Science
Opinion: Wait times go down. Patient satisfaction goes up. What's the matter with letting apps and AI run the ER?
My resident describes our next emergency room patient — a 32-year-old female with severe, crampy mid-abdominal pain, vomiting and occasional loose stools. The symptoms have been present for nearly a week, and there is tenderness to both sides of the upper abdomen. It could be a gallbladder problem, the resident says, hepatitis, pancreatitis, diverticulitis or an atypical appendicitis. She proposes routine blood tests along with an ultrasound and an abdominal CT scan.
This is the time-honored approach to an undifferentiated patient complaint: Generate a list of possible diagnoses, decide which represent a “reasonable” concern and use the results from further testing to conclude what’s going on. Yet increasingly the second phase of this process — evaluating which diagnoses represent a reasonable concern — is getting short shrift. It is the heavy lift of any patient encounter — weighing disease probabilities, probing for details. It’s often simpler, and faster, to cast a wide net, click the standard order for blood work and imaging, and wait for the results to pop up.
The issue of the “busy doctor ordering too many tests” has plagued medicine for decades. Now, as hospitals inject algorithms and technology into their workflow, it’s much worse. Medicine is moving inexorably away from the deductive arts, becoming more technology- and test-dependent and less patient-centric.
Go to an emergency room today and you will likely be met within minutes by a doctor whose sole role is to perform a “rapid medical evaluation.” The provider asks a few questions, ticks boxes on a computer screen and, shazam, you are in line for the most likely series of tests and scans, all based on typically a less than 60-second encounter.
This strategy seems obvious. When workups are initiated as soon as the patient arrives, wait times go down, patient satisfaction goes up, and fewer patients leave out of frustration before even being seen. These are the metrics that put smiles on administrators’ faces and give hospitals high marks in national surveys.
But is it good doctoring? Without the luxury of time, these gateway providers typically lump patients into broad, generic categories: the middle-aged person with chest pain, the short-of-breath asthmatic, the vomiting pregnant patient, the septuagenarian with cough and fever, and so forth. The diagnosis is then reverse-engineered with tests to cover all possible bases for that particular complaint.
In essence this is flipping the script on traditional doctoring while incentivizing doctors to use testing as a surrogate for critical thinking, dumbing down the practice of medicine and throwing gasoline on the problem of over-testing.
Since rapid evaluation became the norm, use of laboratory, CT and ultrasound services at my hospital has increased nearly 20%. Just the other day, a pregnant woman in my ER went through a full battery of time-consuming, expensive and invasive tests even though she’d been through all of them at another hospital the day before. As far as I can tell, the only reason we did that was because that’s what an algorithm told us to do.
This has real effects on patients. Contrary to popular perception, more tests may not supply more answers. That’s because the accuracy of any test depends on the likelihood that the patient has the disease in question before the test is performed. Testing performed without the appropriate indication or context can produce incidental or even spurious results that may have your doctor looking in entirely the wrong direction.
The basic problem with hospitals’ growing obsession with efficiency is this: Algorithmic systems treat all patients the same, expecting precise, like-for-like responses to every question with just the right amount of detail. Except every patient is unique. And they tend to give up their stories at their own pace, in broken, non-linear fits and starts, sometimes conflating truth and fiction in ways that can be counterproductive and frustrating, but also uniquely human. I am often reminded of Jack Webb in the old TV series “Dragnet” imploring a witness to offer “just the facts, ma’am, just the facts.” In real life, whether from situational stress, self-delusion, superstition, health illiteracy, mental illness, drugs or alcohol, my patients’ initial version of their complaint is rarely “just the facts” or the final word on the subject.
A colleague recently described her role in a clinical encounter as 9 parts translator to 1 part doctor. One question leads to another, and then another, and another until she successfully translates the patient’s lived experience into a language modern medicine and its algorithms might begin to understand. My experience is similar. Properly choreographed, the doctor-patient interaction becomes a pas de deux — two people in sync, jointly trying to solve a puzzle with each sharing their perspective and expertise. In the transition to front-loaded care, I worry health decisions will be made with information that may be incomplete or, at times, totally unreliable.
