Saturday, April 22, 2017

Ask your Physician How he is feeling?

A new public health problem has reared it's head. A study recently revealed that 40% of physicians describe themselves as "burned out".

The government insurance programs, health insurers do not care. Their goal is to extract the most from health providers for the least cost. Change is constant and never ending. A literal explosion of programs, MACRA, MIPS, SGR, ACO, and APMs, using HEDIS and STAR ratings to determine if your physician will be penalized for non-compliance.

Some physicians are now actively aware of the burnout issues, and have formed pro-active groups to reduce physician burnout.

Despite reduced reimbursements to physicians health insurance companies continue to make a profit. If their profits decrease, they eliminate programs that are not profitable.
Many physicians will not accept medicare or any insurance plan preferring to develop their own primary care direct payment business model.

Physician leaders’ role in preventing burnout

A few weeks ago, I had the opportunity to interview a faculty physician at a large academic medical center. We spoke about burnout in students and faculty in general terms. He was aware of the problem yet did not seem affected himself.
Hallmark Signs and Symptoms of Burnout
I asked him how he managed to avoid burnout. He talked about remembering his purpose in entering medicine — that the profession is a calling, not just the daily tasks involved — by re-reading thank you cards from patients, residents, and students. He talked about taking time to chat with the staff in the clinics where he works, getting to know the schedulers by name, for example, to create connection in a world where he sees fewer and fewer opportunities to connect than in the past. Then he mentioned his “boss,” the chair of the department, a practicing internist herself.
He told me that her leadership helped him in small ways and large to avoid burnout. He mentioned her habit of asking, “How are you?” and meaning, “How are you doing as a person?” He said he had the sense that she cared about his well-being as well as the advancement of his career. His mention of his supervisor as a source of “burnout protection” caught my attention. The physicians I’ve interviewed rarely speak about their leader’s role in preventing burnout.
Although I haven’t heard physicians point to the importance of leadership, research corroborates this faculty member’s observation. The Mayo Clinic surveys its employees annually about the degree to which certain leadership behaviors are displayed by their immediate supervisors: appreciation, interest in the ideas and careers of those they supervise, transparent communication, and inclusiveness. Their data show significantly lower levels of burnout among physicians whose supervisors achieve higher scores on these behaviors.
Examples in other industries abound of the impact of leaders’ focusing on the well-being of their workforce. Paul O’Neill, former CEO of the manufacturing giant, Alcoa, steered that company to record high profits within a year by making worker safety the number one priority at every level of the organization.  New United Motor Manufacturing, Inc., or NUMMI, a joint venture between General Motors and Toyota, became one of the most productive automobile plants in the world in the 1980s, with consistently high-quality scores. How? In large part by respecting the inherent knowledge of its frontline employees and making a commitment to their welfare.
Organizational leaders may be hesitant to attempt to address the systemic issues that drive physician burnout, thinking that all interventions are complex and costly. Adopting new leadership behaviors is neither — and has proven beneficial effects on physicians’ well-being.
Burnout directly threatens the health of the clinical workforce, the health care organization as a whole, and the ultimate client, the patient. Isn’t it time for leaders of hospitals and medical practices to take a self-assessment and consider the role they play in perpetuating an unsustainable workplace — and their power to build something better? Isn’t it time for leaders to take the longer view and prioritize meaningful systemic improvement — guided by the input of frontline clinicians — to really address this problem?

Given the increasing prevalence of burnout among physicians and the evidence of its wide-ranging negative effects, the time is most definitely now.
Diane W. Shannon is an internal medicine physician who blogs at Shannon Healthcare Communications.

Thursday, April 20, 2017

Reducing Pain through Virtual Reality - The Medical Futurist Newsletter Special Edition

Pain management is a challenge at times. Despite many advances in pharmacology there are pain syndromes that are difficult to manage.

For one, pain is subjective, although at extremes it can be measured by changes in vital signs, heart rate, respiratory rate and involuntary reflexes.

In some cases VR has relieved pain when other medications have not.

attribution: The Medical Futurist Newsletter

Brennan M. Spiegel, MD and his research team at the Cedars-Sinai Medical Center in Los Angeles have already treated more than 300 patients with virtual reality (VR) therapy in a pilot project. These individuals with chronic pain were able to immerse into a VR experience for 20 minutes, and forget about their pain through travelling to Iceland or swimming in the ocean. 

