What It's Like to Be Targeted by an Online Mob
Four Thought-Provoking Book Excerpts You May Have Missed
Advanced Prenatal Testing Means More Gut-Wrenching Decisions Over Abortion
How the Media Came to Embrace Clickbait: An Internet History
Has Technology Ruined the Radiology Profession?
In the Era of Instagram, Narcissism as the New Norm
The Ethics of Withholding Life-Saving Treatment
Will Computers Ever Be as Good as Physicians at Diagnosing Patients?
The Online Life, as Both Liberation and Imprisonment
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The harassment started after an ex-boyfriend published a disparaging blog post about Quinn, and as it spread online, her detractors multiplied, leading to the public posting of her address, the hacking of her internet accounts, and numerous rape and death threats. \u003c/em>\u003c/p>\n\u003cp>\u003cem>This edited excerpt is from Quinn's book \"CRASH OVERRIDE: How Gamergate (Nearly) Destroyed My Life, and How We Can Win the Fight Against Online Hate,\" published in September 2017 by PublicAffairs, an imprint of the Hachette Book Group. \u003c/em>\u003c/p>\n\u003caside class=\"pullquote alignright\">'They were highly organized, discussing how to divide their ranks into specialized groups: one dedicated to getting me in legal trouble, one dedicated to turning all of my friends against me, and another dedicated to pushing me to kill myself.'\u003c/aside>\n\u003cp>As anyone who has ever expressed an opinion on the internet knows, it’s not all sunshine and rainbows. Every rose has its thorn, and every news story has its comments section. As the internet has graduated out of nerds’ basements and into the mainstream, its formerly separate communities have come in closer and closer contact. For years, the people who preferred hanging out in small subcultural message boards and interest-based communities stayed pretty isolated, but with the advent of social media, the people who wind up on \"\u003ca href=\"https://en.wikipedia.org/wiki/To_Catch_a_Predator\" target=\"_blank\" rel=\"noopener\">To Catch a Predator\u003c/a>\" now have accounts on Twitter, Facebook et al., alongside your sweet grandma — assuming your grandmother hasn’t been caught trying to lure kids into a van.\u003c/p>\n\u003cp>Even if you stick mainly to mainstream sites, you’ve probably seen glimpses of the internet’s underbelly in the notorious comments sections at the bottom of news articles. The article could be about a local man saving a box of kittens from a burning building, but no matter: The comments will accuse him of hating dogs, setting the building on fire in the first place, and secretly being Barack Obama’s Kenyan uncle.\u003c/p>\n\u003cp>You’ve probably wondered two things: Who are these people, and what the hell is going on here?\u003c/p>\n\u003caside class=\"alignright\">\n\u003cul>\n\u003cli>\u003ca href=\"http://www.crashoverridenetwork.com/\" target=\"_blank\" rel=\"noopener\">Crash Override Network\u003c/a> -- organization dedicated to fighting online abuse and providing assistance to victims, co-founded by Zoë Quinn. Includes automated \u003ca href=\"http://www.crashoverridenetwork.com/coach.html\" target=\"_blank\" rel=\"noopener\">cybersecurity helper\u003c/a>.\u003c/li>\n\u003c/ul>\n\u003c/aside>\n\u003cp>My teenaged obsession with shock sites like \u003ca href=\"https://theoutline.com/post/2549/rotten-com-is-offline\" target=\"_blank\" rel=\"noopener\">Rotten.com\u003c/a> started a lifelong hobby of spelunking through the weird pockets of the internet. This exploration taught me a lot (and, uh . . . showed me a lot) and exposed the fact that internet culture is essentially a magnificent patchwork of specific subcultures — good, bad and strange as hell. For every harmless community of users into really specific sexual kinks, there is a place like Bareback Exchange, a forum for people who get off on transmitting STDs to as many people as possible, often without consent. For every community of angsty kids who pretend they are secretly vampires, there are seven different forums of white nationalists who sincerely believe that Jewish people are secretly vampires. For every geeky and silly toy collector’s community, there are forums full of dudes collecting upskirt photos of random women and girls who had no idea they were about to become porn.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>\u003ca href=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/12/crashcover.png\">\u003cimg class=\"alignleft wp-image-438546\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/12/crashcover.png\" alt=\"\" width=\"352\" height=\"535\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2019/12/crashcover.png 750w, https://ww2.kqed.org/app/uploads/sites/13/2019/12/crashcover-160x243.png 160w, https://ww2.kqed.org/app/uploads/sites/13/2019/12/crashcover-240x365.png 240w, https://ww2.kqed.org/app/uploads/sites/13/2019/12/crashcover-375x570.png 375w, https://ww2.kqed.org/app/uploads/sites/13/2019/12/crashcover-520x790.png 520w\" sizes=\"(max-width: 352px) 100vw, 352px\">\u003c/a>Attempting to explain anonymous message-board culture to the uninitiated is a lot like trying to explain an inside joke — you can lay out the particulars, but it won’t carry the same weight or meaning. It’s complicated and difficult to parse, like most things about internet culture, but here’s a brief overview. Opened in 1999, a Japanese site called 2channel was the first board in this genre. An anonymous board where admins are virtually nonexistent, this site has enabled corporate whistleblowing as well as frank, open exchanges about taboo subjects like mental health and sexuality. Alongside these generally positive discussions, the boards are teeming with slander, hate speech, porn, nationalism, and general unchecked terribleness.\u003c/p>\n\u003cp>2channel’s American counterpart is 4chan, an image board launched by a 15-year-old boy in 2003. Fourteen years later, 4chan is a hugely influential force on the internet: “the ground zero of Western web culture,” as one journalist put it. Most of the memes you see on social media were invented there — everything from \u003ca href=\"http://knowyourmeme.com/memes/lolcats\" target=\"_blank\" rel=\"noopener\">LOLCats\u003c/a> to \u003ca href=\"http://knowyourmeme.com/memes/rickroll\" target=\"_blank\" rel=\"noopener\">rickrolling\u003c/a>. It’s also a breeding ground for not-so-cute things, including a hoax hashtag with the goal of getting young girls to #CutForBieber, campaigns to troll the social media of dead teenagers, and murderers occasionally posting pictures of their victims.\u003c/p>\n\u003caside class=\"pullquote alignright\">'Pretty much everything we’ve been told about dealing with online abuse is wrong, but the misconception that \"trolls\" will just go away if they’re ignored is possibly the most damaging.'\u003c/aside>\n\u003cp>Reddit has an even larger version of this problem, in both size and scope. Calling itself the “front page of the internet” and clocking in at 36 million user accounts, Reddit allows anyone to create a “subreddit,” a discussion area dedicated to any subculture or interest on its site. This model has allowed mentally ill people to find community without stigma, locals to exchange highly specific information about what’s good in their neighborhoods, and even President Obama to hop online and answer readers’ questions. But, like 4chan, it’s also been a hotbed for communities founded on hatred.\u003c/p>\n\u003cp>Reddit isn’t as anonymous as 4chan — users must create accounts and can be banned — but the site was created with a sort of free-speech absolutism in mind. Before it was shut down, the subreddit /r/Jailbait was a board for sharing sexualized pictures of underaged girls, and “jailbait” was the second-most-popular search term leading people to Reddit. Reddit users voted Jailbait the Best Subreddit of 2008, with double the number of votes received by the runner-up. It took six years and multiple public scandals to finally \u003ca href=\"https://www.dailydot.com/society/reddit-r-jailbait-shutdown-controversy/\" target=\"_blank\" rel=\"noopener\">close it\u003c/a>. Reddit has only recently started banning other repugnant subreddits, including hateful and blatantly racist forums, though many of them live on and new ones spring up constantly.\u003c/p>\n\u003caside class=\"alignright\">\u003ca href=\"https://ww2.kqed.org/forum/2017/10/04/zoe-quinn-on-gamergate-fighting-online-harassment/\" target=\"_blank\" rel=\"noopener\">Zoë Quinn on KQED Forum\u003c/a>\u003c/aside>\n\u003cp>Poorly moderated anonymous communities can have the capricious morality of any mob. In 2009, when two videos featuring the physical abuse of a domestic cat named Dusty by a person calling himself “Timmy” were posted on YouTube, the 4chan community tracked down the originator of the videos and passed his details on to the local police department. The suspect was arrested, and the cat was treated by a veterinarian and taken to a safe place. This kind of “internet detectivery” has been banned from many traditional online forums outside 4chan. It’s invasive, it’s sometimes used simply to intimidate or harass people, and the mob is often wrong, with very real consequences.\u003c/p>\n\u003cp>When you consider how a tendency for vigilante action might manifest itself in a community founded on hating people together, you can see how the results might turn scary. Stormfront, a message board for white supremacists, was founded by former Ku Klux Klan leader Don Black in 1995 and had more than 300,000 users as of May 2015. Calling it “the Web’s first and best-known hate site,” the Southern Poverty Law Center’s March 2014 intelligence report stated, “Stormfront users have been disproportionately responsible for some of the most lethal hate crimes and mass killings since the site was put up in 1995. In the past five years alone, Stormfront members have murdered close to 100 people.”\u003c/p>\n\u003cp>This escalation from hate speech to real action isn’t unique to Stormfront’s user base. Before embarking on a \u003ca href=\"https://ww2.kqed.org/news/2014/05/26/amid-multiple-warning-signs-alleged-isla-vista-killer-slipped-through-system/\" target=\"_blank\" rel=\"noopener\">shooting spree\u003c/a> that killed six and injured 14, Elliot Rodger posted a video on several internet forums dedicated to hating women, discussing the deeply misogynist and racist motives for his rampage. He namechecked one of these sites in his manifesto, saying he had discovered “a forum full of men who are starved of sex, just like me.” The forum had “confirmed many of the theories I had about how wicked and degenerate women really are.”\u003c/p>\n\u003cfigure id=\"attachment_438515\" class=\"wp-caption aligncenter\" style=\"max-width: 640px\">\u003ca href=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/12/zoequinn-e1516148809366.jpg\">\u003cimg class=\"size-large wp-image-438515\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/12/zoequinn-1020x680.jpg\" alt=\"\" width=\"640\" height=\"427\">\u003c/a>\u003cfigcaption class=\"wp-caption-text\">Zoe Quinn (right), with Anita Sarkeesian, also a #Gamergate target, were guest speakers at the introduction of a UN report called '\u003ca href=\"http://www.unwomen.org/~/media/headquarters/attachments/sections/library/publications/2015/cyber_violence_gender%20report.pdf?v=1&d=20150924T154259\">Cyber Violence Against Women and Girls: A World-Wide Wake-Up Call\u003c/a>.' \u003ccite>(UN Women/Ryan Brown)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>\u003cstrong>Bad Advice\u003c/strong>\u003c/p>\n\u003cp>There’s one piece of advice that most often gets passed around to anyone who experiences harassment or abuse on the internet: “Don’t feed the trolls.” This maxim is passed off as gospel and is applied across the board, whether you’re a kid getting into your very first Facebook argument or an experienced developer dealing with death threats.\u003c/p>\n\u003cp>This advice is wrong. Pretty much everything we’ve been told about dealing with online abuse is wrong, but the misconception that \"trolls\" will just go away if they’re ignored is possibly the most damaging.\u003c/p>\n\u003cp>This kind of behavior is not just about terrorizing you; it’s about control. It’s about making you want to disappear, instilling fear and limiting your possibilities. It’s about punishing you for stepping out of line. It’s about isolating and hurting you in specific ways to provoke a reaction.\u003c/p>\n\u003caside class=\"pullquote alignright\">'Anyone to whom I had public ties began to receive nude photos of me and pressure to publicly denounce me or become their next target.'\u003c/aside>\n\u003cp>In my case, it became obvious that my attackers’ dream was to get me to stop “feeding the trolls” and shut up. They didn’t want to tease me; they wanted me gone. There were countless forms of harassment — the same channels that I had used to talk with friends, grow my business, and share weird videos were now full of threats, slurs, and all manner of nastiness. It escalated to include sexual or violent images with my face Photoshopped into them. My inbox started to fill up with pictures of women being raped. As strangers stalked through everything I had said or done online since I was 12, looking for more ammo, lies and conspiracy theories about me snowballed into weirder and more extreme accusations. These would then be blasted out widely, and also directly to my colleagues in games. Anyone to whom I had public ties began to receive nude photos of me and pressure to publicly denounce me or become their next target.\u003c/p>\n\u003cp>\u003cstrong>Tools of Abuse\u003c/strong>\u003c/p>\n\u003cp>It’s one thing to have a single person going after you with all of the above tactics; it’s something else entirely when a community forms around doing so. The networked nature of the internet doesn’t just make it easier for stalkers to find you; it also makes it easier for them to find each other. These tools of abuse serve both as an attack in and of themselves and as a rallying cry. They’re meant to be shared.\u003c/p>\n\u003cp>When you’re the target of abuse like this, you’re basically screwed. Not only does the scope of abuse that you face increase exponentially with every single signal boost from a new member of the mob, but all of the good things about the web’s ability to bring people together are turned against you. The same techniques that people have used to organize important grassroots movements can be used by people trying to destroy someone.\u003c/p>\n\u003cp>[contextly_sidebar id=\"mlpZZdvOLAdS7bEg7MHbtPNH4WgpVTAX\"]Attacking you becomes a participatory game in which people try to one-up each other in terms of who can get to you the most. In my case, I was struck by how many of the threats or disgusting remarks sent my way were made so publicly, usually while tagging other people. The ones that were especially vicious were rewarded with likes, shares, and people joining in on the abuse.\u003c/p>\n\u003cp>This phenomenon is often referred to as “dogpiling.” The cool remix culture that facilitates the spread of fanart and memes suddenly becomes a powerful tool to hurt someone. Photos and videos of you are Photoshopped to label you a whore or to make you look uglier or fatter and then shared the same way cute pictures of cats are. Memes are easily co-opted by other people, who made reams of almost propaganda-like images with my face Photoshopped onto them. It wasn’t really about me anymore. The mob was engaging in a performative group activity.\u003c/p>\n\u003cp>This type of community building is quite deliberate and direct. As the 4chan threads kept growing in size and the mob gained momentum, I noticed that a chatroom had sprung up in the original posts. The chatroom participants worked as a team to try to discover personal information about everyone connected to me, referring to it as “digging” and sharing form letters and tactics on how to best alert anyone in my life that I was a horrible slut. They were highly organized, discussing how to divide their ranks into specialized groups: one dedicated to getting me in legal trouble, one dedicated to turning all of my friends against me, and another dedicated to pushing me to kill myself.\u003c/p>\n\u003cp>They shared elaborate fantasies about raping and murdering me, discussing the pros and cons of each. They talked about how to break into all of my accounts to try to find more ways to invade my privacy. They bragged about victories like flooding my game’s page with hatred and nude photos of me and went so far as to create guides to share tactics on how best to ruin my life. They even orchestrated plans to donate to various charities specifically to make themselves look like concerned citizens and not a mob of people trying to get me killed. They built friendships and bonded with each other by reinforcing their dedication to the righteous cause of taking me down, reminding themselves at every turn that they were the good guys.\u003c/p>\n\u003caside class=\"pullquote alignright\">'For every harmless community of users into really specific sexual kinks, there is a place like Bareback Exchange, a forum for people who get off on transmitting STDs to as many people as possible.'\u003c/aside>\n\u003cp>A mob has more tools at its disposal than individual actors do. Popularity — the quantity of clicks or views on any given page — is tracked and exploited by algorithms online, and a mob is a critical mass. If thousands of people are linking to something about you, that will quickly become the first thing people see when they Google your name, regardless of whether it’s a fact-checked news article or a video about what a bitch you are. Many sites allow their user base to vote on what is good content and what’s garbage, and mobs manipulate these systems to their targets’ detriment. There are also services that direct people away from sketchy websites that contain viruses, and the mob had flooded such services with false reports to make my websites and social media accounts inaccessible. My cohorts and I call this “brigading” — when people manipulate online systems to force their target into silence or hurt the person. Mass false reporting is a common tool to try to make the legitimate sites belonging to targets of online abuse vanish, as many systems are automated to react to a large volume of reports. Law enforcement agencies and government bodies like the IRS have online reporting systems that can also be manipulated this way by a mob.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>As a game designer, I can spot a game being played. And the more people who join in on the “fun,” the faster you become an abstract concept for your aggressors to hate. This might sound sort of comforting or like a way to defang the attacks, but in reality, it’s the opposite — this “game” is another way that you are dehumanized, and it makes it easier for a mob to grow its ranks and escalate its attacks. You’re just data, and data doesn’t bleed. You’re a symbol, and hating you can become part of someone’s identity, just as any other hobby might. Just as they would in a game, they are always trying to make their numbers go up. And plenty of the witch hunters advance from amateur to professional.\u003c/p>\n\n","blocks":[],"excerpt":"After an ex-boyfriend published a disparaging blog post about game designer Zoë Quinn, it rapidly metastasized into a mass campaign of abuse.","status":"publish","parent":0,"modified":1517510528,"stats":{"hasAudio":false,"hasVideo":false,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":29,"wordCount":2792},"headData":{"title":"What It's Like to Be Targeted by an Online Mob | KQED","description":"After an ex-boyfriend published a disparaging blog post about game designer Zoë Quinn, it rapidly metastasized into a mass campaign of abuse.","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"What It's Like to Be Targeted by an Online Mob","datePublished":"2018-01-30T17:09:41.000Z","dateModified":"2018-02-01T18:42:08.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"438097 https://ww2.kqed.org/futureofyou/?p=438097","disqusUrl":"https://ww2.kqed.org/futureofyou/2018/01/30/what-its-like-for-a-woman-to-be-targeted-by-an-online-mob/","disqusTitle":"What It's Like to Be Targeted by an Online Mob","source":"KQED Future of You","nprByline":"Zoë Quinn","path":"/futureofyou/438097/what-its-like-for-a-woman-to-be-targeted-by-an-online-mob","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>\u003cem>Zoë Quinn is a video game developer who was one of several women in the industry targeted by online harassment campaigns using the hashtag \u003ca href=\"https://en.wikipedia.org/wiki/Gamergate_controversy\" target=\"_blank\" rel=\"noopener\">#Gamergate\u003c/a>. The harassment started after an ex-boyfriend published a disparaging blog post about Quinn, and as it spread online, her detractors multiplied, leading to the public posting of her address, the hacking of her internet accounts, and numerous rape and death threats. \u003c/em>\u003c/p>\n\u003cp>\u003cem>This edited excerpt is from Quinn's book \"CRASH OVERRIDE: How Gamergate (Nearly) Destroyed My Life, and How We Can Win the Fight Against Online Hate,\" published in September 2017 by PublicAffairs, an imprint of the Hachette Book Group. \u003c/em>\u003c/p>\n\u003caside class=\"pullquote alignright\">'They were highly organized, discussing how to divide their ranks into specialized groups: one dedicated to getting me in legal trouble, one dedicated to turning all of my friends against me, and another dedicated to pushing me to kill myself.'\u003c/aside>\n\u003cp>As anyone who has ever expressed an opinion on the internet knows, it’s not all sunshine and rainbows. Every rose has its thorn, and every news story has its comments section. As the internet has graduated out of nerds’ basements and into the mainstream, its formerly separate communities have come in closer and closer contact. For years, the people who preferred hanging out in small subcultural message boards and interest-based communities stayed pretty isolated, but with the advent of social media, the people who wind up on \"\u003ca href=\"https://en.wikipedia.org/wiki/To_Catch_a_Predator\" target=\"_blank\" rel=\"noopener\">To Catch a Predator\u003c/a>\" now have accounts on Twitter, Facebook et al., alongside your sweet grandma — assuming your grandmother hasn’t been caught trying to lure kids into a van.\u003c/p>\n\u003cp>Even if you stick mainly to mainstream sites, you’ve probably seen glimpses of the internet’s underbelly in the notorious comments sections at the bottom of news articles. The article could be about a local man saving a box of kittens from a burning building, but no matter: The comments will accuse him of hating dogs, setting the building on fire in the first place, and secretly being Barack Obama’s Kenyan uncle.\u003c/p>\n\u003cp>You’ve probably wondered two things: Who are these people, and what the hell is going on here?\u003c/p>\n\u003caside class=\"alignright\">\n\u003cul>\n\u003cli>\u003ca href=\"http://www.crashoverridenetwork.com/\" target=\"_blank\" rel=\"noopener\">Crash Override Network\u003c/a> -- organization dedicated to fighting online abuse and providing assistance to victims, co-founded by Zoë Quinn. Includes automated \u003ca href=\"http://www.crashoverridenetwork.com/coach.html\" target=\"_blank\" rel=\"noopener\">cybersecurity helper\u003c/a>.\u003c/li>\n\u003c/ul>\n\u003c/aside>\n\u003cp>My teenaged obsession with shock sites like \u003ca href=\"https://theoutline.com/post/2549/rotten-com-is-offline\" target=\"_blank\" rel=\"noopener\">Rotten.com\u003c/a> started a lifelong hobby of spelunking through the weird pockets of the internet. This exploration taught me a lot (and, uh . . . showed me a lot) and exposed the fact that internet culture is essentially a magnificent patchwork of specific subcultures — good, bad and strange as hell. For every harmless community of users into really specific sexual kinks, there is a place like Bareback Exchange, a forum for people who get off on transmitting STDs to as many people as possible, often without consent. For every community of angsty kids who pretend they are secretly vampires, there are seven different forums of white nationalists who sincerely believe that Jewish people are secretly vampires. For every geeky and silly toy collector’s community, there are forums full of dudes collecting upskirt photos of random women and girls who had no idea they were about to become porn.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>\u003ca href=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/12/crashcover.png\">\u003cimg class=\"alignleft wp-image-438546\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/12/crashcover.png\" alt=\"\" width=\"352\" height=\"535\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2019/12/crashcover.png 750w, https://ww2.kqed.org/app/uploads/sites/13/2019/12/crashcover-160x243.png 160w, https://ww2.kqed.org/app/uploads/sites/13/2019/12/crashcover-240x365.png 240w, https://ww2.kqed.org/app/uploads/sites/13/2019/12/crashcover-375x570.png 375w, https://ww2.kqed.org/app/uploads/sites/13/2019/12/crashcover-520x790.png 520w\" sizes=\"(max-width: 352px) 100vw, 352px\">\u003c/a>Attempting to explain anonymous message-board culture to the uninitiated is a lot like trying to explain an inside joke — you can lay out the particulars, but it won’t carry the same weight or meaning. It’s complicated and difficult to parse, like most things about internet culture, but here’s a brief overview. Opened in 1999, a Japanese site called 2channel was the first board in this genre. An anonymous board where admins are virtually nonexistent, this site has enabled corporate whistleblowing as well as frank, open exchanges about taboo subjects like mental health and sexuality. Alongside these generally positive discussions, the boards are teeming with slander, hate speech, porn, nationalism, and general unchecked terribleness.\u003c/p>\n\u003cp>2channel’s American counterpart is 4chan, an image board launched by a 15-year-old boy in 2003. Fourteen years later, 4chan is a hugely influential force on the internet: “the ground zero of Western web culture,” as one journalist put it. Most of the memes you see on social media were invented there — everything from \u003ca href=\"http://knowyourmeme.com/memes/lolcats\" target=\"_blank\" rel=\"noopener\">LOLCats\u003c/a> to \u003ca href=\"http://knowyourmeme.com/memes/rickroll\" target=\"_blank\" rel=\"noopener\">rickrolling\u003c/a>. It’s also a breeding ground for not-so-cute things, including a hoax hashtag with the goal of getting young girls to #CutForBieber, campaigns to troll the social media of dead teenagers, and murderers occasionally posting pictures of their victims.\u003c/p>\n\u003caside class=\"pullquote alignright\">'Pretty much everything we’ve been told about dealing with online abuse is wrong, but the misconception that \"trolls\" will just go away if they’re ignored is possibly the most damaging.'\u003c/aside>\n\u003cp>Reddit has an even larger version of this problem, in both size and scope. Calling itself the “front page of the internet” and clocking in at 36 million user accounts, Reddit allows anyone to create a “subreddit,” a discussion area dedicated to any subculture or interest on its site. This model has allowed mentally ill people to find community without stigma, locals to exchange highly specific information about what’s good in their neighborhoods, and even President Obama to hop online and answer readers’ questions. But, like 4chan, it’s also been a hotbed for communities founded on hatred.\u003c/p>\n\u003cp>Reddit isn’t as anonymous as 4chan — users must create accounts and can be banned — but the site was created with a sort of free-speech absolutism in mind. Before it was shut down, the subreddit /r/Jailbait was a board for sharing sexualized pictures of underaged girls, and “jailbait” was the second-most-popular search term leading people to Reddit. Reddit users voted Jailbait the Best Subreddit of 2008, with double the number of votes received by the runner-up. It took six years and multiple public scandals to finally \u003ca href=\"https://www.dailydot.com/society/reddit-r-jailbait-shutdown-controversy/\" target=\"_blank\" rel=\"noopener\">close it\u003c/a>. Reddit has only recently started banning other repugnant subreddits, including hateful and blatantly racist forums, though many of them live on and new ones spring up constantly.\u003c/p>\n\u003caside class=\"alignright\">\u003ca href=\"https://ww2.kqed.org/forum/2017/10/04/zoe-quinn-on-gamergate-fighting-online-harassment/\" target=\"_blank\" rel=\"noopener\">Zoë Quinn on KQED Forum\u003c/a>\u003c/aside>\n\u003cp>Poorly moderated anonymous communities can have the capricious morality of any mob. In 2009, when two videos featuring the physical abuse of a domestic cat named Dusty by a person calling himself “Timmy” were posted on YouTube, the 4chan community tracked down the originator of the videos and passed his details on to the local police department. The suspect was arrested, and the cat was treated by a veterinarian and taken to a safe place. This kind of “internet detectivery” has been banned from many traditional online forums outside 4chan. It’s invasive, it’s sometimes used simply to intimidate or harass people, and the mob is often wrong, with very real consequences.\u003c/p>\n\u003cp>When you consider how a tendency for vigilante action might manifest itself in a community founded on hating people together, you can see how the results might turn scary. Stormfront, a message board for white supremacists, was founded by former Ku Klux Klan leader Don Black in 1995 and had more than 300,000 users as of May 2015. Calling it “the Web’s first and best-known hate site,” the Southern Poverty Law Center’s March 2014 intelligence report stated, “Stormfront users have been disproportionately responsible for some of the most lethal hate crimes and mass killings since the site was put up in 1995. In the past five years alone, Stormfront members have murdered close to 100 people.”\u003c/p>\n\u003cp>This escalation from hate speech to real action isn’t unique to Stormfront’s user base. Before embarking on a \u003ca href=\"https://ww2.kqed.org/news/2014/05/26/amid-multiple-warning-signs-alleged-isla-vista-killer-slipped-through-system/\" target=\"_blank\" rel=\"noopener\">shooting spree\u003c/a> that killed six and injured 14, Elliot Rodger posted a video on several internet forums dedicated to hating women, discussing the deeply misogynist and racist motives for his rampage. He namechecked one of these sites in his manifesto, saying he had discovered “a forum full of men who are starved of sex, just like me.” The forum had “confirmed many of the theories I had about how wicked and degenerate women really are.”\u003c/p>\n\u003cfigure id=\"attachment_438515\" class=\"wp-caption aligncenter\" style=\"max-width: 640px\">\u003ca href=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/12/zoequinn-e1516148809366.jpg\">\u003cimg class=\"size-large wp-image-438515\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/12/zoequinn-1020x680.jpg\" alt=\"\" width=\"640\" height=\"427\">\u003c/a>\u003cfigcaption class=\"wp-caption-text\">Zoe Quinn (right), with Anita Sarkeesian, also a #Gamergate target, were guest speakers at the introduction of a UN report called '\u003ca href=\"http://www.unwomen.org/~/media/headquarters/attachments/sections/library/publications/2015/cyber_violence_gender%20report.pdf?v=1&d=20150924T154259\">Cyber Violence Against Women and Girls: A World-Wide Wake-Up Call\u003c/a>.' \u003ccite>(UN Women/Ryan Brown)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>\u003cstrong>Bad Advice\u003c/strong>\u003c/p>\n\u003cp>There’s one piece of advice that most often gets passed around to anyone who experiences harassment or abuse on the internet: “Don’t feed the trolls.” This maxim is passed off as gospel and is applied across the board, whether you’re a kid getting into your very first Facebook argument or an experienced developer dealing with death threats.\u003c/p>\n\u003cp>This advice is wrong. Pretty much everything we’ve been told about dealing with online abuse is wrong, but the misconception that \"trolls\" will just go away if they’re ignored is possibly the most damaging.\u003c/p>\n\u003cp>This kind of behavior is not just about terrorizing you; it’s about control. It’s about making you want to disappear, instilling fear and limiting your possibilities. It’s about punishing you for stepping out of line. It’s about isolating and hurting you in specific ways to provoke a reaction.\u003c/p>\n\u003caside class=\"pullquote alignright\">'Anyone to whom I had public ties began to receive nude photos of me and pressure to publicly denounce me or become their next target.'\u003c/aside>\n\u003cp>In my case, it became obvious that my attackers’ dream was to get me to stop “feeding the trolls” and shut up. They didn’t want to tease me; they wanted me gone. There were countless forms of harassment — the same channels that I had used to talk with friends, grow my business, and share weird videos were now full of threats, slurs, and all manner of nastiness. It escalated to include sexual or violent images with my face Photoshopped into them. My inbox started to fill up with pictures of women being raped. As strangers stalked through everything I had said or done online since I was 12, looking for more ammo, lies and conspiracy theories about me snowballed into weirder and more extreme accusations. These would then be blasted out widely, and also directly to my colleagues in games. Anyone to whom I had public ties began to receive nude photos of me and pressure to publicly denounce me or become their next target.\u003c/p>\n\u003cp>\u003cstrong>Tools of Abuse\u003c/strong>\u003c/p>\n\u003cp>It’s one thing to have a single person going after you with all of the above tactics; it’s something else entirely when a community forms around doing so. The networked nature of the internet doesn’t just make it easier for stalkers to find you; it also makes it easier for them to find each other. These tools of abuse serve both as an attack in and of themselves and as a rallying cry. They’re meant to be shared.\u003c/p>\n\u003cp>When you’re the target of abuse like this, you’re basically screwed. Not only does the scope of abuse that you face increase exponentially with every single signal boost from a new member of the mob, but all of the good things about the web’s ability to bring people together are turned against you. The same techniques that people have used to organize important grassroots movements can be used by people trying to destroy someone.\u003c/p>\n\u003cp>\u003c/p>\u003cp>\u003c/p>\u003cp>Attacking you becomes a participatory game in which people try to one-up each other in terms of who can get to you the most. In my case, I was struck by how many of the threats or disgusting remarks sent my way were made so publicly, usually while tagging other people. The ones that were especially vicious were rewarded with likes, shares, and people joining in on the abuse.\u003c/p>\n\u003cp>This phenomenon is often referred to as “dogpiling.” The cool remix culture that facilitates the spread of fanart and memes suddenly becomes a powerful tool to hurt someone. Photos and videos of you are Photoshopped to label you a whore or to make you look uglier or fatter and then shared the same way cute pictures of cats are. Memes are easily co-opted by other people, who made reams of almost propaganda-like images with my face Photoshopped onto them. It wasn’t really about me anymore. The mob was engaging in a performative group activity.\u003c/p>\n\u003cp>This type of community building is quite deliberate and direct. As the 4chan threads kept growing in size and the mob gained momentum, I noticed that a chatroom had sprung up in the original posts. The chatroom participants worked as a team to try to discover personal information about everyone connected to me, referring to it as “digging” and sharing form letters and tactics on how to best alert anyone in my life that I was a horrible slut. They were highly organized, discussing how to divide their ranks into specialized groups: one dedicated to getting me in legal trouble, one dedicated to turning all of my friends against me, and another dedicated to pushing me to kill myself.\u003c/p>\n\u003cp>They shared elaborate fantasies about raping and murdering me, discussing the pros and cons of each. They talked about how to break into all of my accounts to try to find more ways to invade my privacy. They bragged about victories like flooding my game’s page with hatred and nude photos of me and went so far as to create guides to share tactics on how best to ruin my life. They even orchestrated plans to donate to various charities specifically to make themselves look like concerned citizens and not a mob of people trying to get me killed. They built friendships and bonded with each other by reinforcing their dedication to the righteous cause of taking me down, reminding themselves at every turn that they were the good guys.\u003c/p>\n\u003caside class=\"pullquote alignright\">'For every harmless community of users into really specific sexual kinks, there is a place like Bareback Exchange, a forum for people who get off on transmitting STDs to as many people as possible.'\u003c/aside>\n\u003cp>A mob has more tools at its disposal than individual actors do. Popularity — the quantity of clicks or views on any given page — is tracked and exploited by algorithms online, and a mob is a critical mass. If thousands of people are linking to something about you, that will quickly become the first thing people see when they Google your name, regardless of whether it’s a fact-checked news article or a video about what a bitch you are. Many sites allow their user base to vote on what is good content and what’s garbage, and mobs manipulate these systems to their targets’ detriment. There are also services that direct people away from sketchy websites that contain viruses, and the mob had flooded such services with false reports to make my websites and social media accounts inaccessible. My cohorts and I call this “brigading” — when people manipulate online systems to force their target into silence or hurt the person. Mass false reporting is a common tool to try to make the legitimate sites belonging to targets of online abuse vanish, as many systems are automated to react to a large volume of reports. Law enforcement agencies and government bodies like the IRS have online reporting systems that can also be manipulated this way by a mob.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"floatright"},"numeric":["floatright"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>As a game designer, I can spot a game being played. And the more people who join in on the “fun,” the faster you become an abstract concept for your aggressors to hate. This might sound sort of comforting or like a way to defang the attacks, but in reality, it’s the opposite — this “game” is another way that you are dehumanized, and it makes it easier for a mob to grow its ranks and escalate its attacks. You’re just data, and data doesn’t bleed. You’re a symbol, and hating you can become part of someone’s identity, just as any other hobby might. Just as they would in a game, they are always trying to make their numbers go up. And plenty of the witch hunters advance from amateur to professional.\u003c/p>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/438097/what-its-like-for-a-woman-to-be-targeted-by-an-online-mob","authors":["byline_futureofyou_438097"],"categories":["futureofyou_1","futureofyou_73","futureofyou_1061"],"tags":["futureofyou_1445","futureofyou_1439","futureofyou_1275","futureofyou_1442","futureofyou_1446","futureofyou_1444","futureofyou_174","futureofyou_1443"],"featImg":"futureofyou_438541","label":"source_futureofyou_438097"},"futureofyou_438099":{"type":"posts","id":"futureofyou_438099","meta":{"index":"posts_1591205157","site":"futureofyou","id":"438099","score":null,"sort":[1514653242000]},"guestAuthors":[],"slug":"four-thought-provoking-book-excerpts-from-future-of-you","title":"Four Thought-Provoking Book Excerpts You May Have Missed","publishDate":1514653242,"format":"aside","headTitle":"KQED Future of You | KQED Science","labelTerm":{"site":"futureofyou"},"content":"\u003cp>Here at \u003cem>Future of You\u003c/em> headquarters, also known as my desk, we've posted what we think are some compelling and thought-provoking \u003ca href=\"https://ww2.kqed.org/futureofyou/tag/book-excerpts/\" target=\"_blank\" rel=\"noopener\">book excerpts\u003c/a> over the past couple of years. If you are looking to clear your post-New Year's Eve haze, give these a read ...\u003c/p>\n\u003cp>1. \u003ca href=\"https://ww2.kqed.org/futureofyou/2016/04/22/stanfords-virtual-reality-lab-turned-me-into-a-cow-then-sent-me-to-the-slaughterhouse/\" target=\"_blank\" rel=\"noopener\">\u003cstrong>Stanford's Virtual Reality Lab Turned Me Into a Cow, Then Sent Me to the Slaughterhouse\u003c/strong>\u003c/a>\u003c/p>\n\u003cp>\u003ca href=\"https://ww2.kqed.org/futureofyou/2016/04/22/stanfords-virtual-reality-lab-turned-me-into-a-cow-then-sent-me-to-the-slaughterhouse/\" target=\"_blank\" rel='\"noopener'>\u003cimg class=\"aligncenter wp-image-150203\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2016/04/I-Am-a-Cow-1180x467.png\" alt=\"\" width=\"639\" height=\"253\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2016/04/I-Am-a-Cow-1180x467.png 1180w, https://ww2.kqed.org/app/uploads/sites/13/2016/04/I-Am-a-Cow-400x158.png 400w, https://ww2.kqed.org/app/uploads/sites/13/2016/04/I-Am-a-Cow-800x317.png 800w, https://ww2.kqed.org/app/uploads/sites/13/2016/04/I-Am-a-Cow-768x304.png 768w, https://ww2.kqed.org/app/uploads/sites/13/2016/04/I-Am-a-Cow.png 1920w, https://ww2.kqed.org/app/uploads/sites/13/2016/04/I-Am-a-Cow-960x380.png 960w\" sizes=\"(max-width: 639px) 100vw, 639px\">\u003c/a>\u003c/p>\n\u003cp>\u003cem>From \"We Have the Technology: How Biohackers, Foodies, Physicians, and Scientists are Transforming Human Perception, One Sense at a Time,\" by Kara Platoni\u003c/em>\u003c/p>\n\u003cp>If you become a nonhuman in virtual reality, will you gain empathy? This was Platoni's experience at Stanford's Virtual Human Interaction Lab, where she was, through the magic of VR, turned into a cow then unceremoniously killed.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>\"A wave of sadness and horror hits me with the word 'slaughterhouse.' The suddenness of the announcement, the feeling of being trapped, the guilt and responsibility I feel for my cow avatar, who I somehow feel is me ... it's remarkably heavy for having been in this virtual life only a few minutes.\"\u003cstrong>\u003ca href=\"https://ww2.kqed.org/futureofyou/2016/04/22/stanfords-virtual-reality-lab-turned-me-into-a-cow-then-sent-me-to-the-slaughterhouse/\" target=\"_blank\" rel=\"noopener\"> \u003c/a>\u003c/strong>\u003c/p>\n\u003cp>\u003cem>\u003ca href=\"https://ww2.kqed.org/futureofyou/2016/04/22/stanfords-virtual-reality-lab-turned-me-into-a-cow-then-sent-me-to-the-slaughterhouse/\" target=\"_blank\" rel=\"noopener\">Read the excerpt\u003c/a>.\u003c/em>\u003c/p>\n\u003cp>2. \u003ca href=\"https://ww2.kqed.org/futureofyou/2017/01/03/for-first-week-january-on-social-media-the-self-as-its-own-object-of-worship/\" target=\"_blank\" rel=\"noopener\">\u003cstrong>In the Era of Instagram, Narcissism as the New Norm\u003c/strong>\u003c/a>\u003c/p>\n\u003cp>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/01/03/for-first-week-january-on-social-media-the-self-as-its-own-object-of-worship/\" target=\"_blank\" rel=\"noopener\">\u003cimg class=\"aligncenter wp-image-304140 size-large\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2020/12/HillarySelfies-1020x675.jpg\" alt=\"\" width=\"640\" height=\"424\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-1020x675.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-160x106.jpg 160w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-800x530.jpg 800w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-768x508.jpg 768w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-1180x781.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-960x636.jpg 960w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-240x159.jpg 240w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-375x248.jpg 375w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-520x344.jpg 520w\" sizes=\"(max-width: 640px) 100vw, 640px\">\u003c/a>\u003c/p>\n\u003cp>\u003cem>From \"The Attention Merchants,\" by Tim Wu\u003c/em>\u003c/p>\n\u003cp>Social media has created an 'attention economy' that's \"devolved into a chaotic mutual admiration society, full of enterprising Narcissi,\" writes Wu. With the advent of the smartphone and Instagram, \"much of the power of a great film studio was now in every hand attached to a heart yearning for fame; not only could one create an image to rival those of the old icons of glamour, but one could put it on a platform where millions might potentially see it.\" This, Wu argues, \"warps our understanding of our own existence and its relation to others. That this should become the manner of being for us all is surely the definitive dystopic vision of late modernity.\"\u003c/p>\n\u003cp>\u003cem>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/01/03/for-first-week-january-on-social-media-the-self-as-its-own-object-of-worship/\" target=\"_blank\" rel=\"noopener\">Read the excerpt\u003c/a>.\u003c/em>\u003c/p>\n\u003cp>3. \u003cstrong>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/01/28/how-technology-ruined-the-radiology-profession/\" target=\"_blank\" rel=\"noopener\">Has Technology Ruined the Radiology Profession?\u003c/a>\u003c/strong>\u003c/p>\n\u003cp>\u003ca style=\"font-weight: bold;background-color: transparent\" href=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/10/radiology1-e1476734001207.jpg\">\u003cimg class=\"wp-image-264973 size-large\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/10/radiology1-1180x818.jpg\" alt=\"\" width=\"640\" height=\"444\">\u003c/a>\u003c/p>\n\u003cp>\u003cem>From “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,\" by Bob Wachter\u003c/em>\u003c/p>\n\u003cp>Because radiology was the first medical specialty to computerize, what has happened to the profession is our canary in the digital coal mine, Wachter writes. Radiology was once the \"beating heart\" of hospitals, where \"everybody from the lowliest student to the loftiest transplant surgeon\" brought films for deciphering. Now? Game changing technology has created powerful new functionality that has some wondering if radiologists have not been turned into “disembodied functionaries, more akin to servicing technicians than professional colleagues.”