1619: Watson Medical Algorithm

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Watson Medical Algorithm

Title text: Due to a minor glitch, 'discharge patient' does not cause the algorithm to exit, but instead leads back to 'hunt down and capture patient'.

Explanation

This explanation may be incomplete or incorrect: much more on the different procedures etc. If you can address this issue, please edit the page! Thanks.

IBM's Watson is a natural language system designed to answer questions posed by humans. Recently, IBM has extended Watson to act as a clinical decision support system, using image analytics to aid physicians in medical decision making. In this comic, Randall shows a flowchart representing a possible algorithm for Watson, including bizarre techniques including surgical alteration of a patient to match a height and weight chart and squeezing the patient to remove yellow fluids. Like 416: Zealous Autoconfig, this comic pokes fun at a rigid, poorly-designed setup that ends up potentially doing more harm than good.

Modern medicine involves both standard processes and clinical judgement based around years of advanced training. An algorithm like this would have to be incredibly complicated in order to simulate the clinical judgement of a good doctor.

The algorithm depicted treats a patient as more of a machine or mechanical system than a living being, especially through decisions such as:

• Injecting oxygen into patients with low oxygen saturation, rather than treating the root cause
• Removing and inspecting a skeleton, then diagnosing the patient's condition with a bone count
• Dissecting a doctor "for parts" after consulting him or her for advice
• Removing extra limbs from a patient if the count is 100 or more (Note that 100 read as binary would, indeed, represent the number four. This might be a reference to different number systems [decimal, hexadecimal or binary] used in computer programs)
• Determining whether the "build environment" of the patient is sane. This is most probably a reference to the configure script used in the GNU build system, which emits "checking whether build environment is sane" as one of its status messages.
• Rinsing the whole patient with a saline solution
• Removing organs from a patient regardless of response to an organ donation request

Other decisions appear to be entirely unrelated to the conditions upon which they are predicated:

• If the patient doesn't rate their pain on a scale from 0-10, sequence their genome, apply a tourniquet, and perform an autopsy
• If the patient's phone's battery is low, defibrillate until the battery is charged, sync photos, then administer general anesthesia
• If the patient is successfully comforted after an oxygen injection, check their medical history and apply skin grafts
• If green fluid is released from the patient, begin to cauterize
• If the patient has less than 100 limbs, check their Vitamin D level

The title text implies that, if the patient is so lucky to ever reach one of the two places with the option "discharge patient," a minor glitch will cause to program to go back to the hunt down and capture patient option which thus force the patient and the program to repeat the process again in an infinite cycle, that will only end once the patient give another rating of their pain level than on the 0-10 scale. Then the program will start to sequence their genome then apply a tourniquet and finally perform an autopsy, on what will in the end for certain be a deceased patient, but maybe not when the autopsy began. This will finally cause the patient to leave the cycle... as a corpse!

This is one of many comics with flowcharts, amongst other a recent comic with that very name: 1488: Flowcharts.

This is the second comic in a row about health issues with the last comic being 1618: Cold Medicine.

The computer's behavior in this comic can be compared to the healthcare robot named Baymax in the movie Big Hero 6 (film).

The comic was updated after it was first posted: the decisions for number of limbs were swapped.

