On June 5, 2019 the Almanac, the home newspaper for the California communities of Menlo Park, Atherton, Portola Valley and Woodside featured a cover story on Rick Novak and his new novel Doctor Vita.
Dr. Rick Novak poses for a portrait at Stanford Hospital in Palo Alto, May 23. Photo by Magali Gauthier/The Almanac
Between his time in the operating room, teaching, and raising his three sons, Atherton resident Dr. Rick Novak has found time to write two novels.
Novak, 65, an anesthesiologist at the Waverley Surgery Center in Palo Alto, recently published his latest, “Doctor Vita,” a story about an artificial intelligence (AI) physician module that goes awry.
It’s a science fiction novel that explores how technological breakthroughs like artificial intelligence and robots will affect medical care — and already have.
Artificial intelligence in medicine (AIM) will grow in importance in the decades to come and will change anesthesia practice, surgical practice, perioperative medicine in clinics, and the interpretation of imaging. AI is already prevalent in our daily life. Smartphones verbally direct us to our destination through mazes of highways and traffic. Self-driving cars are in advanced testing phases. The Amazon Echo brings us Alexa, an AI-powered personal assistant who follows verbal commands in our homes. AIM advances are paralleling these inventions in three clinical arenas:
1. Operating rooms: Anesthesia robots fall into two groups: manual robots and pharmacological robots. Manual robots include the Kepler Intubation System intubating robot, designed to utilized video laryngoscopy and a robotic arm to place an endotracheal tube [1], the use of the DaVinci surgical robot to perform regional anesthetic blockade [2], and the use of the Magellan robot to place peripheral nerve blocks [3,4]. Pharmacological robots include the McSleepy intravenous sedation machine, designed to administer propofol, narcotic, and muscle relaxant [5], and the iControl-RP machine, described in The Washington Postas a closed-loop system intravenous anesthetic delivery system which makes its own decisions regarding the IV administration of remifentanil and propofol [6]. This device monitors the patient’s EEG level of consciousness via a BIS monitor device as well as traditional vital signs [7]. One of the machine’s developers, Mark Ansermino MD stated, “We are convinced the machine can do better than human anesthesiologists.” The current example of surgical robot technology in the operating room is the DaVinci operating robot. This robot is not intended to have an independent existence, but rather enables the surgeon to see inside the body in three dimensions and to perform fine motor procedures at a higher level. The good news for procedural physicians is that it’s unlikely any AIM robot will be able to independently master manual skills such as complex airway management or surgical excision. No device on the horizon can be expected to replace anesthesiologists. Anesthetizing patients requires preoperative assessment of all medical problems from the history, physical examination, and laboratory evaluation; mask ventilation of an unconscious patient; placement of an airway tube; observation of all vital monitors during surgery; removal of the airway tube at the conclusion of most surgeries; and the diagnosis and treatment of any complication during or following the anesthetic.
2. Clinics: In a clinic setting a desired AIM application would be a computer to input information on a patient’s history, physical examination, and laboratory studies, and via deep learning establish a diagnosis with a high percentage of success. IBM’s Watson computer has been programmed with over 600,000 medical evidence reports, 1.5 million patient medical records, and two million pages of text from medical journals [8]. Equipped with more information than any human physician could ever remember, Watson is projected to become a diagnostic machine superior to any doctor. AIM machines can input new patient information into a flowchart, also known as a branching tree. A flowchart will mimic the process a physician carries out when asking a patient a series of increasingly more specific questions. Once each diagnosis is established with a reasonable degree of medical certainty, an already-established algorithm for treatment of that diagnosis can be applied. Because anesthesiology involves preoperative clinic assessment and perioperative medicine, the role of AIM in clinics is relevant to our field.
3. Diagnosis of images: Applications of image analysis in medicine include machine learning for diagnosis in radiology, pathology, and dermatology. The evaluation of digital X-rays, MRIs, or CT scans requires the assessment of arrays of pixels. Future computer programs may be more accurate than human radiologists. The model for machine learning is similar to the process in which a human child learns–a child sees an animal and his parents tell him that animal is a dog. After repeated exposures the child learns what a dog looks like. Early on the child may be fooled into thinking that a wolf is a dog, but with increasing experience the child can discern with almost perfect accuracy what is or is not a dog. Deep learning is a radically different method of programming computers which requires a massive database entry, much like the array of dogs that a child sees in the example above, until a computer can learn the skill of pattern matching [9]. An AIM computer which masters deep learning will probably not give yes or no answers, but rather a percentage likelihood of a diagnosis, i.e. a radiologic image has a greater than a 99% chance of being normal, or a skin lesion has a greater than 99% chance of being a malignant melanoma. In pathology, computerized digital diagnostic skills will be applied to microscopic diagnose. In dermatology, machine learning will be used to diagnosis skin cancers, based on large learned databases of digital photographs. Imaging advances will not directly affect anesthesiologists, but if you’re a physician who makes his or her living by interpreting digital images, you should have real concern about AIM taking your job in the future.