\u003c/p>\n\u003cp>\u003cem>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/01/28/how-technology-ruined-the-radiology-profession/\" target=\"_blank\" rel=\"noopener\">Read the excerpt.\u003c/a>\u003c/em>\u003c/p>\n\u003cp>4. \u003cstrong>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/11/06/advanced-prenatal-testing-will-mean-more-gut-wrenching-decisions-about-abortion/\" target=\"_blank\" rel=\"noopener\">Advanced Prenatal Testing Means More Gut-Wrenching Decisions Over Abortion\u003c/a>\u003c/strong>\u003c/p>\n\u003cp>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/11/06/advanced-prenatal-testing-will-mean-more-gut-wrenching-decisions-about-abortion/\" target=\"_blank\" rel=\"noopener\">\u003cimg class=\"wp-image-436849 size-large\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2029/11/abortion_genetics1-1020x574.jpg\" alt=\"\" width=\"640\" height=\"360\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-1020x574.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-160x90.jpg 160w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-800x450.jpg 800w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-768x432.jpg 768w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-960x540.jpg 960w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1.jpg 1024w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-240x135.jpg 240w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-375x211.jpg 375w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-520x293.jpg 520w\" sizes=\"(max-width: 640px) 100vw, 640px\">\u003c/a>\u003c/p>\n\u003cp>\u003cem>From \"The Gene Machine,\" by Bonnie Rochman\u003c/em>\u003c/p>\n\u003cp>Advanced prenatal genetic testing has transformed every fetus into an \"at risk\" entity, says Rochman. \"While there are women who’d never opt for an abortion, it’s disingenuous to ignore the fact that terminating a pregnancy is one possible outcome of earlier, more sophisticated genetic tests. The issue of how people feel about disability and, in turn, how that impacts their decisions regarding abortion is an essential aspect of any discussion about advances in prenatal testing.\"\u003c/p>\n\u003cp>\u003cem>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/11/06/advanced-prenatal-testing-will-mean-more-gut-wrenching-decisions-about-abortion/\" target=\"_blank\" rel=\"noopener\">Read the excerpt\u003c/a>.\u003c/em>\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>\u003cem>More excerpts from Future of You:\u003c/em>\u003c/p>\n\u003cul>\n\u003cli>\u003ca href=\"https://ww2.kqed.org/futureofyou/2016/11/07/will-computers-ever-be-able-to-make-diagnoses-as-well-as-physicians/\" target=\"_blank\" rel=\"noopener\">Will Computers Ever Be as Good as Physicians at Diagnosing Patients? \u003c/a>from “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,\" by Bob Wachter\u003c/li>\n\u003cli>\u003ca href=\"https://ww2.kqed.org/futureofyou/2016/11/29/clinical-trials-on-trial-the-ethics-of-withholding-life-saving-treatment/\" target=\"_blank\" rel=\"noopener\">The Ethics of Withholding Lifesaving Treatment\u003c/a>, from “Algorithms to Live By: The Computer Science of Human Decisions,” by Brian Christian and Tom Griffiths\u003c/li>\n\u003cli>\u003ca href=\"https://ww2.kqed.org/futureofyou/2016/06/07/can-taking-tylenol-help-you-get-over-a-romantic-breakup-maybe/\" target=\"_blank\" rel=\"noopener\">Taking Tylenol for Heartache: The Relationship Between Emotional and Physical Pain\u003c/a>, from \"We Have the Technology: How Biohackers, Foodies, Physicians, and Scientists are Transforming Human Perception, One Sense at a Time,\"\u003cem> \u003c/em>by Kara Platoni\u003c/li>\n\u003cli>\u003ca href=\"https://ww2.kqed.org/futureofyou/2016/08/23/the-online-life-as-both-liberation-and-imprisonment/\" target=\"_blank\" rel=\"noopener\">The Online Life, as Both Liberation and Imprisonment\u003c/a>, from \"The Four-Dimensional Human,\" by Laurence Scott\u003c/li>\n\u003cli>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/05/12/how-the-media-came-to-embrace-clickbait-an-internet-history/\" target=\"_blank\" rel=\"noopener\">How the Media Came to Embrace Clickbait: An Internet History\u003c/a>, from \"The Attention Merchants,\" by Tim Wu\u003c/li>\n\u003c/ul>\n\n","blocks":[],"excerpt":"Stanford's VR lab turns one author into a cow then kills her; digital narcissism as the new norm; advanced prenatal testing's real topic: abortion; and ... has technology ruined the radiology profession?","status":"publish","parent":0,"modified":1515776848,"stats":{"hasAudio":false,"hasVideo":false,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":25,"wordCount":672},"headData":{"title":"Four Thought-Provoking Book Excerpts You May Have Missed | KQED","description":"Stanford's VR lab turns one author into a cow then kills her; digital narcissism as the new norm; advanced prenatal testing's real topic: abortion; and ... has technology ruined the radiology profession?","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"Four Thought-Provoking Book Excerpts You May Have Missed","datePublished":"2017-12-30T17:00:42.000Z","dateModified":"2018-01-12T17:07:28.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"438099 https://ww2.kqed.org/futureofyou/?p=438099","disqusUrl":"https://ww2.kqed.org/futureofyou/2017/12/30/four-thought-provoking-book-excerpts-from-future-of-you/","disqusTitle":"Four Thought-Provoking Book Excerpts You May Have Missed","path":"/futureofyou/438099/four-thought-provoking-book-excerpts-from-future-of-you","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>Here at \u003cem>Future of You\u003c/em> headquarters, also known as my desk, we've posted what we think are some compelling and thought-provoking \u003ca href=\"https://ww2.kqed.org/futureofyou/tag/book-excerpts/\" target=\"_blank\" rel=\"noopener\">book excerpts\u003c/a> over the past couple of years. If you are looking to clear your post-New Year's Eve haze, give these a read ...\u003c/p>\n\u003cp>1. \u003ca href=\"https://ww2.kqed.org/futureofyou/2016/04/22/stanfords-virtual-reality-lab-turned-me-into-a-cow-then-sent-me-to-the-slaughterhouse/\" target=\"_blank\" rel=\"noopener\">\u003cstrong>Stanford's Virtual Reality Lab Turned Me Into a Cow, Then Sent Me to the Slaughterhouse\u003c/strong>\u003c/a>\u003c/p>\n\u003cp>\u003ca href=\"https://ww2.kqed.org/futureofyou/2016/04/22/stanfords-virtual-reality-lab-turned-me-into-a-cow-then-sent-me-to-the-slaughterhouse/\" target=\"_blank\" rel='\"noopener'>\u003cimg class=\"aligncenter wp-image-150203\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2016/04/I-Am-a-Cow-1180x467.png\" alt=\"\" width=\"639\" height=\"253\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2016/04/I-Am-a-Cow-1180x467.png 1180w, https://ww2.kqed.org/app/uploads/sites/13/2016/04/I-Am-a-Cow-400x158.png 400w, https://ww2.kqed.org/app/uploads/sites/13/2016/04/I-Am-a-Cow-800x317.png 800w, https://ww2.kqed.org/app/uploads/sites/13/2016/04/I-Am-a-Cow-768x304.png 768w, https://ww2.kqed.org/app/uploads/sites/13/2016/04/I-Am-a-Cow.png 1920w, https://ww2.kqed.org/app/uploads/sites/13/2016/04/I-Am-a-Cow-960x380.png 960w\" sizes=\"(max-width: 639px) 100vw, 639px\">\u003c/a>\u003c/p>\n\u003cp>\u003cem>From \"We Have the Technology: How Biohackers, Foodies, Physicians, and Scientists are Transforming Human Perception, One Sense at a Time,\" by Kara Platoni\u003c/em>\u003c/p>\n\u003cp>If you become a nonhuman in virtual reality, will you gain empathy? This was Platoni's experience at Stanford's Virtual Human Interaction Lab, where she was, through the magic of VR, turned into a cow then unceremoniously killed.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>\"A wave of sadness and horror hits me with the word 'slaughterhouse.' The suddenness of the announcement, the feeling of being trapped, the guilt and responsibility I feel for my cow avatar, who I somehow feel is me ... it's remarkably heavy for having been in this virtual life only a few minutes.\"\u003cstrong>\u003ca href=\"https://ww2.kqed.org/futureofyou/2016/04/22/stanfords-virtual-reality-lab-turned-me-into-a-cow-then-sent-me-to-the-slaughterhouse/\" target=\"_blank\" rel=\"noopener\"> \u003c/a>\u003c/strong>\u003c/p>\n\u003cp>\u003cem>\u003ca href=\"https://ww2.kqed.org/futureofyou/2016/04/22/stanfords-virtual-reality-lab-turned-me-into-a-cow-then-sent-me-to-the-slaughterhouse/\" target=\"_blank\" rel=\"noopener\">Read the excerpt\u003c/a>.\u003c/em>\u003c/p>\n\u003cp>2. \u003ca href=\"https://ww2.kqed.org/futureofyou/2017/01/03/for-first-week-january-on-social-media-the-self-as-its-own-object-of-worship/\" target=\"_blank\" rel=\"noopener\">\u003cstrong>In the Era of Instagram, Narcissism as the New Norm\u003c/strong>\u003c/a>\u003c/p>\n\u003cp>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/01/03/for-first-week-january-on-social-media-the-self-as-its-own-object-of-worship/\" target=\"_blank\" rel=\"noopener\">\u003cimg class=\"aligncenter wp-image-304140 size-large\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2020/12/HillarySelfies-1020x675.jpg\" alt=\"\" width=\"640\" height=\"424\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-1020x675.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-160x106.jpg 160w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-800x530.jpg 800w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-768x508.jpg 768w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-1180x781.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-960x636.jpg 960w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-240x159.jpg 240w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-375x248.jpg 375w, https://ww2.kqed.org/app/uploads/sites/13/2020/12/HillarySelfies-520x344.jpg 520w\" sizes=\"(max-width: 640px) 100vw, 640px\">\u003c/a>\u003c/p>\n\u003cp>\u003cem>From \"The Attention Merchants,\" by Tim Wu\u003c/em>\u003c/p>\n\u003cp>Social media has created an 'attention economy' that's \"devolved into a chaotic mutual admiration society, full of enterprising Narcissi,\" writes Wu. With the advent of the smartphone and Instagram, \"much of the power of a great film studio was now in every hand attached to a heart yearning for fame; not only could one create an image to rival those of the old icons of glamour, but one could put it on a platform where millions might potentially see it.\" This, Wu argues, \"warps our understanding of our own existence and its relation to others. That this should become the manner of being for us all is surely the definitive dystopic vision of late modernity.\"\u003c/p>\n\u003cp>\u003cem>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/01/03/for-first-week-january-on-social-media-the-self-as-its-own-object-of-worship/\" target=\"_blank\" rel=\"noopener\">Read the excerpt\u003c/a>.\u003c/em>\u003c/p>\n\u003cp>3. \u003cstrong>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/01/28/how-technology-ruined-the-radiology-profession/\" target=\"_blank\" rel=\"noopener\">Has Technology Ruined the Radiology Profession?\u003c/a>\u003c/strong>\u003c/p>\n\u003cp>\u003ca style=\"font-weight: bold;background-color: transparent\" href=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/10/radiology1-e1476734001207.jpg\">\u003cimg class=\"wp-image-264973 size-large\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/10/radiology1-1180x818.jpg\" alt=\"\" width=\"640\" height=\"444\">\u003c/a>\u003c/p>\n\u003cp>\u003cem>From “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,\" by Bob Wachter\u003c/em>\u003c/p>\n\u003cp>Because radiology was the first medical specialty to computerize, what has happened to the profession is our canary in the digital coal mine, Wachter writes. Radiology was once the \"beating heart\" of hospitals, where \"everybody from the lowliest student to the loftiest transplant surgeon\" brought films for deciphering. Now? Game changing technology has created powerful new functionality that has some wondering if radiologists have not been turned into “disembodied functionaries, more akin to servicing technicians than professional colleagues.”\u003c/p>\n\u003cp>\u003cem>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/01/28/how-technology-ruined-the-radiology-profession/\" target=\"_blank\" rel=\"noopener\">Read the excerpt.\u003c/a>\u003c/em>\u003c/p>\n\u003cp>4. \u003cstrong>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/11/06/advanced-prenatal-testing-will-mean-more-gut-wrenching-decisions-about-abortion/\" target=\"_blank\" rel=\"noopener\">Advanced Prenatal Testing Means More Gut-Wrenching Decisions Over Abortion\u003c/a>\u003c/strong>\u003c/p>\n\u003cp>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/11/06/advanced-prenatal-testing-will-mean-more-gut-wrenching-decisions-about-abortion/\" target=\"_blank\" rel=\"noopener\">\u003cimg class=\"wp-image-436849 size-large\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2029/11/abortion_genetics1-1020x574.jpg\" alt=\"\" width=\"640\" height=\"360\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-1020x574.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-160x90.jpg 160w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-800x450.jpg 800w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-768x432.jpg 768w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-960x540.jpg 960w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1.jpg 1024w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-240x135.jpg 240w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-375x211.jpg 375w, https://ww2.kqed.org/app/uploads/sites/13/2029/11/abortion_genetics1-520x293.jpg 520w\" sizes=\"(max-width: 640px) 100vw, 640px\">\u003c/a>\u003c/p>\n\u003cp>\u003cem>From \"The Gene Machine,\" by Bonnie Rochman\u003c/em>\u003c/p>\n\u003cp>Advanced prenatal genetic testing has transformed every fetus into an \"at risk\" entity, says Rochman. \"While there are women who’d never opt for an abortion, it’s disingenuous to ignore the fact that terminating a pregnancy is one possible outcome of earlier, more sophisticated genetic tests. The issue of how people feel about disability and, in turn, how that impacts their decisions regarding abortion is an essential aspect of any discussion about advances in prenatal testing.\"\u003c/p>\n\u003cp>\u003cem>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/11/06/advanced-prenatal-testing-will-mean-more-gut-wrenching-decisions-about-abortion/\" target=\"_blank\" rel=\"noopener\">Read the excerpt\u003c/a>.\u003c/em>\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>\u003cem>More excerpts from Future of You:\u003c/em>\u003c/p>\n\u003cul>\n\u003cli>\u003ca href=\"https://ww2.kqed.org/futureofyou/2016/11/07/will-computers-ever-be-able-to-make-diagnoses-as-well-as-physicians/\" target=\"_blank\" rel=\"noopener\">Will Computers Ever Be as Good as Physicians at Diagnosing Patients? \u003c/a>from “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,\" by Bob Wachter\u003c/li>\n\u003cli>\u003ca href=\"https://ww2.kqed.org/futureofyou/2016/11/29/clinical-trials-on-trial-the-ethics-of-withholding-life-saving-treatment/\" target=\"_blank\" rel=\"noopener\">The Ethics of Withholding Lifesaving Treatment\u003c/a>, from “Algorithms to Live By: The Computer Science of Human Decisions,” by Brian Christian and Tom Griffiths\u003c/li>\n\u003cli>\u003ca href=\"https://ww2.kqed.org/futureofyou/2016/06/07/can-taking-tylenol-help-you-get-over-a-romantic-breakup-maybe/\" target=\"_blank\" rel=\"noopener\">Taking Tylenol for Heartache: The Relationship Between Emotional and Physical Pain\u003c/a>, from \"We Have the Technology: How Biohackers, Foodies, Physicians, and Scientists are Transforming Human Perception, One Sense at a Time,\"\u003cem> \u003c/em>by Kara Platoni\u003c/li>\n\u003cli>\u003ca href=\"https://ww2.kqed.org/futureofyou/2016/08/23/the-online-life-as-both-liberation-and-imprisonment/\" target=\"_blank\" rel=\"noopener\">The Online Life, as Both Liberation and Imprisonment\u003c/a>, from \"The Four-Dimensional Human,\" by Laurence Scott\u003c/li>\n\u003cli>\u003ca href=\"https://ww2.kqed.org/futureofyou/2017/05/12/how-the-media-came-to-embrace-clickbait-an-internet-history/\" target=\"_blank\" rel=\"noopener\">How the Media Came to Embrace Clickbait: An Internet History\u003c/a>, from \"The Attention Merchants,\" by Tim Wu\u003c/li>\n\u003c/ul>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/438099/four-thought-provoking-book-excerpts-from-future-of-you","authors":["80"],"categories":["futureofyou_1"],"tags":["futureofyou_1439","futureofyou_1275","futureofyou_80","futureofyou_1447","futureofyou_1104","futureofyou_174","futureofyou_380"],"featImg":"futureofyou_150203","label":"futureofyou"},"futureofyou_435960":{"type":"posts","id":"futureofyou_435960","meta":{"index":"posts_1591205157","site":"futureofyou","id":"435960","score":null,"sort":[1509995619000]},"guestAuthors":[],"slug":"advanced-prenatal-testing-will-mean-more-gut-wrenching-decisions-about-abortion","title":"Advanced Prenatal Testing Means More Gut-Wrenching Decisions Over Abortion","publishDate":1509995619,"format":"standard","headTitle":"KQED Future of You | KQED Science","labelTerm":{"site":"futureofyou"},"content":"\u003cp>\u003cem>Excerpts from \"The Other Scarlet 'A': Abortion's Relationship to Genetic Testing\" from THE GENE MACHINE by Bonnie Rochman. Copyright © 2017 by Bonnie Rochman. Used by permission of \u003ca href=\"https://us.macmillan.com/fsg\" target=\"_blank\" rel=\"noopener\">Farrar, Straus and Giroux\u003c/a>.\u003c/em>\u003c/p>\n\u003cp>When the second purple line appeared on the white plastic wand on a March morning in 2002, I knew next to nothing about pregnancy and even less about raising a child. It was years before I’d go on to cover parenting and pediatrics, and write about sequencing children’s genomes. Yet from the first days of that pregnancy, I was already enmeshed in the most cutting-edge technologies of the time, thanks to my friend Tali, whose son was due a week after mine.\u003c/p>\n\u003caside class=\"pullquote alignright\">How people feel about disability and how that impacts their decisions around abortion are the real topics in any discussion about advanced prenatal testing.\u003c/aside>\n\u003cp>Tali had recently moved to my home state of North Carolina from Israel, where nuchal translucency testing was standard. I had no idea what it was, but I figured it was important, judging by her level of outrage that this test to gauge Down syndrome risk — combination of an ultrasound to measure the collection of fluid under the skin on the back of a fetus’s neck, and a blood draw — wasn’t commonly available in the United States. Within days, she told me that she’d found a doctor who was getting certified to perform the testing. He needed subjects. Tali and I volunteered.\u003c/p>\n\u003cp>I had signed up blithely, without seriously considering what I’d do if the test result came back positive. I expected good news — and, fortunately, I got it. Now, more than a decade later, nuchal translucency is old hat. Other, more sophisticated tests have begun to usurp what was lauded as the latest in prenatal technology in the early aughts.\u003c/p>\n\u003cp>Nuchal translucency offered both Tali and me reassurance. But the various permutations of prenatal screening and testing do not always provide comfort. I am witness to that in the heart of midtown Manhattan, not far from Radio City Music Hall, in a clinic where a woman and her husband have just made a life-altering decision. The woman is 40 years old, with high cheekbones and skin the color of toasted almonds. She is 12-and-a-half weeks pregnant with one baby, but minutes earlier, before she sat down with me in an empty exam room, she was pregnant with two.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>[contextly_sidebar id=\"i4qdnvXQQLlENO4hP9XlMVjlFUStRjgc\"]Her journey to motherhood had not been easy. The twins had been conceived via in vitro fertilization after the woman and her partner had spent more than a year trying to get pregnant the old-fashioned way. A week before, she had had a microarray analysis that peered deeply into the genetic makeup of her twins.\u003c/p>\n\u003cp>Microarray analyzes fetal cells for countless less apparent disorders that occur when a tiny snippet of DNA has been added somewhere it’s not supposed to be or deleted entirely, revealing genetic hiccups that previously could not be detected prenatally. Some of these changes are meaningless; others may be associated with autism or rare disorders such as DiGeorge syndrome, which is characterized by heart problems and a roughly 25 percent risk of developing schizophrenia.\u003c/p>\n\u003cp>As the woman explained, “We made use of technology throughout this process, so it would be a shame not to take advantage of this [test]. I wanted to make sure that, given my age, there was nothing wrong.”\u003c/p>\n\u003cp>She knew that the microarray would reveal all sorts of genetic blips, DNA duplications and deletions too tiny to be seen under a microscope, some of which are associated with worrisome conditions and others of which aren’t understood. The test would also detect major chromosomal problems, of which Down syndrome is the most common.\u003c/p>\n\u003caside class=\"pullquote alignright\">'Just because a patient can know something, must she? What is one of the most joyous times of life has turned into something ominous and fraught, loaded with the potential to go wrong.'\u003c/aside>\n\u003cp>Even at age 40, just 1 of 100 pregnancies results in Down syndrome. And yet the couple beat those odds: one of the twins was confirmed to have the extra 21st chromosome that causes the condition.\u003c/p>\n\u003cp>“You don’t think it’s going to happen to you and then here it is. I still can’t get over the fact. Today we reduced the baby with Down syndrome,” the woman tells me, using a common euphemism for terminating one or more fetuses in cases where a woman is carrying more than she intends to deliver. Many doctors call this “fetal reduction.” She reflects on her decision, made possible by these new tests, as she lowers herself onto an exam table to rest. “I look at this as a sign from God. My mother believes in karma. I think this baby was only meant to be for twelve weeks and his suffering was shortened,” she says. She raises herself up on her elbows and looks at her husband. “Then I feel like, ‘Oh my god, I just killed a baby.’ ”\u003c/p>\n\u003cp>Considering that women have been getting pregnant for a very long time, prenatal diagnosis — the ability to peer inside the womb and emerge with a snapshot of fetal health — is a fairly recent development, a convergence of medical technologies such as amniocentesis and ultrasound with emerging insights about genes and chromosomes. But it’s the legalization of abortion in 1973 that really served as a catalyst for change. After all, without the ability to choose whether or not to continue a pregnancy, knowledge gleaned from prenatal diagnosis would have remained largely theoretical. With the decriminalization of abortion, what to do became a choice.\u003c/p>\n\u003cp>While there are women who’d never opt for an abortion, it’s disingenuous to ignore the fact that terminating a pregnancy is one possible outcome of earlier, more sophisticated genetic tests. The issue of how people feel about disability and, in turn, how that impacts their decisions regarding abortion is an essential aspect of any discussion about advances in prenatal testing.\u003c/p>\n\u003caside class=\"pullquote alignright\">'I don't understand why even women in their twenties aren't undergoing this testing. Knowledge is power.'\u003c/aside>\n\u003cp>Yet abortion remains the elephant in the room when it comes to prenatal testing. When I discuss my work with colleagues and friends interested in the subject, some say, “ You’re not going to mention abortion, are you? My gut tells me that I think you’re walking into a minefield if that becomes a major part of the book.” Others say, “Abortion should definitely be a chapter. How could it not be?”\u003c/p>\n\u003cp>Much of the prenatal testing conversation centers on Down syndrome because the condition is so well- known, unlike others that affect far fewer people. One of every 792 babies born in the United States has Down syndrome. Compared to many other chromosomal conditions, however, Down syndrome is considered a relatively mild genetic complex. Chromosome 21 is the smallest chromosome, so the extra genetic material that accompanies a third copy is not as massive or overwhelming as it would be had it occurred on another, larger chromosome. The genetic disorder that results from a triplication of any chromosome is called a trisomy. A trisomy 22 baby, for example, probably would not make it to birth.\u003c/p>\n\u003cp>Starting in the 1970s, various epidemiologists began making the case that standardizing testing for Down syndrome was a public health priority. Since then, screening for Down syndrome has become broadly accepted by the medical community and, in turn, by many pregnant women and their partners. In 2007, the American College of Obstetrics and Gynecology expanded its prenatal screening recommendations to offer all women, regardless of age, the option of screening and diagnosis for genetic conditions, including Down syndrome.\u003c/p>\n\u003cp>One of the consequences is clear. In 2015, Brian Skotko, who co-directs the Down Syndrome Program at Massachusetts General Hospital, published a comprehensive look at Down syndrome live-birth rates in the United States. Between 2006 and 2010, he and his colleagues calculated that 30 percent fewer babies with Down syndrome were born than were expected, due to elective terminations.\u003c/p>\n\u003cp>Decisions about whether to have a baby with Down syndrome tend to vary geographically and by level of education. In the 2015 study, abortions for reasons of Down syndrome were highest in the Northeast and Hawaii and lowest in the South. Asians were the most likely to terminate due to Down syndrome, while Hispanics and American Indians were the least likely.\u003c/p>\n\u003cfigure id=\"attachment_370960\" class=\"wp-caption aligncenter\" style=\"max-width: 507px\">\u003ca href=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2017/04/Down-syndrome.jpg\">\u003cimg class=\"size-full wp-image-370960\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2017/04/Down-syndrome.jpg\" alt=\"\" width=\"507\" height=\"337\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2017/04/Down-syndrome.jpg 507w, https://ww2.kqed.org/app/uploads/sites/13/2017/04/Down-syndrome-160x106.jpg 160w, https://ww2.kqed.org/app/uploads/sites/13/2017/04/Down-syndrome-240x160.jpg 240w, https://ww2.kqed.org/app/uploads/sites/13/2017/04/Down-syndrome-375x249.jpg 375w\" sizes=\"(max-width: 507px) 100vw, 507px\">\u003c/a>\u003cfigcaption class=\"wp-caption-text\">A baby girl with Down Syndrome and her mother. \u003ccite>( JGI/Tom Grill/Getty Images)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>\u003cstrong>The Rise of Noninvasive Prenatal Screening \u003c/strong>\u003c/p>\n\u003cp>Various forms of prenatal testing have been around for decades, but when noninvasive prenatal screening (NIPS) debuted in 2011, its greater accuracy combined with its ease of use contributed to its rapid uptake. In a few short years, NIPS, also called cell-free DNA screening, has become pervasive in the prenatal-testing market. Rather than face off with a long needle or catheter guided through the cervix or abdomen late in the first trimester, or a long needle in the abdomen in the second trimester, a quick venipuncture can collect enough blood midway through the first trimester to gauge whether the fetus’s chromosomes are intact, with high accuracy and no in utero assault. Within a few weeks of a woman learning she’s pregnant, her blood contains fragments of fetal DNA (NIPS actually detects DNA from the placenta, considered a proxy for fetal DNA, that is free-floating in the mom’s bloodstream). The amount of cell- free DNA from the fetus and mother can then be analyzed to predict Down syndrome (and an increasing number of other chromosomal conditions) with up to 99 percent accuracy — though the concept of accuracy itself is nuanced and complex and fluctuates depending on the age of the mother. NIPS, being a blood test, also sidesteps the very small but still scary risk of miscarriage that accompanies CVS (short for \u003ca href=\"https://www.mayoclinic.org/tests-procedures/chorionic-villus-sampling/basics/definition/prc-20013566\" target=\"_blank\" rel=\"noopener\">chorionic villus sampling\u003c/a>) or amnio.\u003c/p>\n\u003caside class=\"pullquote alignright\">The doctor said: 'I get people coming in here who ... want to know this is 100 percent fine. I can't give you 100 percent. I can give you 80 percent. And I said, \"I'm going to take those odds.\"\u003c/aside>\n\u003cp>Initially reserved for women over 35, NIPS has now spread to younger women as well, and has spawned a $500 million industry expected to balloon to $2 billion by 2020. But who gets the testing ranges widely, depending upon who goes to the doctor in the first place. Lower-income women, due to lack of access, don’t seek out prenatal care nearly as regularly as more well-to-do mothers. If they do, they’re often too far along in their pregnancies to get screened. Due to geographic discrepancies in Medicaid coverage, NIPS or other tests may not be covered. ...\u003c/p>\n\u003cp>Despite its high degree of accuracy, NIPS is not perfect. Nor does it equate with a diagnosis. NIPS is a screening test; it can be complicated by a lower-than-expected fraction of fetal DNA and even by an underlying maternal cancer diagnosis. Only CVS or amnio can offer confirmation. But the message is not always getting across to women — or their doctors. Cases have been reported of women coming close to terminating pregnancies they believed were affected based on NIPS results — only to learn that they were not. Experts blame the companies that market the tests for robust advertising that they say misleads patients — and some physicians — into believing that the results are equivalent to a diagnosis. To address misunderstanding, the American Congress of Obstetricians and Gynecologists issued a statement in 2015 stressing that any positive results need to be confirmed via other tests such as amniocentesis. In other words, ACOG emphasizes, a decision to have an abortion should not be based solely on the results of NIPS.\u003c/p>\n\u003cp>Yet there has been little public conversation about widespread prenatal screening and the “consequences of the transformation of every fetus — and not only the precious fetus produced thanks to complex technological interventions — into an ‘at risk’ entity, extensively tested, measured and evaluated by health professionals,” wrote the science historian Ilana Löwy in a paper about prenatal diagnosis.\u003c/p>\n\u003cp>In an op-ed in The New York Times, “\u003ca href=\"https://opinionator.blogs.nytimes.com/2014/06/04/the-t-m-i-pregnancy/?_r=0\" target=\"_blank\" rel=\"noopener\">The T.M.I. Pregnancy,\u003c/a>” Patricia Volk lamented that all the testing surrounding her daughter-in-law’s supposedly “normal” pregnancy had left them both feeling “guardedly happy.” She recounted a series of scary ultrasound findings that turned out to be nothing, and mused: “Prenatal science has helped a lot [of] people and people-to-be. But just because a patient can know something, must she? Odds are in this baby’s favor, yet every sonogram adds something scary to the pot. What is one of the most joyous times of life has turned into something ominous and fraught, loaded with the potential to go wrong.”\u003c/p>\n\u003cp>Yet one person’s anxiety is another’s sigh of relief. The debate over what testing and how much hinges on so many factors. In fact, two letters to the editor in response to “The T.M.I. Pregnancy” highlight why this push-and-pull is one of the great medical and social conundrums of our time. In one, Alastair Pullen describes his experience declining all testing during his wife’s first pregnancy “for all of the reasons this article mentions.” Halfway through the pregnancy, he and his wife agreed to an ultrasound and discovered their daughter had a fatal condition and would not survive long after birth. “Faced with a horrible decision,” Pullen writes, “we decided to induce preterm labor. Becket was stillborn. The only thing worse would have been if we had had no knowledge of her condition.” Pullen had first decided not to test but ended up grateful he changed his mind. He and his wife welcomed testing in later pregnancies; they now have three healthy children, and, he says, “the barrage of testing affirmed our excitement.”\u003c/p>\n\u003cp>Ingrid Chafee, on the other hand, gave birth when no tests were available. She was shocked when she delivered her firstborn in 1965, only to learn he had hydrocephalus and spina bifida. Surgery repaired much of the damage, but her son — who now holds a doctorate from Oxford — still has physical problems. She concludes: “He has said many times that he is glad that there were no ultrasound tests available at the time of his birth. If there had been, he wouldn’t be here. To know or not to know? It’s up to each to decide.”\u003c/p>\n\u003cp>\u003cstrong>Who Is a Gift and Who a Burden?\u003c/strong>\u003c/p>\n\u003cp>The ethics of abortion are set to become much more complicated as more women have access to powerful genetic tests such as microarray, for these tests can identify genetic flaws that are not readily understood.\u003c/p>\n\u003cp>Microarray had confirmed that the almond skinned woman who had the fetal reduction was carrying one twin with Down syndrome. But in the case of more ambiguous genetic errors in a boy named Ryan Docherty, confirmation was the easy part. It was the interpretation — figuring out the significance of the problems that microarray had detected in utero — that proved difficult.\u003c/p>\n\u003cp>When she was pregnant, Ryan’s mom, Jen Sipress, had a microarray test. You’ll recall that chromosomal microarray analysis can detect deletions and duplications of genetic material — errors that are far smaller than an entire extra chromosome. But just because they’re smaller doesn’t mean they can’t wreak havoc. Some are associated with genetic disorders; many more aren’t associated with anything because they’re so newly discovered or because they don’t appear to be detrimental according to the limited amount of research that exists. Sipress, 42, is a New York City narcotics prosecutor; she thrives on evidence. When her test results came back, the evidence was disconcerting: Ryan, still in utero, had not one but two findings — “variants of uncertain significance” — inherited from his mother and his father. Docherty had passed down a duplication involving six genes, while Sipress had contributed a deletion on chromosome 15 involving four genes. In general, deletions are considered more worrisome than duplications; our bodies can often deal with some extra genetic material, but it’s not as easy to compensate for DNA gone AWOL. To make matters worse, one of the four missing genes had been associated in the medical literature with intellectual and developmental delay. Here’s where things got really confusing: Sipress was missing that same gene and she didn’t appear to be affected at all. She worked hard as the family’s primary income earner, putting drug dealers behind bars. She hadn’t even known she was missing any genes until the microarray results came back. But genes—or their absence — can affect people differently; it’s a phenomenon called “variable expressivity.”\u003c/p>\n\u003cp>Before the amniocentesis to collect fetal cells for the microarray analysis, Sipress and Docherty had decided that were they to learn that their unborn child wouldn’t be able to live independently as an adult, they would end the pregnancy. When they got the results, they leaned toward abortion. After talking to their doctor, Ron Wapner, author of a \u003cem>New England Journal of Medicine\u003c/em> study about microarray’s effectiveness, they changed their minds. As Sipress recalls, Wapner said, “‘I get people coming in here who . . . want to know this is 100 percent fine.’ And he said, ‘I can’t give you 100 percent. I can give you 80 percent.’ And I said, ‘I’m going to take those odds.’ ”\u003c/p>\n\u003cp>Emotionally, it was a terrible time for Sipress and Docherty. Ryan was their first child, and he had been conceived after two rounds of IVF. But Sipress doesn’t regret finding out. “I don’t understand why even women in their 20s aren’t undergoing this testing,” she says. “Knowledge is power. Doesn’t everyone realize that?”\u003c/p>\n\u003cp>It’s certainly made for some awkward conversations with her husband’s family in Scotland, who know about the missing genes. “They ask if there is something wrong with the kid, and I say, ‘Technically, yes, but he’s not exhibiting any symptoms,’ ” says Sipress. To that end, Docherty, who stays home with Ryan, is a vigilant observer. “Are we still worried?” says Docherty. “Absolutely.” It’s easy to attribute every behavioral challenge — Ryan’s not a good sleeper, but neither are lots of babies — to the missing genes. Anticipating this, Wapner has cautioned them against engaging in this sort of genetic determinism. “He said, ‘Go about your business. If you feel something is really wrong, then you act.’ To be honest,” says Docherty, “Ryan doesn’t have a problem, as far as I can see.”\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>To what end are we willing to go to detect disability? Once we find it, is there a dividing line between “good,” or tolerable, disabilities and “bad,” or intolerable, limitations? How do we decide which ones may warrant abortion and which are acceptable? What feels overwhelming to one person— the birth of a child with a genetic disorder— may feel like God’s gift to another. Who are we to judge what — who, more accurately—is a gift and who is a burden?\u003c/p>\n\n","blocks":[],"excerpt":"Advanced prenatal genetic testing transforms every fetus into an 'at risk' entity. And we should be talking about that, says author Bonnie Rochman in 'The Gene Machine.'","status":"publish","parent":0,"modified":1514584359,"stats":{"hasAudio":false,"hasVideo":false,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":36,"wordCount":3388},"headData":{"title":"Advanced Prenatal Testing Means More Gut-Wrenching Decisions Over Abortion | KQED","description":"Advanced prenatal genetic testing transforms every fetus into an 'at risk' entity. And we should be talking about that, says author Bonnie Rochman in 'The Gene Machine.'","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"Advanced Prenatal Testing Means More Gut-Wrenching Decisions Over Abortion","datePublished":"2017-11-06T19:13:39.000Z","dateModified":"2017-12-29T21:52:39.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"435960 https://ww2.kqed.org/futureofyou/?p=435960","disqusUrl":"https://ww2.kqed.org/futureofyou/2017/11/06/advanced-prenatal-testing-will-mean-more-gut-wrenching-decisions-about-abortion/","disqusTitle":"Advanced Prenatal Testing Means More Gut-Wrenching Decisions Over Abortion","nprByline":"Bonnie Rochman","path":"/futureofyou/435960/advanced-prenatal-testing-will-mean-more-gut-wrenching-decisions-about-abortion","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>\u003cem>Excerpts from \"The Other Scarlet 'A': Abortion's Relationship to Genetic Testing\" from THE GENE MACHINE by Bonnie Rochman. Copyright © 2017 by Bonnie Rochman. Used by permission of \u003ca href=\"https://us.macmillan.com/fsg\" target=\"_blank\" rel=\"noopener\">Farrar, Straus and Giroux\u003c/a>.\u003c/em>\u003c/p>\n\u003cp>When the second purple line appeared on the white plastic wand on a March morning in 2002, I knew next to nothing about pregnancy and even less about raising a child. It was years before I’d go on to cover parenting and pediatrics, and write about sequencing children’s genomes. Yet from the first days of that pregnancy, I was already enmeshed in the most cutting-edge technologies of the time, thanks to my friend Tali, whose son was due a week after mine.\u003c/p>\n\u003caside class=\"pullquote alignright\">How people feel about disability and how that impacts their decisions around abortion are the real topics in any discussion about advanced prenatal testing.\u003c/aside>\n\u003cp>Tali had recently moved to my home state of North Carolina from Israel, where nuchal translucency testing was standard. I had no idea what it was, but I figured it was important, judging by her level of outrage that this test to gauge Down syndrome risk — combination of an ultrasound to measure the collection of fluid under the skin on the back of a fetus’s neck, and a blood draw — wasn’t commonly available in the United States. Within days, she told me that she’d found a doctor who was getting certified to perform the testing. He needed subjects. Tali and I volunteered.\u003c/p>\n\u003cp>I had signed up blithely, without seriously considering what I’d do if the test result came back positive. I expected good news — and, fortunately, I got it. Now, more than a decade later, nuchal translucency is old hat. Other, more sophisticated tests have begun to usurp what was lauded as the latest in prenatal technology in the early aughts.\u003c/p>\n\u003cp>Nuchal translucency offered both Tali and me reassurance. But the various permutations of prenatal screening and testing do not always provide comfort. I am witness to that in the heart of midtown Manhattan, not far from Radio City Music Hall, in a clinic where a woman and her husband have just made a life-altering decision. The woman is 40 years old, with high cheekbones and skin the color of toasted almonds. She is 12-and-a-half weeks pregnant with one baby, but minutes earlier, before she sat down with me in an empty exam room, she was pregnant with two.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>\u003c/p>\u003cp>\u003c/p>\u003cp>Her journey to motherhood had not been easy. The twins had been conceived via in vitro fertilization after the woman and her partner had spent more than a year trying to get pregnant the old-fashioned way. A week before, she had had a microarray analysis that peered deeply into the genetic makeup of her twins.\u003c/p>\n\u003cp>Microarray analyzes fetal cells for countless less apparent disorders that occur when a tiny snippet of DNA has been added somewhere it’s not supposed to be or deleted entirely, revealing genetic hiccups that previously could not be detected prenatally. Some of these changes are meaningless; others may be associated with autism or rare disorders such as DiGeorge syndrome, which is characterized by heart problems and a roughly 25 percent risk of developing schizophrenia.\u003c/p>\n\u003cp>As the woman explained, “We made use of technology throughout this process, so it would be a shame not to take advantage of this [test]. I wanted to make sure that, given my age, there was nothing wrong.”\u003c/p>\n\u003cp>She knew that the microarray would reveal all sorts of genetic blips, DNA duplications and deletions too tiny to be seen under a microscope, some of which are associated with worrisome conditions and others of which aren’t understood. The test would also detect major chromosomal problems, of which Down syndrome is the most common.\u003c/p>\n\u003caside class=\"pullquote alignright\">'Just because a patient can know something, must she? What is one of the most joyous times of life has turned into something ominous and fraught, loaded with the potential to go wrong.'\u003c/aside>\n\u003cp>Even at age 40, just 1 of 100 pregnancies results in Down syndrome. And yet the couple beat those odds: one of the twins was confirmed to have the extra 21st chromosome that causes the condition.\u003c/p>\n\u003cp>“You don’t think it’s going to happen to you and then here it is. I still can’t get over the fact. Today we reduced the baby with Down syndrome,” the woman tells me, using a common euphemism for terminating one or more fetuses in cases where a woman is carrying more than she intends to deliver. Many doctors call this “fetal reduction.” She reflects on her decision, made possible by these new tests, as she lowers herself onto an exam table to rest. “I look at this as a sign from God. My mother believes in karma. I think this baby was only meant to be for twelve weeks and his suffering was shortened,” she says. She raises herself up on her elbows and looks at her husband. “Then I feel like, ‘Oh my god, I just killed a baby.’ ”\u003c/p>\n\u003cp>Considering that women have been getting pregnant for a very long time, prenatal diagnosis — the ability to peer inside the womb and emerge with a snapshot of fetal health — is a fairly recent development, a convergence of medical technologies such as amniocentesis and ultrasound with emerging insights about genes and chromosomes. But it’s the legalization of abortion in 1973 that really served as a catalyst for change. After all, without the ability to choose whether or not to continue a pregnancy, knowledge gleaned from prenatal diagnosis would have remained largely theoretical. With the decriminalization of abortion, what to do became a choice.\u003c/p>\n\u003cp>While there are women who’d never opt for an abortion, it’s disingenuous to ignore the fact that terminating a pregnancy is one possible outcome of earlier, more sophisticated genetic tests. The issue of how people feel about disability and, in turn, how that impacts their decisions regarding abortion is an essential aspect of any discussion about advances in prenatal testing.\u003c/p>\n\u003caside class=\"pullquote alignright\">'I don't understand why even women in their twenties aren't undergoing this testing. Knowledge is power.'\u003c/aside>\n\u003cp>Yet abortion remains the elephant in the room when it comes to prenatal testing. When I discuss my work with colleagues and friends interested in the subject, some say, “ You’re not going to mention abortion, are you? My gut tells me that I think you’re walking into a minefield if that becomes a major part of the book.” Others say, “Abortion should definitely be a chapter. How could it not be?”