Algorithmic medicine also seems tailor-made for an AI takeover. The logic is obvious. Use “big data” to assist doctors and nurses struggling to keep up with the demands of modern medicine. AI can ensure a level, consistent floor of care that avoids errors of omission by considering a deliberately broad list of diagnostic possibilities. In an ideal world, a synergy of human and machine intelligence could amplify the patient-doctor encounter. As likely, AI will lead doctors to abdicate judgment and responsibility to the automated response of the machine.
And so, I complimented my resident on her list of concerns but suggested that we spend a little more time with the patient. The story of her symptoms didn’t feel complete. I recommended my resident grab a chair and simply ask the patient about her life. What emerged was the chaotic picture of an exhausted part-time student by day, working two evening waitressing jobs and surviving on pizza, pasta and energy drinks. She had always had a “fragile stomach.”
Our list of reasonable diagnoses was expanding and contracting, replaced with irritable bowel syndrome, food intolerances, gut motility issues, all overlying a stressed individual barely keeping it together. The labs, ultrasound or CT scan initially proposed now seemed irrelevant.
The result: The patient got out of the hospital faster. She received helpful suggestions about stress reduction, diet and sleep habits. She got an appointment with a primary care physician and avoided thousands of dollars in tests. Had we just relied on tests instead of asking a few more questions, there is a good chance we would have missed the best approach to her problem entirely.
ER waiting rooms and wards are bursting at the seams, and the streamlining of care has never felt more essential. But this is not an excuse for doctors to relinquish their humanity or their “method.” We should tweak the process: Allow more time for doctors to get the story right, do less testing until we have weighed the risks and rewards, prioritize asking questions rather than merely looking for answers.
Sociologists coined the term “pre-automation” to describe the transitional phase in which humans lay the groundwork for automation, often by acting in increasingly machine-like ways. As providers, we must not fall in line.
Put another way, with AI primed to take on a substantial role in how doctors deliver care, we should remind ourselves: If we behave like machines, we certainly won’t be missed when machines replace us.
Eric Snoey is an ER doctor at Alameda Health System-Highland Hospital in Oakland.
Science
Southern California mountain lions recommended for threatened status
The California Department of Fish and Wildlife has recommended granting threatened species status to roughly 1,400 mountain lions roaming the Central Coast and Southern California, pointing to grave threats posed by freeways, rat poison and fierce wildfires.
The determination, released Wednesday, is not the final say but signals a possibility that several clans of the iconic cougars will be listed under the California Endangered Species Act.
It’s a move that supporters say would give the vulnerable animals a chance at recovery, but detractors have argued would make it harder to get rid of lions that pose a safety risk to people and livestock.
The recommendation was “overdue,” Charlton Bonham, director of the state wildlife department, said during a California Fish and Game Commission meeting.
It arrives about six years after the Center for Biological Diversity and Mountain Lion Foundation petitioned the commission to consider listing a half-dozen isolated lion populations that have suffered from being hit by cars, poisoned by rodenticides and trapped by development.
The following year, in 2020 the Commission found the request might be warranted, giving the lions temporary endangered species protections as “candidates” for listing. It also prompted the state wildlife department to put together a report to inform the commission’s final decision.
The next step is for state wildlife commissioners to to vote on the protections, possibly in February.
Brendan Cummings, conservation director for Center for Biological Diversity, hailed the moment as “a good day, not just for mountain lions, but for Californians.”
If the commissioners adopt the recommendation, as he believes they will, then the “final listing of the species removes any uncertainty about the state’s commitment to conserving and recovering these ecologically important, charismatic and well-loved species that are so much a part of California.”
The report recommends listing lions “in an area largely coinciding” with what the petitioners requested, which includes the Santa Ana, San Gabriel, San Bernardino, Santa Monica, Santa Cruz and Tehachapi mountains.
It trims off portions along the northern and eastern borders of what was proposed, including agricultural lands in the Bay Area and a southeastern portion of desert — areas where state experts had no records of lions, according to Cummings.
