Sunday, May 24, 2015

Physicians Replaced By Computers - Lessons From A Roomba

My Memorial Day project was purchasing a Roomba and getting it up and running.  I am a big believer that robots will make all of our lives easier at some point and decided now is the time to start walking the walk.  For those not familiar with the Roomba, it is designed as a robotic vacuum cleaner.  Once you have set up the rooms and programmed it, it is basically supposed to vacuum your floors automatically and then park itself in a docking station for charging.  The machine itself is about a 14 inch diameter disk that rises to a height of about 3 1/2 inches off the floor.  It is a light 8.4 pounds.  It is able to accommodate sharp angles with a secondary brush that spins on an arm that extends from under the main disk.  This combination of the main disk spinning and the extended spinning brush cleans the corners of a room.  I purchased the latest model, a Roomba 880 after consulting with friends and relatives who had earlier models.

One of the considerations in buying the Roomba was whether it would help turn my home into an even cleaner environment than it currently is.  That is a tough act.  One of my friends who is a physician gave his opinion that my home is "museum-like".  My office is probably the only problematic room with stacks of books and journals piled everywhere.  Disarray certainly but minimal dust.   My entire first level is hardwood flooring that is typically vacuumed with a built in system.  To its credit the Roomba contains all of the debris in the machine until it is emptied and all of the exhausted air is HEPA filtered to avoid exhausting any dust particles.  The main cleaning mechanism consists of two debris extractors that are rubberized bars that spin at a high rate of speed across the floor surface to capture dust, hair and larger particles.  But the most interesting aspect of the Roomba was going to be its observed behavior.  It has two modes when vacuuming.  It can start in a spot and spin increasing circles in an outward direction until gets to about a 3 foot diameter and then it spirals back in to the center spot.  In the more typical mode it heads to the room perimeter and then "automatically calculates the room size and cleaning time."  The most valuable tip in the manual was to take measures to restrict it to one room at a time and it comes with two Virtual Wall®LighthouseTM devices that allow for easy demarcation of the work area.

The most fascinating aspect of getting started with the Roomba was going to be setting it up and watching how it went about the task of vacuuming.  I did some very minor room preparation, charged it up, and turned it loose.  As expected it headed straight for a wall and then attempted to establish the perimeter.  I remembered this as standard rodent behavior.  If you have ever confronted a mouse in an open area of your floor, their first move is to dash to the baseboards and run parallel to them to escape.  That strategy works well in the wild because the maneuver is associated with more cover and makes them less susceptible to predators.  It works much less well when confronted by a human who knows that it is their first move.  And yes, scientists have bred mice that do not exhibit this behavior.  My guess is that they would not fare well if they made it outside the lab.  The Roomba's behavior is less rigid than a typical mouse with some exceptions.  In the hour and 20 minutes it took to vacuum the adjacent kitchen and great room - it circled a kitchen island perfectly at least 10 times, but at the wall perimeters it was much less predictable.  At times the Roomba would peel off and take off across the room in a single pass or rarely return and continue along the original wall.  Sometimes it would head off the wall at a 45 degree angle and at other times 90 degrees.  There were never the usual adjacent passes that a human would make using a standard vacuum cleaner.

According to the literature,  the Roomba is supposed to "crisscross" the room in order to clean the floor.   I placed two small pieces of popcorn in the middle of a large section for flooring to use as markers of cleaning efficiency.  In the course of an hour, the Roomba passed these markers many times, sometimes very closely without vacuuming them up.  During that time it was very difficult to detect how much crisscrossing had occurred since mouse-like it spent the majority of the time in the periphery, bumping and spinning around walls and furniture.  It eventually did break free from the walls and set off on a 45 degree path picking up one popcorn fragment at about the one hour mark and the other at about one hour and ten minutes.  The old adage about pictures is true and I happened across this 30 minute time lapse photo of the Roomba working a room (with permission from the SIGNALTHEORIST web site).  It correlates well with my description of the actual paths.

As I surveyed the job afterwards, the floor was definitely clean and the warning light on the machine was saying that the dustbin was full.  When emptied, it contained an impressive amount of debris and dust relative to what seemed visible to the naked eye.  Another win for the robots?  Well, not really.  It is an interesting tool that I will continue to use and study, but in comparison with humans it is not efficient and at this point certainly not autonomous.  Despite all of the guidance in the manual the Roomba can still encounter unpredictable surfaces and get itself into trouble.  In my case it was the pedestal of a recliner.  The wood at the edge was about 3/4 of an inch high.  For some reason, the machine did not recognize it as an obstacle and continued to run up the base and get hung up.  A loud spoken error message would sound advising the human in the room to pick it up and start it in a new place.   The other concern is efficiency.  It spent far too much time in the perimeter and a low percentage of time covering the main floor areas.  That was tremendously inefficient.  It took at least 5 times longer to vacuum the main rooms than I would have if I was pushing a vacuum cleaner.  Even though it allows me to do other things, it says something about current state of available and affordable domestic robots.  They can't match the performance of humans on a fairly basic task.  This is an important concept.