\u003c/p>\n\u003cp>Much of the prenatal testing conversation centers on Down syndrome because the condition is so well- known, unlike others that affect far fewer people. One of every 792 babies born in the United States has Down syndrome. Compared to many other chromosomal conditions, however, Down syndrome is considered a relatively mild genetic complex. Chromosome 21 is the smallest chromosome, so the extra genetic material that accompanies a third copy is not as massive or overwhelming as it would be had it occurred on another, larger chromosome. The genetic disorder that results from a triplication of any chromosome is called a trisomy. A trisomy 22 baby, for example, probably would not make it to birth.\u003c/p>\n\u003cp>Starting in the 1970s, various epidemiologists began making the case that standardizing testing for Down syndrome was a public health priority. Since then, screening for Down syndrome has become broadly accepted by the medical community and, in turn, by many pregnant women and their partners. In 2007, the American College of Obstetrics and Gynecology expanded its prenatal screening recommendations to offer all women, regardless of age, the option of screening and diagnosis for genetic conditions, including Down syndrome.\u003c/p>\n\u003cp>One of the consequences is clear. In 2015, Brian Skotko, who co-directs the Down Syndrome Program at Massachusetts General Hospital, published a comprehensive look at Down syndrome live-birth rates in the United States. Between 2006 and 2010, he and his colleagues calculated that 30 percent fewer babies with Down syndrome were born than were expected, due to elective terminations.\u003c/p>\n\u003cp>Decisions about whether to have a baby with Down syndrome tend to vary geographically and by level of education. In the 2015 study, abortions for reasons of Down syndrome were highest in the Northeast and Hawaii and lowest in the South. Asians were the most likely to terminate due to Down syndrome, while Hispanics and American Indians were the least likely.\u003c/p>\n\u003cfigure id=\"attachment_370960\" class=\"wp-caption aligncenter\" style=\"max-width: 507px\">\u003ca href=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2017/04/Down-syndrome.jpg\">\u003cimg class=\"size-full wp-image-370960\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2017/04/Down-syndrome.jpg\" alt=\"\" width=\"507\" height=\"337\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2017/04/Down-syndrome.jpg 507w, https://ww2.kqed.org/app/uploads/sites/13/2017/04/Down-syndrome-160x106.jpg 160w, https://ww2.kqed.org/app/uploads/sites/13/2017/04/Down-syndrome-240x160.jpg 240w, https://ww2.kqed.org/app/uploads/sites/13/2017/04/Down-syndrome-375x249.jpg 375w\" sizes=\"(max-width: 507px) 100vw, 507px\">\u003c/a>\u003cfigcaption class=\"wp-caption-text\">A baby girl with Down Syndrome and her mother. \u003ccite>( JGI/Tom Grill/Getty Images)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>\u003cstrong>The Rise of Noninvasive Prenatal Screening \u003c/strong>\u003c/p>\n\u003cp>Various forms of prenatal testing have been around for decades, but when noninvasive prenatal screening (NIPS) debuted in 2011, its greater accuracy combined with its ease of use contributed to its rapid uptake. In a few short years, NIPS, also called cell-free DNA screening, has become pervasive in the prenatal-testing market. Rather than face off with a long needle or catheter guided through the cervix or abdomen late in the first trimester, or a long needle in the abdomen in the second trimester, a quick venipuncture can collect enough blood midway through the first trimester to gauge whether the fetus’s chromosomes are intact, with high accuracy and no in utero assault. Within a few weeks of a woman learning she’s pregnant, her blood contains fragments of fetal DNA (NIPS actually detects DNA from the placenta, considered a proxy for fetal DNA, that is free-floating in the mom’s bloodstream). The amount of cell- free DNA from the fetus and mother can then be analyzed to predict Down syndrome (and an increasing number of other chromosomal conditions) with up to 99 percent accuracy — though the concept of accuracy itself is nuanced and complex and fluctuates depending on the age of the mother. NIPS, being a blood test, also sidesteps the very small but still scary risk of miscarriage that accompanies CVS (short for \u003ca href=\"https://www.mayoclinic.org/tests-procedures/chorionic-villus-sampling/basics/definition/prc-20013566\" target=\"_blank\" rel=\"noopener\">chorionic villus sampling\u003c/a>) or amnio.\u003c/p>\n\u003caside class=\"pullquote alignright\">The doctor said: 'I get people coming in here who ... want to know this is 100 percent fine. I can't give you 100 percent. I can give you 80 percent. And I said, \"I'm going to take those odds.\"\u003c/aside>\n\u003cp>Initially reserved for women over 35, NIPS has now spread to younger women as well, and has spawned a $500 million industry expected to balloon to $2 billion by 2020. But who gets the testing ranges widely, depending upon who goes to the doctor in the first place. Lower-income women, due to lack of access, don’t seek out prenatal care nearly as regularly as more well-to-do mothers. If they do, they’re often too far along in their pregnancies to get screened. Due to geographic discrepancies in Medicaid coverage, NIPS or other tests may not be covered. ...\u003c/p>\n\u003cp>Despite its high degree of accuracy, NIPS is not perfect. Nor does it equate with a diagnosis. NIPS is a screening test; it can be complicated by a lower-than-expected fraction of fetal DNA and even by an underlying maternal cancer diagnosis. Only CVS or amnio can offer confirmation. But the message is not always getting across to women — or their doctors. Cases have been reported of women coming close to terminating pregnancies they believed were affected based on NIPS results — only to learn that they were not. Experts blame the companies that market the tests for robust advertising that they say misleads patients — and some physicians — into believing that the results are equivalent to a diagnosis. To address misunderstanding, the American Congress of Obstetricians and Gynecologists issued a statement in 2015 stressing that any positive results need to be confirmed via other tests such as amniocentesis. In other words, ACOG emphasizes, a decision to have an abortion should not be based solely on the results of NIPS.\u003c/p>\n\u003cp>Yet there has been little public conversation about widespread prenatal screening and the “consequences of the transformation of every fetus — and not only the precious fetus produced thanks to complex technological interventions — into an ‘at risk’ entity, extensively tested, measured and evaluated by health professionals,” wrote the science historian Ilana Löwy in a paper about prenatal diagnosis.\u003c/p>\n\u003cp>In an op-ed in The New York Times, “\u003ca href=\"https://opinionator.blogs.nytimes.com/2014/06/04/the-t-m-i-pregnancy/?_r=0\" target=\"_blank\" rel=\"noopener\">The T.M.I. Pregnancy,\u003c/a>” Patricia Volk lamented that all the testing surrounding her daughter-in-law’s supposedly “normal” pregnancy had left them both feeling “guardedly happy.” She recounted a series of scary ultrasound findings that turned out to be nothing, and mused: “Prenatal science has helped a lot [of] people and people-to-be. But just because a patient can know something, must she? Odds are in this baby’s favor, yet every sonogram adds something scary to the pot. What is one of the most joyous times of life has turned into something ominous and fraught, loaded with the potential to go wrong.”\u003c/p>\n\u003cp>Yet one person’s anxiety is another’s sigh of relief. The debate over what testing and how much hinges on so many factors. In fact, two letters to the editor in response to “The T.M.I. Pregnancy” highlight why this push-and-pull is one of the great medical and social conundrums of our time. In one, Alastair Pullen describes his experience declining all testing during his wife’s first pregnancy “for all of the reasons this article mentions.” Halfway through the pregnancy, he and his wife agreed to an ultrasound and discovered their daughter had a fatal condition and would not survive long after birth. “Faced with a horrible decision,” Pullen writes, “we decided to induce preterm labor. Becket was stillborn. The only thing worse would have been if we had had no knowledge of her condition.” Pullen had first decided not to test but ended up grateful he changed his mind. He and his wife welcomed testing in later pregnancies; they now have three healthy children, and, he says, “the barrage of testing affirmed our excitement.”\u003c/p>\n\u003cp>Ingrid Chafee, on the other hand, gave birth when no tests were available. She was shocked when she delivered her firstborn in 1965, only to learn he had hydrocephalus and spina bifida. Surgery repaired much of the damage, but her son — who now holds a doctorate from Oxford — still has physical problems. She concludes: “He has said many times that he is glad that there were no ultrasound tests available at the time of his birth. If there had been, he wouldn’t be here. To know or not to know? It’s up to each to decide.”\u003c/p>\n\u003cp>\u003cstrong>Who Is a Gift and Who a Burden?\u003c/strong>\u003c/p>\n\u003cp>The ethics of abortion are set to become much more complicated as more women have access to powerful genetic tests such as microarray, for these tests can identify genetic flaws that are not readily understood.\u003c/p>\n\u003cp>Microarray had confirmed that the almond skinned woman who had the fetal reduction was carrying one twin with Down syndrome. But in the case of more ambiguous genetic errors in a boy named Ryan Docherty, confirmation was the easy part. It was the interpretation — figuring out the significance of the problems that microarray had detected in utero — that proved difficult.\u003c/p>\n\u003cp>When she was pregnant, Ryan’s mom, Jen Sipress, had a microarray test. You’ll recall that chromosomal microarray analysis can detect deletions and duplications of genetic material — errors that are far smaller than an entire extra chromosome. But just because they’re smaller doesn’t mean they can’t wreak havoc. Some are associated with genetic disorders; many more aren’t associated with anything because they’re so newly discovered or because they don’t appear to be detrimental according to the limited amount of research that exists. Sipress, 42, is a New York City narcotics prosecutor; she thrives on evidence. When her test results came back, the evidence was disconcerting: Ryan, still in utero, had not one but two findings — “variants of uncertain significance” — inherited from his mother and his father. Docherty had passed down a duplication involving six genes, while Sipress had contributed a deletion on chromosome 15 involving four genes. In general, deletions are considered more worrisome than duplications; our bodies can often deal with some extra genetic material, but it’s not as easy to compensate for DNA gone AWOL. To make matters worse, one of the four missing genes had been associated in the medical literature with intellectual and developmental delay. Here’s where things got really confusing: Sipress was missing that same gene and she didn’t appear to be affected at all. She worked hard as the family’s primary income earner, putting drug dealers behind bars. She hadn’t even known she was missing any genes until the microarray results came back. But genes—or their absence — can affect people differently; it’s a phenomenon called “variable expressivity.”\u003c/p>\n\u003cp>Before the amniocentesis to collect fetal cells for the microarray analysis, Sipress and Docherty had decided that were they to learn that their unborn child wouldn’t be able to live independently as an adult, they would end the pregnancy. When they got the results, they leaned toward abortion. After talking to their doctor, Ron Wapner, author of a \u003cem>New England Journal of Medicine\u003c/em> study about microarray’s effectiveness, they changed their minds. As Sipress recalls, Wapner said, “‘I get people coming in here who . . . want to know this is 100 percent fine.’ And he said, ‘I can’t give you 100 percent. I can give you 80 percent.’ And I said, ‘I’m going to take those odds.’ ”\u003c/p>\n\u003cp>Emotionally, it was a terrible time for Sipress and Docherty. Ryan was their first child, and he had been conceived after two rounds of IVF. But Sipress doesn’t regret finding out. “I don’t understand why even women in their 20s aren’t undergoing this testing,” she says. “Knowledge is power. Doesn’t everyone realize that?”\u003c/p>\n\u003cp>It’s certainly made for some awkward conversations with her husband’s family in Scotland, who know about the missing genes. “They ask if there is something wrong with the kid, and I say, ‘Technically, yes, but he’s not exhibiting any symptoms,’ ” says Sipress. To that end, Docherty, who stays home with Ryan, is a vigilant observer. “Are we still worried?” says Docherty. “Absolutely.” It’s easy to attribute every behavioral challenge — Ryan’s not a good sleeper, but neither are lots of babies — to the missing genes. Anticipating this, Wapner has cautioned them against engaging in this sort of genetic determinism. “He said, ‘Go about your business. If you feel something is really wrong, then you act.’ To be honest,” says Docherty, “Ryan doesn’t have a problem, as far as I can see.”\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"floatright"},"numeric":["floatright"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>To what end are we willing to go to detect disability? Once we find it, is there a dividing line between “good,” or tolerable, disabilities and “bad,” or intolerable, limitations? How do we decide which ones may warrant abortion and which are acceptable? What feels overwhelming to one person— the birth of a child with a genetic disorder— may feel like God’s gift to another. Who are we to judge what — who, more accurately—is a gift and who is a burden?\u003c/p>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/435960/advanced-prenatal-testing-will-mean-more-gut-wrenching-decisions-about-abortion","authors":["byline_futureofyou_435960"],"categories":["futureofyou_452","futureofyou_1","futureofyou_1064"],"tags":["futureofyou_342","futureofyou_1439","futureofyou_587","futureofyou_1275","futureofyou_1015","futureofyou_120","futureofyou_80","futureofyou_1386","futureofyou_1388","futureofyou_520","futureofyou_1389"],"featImg":"futureofyou_436849","label":"futureofyou"},"futureofyou_387142":{"type":"posts","id":"futureofyou_387142","meta":{"index":"posts_1591205157","site":"futureofyou","id":"387142","score":null,"sort":[1494604808000]},"guestAuthors":[],"slug":"how-the-media-came-to-embrace-clickbait-an-internet-history","title":"How the Media Came to Embrace Clickbait: An Internet History","publishDate":1494604808,"format":"standard","headTitle":"KQED Future of You | KQED Science","labelTerm":{},"content":"\u003cp>\u003cem>From the book \u003ca href=\"http://www.penguinrandomhouse.com/books/234876/the-attention-merchants-by-tim-wu/9780385352017/\" target=\"_blank\" rel=\"noopener noreferrer\">THE ATTENTION MERCHANTS,\u003c/a> by Tim Wu. Copyright © 2016 by Tim Wu. Published by arrangement with Alfred A. Knopf, an imprint of The Knopf Doubleday Publishing Group, a division of Penguin Random House LLC.\u003c/em>\u003c/p>\n\u003cp>\u003cspan style=\"font-size: 4.6875em;float: left;line-height: 0.733em;padding: 0.05em 0.1em 0 0;font-family: times, serif, georgia\">B\u003c/span>ack in 2001, at MIT’s media laboratory in Cambridge, Massachusetts, a former schoolteacher named Jonah Peretti was sitting at his desk and, like so many graduate students, not doing his work. Peretti was meant to be plugging away at his master’s thesis; instead he was playing around with what was already the greatest procrastination aide ever devised, the World Wide Web.\u003c/p>\n\u003caside class=\"pullquote alignright\">One man's Internet pranking evolved to influence the entire online news ecosystem.\u003c/aside>\n\u003cp>Born in California to a Jewish mother and Italian-American father, Peretti was a pretty ordinary and sober-looking young guy. But there was always a slight smile on his lips, a clue to the inveterate prankster beneath the facade of the typical grad student. In fact, he was fascinated by the line between the serious and the absurd, which in his mind also often delineated art from commerce, if not always respectively. Most of his ventures, even those that would prove important, seem to have been conceived as a kind of inside joke, and a test of the limits of possibility.\u003c/p>\n\u003cp>While goofing off—“surfing the web” in the vernacular of the time— Peretti went to Nike’s website and noticed a feature allowing customers to order shoes personalized with any word they might like. On a whim, he placed an order for Nike Zoom XC USA running shoes with the fol- lowing embroidered on them:\u003c/p>\n\u003cblockquote>\u003cp>SWEATSHOP\u003c/p>\u003c/blockquote>\n\u003cp>He thought nothing more of it until the next day, when he received the following email:\u003c/p>\n\u003cblockquote>\u003cp>From: Personalize, NIKE iD To: Jonah H. Peretti\u003c/p>\n\u003cp>Subject: RE: Your NIKE iD order o16468000\u003c/p>\n\u003cp>Your NIKE iD order was cancelled for one or more of the following reasons.\u003c/p>\n\u003cp>1) Your Personal iD contains another party’s trademark or other intellectual property.\u003c/p>\n\u003cp>2) Your Personal iD contains the name of an athlete or team we do not have the legal right to use.\u003c/p>\n\u003cp>3) Your Personal iD was left blank. Did you not want any personalization?\u003c/p>\n\u003cp>4) Your Personal iD contains profanity or inappropriate If you wish to reorder your NIKE iD product with a new personaliza- tion please visit us again at \u003ca href=\"http://www.nike.com/\">www.nike.com\u003c/a>.\u003c/p>\n\u003cp>Thank you, NIKE iD\u003c/p>\u003c/blockquote>\n\u003cp>Seeing comic potential, Peretti wrote back asking just which rule he had broken. A Nike customer service representative replied: “Your NIKE iD order was cancelled because the iD you have chosen contains, as stated in the previous e-mail correspondence, ‘inappropriate slang.’ ”\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>Peretti, just warming up, wrote back:\u003c/p>\n\u003cblockquote>\u003cp>Dear NIKE iD,\u003c/p>\n\u003cp>Thank you for your quick response to my inquiry about my custom ZOOM XC USA running shoes. Although I commend you for your prompt customer service, I disagree with the claim that my personal iD was inappropriate slang. After consulting Webster’s Dictionary, I discovered that “sweatshop” is in fact part of standard English, and not slang. The word means: “a shop or factory in which workers are employed for long hours at low wages and under unhealthy conditions” and its origin dates from 1892. So my personal iD does meet the criteria detailed in your first email. Your web site advertises that the NIKE iD program is “about freedom to choose and freedom to express who you are.” I share Nike’s love of freedom and personal expression. The site also says that “If you want it done right . . . build it yourself.” I was thrilled to be able to build my own shoes, and my personal iD was offered as a small token of appreciation for the sweatshop workers poised to help me realize my vision. I hope that you will value my freedom of expression and reconsider your decision to reject my order.\u003c/p>\n\u003cp>Thank you, Jonah Peretti\u003c/p>\u003c/blockquote>\n\u003cp>In response, Nike simply canceled the order. Peretti wrote one last one email:\u003c/p>\n\u003cblockquote>\u003cp>From: Jonah H. Peretti\u003cbr>\nTo: Personalize, NIKE iD\u003cbr>\nSubject: RE: Your NIKE iD order o16468000\u003c/p>\n\u003cp>Dear NIKE iD,\u003c/p>\n\u003cp>Thank you for the time and energy you have spent on my request. I have decided to order the shoes with a different iD, but I would like to make one small request. Could you please send me a color snapshot of the ten-year-old Vietnamese girl who makes my shoes?\u003c/p>\n\u003cp>Thanks, Jonah Peretti\u003c/p>\u003c/blockquote>\n\u003cp>Amused, Peretti sent a copy of the email chain to 12 or so friends, including one who posted it on his personal website. Within a week, Peretti’s exchange had been shared by people far and wide; first thousands and within a few weeks, millions. Along the way, it was picked up by mainstream media outlets around the world. To use a phrase that did not exist in 2001, the email “went viral.”\u003c/p>\n\u003caside class=\"pullquote alignright\">Jonah Peretti had more or less made himself the world’s expert on contagious media, but the recognition of peers was not enough; the measure of his success would be the ability to generate traffic.\u003c/aside>\n\u003cp>“So then I found myself on the 'Today' show talking with Katie Couric about sweatshop labor,” says Peretti. “It was, like, what do I know about sweatshops?” Here was that mind-warping rush of unexpected renown, of reaching an audience way beyond your wildest expectations. Peretti would later remember it simply: “Something very small became something very big.” Unbeknownst to him at the time, the experience would end up changing his career and his life.\u003c/p>\n\u003cp>Popular email chains have been around nearly as long as email itself, but back in 2001 words like “viral,” “Internet meme,” and “clickbait” were as yet unknown. What Peretti naively experienced was an early version of what would become a pervasive means of harvesting attention in the early 21st century. Peretti, who has a curious, scientific mind, started to consider the phenomenon carefully and systematically. “I looked at stories like the Nike shoe story, and there were actually plenty of other ones. Someone did something, it went big for a while, but then that’s where the story ends.” Having done it once, by accident, he wanted to see if he could make it happen at will. He wanted to see if he could understand what it took to make something “go viral.” For he realized that his weird experience had a deeper significance; it marked a change, made possible by the Internet, in how attention might be cap- tured, and from whom.\u003c/p>\n\u003cp>\u003cimg class=\"aligncenter size-large wp-image-387679\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2017/05/ClickbaitWu-1020x670.jpg\" alt=\"\" width=\"640\" height=\"420\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-1020x670.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-160x105.jpg 160w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-800x525.jpg 800w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-768x504.jpg 768w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-1180x775.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-960x631.jpg 960w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-240x158.jpg 240w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-375x246.jpg 375w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-520x342.jpg 520w\" sizes=\"(max-width: 640px) 100vw, 640px\">\u003c/p>\n\u003cp>\u003cstrong>A Media Contagion Posse\u003c/strong>\u003c/p>\n\u003cp>A few months later, Peretti left MIT to take a job at the Eyebeam art and technology center, a giant space in New York’s West Chelsea neighbor- hood; from the outside it looked like many of the art galleries that sur- rounded it. Here, in his “contagious media laboratory,” he tried to figure out if he could make lightning in a bottle.\u003c/p>\n\u003cp>[contextly_sidebar id=\"Ox3t7sYxxahQwCSVeFRZ4COo0P0an8ZP\"]Peretti started throwing stuff against the web to see if anything might stick. It turned out he was not alone; there were others who shared his fascination with creating zany stuff that might, almost magically, erupt across the Internet. He got to know a man who called himself “Ze Frank,” a sort of self-styled web-jester. Ze Frank’s own road to Damas- cus had involved a web-based birthday invitation in which he was featured, performing funny dance moves; it had earned millions of hits and won him a Webby Award. Peretti also met Cory Arcangel, a conceptual artist who, among other things, had made art that required him to hack Nintendo’s Super Mario Brothers. Then there was a social scientist, Duncan Watts, who tried to understand media contagion with mathematical models. In these guys, Peretti found a posse.\u003c/p>\n\u003cp>His sister, Chelsea Peretti, also got in on the act. Together, they launched www.blackpeopleloveus.com, a fake website featuring a white couple inordinately proud of having made black friends; it attracted 600,000 hits. There was also the “Rejection Line,” a service for those who found it too inconvenient to reject people themselves. As the site said:\u003c/p>\n\u003cblockquote>\u003cp>Someone won’t leave you alone?\u003cbr>\nGive them “your” number: 212-479-7990 The official New York Rejection Line! (operators are standing by!)\u003c/p>\u003c/blockquote>\n\u003cp>It was as if stories from \u003cem>The\u003c/em> \u003cem>Onion\u003c/em> had actually been put into production.\u003c/p>\n\u003cp>Peretti and his pals definitely had some fun at Eyebeam. They held how- to workshops for the public with titles like “The Mass Hoax.” In 2005 they hosted something called the “Contagious Media Showdown,” giv- ing contestants three weeks to get as much traffic as they could. Entries included “hire-a-killer.com,” “Crying While Eating,” “email god,” and “change your race”; the winner (possibly as a result of cheating) was “Forget-me-not-panties.com,” a prank site purporting to sell women’s underwear that broadcasts the wearer’s location to possessive fathers and husbands. “Unlike the cumbersome and uncomfortable chastity belts of the past, these panties are 100% cotton, and use cutting-edge technology to help you protect what matters most.” The site suckered both bloggers and mainstream press, remaining operational for quite some time, albeit with a notice that stock was currently sold out.\u003c/p>\n\u003cp>Peretti may not have been able to create anything while at Eyebeam on the scale of his Nike experience, but he would author a 23-point manifesto that he called “Notes on Contagious Media,” expound- ing just what distinguished that variety from others. Some of it was obvious: “Contagious media is the kind of media you immediately want to share with all your friends. This requires that you take pleasure in consuming the media but also pleasure in the social process of passing it on.” Some more theoretical: “Contagious media is a form of pop conceptual art” in which “the idea is the machine that makes the art (LeWitt, 1967) and the idea is interesting to ordinary people.” For that reason, “a contagious media project should represent the simplest form of an idea. Fancy design or extraneous content made media less contagious. Anything inessential constituted a ‘payload’ that the contagion must drag along as it spreads. The bigger the payload, the more slowly the entire project spreads.” Peretti had more or less made himself the world’s expert on contagious media, but the recognition of peers was not enough; the measure of his success would be the ability to generate traffic. “For the artist, a work can be celebrated even if the only people who like it are a small group of curators and collectors,” he wrote. “For the contagious media designer, all that matters is how other people see the work. If people don’t share the work with their friends, it is a failure regardless of the opinion of the creator, critics, or other elites.”\u003c/p>\n\u003cp>\u003cstrong>The Birth of HuffPo\u003c/strong>\u003c/p>\n\u003cp>In 2004, Peretti was still puttering around at Eyebeam, teaching and throwing stuff on the web, when he was approached by Ken Lerer, a for- mer communications executive at AOL and a committed political activ- ist. A journalist by training and adept at raising money, Lerer presented what he considered an urgent project. Despite every kind of blunder in office, President George W. Bush seemed likely to be re-elected. This was incomprehensible to Lerer and other Democrats, who considered Bush an obvious incompetent; in their view, the internet was in part to blame. The right-wing blogs—above all, the \u003cem>Drudge Report, \u003c/em>the most widely read aggregator of news links—just captured more attention than all the left-wing ones. “You know the Internet, let’s build something,” Lerer cajoled Peretti, who would later explain, “I’m the son of a public defender and a public school teacher” and “it seemed pretty important.”\u003c/p>\n\u003caside class=\"pullquote alignright\">Doing funny GIF posts about cats and hangovers is one thing, but reducing a highly complex political crisis into 2-second moving screen shots of a children’s dinosaur movie is something completely different.\u003c/aside>\n\u003cp>“Something” was at first quite vague. As it evolved, the idea seemed to be this: leverage the left’s superior hold on Hollywood celebrities, as well as Peretti’s knack for driving traffic and Lerer’s touch for fundraising, to create a counterweight to conservative online media. The celebrity part, they decided, was best handled by the third partner, and by far the best connected, Arianna Huffington.\u003c/p>\n\u003cp>On May 10, 2005, just two days after the contagious media contest, the Huffington Post, an online aggregator of news, blogs, and other content, debuted to widespread mainstream coverage. The first issue featured blog posts by Huffington herself and, as planned, various famous people: the renowned historian and Kennedy confidant Arthur M. Schlesinger Jr.; the actor John Cusack; Larry David, producer of \"Seinfeld\"\u003cem>;\u003c/em> the husband- and-wife acting pair Julia Louis-Dreyfus (also of \"Seinfeld\") and Brad Hall, jointly posting on the issue of gun violence.\u003c/p>\n\u003cp>Some credited the idea, but in media it’s not the thought that counts; critics were harsher and louder. And no one came in for more abuse than the partner who’d lent her name. “Celebs to the Slaughter,” wrote LA Weekly: “Judging from Monday’s horrific debut of the humongously pre-hyped celebrity blog the Huffington Post\u003cem>, \u003c/em>the Madonna of the mediapolitic world has undergone one reinvention too many. She has now made an online ass of herself. . . . Her blog is such a bomb that it’s the movie equivalent of \"Gigli\u003cem>,\"\u003c/em> \"Ishtar\" and \"Heaven’s Gate\" rolled into one.”\u003c/p>\n\u003cp>In retrospect, critics like the LA Weekly’s were only proving how little they understood the Internet. Peretti, Lerer, and Huffington were each masters of attention capture, and their collaboration proved more than the sum of its parts. Over time, the political mission was dialed back somewhat—Huffington herself had, after all, previously been a conservative pundit who’d called for the resignation of President Clinton. Soon the Huffington Post was inviting not just celebrities to contribute but students, politicos, activists, book authors—just about anyone except the professional reporter or normal freelancer who expected to be paid. It was a degree of openness more akin to the early days of the web and blogosphere than any older model of media. Minimal costs, maximum traffic, and irresistible content above all—that was the formula.\u003c/p>\n\u003cp>In pursuit of the third element of its triad, the HuffP\u003cem>o\u003c/em> pioneered what would become known as clickbait: sensationally headlined articles, paired with provocative pictures—a bikini-clad celebrity was always good. (“Watch Naked Heidi Klum in Seal’s New Video”). When properly calibrated, such content seemed to take control of the mind, causing the hand almost involuntarily to click on whatever was there. The HuffPo’s “news” was more provocative, more enticing—more clickable— than its competitors’; even for serious topics it managed to channel lurid fascination. To the chagrin of its critics, it quickly outpaced sites like LA Weekly and by the fall of 2007 was capturing more attention than other web magazines like Slate and Salon\u003cem>,\u003c/em> despite their paid writers. By 2010 it was beating most of the newspapers as well. With 24 million monthly readers, it was slightly behind The New York Times\u003cem>,\u003c/em> but ahead of The Washington Post, the Los Angeles Times\u003cem>,\u003c/em> and the rest of what was then called the mainstream media. As the Columbia Journalism Review put it, “The Huffington Post has mastered and fine-tuned not just aggregation, but also social media, comments from readers, and most of all, a sense of what its public wants.”\u003c/p>\n\u003cp>\u003cstrong>Clicks Not Bucks\u003c/strong>\u003c/p>\n\u003cp>And yet the Huffington Post never actually made much money. While its financials have never been fully public, there is good reason to believe it has never turned a solid profit. For one thing, advertisers categorized the Huffington Post as political commentary, and generally, the big-brand advertisers, the Fortune 500, despite the numbers weren’t willing to put their names on HuffPo’s pages. Others tended to credit Google for its traffic. All of this combined to make the site able to sell its impressions for only the lowest rates to bottom-tier advertisers (e.g., “This weird trick can take an inch off your waistline”). The Huffington Post wasn’t making money, but it was nonetheless sucking attention from everything else— especially journalists—on the web. That’s probably why The Washington Post’s executive editor slammed it and similar sites as “parasites living off journalism produced by others.”\u003c/p>\n\u003caside class=\"alignright\">'Here was BuzzFeed, at its height in the 2010s ... ''\n\u003cul>\n\u003cli>'Which Ousted Arab Spring Ruler Are You?'\u003c/li>\n\u003cli>'You Might Be Cleaning Your Penis Wrong'\u003c/li>\n\u003cli>'37 Things Conservatives Would Rather Do Than Watch Obama’s State of the Union Speech'\u003c/li>\n\u003cli>'29 Cats Who Failed So Hard They Won'\u003c/li>\n\u003c/ul>\n\u003c/aside>\n\u003cp>The Huffington Post wasn’t alone. Over the 2000s, none of the pure, content-driven attention merchants were lucrative. This was, in part, because advertisers realized with so many attention merchants in competition, they didn’t necessarily need to “underwrite” the media industry in the manner that they had for newspapers, radio, or television. As advertising executive Rishad Tobaccowala put it in 2010, advertisers long since had grown tired and resentful of any project other than reaching consumers with ads. Fundamentally they “don’t want to pay for creation of content.”\u003c/p>\n\u003cp>So while the Huffington Pos\u003cem>t \u003c/em>certainly succeeded in its original goal of driving more web traffic toward the political left, in most other ways it ended up pleasing no one. Established, traditional newspapers, with their crushing overhead, hated it most. Bill Keller, the executive editor of The New York Times\u003cem>,\u003c/em> was indignant. “Too often it amounts to taking words written by other people, packaging them on your own Web site and harvesting revenue that might otherwise be directed to the originators of the material. In Somalia this would be called piracy. In the mediasphere, it is a respected business model.” Meanwhile, for the dreamers and idealists who always wanted the web to be not just different but loftier and better, the HuffPo’s relentless dependence on celebrity and clickbait was something of a bitter pill.\u003c/p>\n\u003cp>If they weren’t good at making money, no one could deny that those running the site knew how to harvest attention, and for that reason it changed the rules of the game. Like the New York Su\u003cem>n\u003c/em> in the 1830s or People magazine in the 1970s, HuffPo forced the competition to become more like it. Relatively sober sites like Slate and Salon grew more gossipy, superficial, and click-driven; in time, even traditional newspaper websites were also forced to adapt themselves to the standard set by a site with unpaid writers and features on celebrity sideboob. To varying degrees, the style of everything seemed to drift toward tabloid and away from broadsheet, to borrow the parlance of print.\u003c/p>\n\u003cp>AOL, seeking its own resurrection, and having noticed the gap between the Huffington Post’s traffic and its advertising rates, bought the site in 2011 for $315 million and began throwing money at it in an effort to make the site more respectable. This bearing upwind, a variant on CBS’s “Tiffany” strategy from the 1930s, would, it was hoped, attract a higher class of advertiser. With more money, the Huffington Post was now able to hire seasoned reporters who were given full freedom and resources to write on what they wanted. The strategy yielded a Pulitzer Prize for the Huffington Post’s David Wood, a war correspondent who’d cut his teeth at Time in the 1970s and had also worked at the Los Angeles Times, Baltimore Sun\u003ci> \u003c/i>and other papers. So the HuffPost gained some dignity, but because it was expensive still failed to create large profits. Yet by 2015, it was attracting more attention than ever, and management was still saying things like “We could make it profitable right now if we wanted it to be.” Perhaps the site was by its nature never really meant to be a business exactly, but instead just a giant vacuum sucking up human attention.\u003c/p>\n\u003cp>\u003cstrong>The Web Hits Bottom, or .... BuzzFeed\u003c/strong>\u003c/p>\n\u003cp>“Which Ousted Arab Spring Ruler Are You?” “\u003c/p>\n\u003cp>\"You Might Be Cleaning Your Penis Wrong”\u003c/p>\n\u003cp>“37 Things Conservatives Would Rather Do Than Watch Obama’s State of the Union Speech”\u003c/p>\n\u003cp>“29 Cats Who Failed So Hard They Won”\u003c/p>\n\u003cp>Here was BuzzFeed, at its height in the 2010s, undisputed king of clickbait, and the grandmaster of virality. As a cofounder of The Huffington Post\u003cem>, \u003c/em>Jonah Peretti had gained a measure of success, rec- ognition, and personal wealth. But it wouldn’t be long before he lost interest in the operation, which had begun to run itself, and felt compelled to return to his original passion: the pure art and science of harvesting attention with “contagious” or “viral” media. He was still at the Huffington Post when he began to conceive the endpoint, or perhaps the punch line, to his long obsession: a site whose mission would be nothing but to build pure contagion and launch it into the ether.\u003c/p>\n\u003cp>https://www.youtube.com/watch?v=vBQa4lUE5f4\u003c/p>\n\u003cp>BuzzFeed billed itself as the “first true social news organization,” which meant it was designed for a post-Facebook and post-Twitter world, where news gained currency by being shared on social networks, through news feeds, Twitter feeds, and the like. It was also designed to be read on the now ubiquitous mobile platforms; by 2015, 60 percent of its traffic was via phones and other wireless devices (including 21 percent from Snapchat)—the key to success was now getting people to share stuff socially from mobile.\u003c/p>\n\u003cp>By the time Peretti built BuzzFeed, viral media were not an occasional phenomenon, but reaching the public like successive waves crashing on a metaphorical shore, they thus both rivaled and complemented (depending on the context) existing means of capturing attention. It was a time when a random picture of a grumpy-looking cat (Grumpy Cat) posted on the online bulletin board Reddit made a viable career for its owners; when a ridiculous dance video like “Gangnam Style” amassed more than 2.4 billion online views (while the 2014 World Cup, the most watched event in human history, reached about 1 billion).\u003c/p>\n\u003cp>As nothing but a pure embodiment of Peretti’s techniques, BuzzFeed did without even the pretense of a public mission, the only goal being to amuse viewers enough to trigger their sharing. With content often nearly devoid of any meaningful communication, the medium truly was the message. And while this might sound like unprecedented cynicism vis-à- vis the audience, the idea was to transfer creative intention to them; they alone would “decide if the project reaches 10 people or 10 million people.” To help them decide, BuzzFeed pioneered techniques like “headline optimization,” which was meant to make the piece irresistible and clicking on it virtually involuntary. In the hands of the headline doctors, a video like “Zach Wahls Speaks About Family” became “Two Lesbians Raised a Baby and This Is What They Got”—and earned 18 million views. BuzzFeed’s lead data scientist, Ky Harlin, once crisply explained the paradoxical logic of headlining: “You can usually get somebody to click on something just based on their own curiosity or something like that, but it doesn’t mean that they’re actually going to end up liking the content.”\u003c/p>\n\u003cp>BuzzFeed also developed the statistical analysis of sharing, keeping detailed information on various metrics, especially the one they called “viral lift.” Let’s take, for example, a story entitled “48 Pictures That Capture the 1990s,” which garnered over 1.2 million views. BuzzFeed would measure how many people read it (views), and of those, how many went on to share it, whether on Twitter, Facebook, or other sites. If, say, 22 people with whom the link was shared were moved to click on it, the story would be said to have a viral lift of 22x. Such data would help BuzzFeed’s experts refine their understanding of what gets shared, and what doesn’t.\u003c/p>\n\u003cp>Collectively BuzzFeed and its rivals—Mashable, Upworthy, and in time parts of the mainstream media—began to crack the code; eventually they could consistently make content go viral. Much of what they discovered validated Peretti’s original theories—particularly about the necessity of stimulating “pleasure in the social process of passing” something along and of ensuring that the contagion “represent[s] the simplest form of an idea.” But the “pleasure” of sharing did not necessarily mean that viewing the content had been pleasurable. The urge to share was activated by a spectrum of “high-arousal” emotions, like awe, outrage, and anxiety. A story with a headline like “When All Else Fails, Blaming the Patient Often Comes Next,” or “What Red Ink? Wall Street Paid Hefty Bonuses,” or “Rare Treatment Is Reported to Cure AIDS Patient” would trigger one of these emotions—or even better, several at once.\u003c/p>\n\u003cp>\u003cem>From ClickHole, The Onion's parody site of viral videos:\u003c/em>\u003c/p>\n\u003cp>https://www.youtube.com/watch?v=CfI32Phy60c\u003c/p>\n\u003cp>Naked plays for attention always draw scorn, and as BuzzFeed’s fortunes rose in the 2010s, it was no exception. As Ben Cohen, founder of the journalism site The Daily Banter\u003cem>, \u003c/em>wrote: “I loathe BuzzFeed and pretty much everything they do. . . . It could well trump Fox News as the single biggest threat to journalism ever created.”When BuzzFeed presented the Egyptian democratic revolution as a series of GIFs from the film \"Jurassic Park\u003cem>,\" \u003c/em>Cohen fulminated: “To say this is childish, puerile bullshit would be a massive understatement. . . . Doing funny GIF posts about cats and hangovers is one thing, but reducing a highly complex political crisis into 2 second moving screen shots of a children’s dinosaur movie is something completely different. If BuzzFeed really is the future of journalism, we’re completely and utterly fucked.” Indeed, by 2012, the scramble for eyeballs against forces like BuzzFeed seemed to bring news media to a new low. When Fox News broadcast a video of a man com-mitting suicide and BuzzFeed reposted the link, the Columbia Journalism Review was compelled to ask, “Who’s worse? @FoxNews for airing the suicide, or @BuzzFeed for re-posting the video just in case you missed it the first time?”\u003c/p>\n\u003cp>https://www.youtube.com/watch?v=V9gBNBHmA8c\u003c/p>\n\u003cp>\u003cstrong>The Gold Standard for Attention Capture\u003c/strong>\u003c/p>\n\u003cp>BuzzFeed was indeed proving the envy of all other online attention merchants, in traffic at least. By 2015, its 200+ million monthly unique viewers exceeded most of its competitors, and 75 percent of its traffic was coming from social media. Ultimately its techniques were widely copied, not just by its direct competitors like the\u003cem> Daily Mail \u003c/em>or Cracked.com but by \u003cem>the Huffington Post, \u003c/em>Peretti’s previous venture, and more obliquely, by magazines like Slate as well as newspapers like The Washington Post. Even literary magazines like The Atlantic and The New Yorker got in on the act. BuzzFeed thus became the reference point, the gold standard, for attention capture on the web.\u003c/p>\n\u003cp>Not that BuzzFeed was terribly profitable. It lost money for most of its early years, only began to turn a profit in 2013, and never exceeded $10 million (while hardly a fair comparison, Apple’s iTunes store alone, also in the content business, and not considered highly profitable, has been estimated to clear $1 billion in profit per year). Its fortunes reflected the still-low price of digital ads; BuzzFeed’s annual ad revenues of roughly $100 million were still far less than, say, \u003cem>People \u003c/em>magazine (about $1 billion). Nonetheless, BuzzFeed was still growing, and as the decade reached its midpoint, was pegged at $850 million in value; then, over the summer of 2015, the cable giant Comcast bought a stake that valued the company at $1.5 billion.\u003c/p>\n\u003cp>Comcast’s investment in BuzzFeed was at last a consummation of the union between the old and the new media such as Microsoft and AOL– Time Warner had once contemplated, though now involving far less money than in those headier days. For comparison’s sake, though, it is worth remarking that The Washington Post\u003cem>, \u003c/em>with its 47 Pulitzer Prizes, was purchased by Amazon for $250 million in 2013—old media valuations clearly weren’t what they used to be, either. And yet even if BuzzFeed had attracted real dollars, the deal with Comcast nonetheless seemed to diminish the new media in some way. Blogging and other forces that others had predicted were going to demolish the establishment had eventually yielded to BuzzFeed. BuzzFeed was then bought by old media for what amounted to chump change.