Spiegel: “Our experience has shown that when VR works, it really works. But we’ve also found that not everyone is willing yet to try it out, particularly older patients. In our first study, published in JMIR Mental Health, we found that the average age of patients willing to try VR was 49.7 years old, whereas those unwilling to try it were 60.2 years old on average. This is consistent with the known “digital divide” between generations with regard to comfort and familiarity using digital technologies”.

Do you think VR has any side effects? Or that people could become addicted to it?

Spiegel: “We don’t have much information on this yet, at least as it pertains to therapeutic VR. Compared to something like opioids, which have caused a worldwide dependency epidemic of catastrophic proportions, a non-pharmacological pain remedy like VR is highly desirable and not meaningfully addictive in the same manner. But we should not brush aside concerns that VR has potential to be addictive. That said, in our experience to date, we have not seen patients getting obsessed with VR”.

I read that VR reduced pain was 24 per cent in hospitalized patients. That's a very promising result! What are your personal experiences in this regard?

Spiegel: “After practicing medicine for 19 years, I cannot think of any other treatment I’ve used (short of life-saving maneuvers) with a greater immediate impact on patients than VR. In one case, I treated a patient with 8 out of 10 abdominal pain of unclear origin. Narcotics didn’t work and she was receiving an intravenous drip with ketamine – a powerful analgesic that forces patients into a trance-like state. That didn’t work well, either. But within 10 minutes of using VR she reported “zero pain.” She literally said: “I’m ready to go home, as long as I can bring this thing with me.” She was discharged the next day after nearly a week in the hospital”.

In your view, could VR be included soon in everyday hospital practice?

Spiegel: “Using VR in clinical practice turns a lot of heads. Wherever we travel in the hospital with VR goggles, we receive questions from doctors, nurses, and other hospital staff intrigued by the concept of using VR for patient care. It’s hard to leave a unit without allowing curious doctors and nurses to try the headsets. Time and evidence will tell if this excitement should be sustained. We think it will”.

I believe VR will be effective at home as well.

Reducing Pain through Virtual Reality - The Medical Futurist Newsletter Special Edition

Wednesday, April 19, 2017

Cigna to implement prior authorization policy for opioid prescriptions

Use of prescribed opioid down close to 12 percent over 12 months 

among Cigna customers.

Starting July 1, Cigna will require prior authorization for physicians prescribing a long-acting opioid that is not being used as part of treatment for cancer or sickle cell disease, or for hospice care, the insurer said.
Also, most new prescriptions for a short-acting opioid will be subject to quantity limits, Cigna said.
In releasing its new safety measures, Cigna is following Centers for Disease Control and Prevention guidelines issued last year that recommend non-opioid therapy as the preferable treatment for chronic pain outside of cancer treatment, palliative and end-of-life care.

Nearly 62,000 doctors within 158 medical groups that are part of  Cigna collaborative care agreements have signed a pledge to reduce opioid prescribing and to treat opioid use disorder as a chronic condition. 
Cigna is working with doctors and providers by analyzing integrated claims data across pharmacy and medical benefits to detect opioid use patterns that suggest possible misuse by individuals.
The insurer alerts doctors when their opioid prescribing patterns are not consistent with CDC guidelines.
It established a database of opioid quality improvement initiatives for physicians to help them determine the next steps for improving patient care, including referrals into chronic pain management or substance use disorder treatment programs.
This may be a step in the right direction. The reduction of 13% in the use of opioids in Cigna's population is significant, but this is still in the short-term.

Alternative medication therapy as well as physical therapy, electrostimulation, meditation are all available.  Usually a patient will select one and if they do not have relief, physicians will prescribe other therapeutic methods.  The pathway for a patient can be circuitous and stressful.  Many are referred to pain specialists, placing a further burden on them. The use of the other medications are not without serious complications, somnolence, decreased cognition, and mood disorders.  Chronic pain exacerbates other mental disorders, increasing anxiety, irritability, sleep disorder, and isolation.
This pilot program, should it continue to demonstrate significant reductions could alter the pattern of opiod prescriptions.
Poppy seeds, the source for opium
Opiod dependence is a serious event for a patient and their families with multiple mental changes, and physical complication.
Cigna authorization personnel will be busy.

