The Algorithm Will See You Now

MONDAY 08 OCTOBER 2035

7:15 AM

PRIMA, Prognostic Intelligent Medical Algorithms

Main Campus, Seattle

Dr. Hope Kestrel was the only person who knew the patient in Room 132 wasn’t responding to the algorithm-selected treatment.

She shuffled forward in the hospital security line, wanting to get her day started already yet dreading how she’d tell her patient the unexpected and devastating news. The straps from her work bag dug into her right shoulder as she shifted the trays of coffee and scones in her arms, her usual Monday morning offering to the staff. From PRIMA’s lofty location at the top of “Pill Hill,” the floor-to-ceiling windows framed downtown Seattle’s skyline, lit up by the early morning sun—its first appearance in over a week. In the distance, a ribbon of pink sky silhouetted the Space Needle, the tip poking out of the murky blue of the cloud bank. She frowned down at her pale hands, unable to recall the last time her skin had seen the sun. Even her freckles were fading.

Her heart lifted when she spotted Bear, the Security Force service dog, rounding the corner. The German shepherd dashed for her, pulling Kyle, his Security Force guard, with him. The people next to her in line stepped back.

Bear nosed at her lab coat, and she lifted the pastry box in one hand higher while shielding the cardboard carrier of coffee in the other. Hot liquid sloshed onto her wrist, the sting on her skin not far off from the burn in her chest that had been present all morning, triggered by the impending meeting in Room 132. One where she’d need to engage on an interpersonal level without the usual buffering layer of technology.

Her gaze shifted from Bear to the familiar logo on the wall behind Kyle’s head—Prognostic Intelligent Medical Algorithms—and she shut out the searing pain in her chest. They were so close to the breakthrough to enhance the artificial intelligence even further. To render tumors like her mom’s curable. Because to rely on only hopefulness promised everything and got you nothing. No matter her damn name.

She had to focus on the big picture. All she needed was to maintain her top ranking for a few more months. Then the coveted post-residency position at PRIMA would be hers—complete with her own research lab. Soon, she’d work side-by-side with her mentor Cecilia, no longer an underling.

Bear gave a muffled woof and sat down obediently at her feet. Although Kyle would probably deny it if asked, she strongly suspected the guard went out of his way each morning to find her, knowing how much she loved Bear. It had been their unofficial routine for five years now.

Hope gestured with her elbow. “Kyle, could you take this for a sec?”

The burly, middle-aged man accepted the breakfast offerings with a flash of white teeth gleaming in contrast to his warm brown skin. “You got it, High Resident Kestrel.”

“For the millionth time, you can call me Hope.”

His eyes twinkled. “Whatever you say, oh most High One.”

Heat flamed Hope’s cheeks, and she tried to cover it with an eye roll. Three months into her final year, she still wasn’t used to her lofty title. She’d be called the Chief Resident—not the High Resident—at any other program, but PRIMA had its own language.

The loyal dog emitted another stifled woof from his barely contained seated position.

Hope fished in the front pocket of her white scrubs for one of the dog biscuits she always carried and tossed the treat to Bear, who snapped it up.

Kyle returned the pastries, then spoke in the deep, rumbling voice that Hope had come to learn only masked his kindly nature. “He sure loves you, Dr. K. He’d follow you anywhere. Have you reconsidered about one of the puppies?”

She shifted her grip and gave a wistful shake of her head. “It wouldn’t be fair. I’m never home.”

“So? You’d figure it out. Hire a dog walking service—and doggie daycare, too. You don’t have to do it on your own.”

“I’d be nothing more than a familiar stranger who provides shelter and food.”

Kyle bent down to rub Bear behind his ears, only to glance up and hastily straighten into a military posture, shoulders back. He tugged Bear to heel, his gaze fixed over Hope’s head.

The dog sensed his handler’s shift in mood, the fur on his neck bristling upward.

Hope swiveled, following the direction of Kyle’s eyes. More coffee dribbled on her hand, but she barely felt it this time. A man and woman in matching black suits and pressed white shirts were staring in their direction. Hope couldn’t help but stare back. The man was tall and broad-shouldered, mid-thirties, with angular cheekbones and deep-set eyes, his striking features set off by his onyx black hair. The woman appeared to be of similar age and height, equally imposing, with skin paler than Hope’s, commanding eyebrows, and white-blonde hair in an identical short haircut to her partner.

Hope’s eyes darted to Kyle, who flashed another smile, but it didn’t reach his eyes.

“Are those two—?”

“Not regular Security Forces. They’ll notice me deviating from my route.” Kyle grimaced. “And letting Bear interact with civilians.”

“But—”

Kyle dropped his voice. “Last week, another disgruntled non-responder tried to get in.”