Officials in the report note that most of the lion groups proposed for listing are contending with a lack of gene flow because urban barriers keep them from reaching one another.
In Southern California, lions have shown deformities from inbreeding, including kinked tails and malformed sperm. There’s an almost 1 in 4 chance, according to research, that mountain lions could become extinct in the Santa Monica and Santa Ana mountains within 50 years.
The late P-22 — a celebrity mountain lion that inhabited Griffith Park – personified the tribulations facing his kind. Rat poison and car collisions battered him from the inside out. He was captured and euthanized in late 2022, deemed too sick to return to the wild because of injuries and infection.
For some species, protections come in the form of stopping chainsaws or bulldozers. But imperiled lions, Cummings said, need their habitats stitched together in the form of wildlife crossings — such as the gargantuan one being built over the 101 Freeway in Agoura Hills. He added that developments that could restrict their movement should get more scrutiny under the proposed protections.
Critics of the effort to list lion populations have said that it will stymie residential and commercial projects.
California is home to roughly 4,170 mountain lions, according to the recent report, but not all are equal in their struggle.
Many lion populations, particularly in northwest coastal forests, are hearty and healthy.
Protections are not being sought for those cats. Some, in fact, would like to see their numbers reduced amid some high-profile conflicts.
Bonham, the director of the state Department of Fish and Wildlife, spoke to concerns about public safety at the recent meeting, alluding to the tragic death of young man who was mauled by a cougar last year in Northern California.
“These are really delicate issues and the conversation I know in the coming years is going to have to grapple with all that,” said Bonham, who will be stepping down this month after nearly 15 years in his role.
California’s lions already enjoy certain protections. In 1990, voters approved a measure that designated them a “specially protected species” and banned hunting them for sport.
Science
California’s last nuclear plant clears major hurdle to power on
California environmental regulators on Thursday struck a landmark deal with Pacific Gas & Electric to extend the life of the state’s last remaining nuclear power plant in exchange for thousands of acres of new land conservation in San Luis Obispo County.
PG&E’s agreement with the California Coastal Commission is a key hurdle for the Diablo Canyon nuclear plant to remain online until at least 2030. The plant was slated to close this year, largely due to concerns over seismic safety, but state officials pushed to delay it — saying the plant remains essential for the reliable operation of California’s electrical grid. Diablo Canyon provides nearly 9% of the electricity generated in the state, making it the state’s single largest source.
The Coastal Commission voted 9-3 to approve the plan, settling the fate of some 12,000 acres that surround the power plant as a means of compensation for environmental harm caused by its continued operation.
Nuclear power does not emit greenhouse gases. But Diablo Canyon uses an estimated 2.5 billion gallons of ocean water each day to absorb heat in a process known as “once-through cooling,” which kills an estimated two billion or more marine organisms each year.
Some stakeholders in the region celebrated the conservation deal, while others were disappointed by the decision to trade land for marine impacts — including a Native tribe that had hoped the land would be returned to them. Diablo Canyon sits along one of the most rugged and ecologically rich stretches of the California coast.
Under the agreement, PG&E will immediately transfer a 4,500-acre parcel on the north side of the property known as the “North Ranch” into a conservation easement and pursue transfer of its ownership to a public agency such as the California Department of Parks and Recreation, a nonprofit land conservation organization or tribe. A purchase by State Parks would result in a more than 50% expansion of the existing Montaña de Oro State Park.
PG&E will also offer a 2,200-acre parcel on the southern part of the property known as “Wild Cherry Canyon” for purchase by a government agency, nonprofit land conservation organization or tribe. In addition, the utility will provide $10 million to plan and manage roughly 25 miles of new public access trails across the entire property.
“It’s going to be something that changes lives on the Central Coast in perpetuity,” Commissioner Christopher Lopez said at the meeting. “This matters to generations that have yet to exist on this planet … this is going to be a place that so many people mark in their minds as a place that transforms their lives as they visit and recreate and love it in a way most of us can’t even imagine today.”
Critically, the plan could see Diablo Canyon remain operational much longer than the five years dictated by Thursday’s agreement. While the state Legislature only authorized the plant to operate through 2030, PG&E’s federal license renewal would cover 20 years of operations, potentially keeping it online until 2045.