Cigna to implement prior authorization policy for opioid prescriptions

Sunday, April 16, 2017

Comatose and semi-comatose patiients are often aware of their Envionment


Your loved one or friend is lying there in the ICU hooked up to tubes, and ventilators.  They may or many not be able to respond or in a "locked in" state. Neurologists and PCPs are now more aware of this.

Families and friends are often encouraged to treat and speak to 'comatose patients' as if they are fully awake and aware of their environment.

So while you are visiting you do just that, talking to them and encouraging them to 'wake up".  However, what about during non visiting hours or night-time when staff is not available.

The story of FamilyPlug began shortly after the tragic accident of the Formula 1 driver Jules Bianchi in
Japan in 2014 - an accident which left the 25 year-old racer with an extended head injury followed by a
coma and long months of hospitalisation.

A group of developers,  led by an Italian Insead MBA graduate and entrepreneur with the support of a team of French
developers, the company was able to raise important funds from an international panel of angel
investors from Asia and Europe and is about to enter the market expansion phase.

 Recent studies in Rehabilitative Neuro-Science
and Occupational Therapy demonstrate that an active community of
family members and friends around a severely injured patient, has a
concrete beneficial effect on the recovery path. Regular emotional
stimulation is therefore a key element of the treatments currently
available in the most advanced care homes. Unfortunately, the complexity
of maintaining regular contact with a patient in a Comatose or
Post-Comatose state, especially when extended over a long period of
time, generates a distance that the existing remote communication tools
cannot reduce.


 FamilyPlug targets a potential market of over 20 million users in the US and Europe
currently struggling to maintain contact with a patient in an immobilized or
semi-conscious state. Launched on both iOS and Android at the beginning of
February 2017, this App is suitable for all medical environments, including Intensive
Care Units (ICU).

Google Play Store

Launch Video


Media Inquiry Media@FamilyPlug.
Healthcare Media Section WebPage: 


Your physician is the everyday champion

You and your provider have a big investment in your health.  Much of your tax dollars go to scholarships, building state owned medical schools, funding regulatory agencies such as the FDA, HHS, Public Health Services.

Likewise your physician(s), many of whom go into great debt even before earning their first dollar. Their credit rating is now impaired by this investment.  Some cannot get a mortgage, and not because of flagrant spending.  All the banks and loans institutions are concerned with these days is their ability to make the loan payments.  The number of physicians (and other students) who default on their school loans is staggering, and those loans cannot be discharged in a bankruptcy, the same as with tax debt. It's no longer when a city or town decides to fund a young person's medical training.

The average amount of time it takes someone to become a physician is approximately 11 years, and for those pursuing further specialization, one can easily add a couple of years to that. The time certainly adds up by investing years in college, medical school, residency, and fellowship. By the time I will be an independently practicing cardiologist, I would have invested about 16 years into my training. That’s almost half of my lifetime. Every physician has their own reason for pursuing medicine; however, the majority of us go through such an arduous and invigorating training process because ultimately we want to positively impact peoples’ lives.

Our day typically starts at the crack of dawn and at times ends after sunset. There have been days where I have been disconnected from the world, unaware of the outside conditions, and missed important life events and holidays because my priority has been my patients. During my internal medicine training, I can vividly remember countless times where my first meal of the day was when I had returned home from work. I can also recall numerous days where I remained on my feet, worked around the clock, continuously advocated for my patients, and placed their needs above my own.
I have also witnessed these attributes in my peers and mentors, who work equally hard to ensure the best for their patients. Whether it is staying after a long day of work to transmit medication refills to the pharmacy, accounting for all the charting and paperwork, remaining over time to talk to the patient’s loved ones, or coming in the middle of the night to perform emergent procedures, the unrelenting nature of a physician is refreshing, breath-taking, and inspiring.
The path and journey is not a tranquil one. The road is paved with countless sacrifices, tremendous hard work, unwavering commitment, and several failures but also with triumphs. It takes a special individual to embark and complete this journey: someone who is willing to sacrifice their time, youth, money, relationships, and their health. It often is a cold and heartless process.  In the end, we are the ones called upon to impact someone’s life directly. We earn the responsibility of upholding excellent care towards those we encounter every single time. Thus, the next time you visit your physician notice the compassion in their voice, the sacrifices in exchange for their medical wisdom, and exemplification of hard work in their wrinkles. And know that a lot went into the making.
This article is dedicated to all my peers, mentors, and co-physicians who unceasingly work hard to stand on the front line of health, ensuring well-being for every person they encounter, who at times place their patients’ needs above their very own. Here’s to the everyday champion: your physician.