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>So much for all of that.\u003c/p>\n\n","blocks":[],"excerpt":"In the early 2000s, the success of one man's online prank inspired him to examine what has become the primary question of headline writers across the media landscape: What makes people click on a story?","status":"publish","parent":0,"modified":1514568904,"stats":{"hasAudio":false,"hasVideo":true,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":69,"wordCount":5013},"headData":{"title":"How the Media Came to Embrace Clickbait: An Internet History | KQED","description":"In the early 2000s, the success of one man's online prank inspired him to examine what has become the primary question of headline writers across the media landscape: What makes people click on a story?","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"How the Media Came to Embrace Clickbait: An Internet History","datePublished":"2017-05-12T16:00:08.000Z","dateModified":"2017-12-29T17:35:04.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"387142 https://ww2.kqed.org/futureofyou/?p=387142","disqusUrl":"https://ww2.kqed.org/futureofyou/2017/05/12/how-the-media-came-to-embrace-clickbait-an-internet-history/","disqusTitle":"How the Media Came to Embrace Clickbait: An Internet History","source":"KQED Future of You","nprByline":"Tim Wu","path":"/futureofyou/387142/how-the-media-came-to-embrace-clickbait-an-internet-history","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>\u003cem>From the book \u003ca href=\"http://www.penguinrandomhouse.com/books/234876/the-attention-merchants-by-tim-wu/9780385352017/\" target=\"_blank\" rel=\"noopener noreferrer\">THE ATTENTION MERCHANTS,\u003c/a> by Tim Wu. Copyright © 2016 by Tim Wu. Published by arrangement with Alfred A. Knopf, an imprint of The Knopf Doubleday Publishing Group, a division of Penguin Random House LLC.\u003c/em>\u003c/p>\n\u003cp>\u003cspan style=\"font-size: 4.6875em;float: left;line-height: 0.733em;padding: 0.05em 0.1em 0 0;font-family: times, serif, georgia\">B\u003c/span>ack in 2001, at MIT’s media laboratory in Cambridge, Massachusetts, a former schoolteacher named Jonah Peretti was sitting at his desk and, like so many graduate students, not doing his work. Peretti was meant to be plugging away at his master’s thesis; instead he was playing around with what was already the greatest procrastination aide ever devised, the World Wide Web.\u003c/p>\n\u003caside class=\"pullquote alignright\">One man's Internet pranking evolved to influence the entire online news ecosystem.\u003c/aside>\n\u003cp>Born in California to a Jewish mother and Italian-American father, Peretti was a pretty ordinary and sober-looking young guy. But there was always a slight smile on his lips, a clue to the inveterate prankster beneath the facade of the typical grad student. In fact, he was fascinated by the line between the serious and the absurd, which in his mind also often delineated art from commerce, if not always respectively. Most of his ventures, even those that would prove important, seem to have been conceived as a kind of inside joke, and a test of the limits of possibility.\u003c/p>\n\u003cp>While goofing off—“surfing the web” in the vernacular of the time— Peretti went to Nike’s website and noticed a feature allowing customers to order shoes personalized with any word they might like. On a whim, he placed an order for Nike Zoom XC USA running shoes with the fol- lowing embroidered on them:\u003c/p>\n\u003cblockquote>\u003cp>SWEATSHOP\u003c/p>\u003c/blockquote>\n\u003cp>He thought nothing more of it until the next day, when he received the following email:\u003c/p>\n\u003cblockquote>\u003cp>From: Personalize, NIKE iD To: Jonah H. Peretti\u003c/p>\n\u003cp>Subject: RE: Your NIKE iD order o16468000\u003c/p>\n\u003cp>Your NIKE iD order was cancelled for one or more of the following reasons.\u003c/p>\n\u003cp>1) Your Personal iD contains another party’s trademark or other intellectual property.\u003c/p>\n\u003cp>2) Your Personal iD contains the name of an athlete or team we do not have the legal right to use.\u003c/p>\n\u003cp>3) Your Personal iD was left blank. Did you not want any personalization?\u003c/p>\n\u003cp>4) Your Personal iD contains profanity or inappropriate If you wish to reorder your NIKE iD product with a new personaliza- tion please visit us again at \u003ca href=\"http://www.nike.com/\">www.nike.com\u003c/a>.\u003c/p>\n\u003cp>Thank you, NIKE iD\u003c/p>\u003c/blockquote>\n\u003cp>Seeing comic potential, Peretti wrote back asking just which rule he had broken. A Nike customer service representative replied: “Your NIKE iD order was cancelled because the iD you have chosen contains, as stated in the previous e-mail correspondence, ‘inappropriate slang.’ ”\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>Peretti, just warming up, wrote back:\u003c/p>\n\u003cblockquote>\u003cp>Dear NIKE iD,\u003c/p>\n\u003cp>Thank you for your quick response to my inquiry about my custom ZOOM XC USA running shoes. Although I commend you for your prompt customer service, I disagree with the claim that my personal iD was inappropriate slang. After consulting Webster’s Dictionary, I discovered that “sweatshop” is in fact part of standard English, and not slang. The word means: “a shop or factory in which workers are employed for long hours at low wages and under unhealthy conditions” and its origin dates from 1892. So my personal iD does meet the criteria detailed in your first email. Your web site advertises that the NIKE iD program is “about freedom to choose and freedom to express who you are.” I share Nike’s love of freedom and personal expression. The site also says that “If you want it done right . . . build it yourself.” I was thrilled to be able to build my own shoes, and my personal iD was offered as a small token of appreciation for the sweatshop workers poised to help me realize my vision. I hope that you will value my freedom of expression and reconsider your decision to reject my order.\u003c/p>\n\u003cp>Thank you, Jonah Peretti\u003c/p>\u003c/blockquote>\n\u003cp>In response, Nike simply canceled the order. Peretti wrote one last one email:\u003c/p>\n\u003cblockquote>\u003cp>From: Jonah H. Peretti\u003cbr>\nTo: Personalize, NIKE iD\u003cbr>\nSubject: RE: Your NIKE iD order o16468000\u003c/p>\n\u003cp>Dear NIKE iD,\u003c/p>\n\u003cp>Thank you for the time and energy you have spent on my request. I have decided to order the shoes with a different iD, but I would like to make one small request. Could you please send me a color snapshot of the ten-year-old Vietnamese girl who makes my shoes?\u003c/p>\n\u003cp>Thanks, Jonah Peretti\u003c/p>\u003c/blockquote>\n\u003cp>Amused, Peretti sent a copy of the email chain to 12 or so friends, including one who posted it on his personal website. Within a week, Peretti’s exchange had been shared by people far and wide; first thousands and within a few weeks, millions. Along the way, it was picked up by mainstream media outlets around the world. To use a phrase that did not exist in 2001, the email “went viral.”\u003c/p>\n\u003caside class=\"pullquote alignright\">Jonah Peretti had more or less made himself the world’s expert on contagious media, but the recognition of peers was not enough; the measure of his success would be the ability to generate traffic.\u003c/aside>\n\u003cp>“So then I found myself on the 'Today' show talking with Katie Couric about sweatshop labor,” says Peretti. “It was, like, what do I know about sweatshops?” Here was that mind-warping rush of unexpected renown, of reaching an audience way beyond your wildest expectations. Peretti would later remember it simply: “Something very small became something very big.” Unbeknownst to him at the time, the experience would end up changing his career and his life.\u003c/p>\n\u003cp>Popular email chains have been around nearly as long as email itself, but back in 2001 words like “viral,” “Internet meme,” and “clickbait” were as yet unknown. What Peretti naively experienced was an early version of what would become a pervasive means of harvesting attention in the early 21st century. Peretti, who has a curious, scientific mind, started to consider the phenomenon carefully and systematically. “I looked at stories like the Nike shoe story, and there were actually plenty of other ones. Someone did something, it went big for a while, but then that’s where the story ends.” Having done it once, by accident, he wanted to see if he could make it happen at will. He wanted to see if he could understand what it took to make something “go viral.” For he realized that his weird experience had a deeper significance; it marked a change, made possible by the Internet, in how attention might be cap- tured, and from whom.\u003c/p>\n\u003cp>\u003cimg class=\"aligncenter size-large wp-image-387679\" src=\"https://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2017/05/ClickbaitWu-1020x670.jpg\" alt=\"\" width=\"640\" height=\"420\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-1020x670.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-160x105.jpg 160w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-800x525.jpg 800w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-768x504.jpg 768w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-1180x775.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-960x631.jpg 960w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-240x158.jpg 240w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-375x246.jpg 375w, https://ww2.kqed.org/app/uploads/sites/13/2017/05/ClickbaitWu-520x342.jpg 520w\" sizes=\"(max-width: 640px) 100vw, 640px\">\u003c/p>\n\u003cp>\u003cstrong>A Media Contagion Posse\u003c/strong>\u003c/p>\n\u003cp>A few months later, Peretti left MIT to take a job at the Eyebeam art and technology center, a giant space in New York’s West Chelsea neighbor- hood; from the outside it looked like many of the art galleries that sur- rounded it. Here, in his “contagious media laboratory,” he tried to figure out if he could make lightning in a bottle.\u003c/p>\n\u003cp>\u003c/p>\u003cp>\u003c/p>\u003cp>Peretti started throwing stuff against the web to see if anything might stick. It turned out he was not alone; there were others who shared his fascination with creating zany stuff that might, almost magically, erupt across the Internet. He got to know a man who called himself “Ze Frank,” a sort of self-styled web-jester. Ze Frank’s own road to Damas- cus had involved a web-based birthday invitation in which he was featured, performing funny dance moves; it had earned millions of hits and won him a Webby Award. Peretti also met Cory Arcangel, a conceptual artist who, among other things, had made art that required him to hack Nintendo’s Super Mario Brothers. Then there was a social scientist, Duncan Watts, who tried to understand media contagion with mathematical models. In these guys, Peretti found a posse.\u003c/p>\n\u003cp>His sister, Chelsea Peretti, also got in on the act. Together, they launched www.blackpeopleloveus.com, a fake website featuring a white couple inordinately proud of having made black friends; it attracted 600,000 hits. There was also the “Rejection Line,” a service for those who found it too inconvenient to reject people themselves. As the site said:\u003c/p>\n\u003cblockquote>\u003cp>Someone won’t leave you alone?\u003cbr>\nGive them “your” number: 212-479-7990 The official New York Rejection Line! (operators are standing by!)\u003c/p>\u003c/blockquote>\n\u003cp>It was as if stories from \u003cem>The\u003c/em> \u003cem>Onion\u003c/em> had actually been put into production.\u003c/p>\n\u003cp>Peretti and his pals definitely had some fun at Eyebeam. They held how- to workshops for the public with titles like “The Mass Hoax.” In 2005 they hosted something called the “Contagious Media Showdown,” giv- ing contestants three weeks to get as much traffic as they could. Entries included “hire-a-killer.com,” “Crying While Eating,” “email god,” and “change your race”; the winner (possibly as a result of cheating) was “Forget-me-not-panties.com,” a prank site purporting to sell women’s underwear that broadcasts the wearer’s location to possessive fathers and husbands. “Unlike the cumbersome and uncomfortable chastity belts of the past, these panties are 100% cotton, and use cutting-edge technology to help you protect what matters most.” The site suckered both bloggers and mainstream press, remaining operational for quite some time, albeit with a notice that stock was currently sold out.\u003c/p>\n\u003cp>Peretti may not have been able to create anything while at Eyebeam on the scale of his Nike experience, but he would author a 23-point manifesto that he called “Notes on Contagious Media,” expound- ing just what distinguished that variety from others. Some of it was obvious: “Contagious media is the kind of media you immediately want to share with all your friends. This requires that you take pleasure in consuming the media but also pleasure in the social process of passing it on.” Some more theoretical: “Contagious media is a form of pop conceptual art” in which “the idea is the machine that makes the art (LeWitt, 1967) and the idea is interesting to ordinary people.” For that reason, “a contagious media project should represent the simplest form of an idea. Fancy design or extraneous content made media less contagious. Anything inessential constituted a ‘payload’ that the contagion must drag along as it spreads. The bigger the payload, the more slowly the entire project spreads.” Peretti had more or less made himself the world’s expert on contagious media, but the recognition of peers was not enough; the measure of his success would be the ability to generate traffic. “For the artist, a work can be celebrated even if the only people who like it are a small group of curators and collectors,” he wrote. “For the contagious media designer, all that matters is how other people see the work. If people don’t share the work with their friends, it is a failure regardless of the opinion of the creator, critics, or other elites.”\u003c/p>\n\u003cp>\u003cstrong>The Birth of HuffPo\u003c/strong>\u003c/p>\n\u003cp>In 2004, Peretti was still puttering around at Eyebeam, teaching and throwing stuff on the web, when he was approached by Ken Lerer, a for- mer communications executive at AOL and a committed political activ- ist. A journalist by training and adept at raising money, Lerer presented what he considered an urgent project. Despite every kind of blunder in office, President George W. Bush seemed likely to be re-elected. This was incomprehensible to Lerer and other Democrats, who considered Bush an obvious incompetent; in their view, the internet was in part to blame. The right-wing blogs—above all, the \u003cem>Drudge Report, \u003c/em>the most widely read aggregator of news links—just captured more attention than all the left-wing ones. “You know the Internet, let’s build something,” Lerer cajoled Peretti, who would later explain, “I’m the son of a public defender and a public school teacher” and “it seemed pretty important.”\u003c/p>\n\u003caside class=\"pullquote alignright\">Doing funny GIF posts about cats and hangovers is one thing, but reducing a highly complex political crisis into 2-second moving screen shots of a children’s dinosaur movie is something completely different.\u003c/aside>\n\u003cp>“Something” was at first quite vague. As it evolved, the idea seemed to be this: leverage the left’s superior hold on Hollywood celebrities, as well as Peretti’s knack for driving traffic and Lerer’s touch for fundraising, to create a counterweight to conservative online media. The celebrity part, they decided, was best handled by the third partner, and by far the best connected, Arianna Huffington.\u003c/p>\n\u003cp>On May 10, 2005, just two days after the contagious media contest, the Huffington Post, an online aggregator of news, blogs, and other content, debuted to widespread mainstream coverage. The first issue featured blog posts by Huffington herself and, as planned, various famous people: the renowned historian and Kennedy confidant Arthur M. Schlesinger Jr.; the actor John Cusack; Larry David, producer of \"Seinfeld\"\u003cem>;\u003c/em> the husband- and-wife acting pair Julia Louis-Dreyfus (also of \"Seinfeld\") and Brad Hall, jointly posting on the issue of gun violence.\u003c/p>\n\u003cp>Some credited the idea, but in media it’s not the thought that counts; critics were harsher and louder. And no one came in for more abuse than the partner who’d lent her name. “Celebs to the Slaughter,” wrote LA Weekly: “Judging from Monday’s horrific debut of the humongously pre-hyped celebrity blog the Huffington Post\u003cem>, \u003c/em>the Madonna of the mediapolitic world has undergone one reinvention too many. She has now made an online ass of herself. . . . Her blog is such a bomb that it’s the movie equivalent of \"Gigli\u003cem>,\"\u003c/em> \"Ishtar\" and \"Heaven’s Gate\" rolled into one.”\u003c/p>\n\u003cp>In retrospect, critics like the LA Weekly’s were only proving how little they understood the Internet. Peretti, Lerer, and Huffington were each masters of attention capture, and their collaboration proved more than the sum of its parts. Over time, the political mission was dialed back somewhat—Huffington herself had, after all, previously been a conservative pundit who’d called for the resignation of President Clinton. Soon the Huffington Post was inviting not just celebrities to contribute but students, politicos, activists, book authors—just about anyone except the professional reporter or normal freelancer who expected to be paid. It was a degree of openness more akin to the early days of the web and blogosphere than any older model of media. Minimal costs, maximum traffic, and irresistible content above all—that was the formula.\u003c/p>\n\u003cp>In pursuit of the third element of its triad, the HuffP\u003cem>o\u003c/em> pioneered what would become known as clickbait: sensationally headlined articles, paired with provocative pictures—a bikini-clad celebrity was always good. (“Watch Naked Heidi Klum in Seal’s New Video”). When properly calibrated, such content seemed to take control of the mind, causing the hand almost involuntarily to click on whatever was there. The HuffPo’s “news” was more provocative, more enticing—more clickable— than its competitors’; even for serious topics it managed to channel lurid fascination. To the chagrin of its critics, it quickly outpaced sites like LA Weekly and by the fall of 2007 was capturing more attention than other web magazines like Slate and Salon\u003cem>,\u003c/em> despite their paid writers. By 2010 it was beating most of the newspapers as well. With 24 million monthly readers, it was slightly behind The New York Times\u003cem>,\u003c/em> but ahead of The Washington Post, the Los Angeles Times\u003cem>,\u003c/em> and the rest of what was then called the mainstream media. As the Columbia Journalism Review put it, “The Huffington Post has mastered and fine-tuned not just aggregation, but also social media, comments from readers, and most of all, a sense of what its public wants.”\u003c/p>\n\u003cp>\u003cstrong>Clicks Not Bucks\u003c/strong>\u003c/p>\n\u003cp>And yet the Huffington Post never actually made much money. While its financials have never been fully public, there is good reason to believe it has never turned a solid profit. For one thing, advertisers categorized the Huffington Post as political commentary, and generally, the big-brand advertisers, the Fortune 500, despite the numbers weren’t willing to put their names on HuffPo’s pages. Others tended to credit Google for its traffic. All of this combined to make the site able to sell its impressions for only the lowest rates to bottom-tier advertisers (e.g., “This weird trick can take an inch off your waistline”). The Huffington Post wasn’t making money, but it was nonetheless sucking attention from everything else— especially journalists—on the web. That’s probably why The Washington Post’s executive editor slammed it and similar sites as “parasites living off journalism produced by others.”\u003c/p>\n\u003caside class=\"alignright\">'Here was BuzzFeed, at its height in the 2010s ... ''\n\u003cul>\n\u003cli>'Which Ousted Arab Spring Ruler Are You?'\u003c/li>\n\u003cli>'You Might Be Cleaning Your Penis Wrong'\u003c/li>\n\u003cli>'37 Things Conservatives Would Rather Do Than Watch Obama’s State of the Union Speech'\u003c/li>\n\u003cli>'29 Cats Who Failed So Hard They Won'\u003c/li>\n\u003c/ul>\n\u003c/aside>\n\u003cp>The Huffington Post wasn’t alone. Over the 2000s, none of the pure, content-driven attention merchants were lucrative. This was, in part, because advertisers realized with so many attention merchants in competition, they didn’t necessarily need to “underwrite” the media industry in the manner that they had for newspapers, radio, or television. As advertising executive Rishad Tobaccowala put it in 2010, advertisers long since had grown tired and resentful of any project other than reaching consumers with ads. Fundamentally they “don’t want to pay for creation of content.”\u003c/p>\n\u003cp>So while the Huffington Pos\u003cem>t \u003c/em>certainly succeeded in its original goal of driving more web traffic toward the political left, in most other ways it ended up pleasing no one. Established, traditional newspapers, with their crushing overhead, hated it most. Bill Keller, the executive editor of The New York Times\u003cem>,\u003c/em> was indignant. “Too often it amounts to taking words written by other people, packaging them on your own Web site and harvesting revenue that might otherwise be directed to the originators of the material. In Somalia this would be called piracy. In the mediasphere, it is a respected business model.” Meanwhile, for the dreamers and idealists who always wanted the web to be not just different but loftier and better, the HuffPo’s relentless dependence on celebrity and clickbait was something of a bitter pill.\u003c/p>\n\u003cp>If they weren’t good at making money, no one could deny that those running the site knew how to harvest attention, and for that reason it changed the rules of the game. Like the New York Su\u003cem>n\u003c/em> in the 1830s or People magazine in the 1970s, HuffPo forced the competition to become more like it. Relatively sober sites like Slate and Salon grew more gossipy, superficial, and click-driven; in time, even traditional newspaper websites were also forced to adapt themselves to the standard set by a site with unpaid writers and features on celebrity sideboob. To varying degrees, the style of everything seemed to drift toward tabloid and away from broadsheet, to borrow the parlance of print.\u003c/p>\n\u003cp>AOL, seeking its own resurrection, and having noticed the gap between the Huffington Post’s traffic and its advertising rates, bought the site in 2011 for $315 million and began throwing money at it in an effort to make the site more respectable. This bearing upwind, a variant on CBS’s “Tiffany” strategy from the 1930s, would, it was hoped, attract a higher class of advertiser. With more money, the Huffington Post was now able to hire seasoned reporters who were given full freedom and resources to write on what they wanted. The strategy yielded a Pulitzer Prize for the Huffington Post’s David Wood, a war correspondent who’d cut his teeth at Time in the 1970s and had also worked at the Los Angeles Times, Baltimore Sun\u003ci> \u003c/i>and other papers. So the HuffPost gained some dignity, but because it was expensive still failed to create large profits. Yet by 2015, it was attracting more attention than ever, and management was still saying things like “We could make it profitable right now if we wanted it to be.” Perhaps the site was by its nature never really meant to be a business exactly, but instead just a giant vacuum sucking up human attention.\u003c/p>\n\u003cp>\u003cstrong>The Web Hits Bottom, or .... BuzzFeed\u003c/strong>\u003c/p>\n\u003cp>“Which Ousted Arab Spring Ruler Are You?” “\u003c/p>\n\u003cp>\"You Might Be Cleaning Your Penis Wrong”\u003c/p>\n\u003cp>“37 Things Conservatives Would Rather Do Than Watch Obama’s State of the Union Speech”\u003c/p>\n\u003cp>“29 Cats Who Failed So Hard They Won”\u003c/p>\n\u003cp>Here was BuzzFeed, at its height in the 2010s, undisputed king of clickbait, and the grandmaster of virality. As a cofounder of The Huffington Post\u003cem>, \u003c/em>Jonah Peretti had gained a measure of success, rec- ognition, and personal wealth. But it wouldn’t be long before he lost interest in the operation, which had begun to run itself, and felt compelled to return to his original passion: the pure art and science of harvesting attention with “contagious” or “viral” media. He was still at the Huffington Post when he began to conceive the endpoint, or perhaps the punch line, to his long obsession: a site whose mission would be nothing but to build pure contagion and launch it into the ether.\u003c/p>\u003c/p>\u003cp>\u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutube'>\n \u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutubeInside'>\n \u003ciframe\n loading='lazy'\n class='utils-parseShortcode-shortcodes-__youtubeShortcode__youtubePlayer'\n type='text/html'\n src='//www.youtube.com/embed/vBQa4lUE5f4'\n title='//www.youtube.com/embed/vBQa4lUE5f4'\n allowfullscreen='true'\n style='border:0;'>\u003c/iframe>\n \u003c/span>\n \u003c/span>\u003c/p>\u003cp>\u003cp>BuzzFeed billed itself as the “first true social news organization,” which meant it was designed for a post-Facebook and post-Twitter world, where news gained currency by being shared on social networks, through news feeds, Twitter feeds, and the like. It was also designed to be read on the now ubiquitous mobile platforms; by 2015, 60 percent of its traffic was via phones and other wireless devices (including 21 percent from Snapchat)—the key to success was now getting people to share stuff socially from mobile.\u003c/p>\n\u003cp>By the time Peretti built BuzzFeed, viral media were not an occasional phenomenon, but reaching the public like successive waves crashing on a metaphorical shore, they thus both rivaled and complemented (depending on the context) existing means of capturing attention. It was a time when a random picture of a grumpy-looking cat (Grumpy Cat) posted on the online bulletin board Reddit made a viable career for its owners; when a ridiculous dance video like “Gangnam Style” amassed more than 2.4 billion online views (while the 2014 World Cup, the most watched event in human history, reached about 1 billion).\u003c/p>\n\u003cp>As nothing but a pure embodiment of Peretti’s techniques, BuzzFeed did without even the pretense of a public mission, the only goal being to amuse viewers enough to trigger their sharing. With content often nearly devoid of any meaningful communication, the medium truly was the message. And while this might sound like unprecedented cynicism vis-à- vis the audience, the idea was to transfer creative intention to them; they alone would “decide if the project reaches 10 people or 10 million people.” To help them decide, BuzzFeed pioneered techniques like “headline optimization,” which was meant to make the piece irresistible and clicking on it virtually involuntary. In the hands of the headline doctors, a video like “Zach Wahls Speaks About Family” became “Two Lesbians Raised a Baby and This Is What They Got”—and earned 18 million views. BuzzFeed’s lead data scientist, Ky Harlin, once crisply explained the paradoxical logic of headlining: “You can usually get somebody to click on something just based on their own curiosity or something like that, but it doesn’t mean that they’re actually going to end up liking the content.”\u003c/p>\n\u003cp>BuzzFeed also developed the statistical analysis of sharing, keeping detailed information on various metrics, especially the one they called “viral lift.” Let’s take, for example, a story entitled “48 Pictures That Capture the 1990s,” which garnered over 1.2 million views. BuzzFeed would measure how many people read it (views), and of those, how many went on to share it, whether on Twitter, Facebook, or other sites. If, say, 22 people with whom the link was shared were moved to click on it, the story would be said to have a viral lift of 22x. Such data would help BuzzFeed’s experts refine their understanding of what gets shared, and what doesn’t.\u003c/p>\n\u003cp>Collectively BuzzFeed and its rivals—Mashable, Upworthy, and in time parts of the mainstream media—began to crack the code; eventually they could consistently make content go viral. Much of what they discovered validated Peretti’s original theories—particularly about the necessity of stimulating “pleasure in the social process of passing” something along and of ensuring that the contagion “represent[s] the simplest form of an idea.” But the “pleasure” of sharing did not necessarily mean that viewing the content had been pleasurable. The urge to share was activated by a spectrum of “high-arousal” emotions, like awe, outrage, and anxiety. A story with a headline like “When All Else Fails, Blaming the Patient Often Comes Next,” or “What Red Ink? Wall Street Paid Hefty Bonuses,” or “Rare Treatment Is Reported to Cure AIDS Patient” would trigger one of these emotions—or even better, several at once.\u003c/p>\n\u003cp>\u003cem>From ClickHole, The Onion's parody site of viral videos:\u003c/em>\u003c/p>\u003c/p>\u003cp>\u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutube'>\n \u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutubeInside'>\n \u003ciframe\n loading='lazy'\n class='utils-parseShortcode-shortcodes-__youtubeShortcode__youtubePlayer'\n type='text/html'\n src='//www.youtube.com/embed/CfI32Phy60c'\n title='//www.youtube.com/embed/CfI32Phy60c'\n allowfullscreen='true'\n style='border:0;'>\u003c/iframe>\n \u003c/span>\n \u003c/span>\u003c/p>\u003cp>\u003cp>Naked plays for attention always draw scorn, and as BuzzFeed’s fortunes rose in the 2010s, it was no exception. As Ben Cohen, founder of the journalism site The Daily Banter\u003cem>, \u003c/em>wrote: “I loathe BuzzFeed and pretty much everything they do. . . . It could well trump Fox News as the single biggest threat to journalism ever created.”When BuzzFeed presented the Egyptian democratic revolution as a series of GIFs from the film \"Jurassic Park\u003cem>,\" \u003c/em>Cohen fulminated: “To say this is childish, puerile bullshit would be a massive understatement. . . . Doing funny GIF posts about cats and hangovers is one thing, but reducing a highly complex political crisis into 2 second moving screen shots of a children’s dinosaur movie is something completely different. If BuzzFeed really is the future of journalism, we’re completely and utterly fucked.” Indeed, by 2012, the scramble for eyeballs against forces like BuzzFeed seemed to bring news media to a new low. When Fox News broadcast a video of a man com-mitting suicide and BuzzFeed reposted the link, the Columbia Journalism Review was compelled to ask, “Who’s worse? @FoxNews for airing the suicide, or @BuzzFeed for re-posting the video just in case you missed it the first time?”\u003c/p>\u003c/p>\u003cp>\u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutube'>\n \u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutubeInside'>\n \u003ciframe\n loading='lazy'\n class='utils-parseShortcode-shortcodes-__youtubeShortcode__youtubePlayer'\n type='text/html'\n src='//www.youtube.com/embed/V9gBNBHmA8c'\n title='//www.youtube.com/embed/V9gBNBHmA8c'\n allowfullscreen='true'\n style='border:0;'>\u003c/iframe>\n \u003c/span>\n \u003c/span>\u003c/p>\u003cp>\u003cp>\u003cstrong>The Gold Standard for Attention Capture\u003c/strong>\u003c/p>\n\u003cp>BuzzFeed was indeed proving the envy of all other online attention merchants, in traffic at least. By 2015, its 200+ million monthly unique viewers exceeded most of its competitors, and 75 percent of its traffic was coming from social media. Ultimately its techniques were widely copied, not just by its direct competitors like the\u003cem> Daily Mail \u003c/em>or Cracked.com but by \u003cem>the Huffington Post, \u003c/em>Peretti’s previous venture, and more obliquely, by magazines like Slate as well as newspapers like The Washington Post. Even literary magazines like The Atlantic and The New Yorker got in on the act. BuzzFeed thus became the reference point, the gold standard, for attention capture on the web.\u003c/p>\n\u003cp>Not that BuzzFeed was terribly profitable. It lost money for most of its early years, only began to turn a profit in 2013, and never exceeded $10 million (while hardly a fair comparison, Apple’s iTunes store alone, also in the content business, and not considered highly profitable, has been estimated to clear $1 billion in profit per year). Its fortunes reflected the still-low price of digital ads; BuzzFeed’s annual ad revenues of roughly $100 million were still far less than, say, \u003cem>People \u003c/em>magazine (about $1 billion). Nonetheless, BuzzFeed was still growing, and as the decade reached its midpoint, was pegged at $850 million in value; then, over the summer of 2015, the cable giant Comcast bought a stake that valued the company at $1.5 billion.\u003c/p>\n\u003cp>Comcast’s investment in BuzzFeed was at last a consummation of the union between the old and the new media such as Microsoft and AOL– Time Warner had once contemplated, though now involving far less money than in those headier days. For comparison’s sake, though, it is worth remarking that The Washington Post\u003cem>, \u003c/em>with its 47 Pulitzer Prizes, was purchased by Amazon for $250 million in 2013—old media valuations clearly weren’t what they used to be, either. And yet even if BuzzFeed had attracted real dollars, the deal with Comcast nonetheless seemed to diminish the new media in some way. Blogging and other forces that others had predicted were going to demolish the establishment had eventually yielded to BuzzFeed. BuzzFeed was then bought by old media for what amounted to chump change.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"floatright"},"numeric":["floatright"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>So much for all of that.\u003c/p>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/387142/how-the-media-came-to-embrace-clickbait-an-internet-history","authors":["byline_futureofyou_387142"],"categories":["futureofyou_1","futureofyou_73","futureofyou_1061"],"tags":["futureofyou_1439","futureofyou_1268","futureofyou_1269","futureofyou_1267","futureofyou_1266"],"featImg":"futureofyou_388811","label":"source_futureofyou_387142"},"futureofyou_256816":{"type":"posts","id":"futureofyou_256816","meta":{"index":"posts_1591205157","site":"futureofyou","id":"256816","score":null,"sort":[1485624645000]},"guestAuthors":[],"slug":"how-technology-ruined-the-radiology-profession","title":"Has Technology Ruined the Radiology Profession?","publishDate":1485624645,"format":"image","headTitle":"KQED Future of You | KQED Science","labelTerm":{},"content":"\u003cp>\u003cem>This is an edited excerpt from Robert Wachter's \"\u003cem>\u003ca href=\"https://www.amazon.com/Digital-Doctor-Hope-Medicines-Computer/dp/0071849467\" target=\"_blank\" rel=\"noopener\">The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age\u003c/a>\u003c/em>,\" reprinted with permission from McGraw-Hill. Copyright 2015.\u003c/em>\u003c/p>\n\u003cp>\u003cspan style=\"font-size: 4.6875em;float: left;line-height: 0.733em;padding: 0.05em 0.1em 0 0;font-family: times, serif, georgia\">W\u003c/span>hen I was a medical student in the 1980s, the beating heart of the Hospital of the University of Pennsylvania was not the mahogany-lined executive suite, nor the dazzling operating room of L. Henry Edmunds, Jr., HUP's most famed cardiac surgeon. No, it was in the decidedly unglamorous, dimly lit Chest Reading room, where all the X-rays were hung on a moving contraption called an alternator that resembled the one on which the clothes hang at your local dry cleaner. Controlled by a seated radiologist operating a foot pedal, the machine would cycle through panel after panel until it arrived at your films. The radiologist took his foot off the pedal, the machine ground to a halt, and the dark X-ray sheets were brought to life by intense backlighting.\u003c/p>\n\u003cp>At Penn in the 1980s, everybody — and I mean everybody, from the lowliest student to the loftiest transplant surgeon — brought films for deciphering to the late Wallace Miller, Sr., a crusty but endearing professor of radiology and one of the best teachers I've ever known. For students like me, time spent with him was at once exhilarating and terrifying. \"What's this opacity?\" he asked me once, the memory burned into my hippocampus by that cognitive curing process known as overwhelming anxiety. \"A ... a pneumonia?\" I stammered.\u003c/p>\n\u003cp>\"Mooiaaa,\" retorted The Oracle, an unforgettable signature sound uttered as Miller smartly turned his head away in mock disgust. I loved it. We all did.\u003c/p>\n\u003caside class=\"pullquote alignright\">'One day I tried to see if I could go the whole day without speaking to anyone. And that’s what happened—I didn’t speak to a single person.'\u003ccite>A radiologist\u003c/cite>\u003c/aside>\n\u003cp>Today, many of my internal medicine trainees barely know where the radiology department is. Just as your record player and LPs are now long gone, in your local hospital today, the films, the analog X-ray machines, and even those charming film conveyor belts have left the building.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>Why? In 2000, only 8 percent of U.S. hospitals had some version of a game-changing computer technology called the Picture Archiving and Communications System, or PACS. By 2008, more than three out of four did.\u003c/p>\n\u003cp>Because radiology was the first medical specialty to computerize, what has happened to it — at once shocking and, in retrospect, entirely predictable — is our canary in the digital coal mine, its experience offering important lessons for patients, clinicians and health care systems.\u003c/p>\n\u003cp>\u003cstrong>The Beauty of PACS\u003c/strong>\u003c/p>\n\u003cp>While the main catalyst for PACS was economic, the quality of the images and the ability to manipulate them were also important. Unlike regular films, CT scans need to be viewed at various contrast levels: One setting is best to look at bones, another to look at lungs, and still another to look at soft tissue like muscle.\u003c/p>\n\u003cp>PACS allowed radiologists to toggle through these views, in the same way that Instagram lets you play with your photos. You can also use a nifty magnifying glass to zoom in on a part of the image. An unexpected benefit was “stacking”: rather than looking at 100 images arrayed in a 10 × 10 grid on a one-dimensional page, the images could be digitally stacked, one on top of another, allowing the radiologist to scroll through them swiftly by rolling a mouse ball. Moreover, computerization let the radiologist look at the images from home, enabling senior experts to weigh in on subtle findings that trainees might flub. And while the images were fuzzy at first, today they’re as crisp as high-definition television.\u003c/p>\n\u003cp>Perhaps most important, PACS obviated the need for maddening searches for prior X-rays. Twenty years ago, when a chest X-ray revealed a lung nodule, the first commandment on the radiologist’s report was to “obtain old films.” The rationale: If the nodule had been unchanged for many years, it could safely be ignored—such stability simply wasn’t consistent with a diagnosis of cancer. But searching for old films was often an exercise in frustration: They were lost, or locked up, or at another institution, or in a filing cabinet in the thoracic surgeon’s garage, behind the golf clubs. When my colleagues and I came up empty-handed, which was more often than not, the patient frequently paid the price in the form of an unnecessary biopsy. But PACS made finding old films a breeze (assuming that they were done at the same hospital or had been scanned into the system); they’re usually just a click away.\u003c/p>\n\u003cp>While PACS was widely anticipated and generally accepted by radiologists, some prescient observers worried that computerization might lead to unbidden effects on the field. In 1999, Stephen Baker, chair of the Department of Radiology at New Jersey Medical School, fretted that PACS might turn radiologists into “disembodied functionaries, more akin to servicing technicians than professional colleagues.” Paul Chang, professor of radiology at the University of Chicago and an early leader in digital radiology, describes the day his father, a retired radiologist, took him to task.\u003c/p>\n\u003cp>“Before PACS, we were the doctor’s doctor,” his father berated him. “Medicine and surgery rounds started in radiology. . . . Every morning the clinicians and the radiologists collaborated.”\u003c/p>\n\u003cp>His father’s less-than-endearing nickname for his famous son: “The Man Who Ruined Radiology.”\u003c/p>\n\u003cp>The advantages of PACS are so vast that few would want to turn back the clock. Yet the effects on those of us who order X-rays and the radiologists who read them have been profound, and they’re not all positive. The fact that we can now review our images without trekking down to radiology means that we rarely do make the trip.\u003c/p>\n\u003cp>https://www.youtube.com/watch?v=fHUzVqoDnts&ab_channel=DoctorKlioze\u003c/p>\n\u003cp>\u003cstrong>An Awkward Trip to Radiology\u003c/strong>\u003c/p>\n\u003cp>A few years ago, when I asked my interns and students to visit the radiology department to review the key films, they looked at me as if I had grown a second head. After my team humored me by accompanying me to the radiology department, I conducted a little sociology experiment. Standing outside my hospital’s chest reading room, I delivered a brief speech:\u003c/p>\n\u003caside class=\"pullquote alignright\">'Did you look at the official report?' he hissed. The unspoken message was clear: Get out of my space; I’m busy.\u003c/aside>\n\u003cp>\"Watch what happens when we enter. Does anybody turn around and welcome us, ask, 'How can I help you?' and seem genuinely enthusiastic? When they go over the X-ray, do they delve a layer deeper than what they said in the formal report? Do they make any teaching points? Does the radiologist suggest courses of action or ask provocative questions?\"\u003c/p>\n\u003cp>I did this because I am deeply concerned that mine is the last generation to have learned the habit of going to the radiology department. Nostalgic for my interactions with Wally Miller and his like, it saddens me that our current trainees will never know how much they can learn from a great radiology teacher, and how much their patients’ care can be improved by actually talking to a real live radiologist. Yet I know that even if I bring my young horses to water, whether they visit the radiology department after I am no longer their wrangler will be determined by the quality of their experience.\u003c/p>\n\u003cp>We entered the chest reading room and were greeted by a wall of radiologists’ backs, their faces trained like lasers on the computer screens in front of them. Not a single head—located atop the shoulders of about eight different radiologists—turned to greet us.\u003c/p>\n\u003cp>After a couple of awkward minutes of crescendo throat-clearing, one of the radiologists grudgingly swiveled around to face my team and me. “Oh, do you need something?” he asked.\u003c/p>\n\u003cp>“Sure; can you help us look at a few films?”\u003c/p>\n\u003cp>He did, kind of, but offered his help in a whisper animated mostly by passive aggressiveness.\u003c/p>\n\u003cp>I thought it couldn’t get any worse, but it did.\u003c/p>\n\u003cp>“What do you think of this area?” I asked him, pointing to a confusing patch of whiteness on one patient’s chest CT scan.\u003c/p>\n\u003cp>“Did you look at the official report?” he hissed. (In other words: \"Perhaps you don’t know how to turn on your computer?\")\u003c/p>\n\u003cp>The unspoken message was clear: Get out of my space; I’m busy.\u003c/p>\n\u003cp>Now, I understand that he might well be busy, and that it has to be annoying having clinicians interrupt you every few minutes to go over images, particularly after you’ve just reviewed them with a different set of specialists and dictated a report. But that is the radiologist’s job. Or at least it used to be.\u003c/p>\n\u003cp>Allison Tillack, a young radiologist and a medical anthropologist whose Ph.D. thesis involved observing the world of radiologists for a year at a prominent academic hospital, has explored how the computerization of radiology has transformed the worlds of radiologists and those who use their services.\u003c/p>\n\u003cp>\"The ability of PACS to alter the accessibility and tempo of medical imaging has resulted in visits to the reading room being viewed now by non-radiology clinicians as a ‘waste of time’ and by radiologists as an ‘interruption,’” she wrote.\u003c/p>\n\u003cp>\u003cstrong>In a Funk\u003c/strong>\u003c/p>\n\u003cp>While I was well aware of the changing perceptions of radiology by nonradiologists, I had not, until I met Tillack, appreciated the degree to which the field of radiology is itself in a PACS-fueled funk.\u003c/p>\n\u003cp>After all, the field remains extremely popular among medical students, as many perceive it as offering the perfect blend of “great lifestyle” (that is, banker’s hours and limited overnight call) and high income, which averaged $340,000 in 2013. In fact, it’s often said that today’s medical students are attracted to the “ROAD specialties”: Radiology, Ophthalmology, Anesthesiology, and Dermatology, all of which are lucrative and none of which involves a lot of contact with those pesky sick people. In her research, Tillack found that the vast majority of radiologists and radiology residents identified the lack of direct patient contact as one of the main attractions of the field.