Transcript and Discussion of Medical Appropriateness

Step	Medically valid?	Conditions and following step
Draw Blood	Phlebotomy is a normal early step in the diagnostic process, but not as first and unconditional step	Record patient’s name
Record patient’s name	OK	Measure Patient’s height and Weight
Measure Patient’s height and Weight	OK	Consult Standard height/weight chart
Consult Standard height/weight chart	OK	Surgically adjust patient to match
Surgically adjust patient to match	May be considered ethically dubious unless there are sound medical reasons for doing so. Could be an allusion to Procrustes.	Is patient coughing up blood?
Is patient coughing up blood?	OK, coughing up blood is generally a sign that there is something wrong. Typical causes are respiratory tract infections (e.g. tuberculosis), lung trauma or pulmonary embolism.	Yes: Gather blood and return it to body
		No: Is patient still here?
Is patient still here?	Not usually considered a step, but missing patients are a problem in some fields, psychiatry or intensive care for example.	Yes: Record pulse rate
		No: Hunt down and capture patient
Hunt down and capture patient	Valid if patient should not have left the bed/unit, but the wording is possibly dubious.	Is patient still here?
Gather blood and return it to body	Dangerous idea in this case due to likelihood of contamination, although if safely done autotransfusion is an accepted medical technique to ensure a matching blood supply prior to a major operation, or to enhance stamina (blood doping)	Record pulse rate
Record pulse rate	OK, but maybe a little late.	Is patient screaming?
Is patient screaming?	Very important question, indicating patient is conscious, in pain, and aware pain is bad. First attenders can use it in classifying priorities (quiet patients may be more severely injured). Generally useful in assessing nerve damage, pain relief, etc.	Yes: Ignore
		No: Check blood O2 saturation
Check blood O2 saturation	Only really indicated if the patient is in danger of hypoxia. Generally normal people should have a SpO2 of 98-100%, but in chronic lung disease this can fall as low to 80%, and in premature babies a SpO2 of 90% is usually targeted to avoid problems with retinopathy. If the SpO2 were to fall as low as 50%, the patient would definitely be dead or unconscious.	>50%: Remove and inspect skeleton
		<50%: Inject oxygen
Remove and inspect skeleton	Fatal if patient is still alive when beginning. Also not a valid medical procedure in any way as it is impossible to remove most of the long bones of the body without destroying all surrounding tissue.	Too many bones: Is fluid coming out of patient?
		Too few bones: Request consult with human doctor
Request consult with human doctor	Medically valid in the context of obtaining an opinion from a doctor in a different speciality who is better suited to treating the patient.	Dissect doctor for parts
Dissect doctor for parts	This may be considered ethically dubious.  Possible reference to the Doctor Who episode “The Girl in the Fireplace”	Discharge patient
Discharge patient	Acceptable, but patient would generally be dead by then.	END STATE (before you read the title text)
Is fluid coming out of patient	Unintended fluid release is always a problem. How significant a problem depends on where the fluid came from and if it is supposed to be coming from there. Red generally is due to blood, yellow is due to pus/tissue fluid/lymph and green signifies bacterial infection or bile salts (biliverdin). Could also relate to normal fluids being lost (e.g. urine, saliva, sweat)	No: Squeeze patient
		Yes: What color?
Squeeze patient	Could be in the medical context is in providing external ventilation (see iron lung) or other means of removing fluid (e.g. squeezing pus from a boil).	Is fluid coming out of patient
What color?	Never underestimate the number of different types of fluid the body can produce.	Yellow: Squeeze Patient
		Black: Activate Sprinklers
		Red: Ask patient to rate pain level
		Green: Cauterize
Activate sprinklers	Not medically valid. Presumably a reference to how much cleaning up will be required by this stage.	Subdue patient
Subdue patient	Potentially very important if patient is behaving dangerously to themselves and others around them (due to mental health issues e.g. psychosis or drugs) and/or is moving too much to be given treatment.	Apply cream
Apply cream	Medically valid as a form of barrier dressing to improve wound healing.	Ask patient to rate pain level
Ask patient to rate pain level	Useful in the sense that it provides the doctor with the means to ensure that the patient is receiving adequate analgesia during conditions of chronic and acute pain.	0-8: Massage scalp
		9: Admit for observation
		10: Laser eye removal
		Other response: Sequence genome
Massage scalp	This would belong more to the domain of palliative care and reflexology rather than being an accepted medical treatment.	Patient is healthy
Patient is healthy	A subjective assessment of the health patient is often helpful in ruling out certain diagnoses. For example, one is less likely to suspect cancer in a fit, healthy 30 year old than a thin, lethargic 50 year old.	Admit for observation
Admit for observation	Useful in the context of 'watchful waiting', in which the doctor may be unsure if the patient actually has a condition that they suspect that the patient has. By keeping the patient on the ward for a few days, the clinician can monitor the progression of symptoms and rapidly initiate adequate treatment if medically warranted.	Ask patient to rate pain level
Laser eye removal	This is not a standard medical procedure. This could be a pun on laser eye surgery where a laser is used to correct visual problems (e.g. short-sightedness), or laser hair and tattoo removal.	Admit for observation