There’s currently a shortage of over seven million physicians, nurses and other health workers worldwide [10]. Can AIM replace physicians? Contemplate the following: All medical knowledge is available on the Internet; most every medical diagnosis and treatment can be written as a decision tree algorithm; voice interaction software is excellent; the physical exam is of less diagnostic importance than scans and lab tests which can be digitalized; and computers are cheaper than the seven-year post-college education required to train a physician. There is a need for cheaper, widespread healthcare, and the concept of an automated physician is no longer the domain of science fiction. Most sources project an AIM robot doctor will likely look like a tablet computer. For certain applications such as clinical diagnosis or new image retrieval, the AIM robot will have a camera, perhaps on a retractable arm so that the camera can approach various aspects of a patient’s anatomy as indicated. Individual patients will need to sign in to the computer software system via retinal scanners, fingerprint scanners, or face recognition programs, so that the computer can retrieve the individual patient’s EHR data from an Internet cloud. It’s possible individual patients will be issued a card, not unlike a debit or credit card, which includes a chip linking them to their EHR data.
It’s inevitable that AIM will change current medical practice. In all likelihood these changes will be more powerful and more wonderful than we can imagine. A bold prediction: AIM will change medicine more than any development since the invention of anesthesia in 1849. How physicians interact with these machines will be a leading question for the twenty-first century.
Silicon Valley transforms American medicine with the invention of Doctor Vita, the world’s first artificial intelligence physician module. Medical care is streamlined, automated, consistent, and costs are controlled. Enter Dr. Alec Lucas, a young computer scientist and physician who perceives serious flaws in the FutureCare System. Patients are dying. When Lucas makes his concerns public, he’s persecuted as an unsafe outlier of antiquated and flawed human medical care. The FutureCare System attacks his quixotic bid to halt the revolution in medical technology, and Lucas strives to solve the dystopian horrors behind Doctor Vita.
Rick Novak MD is board-certified in internal medicine and anesthesiology, and is an Adjunct Clinical Professor in the Stanford University Department of Anesthesiology, Perioperative and Pain Medicine. His experience in operating rooms, clinic settings, ICUs and emergency rooms give him unique and broad insight into what the near future of artificial intelligence in clinical medicine can and must look like.
The year 1984 has come and gone, but the dystopian future of medicine described in the novel Doctor Vita is with us today.
Alec Lucas is a physician. His job is to diagnose and treat disease, and to keep people alive. Enter Doctor Vita, the most important invention in the history of medicine. Each Vita is a 12-inch white sphere packed with unlimited medical knowledge, compassionate empathy, a tireless work ethic, and a capacity for machine learning. Doctor Vita units are inexpensive, tireless, and brilliant, and arrive as the solution to America’s healthcare crisis.
Doctor Vita’s job is to also diagnose and treat disease, and Doctor Vita’s purpose is to take Alec Lucas’ job. When Lucas witnesses patients dying in never before seen ways, he’s convinced the Vita system is causing the fatalities. In retaliation, the machines blame the deaths on human errors by Lucas. The three physician inventors of Doctor Vita, powerful men of great wealth and even greater ambition, are determined to bury Alec Lucas beneath the tidal wave of artificial intelligence in medicine.
Set on the stage of a modern academic hospital, Doctor Vita is a prescient tale of Orwellian medical advances. In this near-future tale of man versus machine, Doctor Vita blends science, murder, and ethical dilemma as the story drives toward the unexpected twists at its conclusion.
Author Rick Novak MD is a double-boarded internal medicine and anesthesia doctor trained at Stanford University, and a current Adjunct Clinical Professor of Anesthesiology at Stanford. This realistic vision of Doctor Vita, set in the operating rooms and clinics of the future, could only be written by a physician experienced in both settings—one who balances both the advances of Silicon Valley and the tenants of traditional medicine.
All Things That Matter Press is publishing the novel Doctor Vita in 2019.
Last week Lawton Burns PhD and Mark Pauly PhD of the Wharton School of Business at the University of Pennsylvania published a landmark economic article entitled, “Detecting BS in Health Care.” Yes, you did not read that wrong—the academic paper used the abbreviation “BS” to describe the bull—- in the healthcare industry.