\u003c/p>\n\u003cp>Given all these pluses, many frontline clinicians think of radiologists as having “won the game.” Yet I should have gotten a hint of the field’s handwringing in 2005, when I saw the results of a survey of physicians regarding their satisfaction with their chosen specialty. The happiest doctors were radiation oncologists (the folks who deliver radiation therapy to cancer patients), who do satisfying work, earn a good income, and have predictable hours. The least happy were cardiac surgeons, who train forever and, in recent years, have seen much of their business eroded by stents and other nonsurgical approaches to heart disease.\u003c/p>\n\u003cp>Radiologists show up a bit below the mean on the satisfaction scale—just behind the perennially overwhelmed and undercompensated primary care doctors.\u003c/p>\n\u003cp>In a 2012 paper, Tillack and a colleague described “the loneliness of the long distance radiologist.” One radiologist told them, “Before, I knew the face, name, wife’s name, and kids’ names of all the clinicians, but now I don’t know who you are if you joined the medical staff after we got PACS. . . . Before, when a clinician showed up, I could ask them and find out what’s really going on with the patient.”\u003c/p>\n\u003cp>I hear similar stories from every radiologist I meet. Patrick Luetmer, a Mayo Clinic neuroradiologist, described what happened when his MRI suite was remodeled. The suite was originally configured with two MRI “donuts” (the huge magnets that are responsible for the image) on either side of a central workstation in which Luetmer sat. There, he could monitor the scans as they were being performed, and talk to both the patients and the radiology assistants. Clinicians sometimes wandered down to look at the scans with him.\u003c/p>\n\u003cp>A few years ago, as part of a big efficiency push, Mayo decided that a third MRI machine was a better use of that central area than the radiologist’s air traffic control desk. Luetmer’s workstation was moved to an office a few hundred feet away, where he could follow the scans on his computer monitor and communicate with the techs via a special text messaging system.\u003c/p>\n\u003cp>“One day I tried to see if I could go the whole day without speaking to anyone. And that’s what happened—I didn’t speak to a single person. It was incredibly isolating.”\u003c/p>\n\u003cfigure id=\"attachment_264998\" class=\"wp-caption aligncenter\" style=\"max-width: 640px\">\u003ca href=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/10/radiology2.jpg\">\u003cimg class=\"size-large wp-image-264998\" src=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/10/radiology2-1180x953.jpg\" alt=\"1950s-era radiology at the U.S. Naval Hospital, Charleston, South Carolina.\" width=\"640\" height=\"517\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2019/10/radiology2-1180x953.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/13/2019/10/radiology2-400x323.jpg 400w, https://ww2.kqed.org/app/uploads/sites/13/2019/10/radiology2-743x600.jpg 743w, https://ww2.kqed.org/app/uploads/sites/13/2019/10/radiology2-768x620.jpg 768w, https://ww2.kqed.org/app/uploads/sites/13/2019/10/radiology2-1920x1550.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/13/2019/10/radiology2-960x775.jpg 960w\" sizes=\"(max-width: 640px) 100vw, 640px\">\u003c/a>\u003cfigcaption class=\"wp-caption-text\">1950s-era radiology at the U.S. Naval Hospital, Charleston, South Carolina. \u003ccite>(National Library of Medicine)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>The radiologists were lonely, sure, but their situation involves something far deeper. Hari Tsoukas, an expert in organizational studies at the University of Cyprus, highlights the distinction between “information” and “knowledge.” Information, he wrote, “consists of objectified, decontextualized, time-less, impersonal, value-free representations,” whereas knowledge is “context-dependent, personalized, time-bound, and infused with values.”\u003c/p>\n\u003cp>Adds Tillack, “Hunches, hypotheses, frustrations with patients or their families, second guessing, judging of colleagues, and similar activities that mark how uncertainty is negotiated on a daily basis in medical practice are rarely reflected in the medical record . . . this knowledge can only circulate in private or semi-private contexts—by its very definition, this knowledge cannot be made a matter of public record.”\u003c/p>\n\u003cp>By purging the informal conversations during which such information was exchanged, the emergence of PACS left radiologists information-rich (Think of all those pixels! And old films just a click away!), but knowledge-poor.\u003c/p>\n\u003cp>\u003cstrong>'Great Case. Next Case.'\u003c/strong>\u003c/p>\n\u003cp>Radiologists’ alienation runs deeper than the lack of collegial exchange and the inability to find out what’s really going on with the patients. It’s also about power, status, and expertise. The fact that the traditional film lived only in the radiology reading room gave radiologists a monopoly over their entire ecosystem. PACS, observes Tillack, created a new normal in which “the ‘right’ to see [the image] is no longer mediated by radiologists, as it was in the reading room,” and has thus “eroded radiologists’ claims for authoritative knowledge over the interpretation of medical images.”\u003c/p>\n\u003cp>Once the radiology department no longer housed the films, the impact was immediate and dramatic. Without any changes in policy or very much forethought, the mid-1990s transition to filmless operations at the Baltimore VA hospital led to an 82 percent decrease in in-person consultation rates for general radiology studies. Today, many clinicians—particularly specialists like neurologists, pulmonologists, and surgeons—look at images themselves and act on their own interpretations; Many don’t even bother to read the radiologist’s formal report (which usually takes several hours, sometimes even a day, to reach the chart) unless they have unanswered questions or judge the study to be particularly challenging.\u003c/p>\n\u003cp>PACS was to increase efficiency, but that virtue has also become a curse, as radiologists increasingly feel like Lucy and Ethel on the assembly line of the chocolate factory. Among teleradiologists (radiologists reading x-rays from a distant site, often covering emergency departments at night while the hospital’s own radiologists are sleeping), there’s a well-known adage that captures the relentless objectification of their modern predicament: “Great case. Next case.\" As with so many other aspects of our modern digital lives, PACS sped up the clock, and did so without mercy.\u003c/p>\n\u003cp>That clock is constantly ticking. “Instead of waiting for films to be acquired, printed, sorted, and hung, radiologists now are always playing catch-up, looking at more ‘stuff’ in less time,” observed Tillack. That miraculous access to old films also creates an obligation for the radiologist to actually review them.\u003c/p>\n\u003cp>And it’s not just the old films that need to be examined; PACS makes vast amounts of information available with every study. In the early days of CT, the output of a scan might have been about 12 “slices,” each one representing a ¼-inch section through the thorax or abdomen, akin to a thick slice of deli-cut salami. But today’s ultra-fast CT scanners can produce images of more than 50 slices per inch of the human body, more like ultra-thin cuts of prosciutto. And PACS, with its massive memory bank and blazingly fast transmission speeds,can easily display every slice, which means that the radiologist has to scroll through hundreds of images in order to read a single CT study. This combination of more information in each scan, more old studies to compare, and more time pressure is unremitting.\u003c/p>\n\u003cp>The clock is ticking for other reasons as well. Since the image is available to the ordering clinician the moment it is created, radiologists feel obliged to perform their review quickly lest their reading seem like old news, like an afternoon newspaper in the Age of Twitter. Piling on, after recognizing the efficiency of PACS, insurance companies and Medicare slashed the reimbursement for each interpretation, pushing radiologists to read more films in less time in order to maintain their incomes. Said one radiologist, “With PACS, work is busier now. We have 70 percent more cases to read than 10 years ago. . . . At the end of the day . . . I’m fried.”\u003c/p>\n\u003cp>On top of this, there are even greater threats to radiologists’ livelihoods and happiness. One of them flows from the growing pressure on health care systems to slash their costs. Currently, virtually every X-ray performed at a U.S. hospital is sent for a formal reading by a radiologist, who is paid a fee by an insurance company. In today’s cost-cutting environment, it’s probably only a matter of time before some health care systems permit their frontline specialists to officially read certain films, reserving radiologist “overreads” for those images that the clinicians have questions about or the ones with super-high malpractice risk if they are misread. Radiologists can be counted on to fight such a move by frantically waving the banner of quality, but they will need to demonstrate that the value of having them review every film is worth the considerable expense.\u003c/p>\n\u003cp>Moreover, a major theme of Obama-era health reform is a shift from our historical fee-for-service, piecework payment model to one that dispenses a single payment to a hospital and doctors to manage all the care for a group of patients (“accountable care organizations,” ACOs for short) or a given episode of disease (“bundled payments”). Under such systems, the risk for the cost of care shifts from the insurer to the providers, and it’s up to the latter to decide how to divvy up the cash. Ron Arenson, chairman of the department of radiology at the University of California, San Francisco, sees this as the greatest threat to his field.\u003c/p>\n\u003cp>“If the world moves to bundled payments, we won’t do well,” he said. “We’re not very high in the pecking order.”\u003c/p>\n\u003cp>Some nonradiologists, particularly ER doctors working nights and weekends, have little sympathy for their colleagues’ new predicament. In fact, they have begun to wonder why radiologists should be compensated for next-day readings when they’ve already looked at the images themselves, acted on their interpretations, and assumed the risk of being sued if anything goes wrong. In a 2011 editorial entitled “The Life Cycle of a Parasitic Specialist,” ER physician William Mallon took off the gloves.\u003c/p>\n\u003cblockquote>\u003cp>[On Monday morning] these parasites will commence to feed on the financial juices of the lowly unfortunate emergency physicians, who had to work the entire weekend without radiologic support or backup. . . . The radiologist arrives well rested, café latte in hand, and promptly installs himself in a dark room to re-read and bill for all the films the emergency physicians read over the weekend. . . . Never has a specialty done so little for so many and been paid so much.\u003c/p>\u003c/blockquote>\n\u003cp>Ouch.\u003c/p>\n\u003cp>Another challenge to radiology made possible by the death of film has come in the form of teleradiology. Once X-rays went digital, it was no longer crucial for radiologists to be in the same building as the patient or the treating clinicians. As a result, many multihospital systems consolidated their reading rooms, particularly on weekends and nights, with centralized radiologists supporting multiple sites. Predictably, once the technical challenges of connectivity were solved, teleradiology companies emerged to fill this need. As is often the case with contented “legacy” providers (in health care and other industries), traditional radiologists were only too happy to have their colleagues read their films during off-hours. Who wouldn’t be?\u003c/p>\n\u003cp>The playing field soon expanded across national borders, as radiologists in Zurich, Israel, and Singapore began to read nighttime X-rays for American hospitals during their own local daytimes. Hundreds of hospitals now use these \"nighthawks,\" and everybody seems happy about it, including the domestic radiologists, who are sleeping soundly while the overnight images are read half a world away.\u003c/p>\n\u003cp>But one wonders whether this is the start of so-called disruptive innovation, the concept made famous by Harvard’s Clay Christensen. Disruption often begins with a fat and happy incumbent content to preserve its existing enviable position in a market. In industries ranging from commercial aviation to steel manufacturing, an upstart comes in and grabs an unattractive part of the market (in this case, nights and weekends). But once a low-cost company has squeezed through a crack to capture a slice of a previously locked franchise, it is rarely content to stay put. With the average U.S. radiologist earning about $350,000 per year and the average Indian radiologist earning less than one-tenth of that, one wonders whether the same World-is-Flat forces that have revolutionized other industries but mostly bypassed health care will be unleashed.\u003c/p>\n\u003cp>This is where radiologists’ loss of trust and collegiality with other clinicians may exact its heaviest toll. “Some people see teleradiology as a big threat, but I don’t,” UCSF’s Arenson told me. “I think that relationships with radiologists are important.” I do too, which is why I believe he may have his head in the sand: If physicians don’t get much out of visiting the radiology department or have even forgotten where it is located, we have little reason to fight to keep it in our buildings. Or, for that matter, our country.\u003c/p>\n\u003cp>Like all legacy providers faced with a technological or global workforce threat, radiologists can be counted on to argue that quality would take a huge hit if we outsourced their work to less expensive providers, domestic or foreign. The degree to which the field has accepted nighttime readings from non-U.S. radiologists will, of course, undermine this argument. It’s hard to make the claim that a Bangalore-based teleradiologist is sufficiently competent to read an image for your hospital at 3 a.m., but not at 3 p.m.\u003c/p>\n\u003cp>\u003cstrong>The Ultimate Threat\u003c/strong>\u003c/p>\n\u003cp>Finally, there is the ultimate threat: replacement by the machine. Of course, this issue is marbled throughout health care as we enter the digital age. To date, most claims that “this technology will replace doctors” (in areas ranging from diagnostic reasoning to robotic surgery) have proven to be hype.\u003c/p>\n\u003cp>However, in fields that are primarily about visual pattern recognition, the promise (or, if you’re a radiologist, the threat) is much more real. Studies have shown that computers can detect significant numbers of breast cancers and pulmonary emboli missed by radiologists, although nobody has yet taken the bold step of having the computers completely supplant the humans, partly because there are armadas of malpractice attorneys waiting to pounce, and partly because, at least for now, the combination of human and machine seems to perform better than either alone.\u003c/p>\n\u003cp>But over the long haul, I wouldn’t bet on the humans here, particularly since one of the hottest areas in artificial intelligence research is “deep learning”—research that has created computers that are reasonably skilled at “reading,” “hearing,” and, yes, “seeing.” The same kind of software that now allows Facebook to guess that a certain collection of pixels is a picture of you, or that alerts the casino’s security guards to keep an eye on that guy, is likely to eventually crack the code in radiology, and in similar areas such as dermatology and pathology.\u003c/p>\n\u003cp>Slowly, radiologists are waking up to their peril. Rather than isolating themselves from clinical care, some are now relocating their reading stations in clinical areas, such as the ER and the ICU, to be in the line of sight of their clinician colleagues. Others are resurrecting interdisciplinary conferences and training their staff in customer service. Technological solutions that allow radiologists and frontline clinicians to communicate through PACS and the electronic health record are springing up (through programs that create a mash-up of a Skype-like communication tool and a John Madden–style telestrator).\u003c/p>\n\u003cp>Said Paul Chang, the University of Chicago radiologist whose advocacy of PACS so upset his father, “We have to go beyond isolating ourselves and concentrating on messages in a bottle, where we just write a report and are done with it, but instead fostering collaboration.”\u003c/p>\n\u003cp>Since radiology represents such a large segment of health care expenditures (and also a source of harm through the risk of radiation), some health care systems are even putting radiologists in the position of being gatekeepers to their own technology. It’s a role they might not have accepted in the past, but, faced with an existential threat, many now welcome it. Said David Levin, a radiologist at Thomas Jefferson University, “We have to act more like consulting physicians . . . to look at the appropriateness of the requests for advanced imaging studies . . . rather than just going ahead and doing the study.”\u003c/p>\n\u003cp>Radiology’s experience over the past 15 years offers a crystal ball for the rest of the health care system. The speed with which computerization unleashed a series of forces that completely transformed an established field would be all too familiar to travel agents, journalists, and others who have been run over by the digital bulldozer, but it has shocked many health care observers, even astute ones.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>Will the computerization of the rest of medicine similarly upend the lives of other kinds of doctors, as well as their patients? The early returns are in, and the answer is yes.\u003c/p>\n\n","blocks":[],"excerpt":"Because radiology was the first medical specialty to computerize, what has happened to it -- at once shocking and, in retrospect, entirely predictable -- is our canary in the digital coal mine.","status":"publish","parent":0,"modified":1514581391,"stats":{"hasAudio":false,"hasVideo":true,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":71,"wordCount":4601},"headData":{"title":"Has Technology Ruined the Radiology Profession? | KQED","description":"Because radiology was the first medical specialty to computerize, what has happened to it -- at once shocking and, in retrospect, entirely predictable -- is our canary in the digital coal mine.","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"Has Technology Ruined the Radiology Profession?","datePublished":"2017-01-28T17:30:45.000Z","dateModified":"2017-12-29T21:03:11.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"256816 http://ww2.kqed.org/futureofyou/?p=256816","disqusUrl":"https://ww2.kqed.org/futureofyou/2017/01/28/how-technology-ruined-the-radiology-profession/","disqusTitle":"Has Technology Ruined the Radiology Profession?","source":"Future of You","customPermalink":"2016/10/25/technology-radiology/","nprByline":"Bob Wachter","path":"/futureofyou/256816/how-technology-ruined-the-radiology-profession","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>\u003cem>This is an edited excerpt from Robert Wachter's \"\u003cem>\u003ca href=\"https://www.amazon.com/Digital-Doctor-Hope-Medicines-Computer/dp/0071849467\" target=\"_blank\" rel=\"noopener\">The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age\u003c/a>\u003c/em>,\" reprinted with permission from McGraw-Hill. Copyright 2015.\u003c/em>\u003c/p>\n\u003cp>\u003cspan style=\"font-size: 4.6875em;float: left;line-height: 0.733em;padding: 0.05em 0.1em 0 0;font-family: times, serif, georgia\">W\u003c/span>hen I was a medical student in the 1980s, the beating heart of the Hospital of the University of Pennsylvania was not the mahogany-lined executive suite, nor the dazzling operating room of L. Henry Edmunds, Jr., HUP's most famed cardiac surgeon. No, it was in the decidedly unglamorous, dimly lit Chest Reading room, where all the X-rays were hung on a moving contraption called an alternator that resembled the one on which the clothes hang at your local dry cleaner. Controlled by a seated radiologist operating a foot pedal, the machine would cycle through panel after panel until it arrived at your films. The radiologist took his foot off the pedal, the machine ground to a halt, and the dark X-ray sheets were brought to life by intense backlighting.\u003c/p>\n\u003cp>At Penn in the 1980s, everybody — and I mean everybody, from the lowliest student to the loftiest transplant surgeon — brought films for deciphering to the late Wallace Miller, Sr., a crusty but endearing professor of radiology and one of the best teachers I've ever known. For students like me, time spent with him was at once exhilarating and terrifying. \"What's this opacity?\" he asked me once, the memory burned into my hippocampus by that cognitive curing process known as overwhelming anxiety. \"A ... a pneumonia?\" I stammered.\u003c/p>\n\u003cp>\"Mooiaaa,\" retorted The Oracle, an unforgettable signature sound uttered as Miller smartly turned his head away in mock disgust. I loved it. We all did.\u003c/p>\n\u003caside class=\"pullquote alignright\">'One day I tried to see if I could go the whole day without speaking to anyone. And that’s what happened—I didn’t speak to a single person.'\u003ccite>A radiologist\u003c/cite>\u003c/aside>\n\u003cp>Today, many of my internal medicine trainees barely know where the radiology department is. Just as your record player and LPs are now long gone, in your local hospital today, the films, the analog X-ray machines, and even those charming film conveyor belts have left the building.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>Why? In 2000, only 8 percent of U.S. hospitals had some version of a game-changing computer technology called the Picture Archiving and Communications System, or PACS. By 2008, more than three out of four did.\u003c/p>\n\u003cp>Because radiology was the first medical specialty to computerize, what has happened to it — at once shocking and, in retrospect, entirely predictable — is our canary in the digital coal mine, its experience offering important lessons for patients, clinicians and health care systems.\u003c/p>\n\u003cp>\u003cstrong>The Beauty of PACS\u003c/strong>\u003c/p>\n\u003cp>While the main catalyst for PACS was economic, the quality of the images and the ability to manipulate them were also important. Unlike regular films, CT scans need to be viewed at various contrast levels: One setting is best to look at bones, another to look at lungs, and still another to look at soft tissue like muscle.\u003c/p>\n\u003cp>PACS allowed radiologists to toggle through these views, in the same way that Instagram lets you play with your photos. You can also use a nifty magnifying glass to zoom in on a part of the image. An unexpected benefit was “stacking”: rather than looking at 100 images arrayed in a 10 × 10 grid on a one-dimensional page, the images could be digitally stacked, one on top of another, allowing the radiologist to scroll through them swiftly by rolling a mouse ball. Moreover, computerization let the radiologist look at the images from home, enabling senior experts to weigh in on subtle findings that trainees might flub. And while the images were fuzzy at first, today they’re as crisp as high-definition television.\u003c/p>\n\u003cp>Perhaps most important, PACS obviated the need for maddening searches for prior X-rays. Twenty years ago, when a chest X-ray revealed a lung nodule, the first commandment on the radiologist’s report was to “obtain old films.” The rationale: If the nodule had been unchanged for many years, it could safely be ignored—such stability simply wasn’t consistent with a diagnosis of cancer. But searching for old films was often an exercise in frustration: They were lost, or locked up, or at another institution, or in a filing cabinet in the thoracic surgeon’s garage, behind the golf clubs. When my colleagues and I came up empty-handed, which was more often than not, the patient frequently paid the price in the form of an unnecessary biopsy. But PACS made finding old films a breeze (assuming that they were done at the same hospital or had been scanned into the system); they’re usually just a click away.\u003c/p>\n\u003cp>While PACS was widely anticipated and generally accepted by radiologists, some prescient observers worried that computerization might lead to unbidden effects on the field. In 1999, Stephen Baker, chair of the Department of Radiology at New Jersey Medical School, fretted that PACS might turn radiologists into “disembodied functionaries, more akin to servicing technicians than professional colleagues.” Paul Chang, professor of radiology at the University of Chicago and an early leader in digital radiology, describes the day his father, a retired radiologist, took him to task.\u003c/p>\n\u003cp>“Before PACS, we were the doctor’s doctor,” his father berated him. “Medicine and surgery rounds started in radiology. . . . Every morning the clinicians and the radiologists collaborated.”\u003c/p>\n\u003cp>His father’s less-than-endearing nickname for his famous son: “The Man Who Ruined Radiology.”\u003c/p>\n\u003cp>The advantages of PACS are so vast that few would want to turn back the clock. Yet the effects on those of us who order X-rays and the radiologists who read them have been profound, and they’re not all positive. The fact that we can now review our images without trekking down to radiology means that we rarely do make the trip.\u003c/p>\u003c/p>\u003cp>\u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutube'>\n \u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutubeInside'>\n \u003ciframe\n loading='lazy'\n class='utils-parseShortcode-shortcodes-__youtubeShortcode__youtubePlayer'\n type='text/html'\n src='//www.youtube.com/embed/fHUzVqoDnts'\n title='//www.youtube.com/embed/fHUzVqoDnts'\n allowfullscreen='true'\n style='border:0;'>\u003c/iframe>\n \u003c/span>\n \u003c/span>\u003c/p>\u003cp>\u003cp>\u003cstrong>An Awkward Trip to Radiology\u003c/strong>\u003c/p>\n\u003cp>A few years ago, when I asked my interns and students to visit the radiology department to review the key films, they looked at me as if I had grown a second head. After my team humored me by accompanying me to the radiology department, I conducted a little sociology experiment. Standing outside my hospital’s chest reading room, I delivered a brief speech:\u003c/p>\n\u003caside class=\"pullquote alignright\">'Did you look at the official report?' he hissed. The unspoken message was clear: Get out of my space; I’m busy.\u003c/aside>\n\u003cp>\"Watch what happens when we enter. Does anybody turn around and welcome us, ask, 'How can I help you?' and seem genuinely enthusiastic? When they go over the X-ray, do they delve a layer deeper than what they said in the formal report? Do they make any teaching points? Does the radiologist suggest courses of action or ask provocative questions?\"\u003c/p>\n\u003cp>I did this because I am deeply concerned that mine is the last generation to have learned the habit of going to the radiology department. Nostalgic for my interactions with Wally Miller and his like, it saddens me that our current trainees will never know how much they can learn from a great radiology teacher, and how much their patients’ care can be improved by actually talking to a real live radiologist. Yet I know that even if I bring my young horses to water, whether they visit the radiology department after I am no longer their wrangler will be determined by the quality of their experience.\u003c/p>\n\u003cp>We entered the chest reading room and were greeted by a wall of radiologists’ backs, their faces trained like lasers on the computer screens in front of them. Not a single head—located atop the shoulders of about eight different radiologists—turned to greet us.\u003c/p>\n\u003cp>After a couple of awkward minutes of crescendo throat-clearing, one of the radiologists grudgingly swiveled around to face my team and me. “Oh, do you need something?” he asked.\u003c/p>\n\u003cp>“Sure; can you help us look at a few films?”\u003c/p>\n\u003cp>He did, kind of, but offered his help in a whisper animated mostly by passive aggressiveness.\u003c/p>\n\u003cp>I thought it couldn’t get any worse, but it did.\u003c/p>\n\u003cp>“What do you think of this area?” I asked him, pointing to a confusing patch of whiteness on one patient’s chest CT scan.\u003c/p>\n\u003cp>“Did you look at the official report?” he hissed. (In other words: \"Perhaps you don’t know how to turn on your computer?\")\u003c/p>\n\u003cp>The unspoken message was clear: Get out of my space; I’m busy.\u003c/p>\n\u003cp>Now, I understand that he might well be busy, and that it has to be annoying having clinicians interrupt you every few minutes to go over images, particularly after you’ve just reviewed them with a different set of specialists and dictated a report. But that is the radiologist’s job. Or at least it used to be.\u003c/p>\n\u003cp>Allison Tillack, a young radiologist and a medical anthropologist whose Ph.D. thesis involved observing the world of radiologists for a year at a prominent academic hospital, has explored how the computerization of radiology has transformed the worlds of radiologists and those who use their services.\u003c/p>\n\u003cp>\"The ability of PACS to alter the accessibility and tempo of medical imaging has resulted in visits to the reading room being viewed now by non-radiology clinicians as a ‘waste of time’ and by radiologists as an ‘interruption,’” she wrote.\u003c/p>\n\u003cp>\u003cstrong>In a Funk\u003c/strong>\u003c/p>\n\u003cp>While I was well aware of the changing perceptions of radiology by nonradiologists, I had not, until I met Tillack, appreciated the degree to which the field of radiology is itself in a PACS-fueled funk.\u003c/p>\n\u003cp>After all, the field remains extremely popular among medical students, as many perceive it as offering the perfect blend of “great lifestyle” (that is, banker’s hours and limited overnight call) and high income, which averaged $340,000 in 2013. In fact, it’s often said that today’s medical students are attracted to the “ROAD specialties”: Radiology, Ophthalmology, Anesthesiology, and Dermatology, all of which are lucrative and none of which involves a lot of contact with those pesky sick people. In her research, Tillack found that the vast majority of radiologists and radiology residents identified the lack of direct patient contact as one of the main attractions of the field.\u003c/p>\n\u003cp>Given all these pluses, many frontline clinicians think of radiologists as having “won the game.” Yet I should have gotten a hint of the field’s handwringing in 2005, when I saw the results of a survey of physicians regarding their satisfaction with their chosen specialty. The happiest doctors were radiation oncologists (the folks who deliver radiation therapy to cancer patients), who do satisfying work, earn a good income, and have predictable hours. The least happy were cardiac surgeons, who train forever and, in recent years, have seen much of their business eroded by stents and other nonsurgical approaches to heart disease.\u003c/p>\n\u003cp>Radiologists show up a bit below the mean on the satisfaction scale—just behind the perennially overwhelmed and undercompensated primary care doctors.\u003c/p>\n\u003cp>In a 2012 paper, Tillack and a colleague described “the loneliness of the long distance radiologist.” One radiologist told them, “Before, I knew the face, name, wife’s name, and kids’ names of all the clinicians, but now I don’t know who you are if you joined the medical staff after we got PACS. . . . Before, when a clinician showed up, I could ask them and find out what’s really going on with the patient.”\u003c/p>\n\u003cp>I hear similar stories from every radiologist I meet. Patrick Luetmer, a Mayo Clinic neuroradiologist, described what happened when his MRI suite was remodeled. The suite was originally configured with two MRI “donuts” (the huge magnets that are responsible for the image) on either side of a central workstation in which Luetmer sat. There, he could monitor the scans as they were being performed, and talk to both the patients and the radiology assistants. Clinicians sometimes wandered down to look at the scans with him.\u003c/p>\n\u003cp>A few years ago, as part of a big efficiency push, Mayo decided that a third MRI machine was a better use of that central area than the radiologist’s air traffic control desk. Luetmer’s workstation was moved to an office a few hundred feet away, where he could follow the scans on his computer monitor and communicate with the techs via a special text messaging system.\u003c/p>\n\u003cp>“One day I tried to see if I could go the whole day without speaking to anyone. And that’s what happened—I didn’t speak to a single person. It was incredibly isolating.”\u003c/p>\n\u003cfigure id=\"attachment_264998\" class=\"wp-caption aligncenter\" style=\"max-width: 640px\">\u003ca href=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/10/radiology2.jpg\">\u003cimg class=\"size-large wp-image-264998\" src=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2019/10/radiology2-1180x953.jpg\" alt=\"1950s-era radiology at the U.S. Naval Hospital, Charleston, South Carolina.\" width=\"640\" height=\"517\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2019/10/radiology2-1180x953.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/13/2019/10/radiology2-400x323.jpg 400w, https://ww2.kqed.org/app/uploads/sites/13/2019/10/radiology2-743x600.jpg 743w, https://ww2.kqed.org/app/uploads/sites/13/2019/10/radiology2-768x620.jpg 768w, https://ww2.kqed.org/app/uploads/sites/13/2019/10/radiology2-1920x1550.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/13/2019/10/radiology2-960x775.jpg 960w\" sizes=\"(max-width: 640px) 100vw, 640px\">\u003c/a>\u003cfigcaption class=\"wp-caption-text\">1950s-era radiology at the U.S. Naval Hospital, Charleston, South Carolina. \u003ccite>(National Library of Medicine)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>The radiologists were lonely, sure, but their situation involves something far deeper. Hari Tsoukas, an expert in organizational studies at the University of Cyprus, highlights the distinction between “information” and “knowledge.” Information, he wrote, “consists of objectified, decontextualized, time-less, impersonal, value-free representations,” whereas knowledge is “context-dependent, personalized, time-bound, and infused with values.”\u003c/p>\n\u003cp>Adds Tillack, “Hunches, hypotheses, frustrations with patients or their families, second guessing, judging of colleagues, and similar activities that mark how uncertainty is negotiated on a daily basis in medical practice are rarely reflected in the medical record . . . this knowledge can only circulate in private or semi-private contexts—by its very definition, this knowledge cannot be made a matter of public record.”\u003c/p>\n\u003cp>By purging the informal conversations during which such information was exchanged, the emergence of PACS left radiologists information-rich (Think of all those pixels! And old films just a click away!), but knowledge-poor.\u003c/p>\n\u003cp>\u003cstrong>'Great Case. Next Case.'\u003c/strong>\u003c/p>\n\u003cp>Radiologists’ alienation runs deeper than the lack of collegial exchange and the inability to find out what’s really going on with the patients. It’s also about power, status, and expertise. The fact that the traditional film lived only in the radiology reading room gave radiologists a monopoly over their entire ecosystem. PACS, observes Tillack, created a new normal in which “the ‘right’ to see [the image] is no longer mediated by radiologists, as it was in the reading room,” and has thus “eroded radiologists’ claims for authoritative knowledge over the interpretation of medical images.”\u003c/p>\n\u003cp>Once the radiology department no longer housed the films, the impact was immediate and dramatic. Without any changes in policy or very much forethought, the mid-1990s transition to filmless operations at the Baltimore VA hospital led to an 82 percent decrease in in-person consultation rates for general radiology studies. Today, many clinicians—particularly specialists like neurologists, pulmonologists, and surgeons—look at images themselves and act on their own interpretations; Many don’t even bother to read the radiologist’s formal report (which usually takes several hours, sometimes even a day, to reach the chart) unless they have unanswered questions or judge the study to be particularly challenging.\u003c/p>\n\u003cp>PACS was to increase efficiency, but that virtue has also become a curse, as radiologists increasingly feel like Lucy and Ethel on the assembly line of the chocolate factory. Among teleradiologists (radiologists reading x-rays from a distant site, often covering emergency departments at night while the hospital’s own radiologists are sleeping), there’s a well-known adage that captures the relentless objectification of their modern predicament: “Great case. Next case.\" As with so many other aspects of our modern digital lives, PACS sped up the clock, and did so without mercy.\u003c/p>\n\u003cp>That clock is constantly ticking. “Instead of waiting for films to be acquired, printed, sorted, and hung, radiologists now are always playing catch-up, looking at more ‘stuff’ in less time,” observed Tillack. That miraculous access to old films also creates an obligation for the radiologist to actually review them.\u003c/p>\n\u003cp>And it’s not just the old films that need to be examined; PACS makes vast amounts of information available with every study. In the early days of CT, the output of a scan might have been about 12 “slices,” each one representing a ¼-inch section through the thorax or abdomen, akin to a thick slice of deli-cut salami. But today’s ultra-fast CT scanners can produce images of more than 50 slices per inch of the human body, more like ultra-thin cuts of prosciutto. And PACS, with its massive memory bank and blazingly fast transmission speeds,can easily display every slice, which means that the radiologist has to scroll through hundreds of images in order to read a single CT study. This combination of more information in each scan, more old studies to compare, and more time pressure is unremitting.\u003c/p>\n\u003cp>The clock is ticking for other reasons as well. Since the image is available to the ordering clinician the moment it is created, radiologists feel obliged to perform their review quickly lest their reading seem like old news, like an afternoon newspaper in the Age of Twitter. Piling on, after recognizing the efficiency of PACS, insurance companies and Medicare slashed the reimbursement for each interpretation, pushing radiologists to read more films in less time in order to maintain their incomes. Said one radiologist, “With PACS, work is busier now. We have 70 percent more cases to read than 10 years ago. . . . At the end of the day . . . I’m fried.”\u003c/p>\n\u003cp>On top of this, there are even greater threats to radiologists’ livelihoods and happiness. One of them flows from the growing pressure on health care systems to slash their costs. Currently, virtually every X-ray performed at a U.S. hospital is sent for a formal reading by a radiologist, who is paid a fee by an insurance company. In today’s cost-cutting environment, it’s probably only a matter of time before some health care systems permit their frontline specialists to officially read certain films, reserving radiologist “overreads” for those images that the clinicians have questions about or the ones with super-high malpractice risk if they are misread. Radiologists can be counted on to fight such a move by frantically waving the banner of quality, but they will need to demonstrate that the value of having them review every film is worth the considerable expense.\u003c/p>\n\u003cp>Moreover, a major theme of Obama-era health reform is a shift from our historical fee-for-service, piecework payment model to one that dispenses a single payment to a hospital and doctors to manage all the care for a group of patients (“accountable care organizations,” ACOs for short) or a given episode of disease (“bundled payments”). Under such systems, the risk for the cost of care shifts from the insurer to the providers, and it’s up to the latter to decide how to divvy up the cash. Ron Arenson, chairman of the department of radiology at the University of California, San Francisco, sees this as the greatest threat to his field.\u003c/p>\n\u003cp>“If the world moves to bundled payments, we won’t do well,” he said. “We’re not very high in the pecking order.”\u003c/p>\n\u003cp>Some nonradiologists, particularly ER doctors working nights and weekends, have little sympathy for their colleagues’ new predicament. In fact, they have begun to wonder why radiologists should be compensated for next-day readings when they’ve already looked at the images themselves, acted on their interpretations, and assumed the risk of being sued if anything goes wrong. In a 2011 editorial entitled “The Life Cycle of a Parasitic Specialist,” ER physician William Mallon took off the gloves.\u003c/p>\n\u003cblockquote>\u003cp>[On Monday morning] these parasites will commence to feed on the financial juices of the lowly unfortunate emergency physicians, who had to work the entire weekend without radiologic support or backup. . . . The radiologist arrives well rested, café latte in hand, and promptly installs himself in a dark room to re-read and bill for all the films the emergency physicians read over the weekend. . . . Never has a specialty done so little for so many and been paid so much.\u003c/p>\u003c/blockquote>\n\u003cp>Ouch.\u003c/p>\n\u003cp>Another challenge to radiology made possible by the death of film has come in the form of teleradiology. Once X-rays went digital, it was no longer crucial for radiologists to be in the same building as the patient or the treating clinicians. As a result, many multihospital systems consolidated their reading rooms, particularly on weekends and nights, with centralized radiologists supporting multiple sites. Predictably, once the technical challenges of connectivity were solved, teleradiology companies emerged to fill this need. As is often the case with contented “legacy” providers (in health care and other industries), traditional radiologists were only too happy to have their colleagues read their films during off-hours. Who wouldn’t be?\u003c/p>\n\u003cp>The playing field soon expanded across national borders, as radiologists in Zurich, Israel, and Singapore began to read nighttime X-rays for American hospitals during their own local daytimes. Hundreds of hospitals now use these \"nighthawks,\" and everybody seems happy about it, including the domestic radiologists, who are sleeping soundly while the overnight images are read half a world away.\u003c/p>\n\u003cp>But one wonders whether this is the start of so-called disruptive innovation, the concept made famous by Harvard’s Clay Christensen. Disruption often begins with a fat and happy incumbent content to preserve its existing enviable position in a market. In industries ranging from commercial aviation to steel manufacturing, an upstart comes in and grabs an unattractive part of the market (in this case, nights and weekends). But once a low-cost company has squeezed through a crack to capture a slice of a previously locked franchise, it is rarely content to stay put. With the average U.S. radiologist earning about $350,000 per year and the average Indian radiologist earning less than one-tenth of that, one wonders whether the same World-is-Flat forces that have revolutionized other industries but mostly bypassed health care will be unleashed.\u003c/p>\n\u003cp>This is where radiologists’ loss of trust and collegiality with other clinicians may exact its heaviest toll. “Some people see teleradiology as a big threat, but I don’t,” UCSF’s Arenson told me. “I think that relationships with radiologists are important.” I do too, which is why I believe he may have his head in the sand: If physicians don’t get much out of visiting the radiology department or have even forgotten where it is located, we have little reason to fight to keep it in our buildings. Or, for that matter, our country.\u003c/p>\n\u003cp>Like all legacy providers faced with a technological or global workforce threat, radiologists can be counted on to argue that quality would take a huge hit if we outsourced their work to less expensive providers, domestic or foreign. The degree to which the field has accepted nighttime readings from non-U.S. radiologists will, of course, undermine this argument. It’s hard to make the claim that a Bangalore-based teleradiologist is sufficiently competent to read an image for your hospital at 3 a.m., but not at 3 p.m.\u003c/p>\n\u003cp>\u003cstrong>The Ultimate Threat\u003c/strong>\u003c/p>\n\u003cp>Finally, there is the ultimate threat: replacement by the machine. Of course, this issue is marbled throughout health care as we enter the digital age. To date, most claims that “this technology will replace doctors” (in areas ranging from diagnostic reasoning to robotic surgery) have proven to be hype.\u003c/p>\n\u003cp>However, in fields that are primarily about visual pattern recognition, the promise (or, if you’re a radiologist, the threat) is much more real. Studies have shown that computers can detect significant numbers of breast cancers and pulmonary emboli missed by radiologists, although nobody has yet taken the bold step of having the computers completely supplant the humans, partly because there are armadas of malpractice attorneys waiting to pounce, and partly because, at least for now, the combination of human and machine seems to perform better than either alone.\u003c/p>\n\u003cp>But over the long haul, I wouldn’t bet on the humans here, particularly since one of the hottest areas in artificial intelligence research is “deep learning”—research that has created computers that are reasonably skilled at “reading,” “hearing,” and, yes, “seeing.” The same kind of software that now allows Facebook to guess that a certain collection of pixels is a picture of you, or that alerts the casino’s security guards to keep an eye on that guy, is likely to eventually crack the code in radiology, and in similar areas such as dermatology and pathology.