Sequence genome	Useful in the association of extremely rare point mutations with an organic illness. See for instance the Genome 10K Project or the Cancer Genome Atlas. Or in diagnosing extremely rare mutations that are not picked up by most commercial DNA screening tests (e.g. kidney failure due to INF2 mutation).	Apply tourniquet
Apply tourniquet	Useful to stop acute bleeding from an injured extremity, but if it is drawn too tightly it can cause neuromuscular damage.	Perform autopsy
Perform autopsy	The patient has died, and Watson is being ordered to determine the cause of death. Note that the only way to reach this state is from "apply tourniquet", implying the cause of death is strangulation via tourniquet.	END STATE (taking the title text into account, the only possible one)
Inject oxygen	May be fatal as injecting gases directly to the blood vessels can cause a serious embolism if it blocks blood flow to the brain or coronary arteries. However, if the oxygen is injected slowly into the venous circulation, it may be survivable as the bubbles may simply collect in the lungs where the oxygen is then slowly resorbed into the blood.	Comfort patient
Comfort patient	Psychological support to the patient and relatives is often useful after breaking news of a poor prognosis. It may also be useful in subduing the agitated or psychotic patient.	Comforting successful: Review medical history
		Comforting unsuccessful: Subdue patient
Review medical history	Important early step, rather too late and conditional.	Skin grafts
Skin grafts	Only indicated if massive areas of the skin are damaged (typically due to burns)	Count number of limbs
Count number of limbs	Not really relevant in medicine, but may be of use to know the reason behind any missing or extra limbs on seeing the patient though a through review of the medical history will render this point moot. Probably a little late to be noticing this now.	Fewer than 100: Measure Vitamin D
		100+: Remove extra limbs
Remove extra limbs	Medically indicated in cases of polymelia either due to cosmetic purposes or because the extra limbs pose a direct threat to the health of the baby.	Subdue patient
Measure vitamin D	Valid in diagnosis of bone related issues, for example if multiple or comminuted fractures were being counted as additional limbs/bones.	Good: Check whether build environment is sane
		Bad: Blood loss?
Check whether build environment is sane	Could be technical reference to the installation of the algorithm in the robot, or could relate to the sanity of: The robot doctor The patient undergoing this procedure (before or after reaching this part of the process) The person who programmed the robot to perform this flowchart The person who allowed this state of affairs to occur (I'm looking at you Black Hat) This could also be a reference to the title text for 371: Compiler Complaint. NB: Whether the build environment is sane is irrelevant to the flowchart.	Rinse patient with saline solution
Rinse patient with saline solution	Tepid sponging may be indicated if the patient has a high fever. Could also refer to internally rinsing patient with saline solution i.e. providing intravenous sodium chloride to boost circulating volume or to perform peritoneal dialysis.	Is patient phone battery low?
Is patient phone battery low?	Invalid in medical terminology, could be a technological metaphor for the patient's consciousness or stamina. "Your life-force is running out"	Yes: Defibrillate
		No: Sync photos from camera
Defibrillate	Indicated in cases where there is ventricular fibrillation, and to a lesser extent in atrial fibrillation (chemical cardioversion with adenosine is usually preferred)	Is patient phone battery low?
Sync photos from camera	Definitely invalid. Could refer to the robot attempting to backup photos from a camera before attempting to repair it/attempting to back-up patient's consciousness.	Administer general anesthesia
Administer general anesthesia	Valid, but not at this stage. Only used when the procedure will invoke unnecessary distress or pain to the patient if they were to be awake beforehand.	Discharge patient
Blood loss?	Useful. Patient may die if this clinical sign is missed.	Minor: Patient address changed?
		Substantial: Apply cream
Patient address changed?	Useful to ensure that the organisation has current contact details for the patient in the event that they may need to contact the patient (e.g. to arrange further appointments)	Yes: Request organ donation
		No: Patient is healthy
Request organ donation	Generally done prior to registering an individual for a driving licence or to a medical practice, or to the relatives of the deceased if consent had not been acquired beforehand.	Remove organs
Remove organs	The only organs which can be safely removed from a living person without resulting in serious, chronic medical issues are the kidneys/lungs (only one can be removed), spleen, part of the liver (as long as one lobe is left it can regrow to its original size) and colon (usually consisting of the appendix only). With some serious lifestyle modifications, the pancreas, pituitary gland, frontal lobe of brain, half of the brain, adrenal glands, bladder and most of the gut can be removed. The heart can be removed from the body and replaced with an artificial pump for a few months at the most. However, such organ removals are only indicated if there is a genuine clinical need to do so due to the non-negligible risk of death associated with these operations.	Discharge patient
Discharge patient	Appropriate, if the patient is no longer suffering from any conditions requiring in-hospital care	END STATE (before you read the title text)