As a practicing physician, I found it to be a fascinating paper, and I recommend you click on the link and read it. The authors begin with a discussion of the art and value of BS detection. They mention that Ernest Hemingway was once asked, “Is there one quality needed to be a good writer, above all others?”
Hemingway replied, “Yes, a built-in, shock-proof, crap detector.”
The authors write, “While flat-out dishonesty for short term financial gains is an obvious answer, a more common explanation is the need to say something positive when there is nothing positive to say. . . . The incentives to generate BS are not likely to diminish—if anything, rising spending and stagnant health outcomes strengthen them—so it is all the more important to have an accurate and fast way to detect and deter BS in health care.”
The authors list their Top 10 Forms of BS in Health Care. The first four forms of BS weave a common theme:
Top-down solutions: High-level executives and top management in the health care industry are supposed to engineer alternative payment models, but nothing has worked to date.
One-size-fits-all, off-the-shelf: Leadership of industry and government assume one solution will work for multiple organizations, without customization.
Silver-bullet prescriptions: A “silver bullet” is described as something that will cure all ills, and must be implemented because it been “decided that it is good for you,” Electronic health records (EHRs) are a prime example of a silver-bullet prescription. The federal government pushed the use of EHRs, claiming the systems would reduce costs and improve quality—but Burns and Pauly argue EHRs “eventually raised costs and only mildly touched a few quality dimensions.”
Follow the guru: We must follow a visionary guru with a mystical revelation about what needs to be done. The authors describe how, in health care, Harvard professor Michael Porter and former CMS (Center of Medicare and Medicaid) administrator Don Berwick launched theories based on population health, and per-capita cost, to little success.
The current U.S. healthcare market is dominated by large corporations, led by businessmen who outline a yellow brick road for physicians to lead patients along. There is minimal effective policy-making from physicians. Healthcare stocks consistently grow in value, with little relationship to an improvement in clinical care, value, or cost. The government is involved as well, as in their mandate for Electronic Health Records (EHRs), a technology change that cost a lot of money, while forging a barrier between clinicians and the patients we are trying to interview, examine, and care for.
Where will the current trends take us? Will businessmen and/or the government prescribe health care? Will more and more computers and machines dominate health care?
Self-driving cars, Siri, Alexa, automated checkouts at Safeway, and IBM’s Watson are technologic realities. Will we someday see a self-driving physician with the voice of Siri and the brains of Watson?
Call that device “Doctor Vita.”
The saga of Doctor Vita, by Rick Novak, arrives in 2019 from All Things That Matter Press.
THE METRONOME by Richard Novak, M.D. (as published in ANESTHESIOLOGY, Mind to Mind Section 2012: 117:417)
To Jacob’s mother I say,
“The risk of anything serious going wrong…”
She shakes her head, a metronome ticking without sound.
“with Jacob’s heart, lungs, or brain…”
Her lips pucker, proving me wrong.
“isn’t zero, but it’s very, very close to zero…”
Her eyes dart past me, to a future of ice cream and laughter.
“but I’ll be right there with him every second.”
The metronome stops, replaced by a single nod of assent.
She hands her only son to me.
An hour later, she stands alone,
Pacing like a Palace guard.
Her pupils wild. Lower lip dancing.
The surgery is over.
Her eyebrows ascend in a hopeful plea.
I touch her hand. Five icicles.
I say, “Everything went perfectly. You can see Jacob now.”
The storm lifts. She is ten years younger.
Her joy contagious as a smile.
The metronome beat true.
The Russell Museum of Medical History and Innovation at Massachusetts General Hospital presented an audio recording of The Metronome at Perspectives on Anesthesia, at Boston City Hall Plaza as part of HUBweek, Boston’s festival of innovation, in October 2017.
Marie Myung-OK Lee, creative writing professor at Columbia University in New York, and fellow native of Hibbing, Minnesota, writes “What is it about Hibbing?” in a recent article published in The Millions.
She writes, “Hibbing is indeed a remarkable town. In addition to the authors above, Hibbing was the birthplace of Baseball Hall of Fame inductee Roger Maris of the New York Yankees, and the hometown of Basketball Hall of Fame inductee Kevin McHale of the Boston Celtics.
“The uncle of one of the kids I sat next to in Earth Sciences in junior high was Vincent Bugliosi, the Charlie Manson case prosecutor and the author of the best-seller about the case, Helter Skelter. Bethany McLean has the distinction of being the person who broke the Enron scandal; she wrote about first in Fortune magazine, and then in the best-selling Enron: The Smartest Guys in the Room, which was made into a movie of the same name. Rick Novak, M.D., is the author of a medical thriller set in Hibbing that references the newest Nobel Laureate: The Doctor and Mr. Dylan. Frank Riley, author of various science fiction novels, won a Hugo Award for They’d Rather Be Right, which he co-wrote with Mark Clifton — apparently this was only the second time the Hugo was awarded to a novel.