\u003c/p>\n\u003cp>Slowly, radiologists are waking up to their peril. Rather than isolating themselves from clinical care, some are now relocating their reading stations in clinical areas, such as the ER and the ICU, to be in the line of sight of their clinician colleagues. Others are resurrecting interdisciplinary conferences and training their staff in customer service. Technological solutions that allow radiologists and frontline clinicians to communicate through PACS and the electronic health record are springing up (through programs that create a mash-up of a Skype-like communication tool and a John Madden–style telestrator).\u003c/p>\n\u003cp>Said Paul Chang, the University of Chicago radiologist whose advocacy of PACS so upset his father, “We have to go beyond isolating ourselves and concentrating on messages in a bottle, where we just write a report and are done with it, but instead fostering collaboration.”\u003c/p>\n\u003cp>Since radiology represents such a large segment of health care expenditures (and also a source of harm through the risk of radiation), some health care systems are even putting radiologists in the position of being gatekeepers to their own technology. It’s a role they might not have accepted in the past, but, faced with an existential threat, many now welcome it. Said David Levin, a radiologist at Thomas Jefferson University, “We have to act more like consulting physicians . . . to look at the appropriateness of the requests for advanced imaging studies . . . rather than just going ahead and doing the study.”\u003c/p>\n\u003cp>Radiology’s experience over the past 15 years offers a crystal ball for the rest of the health care system. The speed with which computerization unleashed a series of forces that completely transformed an established field would be all too familiar to travel agents, journalists, and others who have been run over by the digital bulldozer, but it has shocked many health care observers, even astute ones.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"floatright"},"numeric":["floatright"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>Will the computerization of the rest of medicine similarly upend the lives of other kinds of doctors, as well as their patients? The early returns are in, and the answer is yes.\u003c/p>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/256816/how-technology-ruined-the-radiology-profession","authors":["byline_futureofyou_256816"],"categories":["futureofyou_452","futureofyou_1","futureofyou_73"],"tags":["futureofyou_1105","futureofyou_1439","futureofyou_1104","futureofyou_1106"],"featImg":"futureofyou_264973","label":"source_futureofyou_256816"},"futureofyou_302169":{"type":"posts","id":"futureofyou_302169","meta":{"index":"posts_1591205157","site":"futureofyou","id":"302169","score":null,"sort":[1483459250000]},"guestAuthors":[],"slug":"for-first-week-january-on-social-media-the-self-as-its-own-object-of-worship","title":"In the Era of Instagram, Narcissism as the New Norm","publishDate":1483459250,"format":"standard","headTitle":"KQED Future of You | KQED Science","labelTerm":{"site":"futureofyou"},"content":"\u003cp>\u003cem>From the book \u003ca href=\"http://www.penguinrandomhouse.com/books/234876/the-attention-merchants-by-tim-wu/9780385352017/\" target=\"_blank\" rel=\"noopener\">THE ATTENTION MERCHANTS\u003c/a>, by Tim Wu. Copyright © 2016 by Tim Wu. Published by arrangement with Alfred A. Knopf, an imprint of The Knopf Doubleday Publishing Group, a division of Penguin Random House LLC.\u003c/em>\u003c/p>\n\u003cp>For most of human history, the proliferation of the individual likeness was the sole prerogative of the illustrious, whether it was the face of the emperor on a Roman coin or the face of Garbo on the silver screen. The commercialization of photography may have broadened access to portraiture somewhat, but apart from 'WANTED' posters, the image of most common people would never be widely propagated. In the 20th century, Hollywood created a cohort of demigods, whose image everyone recognized and many, in effect, worshiped.\u003c/p>\n\u003caside class=\"pullquote alignright\">'I feel anxiety over how many likes I get after I post a picture. If I get two likes, I feel like, what’s wrong with me?'\u003c/aside>\n\u003cp>With the arrival of the smartphone and Instagram, however, much of the power of a great film studio was now in every hand attached to a heart yearning for fame; not only could one create an image to rival those of the old icons of glamour, but one could put it on a platform where millions might potentially see it.\u003c/p>\n\u003cp>Perhaps a century of the ascendant self, of the self’s progressive liberation from any trammels not explicitly conceived to protect other selves, perhaps this progression, when wedded to the magic of technology serving not the state or even the corporation but the individual ego, perhaps it could reach no other logical endpoint, but the self as its own object of worship.\u003c/p>\n\u003cp>Of course, it is easy to denigrate as vanity even harmless forms of self-expression. Indulging in a bit of self-centeredness from time to time, playing with the trappings of fame, can be a form of entertainment for oneself and one’s friends, especially when undertaken with a sense of irony. Certainly, too, the self-portrait, and the even more patently ludicrous invention, the selfie stick, has become too easy a target for charges of self-involvement. Humans, after all, have sought the admiration of others in various ways since the dawn of time; it is a feature of our social and sexual natures. The desire of men and women to dress up and parade may be as deeply rooted as the peacock’s impulse to strut. Like all attention harvesters, Instagram has not stirred any new yearning within us, merely acted upon one already there, and facilitated its gratification to an unimaginable extent. Therein lies the real problem.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>Technology doesn’t follow culture so much as culture follows technology. New forms of expression naturally arise from new media, but so do new sensibilities and new behaviors. All desire, the philosopher and critic René Girard wrote, is essentially mimetic; beyond our elemental needs, we are led to seek after things by the example of others, those whom we may know personally or through their fame. When our desires go beyond the elemental, they enter into their metaphysical dimension, in which, as Girard wrote, “All desire is a desire to be,” to enjoy an image of fulfillment such as we have observed in others.\u003c/p>\n\u003cp>This is the essential problem with the preening self unbound by social media, and the democratization of fame. By presenting us with example upon example, it legitimates self-aggrandizement as an objective for ever more of us. By encouraging anyone to capture the attention of others with the spectacle of one’s self—in some cases, even to the point of earning a living by it—it warps our understanding of our own existence and its relation to others. That this should become the manner of being for us all is surely the definitive dystopic vision of late modernity.\u003c/p>\n\u003caside class=\"pullquote alignright\">Humans, after all, have sought the admiration of others in various ways since the dawn of time; it is a feature of our social and sexual natures.\u003c/aside>\n\u003cp>In the fall of 2015, an Australian teenager, Essena O’Neill, quit Instagram in utter despair. A natural beauty and part-time model, she had become an Instagram celebrity, thanks to her pictures, which had drawn half a million followers. But her Instagram career, she explained, had made her life a torment.\u003c/p>\n\u003cp>“I had the dream life. I had half a million people interested in me on Instagram. I had over a hundred thousand views on most of my videos on YouTube. To a lot of people, I made it,” she confessed in a video. But suddenly it had all become too much.\u003c/p>\n\u003cblockquote>\u003cp>Everything I was doing was edited and contrived and to get more views. . . . Everything I did was for views, for likes, for followers. . . . Social media, especially how I used it, isn’t real. It’s contrived images and edited clips ranked against each other. It’s a system based on social approval, likes, validation in views, success in followers. It’s perfectly orchestrated self-absorbed judgement. . . . I met people that are far more successful online than I am, and they are just as miserable and lonely and scared and lost. We all are.\u003c/p>\u003c/blockquote>\n\u003cp>A survey of Instagram and other social media users by the London Guardian yielded similar responses, suggesting that even among those with relatively few followers the commitment is grim. “I feel anxiety over how many likes I get after I post a picture. If I get two likes, I feel like, what’s wrong with me?” wrote one woman. “I do feel insecure if I see girls who look prettier than me,” wrote another, “or if they post really pretty pictures, and I know I won’t look as good in any that I post. I do feel pressure to look good in the photos I put up. I don’t feel anxious about not getting enough likes on a photo but if it doesn’t get enough likes, I will take it down.”\u003c/p>\n\u003cp>In April 2012, a mere 18 months after its debut, Instagram was purchased by Facebook for $1 billion. The high-flying start-up’s founders had cashed out without ever having devised a business model. No matter. By November the following year, the first ad feed would run in Instagram, following Facebook principles of limited targeting. The acquisition would prove astute. In April 2012 Instagram had 30 million users, but by the fall of 2015 it had 400 million, more than Twitter. And so Facebook would join the ranks of hoary behemoths with a war chest. A transfusion of young blood would preserve their status in the uppermost echelon of attention merchants.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>As for Instagram, its upward glide portended a future in which the line between the watcher and the watched, the buyer and the seller, was more blurred than ever. The once highly ordered attention economy had seemingly devolved into a chaotic mutual admiration society, full of enterprising Narcissi, surely an arrangement of affairs without real precedent in human history.\u003c/p>\n\n","blocks":[],"excerpt":"Social media has created an 'attention economy' that's devolved into a chaotic mutual admiration society, full of enterprising Narcissi, writes Tim Wu in his book, 'The Attention Merchants.' ","status":"publish","parent":0,"modified":1514587834,"stats":{"hasAudio":false,"hasVideo":false,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":15,"wordCount":1198},"headData":{"title":"In the Era of Instagram, Narcissism as the New Norm | KQED","description":"Social media has created an 'attention economy' that's devolved into a chaotic mutual admiration society, full of enterprising Narcissi, writes Tim Wu in his book, 'The Attention Merchants.' ","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"In the Era of Instagram, Narcissism as the New Norm","datePublished":"2017-01-03T16:00:50.000Z","dateModified":"2017-12-29T22:50:34.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"302169 http://ww2.kqed.org/futureofyou/?p=302169","disqusUrl":"https://ww2.kqed.org/futureofyou/2017/01/03/for-first-week-january-on-social-media-the-self-as-its-own-object-of-worship/","disqusTitle":"In the Era of Instagram, Narcissism as the New Norm","nprByline":"Tim Wu","path":"/futureofyou/302169/for-first-week-january-on-social-media-the-self-as-its-own-object-of-worship","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>\u003cem>From the book \u003ca href=\"http://www.penguinrandomhouse.com/books/234876/the-attention-merchants-by-tim-wu/9780385352017/\" target=\"_blank\" rel=\"noopener\">THE ATTENTION MERCHANTS\u003c/a>, by Tim Wu. Copyright © 2016 by Tim Wu. Published by arrangement with Alfred A. Knopf, an imprint of The Knopf Doubleday Publishing Group, a division of Penguin Random House LLC.\u003c/em>\u003c/p>\n\u003cp>For most of human history, the proliferation of the individual likeness was the sole prerogative of the illustrious, whether it was the face of the emperor on a Roman coin or the face of Garbo on the silver screen. The commercialization of photography may have broadened access to portraiture somewhat, but apart from 'WANTED' posters, the image of most common people would never be widely propagated. In the 20th century, Hollywood created a cohort of demigods, whose image everyone recognized and many, in effect, worshiped.\u003c/p>\n\u003caside class=\"pullquote alignright\">'I feel anxiety over how many likes I get after I post a picture. If I get two likes, I feel like, what’s wrong with me?'\u003c/aside>\n\u003cp>With the arrival of the smartphone and Instagram, however, much of the power of a great film studio was now in every hand attached to a heart yearning for fame; not only could one create an image to rival those of the old icons of glamour, but one could put it on a platform where millions might potentially see it.\u003c/p>\n\u003cp>Perhaps a century of the ascendant self, of the self’s progressive liberation from any trammels not explicitly conceived to protect other selves, perhaps this progression, when wedded to the magic of technology serving not the state or even the corporation but the individual ego, perhaps it could reach no other logical endpoint, but the self as its own object of worship.\u003c/p>\n\u003cp>Of course, it is easy to denigrate as vanity even harmless forms of self-expression. Indulging in a bit of self-centeredness from time to time, playing with the trappings of fame, can be a form of entertainment for oneself and one’s friends, especially when undertaken with a sense of irony. Certainly, too, the self-portrait, and the even more patently ludicrous invention, the selfie stick, has become too easy a target for charges of self-involvement. Humans, after all, have sought the admiration of others in various ways since the dawn of time; it is a feature of our social and sexual natures. The desire of men and women to dress up and parade may be as deeply rooted as the peacock’s impulse to strut. Like all attention harvesters, Instagram has not stirred any new yearning within us, merely acted upon one already there, and facilitated its gratification to an unimaginable extent. Therein lies the real problem.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>Technology doesn’t follow culture so much as culture follows technology. New forms of expression naturally arise from new media, but so do new sensibilities and new behaviors. All desire, the philosopher and critic René Girard wrote, is essentially mimetic; beyond our elemental needs, we are led to seek after things by the example of others, those whom we may know personally or through their fame. When our desires go beyond the elemental, they enter into their metaphysical dimension, in which, as Girard wrote, “All desire is a desire to be,” to enjoy an image of fulfillment such as we have observed in others.\u003c/p>\n\u003cp>This is the essential problem with the preening self unbound by social media, and the democratization of fame. By presenting us with example upon example, it legitimates self-aggrandizement as an objective for ever more of us. By encouraging anyone to capture the attention of others with the spectacle of one’s self—in some cases, even to the point of earning a living by it—it warps our understanding of our own existence and its relation to others. That this should become the manner of being for us all is surely the definitive dystopic vision of late modernity.\u003c/p>\n\u003caside class=\"pullquote alignright\">Humans, after all, have sought the admiration of others in various ways since the dawn of time; it is a feature of our social and sexual natures.\u003c/aside>\n\u003cp>In the fall of 2015, an Australian teenager, Essena O’Neill, quit Instagram in utter despair. A natural beauty and part-time model, she had become an Instagram celebrity, thanks to her pictures, which had drawn half a million followers. But her Instagram career, she explained, had made her life a torment.\u003c/p>\n\u003cp>“I had the dream life. I had half a million people interested in me on Instagram. I had over a hundred thousand views on most of my videos on YouTube. To a lot of people, I made it,” she confessed in a video. But suddenly it had all become too much.\u003c/p>\n\u003cblockquote>\u003cp>Everything I was doing was edited and contrived and to get more views. . . . Everything I did was for views, for likes, for followers. . . . Social media, especially how I used it, isn’t real. It’s contrived images and edited clips ranked against each other. It’s a system based on social approval, likes, validation in views, success in followers. It’s perfectly orchestrated self-absorbed judgement. . . . I met people that are far more successful online than I am, and they are just as miserable and lonely and scared and lost. We all are.\u003c/p>\u003c/blockquote>\n\u003cp>A survey of Instagram and other social media users by the London Guardian yielded similar responses, suggesting that even among those with relatively few followers the commitment is grim. “I feel anxiety over how many likes I get after I post a picture. If I get two likes, I feel like, what’s wrong with me?” wrote one woman. “I do feel insecure if I see girls who look prettier than me,” wrote another, “or if they post really pretty pictures, and I know I won’t look as good in any that I post. I do feel pressure to look good in the photos I put up. I don’t feel anxious about not getting enough likes on a photo but if it doesn’t get enough likes, I will take it down.”\u003c/p>\n\u003cp>In April 2012, a mere 18 months after its debut, Instagram was purchased by Facebook for $1 billion. The high-flying start-up’s founders had cashed out without ever having devised a business model. No matter. By November the following year, the first ad feed would run in Instagram, following Facebook principles of limited targeting. The acquisition would prove astute. In April 2012 Instagram had 30 million users, but by the fall of 2015 it had 400 million, more than Twitter. And so Facebook would join the ranks of hoary behemoths with a war chest. A transfusion of young blood would preserve their status in the uppermost echelon of attention merchants.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"floatright"},"numeric":["floatright"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>As for Instagram, its upward glide portended a future in which the line between the watcher and the watched, the buyer and the seller, was more blurred than ever. The once highly ordered attention economy had seemingly devolved into a chaotic mutual admiration society, full of enterprising Narcissi, surely an arrangement of affairs without real precedent in human history.\u003c/p>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/302169/for-first-week-january-on-social-media-the-self-as-its-own-object-of-worship","authors":["byline_futureofyou_302169"],"categories":["futureofyou_1","futureofyou_1061"],"tags":["futureofyou_1439","futureofyou_178","futureofyou_1022","futureofyou_1115","futureofyou_174","futureofyou_1155"],"featImg":"futureofyou_304140","label":"futureofyou"},"futureofyou_180495":{"type":"posts","id":"futureofyou_180495","meta":{"index":"posts_1591205157","site":"futureofyou","id":"180495","score":null,"sort":[1480435233000]},"guestAuthors":[],"slug":"clinical-trials-on-trial-the-ethics-of-withholding-life-saving-treatment","title":"The Ethics of Withholding Life-Saving Treatment","publishDate":1480435233,"format":"standard","headTitle":"KQED Future of You | KQED Science","labelTerm":{},"content":"\u003cp>\u003cem>From the authors of \"\u003ca href=\"http://us.macmillan.com/algorithmstoliveby/brianchristian\" target=\"_blank\">ALGORITHMS TO LIVE BY: The Computer Science of Human Decisions\u003c/a>,\" published by Henry Hold and Co.\u003c/em>\u003c/p>\n\u003cp>Every day we make a series of choices that are all really the same choice underneath: between our \u003cem>favorite\u003c/em> things and \u003cem>new\u003c/em> ones. Do we go to the restaurant we adore, or the place down the road that just opened up? Get our “usual,” or try the special? Invite our best friend, or reach out to a new acquaintance we’d like to get to know better? We intuitively understand that life is a balance between novelty and familiarity, between the latest and the greatest, between taking chances and savoring what we know and love. But the unanswered question is: What is that balance?\u003c/p>\n\u003caside class=\"pullquote alignright\">The cost of knowledge: Twenty-four more infants died in a group receiving conventional treatment than in a group receiving the treatment being tested.\u003c/aside>\n\u003cp>It’s a question with higher stakes than we might realize. And it has a more explicit answer, from a field we don’t often turn to in moments of human indecision, though perhaps we should: computer science. Indeed, computer scientists have been working on finding this balance for more than 50 years. They even have a name for it: the “explore/exploit” tradeoff.\u003c/p>\n\u003cp>Today, algorithms derived from studying the explore/exploit tradeoff power a sizable fraction of the Internet economy, including the advertising business responsible for almost all of Google’s revenue -- they determine when to display the ad that has performed the best so far and when to experiment with potentially superior alternatives. Algorithms have also become essential to political campaigning, an indispensable part of honing messaging and donation appeals.\u003c/p>\n\u003cp>The single most important application of explore/exploit algorithms, however, is a domain where human lives are directly on the line. That domain is clinical trials, and a growing community of doctors, statisticians, and computer scientists think we’re doing them wrong.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>In English, the words “explore” and “exploit” come loaded with opposite connotations. But to a computer scientist, these words have much more specific and neutral meanings. Simply put, exploration is \u003cem>gathering\u003c/em> information, and exploitation is \u003cem>using\u003c/em> the information you have to get a known good result. It’s fairly intuitive that never exploring is no way to live. But computer science shows that failing to exploit can be every bit as bad.\u003c/p>\n\u003cfigure id=\"attachment_180526\" class=\"wp-caption aligncenter\" style=\"max-width: 2592px\">\u003ca href=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program.jpg\">\u003cimg class=\"size-full wp-image-180526\" src=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program.jpg\" alt=\"Respiratory therapist Michelle Sirra takes a blood sample from 3-day-old Stuart Parker in preparation for transfer to an Extracorporeal Membrane Oxygenation unit on Friday, July 21, in San Juan, Puerto Rico. An ECMO team comprised Air Force and Army medical specialists from the Wilford Hall Medical Center at Lackland Air Force Base, Texas, flew to Puerto Rico to transport Stuart to San Antonio for more advanced care. \" width=\"2592\" height=\"1944\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program.jpg 2592w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program-400x300.jpg 400w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program-800x600.jpg 800w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program-768x576.jpg 768w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program-1180x885.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program-1920x1440.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program-960x720.jpg 960w\" sizes=\"(max-width: 2592px) 100vw, 2592px\">\u003c/a>\u003cfigcaption class=\"wp-caption-text\">Respiratory therapist Michelle Sirra takes a blood sample from 3-day-old Stuart Parker in preparation for transfer to an Extracorporeal Membrane Oxygenation unit on Friday, July 21, in San Juan, Puerto Rico. An ECMO team comprised Air Force and Army medical specialists from the Wilford Hall Medical Center at Lackland Air Force Base, Texas, flew to Puerto Rico to transport Stuart to San Antonio for more advanced care. \u003ccite>(Staff Sgt. Matthew Rosine)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>One of the fundamental maxims in medical ethics is the oath to “first, do no harm.” But this is not always as straightforward as it sounds. In clinical trials, doctors and scientists encounter directly the tension between acting on one’s best knowledge and gathering more. Do you give someone the best known conventional treatment, even if it’s not very good? Or do you give them an experimental treatment that \u003cem>might \u003c/em>be significantly better—but might also be worse? Computer science is no substitute for ethics, but perhaps it can offer a degree of precision that ethics alone cannot.\u003c/p>\n\u003cp>The question that has arisen over the last several decades is whether the standard approach to conducting clinical trials really does minimize risk to patients. In a conventional clinical trial, patients are split into equal groups, and each group is assigned to receive a different treatment for the duration of the study. (Only in exceptional cases does a trial get stopped early.) This procedure focuses on decisively resolving the question of which treatment is better, rather than on providing the best treatment to each patient in the trial itself. Maybe this is a false choice. Doctors are gaining some information about which option is better \u003cem>while\u003c/em> the trial proceeds—information that could be used to improve outcomes not only for future patients beyond the trial, but also for the patients currently in it.\u003c/p>\n\u003cp>\u003ca href=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2016/06/iStock_17372419_LARGE.jpg\">\u003cimg class=\"aligncenter size-full wp-image-180561\" src=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2016/06/iStock_17372419_LARGE.jpg\" alt=\"Juggling balls\" width=\"2715\" height=\"1810\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2016/06/iStock_17372419_LARGE.jpg 2715w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/iStock_17372419_LARGE-400x267.jpg 400w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/iStock_17372419_LARGE-800x533.jpg 800w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/iStock_17372419_LARGE-768x512.jpg 768w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/iStock_17372419_LARGE-1180x787.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/iStock_17372419_LARGE-1920x1280.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/iStock_17372419_LARGE-960x640.jpg 960w\" sizes=\"(max-width: 2715px) 100vw, 2715px\">\u003c/a>In 1969, Marvin Zelen, a biostatistician who spent most of his career at Harvard, proposed conducting “adaptive” trials, in which the chance of using a given treatment increases with each success and decreases with each failure. In his proposal, you start with a hat that contains one ball for each of the two treatment options being studied. The treatment for the first patient is selected by drawing a ball at random from the hat. (The ball is put back afterward.) If the chosen treatment is a success, you put another ball of the same kind into the hat—now you have three balls, two of which are for the successful treatment. If it fails, however, then you instead put another ball for the \u003cem>other\u003c/em> treatment into the hat, making it more likely you’ll choose the alternative.\u003c/p>\n\u003cp>Zelen’s algorithm was first used in a clinical trial 16 years later, for a study of extracorporeal membrane oxygenation, or “ECMO”—an audacious approach to treating respiratory failure in infants. Developed in the 1970s by Robert Bartlett of the University of Michigan, ECMO takes blood that’s heading for the lungs and routes it instead out of the body, where it is oxygenated by a machine and returned to the heart. It is a drastic measure, with risks of its own (including the possibility of embolism), but it offered a possible approach in situations where no other options remained. In 1975 ECMO saved the life of a newborn girl in Orange County, California, for whom even a ventilator was not providing enough oxygen. But in its early days the ECMO technology and procedure were considered highly experimental, and early studies in adults showed no benefit compared to conventional treatments.\u003c/p>\n\u003cp>From 1982 to 1984, Bartlett and his colleagues at the University of Michigan performed a study on newborns with respiratory failure. The team was clear that they wanted to address, as they put it, “the ethical issue of withholding an unproven but potentially lifesaving treatment,” and were “reluctant to withhold a lifesaving treatment from alternate patients simply to meet conventional random assignment technique.” Hence they turned to Zelen’s algorithm. The strategy resulted in one infant being assigned the “conventional” treatment and dying, and 11 infants in a row being assigned the experimental ECMO treatment, all of them surviving. Between April and November of 1984, after the end of the official study, 10 additional infants met the criteria for ECMO treatment. Eight were treated with ECMO, and all eight survived. Two were treated conventionally, and both died.\u003c/p>\n\u003cp>These are eye-catching numbers, yet shortly after the University of Michigan study on ECMO was completed, it became mired in controversy. Having so few patients in a trial receive the conventional treatment deviated significantly from standard methodology, and the procedure itself was highly invasive and potentially risky. After the publication of the paper, Jim Ware, professor of biostatistics at the Harvard School of Public Health, and his medical colleagues examined the data carefully and concluded that they “did not justify routine use of ECMO without further study.” So Ware and his colleagues designed a second clinical trial, still trying to balance the acquisition of knowledge with the effective treatment of patients but using a less radical design. They would randomly assign patients to either ECMO or the conventional treatment until a pre-specified number of deaths was observed in one of the groups. Then they would switch all the patients in the study to the more effective treatment of the two.\u003c/p>\n\u003cp>In the first phase of Ware’s study, four of 10 infants receiving conventional treatment died, and all of the nine infants receiving ECMO survived. The four deaths were enough to trigger a transition to the second phase, where all 20 patients were treated with ECMO and 19 survived. Ware and colleagues were convinced, concluding that “it is difficult to defend further randomization ethically.”\u003c/p>\n\u003cp>[contextly_sidebar id=\"4oUXD2ItgXLntfzkJ3EfFLruRYG726oT\"]But some had already concluded this \u003cem>before\u003c/em> the Ware study, and were vocal about it. The critics included Don Berry, one of the world’s leading experts on the explore/exploit tradeoff. In a comment that was published alongside the Ware study, Berry wrote that “randomizing patients to non-ECMO therapy as in the Ware study was unethical. . . . In my view, the Ware study should not have been conducted.”\u003c/p>\n\u003cp>And yet even the Ware study was not conclusive for all in the medical community. In the 1990s yet another study on ECMO was conducted, enrolling nearly 200 infants in the United Kingdom. Instead of using adaptive algorithms, this study followed the traditional methods, splitting the infants randomly into two equal groups. The researchers justified the experiment by saying that ECMO’s usefulness “is controversial because of varying interpretation of the available evidence.” As it turned out, the difference between the treatments wasn’t as pronounced in the United Kingdom as it had been in the two American studies, but the results were nonetheless declared “in accord with the earlier preliminary findings that a policy of ECMO support reduces the risk of death.” The cost of that knowledge? Twenty-four more infants died in the “conventional” group than in the group receiving ECMO treatment.\u003c/p>\n\u003cp>Zelen’s algorithm offers one simple way to navigate the explore/exploit tradeoff, and in the decades since it was first proposed, computer scientists have developed a host of even more refined strategies for how best to gain new information while leveraging what’s been gained so far. These approaches are finally beginning to gain acceptance within the medical mainstream\u003cstrong>.\u003c/strong> Don Berry, for example, has joined the MD Anderson Cancer Center in Houston, where he uses methods developed by studying the explore/exploit tradeoff to design clinical trials for a variety of cancer treatments. And in 2010 and 2015, the FDA released a pair of draft “guidance” documents on “Adaptive Design Clinical Trials” for drugs and medical devices, which suggests that—despite a long history of sticking to an option they trust—they might at last be willing to explore alternatives.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>We don’t think of a doctor choosing which treatment to give a patient as being in the same position as Google’s servers deciding which ad to show next. And we don’t think of Google’s ad servers when we waver over whether to get our favorite dish yet again or branch out. But computer science shows us that these are, in a fundamental and real way, the same problem. In so doing, it offers a profound glimpse into the structure of human decision-making. And a guide for us, in the times when it matters most.\u003c/p>\n\n","blocks":[],"excerpt":"The authors of 'Algorithms to Live By' say the conventional way clinical trials are conducted do not always live up to the medical maxim 'First, do no harm.'","status":"publish","parent":0,"modified":1514569063,"stats":{"hasAudio":false,"hasVideo":false,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":19,"wordCount":1888},"headData":{"title":"The Ethics of Withholding Life-Saving Treatment | KQED","description":"The authors of 'Algorithms to Live By' say the conventional way clinical trials are conducted do not always live up to the medical maxim 'First, do no harm.'","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"The Ethics of Withholding Life-Saving Treatment","datePublished":"2016-11-29T16:00:33.000Z","dateModified":"2017-12-29T17:37:43.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"180495 http://ww2.kqed.org/futureofyou/?p=180495","disqusUrl":"https://ww2.kqed.org/futureofyou/2016/11/29/clinical-trials-on-trial-the-ethics-of-withholding-life-saving-treatment/","disqusTitle":"The Ethics of Withholding Life-Saving Treatment","source":"Big Ideas","customPermalink":"2016/06/10/clinical-trials-on-trial-the-ethics-of-withholding-life-saving-treatment/","nprByline":"Brian Christian and Tom Griffiths","path":"/futureofyou/180495/clinical-trials-on-trial-the-ethics-of-withholding-life-saving-treatment","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>\u003cem>From the authors of \"\u003ca href=\"http://us.macmillan.com/algorithmstoliveby/brianchristian\" target=\"_blank\">ALGORITHMS TO LIVE BY: The Computer Science of Human Decisions\u003c/a>,\" published by Henry Hold and Co.\u003c/em>\u003c/p>\n\u003cp>Every day we make a series of choices that are all really the same choice underneath: between our \u003cem>favorite\u003c/em> things and \u003cem>new\u003c/em> ones. Do we go to the restaurant we adore, or the place down the road that just opened up? Get our “usual,” or try the special? Invite our best friend, or reach out to a new acquaintance we’d like to get to know better? We intuitively understand that life is a balance between novelty and familiarity, between the latest and the greatest, between taking chances and savoring what we know and love. But the unanswered question is: What is that balance?\u003c/p>\n\u003caside class=\"pullquote alignright\">The cost of knowledge: Twenty-four more infants died in a group receiving conventional treatment than in a group receiving the treatment being tested.\u003c/aside>\n\u003cp>It’s a question with higher stakes than we might realize. And it has a more explicit answer, from a field we don’t often turn to in moments of human indecision, though perhaps we should: computer science. Indeed, computer scientists have been working on finding this balance for more than 50 years. They even have a name for it: the “explore/exploit” tradeoff.\u003c/p>\n\u003cp>Today, algorithms derived from studying the explore/exploit tradeoff power a sizable fraction of the Internet economy, including the advertising business responsible for almost all of Google’s revenue -- they determine when to display the ad that has performed the best so far and when to experiment with potentially superior alternatives. Algorithms have also become essential to political campaigning, an indispensable part of honing messaging and donation appeals.\u003c/p>\n\u003cp>The single most important application of explore/exploit algorithms, however, is a domain where human lives are directly on the line. That domain is clinical trials, and a growing community of doctors, statisticians, and computer scientists think we’re doing them wrong.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>In English, the words “explore” and “exploit” come loaded with opposite connotations. But to a computer scientist, these words have much more specific and neutral meanings. Simply put, exploration is \u003cem>gathering\u003c/em> information, and exploitation is \u003cem>using\u003c/em> the information you have to get a known good result. It’s fairly intuitive that never exploring is no way to live. But computer science shows that failing to exploit can be every bit as bad.\u003c/p>\n\u003cfigure id=\"attachment_180526\" class=\"wp-caption aligncenter\" style=\"max-width: 2592px\">\u003ca href=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program.jpg\">\u003cimg class=\"size-full wp-image-180526\" src=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program.jpg\" alt=\"Respiratory therapist Michelle Sirra takes a blood sample from 3-day-old Stuart Parker in preparation for transfer to an Extracorporeal Membrane Oxygenation unit on Friday, July 21, in San Juan, Puerto Rico. An ECMO team comprised Air Force and Army medical specialists from the Wilford Hall Medical Center at Lackland Air Force Base, Texas, flew to Puerto Rico to transport Stuart to San Antonio for more advanced care. \" width=\"2592\" height=\"1944\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program.jpg 2592w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program-400x300.jpg 400w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program-800x600.jpg 800w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program-768x576.jpg 768w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program-1180x885.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program-1920x1440.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/A_Resperatory_Therapist_treating_a_newborn_child_Pulaski_County_Technical_College_Respiratory_Therapist_Program-960x720.jpg 960w\" sizes=\"(max-width: 2592px) 100vw, 2592px\">\u003c/a>\u003cfigcaption class=\"wp-caption-text\">Respiratory therapist Michelle Sirra takes a blood sample from 3-day-old Stuart Parker in preparation for transfer to an Extracorporeal Membrane Oxygenation unit on Friday, July 21, in San Juan, Puerto Rico. An ECMO team comprised Air Force and Army medical specialists from the Wilford Hall Medical Center at Lackland Air Force Base, Texas, flew to Puerto Rico to transport Stuart to San Antonio for more advanced care. \u003ccite>(Staff Sgt. Matthew Rosine)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>One of the fundamental maxims in medical ethics is the oath to “first, do no harm.” But this is not always as straightforward as it sounds. In clinical trials, doctors and scientists encounter directly the tension between acting on one’s best knowledge and gathering more. Do you give someone the best known conventional treatment, even if it’s not very good? Or do you give them an experimental treatment that \u003cem>might \u003c/em>be significantly better—but might also be worse? Computer science is no substitute for ethics, but perhaps it can offer a degree of precision that ethics alone cannot.\u003c/p>\n\u003cp>The question that has arisen over the last several decades is whether the standard approach to conducting clinical trials really does minimize risk to patients. In a conventional clinical trial, patients are split into equal groups, and each group is assigned to receive a different treatment for the duration of the study. (Only in exceptional cases does a trial get stopped early.) This procedure focuses on decisively resolving the question of which treatment is better, rather than on providing the best treatment to each patient in the trial itself. Maybe this is a false choice. Doctors are gaining some information about which option is better \u003cem>while\u003c/em> the trial proceeds—information that could be used to improve outcomes not only for future patients beyond the trial, but also for the patients currently in it.\u003c/p>\n\u003cp>\u003ca href=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2016/06/iStock_17372419_LARGE.jpg\">\u003cimg class=\"aligncenter size-full wp-image-180561\" src=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2016/06/iStock_17372419_LARGE.jpg\" alt=\"Juggling balls\" width=\"2715\" height=\"1810\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2016/06/iStock_17372419_LARGE.jpg 2715w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/iStock_17372419_LARGE-400x267.jpg 400w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/iStock_17372419_LARGE-800x533.jpg 800w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/iStock_17372419_LARGE-768x512.jpg 768w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/iStock_17372419_LARGE-1180x787.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/iStock_17372419_LARGE-1920x1280.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/13/2016/06/iStock_17372419_LARGE-960x640.jpg 960w\" sizes=\"(max-width: 2715px) 100vw, 2715px\">\u003c/a>In 1969, Marvin Zelen, a biostatistician who spent most of his career at Harvard, proposed conducting “adaptive” trials, in which the chance of using a given treatment increases with each success and decreases with each failure. In his proposal, you start with a hat that contains one ball for each of the two treatment options being studied. The treatment for the first patient is selected by drawing a ball at random from the hat. (The ball is put back afterward.) If the chosen treatment is a success, you put another ball of the same kind into the hat—now you have three balls, two of which are for the successful treatment. If it fails, however, then you instead put another ball for the \u003cem>other\u003c/em> treatment into the hat, making it more likely you’ll choose the alternative.\u003c/p>\n\u003cp>Zelen’s algorithm was first used in a clinical trial 16 years later, for a study of extracorporeal membrane oxygenation, or “ECMO”—an audacious approach to treating respiratory failure in infants. Developed in the 1970s by Robert Bartlett of the University of Michigan, ECMO takes blood that’s heading for the lungs and routes it instead out of the body, where it is oxygenated by a machine and returned to the heart. It is a drastic measure, with risks of its own (including the possibility of embolism), but it offered a possible approach in situations where no other options remained. In 1975 ECMO saved the life of a newborn girl in Orange County, California, for whom even a ventilator was not providing enough oxygen. But in its early days the ECMO technology and procedure were considered highly experimental, and early studies in adults showed no benefit compared to conventional treatments.\u003c/p>\n\u003cp>From 1982 to 1984, Bartlett and his colleagues at the University of Michigan performed a study on newborns with respiratory failure. The team was clear that they wanted to address, as they put it, “the ethical issue of withholding an unproven but potentially lifesaving treatment,” and were “reluctant to withhold a lifesaving treatment from alternate patients simply to meet conventional random assignment technique.” Hence they turned to Zelen’s algorithm. The strategy resulted in one infant being assigned the “conventional” treatment and dying, and 11 infants in a row being assigned the experimental ECMO treatment, all of them surviving. Between April and November of 1984, after the end of the official study, 10 additional infants met the criteria for ECMO treatment. Eight were treated with ECMO, and all eight survived. Two were treated conventionally, and both died.\u003c/p>\n\u003cp>These are eye-catching numbers, yet shortly after the University of Michigan study on ECMO was completed, it became mired in controversy. Having so few patients in a trial receive the conventional treatment deviated significantly from standard methodology, and the procedure itself was highly invasive and potentially risky. After the publication of the paper, Jim Ware, professor of biostatistics at the Harvard School of Public Health, and his medical colleagues examined the data carefully and concluded that they “did not justify routine use of ECMO without further study.” So Ware and his colleagues designed a second clinical trial, still trying to balance the acquisition of knowledge with the effective treatment of patients but using a less radical design. They would randomly assign patients to either ECMO or the conventional treatment until a pre-specified number of deaths was observed in one of the groups. Then they would switch all the patients in the study to the more effective treatment of the two.\u003c/p>\n\u003cp>In the first phase of Ware’s study, four of 10 infants receiving conventional treatment died, and all of the nine infants receiving ECMO survived. The four deaths were enough to trigger a transition to the second phase, where all 20 patients were treated with ECMO and 19 survived. Ware and colleagues were convinced, concluding that “it is difficult to defend further randomization ethically.”