Your physician is the everyday champion

Saturday, April 15, 2017

Yelp reviews prove a reliable tool for determining hospital quality, New York State Health Foundation study says

You cannot base the quality of health care based upon one measure.

Yelp does just that, and is highly misleading to the public.

More consumers use those platforms and comment on them, creating a real-time feedback loop, Foundation says.

According to the New York State Health Foundation, 

"As online tools like Yelp become increasingly popular with consumers looking for information about doctors and hospitals, a study sponsored by the New York State Health Foundation showed yelp ratings were a clear and reliable tool for determining hospital quality as defined by potentially preventable readmissions rates."
"The news for hospitals is positive as well -- by pointing people to higher-quality doctors and hospitals, those institutions can attract market share, leading to more lives saved and more costs avoided for patients, taxpayers and employers."
The results are from crowd-sourced surveys conducted by Yelp.
These internet based rating services are highly inaccurate, misleading and contain faulty data.
Data Metrics
The authors stressed that while there's a strong correlation between Yelp reviews and 30-day readmission rates, there's a lesser correlation when it comes to other quality measures, such as mortality, morbidity and patient outcomes, infection rates, never happen episodes, none of which reflect or influence readmission rates.
The news comes as high-deductible health plans are gaining steam, covering nearly one in three Americans in 2016. The spread of these plans means consumers are paying for more and more of their care out of pocket, giving them a reason to seek out high-quality care at the lowest possible cost.
One-on-one assessment.  
I searched on Yelp for hospitals in my region of Southern California. This area includes a major University Medical Center, A UC Medical School, A regional county medical center which has merged with the new UC Riverside School of Medicine.
Here are the surprising results.  There were many small entities rated side by side along with major secondary and tertiary centers.
Typical Scores
The ratings (according to the number of 'gold stars' reveal how incorrectly Yelp has rates the hospitals in my area.  Perhaps things are different in New York State. In New York State the foundation has it's own self-interests and is biased in it's results to influence acceptance of many government programs for measuring quality and cost.

There may be some lag in the accuracy of the data, even measuring this one metric. And the outcome is highly inaccurate, just based upon one data set. Healthcare is complicated, and measuring it even more so.

The public must become more literate in understanding measures of health care, who is reporting it, and if the data is truly accurate or self serving to the reporting entity.

Much more accurate data can be found at the Medicare Web Site

Medicare provides a consumer experience rating based upon patient surveys as well as metrics established to improve patient outcomes.

Other more reputable rating sites are available. Beware of some of them.

