summed up its importance as follows:

What if we could develop electronic systems that we wrap around a bridge or cover an entire highway, or the walls of our office and bring electronic intelligence to everything around us? How do you provide energy for those electronics? We have come up with a new way to power the electronics systems of the future — by harvesting Wi-Fi energy in a way that’s easily integrated in large areas — to bring intelligence to every object around us.

Rectennas catch AC electromagnetic waves, including Wi-Fi or Bluetooth, and transmit them to a "two-dimensional" semi-conductor that transforms them into DC.  Previous versions of rectennas had either been too rigid to be cost-effective, or, if flexible, couldn't catch/convert enough power to make them useful.  These new rectennas are cheaper, faster, and more flexible than earlier rectennas.

Credit: ExtremeTech

They can convert 10 GHz of wireless signals with 30% efficiency, and produce 40 microwatts of power.  The 40 microwatts is plenty to power small devices, including wearables or certain medical devices.

The accompanying MIT press release specifically mentioned implantable medical devices and smart pills as promising early applications.  Another study coauthor, Jesús Grajal, a researcher at the Technical University of Madrid, pointed out a key advantage of rectennas: 

Ideally you don’t want to use batteries to power these systems, because if they leak lithium, the patient could die.  It is much better to harvest energy from the environment to power up these small labs inside the body and communicate data to external computers. 

Yes, you'd have to say that would be much better.

For any engineering nerds out there, first author Xu Zhang described their work as follows: “By engineering MoS₂ into a 2-D semiconducting-metallic phase junction, we built an atomically thin, ultrafast Schottky diode that simultaneously minimizes the series resistance and parasitic capacitance."

I think we know who came up with that study title.

Credit: Kong et. al. , Advanced Materials Technologies

The trick now is finding the right applications.  For example, another set of MIT researchers have developed an "ingestible electronic pill" that releases medications only when necessary and includes sensors that can help monitor a patient's conditions, alerting physicians and/or varying dosage as warranted. 

The electronic pill currently uses a small silver oxide battery, but R&D Magazine noted that the researchers are "exploring using alternative power sources."  Perhaps they should walk down the hall and find out more about rectennas.

It is not clear how quickly these advances can be commercialized, but it can't be soon enough.  The healthcare IoT market is predicted to reach $323b by 2025, with a CAGR of 20.6% from 2017 to 2025.   Maybe a lot of that could use wireless charging, but that'd still require a lot of batteries and a lot of time charging.

Of course, power is only one of the major issues IoT will have to figure out; security is another.  Many current IoT devices are not very secure, nor are many current medical devices.  A coalition of healthcare organizations and medical device manufacturers are trying to catch up, recently issuing a Joint Security Plan of actions that need to be taken.  The actions are, unfortunately, only first steps and are voluntary.

The micro-robots may have to wait -- hopefully, not for too long.

Our mental model of mobile devices has always had to include, and be limited by, their batteries -- how big they need to be, how much power they can produce, and how long they can last.  We've done some impressive things within their constraints, but it will be very interesting to see what kinds of new devices and new uses we can come up with when we don't have to be constrained by them.

What can you imagine if you don't need batteries to power it?

Do Unto Robots As You...

It was very clever of The New York Times to feature two diametrically different perspectives on robots on the same day: Do You Take This Robot... and Why Do We Hurt Robots?   They help illustrate that, as robots become more like humans in their abilities and even appearance, we're capable of treating them just as well, and as badly, as we do each other. 

As fans of HBO's Westworld or Channel 4's Humans know, it's possible, perhaps even likely, that at some point the robots are going to realize this -- and they may be pissed about it. 

We're going to have robots in our healthcare system (Global Market Insights forecasts assistive healthcare robots could be a $1.2b market by 2024), in our workplaces, and in our homes.  Some of them will be unobtrusive, some we'll interact with frequently, and some we'll become close to.  How to treat them is something we're going to have to figure out.

Credit: IEEE Spectrum

Written by Alex Williams, Do You Take This Robot... focuses on people actually falling in love with (or at least prefering to be involved with) robots. Sex toys, even sex robots, have been around, but this takes it to a new level.  The term for it is "digisexual."

As Professor Neil McArthur, who studies such things, explained to Discover last year: 

We use the term ‘digisexuals’ to describe people who, mostly as a result of these more intense and immersive new technologies, come to prefer sexual experiences that use them, who don’t necessarily feel the need to involve a human partner, and who define their sexual identity in terms of their use of these technologies. 