A non-responder. A patient the algorithm had identified as refractory—resistant to all known therapeutics—and therefore wouldn’t be offered treatment at PRIMA. Or shouldn’t, at least.

Hope went cold all over. All patient volunteers agreed to abide by the algorithm’s determinations in exchange for free healthcare. What would the guards do if they discovered another non-responder already here, admitted by mistake? On Hope’s service, no less.

But that wasn’t her fault—

“You’re a busy doctor, and we shouldn’t be holding you up.” Kyle tugged Bear away before she could ask him anything more. “We’ll see you again soon, Dr. K.”

Before the dog was out of reach, Hope hurried to transfer the pastry box to the crook of her elbow, bracing it against her side enough to allow her to extend a hand to trail her fingers in Bear’s soft fur. The brief comfort the touch provided would have to last until tomorrow. She re-joined the line to watch the man and woman cut through the security checkpoint.

Her muscles tightened, and she forced them to relax. She needed to focus. At least medical training had made her a champion at putting extraneous thoughts out of her mind. Compartmentalization for the win.

A few moments later, she passed through the checkpoint and stepped onto OASIS—the Oncologic and Surgical Intervention Success Unit—and its familiar buzz of activity.

Patients strolled the oval hallway in the sunshine-yellow robes and plush slippers allocated upon admission. If not for the slim IV poles, they might be in a luxury hotel. The hidden panels in the walls and ceiling secured all medical equipment out of sight.

Abbie Fuentes, the charge nurse on OASIS for as long as Hope or anyone else could remember, spotted her arrival and trailed her into the break room. Hope wordlessly handed her one of the coffees, and she took a noisy sip while scanning Hope up and down, her impeccably bobbed hair not moving an inch. “What’s going on with you today? You’re late.”

Hope shrugged. The nurses hadn’t yet seen her patient’s latest test results, and the part of Hope that feared being perceived a failure planned to wait until the last possible moment to tell them. “Line at security. You know, it’s getting slower every day.”

Abbie grunted in assent, taking another greedy gulp and releasing a satisfied sigh. With the other hand, she jerked a thumb at the tall, young woman who’d slipped in behind her, wearing the deer-in-the-headlights expression of a fresh intern. “Found you a present, too.”

The intern took a nervous step forward, twisting her slender hands, the standard-issue white scrubs highlighting her dark complexion. She hunched her shoulders as if out of habit, although it didn’t disguise her striking height, a good half a foot over Hope’s five foot five. “Dr. Kestrel? I’m Jacie Stone. Your new intern.”

She’d artfully draped a bright purple scarf around her neck, making her stand out from the conformity of the other residents. The color matched her glasses and complimented her skin tone. Behind the glasses, a fervor shone out of her eyes. She had a restless manner that made Hope think of a coiled spring—filled with potential energy ready to explode.

Before Hope had the chance to greet her, Abbie interjected. “You forgot, didn’t you?”

“What? Of course I didn’t.”

Abbie arched her eyebrows at Hope and then turned to Jacie. “She forgot. But don’t worry, she’ll still take good care of you.”

“Don’t listen to her.” Hope steered Jacie by the elbow. Even though truth be told, she’d prefer to leave the intern there. But if she left Jacie in the break room, Abbie would ask why. So, no, she couldn’t leave Jacie behind. She’d have to bring her along to witness her failure.

She stopped at the workstation in front of Room 132 and pulled out her tablet. Out of habit, she did a quick scroll to first check her ranking. She stifled a breath of relief to find she remained at the top, with Leach—her main rival—second. Too bad her High Resident position didn’t give her any advantage in PRIMA’s resident physician ranking system, but she wouldn’t want it even if it did. She’d earned her top place.

Jacie cleared her throat. “Would you like me to activate Osler for you?”

Osler was OSLR, the Online Speech and Language Recognition assistant. But the residents had long since dubbed it Osler—after Sir William Osler, the so-called Father of Modern Medicine—and like most, Hope thought of it as a him. He—or it—could be called on from anywhere in the hospital.

“No, I’ve got it.”

Each workstation came equipped with a large flatscreen that would sync to their tablets and an optional keyboard—rarely used since OSLR responded to voice commands. Hope spoke briskly in the monitor’s direction. “Osler, open the chart for patient last name Medrano, first name Sean.”

The AI’s masculine voice, with its hint of nonspecific accent, floated down from the ceiling.

“Good morning, Doctor Kestrel. Opening chart for Patron 564.”

Jacie cleared her throat again. “Did you know PRIMA decided against a female-coded AI assistant? Because supposedly doctors of all genders are more responsive to a male voice?”

Hope gave her an appraising glance. She did know.

Jacie interpreted it as permission to keep the questions coming. “And why are we calling patients ‘Patrons’ now?”