The highest rated doctors may not provide the best care

The public can rate and review most things today: books, hotels, and restaurants, to name a few.  Even doctors.  There are more options than ever where patients can rate their doctors online, and hospitals also routinely survey patients about how satisfied they are with their physicians. But while you’re pretty much assured a great meal at a 5-star restaurant, whether you receive excellent care from a 5-star doctor is less certain.
Doctor ratings generally focus on the patient experience, such as wait times, time spent with the doctor, and physician courtesy.  Those are obviously important issues, but they paint an incomplete picture.  Doctors with stellar interpersonal skills may not be the best at controlling patients’ blood pressures or managing their diabetes.  High ratings may identify surgeons with great bedside manner, but mask high surgical infection rates.
The quest for ratings perfection influences medical decision making, as patient satisfaction increasingly affects doctors’ salaries.  According to the management consulting firm Hay Group, more than two-thirds of physician pay incentives are based on patient satisfaction scores.  And Medicare withholds as much as $850 million in payments to hospitals who fail to meet various quality metrics, with patient satisfaction being a significant component.
But doing what’s best for patients won’t necessarily make them happy.  Denying antibiotics for viral infections or saying no to routine MRIs for patients with back pain are both sound medical decisions, but can anger patients; some vent their frustration by poorly rating their doctors. It’s no wonder that many physicians acquiesce to patient requests. In a survey by Emergency Physicians Monthly, 59% of emergency physicians said patient satisfaction surveys increased the amount of tests they ordered.  In another survey by the South Carolina Medical Association, almost half of physicians said that pressure to improve patient satisfaction led them to inappropriately prescribe antibiotics or narcotics.  In fact, Senators Dianne Feinstein (D-California) and Charles Grassley (R-Iowa) wrote a letter to Marilyn Tavenner, administrator of the Centers for Medicaid & Medicare Services, saying that “there is growing anecdotal evidence that these [patient satisfaction] surveys may be having the unintended effect of encouraging practitioners to prescribe opioid pain relievers (OPRs) unnecessarily and improperly, which can ultimately harm patients and further contribute to the United States’ prescription OPR epidemic.”
These extra tests and treatments are expensive and can hurt patients.  A landmark study from JAMA Internal Medicine analyzed over 50,000 patient satisfaction surveys, and found that patients who were more satisfied with their doctors had higher health care costs, were hospitalized more frequently, and had higher death rates compared to less satisfied patients. That makes sense: Patients who receive more drugs and tests are exposed to their harmful side effects and complications.
Now, I’m not saying physicians shouldn’t be graded by patients. Subjective physician evaluations are valuable, but not by themselves. They need to be complemented with objective measures of medical care, like a surgeon’s operative complication rate, for instance. Until physician ratings evolve into a more holistic representation of doctors, they must not be financially tied to how physicians are paid.
And to patients: Don’t automatically choose doctors with the highest online ratings or perfect patient satisfaction scores, because they may be the ones who reflexively prescribe antibiotics or narcotic drugs to inflate their grade.  It’s conceivable that those who have mixed reviews may actually provide better care.  Because they could be the physicians who make the effort and take the time to occasionally say no to patients.

Yelp reviews prove a reliable tool for determining hospital quality, New York State Health Foundation study says

Friday, April 14, 2017

I am the Old Fish

Young fish are swimming in a river and come across an older fish. 

He says to them, “Morning, boys. How’s the water?” The young fish swim on, but after some time one asks “What the heck is water?”

As I continue to interface with younger physicians and trainees I am struck with how content and unruffled the majority of them are in today's chaotic (to me and my genre) health care world.
What seems disruptive and chaotic to the older fish is that many changes are transparent to the minnows.
At the start of my career  Medicare (1966) was just started, there wereno electronic health records, no HMOs, contracting with physicians was a questionable and frowned upon business model. There were many many diseases that were not treatable.  The life span of a child with cystic fibrosis was about 10 yrs. Professional advertising was considered unethical, and more.

There were no genomics, the understanding of DNA was in it's early phase. The idea of genetic engineering a distant gleam, stem cells were poorly understood and not yet clearly identified.

Today physicians swim in a sea of knowledge that almost seems a given, except for those who remember the 'old days'.

Perhaps the one thing that makes medicine so exciting and invigorating is the constant evolution and discovery.  However, it is a double edged sword.  The rapidity of change requires enormous energy to stay current and competent.

The old fish says lead on and the rest of health care follows. The new fish looks around, and is led by many non-physicians and/or regulators who have no knowledge of medicine other than a list of practice patterns and cost for treatments.  In a method counter to the old fish's training of treat the patient, first, worry about cost later, all fish now must add an entire new dimension to their treatment choices.

As the young fish now says to the old fish . "Tell me what it was like in the golden era of medicine?" And the old fish responds,  "I don't remember, but it seemed better, and more fun!"

I don't remember hearing about burnout...I wonder why ?

In Idaho, Tiny Facility Lights Way For Stressed Rural Hospitals By Anna Gorman

Rural hospitals are facing one of the great slow-moving crises in American health care. Across the U.S., they’ve been closing at a rate of about one per month since 2010 — a total of 78, or about 6 percent. About 14 percent of the U.S. population lives in rural counties, a proportion that has dropped as the number of urban dwellers grows. Declining populations mean a smaller base of patients and less revenue. And the hospitals are caught in a squeeze: Because many patients in the countryside are older and sicker, they require more intensive and often expensive care.

