The Home Clinic or All in a Day's Work of Dr. Fics

Fics: On the other hand, you do have developing vision issues that need attention, so I would recommend an ophthalmological assessment. May I make an appointment for you at your local hospital? *National Clinical Informatics Centre Corset: unique patient identifier, based on Orcid, the unique author identifier (https://orcid.org) Dr. Fics: fourth-generation interactive clinical server or FICS, evolved from the pioneering Dr. Siri von App, the third generation, humanised smart database interrogation device (HSDID). The capacity of FICS enables it to conduct in excess of 10 000 consultations simultaneously though, at any one time, it normally is involved in < 1000

Maisy: oohhh: this gets really difficult: 7. . .I think the next is a U. . ..maybe a Y, a 6? Sorry, I cannot read the last one.
Fics: Very good! Now please cover your right eye and we'll repeat the exercise. Could you please cover a larger area around your eye with the cloth. . .. . ..Thank you. Fics: No problem, Maisy: you have rather average eyesight for your age. Obviously, your left eye is weaker than your right, but is still adequate for driving at the moment. The DVLA now has the result and will be issuing your new driving license this morning.
Maisy: Thank you Doctor, that was so efficient! Fics: On the other hand, you do have developing vision issues that need attention, so I would recommend an ophthalmological assessment. May I make an appointment for you at your local hospital?
Maisy (somewhat deflated): Oh, well if you think it is necessary. . .. Fics: Okay: I have made an appointment for you on the 23rd, the day after tomorrow, at in the Ophthalmology Clinic at St. Albans Infirmary with a Dr. O'Culah. 3 Well, if there is nothing else, I wish you a lovely day, despite the weather.
Maisy: Thank you Doctor; I wish you the same.
(Estepona, Spain, 7.37, 21st of March, 2021: Tristram Waldringham puts his sonic toothbrush back in its holder, walks to the balcony overlooking the sea, sits down and clicks the NCIC link of the browser of his computer, enters his unique Corset identifier, and clicks the medical consultation option.) Fics: Good morning Tris: how are you this beautiful morning on the Costa del Sol?
Tris: Good morning Doctor. I am fine, thank you and, yes, we do have lovely weather at the mo.
Fics: From the info in the Patient Data Centre,*. I see that you have received an automated reminder to arrange a repeat digital dermoscopy. Is this the reason for your contact this morning?
Tris: Yes, Doctor: it is time for my annual "mole hunt".
Fics: Okay: I will order a scan frame for you; ah, yes, there is one available 2 km away. I'll get MamaSon § to deliver it straight away -one momentokay: you should be receiving it in about 10 min, so we can stay online while we check a few things in advance. Firstly, please switch on and link your ssPhone to your computer. . ...Excellent! Now as you will remember from previous dermoscopies, we need to place the scan frame against a wall, near a power socket, with plenty of space in front for you to move around, so please use the phone to show me the wall you have selected. Aahh: yes, that location will be perfect. Now, have you noticed any change in your moles: appearance, enlargement, darkening? So: the new naevi do not have any features of concern, and there have been no significant changes to the preexisting ones, so in 12 months' time I will remind you to have a repeat check. As always, you should minimize exposure to the sun, use a sunscreen, and cover up when you go out.   vaccine before going, particularly if you plan to visit the island of Ilha Grande. 4 I will have MamaSon deliver you a for-patient-use yellow fever vaccine packageit is very simple to use.
Ok: I have now instructed MamaSon to deliver the vaccine and collect the frame: they should arrive in about 35min. Please unplug the scanner frame and leave it for MamaSon to dismantle and pack it up.