\u003c/p>\n\u003cp>\u003c/p>\u003cp>\u003c/p>\u003cp>But some had already concluded this \u003cem>before\u003c/em> the Ware study, and were vocal about it. The critics included Don Berry, one of the world’s leading experts on the explore/exploit tradeoff. In a comment that was published alongside the Ware study, Berry wrote that “randomizing patients to non-ECMO therapy as in the Ware study was unethical. . . . In my view, the Ware study should not have been conducted.”\u003c/p>\n\u003cp>And yet even the Ware study was not conclusive for all in the medical community. In the 1990s yet another study on ECMO was conducted, enrolling nearly 200 infants in the United Kingdom. Instead of using adaptive algorithms, this study followed the traditional methods, splitting the infants randomly into two equal groups. The researchers justified the experiment by saying that ECMO’s usefulness “is controversial because of varying interpretation of the available evidence.” As it turned out, the difference between the treatments wasn’t as pronounced in the United Kingdom as it had been in the two American studies, but the results were nonetheless declared “in accord with the earlier preliminary findings that a policy of ECMO support reduces the risk of death.” The cost of that knowledge? Twenty-four more infants died in the “conventional” group than in the group receiving ECMO treatment.\u003c/p>\n\u003cp>Zelen’s algorithm offers one simple way to navigate the explore/exploit tradeoff, and in the decades since it was first proposed, computer scientists have developed a host of even more refined strategies for how best to gain new information while leveraging what’s been gained so far. These approaches are finally beginning to gain acceptance within the medical mainstream\u003cstrong>.\u003c/strong> Don Berry, for example, has joined the MD Anderson Cancer Center in Houston, where he uses methods developed by studying the explore/exploit tradeoff to design clinical trials for a variety of cancer treatments. And in 2010 and 2015, the FDA released a pair of draft “guidance” documents on “Adaptive Design Clinical Trials” for drugs and medical devices, which suggests that—despite a long history of sticking to an option they trust—they might at last be willing to explore alternatives.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"floatright"},"numeric":["floatright"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>We don’t think of a doctor choosing which treatment to give a patient as being in the same position as Google’s servers deciding which ad to show next. And we don’t think of Google’s ad servers when we waver over whether to get our favorite dish yet again or branch out. But computer science shows us that these are, in a fundamental and real way, the same problem. In so doing, it offers a profound glimpse into the structure of human decision-making. And a guide for us, in the times when it matters most.\u003c/p>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/180495/clinical-trials-on-trial-the-ethics-of-withholding-life-saving-treatment","authors":["byline_futureofyou_180495"],"categories":["futureofyou_452","futureofyou_1"],"tags":["futureofyou_1439","futureofyou_717","futureofyou_954","futureofyou_953"],"featImg":"futureofyou_180523","label":"source_futureofyou_180495"},"futureofyou_274449":{"type":"posts","id":"futureofyou_274449","meta":{"index":"posts_1591205157","site":"futureofyou","id":"274449","score":null,"sort":[1478540165000]},"guestAuthors":[],"slug":"will-computers-ever-be-able-to-make-diagnoses-as-well-as-physicians","title":"Will Computers Ever Be as Good as Physicians at Diagnosing Patients?","publishDate":1478540165,"format":"image","headTitle":"KQED Future of You | KQED Science","labelTerm":{},"content":"\u003cp>\u003cem>This is an edited excerpt from Robert Wachter’s “\u003ca href=\"https://www.amazon.com/Digital-Doctor-Hope-Medicines-Computer/dp/0071849467\" target=\"_blank\">The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age\u003c/a>,” reprinted with permission from McGraw-Hill. Copyright 2015.\u003c/em>\u003c/p>\n\u003cp>Since 2012, Vinod Khosla, a co-founder of Sun Microsystems, has been predicting that most of what physicians currently do can, will, and should be done by computers. “By 2025,” he has written, “more data-driven, automated health care will displace up to 80 percent of physicians’ diagnostic and prescription work.”\u003c/p>\n\u003caside class=\"pullquote alignright\">A computer can’t read a patient’s tone of voice or anxious look. These clues—like one patient saying, “I have chest pain,” and another, “I HAVE CHEST PAIN!!!”—can make all the difference in diagnosis.\u003c/aside>\n\u003cp>Though Khosla’s comments have irked many a physician, I’m not willing to dismiss him as a kooky provocateur or a utopian techno-evangelist. First of all, his investment track record has made him a Silicon Valley rock star. More important, as recently as a decade ago, some very smart and savvy computer engineers and economists believed that another seemingly intractable problem, building a driverless car, was beyond the reach of modern technology. As of April 2014, the Google car had clocked nearly 700,000 miles and been involved in just two accidents.\u003c/p>\n\u003cp>If the driverless car weren’t enough of a challenge to human superiority, who could have watched IBM’s Watson supercomputer defeat the Jeopardy Hall of Famers in 2011 and not fretted about the future of physicians, or any highly skilled workers, for that matter?\u003c/p>\n\u003cp>\"Just as factory jobs were eliminated in the twentieth century by new assembly-line robots,” wrote all-time (human) Jeopardy champion Ken Jennings soon after the lopsided match ended, “Brad [Rutter, the other defeated champ] and I were the first knowledge-industry workers put out of work by the new generation of ‘thinking’ machines. ‘Quiz show contestant’ may be the first job made redundant by Watson, but I’m sure it won’t be the last.”\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>Soon after the well-publicized trouncing, IBM announced that one of its first “use cases” for Watson would be medicine. Sean Hogan, vice president for IBM Healthcare, told me that “health care jumped out as an area whose complexity and nuances would be\u003ca href=\"https://contextly.com/redirect/?id=K8AsBQdj7f:274449:4068:13:::sidebar:5820be532053f2-30720465\" target=\"_blank\"> receptive to what Watson was representing\u003c/a>.”\u003c/p>\n\u003cp>\u003cstrong>Sticking Up for Team Human\u003c/strong>\u003c/p>\n\u003cp>Andy McAfee, coauthor with Erik Brynjolfsson of the terrific book \"The Second Machine Age,\" agrees with Khosla that computers will ultimately take over much of what physicians do, including diagnosis. “I can’t see how that doesn’t happen,” McAfee, a self-described “technology optimist,” told me when we met for lunch near his MIT office. McAfee and Brynjolfsson argue that the confluence of staggering growth in computing power, zetabytes of fully networked information available on the Web, and the “combinatorial power” of innovation mean that areas that seemed like dead ends, such as artificial intelligence in medicine, are now within reach. They liken the speed with which old digital barriers are falling to Hemingway’s observation about how a person goes broke: “gradually, then suddenly.\"\u003c/p>\n\u003cp>In speaking with both McAfee and Khosla, I felt a strange obligation to stick up for my teams: humans and the subset of humans called doctors. I told McAfee that while I was in awe of the driverless car and IBM’s victories in chess (over world champion Garry Kasparov in 1997) and Jeopardy, he just didn’t understand how hard medicine is. Answering questions posed by Alex Trebek like, “While Maltese borrows many words from Italian, it developed from a dialect of this Semitic language” (the correct response is “What is Arabic?”—Watson answered it, and 65 of the 74 other questions it rang in for, correctly) is tricky, sure, but, at the end of the day, one is simply culling a series of databases to find a fact—a single right answer.\u003c/p>\n\u003caside class=\"pullquote alignright\">‘Quiz show contestant’ may be the first job made redundant by Watson, but I’m sure it won’t be the last.'\u003ccite>(Human) 'Jeopardy' champ Ken Jennings\u003c/cite>\u003c/aside>\n\u003cp>Medical diagnosis isn’t like that. For one thing, uncertainty is endemic, so that the “correct” answer is often a surprisingly probabilistic notion. For another, many diagnoses reveal themselves over time. The patient may present with, say, a headache, but not a worrisome one, and so the primary treatment is reassurance, Tylenol, and time. If the headache worsens over the next two weeks—particularly if it is now accompanied by additional symptoms such as weakness or nausea—that’s an entirely different story.\u003c/p>\n\u003cp>McAfee listened sympathetically—he’s obviously heard scores of versions of the \"You just don’t understand; my work is different\" argument—and then said, “I imagine there are a bunch of really smart geeks at IBM taking notes as guys like you describe this situation. In their heads, they’re asking, ‘How do I model that?’”\u003c/p>\n\u003cp>Undaunted, I tried another tack on Khosla when we met in his office in Menlo Park. “Vinod,” I said, “in medicine we have something we call the ‘eyeball test.’ That means I can see two patients whose numbers look the same”—things like temperature, heart rate, and blood counts—“and my training allows me to say, ‘That guy is sick [I pointed to an imaginary person across the imposing conference table] and the other is okay.’” And good doctors are usually right, I told him, as we possess a kind of sixth sense that we acquire from our training, our role models, and a thousand cases of trial and error.\u003c/p>\n\u003cp>Before Khosla could dismiss this as the usual whining from a dinosaur on the edge of extinction, I tossed him an example from his own world. “I’ll bet you have CEOs of start-ups constantly coming through this office pitching their companies,” I said. “I can imagine two companies that look the same on paper: both CEOs have Stanford MBAs; the proposals have similar financials. Your skill is to be able to point to one and say, ‘Winner’ and to the other, ‘Loser,’ and I’m guessing you’re right more often than not. You’re using information that isn’t measurable. Right?”\u003c/p>\n\u003cp>Nice try. He didn’t budge. “The question is, ‘Is it not measurable or is it not being measured?’” he responded. “And, when does your instinct work and when does it mislead? I think if you did a rigorous study, you’d find that your ‘eyeball test’ is far less effective than you think.”\u003c/p>\n\u003cp>https://www.youtube.com/watch?v=P18EdAKuC1U\u003c/p>\n\u003cp>\u003cstrong>Secrets of the Great Diagnosticians\u003c/strong>\u003c/p>\n\u003cp>There is a rich 50-year history of efforts to build artificial intelligence (AI) systems in health care, and it’s not a particularly uplifting story. Even technophiles admit that the quest to replace doctors with computers—or even the more modest ambition of providing them with useful guidance at the point of care—has been overhyped and unproductive. But times have changed. The growing prevalence of electronic health records offers grist for the AI and big data mills, grist that wasn’t available when the records were on paper. And in this, the Age of Watson, we have new techniques, like natural language processing and machine learning, at our disposal. Perhaps this is our “gradually, then suddenly” moment.\u003c/p>\n\u003caside class=\"pullquote alignright\">Early attempts to use computers for diagnosis were like tackling Saturday’s crossword puzzle in the New York Times before first mastering the one in USA Today.\u003c/aside>\n\u003cp>The public worships dynamic, innovative surgeons like Michael DeBakey; passionate, insightful researchers like Jonas Salk; and telegenic show horses like Mehmet Oz. But we seldom hear about those doctors whom other physicians tend to hold in the highest esteem: the great medical diagnosticians. These sages, like the legendary Johns Hopkins professors William Osler and A. McGehee Harvey, had the uncanny ability to deduce the truth from what others found to be a jumble of symptoms, signs, and lab results. In fact, Sir Arthur Conan Doyle, a physician by training, modeled Sherlock Holmes on one of his old professors, Joseph Bell, a renowned diagnostician at Edinburgh’s medical school.\u003c/p>\n\u003cp>For most doctors, diagnosis forms the essence of their practice (and of their professional souls), which may help explain why we find it so painful to believe that this particular skill could be replaced by silicon wafers.\u003c/p>\n\u003cp>In the 1970s, a Tufts kidney specialist named Jerome Kassirer (who later became editor of the New England Journal of Medicine) decided to try to unlock the cognitive secrets of the great diagnosticians. If he succeeded, the rewards could be great. The insights, problem-solving strategies, and reasoning patterns of these medical geniuses might be teachable to other physicians, perhaps even programmed into computers.\u003c/p>\n\u003cp>Kassirer focused first on the differential diagnosis, the method that doctors have long used to inventory and sort through their patients’ problems. The differential diagnosis is to a physician what the building of hypotheses is to a basic scientist: the core work of the professional mind. Let’s say a female patient complains of right lower abdominal pain and fever. We automatically begin to generate “a differential,” including appendicitis, pelvic inflammatory disease, kidney infection, and a host of less common disorders—some of them quite serious. Our job is to weigh the facts at hand in an effort to ultimately “rule in” one diagnosis on the list and “rule out” the others. Sometimes, the information we gather from the history and physical examination is sufficient.\u003c/p>\n\u003cp>More often, particularly when patients are truly ill, we require additional laboratory or radiographic studies to push one of the diagnoses over the “rule in” line. There is considerable skill, and no small amount of art, involved in this process. For one thing, we need to figure out whether the patient’s symptoms are part of a single disease or are manifestations of two or more distinct illnesses. The principle known as\u003ca href=\"http://www.medicinenet.com/script/main/art.asp?articlekey=26739\" target=\"_blank\"> Occam’s Razor\u003c/a> bids us to try to find a unifying diagnosis for all of a patient’s symptoms. But as soon as medical students memorize this so-called Law of Clinical Parsimony, we whipsaw them with \u003ca href=\"http://www.emergencymedicalparamedic.com/what-is-hickams-dictum/\" target=\"_blank\">Hickam’s Dictum\u003c/a>, which counters, irreverently, that “patients can have as many diseases as they damn well please.”\u003c/p>\n\u003cp>[contextly_sidebar id=\"fXsrKyRyGekfunOt3dsmZPdJAbzwHrbd\"]\u003c/p>\n\u003cp>Setting the “rule in” threshold is yet another challenge, since it’s wholly dependent on the context. For diseases with relatively benign treatments and prognoses—let’s say, stomach discomfort with no alarming features—I might make the diagnosis of “nonulcer dyspepsia” if I’m 75 percent certain that this is what’s going on. Why? Dyspepsia is a not-too-serious illness, the other illnesses that might present with the same symptoms aren’t likely to be acutely life-threatening either, and dyspepsia has a safe, inexpensive, and fairly effective treatment. All of this makes a 75 percent threshold high enough for me to try an acid-blocker and see what happens.\u003c/p>\n\u003cp>Now let’s turn to a patient who presents with acute shortness of breath and pleuritic chest pain. In this patient, I’m considering the diagnosis of pulmonary embolism (a blood clot to the lungs), a more serious disorder whose treatment (blood thinners) is riskier. Now, I’d want to be at least 95 percent sure before attaching that diagnostic label. And I won’t rule in a diagnosis of cancer—with its psychological freight, prognostic implications, and toxic treatments—unless I’m close to 100 percent certain, even if it takes a surgical biopsy to achieve this level of confidence.\u003c/p>\n\u003cp>Kassirer and his colleagues observed the diagnostic reasoning of scores of clinicians. They found that the good ones employed robust strategies to answer these knotty questions, even if they couldn’t always articulate what they were doing and why. The researchers ultimately came to appreciate that the physicians were engaging in a process called “iterative hypothesis testing” to transform the differential diagnosis (or, more accurately, diagnoses, since sick patients often have a variety of abnormalities to be explained) into something actionable. After hearing the initial portion of a case, the doctors began drawing possible scenarios to explain it, modifying their opinions as they went along and more information became available.\u003c/p>\n\u003cp>For example, when a physician confronts a case that begins with, “This 57-year-old man has three days of chest pain, shortness of breath, and lightheadedness,” she responds by thinking, “The worst thing this could be is a heart attack or a pulmonary embolism. I need to ask if the chest pain bores through to the back, which would make me worry about aortic dissection [a rip in the aorta]. I’ll also inquire about typical cardiac symptoms, such as sweating and nausea, and see if the pain is squeezing or radiates to the left arm or jaw. But even if it doesn’t, I’ll certainly get an EKG to rule out a heart attack or pericarditis [inflammation of the sac that surrounds the heart]. If he also reports a fever or a cough, I might begin to suspect pneumonia or pleurisy. The chest X-ray should help sort that out.”\u003c/p>\n\u003cp>Every answer the patient gives, and each positive or negative finding on the physical examination (yes, there is a heart murmur; no, the liver is not enlarged) triggers an automatic, almost intuitive recalibration of the most likely alternatives. When I see a master clinician at work—my favorite is my UCSF colleague Gurpreet Dhaliwal, who was profiled in a 2012\u003ca href=\"http://www.nytimes.com/2012/12/04/health/quest-to-eliminate-diagnostic-lapses.html\" target=\"_blank\"> New York Times article\u003c/a>—I know that these synapses are firing as he asks a patient a series of questions that may seem unrelated to the patient’s presenting complaint but are directed toward “narrowing the differential.” It turns out that there’s an even more impressive piece of cognitive magic going on. The master clinician embraces certain pieces of data (the patient’s trip to rural Thailand last year) while discarding others (an episode of belly pain and bloating three weeks ago). This is the part of diagnostic reasoning that beginners find most vexing, since they lack the foundational knowledge to understand why their teacher focused so intently on one nugget of information and all but ignored others that, to the novice, seemed equally crucial. How do the great diagnosticians make such choices?\u003c/p>\n\u003cp>We now recognize this as a relatively intuitive version of \u003ca href=\"http://www.medicinenet.com/script/main/art.asp?articlekey=10301\" target=\"_blank\">Bayes’ theorem\u003c/a>. Developed by the eighteenth-century British theologian-turned-mathematician Thomas Bayes, this theorem (often ignored by students because it is taught to them with the dryness of a Passover matzo) is the linchpin of clinical reasoning. In essence, Bayes’ theorem says that any medical test must be interpreted from two perspectives. The first: How accurate is the test—that is, how often does it give right or wrong answers? The second: How likely is it that this patient has the disease the test is looking for?\u003c/p>\n\u003cp>These deceptively simple questions explain why, in the early days of the AIDS epidemic (when HIV testing was far less accurate than it is today), it was silly to test heterosexual couples applying for a marriage license, since the vast majority of positive tests in this very low-risk group would be wrong. Similarly, they show why it is foolish to screen healthy 36-year-old executives with a cardiac treadmill test or a heart scan, since positive results will mostly be false positives, serving only to scare the bejesus out of the patients and run up bills for unnecessary follow-up tests. Conversely, in a 68-year-old smoker with diabetes and high cholesterol who develops squeezing chest pain while jogging, there is a 95 percent chance that those pains are from coronary artery disease. In this case, a negative treadmill test only lowers this probability to about 80 percent, so the clinician who reassures the patient that his negative test means that his heart is fine—“take some antacids; it’s OK to keep jogging”—is making a terrible, and potentially fatal, mistake.\u003c/p>\n\u003cp>\u003cstrong>The AI Challenge\u003c/strong>\u003c/p>\n\u003cp>As if this weren’t complicated enough for the poor IBM engineer gearing up to retool Watson from answering questions about “Potent Potables” to diagnosing sick patients, there’s more. While the EHR at least offers a fighting chance for computerized diagnosis (older medical AI programs, built in the pen-and-paper era, required busy physicians to write their notes and then reenter all the key data), parsing an electronic medical record is far from straightforward. Natural language processing is getting much better, but it still has real problems with negation (“the patient has no history of chest pain or cough”) and with family history (“there is a history of arthritis in the patient’s sister, but his mother is well”), to name just a couple of issues. Certain terms have multiple meanings: when written by a psychiatrist, the term depression is likely to refer to a mood disorder, while when it appears in a cardiologist’s note (“there was no evidence of ST-depression”) it probably refers to a dip in the EKG tracing that is often a clue to coronary disease. Ditto abbreviations: Does the patient with “MS” have multiple sclerosis or mitral stenosis, a sticky heart valve? Finally, the computer can’t read a patient’s tone of voice or the anxious look on her face, although engineers are working on this. These clues—like one patient saying, “I have chest pain,” and another, “I HAVE CHEST PAIN!!!”—can make all the difference in the world diagnostically.\u003c/p>\n\u003cp>Perhaps the trickiest problem of all is that—at least today—the very collection of the facts needed to feed an AI system is itself a cognitively complex process. Let’s return to the example of aortic dissection, a rip in the aorta that is often fatal if it is not treated promptly. If the initial history raises the slightest concern about dissection, I’m going to ask questions about whether the pain bores through to the back and check carefully for the quiet murmur of aortic insufficiency as well as for asymmetric blood pressure readings in the two arms, all clues to dissection. If I don’t harbor a suspicion of this scary (and unusual) disease, I’m not going to look for these things—they’re not part of a routine exam.\u003c/p>\n\u003cp>Decades ago, MIT’s Peter Szolovits, an AI expert who worked with Kassirer and his colleagues in the early days, gave up thinking about diagnosis as a simple matter of question answering. This was mostly because he came to appreciate the importance of timing—a nonissue in Jeopardy but a pivotal one in medicine. “A heart attack that happened five years ago has different implications from one that happened five minutes ago,” he explained, and a computer can’t “know” this unless it is programmed to do so. (It turns out that such issues of foundational knowledge are fundamental in AI—computers have no way of “knowing” some of the basic assumptions that allow us to get through our days, things like water is wet, love is good, and death is permanent.)\u003c/p>\n\u003cp>Moreover, much of medical reasoning relies on feedback loops: observing how events unfold and using that information to refine the diagnostic possibilities.We think a patient has bacterial pneumonia, and so we treat the “pneumonia” with antibiotics, but the patient’s fever doesn’t break after three days. So now we consider the possibility of tuberculosis or lupus. This is the cognitive work of the practicing clinician—focused a bit less on “What is the diagnosis?” and more on “How do I best manage this situation?”—and an AI program that doesn’t account for this will be of limited value.\u003c/p>\n\u003cp>\u003cstrong>Early Attempts\u003c/strong>\u003c/p>\n\u003cp>Now that you appreciate the nature of the problem, it’s easy (in retrospect, at least) to see why the choice by early health care computer experts to focus on diagnosis was risky, perhaps even wrongheaded. It’s like tackling Saturday’s crossword puzzle in the New York Times before first mastering the one in USA Today.\u003c/p>\n\u003cp>Larry Fagan, an early Stanford computing pioneer, told me, “We were not naive about the complexity. It’s just that it was the most exciting question.” Diagnosis is not just exciting, it’s at the heart of safe medical care. Diagnostic errors are common, and they can be fatal. A number of autopsy studies conducted over the past 40 years have shown that major diagnoses were overlooked in nearly one in five patients. With the advent of CT scans and MRIs, the number has gone down a bit, but it still hovers around one in ten. Diagnostic errors contribute to 40,000 to 80,000 deaths per year in the United States. And reviews of malpractice cases have demonstrated that diagnostic errors are the most common source of mistakes leading to successful lawsuits.\u003c/p>\n\u003cp>Medical IT experts jumped into the fray in the 1970s, designing a series of computer programs that they believed could help physicians be better diagnosticians, or perhaps even replace them entirely. That decade’s literature was replete with enthusiastic articles about how microprocessors, programmed to think like experts, would soon replace the brains of harried doctors. The attitude was captured by one early computing pioneer in a 1971 paean to his computer: “It is immune from fatigue and carelessness; and it works day and night, weekends and holidays, without coffee breaks, overtime, fringe benefits or human courtesy.”\u003c/p>\n\u003cp>By the mid-1980s, disappointment had set in. The tools that had seemed so promising a decade earlier were, by and large, unable to manage the complexity of clinical medicine, and they garnered few clinician advocates and miniscule commercial adoption. The medical AI movement skidded to a halt, marking the start of a 20-year period that insiders still refer to as the “AI winter.” Ted Shortliffe, one of the field’s longstanding leaders, has said that the early experience with programs like INTERNIST, DXplain, and MYCIN reminded him of this cartoon:\u003c/p>\n\u003cp>\u003ca href=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2016/11/cartoon.jpg\">\u003cimg class=\"aligncenter size-full wp-image-276235\" src=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2016/11/cartoon.jpg\" alt=\"cartoon\" width=\"300\" height=\"373\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2016/11/cartoon.jpg 300w, https://ww2.kqed.org/app/uploads/sites/13/2016/11/cartoon-160x199.jpg 160w, https://ww2.kqed.org/app/uploads/sites/13/2016/11/cartoon-240x298.jpg 240w\" sizes=\"(max-width: 300px) 100vw, 300px\">\u003c/a>\u003c/p>\n\u003cp>\u003cstrong>'Version 0'\u003c/strong>\u003c/p>\n\u003cp>Vinod Khosla is prepared for this. He knows that even today’s generation of medical AI programs will produce some crazy output, akin to when Watson famously mistook Toronto for an American city during its Jeopardy triumph. (It was worse in rehearsal, when Watson referred to civil rights leader Malcolm X as “Malcolm Ten.”) Khosla points out that the enormous cellphones of the late 1980s would seem equally ridiculous when placed alongside our iPhone 6.0s. He calls today’s medical AI programs “Version 0,” and cautions that people should “expect these early systems and tools to be the butt of jokes from many a writer and physician.”\u003c/p>\n\u003cp>These cases illustrate a perennial debate in AI, one that pits two camps against each other: the “neats” and the “scruffies.” The neats seek solutions that are elegant and provable; they try to model the way experts think and work, and then code that into AI tools. The scruffies are the pragmatists, the hackers, the crazy ones; they believe that problems should be attacked through whatever means work, and that modeling the behavior of experts or the scientific truth of a situation isn’t all that important. IBM’s breakthrough was to figure out that a combination of neat and scruffy—programming in some of the core rules of the game, but then folding in the fruits of machine learning and natural language processing—could solve truly complicated problems.\u003c/p>\n\u003cp>When he was asked about the difference between human thinking and Watson’s method, Eric Brown, who runs IBM’s Watson Technologies group, gave a careful answer (note the shout-out to the humans, the bit players who made it all possible):\u003c/p>\n\u003cblockquote>\u003cp>A lot of the way that Watson works is motivated by the way that humans analyze problems and go about trying to find solutions, especially when it comes to dealing with complex problems where there are a number of intermediate steps toget you to the final answer. So it certainly is inspired by that process. . . . But a lot of it is different from the ways humans work; it tends to leverage the powers and advantages of a computer system, and its ability to rapidly analyze huge amounts of data and text that humans just can’t keep track of.\u003c/p>\u003c/blockquote>\n\u003cp>However Watson works, we find ourselves today in a world with new tools, new mental models, and a new sense of optimism that computers can do pretty much anything. But have we finally reached the age when computers can master the art of clinical reasoning?\u003c/p>\n\u003cp>I asked Eric Brown, who worked on the \"Jeopardy\" project and is now helping to lead Watson’s efforts in medicine, what the equivalent event might be in health care, the moment when his team could finally congratulate itself on its successes. I wondered if it would be the creation of some kind of holographic physician—like “\u003ca href=\"http://memory-alpha.wikia.com/wiki/Emergency_Medical_Holographic_program\" target=\"_blank\">The Doctor\u003c/a>” on Star Trek Voyager—with Watson serving as the cognitive engine. His answer, though, reflected the deep respect he and his colleagues have for the magnitude of the challenge:\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>“It will be when we have a technology that physicians suddenly can’t live without.”\u003c/p>\n\n","blocks":[],"excerpt":"When it comes to the art of medical diagnosis, has Team Human finally triumphed over AI? Or is it only a matter of time before computers supplant the physician's brain? ","status":"publish","parent":0,"modified":1517000026,"stats":{"hasAudio":false,"hasVideo":true,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":50,"wordCount":4460},"headData":{"title":"Will Computers Ever Be as Good as Physicians at Diagnosing Patients? | KQED","description":"When it comes to the art of medical diagnosis, has Team Human finally triumphed over AI? Or is it only a matter of time before computers supplant the physician's brain? ","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"Will Computers Ever Be as Good as Physicians at Diagnosing Patients?","datePublished":"2016-11-07T17:36:05.000Z","dateModified":"2018-01-26T20:53:46.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"274449 http://ww2.kqed.org/futureofyou/?p=274449","disqusUrl":"https://ww2.kqed.org/futureofyou/2016/11/07/will-computers-ever-be-able-to-make-diagnoses-as-well-as-physicians/","disqusTitle":"Will Computers Ever Be as Good as Physicians at Diagnosing Patients?","source":"Future of You","customPermalink":"2016/11/07/AI-computers-diagnosis-watson/","nprByline":"Bob Wachter","path":"/futureofyou/274449/will-computers-ever-be-able-to-make-diagnoses-as-well-as-physicians","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>\u003cem>This is an edited excerpt from Robert Wachter’s “\u003ca href=\"https://www.amazon.com/Digital-Doctor-Hope-Medicines-Computer/dp/0071849467\" target=\"_blank\">The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age\u003c/a>,” reprinted with permission from McGraw-Hill. Copyright 2015.\u003c/em>\u003c/p>\n\u003cp>Since 2012, Vinod Khosla, a co-founder of Sun Microsystems, has been predicting that most of what physicians currently do can, will, and should be done by computers. “By 2025,” he has written, “more data-driven, automated health care will displace up to 80 percent of physicians’ diagnostic and prescription work.”\u003c/p>\n\u003caside class=\"pullquote alignright\">A computer can’t read a patient’s tone of voice or anxious look. These clues—like one patient saying, “I have chest pain,” and another, “I HAVE CHEST PAIN!!!”—can make all the difference in diagnosis.\u003c/aside>\n\u003cp>Though Khosla’s comments have irked many a physician, I’m not willing to dismiss him as a kooky provocateur or a utopian techno-evangelist. First of all, his investment track record has made him a Silicon Valley rock star. More important, as recently as a decade ago, some very smart and savvy computer engineers and economists believed that another seemingly intractable problem, building a driverless car, was beyond the reach of modern technology. As of April 2014, the Google car had clocked nearly 700,000 miles and been involved in just two accidents.\u003c/p>\n\u003cp>If the driverless car weren’t enough of a challenge to human superiority, who could have watched IBM’s Watson supercomputer defeat the Jeopardy Hall of Famers in 2011 and not fretted about the future of physicians, or any highly skilled workers, for that matter?\u003c/p>\n\u003cp>\"Just as factory jobs were eliminated in the twentieth century by new assembly-line robots,” wrote all-time (human) Jeopardy champion Ken Jennings soon after the lopsided match ended, “Brad [Rutter, the other defeated champ] and I were the first knowledge-industry workers put out of work by the new generation of ‘thinking’ machines. ‘Quiz show contestant’ may be the first job made redundant by Watson, but I’m sure it won’t be the last.”\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>Soon after the well-publicized trouncing, IBM announced that one of its first “use cases” for Watson would be medicine. Sean Hogan, vice president for IBM Healthcare, told me that “health care jumped out as an area whose complexity and nuances would be\u003ca href=\"https://contextly.com/redirect/?id=K8AsBQdj7f:274449:4068:13:::sidebar:5820be532053f2-30720465\" target=\"_blank\"> receptive to what Watson was representing\u003c/a>.”\u003c/p>\n\u003cp>\u003cstrong>Sticking Up for Team Human\u003c/strong>\u003c/p>\n\u003cp>Andy McAfee, coauthor with Erik Brynjolfsson of the terrific book \"The Second Machine Age,\" agrees with Khosla that computers will ultimately take over much of what physicians do, including diagnosis. “I can’t see how that doesn’t happen,” McAfee, a self-described “technology optimist,” told me when we met for lunch near his MIT office. McAfee and Brynjolfsson argue that the confluence of staggering growth in computing power, zetabytes of fully networked information available on the Web, and the “combinatorial power” of innovation mean that areas that seemed like dead ends, such as artificial intelligence in medicine, are now within reach. They liken the speed with which old digital barriers are falling to Hemingway’s observation about how a person goes broke: “gradually, then suddenly.\"\u003c/p>\n\u003cp>In speaking with both McAfee and Khosla, I felt a strange obligation to stick up for my teams: humans and the subset of humans called doctors. I told McAfee that while I was in awe of the driverless car and IBM’s victories in chess (over world champion Garry Kasparov in 1997) and Jeopardy, he just didn’t understand how hard medicine is. Answering questions posed by Alex Trebek like, “While Maltese borrows many words from Italian, it developed from a dialect of this Semitic language” (the correct response is “What is Arabic?”—Watson answered it, and 65 of the 74 other questions it rang in for, correctly) is tricky, sure, but, at the end of the day, one is simply culling a series of databases to find a fact—a single right answer.\u003c/p>\n\u003caside class=\"pullquote alignright\">‘Quiz show contestant’ may be the first job made redundant by Watson, but I’m sure it won’t be the last.'\u003ccite>(Human) 'Jeopardy' champ Ken Jennings\u003c/cite>\u003c/aside>\n\u003cp>Medical diagnosis isn’t like that. For one thing, uncertainty is endemic, so that the “correct” answer is often a surprisingly probabilistic notion. For another, many diagnoses reveal themselves over time. The patient may present with, say, a headache, but not a worrisome one, and so the primary treatment is reassurance, Tylenol, and time. If the headache worsens over the next two weeks—particularly if it is now accompanied by additional symptoms such as weakness or nausea—that’s an entirely different story.\u003c/p>\n\u003cp>McAfee listened sympathetically—he’s obviously heard scores of versions of the \"You just don’t understand; my work is different\" argument—and then said, “I imagine there are a bunch of really smart geeks at IBM taking notes as guys like you describe this situation. In their heads, they’re asking, ‘How do I model that?’”\u003c/p>\n\u003cp>Undaunted, I tried another tack on Khosla when we met in his office in Menlo Park. “Vinod,” I said, “in medicine we have something we call the ‘eyeball test.’ That means I can see two patients whose numbers look the same”—things like temperature, heart rate, and blood counts—“and my training allows me to say, ‘That guy is sick [I pointed to an imaginary person across the imposing conference table] and the other is okay.’” And good doctors are usually right, I told him, as we possess a kind of sixth sense that we acquire from our training, our role models, and a thousand cases of trial and error.\u003c/p>\n\u003cp>Before Khosla could dismiss this as the usual whining from a dinosaur on the edge of extinction, I tossed him an example from his own world. “I’ll bet you have CEOs of start-ups constantly coming through this office pitching their companies,” I said. “I can imagine two companies that look the same on paper: both CEOs have Stanford MBAs; the proposals have similar financials. Your skill is to be able to point to one and say, ‘Winner’ and to the other, ‘Loser,’ and I’m guessing you’re right more often than not. You’re using information that isn’t measurable. Right?”\u003c/p>\n\u003cp>Nice try. He didn’t budge. “The question is, ‘Is it not measurable or is it not being measured?’” he responded. “And, when does your instinct work and when does it mislead? I think if you did a rigorous study, you’d find that your ‘eyeball test’ is far less effective than you think.”\u003c/p>\u003c/p>\u003cp>\u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutube'>\n \u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutubeInside'>\n \u003ciframe\n loading='lazy'\n class='utils-parseShortcode-shortcodes-__youtubeShortcode__youtubePlayer'\n type='text/html'\n src='//www.youtube.com/embed/P18EdAKuC1U'\n title='//www.youtube.com/embed/P18EdAKuC1U'\n allowfullscreen='true'\n style='border:0;'>\u003c/iframe>\n \u003c/span>\n \u003c/span>\u003c/p>\u003cp>\u003cp>\u003cstrong>Secrets of the Great Diagnosticians\u003c/strong>\u003c/p>\n\u003cp>There is a rich 50-year history of efforts to build artificial intelligence (AI) systems in health care, and it’s not a particularly uplifting story. Even technophiles admit that the quest to replace doctors with computers—or even the more modest ambition of providing them with useful guidance at the point of care—has been overhyped and unproductive. But times have changed. The growing prevalence of electronic health records offers grist for the AI and big data mills, grist that wasn’t available when the records were on paper. And in this, the Age of Watson, we have new techniques, like natural language processing and machine learning, at our disposal. Perhaps this is our “gradually, then suddenly” moment.\u003c/p>\n\u003caside class=\"pullquote alignright\">Early attempts to use computers for diagnosis were like tackling Saturday’s crossword puzzle in the New York Times before first mastering the one in USA Today.\u003c/aside>\n\u003cp>The public worships dynamic, innovative surgeons like Michael DeBakey; passionate, insightful researchers like Jonas Salk; and telegenic show horses like Mehmet Oz. But we seldom hear about those doctors whom other physicians tend to hold in the highest esteem: the great medical diagnosticians. These sages, like the legendary Johns Hopkins professors William Osler and A. McGehee Harvey, had the uncanny ability to deduce the truth from what others found to be a jumble of symptoms, signs, and lab results. In fact, Sir Arthur Conan Doyle, a physician by training, modeled Sherlock Holmes on one of his old professors, Joseph Bell, a renowned diagnostician at Edinburgh’s medical school.\u003c/p>\n\u003cp>For most doctors, diagnosis forms the essence of their practice (and of their professional souls), which may help explain why we find it so painful to believe that this particular skill could be replaced by silicon wafers.\u003c/p>\n\u003cp>In the 1970s, a Tufts kidney specialist named Jerome Kassirer (who later became editor of the New England Journal of Medicine) decided to try to unlock the cognitive secrets of the great diagnosticians. If he succeeded, the rewards could be great. The insights, problem-solving strategies, and reasoning patterns of these medical geniuses might be teachable to other physicians, perhaps even programmed into computers.\u003c/p>\n\u003cp>Kassirer focused first on the differential diagnosis, the method that doctors have long used to inventory and sort through their patients’ problems. The differential diagnosis is to a physician what the building of hypotheses is to a basic scientist: the core work of the professional mind. Let’s say a female patient complains of right lower abdominal pain and fever. We automatically begin to generate “a differential,” including appendicitis, pelvic inflammatory disease, kidney infection, and a host of less common disorders—some of them quite serious. Our job is to weigh the facts at hand in an effort to ultimately “rule in” one diagnosis on the list and “rule out” the others. Sometimes, the information we gather from the history and physical examination is sufficient.\u003c/p>\n\u003cp>More often, particularly when patients are truly ill, we require additional laboratory or radiographic studies to push one of the diagnoses over the “rule in” line. There is considerable skill, and no small amount of art, involved in this process. For one thing, we need to figure out whether the patient’s symptoms are part of a single disease or are manifestations of two or more distinct illnesses. The principle known as\u003ca href=\"http://www.medicinenet.com/script/main/art.asp?articlekey=26739\" target=\"_blank\"> Occam’s Razor\u003c/a> bids us to try to find a unifying diagnosis for all of a patient’s symptoms. But as soon as medical students memorize this so-called Law of Clinical Parsimony, we whipsaw them with \u003ca href=\"http://www.emergencymedicalparamedic.com/what-is-hickams-dictum/\" target=\"_blank\">Hickam’s Dictum\u003c/a>, which counters, irreverently, that “patients can have as many diseases as they damn well please.”\u003c/p>\n\u003cp>\u003c/p>\u003cp>\u003c/p>\u003cp>\u003c/p>\n\u003cp>Setting the “rule in” threshold is yet another challenge, since it’s wholly dependent on the context. For diseases with relatively benign treatments and prognoses—let’s say, stomach discomfort with no alarming features—I might make the diagnosis of “nonulcer dyspepsia” if I’m 75 percent certain that this is what’s going on. Why? Dyspepsia is a not-too-serious illness, the other illnesses that might present with the same symptoms aren’t likely to be acutely life-threatening either, and dyspepsia has a safe, inexpensive, and fairly effective treatment. All of this makes a 75 percent threshold high enough for me to try an acid-blocker and see what happens.\u003c/p>\n\u003cp>Now let’s turn to a patient who presents with acute shortness of breath and pleuritic chest pain. In this patient, I’m considering the diagnosis of pulmonary embolism (a blood clot to the lungs), a more serious disorder whose treatment (blood thinners) is riskier. Now, I’d want to be at least 95 percent sure before attaching that diagnostic label. And I won’t rule in a diagnosis of cancer—with its psychological freight, prognostic implications, and toxic treatments—unless I’m close to 100 percent certain, even if it takes a surgical biopsy to achieve this level of confidence.\u003c/p>\n\u003cp>Kassirer and his colleagues observed the diagnostic reasoning of scores of clinicians. They found that the good ones employed robust strategies to answer these knotty questions, even if they couldn’t always articulate what they were doing and why. The researchers ultimately came to appreciate that the physicians were engaging in a process called “iterative hypothesis testing” to transform the differential diagnosis (or, more accurately, diagnoses, since sick patients often have a variety of abnormalities to be explained) into something actionable. After hearing the initial portion of a case, the doctors began drawing possible scenarios to explain it, modifying their opinions as they went along and more information became available.\u003c/p>\n\u003cp>For example, when a physician confronts a case that begins with, “This 57-year-old man has three days of chest pain, shortness of breath, and lightheadedness,” she responds by thinking, “The worst thing this could be is a heart attack or a pulmonary embolism. I need to ask if the chest pain bores through to the back, which would make me worry about aortic dissection [a rip in the aorta]. I’ll also inquire about typical cardiac symptoms, such as sweating and nausea, and see if the pain is squeezing or radiates to the left arm or jaw. But even if it doesn’t, I’ll certainly get an EKG to rule out a heart attack or pericarditis [inflammation of the sac that surrounds the heart]. If he also reports a fever or a cough, I might begin to suspect pneumonia or pleurisy. The chest X-ray should help sort that out.”