Faced with these dramatic economic and demographic pressures, however, some hospitals are surviving — even thriving — by taking advantage of some of the most cutting-edge trends in health care. They are experimenting with telemedicine, using remote monitors to track patients and purchasing high-tech equipment to perform scans and other types of exams. And because many face physician shortages, they are partnering with universities and increasingly relying on nurse practitioners, paramedics and others to deliver care. In parts of rural Oregon and Washington, veterans can get counseling through a tele-mental health program. Physicians in Iowa and North Dakota have access to virtual emergency room support.

Telemedicine, remote monitoring and offsite specialty consultation are essential to maintain quality of care in many smaller towns across America.

In Idaho, Tiny Facility Lights Way For Stressed Rural Hospitals By Anna Gorman

Wednesday, April 12, 2017

Four Observations from the 2018 Medicare Advantage call letter |

It's that time of year.....CMS announces the plan for 2018 for it's programs, in this case the Medicare Advantage Programs.  And there are many, with differing deductibles and co-pays as well.  

Medicare anticipates changes in premiums based upon the average rate increase for health plans after careful deliberation finalized its 2018 payment rates for Medicare Advantage plans, settling on an average rate increase of 0.45% after initially proposing a 0.25% increase.

The CMS says the updated policies included in this year's rate announcement give MA organizations the incentive to develop new plan offerings with "innovative provider network arrangements" that may further encourage enrollees to access high-quality healthcare services.

The policy drew the approval of AMGA, a trade group that represents multispecialty medical groups and integrated systems of care.

The complete 185 page CMS document can be downloaded here

A few highpoints are listed below

The Table II-1 below shows the National Per Capita MA Growth Percentage (NPCMAGP) for

An adjustment of −0.226 percent for the combined aged and disabled is included in the
NPCMAGP to account for corrections to prior years’ estimates as required by section

The combined aged and disabled change is used in the development of the

Table II-1. Increase in the National Per Capita MA Growth Percentages for 2018 

Prior increases Current increases NPCMAGP for 2018
with §1853(c)(6)(C)
2003 to 2017 2003 to 2017 2017 to 2018 2003 to 2018
Aged + Disabled 54.84% 54.49% 2.76% 58.76% 2.53%

Current increases for 2003-2018 divided by the prior increases for 2003-2017 

The Affordable Care Act of 2010 requires the Medicare Advantage benchmark amounts be tied
to a percentage of the county FFS amounts. 

Table II-2 below provides the change in the FFS
USPCC which was used in the development of the county benchmark. The percentage change in
the FFS USPCC is shown as the current projected FFS USPCC for 2018 divided by projected
FFS USPCC for 2017 as estimated in the 2017 Rate Announcement released on April 4, 2016. 

Table II-2 – FFS USPCC Growth Percentage for CY 2018
Aged + Disabled Dialysis–only ESRD
Current projected 2018 FFS USPCC $847.73 $7,133.42
Prior projected 2017 FFS USPCC 825.20 7,023.24
Percent change 2.73% 1

The information on the CMS web site is only understood by those with accounting and statistical backgrounds.  The overall simplification appears in the blue section of the post.

4 observations from the 2018 Medicare Advantage call letter | FierceHealthcare

Patient Savings Solutions

Do you remember those Prescription discount cards ? Many patients who were formerly uninsured prior to the Affordable Care Act used them to obtain critical medications at substantial discounts. The truth may it be known is that few if any patients pay retail rates for medications.  Most of the time pharmacies have contracts with payors or pharma to offer their medications at reduced rates.

Using this new online application patients can request Patient Discount coupons online, search for your medication using the mobile app for iPhone or Google Play. By using this app and/or others to comparison shop should afford you the lowest prices.  There may be differences in prices according to ZIPcode.

Script Relief Partner Brands include HelpRx, NPSN, IDC, Discounted Prescriptions Network


Tuesday, April 11, 2017

Elon Musk, and the Fate of Man and Machine | Roy Smythe, M.D.