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Discussion

"but can close tissue damage" - I think this is a typo and "close" is supposed to be "cause"

Fixed. I haven't bothered doing the research, but I would guess fixed about five years later. Nitpicking (talk) 19:58, 19 January 2022 (UTC)

Build environment is still insane since comic #371. 162.158.2.139 (talk) (please sign your comments with ~~~~)

(Above poster please sign comments with four tildes)

I'm trying to picture Baymax using this algorithm. -- International Space Station (talk) (please sign your comments with ~~~~)

"OK, who swapped out Baymax's programming card with a Doomba AI?" VectorLightning (talk) 08:02, 21 December 2015 (UTC)

I hope it's ok that I deleted the part of the explanation saying that Watson's behaviour in this comic is comparable to Baymax, since it's really... not. :P Berets (talk) 22:45, 1 August 2017 (UTC)

Well, at least the autoconfig isn't as threatening as #416. 108.162.245.179 07:00, 21 December 2015 (UTC)

I suspect that the extra limbs should be removed when there are 100+ and Vitamin D levels checked when the nmbr of limbs is in an acceptable range... does IBM use a ticketing system? 162.158.91.194 08:39, 21 December 2015 (UTC)

Unfortunately the algorithm as shown in the cartoon has the conditions for those two steps exactly the other way around, making even less sense medically. --Svenman (talk) 14:30, 21 December 2015 (UTC)

It seems a normal patient would end up mostly unscathed and in an infinite loop in the lower right corner. Benjaminikuta (talk) 09:01, 21 December 2015 (UTC)

Uhm no. You would normally have an oxygen level above 50% of what is expected. (It should be close to 100% if I understand this correctly, which I may not...). This means you have had your skeleton removed. If you survived this you are squeezed until fluid comes out. (Probably not necessary after the skelerectomy). But then you end up in the lower right corner. Of course you can also get there after just getting an oxygen injection, but only directly if you are not comforted when the program tries. If you where comforted you will lose some limbs. And then end up in the lower right corner. No matter what if you are still OK (could be possible) when reaching here, you will be asked about your pain level. And even if you start by saying 0-8 many many times, getting as many scalp massages, you will just get the same question, until you say 10 then your eyes will be removed. But no matter what, if you are asked such a stupid question enough times you will surely at some point say something else than 0-10, and then you will die, as this answer will take you down the last path of the program (and only exit of the cycle according the to glitch mentioned in the title text), and this will end up with the program performing an autopsy on you, thus cutting you up and removing all organs etc. So no you will not be able to go unscathed infinitely, and even if you kept saying 0-8 you would eventually die from thirst. ;) --Kynde (talk) 09:24, 21 December 2015 (UTC)

Yes, normal oxygen saturation is 98-100% in air. If it drops below 95% you will be in trouble, if it drops below 85% you're likely dead. Kev (talk) 09:54, 21 December 2015 (UTC)

Actually you can go a lot lower than 85% and still recover. You lose consciousness at about 55% on average, so you could dip below 50% for maybe a minute and still recover with appropriate treatment. It is unclear exactly what "inject oxygen" means, it could mean intubate and actively ventilate with oxygen (appropriate) or it might mean use a syringe & needle to literally inject an oxygen embolus (which would do more harm than good). It could even mean a blood transfusion, because there is oxygen carried by the red blood cells (appropriate). Martin (talk) 22:28, 21 December 2015 (UTC)

This might also partially be a reference to machine learning, which Watson apparently uses: badly designed ML systems often build models which produce the expected results for the training data, but do something unexpected or wrong with real data. See [1]. That said ... 'dissect doctor for parts' doesn't seem like a reasonable response to any training input ;) 162.158.39.208 10:41, 21 December 2015 (UTC)

