Anne-Tze’s Appointment

Dr Obagnale answered quickly, but the patient died, as very sick patients do. This ended the call.

Anne-Tze was alive, and two back in his queue. Her chair gently detached from her desk, spun her around and ever-so-gently withdrew, lingering just long enough to promote her micro-lordosis realignment. It then locked up, refusing to return to its desk and also failing to release her. Her mother thumped the motor, which of course did nothing. Anne-Tze pulled the power cord out from the chair with her toes and then plugged in again, in a motion practiced and ballet-like. The medically-prescribed chair freed its hostage.

"Anne-Tze, you need to stop studying and get outside before the doctor comes on-line."

"Mum, the greenspace is only three minutes down and one across. I can get my heart rate up a in a minute or two. When has a level two triage doctor ever completed two cons in six minutes?"

Since the call ticket involved healthcare, a helpful medical support bot heard the question and attempted to answer it.  A retina display prompted that an Austrian doctor registered extra-territorially had -- just nineteen seconds previously -- done precisely that. A counter began to tick upwards and then abruptly reset itself to zero (changing the text to read "Uzbekistan") before continuing its upward count.

When the bot was swiped away for uselessness and irrelevance, an equally enthusiastic scientific history bot picked up on the inadequate first answer, the word "when" and "ever" and decided that an aggregative and statistical answer (23 million times, which was approximately 0.00003% of all consecutive consultation pairs) was more appropriate.

Miffed -- which was an odd pseudo-emotion for someone to have encoded in a bot -- the first bot interrupted to reply that short consultations were highly correlated with physical conditions such as emergency accidental amputations and psychological conditions such as extreme iatrophobia (fear of talking to a doctor).

The history bot started an analysis of the progression of iatrophobia in conjunction with triage and proposed a theory that it spiked in the years leading up to the development of anaesthetics.

By then Anne-Tze's mother had tossed a spectrometer and an MRI scanner in her daughter's general direction. The bots could find both too little and too much correlation between the tools and their previous chatter topics. Coupled with the bots' failure to find any evidence of pertinent human interest -- not even an eyebrow muscle potential -- they saved their state and then terminated themselves.

The girl caught a tool in each hand -- noting that her ambidexterity treatment was obviously progressing well -- and tried to rid her mind of her schoolwork. Even with the attention drugs her class mentor had prescribed for her the anxiety she had around this call to the doctor trickled easily through the unfog and she was able to summon the coherence to request some general athletic shoes without assistance.

Four minutes later she stood in the forest on a footpath of loose pebbles. She even noticed a few pebbles below the regulation 2cm minimum for a barefoot walk and wondered whether she was about to interrupt a trial of something. It was hard to imagine an outdoor nature facility being so carelessly maintained and still keeping its medical accreditation.

But there was clean air and lots of stress-relieving green foliage. As far as she could see, there were no small furry animals which could confuse the instruments' IR-frequency body identification algorithms. That and the clean air should give noise-free measurements of her skin, secretions, pulse and other vitals.

Anne-Tze started to jog on the spot and just when she began to sweat the spectrometer locked up, refusing to respond. She sighed a little, realising that her mother hadn't let it update itself for weeks.

The spectrometer blinked and beachballed and swooshed, all the while failing to negotiate any kind of upload protocol. Anne-Tze gave up, hard-reset it and interrupted its boot process to change settings before it tried to do anything even more stupid.

By the time she had done this, Dr Obagnale (registered in some African city that Anne-Tze didn't recognise) had connected.

"Good afternoon, Anne-Tze. Your reference number for this call is SD84101525925. Please be aware that this call may be monitored and recorded for training purposes unless you specifically request otherwise which you may do at any time. If you would like I can have our privacy policy read out to you. I have been provided with a record of the conversation you had with the level one triage bot but in accordance with medical practice I will not refer to it until after you have described your symptoms to me again in your own words."

Dr Obagnale had of course pre-recorded almost everything -- and together with every digit and ordinal -- the speech has been spliced together automatically. The result had been heard and reheard by a team of speech psychologists and medical interview specialists as having the optimal pace, tone and structure to establish patient rapport.