The Fate of Man and the Machine

Fata homo et machina- the fate of man and machine. Elon Musk is so concerned about this combined fate he has created an enterprise to merge humans and technology - in hopes of modulating any dominance artificial intelligence could develop over our organic form.

This has become a dominant worry for many people. Who are they ?
Health care algorithms are becoming prevalent and are already in daily use by payers, CMS, health policy pundits, and analysts.

The evolution of the process for health care is similar to most other industries.

Rather than considering it the 'evil twin brother' of health information technology, consider it's positive attributes:             
  • Creation of machines allowing us to be more effective or efficient at a task
  • Reliance on a limited number of experts to operate these machines so we may benefit, and eventually...
  • Democratization of competence so individuals may operate these machines themselves.
Other examples besides transportation include things such as cooking, reading and writing as well as making music and art. In the future this will extend to countless other things such as much of the delivery of diagnostic and therapeutic healthcare by individuals themselves, and their manufacture of increasingly complex objects. What is dramatically different for our species in the present moment; however, is this fourth step:
  • Machines become competent to complete tasks more effectively and efficiently themselves, without the need for human involvement, or skill.
As long as we all become more effective and efficient at completing tasks, shouldn’t we welcome this fourth step? There is no simple yes or no answer. While the task itself is more effectively and efficiently completed by the machine, our individual contribution and competence become irrelevant. The car drives itself.
I first began to ponder this topic while teaching medical students. When I was one of them myself, I had to commit large amounts of information to memory in order to be able to answer my professor’s bedside questions. When in turn I became the professor, I witnessed the increasingly common use of the hand held computer’s memory by students, rather than their own, to answer my questions. I rationalized this on the basis of two considerations - one, the continually expanding codex of medical knowledge renders it absolutely impossible to commit all to memory, and two, it didn’t seem as if we would run out of electricity any time soon. Now, of course, we contemplate technologies that will replace the need for any human medical decision-makingwhatsoever, perhaps making my rationalization as dated as the actual memorization of facts in medical education.
One oft-stated argument in support of machine competence is not democratization, but rather liberation. Wouldn't it be wonderful to no longer be a slave to "doing things"? Wouldn't we have more time to be creative, and connect with one another in deeper, richer ways? Couldn't this actually make us "more human"? Perhaps... but perhaps not. While allowing technology to relieve us of the imperative to interact with our somewhat random environment, and accept human successes as well as mistakes in the process - we may deprive ourselves of critical human needs. We know dopamine release is modulated by both reward (up) and error (down) in the brain, and we likely need both to be motivated to explore, and to learn. In addition, throughout history we have repeatedly seen excessive centralization of authority and subsequent emasculation of individuals leads to what the philosopher Bertrand Russell characterized as human “listlessness”. Historically, this has often then led to defeat or collapse of civilizations. Consider how authority is increasingly being centralized in technologies - and ponder the fate of Rome. 
If we are increasingly insulated from the contingencies of the world by our technology, we could become a listless and perhaps even irrelevant species - providing little value to each other, or to our machines. If this is indeed "fata homo et machina", I support the desire of Elon Musk and others to eventually merge our minds with artificial intelligence. Doing so might keep us in the real world, rather than allowing our machines to be in the world exclusive of us. It could also allow us to continue to perceive and interact with unpredictability and randomness. As a result we would still struggle with trial and error - which we may require to learn - rather than just having “experiences” facilitated by technology. Finally, we could continue to insert unpredictable human emotion and behavior - our own randomness - into the mix. This seems important, as a great deal of human inspiration defies logic or algorithm. After all, Neils Bohr’s concept of atomic structure, Mary Shelley’s Frankenstein and even Einstein’s relativity were all conceived in dreams.
The ultimate fate of man and machine is obviously yet to be determined.  The essential ingredient will be an active interface with any system and the choice of accepting the computed recomendation, or denying it.
I remain the optimist. I believe mankind will not yield to a machine....(then again, how many times have I heard,  "I am sorry, but the computer says this or that, and it cannot be changed". I usually revert to my polished answer. "Then connect me with someone who can, or your supervisor".

Elon Musk, and the Fate of Man and Machine | Roy Smythe, M.D. | Pulse | LinkedIn