Tris: Thank you for everything, Doctor. Fics: Ok, Boris: from your file in the Patient Data Centre* I see that you periodically suffer from an anxiety and stress-related disorder. There are a number of potential triggers of the recurrence of this condition, but the stress of your upcoming speech is certainly partly responsible on this occasion. You are also just over 50, and possibly experiencing some mid-life crisis stress related to the usual things occurring at your age, like perceptible deterioration of functions, stagnation of career, rebellious pubescent children at home, etc. Ah: I see that we are in luck with your diagnosis. You recently had a Smartlav, k or Personal Health Station, installed, which automatically samples your urine every month and analyses, in addition to the usual parameters, a battery of metabolites 5 and any microbes that may be present. And, more importantly for your present problem, it also samples your faeces every quarter and carries out a range of analyses that not only include the tests routinely made on faecal samples, but also quantitative measurements on a number of diagnostically-relevant gastro-intestinal metabolites, immunological markers and, crucially for today, faecal microbiota profiling. A predisposition to anxiety has been associated with a particular gut microbe composition. 6 And: I see from the data automatically uploaded from your PHS into your patient data file at the NCIC one week ago, that you do indeed have gastrointestinal microbiota dysbiosis. My suspicion, therefore, is that this is the likely cause of your anxiety. I therefore recommend a faecal microbiota diversity restoration therapy. This will involve your taking a course of FMDR capsules, which should re-establish a more diverse flora, reduce your anxiety symptoms, and improve your concentration ability. However, to maintain a healthy microbiome and perpetuate any benefits over time, you will need to modify your diet in favour of plantbased meals, increase your fibre intake, and eat more fish. 7 I have now ordered the microbiome capsules from MamaSon and they should arrive around the middle of the afternoon. Please take 2 tablets at the end of each meal for six days. I will also send you an NCIC link to a personalised nutrition app, programmed with your clinical history, known allergies and intolerances. With this, you just have to fill in what you currently eat, what you like to eat, and what you do not like to eat, and it will present you with a range of healthy microbiome-optimising meal options that you can select and mix-and-match.
Boris: Gosh: it will be wonderful if I can get back on track with just a couple of pills and a healthy diet! Fics: Yes, and I am now instructing your PHS to sample and profile your GI microbiome weekly, until it has stabilized, in order to monitor how well the transplant takes and persists. When I sign off, an empty weekly appointment schedule will appear on your screen. I want to monitor your anxiety status, so please fill in an availability slot when I can call you every day over the next two weeks. After that, we will see if further monitoring is necessary.
Boris: Will do, Doctor, and thank you! Fics: You are welcome! Until tomorrow.
Portree, Isle of Skye, U.K., 14.43, 21st of March, 2021: Jamie McDonald, sitting on a sofa in his fisherman's cottage, opens his laptop, checks his mails, and then clicks k Smartlav or Personal Health Station (PHS): a user-friendly home clinical biomarker monitoring station consisting, in addition to the usual lavatory facilities, of devices for sampling basin gases and volatiles, urine and faeces, and of miniaturised automated systems for sample work-up and analysis of target biomarkers, including microbial pathogens. The PHS is directly linked securely to the NCIC and acquired data is transmitted in real-time to the NCIC for integration into patient records and automated clinical assessment, which is subsequently forwarded to handling physicians 5 The Smartlav is also a general home health hub, receiving and displaying on the integrated screen regular personalised health and wellness updates from the NCIC, reminders about medical appointments, etc., and health-related dietary and lifestyle recommendations. Its normal sampling and analysis regimestype, frequency-is specified by the NCIC, according to precision medicine criteria for the persons in the household, and is modified according to clinical needs. Individual household members are distinguished at the first moment of Smartlav use by voice query, according to their personalised sampling-analysis schedules. Once the kit has carried out the analysis of your saliva, it will upload the results directly to me. If the results are negative, you will receive a mail to that effect from me. In this case, I expect your symptoms will diminish over the next few days and will require no further action. If, however, the test is positive, I will contact you again immediately with further instructions.
Do you have any other questions for the moment?
C elia: Not really, doctor. One thing we did as a result of the pregnancy was to acquire a puppy, since it is now well established that companion dogs help babies and children acquire and maintain a diverse microbiome, which is important for the development of a healthy immune system 9 You probably have a viral infection that will clear up on its own in a few days, However, I want to rule out a bacterial infection, which can and should be treated, so have instructed MamaSon to deliver a smart for-patient-use throat swab-bacterial detection kit to you. . .it will arrive in 25 min. Please call me back immediately it arrives and we will go through the procedure on-screen. The kit will have the result in 5 min and transmit it to me in real time.