\u003c/p>\n\u003cp>Every answer the patient gives, and each positive or negative finding on the physical examination (yes, there is a heart murmur; no, the liver is not enlarged) triggers an automatic, almost intuitive recalibration of the most likely alternatives. When I see a master clinician at work—my favorite is my UCSF colleague Gurpreet Dhaliwal, who was profiled in a 2012\u003ca href=\"http://www.nytimes.com/2012/12/04/health/quest-to-eliminate-diagnostic-lapses.html\" target=\"_blank\"> New York Times article\u003c/a>—I know that these synapses are firing as he asks a patient a series of questions that may seem unrelated to the patient’s presenting complaint but are directed toward “narrowing the differential.” It turns out that there’s an even more impressive piece of cognitive magic going on. The master clinician embraces certain pieces of data (the patient’s trip to rural Thailand last year) while discarding others (an episode of belly pain and bloating three weeks ago). This is the part of diagnostic reasoning that beginners find most vexing, since they lack the foundational knowledge to understand why their teacher focused so intently on one nugget of information and all but ignored others that, to the novice, seemed equally crucial. How do the great diagnosticians make such choices?\u003c/p>\n\u003cp>We now recognize this as a relatively intuitive version of \u003ca href=\"http://www.medicinenet.com/script/main/art.asp?articlekey=10301\" target=\"_blank\">Bayes’ theorem\u003c/a>. Developed by the eighteenth-century British theologian-turned-mathematician Thomas Bayes, this theorem (often ignored by students because it is taught to them with the dryness of a Passover matzo) is the linchpin of clinical reasoning. In essence, Bayes’ theorem says that any medical test must be interpreted from two perspectives. The first: How accurate is the test—that is, how often does it give right or wrong answers? The second: How likely is it that this patient has the disease the test is looking for?\u003c/p>\n\u003cp>These deceptively simple questions explain why, in the early days of the AIDS epidemic (when HIV testing was far less accurate than it is today), it was silly to test heterosexual couples applying for a marriage license, since the vast majority of positive tests in this very low-risk group would be wrong. Similarly, they show why it is foolish to screen healthy 36-year-old executives with a cardiac treadmill test or a heart scan, since positive results will mostly be false positives, serving only to scare the bejesus out of the patients and run up bills for unnecessary follow-up tests. Conversely, in a 68-year-old smoker with diabetes and high cholesterol who develops squeezing chest pain while jogging, there is a 95 percent chance that those pains are from coronary artery disease. In this case, a negative treadmill test only lowers this probability to about 80 percent, so the clinician who reassures the patient that his negative test means that his heart is fine—“take some antacids; it’s OK to keep jogging”—is making a terrible, and potentially fatal, mistake.\u003c/p>\n\u003cp>\u003cstrong>The AI Challenge\u003c/strong>\u003c/p>\n\u003cp>As if this weren’t complicated enough for the poor IBM engineer gearing up to retool Watson from answering questions about “Potent Potables” to diagnosing sick patients, there’s more. While the EHR at least offers a fighting chance for computerized diagnosis (older medical AI programs, built in the pen-and-paper era, required busy physicians to write their notes and then reenter all the key data), parsing an electronic medical record is far from straightforward. Natural language processing is getting much better, but it still has real problems with negation (“the patient has no history of chest pain or cough”) and with family history (“there is a history of arthritis in the patient’s sister, but his mother is well”), to name just a couple of issues. Certain terms have multiple meanings: when written by a psychiatrist, the term depression is likely to refer to a mood disorder, while when it appears in a cardiologist’s note (“there was no evidence of ST-depression”) it probably refers to a dip in the EKG tracing that is often a clue to coronary disease. Ditto abbreviations: Does the patient with “MS” have multiple sclerosis or mitral stenosis, a sticky heart valve? Finally, the computer can’t read a patient’s tone of voice or the anxious look on her face, although engineers are working on this. These clues—like one patient saying, “I have chest pain,” and another, “I HAVE CHEST PAIN!!!”—can make all the difference in the world diagnostically.\u003c/p>\n\u003cp>Perhaps the trickiest problem of all is that—at least today—the very collection of the facts needed to feed an AI system is itself a cognitively complex process. Let’s return to the example of aortic dissection, a rip in the aorta that is often fatal if it is not treated promptly. If the initial history raises the slightest concern about dissection, I’m going to ask questions about whether the pain bores through to the back and check carefully for the quiet murmur of aortic insufficiency as well as for asymmetric blood pressure readings in the two arms, all clues to dissection. If I don’t harbor a suspicion of this scary (and unusual) disease, I’m not going to look for these things—they’re not part of a routine exam.\u003c/p>\n\u003cp>Decades ago, MIT’s Peter Szolovits, an AI expert who worked with Kassirer and his colleagues in the early days, gave up thinking about diagnosis as a simple matter of question answering. This was mostly because he came to appreciate the importance of timing—a nonissue in Jeopardy but a pivotal one in medicine. “A heart attack that happened five years ago has different implications from one that happened five minutes ago,” he explained, and a computer can’t “know” this unless it is programmed to do so. (It turns out that such issues of foundational knowledge are fundamental in AI—computers have no way of “knowing” some of the basic assumptions that allow us to get through our days, things like water is wet, love is good, and death is permanent.)\u003c/p>\n\u003cp>Moreover, much of medical reasoning relies on feedback loops: observing how events unfold and using that information to refine the diagnostic possibilities.We think a patient has bacterial pneumonia, and so we treat the “pneumonia” with antibiotics, but the patient’s fever doesn’t break after three days. So now we consider the possibility of tuberculosis or lupus. This is the cognitive work of the practicing clinician—focused a bit less on “What is the diagnosis?” and more on “How do I best manage this situation?”—and an AI program that doesn’t account for this will be of limited value.\u003c/p>\n\u003cp>\u003cstrong>Early Attempts\u003c/strong>\u003c/p>\n\u003cp>Now that you appreciate the nature of the problem, it’s easy (in retrospect, at least) to see why the choice by early health care computer experts to focus on diagnosis was risky, perhaps even wrongheaded. It’s like tackling Saturday’s crossword puzzle in the New York Times before first mastering the one in USA Today.\u003c/p>\n\u003cp>Larry Fagan, an early Stanford computing pioneer, told me, “We were not naive about the complexity. It’s just that it was the most exciting question.” Diagnosis is not just exciting, it’s at the heart of safe medical care. Diagnostic errors are common, and they can be fatal. A number of autopsy studies conducted over the past 40 years have shown that major diagnoses were overlooked in nearly one in five patients. With the advent of CT scans and MRIs, the number has gone down a bit, but it still hovers around one in ten. Diagnostic errors contribute to 40,000 to 80,000 deaths per year in the United States. And reviews of malpractice cases have demonstrated that diagnostic errors are the most common source of mistakes leading to successful lawsuits.\u003c/p>\n\u003cp>Medical IT experts jumped into the fray in the 1970s, designing a series of computer programs that they believed could help physicians be better diagnosticians, or perhaps even replace them entirely. That decade’s literature was replete with enthusiastic articles about how microprocessors, programmed to think like experts, would soon replace the brains of harried doctors. The attitude was captured by one early computing pioneer in a 1971 paean to his computer: “It is immune from fatigue and carelessness; and it works day and night, weekends and holidays, without coffee breaks, overtime, fringe benefits or human courtesy.”\u003c/p>\n\u003cp>By the mid-1980s, disappointment had set in. The tools that had seemed so promising a decade earlier were, by and large, unable to manage the complexity of clinical medicine, and they garnered few clinician advocates and miniscule commercial adoption. The medical AI movement skidded to a halt, marking the start of a 20-year period that insiders still refer to as the “AI winter.” Ted Shortliffe, one of the field’s longstanding leaders, has said that the early experience with programs like INTERNIST, DXplain, and MYCIN reminded him of this cartoon:\u003c/p>\n\u003cp>\u003ca href=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2016/11/cartoon.jpg\">\u003cimg class=\"aligncenter size-full wp-image-276235\" src=\"http://ww2.kqed.org/futureofyou/wp-content/uploads/sites/13/2016/11/cartoon.jpg\" alt=\"cartoon\" width=\"300\" height=\"373\" srcset=\"https://ww2.kqed.org/app/uploads/sites/13/2016/11/cartoon.jpg 300w, https://ww2.kqed.org/app/uploads/sites/13/2016/11/cartoon-160x199.jpg 160w, https://ww2.kqed.org/app/uploads/sites/13/2016/11/cartoon-240x298.jpg 240w\" sizes=\"(max-width: 300px) 100vw, 300px\">\u003c/a>\u003c/p>\n\u003cp>\u003cstrong>'Version 0'\u003c/strong>\u003c/p>\n\u003cp>Vinod Khosla is prepared for this. He knows that even today’s generation of medical AI programs will produce some crazy output, akin to when Watson famously mistook Toronto for an American city during its Jeopardy triumph. (It was worse in rehearsal, when Watson referred to civil rights leader Malcolm X as “Malcolm Ten.”) Khosla points out that the enormous cellphones of the late 1980s would seem equally ridiculous when placed alongside our iPhone 6.0s. He calls today’s medical AI programs “Version 0,” and cautions that people should “expect these early systems and tools to be the butt of jokes from many a writer and physician.”\u003c/p>\n\u003cp>These cases illustrate a perennial debate in AI, one that pits two camps against each other: the “neats” and the “scruffies.” The neats seek solutions that are elegant and provable; they try to model the way experts think and work, and then code that into AI tools. The scruffies are the pragmatists, the hackers, the crazy ones; they believe that problems should be attacked through whatever means work, and that modeling the behavior of experts or the scientific truth of a situation isn’t all that important. IBM’s breakthrough was to figure out that a combination of neat and scruffy—programming in some of the core rules of the game, but then folding in the fruits of machine learning and natural language processing—could solve truly complicated problems.\u003c/p>\n\u003cp>When he was asked about the difference between human thinking and Watson’s method, Eric Brown, who runs IBM’s Watson Technologies group, gave a careful answer (note the shout-out to the humans, the bit players who made it all possible):\u003c/p>\n\u003cblockquote>\u003cp>A lot of the way that Watson works is motivated by the way that humans analyze problems and go about trying to find solutions, especially when it comes to dealing with complex problems where there are a number of intermediate steps toget you to the final answer. So it certainly is inspired by that process. . . . But a lot of it is different from the ways humans work; it tends to leverage the powers and advantages of a computer system, and its ability to rapidly analyze huge amounts of data and text that humans just can’t keep track of.\u003c/p>\u003c/blockquote>\n\u003cp>However Watson works, we find ourselves today in a world with new tools, new mental models, and a new sense of optimism that computers can do pretty much anything. But have we finally reached the age when computers can master the art of clinical reasoning?\u003c/p>\n\u003cp>I asked Eric Brown, who worked on the \"Jeopardy\" project and is now helping to lead Watson’s efforts in medicine, what the equivalent event might be in health care, the moment when his team could finally congratulate itself on its successes. I wondered if it would be the creation of some kind of holographic physician—like “\u003ca href=\"http://memory-alpha.wikia.com/wiki/Emergency_Medical_Holographic_program\" target=\"_blank\">The Doctor\u003c/a>” on Star Trek Voyager—with Watson serving as the cognitive engine. His answer, though, reflected the deep respect he and his colleagues have for the magnitude of the challenge:\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"floatright"},"numeric":["floatright"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>“It will be when we have a technology that physicians suddenly can’t live without.”\u003c/p>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/274449/will-computers-ever-be-able-to-make-diagnoses-as-well-as-physicians","authors":["byline_futureofyou_274449"],"categories":["futureofyou_452","futureofyou_1","futureofyou_73"],"tags":["futureofyou_849","futureofyou_1105","futureofyou_1439","futureofyou_915","futureofyou_190","futureofyou_1014","futureofyou_80","futureofyou_1106"],"featImg":"futureofyou_274615","label":"source_futureofyou_274449"},"futureofyou_229192":{"type":"posts","id":"futureofyou_229192","meta":{"index":"posts_1591205157","site":"futureofyou","id":"229192","score":null,"sort":[1471971450000]},"guestAuthors":[],"slug":"the-online-life-as-both-liberation-and-imprisonment","title":"The Online Life, as Both Liberation and Imprisonment","publishDate":1471971450,"format":"standard","headTitle":"KQED Future of You | KQED Science","labelTerm":{"site":"futureofyou"},"content":"\u003cp>\u003cem>Excerpt from The Four-Dimensional Human by Laurence Scott. Copyright © 2015 by Laurence Scott. With permission of the publisher, W. W. Norton & Company, Inc. All rights reserved.\u003c/em>\u003c/p>\n\u003cp>\u003cem>'The 'four-dimensional human' is my name for a person whose life is divided between the physical world and the digital realm, with all of its new expectations, wonders and emotions. I wanted to explore the tension between our anxieties over digital technologies and the idea that we can no longer exist as fully fledged citizens without them.\u003c/em>\u003cbr>\n\u003cem> --Laurence Scott\u003c/em>\u003c/p>\n\u003cp>\u003cspan style=\"font-size: 4.6875em;float: left;line-height: 0.733em;padding: 0.05em 0.1em 0 0;font-family: times, serif, georgia\">A\u003c/span> study has recently suggested that our sleep hormones are being blanched from the light of our various nighttime screens. As a result we may sleep less well, and wake up more tired. Our phones are black on the bedside table, sleeping the sleep of the just, but their light swirls on behind our closed eyes, so the survey says.\u003c/p>\n\u003caside class=\"pullquote alignright\">An ongoing narrative of toxicity and depression shadows digital progress, in conjunction with a sense that this progress is both for the best and inevitable.\u003c/aside>\n\u003cp>We resolve, in the dark, to get an old-school alarm clock, and to keep the phones and laptops on the other side of the bedroom door. Everything must go. Except there’s no landline now, sitting venerably on that little table by the stairs. What if someone needs to call us in the middle of the night? That is a call we should take. And so the phone stays resting on the nightstand, undisturbed.\u003c/p>\n\u003cp>Oh, those studies. Despite them being everywhere, most of us, most of the time, see them out of the corners of our eyes; we catch them fluttering down the pavements, we hear snatches of them on the wind. Most of us have little inclination to spend much time at the coal face of raw findings. But we get the gist, and the gist is not good.\u003c/p>\n\u003caside class=\"pullquote alignright\">Everyone knows someone perpetually on the brink of quitting Facebook.\u003c/aside>\n\u003cp>Fearing the toxicity of our gadgets is not a new pastime. On Christmas Day in 1991, my aunt, then in her late 50s, sat in her dressing gown with the \u003ca href=\"http://www.freesimon.org/\" target=\"_blank\" rel=\"noopener\">electronic memory game Simon\u003c/a> in her lap. On my request she was giving this new present a reluctant go, tapping at its four, big, colored buttons, as they lit up in sequence. I remember Simon flashing and bleeping with the ponderous, patronizing lethargy of its easiest setting. When it eventually caught her out she passed the plump little flying saucer back to me and straightened the skirts of her dressing gown. \"They say all this electrical stuff will give us cancer,\" she remarked.As well as stunning our melatonin like a deer in the headlights, our screens are, it seems, less easy to learn from. While there is still much debate, there have been enough proclamations for these headlines to bypass our brains and go straight into our nervous systems. We worry for our concentrations, our ability to absorb information and to memorize. It is easy and understandable to feel that we are running our own labs, producing reams of intuition, if not data. A friend’s mother warned him not to keep his phone in his pocket--‘\"You’re microwaving your testicles.\" No body part, or faculty, is safe. Meanwhile, studies about the health benefits of pet ownership glow with good tidings, year after year.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>https://www.youtube.com/watch?v=yPnoFDk2eGU&ab_channel=wtcvidman\u003c/p>\n\u003cp>Similarly, like every post-1950s generation, when I was young I was told not to sit too closely to the television. But while the pastime isn’t new, the stakes have been raised by our latter-day habit of fondling such gadgets from the moment we wake to the clunk of the power cord and the click of the light. Simon, by contrast, knew his place. Now I take the television into bed with me, and it lies warmly, companionably against my stomach. A degree of lassitude usually accompanies this pose, but nevertheless I entertain an occasional thought for my organs beneath that spreading warmth, and I wonder how they’re taking to all of this, what grudge is accumulating night by night, and what they have in store.\u003c/p>\n\u003cp>The studies, alas, don’t stop with toxicity. Another narrative running alongside digital progress is one of emotional fragility, of depression and addiction. Science is regularly finding new ways that \u003ca href=\"https://ww2.kqed.org/futureofyou/2016/07/06/does-facebook-really-make-you-depressed/\" target=\"_blank\" rel=\"noopener\">social media is making people sadder\u003c/a>, though whether it is generating rather than displacing sadness is difficult to judge.\u003c/p>\n\u003cp>Regardless, the effect of this pervasive suspicion can be as enfeebling as someone repeatedly telling you how tired you look. Anecdotally, this discontent seems apparent enough. You know that the party is definitely over when conversation becomes a healing circle for Facebook sufferers. In the last year, my students have begun to mention the guilt of what they call \"\u003ca href=\"http://www.webmd.com/lung/news/20160725/is-binge-watching-hazardous-to-your-health\" target=\"_blank\" rel=\"noopener\">Netflix binges\u003c/a>,\" suggesting that, with their mouths ever open to a menu of online \"feeds,\" they’re imagining themselves as gluttons.\u003c/p>\n\u003cp>Unsurprisingly, then, a Lenten spirit is emerging as a counterbalance. Internet usage (the social media wing in particular) is now a staple denial on Lent’s annual blacklist. The restaurant game \"Phone Stack\" acknowledges our compulsions: In the game the diners pile their phones in the middle of the table and the first person to make a grab during the meal picks up the bill.\u003c/p>\n\u003cp>https://www.youtube.com/watch?v=Zh1m2Io_foo&ab_channel=FunkdupFilms\u003c/p>\n\u003cp>But from where does this feeling of taint arise, and how does it come to run in perfect parallel with our online enthusiasms and pleasures? When social media works, it feels so like the everyday conviviality and friendship of physical interactions that one could nearly forget to give it any credit. \"Social media\" as a formal topic is generally a troubled one. At such times it is characterized as an addictive substance, a depressant that needs to be managed and curbed. Everyone knows someone perpetually on the brink of quitting Facebook.\u003c/p>\n\u003cp>One hypothesis for this malaise suggests that the gloss people give to their crafted online personae creates an epidemic of inferiority among those of us watching them, as well as an ongoing amnesia toward our own canny uploads. This gulf widens when you consider where we do this watching: from the unglamorous heap of our insomnia, on the choked bus to work, the windows so fogged with kettled breath that you can’t even dream out of them. If this hypothesis is true, then when people log on to social media, they are apt to feel as though entering a joust, with their friends’ successes and wit, their general robustness for life, coming at them like lances. The overt and odious phrase \"You \u003ca href=\"https://twitter.com/search?q=wins%20the%20internet\" target=\"_blank\" rel=\"noopener\">win the internet\u003c/a>\"--deployed to congratulate an exemplary piece of digital behavior--does nothing to soothe suspicions of tacit competitiveness.\u003c/p>\n\u003cp>https://twitter.com/MazJobrani/status/765731094381465600\u003c/p>\n\u003cp>The inferiority theory is too easy to be the whole story, but nevertheless there is a strong and widespread feeling that our relationship with digital technologies has to be managed as a sort of chronic problem. Simultaneously we are rightly enamored with all the ease and enrichment they provide. The four-dimensional human thus regularly experiences two types of breathlessness. The first is due to the thrill of roving over the world, of dropping in on a sibling and their baby on another continent, of staying for five minutes and laughing the whole time, then swooping back into your skin.\u003c/p>\n\u003cp>The second breathlessness is not cheerful, and arises in the moments when all this liberty seems to come at the price of its opposite, when the sum of digital life feels more like a cage than a flying carpet. The ongoing narrative of toxicity and depression that shadows digital progress, in conjunction with a sense that this progress is both for the best and inevitable, creates a pervasive atmosphere of claustrophobia. The weather is often close in the fourth dimension.\u003c/p>\n\u003cp>A small signal of this confinement is how the phrase \"surfing the internet\" is used much less frequently now than in the old days. Rather than coursing the waves, we are simply, immovably, online. When multiple aspects of digital life are consistently figured as sources, suspected or confirmed, of bodily and psychological pollution, then our irreversible journey deeper and deeper into the network can, in one’s less hardy moments, feel like an imprisonment.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>As a result, when sleep does come, the four-dimensional human begins to dream of escape.\u003c/p>\n\n","blocks":[],"excerpt":"There is an ongoing narrative of toxicity and depression that shadows the idea that digital progress is both for the best and inevitable. An excerpt from 'The four-Dimensional Human.'","status":"publish","parent":0,"modified":1514583830,"stats":{"hasAudio":false,"hasVideo":true,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":18,"wordCount":1433},"headData":{"title":"The Online Life, as Both Liberation and Imprisonment | KQED","description":"There is an ongoing narrative of toxicity and depression that shadows the idea that digital progress is both for the best and inevitable. An excerpt from 'The four-Dimensional Human.'","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"The Online Life, as Both Liberation and Imprisonment","datePublished":"2016-08-23T16:57:30.000Z","dateModified":"2017-12-29T21:43:50.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"229192 http://ww2.kqed.org/futureofyou/?p=229192","disqusUrl":"https://ww2.kqed.org/futureofyou/2016/08/23/the-online-life-as-both-liberation-and-imprisonment/","disqusTitle":"The Online Life, as Both Liberation and Imprisonment","nprByline":"Laurence Scott","path":"/futureofyou/229192/the-online-life-as-both-liberation-and-imprisonment","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>\u003cem>Excerpt from The Four-Dimensional Human by Laurence Scott. Copyright © 2015 by Laurence Scott. With permission of the publisher, W. W. Norton & Company, Inc. All rights reserved.\u003c/em>\u003c/p>\n\u003cp>\u003cem>'The 'four-dimensional human' is my name for a person whose life is divided between the physical world and the digital realm, with all of its new expectations, wonders and emotions. I wanted to explore the tension between our anxieties over digital technologies and the idea that we can no longer exist as fully fledged citizens without them.\u003c/em>\u003cbr>\n\u003cem> --Laurence Scott\u003c/em>\u003c/p>\n\u003cp>\u003cspan style=\"font-size: 4.6875em;float: left;line-height: 0.733em;padding: 0.05em 0.1em 0 0;font-family: times, serif, georgia\">A\u003c/span> study has recently suggested that our sleep hormones are being blanched from the light of our various nighttime screens. As a result we may sleep less well, and wake up more tired. Our phones are black on the bedside table, sleeping the sleep of the just, but their light swirls on behind our closed eyes, so the survey says.\u003c/p>\n\u003caside class=\"pullquote alignright\">An ongoing narrative of toxicity and depression shadows digital progress, in conjunction with a sense that this progress is both for the best and inevitable.\u003c/aside>\n\u003cp>We resolve, in the dark, to get an old-school alarm clock, and to keep the phones and laptops on the other side of the bedroom door. Everything must go. Except there’s no landline now, sitting venerably on that little table by the stairs. What if someone needs to call us in the middle of the night? That is a call we should take. And so the phone stays resting on the nightstand, undisturbed.\u003c/p>\n\u003cp>Oh, those studies. Despite them being everywhere, most of us, most of the time, see them out of the corners of our eyes; we catch them fluttering down the pavements, we hear snatches of them on the wind. Most of us have little inclination to spend much time at the coal face of raw findings. But we get the gist, and the gist is not good.\u003c/p>\n\u003caside class=\"pullquote alignright\">Everyone knows someone perpetually on the brink of quitting Facebook.\u003c/aside>\n\u003cp>Fearing the toxicity of our gadgets is not a new pastime. On Christmas Day in 1991, my aunt, then in her late 50s, sat in her dressing gown with the \u003ca href=\"http://www.freesimon.org/\" target=\"_blank\" rel=\"noopener\">electronic memory game Simon\u003c/a> in her lap. On my request she was giving this new present a reluctant go, tapping at its four, big, colored buttons, as they lit up in sequence. I remember Simon flashing and bleeping with the ponderous, patronizing lethargy of its easiest setting. When it eventually caught her out she passed the plump little flying saucer back to me and straightened the skirts of her dressing gown. \"They say all this electrical stuff will give us cancer,\" she remarked.As well as stunning our melatonin like a deer in the headlights, our screens are, it seems, less easy to learn from. While there is still much debate, there have been enough proclamations for these headlines to bypass our brains and go straight into our nervous systems. We worry for our concentrations, our ability to absorb information and to memorize. It is easy and understandable to feel that we are running our own labs, producing reams of intuition, if not data. A friend’s mother warned him not to keep his phone in his pocket--‘\"You’re microwaving your testicles.\" No body part, or faculty, is safe. Meanwhile, studies about the health benefits of pet ownership glow with good tidings, year after year.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\u003c/p>\u003cp>\u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutube'>\n \u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutubeInside'>\n \u003ciframe\n loading='lazy'\n class='utils-parseShortcode-shortcodes-__youtubeShortcode__youtubePlayer'\n type='text/html'\n src='//www.youtube.com/embed/yPnoFDk2eGU'\n title='//www.youtube.com/embed/yPnoFDk2eGU'\n allowfullscreen='true'\n style='border:0;'>\u003c/iframe>\n \u003c/span>\n \u003c/span>\u003c/p>\u003cp>\u003cp>Similarly, like every post-1950s generation, when I was young I was told not to sit too closely to the television. But while the pastime isn’t new, the stakes have been raised by our latter-day habit of fondling such gadgets from the moment we wake to the clunk of the power cord and the click of the light. Simon, by contrast, knew his place. Now I take the television into bed with me, and it lies warmly, companionably against my stomach. A degree of lassitude usually accompanies this pose, but nevertheless I entertain an occasional thought for my organs beneath that spreading warmth, and I wonder how they’re taking to all of this, what grudge is accumulating night by night, and what they have in store.\u003c/p>\n\u003cp>The studies, alas, don’t stop with toxicity. Another narrative running alongside digital progress is one of emotional fragility, of depression and addiction. Science is regularly finding new ways that \u003ca href=\"https://ww2.kqed.org/futureofyou/2016/07/06/does-facebook-really-make-you-depressed/\" target=\"_blank\" rel=\"noopener\">social media is making people sadder\u003c/a>, though whether it is generating rather than displacing sadness is difficult to judge.\u003c/p>\n\u003cp>Regardless, the effect of this pervasive suspicion can be as enfeebling as someone repeatedly telling you how tired you look. Anecdotally, this discontent seems apparent enough. You know that the party is definitely over when conversation becomes a healing circle for Facebook sufferers. In the last year, my students have begun to mention the guilt of what they call \"\u003ca href=\"http://www.webmd.com/lung/news/20160725/is-binge-watching-hazardous-to-your-health\" target=\"_blank\" rel=\"noopener\">Netflix binges\u003c/a>,\" suggesting that, with their mouths ever open to a menu of online \"feeds,\" they’re imagining themselves as gluttons.\u003c/p>\n\u003cp>Unsurprisingly, then, a Lenten spirit is emerging as a counterbalance. Internet usage (the social media wing in particular) is now a staple denial on Lent’s annual blacklist. The restaurant game \"Phone Stack\" acknowledges our compulsions: In the game the diners pile their phones in the middle of the table and the first person to make a grab during the meal picks up the bill.\u003c/p>\u003c/p>\u003cp>\u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutube'>\n \u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutubeInside'>\n \u003ciframe\n loading='lazy'\n class='utils-parseShortcode-shortcodes-__youtubeShortcode__youtubePlayer'\n type='text/html'\n src='//www.youtube.com/embed/Zh1m2Io_foo'\n title='//www.youtube.com/embed/Zh1m2Io_foo'\n allowfullscreen='true'\n style='border:0;'>\u003c/iframe>\n \u003c/span>\n \u003c/span>\u003c/p>\u003cp>\u003cp>But from where does this feeling of taint arise, and how does it come to run in perfect parallel with our online enthusiasms and pleasures? When social media works, it feels so like the everyday conviviality and friendship of physical interactions that one could nearly forget to give it any credit. \"Social media\" as a formal topic is generally a troubled one. At such times it is characterized as an addictive substance, a depressant that needs to be managed and curbed. Everyone knows someone perpetually on the brink of quitting Facebook.\u003c/p>\n\u003cp>One hypothesis for this malaise suggests that the gloss people give to their crafted online personae creates an epidemic of inferiority among those of us watching them, as well as an ongoing amnesia toward our own canny uploads. This gulf widens when you consider where we do this watching: from the unglamorous heap of our insomnia, on the choked bus to work, the windows so fogged with kettled breath that you can’t even dream out of them. If this hypothesis is true, then when people log on to social media, they are apt to feel as though entering a joust, with their friends’ successes and wit, their general robustness for life, coming at them like lances. The overt and odious phrase \"You \u003ca href=\"https://twitter.com/search?q=wins%20the%20internet\" target=\"_blank\" rel=\"noopener\">win the internet\u003c/a>\"--deployed to congratulate an exemplary piece of digital behavior--does nothing to soothe suspicions of tacit competitiveness.\u003c/p>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"singleTwitterStatus","attributes":{"named":{"id":"765731094381465600"},"numeric":[]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\n\u003cp>The inferiority theory is too easy to be the whole story, but nevertheless there is a strong and widespread feeling that our relationship with digital technologies has to be managed as a sort of chronic problem. Simultaneously we are rightly enamored with all the ease and enrichment they provide. The four-dimensional human thus regularly experiences two types of breathlessness. The first is due to the thrill of roving over the world, of dropping in on a sibling and their baby on another continent, of staying for five minutes and laughing the whole time, then swooping back into your skin.\u003c/p>\n\u003cp>The second breathlessness is not cheerful, and arises in the moments when all this liberty seems to come at the price of its opposite, when the sum of digital life feels more like a cage than a flying carpet. The ongoing narrative of toxicity and depression that shadows digital progress, in conjunction with a sense that this progress is both for the best and inevitable, creates a pervasive atmosphere of claustrophobia. The weather is often close in the fourth dimension.\u003c/p>\n\u003cp>A small signal of this confinement is how the phrase \"surfing the internet\" is used much less frequently now than in the old days. Rather than coursing the waves, we are simply, immovably, online. When multiple aspects of digital life are consistently figured as sources, suspected or confirmed, of bodily and psychological pollution, then our irreversible journey deeper and deeper into the network can, in one’s less hardy moments, feel like an imprisonment.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"floatright"},"numeric":["floatright"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>As a result, when sleep does come, the four-dimensional human begins to dream of escape.\u003c/p>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/229192/the-online-life-as-both-liberation-and-imprisonment","authors":["byline_futureofyou_229192"],"categories":["futureofyou_1061"],"tags":["futureofyou_1439","futureofyou_178","futureofyou_174"],"featImg":"futureofyou_198462","label":"futureofyou"}},"programsReducer":{"possible":{"id":"possible","title":"Possible","info":"Possible is hosted by entrepreneur Reid Hoffman and writer Aria Finger. Together in Possible, Hoffman and Finger lead enlightening discussions about building a brighter collective future. The show features interviews with visionary guests like Trevor Noah, Sam Altman and Janette Sadik-Khan. Possible paints an optimistic portrait of the world we can create through science, policy, business, art and our shared humanity. It asks: What if everything goes right for once? How can we get there? Each episode also includes a short fiction story generated by advanced AI GPT-4, serving as a thought-provoking springboard to speculate how humanity could leverage technology for good.","airtime":"SUN 2pm","imageSrc":"https://cdn.kqed.org/wp-content/uploads/2024/04/Possible-Podcast-Tile-360x360-1.jpg","officialWebsiteLink":"https://www.possible.fm/","meta":{"site":"news","source":"Possible"},"link":"/radio/program/possible","subscribe":{"apple":"https://podcasts.apple.com/us/podcast/possible/id1677184070","spotify":"https://open.spotify.com/show/730YpdUSNlMyPQwNnyjp4k"}},"1a":{"id":"1a","title":"1A","info":"1A is home to the national conversation. 1A brings on great guests and frames the best debate in ways that make you think, share and engage.","airtime":"MON-THU 11pm-12am","imageSrc":"https://ww2.kqed.org/radio/wp-content/uploads/sites/50/2018/04/1a.jpg","officialWebsiteLink":"https://the1a.org/","meta":{"site":"news","source":"npr"},"link":"/radio/program/1a","subscribe":{"npr":"https://rpb3r.app.goo.gl/RBrW","apple":"https://itunes.apple.com/WebObjects/MZStore.woa/wa/viewPodcast?s=143441&mt=2&id=1188724250&at=11l79Y&ct=nprdirectory","tuneIn":"https://tunein.com/radio/1A-p947376/","rss":"https://feeds.npr.org/510316/podcast.xml"}},"all-things-considered":{"id":"all-things-considered","title":"All Things Considered","info":"Every weekday, \u003cem>All Things Considered\u003c/em> hosts Robert Siegel, Audie Cornish, Ari Shapiro, and Kelly McEvers present the program's trademark mix of news, interviews, commentaries, reviews, and offbeat features. Michel Martin hosts on the weekends.","airtime":"MON-FRI 1pm-2pm, 4:30pm-6:30pm\u003cbr />SAT-SUN 5pm-6pm","imageSrc":"https://cdn.kqed.org/wp-content/uploads/2024/04/All-Things-Considered-Podcast-Tile-360x360-1.jpg","officialWebsiteLink":"https://www.npr.org/programs/all-things-considered/","meta":{"site":"news","source":"npr"},"link":"/radio/program/all-things-considered"},"american-suburb-podcast":{"id":"american-suburb-podcast","title":"American Suburb: The Podcast","tagline":"The flip side of gentrification, told through one town","info":"Gentrification is changing cities across America, forcing people from neighborhoods they have long called home. Call them the displaced. Now those priced out of the Bay Area are looking for a better life in an unlikely place. American Suburb follows this migration to one California town along the Delta, 45 miles from San Francisco. 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You ask the questions. You decide what Bay Curious investigates. And you join us on the journey to find the answers.","imageSrc":"https://cdn.kqed.org/wp-content/uploads/2024/04/Bay-Curious-Podcast-Tile-703x703-1.jpg","imageAlt":"\"KQED Bay Curious","officialWebsiteLink":"/news/series/baycurious","meta":{"site":"news","source":"kqed","order":"4"},"link":"/podcasts/baycurious","subscribe":{"apple":"https://podcasts.apple.com/us/podcast/bay-curious/id1172473406","npr":"https://www.npr.org/podcasts/500557090/bay-curious","rss":"https://ww2.kqed.org/news/category/bay-curious-podcast/feed/podcast","google":"https://podcasts.google.com/feed/aHR0cHM6Ly93dzIua3FlZC5vcmcvbmV3cy9jYXRlZ29yeS9iYXktY3VyaW91cy1wb2RjYXN0L2ZlZWQvcG9kY2FzdA","stitcher":"https://www.stitcher.com/podcast/kqed/bay-curious","spotify":"https://open.spotify.com/show/6O76IdmhixfijmhTZLIJ8k"}},"bbc-world-service":{"id":"bbc-world-service","title":"BBC World Service","info":"The day's top stories from BBC News compiled twice daily in the week, once at weekends.","airtime":"MON-FRI 9pm-10pm, TUE-FRI 1am-2am","imageSrc":"https://cdn.kqed.org/wp-content/uploads/2024/04/BBC-World-Service-Podcast-Tile-360x360-1.jpg","officialWebsiteLink":"https://www.bbc.co.uk/sounds/play/live:bbc_world_service","meta":{"site":"news","source":"BBC World Service"},"link":"/radio/program/bbc-world-service","subscribe":{"apple":"https://itunes.apple.com/us/podcast/global-news-podcast/id135067274?mt=2","tuneIn":"https://tunein.com/radio/BBC-World-Service-p455581/","rss":"https://podcasts.files.bbci.co.uk/p02nq0gn.rss"}},"code-switch-life-kit":{"id":"code-switch-life-kit","title":"Code Switch / Life Kit","info":"\u003cem>Code Switch\u003c/em>, which listeners will hear in the first part of the hour, has fearless and much-needed conversations about race. Hosted by journalists of color, the show tackles the subject of race head-on, exploring how it impacts every part of society — from politics and pop culture to history, sports and more.\u003cbr />\u003cbr />\u003cem>Life Kit\u003c/em>, which will be in the second part of the hour, guides you through spaces and feelings no one prepares you for — from finances to mental health, from workplace microaggressions to imposter syndrome, from relationships to parenting. The show features experts with real world experience and shares their knowledge. Because everyone needs a little help being human.\u003cbr />\u003cbr />\u003ca href=\"https://www.npr.org/podcasts/510312/codeswitch\">\u003cem>Code Switch\u003c/em> offical site and podcast\u003c/a>\u003cbr />\u003ca href=\"https://www.npr.org/lifekit\">\u003cem>Life Kit\u003c/em> offical site and podcast\u003c/a>\u003cbr />","airtime":"SUN 9pm-10pm","imageSrc":"https://cdn.kqed.org/wp-content/uploads/2024/04/Code-Switch-Life-Kit-Podcast-Tile-360x360-1.jpg","meta":{"site":"radio","source":"npr"},"link":"/radio/program/code-switch-life-kit","subscribe":{"apple":"https://podcasts.apple.com/podcast/1112190608?mt=2&at=11l79Y&ct=nprdirectory","google":"https://podcasts.google.com/feed/aHR0cHM6Ly93d3cubnByLm9yZy9yc3MvcG9kY2FzdC5waHA_aWQ9NTEwMzEy","spotify":"https://open.spotify.com/show/3bExJ9JQpkwNhoHvaIIuyV","rss":"https://feeds.npr.org/510312/podcast.xml"}},"commonwealth-club":{"id":"commonwealth-club","title":"Commonwealth Club of California Podcast","info":"The Commonwealth Club of California is the nation's oldest and largest public affairs forum. As a non-partisan forum, The Club brings to the public airwaves diverse viewpoints on important topics. The Club's weekly radio broadcast - the oldest in the U.S., dating back to 1924 - is carried across the nation on public radio stations and is now podcasting. Our website archive features audio of our recent programs, as well as selected speeches from our long and distinguished history. This podcast feed is usually updated twice a week and is always un-edited.","airtime":"THU 10pm, FRI 1am","imageSrc":"https://cdn.kqed.org/wp-content/uploads/2024/04/Commonwealth-Club-Podcast-Tile-360x360-1.jpg","officialWebsiteLink":"https://www.commonwealthclub.org/podcasts","meta":{"site":"news","source":"Commonwealth Club of California"},"link":"/radio/program/commonwealth-club","subscribe":{"apple":"https://itunes.apple.com/us/podcast/commonwealth-club-of-california-podcast/id976334034?mt=2","google":"https://podcasts.google.com/feed/aHR0cDovL3d3dy5jb21tb253ZWFsdGhjbHViLm9yZy9hdWRpby9wb2RjYXN0L3dlZWtseS54bWw","tuneIn":"https://tunein.com/radio/Commonwealth-Club-of-California-p1060/"}},"considerthis":{"id":"considerthis","title":"Consider This","tagline":"Make sense of the day","info":"Make sense of the day. Every weekday afternoon, Consider This helps you consider the major stories of the day in less than 15 minutes, featuring the reporting and storytelling resources of NPR. Plus, KQED’s Bianca Taylor brings you the local KQED news you need to know.","imageSrc":"https://cdn.kqed.org/wp-content/uploads/2024/04/Consider-This-Podcast-Tile-703x703-1.jpg","imageAlt":"Consider This from NPR and KQED","officialWebsiteLink":"/podcasts/considerthis","meta":{"site":"news","source":"kqed","order":"7"},"link":"/podcasts/considerthis","subscribe":{"apple":"https://podcasts.apple.com/podcast/id1503226625?mt=2&at=11l79Y&ct=nprdirectory","npr":"https://rpb3r.app.goo.gl/coronavirusdaily","google":"https://podcasts.google.com/feed/aHR0cHM6Ly9mZWVkcy5ucHIub3JnLzUxMDM1NS9wb2RjYXN0LnhtbA","spotify":"https://open.spotify.com/show/3Z6JdCS2d0eFEpXHKI6WqH"}},"forum":{"id":"forum","title":"Forum","tagline":"The conversation starts here","info":"KQED’s live call-in program discussing local, state, national and international issues, as well as in-depth interviews.","airtime":"MON-FRI 9am-11am, 10pm-11pm","imageSrc":"https://cdn.kqed.org/wp-content/uploads/2024/04/Forum-Podcast-Tile-703x703-1.jpg","imageAlt":"KQED Forum with Mina Kim and Alexis Madrigal","officialWebsiteLink":"/forum","meta":{"site":"news","source":"kqed","order":"8"},"link":"/forum","subscribe":{"apple":"https://podcasts.apple.com/us/podcast/kqeds-forum/id73329719","google":"https://podcasts.google.com/feed/aHR0cHM6Ly9mZWVkcy5tZWdhcGhvbmUuZm0vS1FJTkM5NTU3MzgxNjMz","npr":"https://www.npr.org/podcasts/432307980/forum","stitcher":"https://www.stitcher.com/podcast/kqedfm-kqeds-forum-podcast","rss":"https://feeds.megaphone.fm/KQINC9557381633"}},"freakonomics-radio":{"id":"freakonomics-radio","title":"Freakonomics Radio","info":"Freakonomics Radio is a one-hour award-winning podcast and public-radio project hosted by Stephen Dubner, with co-author Steve Levitt as a regular guest. 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One of public radio's most popular programs, Fresh Air features intimate conversations with today's biggest luminaries.","airtime":"MON-FRI 7pm-8pm","imageSrc":"https://cdn.kqed.org/wp-content/uploads/2024/04/Fresh-Air-Podcast-Tile-360x360-1.jpg","officialWebsiteLink":"https://www.npr.org/programs/fresh-air/","meta":{"site":"radio","source":"npr"},"link":"/radio/program/fresh-air","subscribe":{"npr":"https://rpb3r.app.goo.gl/4s8b","apple":"https://itunes.apple.com/WebObjects/MZStore.woa/wa/viewPodcast?s=143441&mt=2&id=214089682&at=11l79Y&ct=nprdirectory","tuneIn":"https://tunein.com/radio/Fresh-Air-p17/","rss":"https://feeds.npr.org/381444908/podcast.xml"}},"here-and-now":{"id":"here-and-now","title":"Here & Now","info":"A live production of NPR and WBUR Boston, in collaboration with stations across the country, Here & Now reflects the fluid world of news as it's happening in the middle of the day, with timely, in-depth news, interviews and conversation. 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