There was a brief jolted pause as his video stream failed to correctly transition between the recording and his present reality. This broke the illusion very awkwardly. Dr Obagnale hoped that his newest patient would just put that down to a transitory network failure but doubted that she would.

When Anne-Tze didn't reply for a moment, Dr Obagnale asked, "how can I assist you?"

She hadn't replied because she had heard the echo of his voice against a eucalypt several metres away and against a curiously shaped red-pebble on the ground.

Her father had purchased genetically enhanced sonic perception for her at conception-time. Someone at the clinic had overstocked on sonic super-perception and understocked on musical ability. The resulting mismatch had left the clinic running a special that her father just couldn't let pass.

The combination -- an ability to discriminate which of two dropped pins had struck the higher note together with a complete inability to sing or play any kind of musical instrument -- was so unique that half the genetic therapies she had received had had to be signed off by a board-level specialist. It also made compulsory choir one of the most emotionally traumatic experiences of her life.

Anne-Tze's father hadn't done anything as rash as that since his work had required him to install an anti-impulsiveness blocker. In fact, it made him positively dull -- even during weekends when his contract let him drop it down a third or during the odd times when he could get a nurses' certificate for a weaker drug.

Still, it had let Anne-Tze realise that she had left her anti-sound field off and anyone could have heard the whole consultation. She blinked repeatedly to make it turn on and in the end gave up when its battery life indicator faded to nothing.

"I'm calling about a concentration problem I'm having in school. I've had several afternoons recently when I've felt a bit sleepy." Which wasn't exactly the truth; distraction and day-dreaming were well identified as different states to mild sleepiness. And not concentrating because you were trying to attract the attentions of a particular someone who had a very divergent histamine complex... well, that was another state again. But they were not so easy to distinguish in a cursory MRI scan that anyone would question it.

"Oh dear. That could affect your learning and at your age that could cause later psychological problems. Let me look at your biochemicals."

There was a pause as Dr Obagnale looked through a list of numbers and some charts. Anne-Tze wondered why he was just using eye motions to sift through the data initially until she realised that he was actually completely motionless from the neck down.

Anne-Tze tried to think of what Dr Obagnale could be doing that would require full scale quadriplegic isolation treatment. One of her basketballing friends had gone through with it in order to grow a couple of extra inches, but that had been authorised by the national institute of sport. He'd said that it had been quite refreshing and relaxing for a while, but that it had become very tedious even by the start of the third week of being unable to move without robotic assistance.

"Your mother has authorised the release of any data that you wish to share, but I don't see your current data. This will make it much harder to diagnose. Would you be able to authorise release?"

"Sorry, Dr Obagnale." She had no idea how to address him as his address-by profile field was blank. She even had to take a guess at how to pronounce his name. "My current secretion spectral analysis is still uploading."

"Oh, I see," said the doctor. "How very annoying. If it is not going to be long, I could do a parental assay first. I'll call your mother in to ask her for her biochems at the same age."

Anne-Tze failed to complete her interjection, "but -" before her mother was already connected.

"Yes, Dr, umm, Obagnale," said her mother, reeling from being brought into the call on such short notice and suffering from his incomplete profile. She obviously had set high-priority calls to auto answer and she had -- very reasonably -- tagged all calls about her daughter's health as high-priority.  "What can I help you with? I've delegated parental authority to Anne-Tze for this call already."

"Much appreciated, it makes the job substantially easier," said Dr Obagnale. "But I was hoping to do a mother-daughter comparative assay, and the only accessible data I have for you is, umm." He paused incredulously. "A blood test." And then repeated himself. "A blood test. Taken in Ulan Bator when you were a year younger than Anne-Tze is now. And nothing else."

Both mother and daughter laughed. This wasn't the first time this had happened.

"Look at the note after that," said Anne-Tze. Her mother nodded an approval, which the system would have given automatically anyway for something so minor.