Credit: Dilbert/Scott Adams

Apparently we're already in digisexuality's second wave, in which people take advantage of those immersive technologies -- VR/AR or AI-enable robots -- to form deeper relationships.  Professor Markie Twist, who co-wrote The Rise of Digital Sexuality with Professor McArthur in 2017, told Mr. Williams she has several patients in her clinical practice who qualify as digisexuals. 

Writer Emily Witt told Mr. Williams, "Digital sexuality allows for possibilities of anonymity, gender-bending, fetish play and other modes of experimentation with a degree of safety and autonomy that’s not present in the physical world," and Dr. Twist added: 

Research already shows that people can achieve orgasm with inanimate objects, and we already see how people have a longing for their tech devices, and feel separation anxiety when they are not around.  I think it’s easily possible that people might develop actual love for their technology. They already come up with affectionate names for their cars and boats."

And it's not just about sex.  There are a number of companion robots available or in the pipeline, such as:

• Ubtech's Walker.  The company describes it as: "Walker is your agile smart companion—an intelligent, bipedal humanoid robot that aims to one day be an indispensable part of your family."  
• Washington State University's more prosaically named Robot Activity Support System (RAS), aimed at helping people age in place.  
• Toyota's T-HR3, part of Toyota's drive to put a robot in every home, which sounds like Bill Gates' 1980's vision for PCs.   One Toyota advisor said: "The idea is for the robot to be a friend."
• Intuition Robot's "social robot" ElliQ.  The company's testing summed up users' reaction: "It’s clearly not just a device, but it’s clearly not a person.  They said it’s a new entity, a new creature, a presence, or a companion...They fully bought into ElliQ’s persona."
• A number of cute robot pets., such as Zoetic's Kiki or Sony's Aibo.  

All that sounds very helpful, so why, as Jonah Engel Bromwich describes in Why Do We Hurt Robots?, do we have situations like: 

A hitchhiking robot was beheaded in Philadelphia. A security robot was punched to the ground in Silicon Valley. Another security bot, in San Francisco, was covered in a tarp and smeared with barbecue sauce...In a mall in Osaka, Japan, three boys beat a humanoid robot with all their strength. In Moscow, a man attacked a teaching robot named Alantim with a baseball bat, kicking it to the ground, while the robot pleaded for help.

One might understand a factory worker taking an opportunity to damage the robot which took his job, but what do the kids below have against the robot?

Cognitive psychologist Agnieszka Wykowska told Mr. Bromwich that we hurt robots in much the same way we hurt each other.  She noted: "So you probably very easily engage in this psychological mechanism of social ostracism because it’s an out-group member. That’s something to discuss: the dehumanization of robots even though they’re not humans."

As Mr. Bromwich concluded: "Paradoxically, our tendency to dehumanize robots comes from the instinct to anthropomorphize them."  In a previous article I discussed how easy it was to get people to treat robots like persons, and quoted researcher Nicole Kramer: "We are preprogrammed to react socially.  We have not yet learned to distinguish between human social cues and artificial entities who present social cues."

Get ready for it.  Sextech expert Bryony Cole told Mr. Williams: 

In the future, the term ‘digisexual’ will not be relevant.  Subsequent generations will have never known a distinction between their online and offline lives. They may grow up with sex education chatbots, make love to the universe in their own V.R.-created world, or meet their significant other through a hologram. This will be as normal as the sex education we had in schools using VHS tapes.

And you were worried about Fortnite.

Robots have already gotten married, been granted citizenship, and may be granted civil rights sooner than we expect.   If corporations can be "people," we better expect that robots will be as well.

We seem to think of robots as necessarily obeying Asimov's Three Laws of Robotics, designed to ensure that robots could cause no harm to humans, but we often forget that even in the Asimov universe in which the laws applied, humans weren't always "safe" from robots.  More importantly, that was a fictional universe.  

In our universe, though, self-driving cars can kill people, factory robots can spray people with bear repellent, and robots can learn to defend themselves.  So if we think we can treat robots however we like, we may find ourselves on the other end of that same treatment.  

Increasingly, our health is going to depend on how well robots (and other AI) treat us.  It would be nice (and, not to mention, in our best interests) if we could treat them at least considerately in return. 

On to the Next Big Thing

It's amusing to watch old movies where plot points often involved someone's inability to talk to the person they needed, in the pre-mobile phone era.  We take our smartphone's omnipresence and virtual omnipotence as a given in our daily lives, and treat even its temporary loss as a major inconvenience.

So why are people already wondering if the smartphone era is almost over?

Speculation on this is not new (voice has been touted as the next big platform for years), but intensified after Apple announced reduced revenue expectations earlier this year -- the first time in 16 years. It specifically cited slower iPhone sales in China and, even more jarring, said it would no longer break out unit sales of iPhones.