Should that happen, the utility would need to make additional land concessions, including expanding an existing conservation area on the southern part of the property known as the “South Ranch” to 2,500 acres. The plan also includes rights of first refusal for a government agency or a land conservation group to purchase the entirety of the South Ranch, 5,000 acres, along with Wild Cherry Canyon — after 2030.
Pelicans along the concrete breakwater at Pacific Gas and Electric’s Diablo Canyon Power Plant
(Brian van der Brug/Los Angeles Times)
Many stakeholders were frustrated by the carve-out for the South Ranch, but still saw the agreement as an overall victory for Californians.
“It is a once in a lifetime opportunity,” Sen. John Laird (D-Santa Cruz) said in a phone call ahead of Thursday’s vote. “I have not been out there where it has not been breathtakingly beautiful, where it is not this incredible, unique location, where you’re not seeing, for much of it, a human structure anywhere. It is just one of those last unique opportunities to protect very special land near the California coast.”
Others, however, described the deal as disappointing and inadequate.
That includes many of the region’s Native Americans who said they felt sidelined by the agreement. The deal does not preclude tribal groups from purchasing the land in the future, but it doesn’t guarantee that or give them priority.
The yak titʸu titʸu yak tiłhini Northern Chumash Tribe of San Luis Obispo County and Region, which met with the Coastal Commission several times in the lead-up to Thursday’s vote, had hoped to see the land returned to them.
Scott Lanthrop is a member of the tribe’s board and has worked on the issue for several years.
“The sad part is our group is not being recognized as the ultimate conservationist,” he told The Times. “Any normal person, if you ask the question, would you rather have a tribal group that is totally connected to earth and wind and water, or would you like to have some state agency or gigantic NGO manage this land, I think the answer would be, ‘Hey, you probably should give it back to the tribe.’”
Tribe chair Mona Tucker said she fears that free public access to the land could end up harming it instead of helping it, as the Coastal Commission intends.
“In my mind, I’m not understanding how taking the land … is mitigation for marine life,” Tucker said. “It doesn’t change anything as far as impacts to the water. It changes a lot as far as impacts to the land.”
Montaña de Oro State Park.
(Christopher Reynolds / Los Angeles Times)
The deal has been complicated by jurisdictional questions, including who can determine what happens to the land. While PG&E owns the North Ranch parcel that could be transferred to State Parks, the South Ranch and Wild Cherry Canyon are owned by its subsidiary, Eureka Energy Company.
What’s more, the California Public Utilities Commission, which regulates utilities such as PG&E, has a Tribal Land Transfer Policy that calls for investor-owned power companies to transfer land they no longer want to Native American tribes.
In the case of Diablo Canyon, the Coastal Commission became the decision maker because it has the job of compensating for environmental harm from the facility’s continued operation. Since the commission determined Diablo’s use of ocean water can’t be avoided, it looked at land conservation as the next best method.
This “out-of-kind” trade-off is a rare, but not unheard of way of making up for the loss of marine life. It’s an approach that is “feasible and more likely to succeed” than several other methods considered, according to the commission’s staff report.
“This plan supports the continued operation of a major source of reliable electricity for California, and is in alignment with our state’s clean energy goals and focus on coastal protection,” Paula Gerfen, Diablo Canyon’s senior vice president and chief nuclear officer, said in a statement.
But Assemblymember Dawn Addis (D-Morro Bay) said the deal was “not the best we can do” — particularly because the fate of the South Ranch now depends on the plant staying in operation beyond 2030.
“I believe the time really is now for the immediate full conservation of the 12,000 [acres], and to bring accountability and trust back for the voters of San Luis Obispo County,” Addis said during the meeting.
There are also concerns about the safety of continuing to operate a nuclear plant in California, with its radioactive waste stored in concrete casks on the site. Diablo Canyon is subject to ground shaking and earthquake hazards, including from the nearby Hosgri Fault and the Shorline Fault, about 2.5 miles and 1 mile from the facility, respectively.