They both looked at the doctor and tried to guess his age and when he had done his training.

"Yes, it says, `Global Medico' and then I can't access any data behind it."

It was hard to tell. So many of the externally visible signs of aging were reversible.

"Doesn't the name 'Global Medico' ring any bells?" asked the mother. "Collapse of the gang of five? The end of the cloud-only medical data era?"

He must have been very young during the cloud-storm years.

"A bit before my time, actually," admitted Dr Obagnale. "Something about medical data being lost because of some bankruptcies?"

"That's right," said Anne-Tze's mother. "Every byte of medical history lost from age six to age twenty three. There is not even a record of what I ate or what exercise I did. And my parents are from before the era."

A micro-expression somewhere between fear and amazement flickered for a moment across Dr Obagnale's face before a video filter broke into the stream, filling it accidentally with a swathe of white noise before replacing it with a neutralised version of the doctor saying that that would rule out any kind of family history comparison.

That was not my most professional moment, Dr Obagnale thought to himself. He had been trained to be careful in his facial expressions, as so much of the patient-doctor relationship was driven by non-verbal cues. The interception algorithms were fast, but not quite fast enough to hide all evidence if the patient was attentive. And you couldn't rely on face neutralisation anyway, because if they worked too hard the interceptors would decide that that was your real, normal, neutral face and warp everything to match you looking surprised or yawning or picking your nose. Every doctor had heard the story of the pediatrician who carried a teddy bear in every consultation -- but surely most of those 'terrified' children would actually have enjoyed it when the doctor's expressions got mapped onto the wrong face.

The interception would show up in the automated review of the consultation, even if the patient didn't mention it. Dr Obagnale felt a stretch in his lower abdomen that he needed no automated tools to diagnose correctly as being anxiety related. He could not afford too many more low reviews as he was already only just in the second quintile.

He decided he would probably have to punt. Everybody has something anomalous; if he could quickly find something in this girl that he could flag for triage three then there would be a 50% professional review which would dilute the automated and patient reviews. And professional's reviews were always a little more generous even when scaling was applied.

Dr Obagnale daydreamed for a moment about what it must be like in psychiatry where you can go months or even years without a patient review ever being recorded. Not that most psychiatric patients realised that.

He recomposed himself and the video filter eased itself away leaving the stream reporting reality again and asked, "What about the blood test?"

"The doctor used to be a full-time pathologist. He was drunk at the time, forgot what he was doing. He printed it out on paper, and was so ashamed that he didn't send it. The paperwork was found in his file when he died and it was submitted posthumously." Anne-Tze's mother paused. "Anything else I can help you with?"

"Ah, no, I don't think there is," said Dr Obagnale. "Anne-Tze," he continued, as the conference dropped down from three parties to two. "I don't think there is anything more I can do for you with no parental history and no current spectral analysis of body fluids."

"It'll only be a moment", said Anne-Tze, looking down at the progress of the spectrometer which was indicating much more than a few moments. "Couldn't you wait?"

If he'd been able to, Dr Obagnale would have shaken his head. It was a silly question; he would if she could afford it, but that didn't look even vaguely possible. Unsatisfied customer, thought Dr Obagnale, or over-time. No chance of a punt, either.

And then a miracle happened. A high-priority commercial call! A customer paying full charges with choice-of-doctor rights. Hurriedly, Dr Obagnale said, "Can I suggest that you request the privacy statement? That will take several minutes. There might be changes of importance since it was last presented to you. It will give your upload time to finish. I'll be back after I handle another patient. Approve?" And leaving Anne-Tze's "y-" floating in the air unfinished he accepted the job and answered it immediately.

Anne-Tze meanwhile listened to tortured legalease explaining her rights under her local city laws, her state laws, the national laws governing the system she was using, the international general treaty laws, the guidelines issued by Dr Obagnale's accreditation body, and so on. As it turned out, nothing had changed, and if it had been, it was beyond the horizons of probability that someone without a PhD in medical-paralegal legislature would have known the implications of it anyway.

After a short wait, doctor and patient reconnected.