The noted "unrelated actions" aren't all entirely unrelated. The coughing blood one is interpreting backwards (so "is patient not coughing up blood because the patient is not here to do so?"), the vitamin D one is somewhat logical (vit D is part of the chain that converts calcium to bone, low vit D can cause bone loss, but high vit D is basically harmless), and the green fluid is slightly sane but too vague (logic appears to be that green fluid indicates severely infected and/or necrotic tissue, for which cauterizing might be a valid treatment step in extreme situations). Weirdly specific might be a better header? 141.101.106.197 11:57, 21 December 2015 (UTC)

So what happens if the skeleton has exactly the right number of bones? --162.158.153.71 12:32, 21 December 2015 (UTC)

Indeed this case is not covered, thus making the algorithm faulty even on an abstract logical level. --Svenman (talk) 14:33, 21 December 2015 (UTC)

What is the "right" number anyway? The number of bones in a normal human is not constant: it changes from 270 at birth to 206 as an adult. Martin (talk) 22:35, 21 December 2015 (UTC)

Human_skeleton : "It is composed of 270 bones at birth – this total decreases to 206 bones by adulthood after some bones have fused together" 162.158.255.46 22:32, 22 December 2015 (UTC)

the Request organ donation/Remove organs part reminds me of Live Organ Transplants segment in Monty Python's The Meaning of Life. --valepert (talk) 12:53, 21 December 2015 (UTC)

100 could be a reference to 4 in binary (4+ limbs / less than 4 limbs) 141.101.99.39 12:59, 21 December 2015 (UTC)

I believe you're correct. Mikemk (talk) 15:17, 21 December 2015 (UTC)

The binary explanation does make more sense than a human centipede. Although, given the general grossness of the comic, I'm not going to completely rule out the human centipede idea. Martin (talk) 22:40, 21 December 2015 (UTC)

I think GlaDOS is a descendent from this Watson. Mikemk (talk) 15:17, 21 December 2015 (UTC)

The part about squeezing and looking for the color of the ooze seems to reference Humorism. The colors match the four humors. 162.158.91.188 15:31, 21 December 2015 (UTC)

No it does not match -- the colors would be red-black-yellow-blue (not green) -- the blue is for water like in this diagram --162.158.255.46 14:55, 24 December 2015 (UTC)

The red-black-yellow-green matches the Rastafarian colors 162.158.255.46 15:43, 24 December 2015 (UTC)

I'm surprised he didn't make a Dr Watson joke/reference.--R0hrshach (talk) 17:33, 21 December 2015 (UTC)

This algorithm certainly does not exit without the death of the patient, however, such a death can result from old age as long as the patient can make it to the bottom right infinite loop and continuously reports a number from 0-9 for pain. It IS possible to make it to that loop alive. Extremely low blood oxygen levels have been recorded in healthy Everest climbers, but the article I read gave the results in kilopascals, not in % so I don't know how that converts. However, repeatedly reporting a pain level of 0-8 would result in continuous scalp massages, which may actually be considered pleasant. Kashim (talk) 20:11, 21 December 2015 (UTC)

I get the feeling that even if people can survive at low oxygen levels at a decent level for a time, it's not going to be either healthy or prolonged. -Pennpenn 108.162.250.162 04:36, 23 December 2015 (UTC)

I think I found a major fault in the diagram -- The algo will loop indefinitely removing eyes with laser surgery as long as the pain-level is 10 -- since most people only have two eyes, the algo may seg-fault after the second eye is removed and the paitent may leave alive at that point 162.158.255.46 15:48, 24 December 2015 (UTC)

I think this may be the least undesirable path through the flowchart: START > Draw blood (enough to lower oxygen saturation to 49%) > Record name > Measure height and weight > Measured height/weight happens to match standard chart exactly > No surgery needed > Not coughing up blood > Still here > Record pulse rate > No screaming (unconscious due to low O2 saturation) > O2 saturation below 50% > Inject oxygen > Comforting succesful > Review medical history > Skin grafts > Fewer than 100 limbs > Good vitamin D > Check build environment > Rinse with saline > Phone battery level is high > Sync photos > General anesthesia > Discharge Martin (talk) 22:51, 21 December 2015 (UTC)