“Part of PRIMA’s new marketing plan. Personalized, precision care.” Hope channeled her High Resident persona, imbuing her words with confidence. At twenty-nine, she was probably only a few years older than Jacie, but most days, her own internship faded into the distant past. Even though inside, a part of her remained that young woman who’d arrived five years ago in awe of the AI technology. Apparently, these new interns were harder to impress. She returned her attention to the monitor. “Osler, bring up this morning’s CT scan.”

The images appeared. Hope used her thumb and index finger to pinch and magnify one in particular. “The largest tumor in the liver is blocking the bile duct. Obstructing the normal outflow of bile, which causes?”

Jacie glanced from the images to Hope. “Jaundice. But can’t you stent it?”

“You’re asking the wrong question. Can I? Yes—I’m a pro at endoscopic stenting. However, should we stent it? That’s the more relevant question.” Hope addressed the workstation. “Osler, what’s the prognosis after stenting the biliary obstruction?”

“The stent would relieve the obstruction but would not add survival time. Primary resistance to this targeted therapy is a predictor of refractory disease. Estimated time to death is three weeks. No available intervention can change the prognosis.”

Jacie’s eyes darted over the images on the monitor. “But shouldn’t we try? To stent it anyway?”

Hope shut off the workstation. “You heard Osler. It would be futile.”

“But what if it’s wrong?”

Hope forced herself to take a slow breath. The interns never got it at first. “Look, it’s normal to want to save everyone. But the AI ensures we’re using the right treatments on the right people, not ineffective treatments on refractory disease.”

Jacie’s face fell. “Oh… what do we do then?”

Hope studied the monitor, where the PRIMA motto had appeared as the screensaver. We Optimize so You can Flourish.

She looked Jacie full in the eyes and forced herself to say the words she’d been dreading. “The recommendation is for transfer to HEARTH. There’s nothing more to be done.”

Jacie’s head flinched back slightly. “Hearth?”

“The Hospice and Restful Transitions House—our hospice facility.”

“I know, but… I don’t understand.” Jacie glanced around as if looking for answers before her gaze returned to Hope. “To become a Patron means PRIMA tagged him as a responder. The machine learner algorithm matched his data to a therapeutic protocol and assigned him Patron status, right?”

“Very good. That’s a textbook recitation from your first-year curriculum.”

“But he shouldn’t be here at all.”

The very problem that had Hope replaying his results in her head all morning. She told Jacie the same thing she’d been telling herself, although it hadn’t helped. “This case is a one in ten thousand occurrence.”

PRIMA was everything Hope had wanted, the healthcare system she’d dreamed of, the one she wished had existed for her mom. The AI kept doctors on track. It ensured she’d be the right kind of doctor and represented her life’s work. She struggled to find the words to make Jacie understand. “I know it’s difficult, but an individual with no chance of benefit from a particular treatment should be spared that treatment. Administering toxic therapies to a non-responder would be no better than torture.”

Jacie’s brows drew closer, her face tightening. “What if it’s a mistake?”

“The algorithm re-examined all options for him. It determines which tumors respond to particular treatments and which don’t—at the DNA level.” Hope paused, then continued in a softer voice. “His cancer is incurable.”

She knew she sounded cold, even uncaring. But how else to keep back the empathy that made her job too difficult? She’d been the one to sign the orders on his treatment. She’d let this happen. Allowed him to believe he’d get better when he never would. Now, she’d have to deliver the worst news. He was dying.

Jacie stared at the floor.

Hope forced herself to speak slowly to portray a calm she didn’t feel. “You don’t know how lucky you are. Because of the algorithm, PRIMA has compressed your pre-clinical training, and you start internship sooner. But that means you’ve got a lot to learn.”

Jacie cocked her head. “But if something like this happens, can we trust it?”

A flashback of her mom’s chemotherapy-wracked body played in Hope’s mind, and her vision clouded for a second. Jacie didn’t yet understand. Identifying non-responders to spare them the needless suffering of ineffective treatments was a necessity—not only a practical imperative but a moral one.

She needed Jacie to understand. “Don’t you see? The AI frees both patients and doctors from the fallacy of choice. The algorithms are more trustworthy than people. It’s like DNA.”

Jacie fiddled with her scarf. “I don’t—”

“DNA doesn’t waste its time over choice. G doesn’t dither about partnering with C, and T doesn’t debate endlessly over whether it should partner with A. There are rules to how it all works. It doesn’t matter if we want it to be different. Some things we can’t change.”

Jacie’s stance went rigid. “So, you would trust it with your family?”

If only her family had been afforded that chance. Because Hope had learned the hard way—relying on hopefulness promised everything and got you nothing. She spoke through clenched teeth. “Absolutely.”