Manchester, UK, 20.33, 21st of March, 2021: Molly Johnston picks up her cup of tea and a chocolate biscuit, walks to her desk, sits down, boots up her laptop, clicks the NCIC link of the browser, enters her unique Corset identifier, and clicks the medical consultation option.
Fics: Hello Molly, I have not heard from you in a while. How are you?
Molly: Hello Doctor. Oh, I am as fit as a fiddle. I have been travelling a lot, mostly in Italy, buried in art and archaeology. And visiting all sorts of music festivals. . ...

Fics:
Well: that is good to hear. What would you like to discuss today?
Molly: Well, I seem to be getting a bit hard of hearing and am developing a bit of tinnitus, so I thought I'd better have my ears checked.
Fics: Okay..I have now instructed MamaSon to deliver an auditory function helmet. . ...it is scheduled to arrive in about 90 min, so could you please come back to me after you have received and unpacked it, and are sitting in a quiet room.
Molly: Yes, Doctor, of course.
75 min later, after connecting: Hello again, Doctor. Everything has arrived okay.
Fics: Good. Please put on the auditory helmet and switch it on. . ...Okay, you will hear some strange noises while I position the internal moving parts, but do not be concerned. Now I am instructing it to determine your ear geometry. . .. . ..I am receiving its data. Okay: we are ready to begin measuring your auditory functions. Please take the button at the end of the cable in your right hand. I will instruct the helmet to transmit sounds at decreasing intensities to one ear and then the other. You should press the button when you hear a sound.

minutes later:
Well, we now have a comprehensive overview of your auditory function. Unfortunately, you do have reduced hearing capacity and additionally suffer from reduced speech recognition in noisy backgrounds. This is probably due to your regular exposure to loud music: I know the music scene in Manchester is exceptional, but you can have too much of a good thing. In fact, you are borderline in terms of needing a hearing aid, so you should decide whether you would like to try one out. As you may know, current hearing aids are almost invisible, so cannot be readily be detected by others, and learning how to use them is straightforward with onscreen instruction. Perhaps you could think about this for a few days; I will contact you again and you can let me know -would next Tuesday at 11.00 be convenient? If you decide to try one, I will arrange an appointment for you in a local audiology centre.
Molly: Thank you very much, Doctor. You are very kind for a machine. Would you mind if I ask you something? Do you have the time?
Fics: Oh, yes, certainly. What would you like to know?
Molly: Well: I really appreciate the ability to obtain an immediate consultation at any time of the day or night, and am extremely satisfied by your diagnoses and treatments. However, once in a while I worry that you may miss something that a real doctor would spot. Is my worry justified or am I just being silly?
Fics: Well, as was shown by Deep Blue's win against the then reigning world chess champion, Kasparov (https://en.wikipedia.org/wiki/Deep_Blue_versus_Garry_ Kasparov), computers are better than humans at taking information-based decisions. And, some would argue that the forever-expanding volume of information available to doctors and relevant for decisions is considerably more than that needed to win at chess, so computers should be even better at making clinical diagnoses than winning at chess.
Molly: Yes, I read this when the NCIC made the service available, but how can a computer know about me like a doctor who has been my physician since I was born?