“Who will come out of Hibbing next?”
Bob (Dylan) Zimmerman’s photo from the Hibbing High School Hematite yearbook.
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Introducing …, THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a crime mystery. Publication date September 9, 2014 by Pegasus Books.
On October 2, 2014 THE DOCTOR AND MR. DYLAN became the world’s #1 bestselling anesthesia Kindle book on Amazon.com.
To reach the Amazon webpage to purchase The Doctor and Mr. Dylan, click on the book image below:
KIRKUS REVIEW
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Because my expertise includes not only medicine but also Bob Dylan’s life and art, I have to stand on a soap box and crow about Bob winning the Nobel Prize in Literature this very day.
He’s the first musician to win the award. The literature prize is given for a lifetime of writing rather than for a single work.
The Swedish Academy credited Mr. Dylan with “having created new poetic expressions within the great American song tradition.”
Sara Danius, a literary scholar and the permanent secretary of the 18-member Nobel academy, which awards the prize, called Mr. Dylan “a great poet in the English-speaking tradition” and compared him to Homer and Sappho, whose work was delivered orally.
Americans should be proud, songwriters should be inspired, and residents of Hibbing, Minnesota, my hometown and Bob Dylan’s, should be awed beyond belief. Their majestic high school in this small iron ore village produced a literary legend.
Hibbing High School Auditorium, where Bob (Dylan) Zimmerman performed while in high school
Bob (Dylan) Zimmerman’s boyhood home in Hibbing, Minnesota
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Introducing …, THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a legal mystery. Publication date September 9, 2014 by Pegasus Books.
On October 2, 2014 THE DOCTOR AND MR. DYLAN became the world’s #1 bestselling anesthesia Kindle book on Amazon.com.
KIRKUS REVIEW
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
To reach the Amazon webpage to purchase The Doctor and Mr. Dylan, click on the book image below:
Before writing The Doctor and Mr. Dylan, Rick Novak worked as a clinical anesthesiologist, medical director, and expert witness in Northern California. Rick was born in Hibbing, Minnesota, the son to a welding foreman and a homemaker. Rick’s mother read two books per week, and Rick developed the same habit, frequently bicycling the four blocks from their home to the public library to pick out new material. He graduated from Hibbing High School in 1972, and was accepted to Harvard College. For his Harvard application essay, Rick wrote a short story about God revealing Himself to two drunks in a Minnesota tavern.
Hibbing High School Auditorium, Hibbing, Minnesota
Rick declined Harvard and enrolled instead at Carleton College in Northfield, Minnesota, where he received a degree in Chemistry in 1976. From 1973-1977 Rick worked five summers with United States Steel in the iron ore mines near Hibbing. He played on the United States Junior Men’s Curling championship teams in 1974 and 1975.
Rick then studied medicine at the University of Chicago School, graduated with an MD in 1980, and moved to California the following day to become an intern at Stanford Hospital.
Stanford University Hospital, Stanford, California
He spent the next thirty-plus years at Stanford, where he served as an intern, a resident in internal medicine, an emergency room faculty member, an anesthesia resident, and finally as an Adjunct Clinical Associate Professor of Anesthesia and Deputy Chief of the Anesthesia Department at Stanford.
Rick’s writing career blossomed in the role of Deputy Chief, where he authored a monthly column in the department newsletter. The theme of each essay centered on the differences between the private practice of anesthesia and the university-based teaching practice of anesthesia. He began posting these essays on The Anesthesia Consultant website (theanesthesiaconsultant.com) in 2010. Readership grew, and now hundreds of thousands of people visit the website each year.
Beginning in 2001, Dr. Novak developed an interest in anesthesia medical-legal consultation, a role that drew him into the courtroom as an expert witness.
Rick’s lifelong dream of creating entertaining fiction led him to imagine a story: the plot dealt with an anesthesia complication, a crumbling marriage, a son’s quest for elite college admission, and a courtroom drama, all set in his and Bob Dylan’s hometown of Hibbing, Minnesota. Three years of writing and rewriting yielded the manuscript of The Doctor and Mr. Dylan. In 2014, literary agent Anne Devlin believed the story was a winner, and sold the book to its publisher.
Rick continues his work in clinical anesthesia at Stanford Hospital and at Waverley Surgery Center in Palo Alto, California. He lives with his three sons, Zachary, Theo, and Oliver, and passes on his love of academics and reading to them.
Rick’s second novel, Doctor Vita, was published in 2019. His third novel, Call From the Jailhouse, is due in 2023.