PG&E says the plant has been built to withstand hazards. It completed a seismic hazard assessment in 2024, and determined Diablo Canyon is safe to continue operation through 2030. The Coastal Commission, however, found if the plant operates longer, it would warrant further seismic study.
A key development for continuing Diablo Canyon’s operation came in 2022 with Senate Bill 846, which delayed closure by up to five additional years. At the time, California was plagued by rolling blackouts driven extreme heat waves, and state officials were growing wary about taking such a major source of power offline.
But California has made great gains in the last several years — including massive investments in solar energy and battery storage — and some questioned whether the facility is still needed at all.
Others said conserving thousands of acres of land still won’t make up for the harms to the ocean.
“It is unmitigatable,” said David Weisman, executive director of the nonprofit Alliance for Nuclear Responsibility. He noted that the Coastal Commission’s staff report says it would take about 99 years to balance the loss of marine life with the benefits provided by 4,500 acres of land conservation. Twenty more years of operation would take about 305 years to strike that same balance.
But some pointed out that neither the commission nor fisheries data find Diablo’s operations cause declines in marine life. Ocean harm may be overestimated, said Seaver Wang, an oceanographer and the climate and energy director at the Breakthrough Institute, a Berkeley-based research center.
In California’s push to transition to clean energy, every option comes with downsides, Wang said. In the case of nuclear power — which produces no greenhouse gas emissions — it’s all part of the trade off, he said.
“There’s no such thing as impacts-free energy,” he said.
The Coastal Commission’s vote is one of the last remaining obstacles to keeping the plant online. PG&E will also need a final nod from the Regional Water Quality Control Board, which decides on a pollution discharge permit in February.
The federal Nuclear Regulatory Commission will also have to sign off on Diablo’s extension.
Science
In search for autism’s causes, look at genes, not vaccines, researchers say
Earlier this year, Health and Human Services Secretary Robert F. Kennedy Jr. pledged that the search for autism’s cause — a question that has kept researchers busy for the better part of six decades — would be over in just five months.
“By September, we will know what has caused the autism epidemic, and we’ll be able to eliminate those exposures,” Kennedy told President Trump during a Cabinet meeting in April.
That ambitious deadline has come and gone. But researchers and advocates say that Kennedy’s continued fixation on autism’s origins — and his frequent, inaccurate claims that childhood vaccines are somehow involved — is built on fundamental misunderstandings of the complex neurodevelopmental condition.
Even after more than half a century of research, no one yet knows exactly why some people have autistic traits and others do not, or why autism spectrum disorder looks so different across the people who have it. But a few key themes have emerged.
Researchers believe that autism is most likely the result of a complex set of interactions between genes and the environment that unfold while a child is in the womb. It can be passed down through families, or originate with a spontaneous gene mutation.
Environmental influences may indeed play a role in some autism cases, but their effect is heavily influenced by a person’s genes. There is no evidence for a single trigger that causes autism, and certainly not one a child encounters after birth: not a vaccine, a parenting style or a post-circumcision Tylenol.
“The real reason why it’s complicated, the more fundamental one, is that there’s not a single cause,” said Irva Hertz-Picciotto, a professor of public health science and director of the Environmental Health Sciences Center at UC Davis. “It’s not a single cause from one person to the next, and not a single cause within any one person.”
Kennedy, an attorney who has no medical or scientific training, has called research into autism’s genetics a “dead end.” Autism researchers counter that it’s the only logical place to start.
“If we know nothing else, we know that autism is primarily genetic,” said Joe Buxbaum, a molecular neuroscientist who directs the Seaver Autism Center for Research and Treatment at the Icahn School of Medicine at Mount Sinai. “And you don’t have to actually have the exact genes [identified] to know that something is genetic.”
Some neurodevelopment disorders arise from a difference in a single gene or chromosome. People with Down syndrome have an extra copy of chromosome 21, for example, and Fragile X syndrome results when the FMR1 gene isn’t expressed.
Autism in most cases is polygenetic, which means that multiple genes are involved, with each contributing a little bit to the overall picture.