Its guidance may have more to do with China's slowing economy, Chinese competitors, or U.S. tariffs on smartphone imports than to anything about the smartphone era, but, as John D. Stoll pointed out in The Wall Street Journal, the iPhone has now been around for almost 12 years, and Apple is overdue for their next big product (the iPad was introduced in 2010). 

Mr. Stoll quotes McKinsey's Nick Santhanam: "Over time, every franchise dies.  You can innovate on an amazing mousetrap, but if people eventually don’t want a mousetrap, you’re screwed.”

Similarly, and also in the Journal, Timothy W. Martin and Sarah Krouse warn:

Today, it looks like the era of smartphone supremacy is starting to wane. The devices aren’t going away any time soon, but their grip on the consumer is weakening. A global sales slump and a lack of hit new advancements has underlined a painful reality for the matured industry: smartphones don’t look so singularly smart anymore.

They point to other "smart" options, including wearables, voice assistants, and connected vehicles.  Wayne Lam of IHS Markit told them: "We may even need another word for whatever the smartphone will become because when ‘smart’ is everywhere that term becomes almost meaningless."  

Jaede Tan, a director at App Annie, told Mr. Stoll: 

What’s not going to go away: the need to have a device that’s constantly with you, to remote control your life. At the moment, we call that the smartphone.  Does it become smaller, sit on your wrist, a chip in the back of your mouth? Maybe. The concept needs to remain constant.

I'll come back to that "chip in the back of your mouth."

There's growing consensus that the future is going to entail the Internet of Things (IoT), in which most everything will be connected and much of that will also be "smart."  It goes to what AI expert Kai-Fu Lee calls "OMO" -- online merges with offline.  He says: "As a next step, offline and online data can be combined...OMO and AI will take us into a future where any distinction between these worlds disappears."


Many believe that this future will be controlled by our voice assistants.  As MIT Technology Review put it: "Everything you own in the future will be controlled by your voice. That’s what this year’s CES, the world’s largest annual gadget bonanza, has made abundantly clear."

TechSpot agreed:  "One of the clearest developments that came out of 2018, and prominently on display last week at CES 2019, was the rise of the embedded voice assistant. Amazon’s Alexa and Google’s Assistant were omnipresent at the show...," although they also noted the problem of multiple voice assistants.  

I'm not convinced about voice assistants as the next big platform.  Yes, they will be more pervasive.  But look at it this way: if the voice advocates are right, then in 2025 we're going to be typing less and talking more, only we'll not be talking to each other, but to our ubiquitous devices.  That assumes we'll figure out how to make the voice assistants figure out what we're actually saying, and smart enough to know what do in response. 

That's not what I have a problem with.

We all have had the experience of someone talking too loudly near us on their mobile phone.  It's annoying.  It's distracting.  Imagine what it will be like when it is not just people actually making phone calls, but doing anything.  Imagine what it will be like when I'm talking to the car using Alexa while you're sitting next to me talking to Siri on your Apple wearable and the kids are in the backseat playing Fortnite using Google Assistant. 

We can think faster than we can read, we can read faster than we can talk, and we can (usually) talk faster than we can type.  The future of smart devices is certainly not keyboards but it's not talking either. 

We're going to control our surroundings, or at least the connected devices in it, with our brains, using a brain-computer interface.  It sounds like science fiction, or promises from the Singularity Hub, but it is starting to become real. 

a T9 performing a video search.
  b T9 searching for artists from a music streaming program.
Credit: Nuyujukian et. alia, Plos One

The BrainGate consortium, for example, has been working on this, with some successes.  In their most recent BrainGate 2 clinical trial, several paralyzed participants used a brain-computer interface (BCI) to control an off-the-shelf tablet. 

Study co-author Leigh Hockberg told IEEE Spectrum: "We wanted to see if we could allow somebody to control not an augmentative or alternative communication device, but the same ubiquitous device that people without physical disabilities use every day." 

They could.  Their paper reported:

one user noted, “[T]he tablet became second nature to me, very intuitive. It felt more natural than the times I remember using a mouse.” Another said, “[A]mazing! I have more control over this than what I normally use.” The third added that he “loved” sending text messages via the tablet.

This is cool stuff.  This is exciting stuff.  And it is the future, not just for those with impairments but for most of us.  

Healthcare took 10 - 15 years longer than other industries to really computerize, and is taking 5-10 years longer to get on the smartphone bandwagon.  It should quickly figure out what roles voice assistants can play -- EHR input, anyone? -- but maybe healthcare doesn't have to wait for the next truly big bandwagon to move by it before jumping on.