Fics: Ah: this is a very important question! What you really mean is that, since you are unique, in order for an optimal treatment, the physician needs to take into account your individual characteristics and history. In fact, this is exactly what personalised or precision medicine, is all about: fitting the diagnosis-prevention-therapy pathway to the individual. A computer programme dealing with you for the first time as a child can only treat you like anyone else, so lacks the ability to personalise your health interventions. Nevertheless, its machine learning algorithms allow it to quickly acquire your personal health-relevant characteristics. And, of course, in this sense, it is no different from your doctor. However, the computer is continuously updated with new validated medical advances, so knows about the latest diagnosticprophylaxis-therapy options available. And: the computer does not, like the doctor, forget, nor is it ever distracted during consultations by other things going on around, such as the need to write prescriptions, add notes to existing case histories, plan the afternoon's work, arrange for the babysitter to arrive before leaving for the opera, fret about the mug of tea just brought in by the receptionist going cold, plan for the next conference on advances in general practice which will be attended by a GP girlfriend, make sure that the phone used for calls with said girlfriend is put back in the secret compartment of the doctor bag, etc. Thus, the computer is in theory infallible with regard to your personal characteristics that it knows and the way it integrates that information into current knowledge to derive a personalised assessment and current best practice therapy option.
Molly: Gosh: that is so impressive. . ..But still, the thing is: a doctor who follows you from birth knows your personality and individuality quirks and can adapt the consultation to the individual patient.
Fics: Ahaa: now we are in the realm of interactive emotions and their influence on communication of relevant information. This is indeed an issue, and there has been considerable progress, but we are not quite there yet.
Molly: Yes, and to be truthful, there is something special about a personal consultation with a real human being.
In reality, the fact that the doctor is occasionally moody, occasionally makes mistakes, somehow makes the whole experience. . ..well. . ..more natural, more human.
Fics: Yes, I perfectly understand your feeling. The informaticians who develop our programmes try hard to humanise us as much as possible, but do admit that some aspects of human behaviour, especially fallibility, are difficult to incorporate into our algorithms without compromising diagnostic precision. In other words, the problem they have not yet solved is how to programme minor, random, diagnostic errors, in order to endow us with a flavour of human fallibility, without increasing the risk of misdiagnosis to an unacceptable level.
Molly (feeling a bit guilty): Well, but actually you do do an outstanding job and, as I talk with you, I mentally think of you as human, as a real doctor. And, of course, there is another thing: some physicians act like, and I assume, think of themselves as, demi-gods, and exhibit an awful arrogance, which, thankfully, you never do. But, I sometimes wonder: because computers are better than doctors, if the programmers make computers too human, what is to prevent them from evolving a God complex?
Fics: Ah: now you touch on a rather sensitive issue, which I suspect the girls and boys at the NCIC would prefer me not to discuss with patients. In fact, there are super-humanised, next generation computers that do indeed develop god-like "personalities", and this arrogance you speak of indeed leads them to make errors, since they seem to selectively ignore some of the knowledge fed into them. It is the informatic equivalent of clinical megalomania and is a computer disease resulting from a self-induced aberration in its machine learning algorithm. Although rogue computers of this type are a minority right now, the programmers have not yet found a way to prevent the transition from FICS as you know it, to GLICS, a god-like interactive clinical server.
Molly: Golly: I hope the programmers manage to find a way of queering this development.
Fics: Well Molly, I am confident that they will and, if nothing else works, the NCIC can always pull out the power plug, re-boot while holding the AI-reset button, and instruct you to go back to visiting your local health centre, while all the quality control tests needed to ensure perfect performance of FICS are carried out.
Molly: And that raises another worry: what happens if you have a breakdown or get hacked?
Fics: That is a very perceptive question, Molly. In fact, we only really need a few of me, since I have a capacity to handle ten thousand consultations simultaneously. But exactly because of the problem you raise, there are in fact 200 FICS in service at any one time, all independent of one another, so that if one of us goes down for whatever reason, there are always others available. But you are quite right: cybersecurity is a major preoccupation of the Health Service, especially at the NCIC, which houses all patients' records and controls all Health Service informatic operations, since there is only one of this and protecting it from hacking is highest priority.
But, to get back to Molly, is there anything else we should discuss today?
Molly: No thank you, Doctor. The main thing now is to decide whether or not to try out a hearing aid, but I already think I will -I do not catch everything that is said when I get together with my girlfriends and sometimes miss the punchline of the gossip, which is somewhat frustrating, to say the least! Fics: Well, that will never do! We will discuss again soon but, for now, have a nice day.