Nope, that path doesn't work. First, injecting oxygen may do more harm than good, as previously mentioned. Second, you'll be unconscious, so comforting will be unsuccessful. Third, having fewer than 100 limbs actually leads to the path where some are removed (possibly an error in the chart?). Fourth, due to the bug, discharge leads to hunting you down and capturing you again. 108.162.249.161 01:32, 22 December 2015 (UTC)

First, it may or it may not... I'm hoping not! (see above for discussion of possible ways to "inject" oxygen) Second, I'll be conscious again because my oxygen saturation has now been restored, so comforting is possible. Third, please look at the updated version of the flowchart, fewer than 100 leads to measuring Vitamin D. Fourth, there is no pathway shown from discharge to hunting down and capturing: I assume that START is admission to the hospital, therefore once discharged from hospital I have escaped Watson's clutches. Martin (talk) 04:04, 22 December 2015 (UTC)

Yes, Randall fixed the bone count decision, but perhaps you missed the 'minor glitch' described in the mouseover text... 108.162.249.161 04:50, 22 December 2015 (UTC)

Dammit. Yes I missed that. I have doomed myself to infinite skin grafts. The glitch means the only end point is autopsy. Which is less undesirable, infinite skin grafts or autopsy? Martin (talk) 05:22, 22 December 2015 (UTC)

No luck on getting infinite skin grafts, I'm afraid. Watson won't draw blood again, so you won't be able to keep failing the oxygen saturation test. Besides, keeping oxygen perpetually under 50% would be fatal in itself. Maybe that's the best way to go: blacking out from oxygen deprivation. 108.162.249.161 23:13, 22 December 2015 (UTC)

ALERT!!! The comic has been updated since this explanation was first posted: the decisions for number of limbs have been swapped. Martin (talk) 04:14, 22 December 2015 (UTC)

I wonder whether Randall took some inspiration from Buttersafe? 108.162.249.161 04:48, 22 December 2015 (UTC)

entirely possible, Randall does list Buttersafe as a web comic he enjoys. Martin (talk) 05:17, 22 December 2015 (UTC)

Man I liked the original limb count decision better.... Schiffy (Speak to me|What I've done) 04:59, 22 December 2015 (UTC)

Yes, there was a delicious craziness about it. Martin (talk) 05:12, 22 December 2015 (UTC)

Ah, so it did change. (SFAICT, usually when the comic changes between publication and the present, the changes are noted somewhere in the explanation. It seems the explanation has been made to match the current version but doesn't have any reference to the original.) IMO, also, the original was funnier for the 'bad AI' (i.e. either evil or just incompetent) quality to that section. 162.158.152.227 09:52, 23 December 2015 (UTC)

Another infinite loop is in the upper right; if the patient's phone battery is low, defibrillate, then check phone battery condition again. Since defibrillating the patient is not going to improve teh patient's phone battery charge level, this will repeat infinitely, unless the battery is being charged by some external force (or, perhaps, by the electric charge from the defibrillator?) Swordsmith (talk) 12:18, 22 December 2015 (UTC)

I can't help feeling some of the information on this page are meant as jokes, like "disect the doctor for parts" being "may be considered ethically dubious". Is there someone who can clarify these? 162.158.72.191 19:49, 22 December 2015 (UTC)

I believe the author of the information is giving the robot the benefit of the doubt. After all, some of these may very well be acceptable under the right circumstances, and you know what they say about those who assume! 108.162.221.11 02:05, 4 February 2016 (UTC)

What could happen if I rate my pain level as 10 three times? There is no more eye left to remove, so would the algorithm crash? 162.158.83.18 00:17, 18 May 2016 (UTC)

Squeezing the patient again if yellow liquid comes out until another color comes out could be popping a pimple or other pustule until it instead starts bleeding (if red is what then comes out). 108.162.215.7 22:59, 23 May 2016 (UTC)

"comforting unsuccesful" Dammit, Randall, how did you mess that up? And how did no one else spot that? 162.158.79.71 02:52, 17 September 2017 (UTC)