Before any of the futurists out there jump on me for being a Luddite, let me disclose a few details.  I am a member of the IEEE and have been for the past 18 years.  I am currently a member of the IEEE Robotics and Automation Society.  I am not an electrical engineer and I have not designed or built any robots, but hope to start doing this when I retire from psychiatry.  I consider myself to be an expert in the human brain and the advantages it confers on humans over other animals and machines.  The Roomba is a basic case in point.  It cannot sense and adapt to novel conditions quickly enough to match a human doing the same task.  Even more striking is that although it is designed to vacuum homes and I have a fairly typical home with a better than average floor surface, it still encounters situations that exceed its response capacity.  In those situations it needs a human assist.  What is it about the human brain that leads to that kind of an advantage?  First and foremost, it is a rate of pattern matching and pattern completion capacity that allows us to recognize vacuuming problems, anticipate them and correct them by developing novel solutions even before the problem leads to a stop in action.  Some of this happens when a human goes around the room to set it up for the first time for the Roomba.  That human has made some assessment of the machines capacities and limitations and is problem solving for the machine before it is turned on.

Observing the limitation of the Roomba leads me to a point where I can address both the idea of computers replacing doctors and how that fits into the common anti-physician narrative in this country.  Is there a connection between the two?  My experience tells me that there is.  For nearly 30 years there has been a constant stream of antiphysician rhetoric.  The sources have been expected.  One of them is the key opinion leaders (KOLs) of the managed care industry.  I can recall reading one of the the first books written by one of them, a non-physician who was widely acclaimed as being an expert in managed care.  His early theory was that the high cost of health care was due to the decisions that physicians make.  But in the middle of the book he wrote what he thought of physician salaries and only grudgingly acknowledged that they should probably be paid a good wage due to their education.   I have posted here many times my experience at a managed care conference in the 1990s.  The speakers at that conference were very clear that the explicit agenda of their industry was to replace all of the specialists with primary care physicians.  The examples given were orthopedic surgeons and psychiatrists.  When a psychiatrist in the crowd pointed out the shortcomings of that philosophy - he was called a "whiner" by a Governor who was an anointed KOL in the industry.  Then the KOLs from the financial services industry started weighing in.  You could find glimpses of it while reading the investment literature.  People who were investors with no particular degree started saying that some day, physicians would get what they deserve - with the implication being that whatever that was - it was not good.  Any physician has experienced this prejudice.  The comments about how physicians are "expensive" as a rationalization for working them to death by not hiring any additional help.  Replacing physicians with computers seems like a logical extension of this rhetoric.  Googling this topic returns a number of provocative articles written from a point of view that is generally consistent with who the author is.

I know that some of those authors know the difference between a robot or a computer and a doctor, but it is also clear that some do not.  They certainly don't seem to understand that the real processing power of a human diagnostician's brain is in the area of pattern matching.  In order to duplicate that property with current technology, takes a massive computer and it is one of the reasons why my new $700 Roomba, although well designed - can easily be beaten by a human with a standard vacuum cleaner.  But the human advantage goes far beyond that.  Human diagnosticians do far more than match simple patterns.  They are able to complete fragments of patterns and anticipate what the whole pattern should be.  For example, is it likely that a depressed person is in this current state as the result of an inherited form of depression, their current state of detox from an opioid and/or benzodiazepine, current stressors or interpersonal conflicts, brain trauma, an undiagnosed medical condition, childhood adversity, psychological trauma as an adult, or defects in reasoning at either the emotional or cognitive levels.  Then there is the matter of acquiring all of the data to make the determinations.  Patterns upon patterns of data.  The Roomba-like approach would be to give the person a checklist of depressive symptoms and pretend that is all that needs to be known.  Checklists are already being administered by a computer and may be administered by robots someday.  

Yet it takes the pattern recognition, and several layers of it, as well as human experience dependent learning in order to make a real medical or psychiatric diagnosis.

George Dawson, MD, DFAPA

Supplementary 1:  The graphic at the top of this post is a photo that I shot of the inside of the box that my Roomba came in.

Supplementary 2:  I don't want to give the false impression that I do a lot of vacuuming.  My wife does practically all of it, but I am trying to do more especially if there is a high tech twist to it.  Some of the first robotics I hope to work on will be human controlled arms and hands designed to do yard work and move heavy objects around in the house.  I can't believe this is an area that has been ignored.

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