Researchers have found hundreds of genes that could be associated with autism; there may be many more among the roughly 20,000 in the human genome.
In the meantime, the strongest evidence that autism is genetic comes from studies of twins and other sibling groups, Buxbaum and other researchers said.
The rate of autism in the U.S. general population is about 2.8%, according to a study published last year in the journal Pediatrics. Among children with at least one autistic sibling, it’s 20.2% — about seven times higher than the general population, the study found.
Twin studies reinforce the point. Both identical and fraternal twins develop in the same womb and are usually raised in similar circumstances in the same household. The difference is genetic: identical twins share 100% of their genetic information, while fraternal twins share about 50% (the same as nontwin siblings).
If one fraternal twin is autistic, the chance that the other twin is also autistic is about 20%, or about the same as it would be for a nontwin sibling.
But if one in a pair of identical twins is autistic, the chance that the other twin is also autistic is significantly higher. Studies have pegged the identical twin concurrence rate anywhere from 60% to 90%, though the intensity of the twins’ autistic traits may differ significantly.
Molecular genetic studies, which look at the genetic information shared between siblings and other blood relatives, have found similar rates of genetic influence on autism, said Dr. John Constantino, a professor of pediatrics, psychiatry and behavioral sciences at the Emory University School of Medicine and chief of behavioral and mental health at Children’s Healthcare of Atlanta.
Together, he said, “those studies have indicated that a vast share of the causation of autism can be traced to the effects of genetic influences. That is a fact.”
Buxbaum compares the heritability of autism to the heritability of height, another polygenic trait.
“There’s not one gene that’s making you taller or shorter,” Buxbaum said. Hundreds of genes play a role in where you land on the height distribution curve. A lot of those genes run in families — it’s not unusual for very tall people, for example, to have very tall relatives.
But parents pass on a random mix of their genes to their children, and height distribution across a group of same-sex siblings can vary widely. Genetic mutations can change the picture. Marfan syndrome, a condition caused by mutations in the FBN1 gene, typically makes people grow taller than average. Hundreds of genetic mutations are associated with dwarfism, which causes shorter stature.
Then once a child is born, external factors such as malnutrition or disease can affect the likelihood that they reach their full height potential.
So genes are important. But the environment — which in developmental science means pretty much anything that isn’t genetics, including parental age, nutrition, air pollution and viruses — can play a major role in how those genes are expressed.
“Genetics does not operate in a vacuum, and at the same time, the impact of the environment on people is going to depend on a person’s individual genetics,” said Brian K. Lee, a professor of epidemiology and biostatistics at Drexel University who studies the genetics of developmental disorders.
Unlike the childhood circumstances that can affect height, the environmental exposures associated with autism for the most part take place in utero.
Researchers have identified multiple factors linked to increased risks of the disorder, including older parental age, infant prematurity and parental exposure to air pollution and industrial solvents.
Investigations into some of these linkages were among the more than 50 autism-related studies whose funding Kennedy has cut since taking office, a ProPublica investigation found. In contrast, no credible study has found links between vaccines and autism — and there have been many.
One move from the Department of Health and Human Services has been met with cautious optimism: even as Kennedy slashed funding to other research projects, the department in September announced a $50-million initiative to explore the interactions of genes and environmental factors in autism, which has been divided among 13 different research groups at U.S. universities, including UCLA and UC San Diego.
The department’s selection of well-established, legitimate research teams was met with relief by many autism scientists.
But many say they fear that such decisions will be an anomaly under Kennedy, who has repeatedly rejected facts that don’t conform to his preferred hypotheses, elevated shoddy science and muddied public health messaging on autism with inaccurate information.
Disagreements are an essential part of scientific inquiry. But the productive ones take place in a universe of shared facts and build on established evidence.
And when determining how to spend limited resources, researchers say, making evidence-based decisions is vital.
“There are two aspects of these decisions: Is it a reasonable expenditure based on what we already know? And if you spend money here, will you be taking money away from HHS that people are in desperate need of?” Constantino said. “If you’re going to be spending money, you want to do that in a way that is not discarding what we already know.”
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