"I don't see anything in your biochems of any concern. Everything is within normal parameters. You are already on an adequate dose of stimulants. I don't think I could authorise anything more based on what I've seen and what you've told me."

"Isn't there anything wrong?" Anne-Tze asked. Desperate, hoping that it would not be too unsubtle... "maybe I could have a higher carbo threshold?"

"I don't really think a physiological solution is required. I certainly couldn't justify getting you seen by someone based on what little is in front of me."

"So what have you got?"

"The best data suggests that a psycho-social solution would be best. That is, it would probably be a referral to a medico-socio-psychologist. They will probably permit your school's teaching system to be additionally encouraging and also permit your fellow students a small range of negative sentiment. This should activate one of the ion pathways associated with motivation and give you a little wake-me-up during the afternoon. How does that sound?"

Anne-Tze wasn't happy. She could make any face she liked without any filter interrupting.

Desperate to save the call, Dr Obagnale asked "is there anything else I can help you with?"

Anne-Tze's heart stopped a moment and a tiny burst of adrenaline spiked. With instruments still on Dr Obagnale could see that as easily as Anne-Tze could feel it.

Anne-Tze made a decision. She would tell the whole truth. Dr Obagnale would have known that something odd transpired in this call based on that response a moment ago anyway. Was he doing some sort of truth detection? That wouldn't be unheard of. How much could he guess from her psych profile anyway?

Her silence field had recharged itself enough that it could function. Then, she checked three times to make sure her mother had no authority to listen on the call, or even to see her next action. She turned on total privacy.

"Yes..." Anne-Tze started. And then... "I don't want to be hungry. I don't want to be a low-calorie long-lifer." There. She'd said it. Almost. In a world of controlled stomach bioflora, thin was easy. Curvaceous was rare. Just a few hundred extra joules per day throughout her teens would be all she needed.

Dr Obagnale paused. All else would be forgotten, he thought. Patients were like that. You could get everything wrong and one really important thing right, and you were on your way to a great review.

"At birth you had a 30% chance of doing this anyway, but your stomach bacteria were realigned towards less nutrients and a lighter frame in line with normal developed-world guidelines. So, I guess we only need to take this interaction we are having now and escalate it to a change."

"No, it can't be a change. Just escalate it to an incident. Just say that I can't concentrate because I need a higher sugar level in my blood. Please."

Dr Obagnale suppressed his frown and his disappointment. "You know I can't do that. It is a change; it requires a proper approval process. It's not contra-indicated medically, so when I escalate this, I'm sure there will be no problem with the medical approval."

"Yes, Dr Obagnale." Anne-Tze had researched this and tried to explain. "But if you look at phase three in the workflow, I'm a minor, and parental approval will be required."


"My parents are faminists. They will never let me authorise a change to let me eat more. They'll say I'm taking food away from hungry people elsewhere in the world."

"I didn't know there were any of either still alive," said Dr Obagnale, as Anne-Tze laughed.  He was being hopelessly politically incorrect -- denigrating a faminist view-point, to add to his litany of other mistakes on this job. But the patient had requested total privacy. Nothing recorded! The patient had no right to any recourse over anything he said.

Giddy with the novelty of it -- no-one ever turned on total privacy! -- he let loose.  "I once had a young patient who asked for a complete re-psych so that he could be a nastier person. His parents wouldn't allow it though; they had all bought into the sweetness-and-happiness philosophy. But I found an excuse; he lived in the tropics and we could use a historical argument to justify a higher level of aggression."

Numbers raced past. Dr Obagnale remoted the MRI to do another scan. And another. And then a microscopic one. A few moments later, and it was confirmed.

Anne-Tze waited. Silent, hoping against hope.

"You have a malignant cancer in your thyroid, Anne-Tze. We would have picked it up automatically anyway next Thursday, but it's visible now. We have our incident! Let's find some justification for your extra calorie intake."

A dozen bots researched and synthesised and confirmed that children under 14 with genetic profiles clustered in the neighbourhood of Anne-Tze's profile who were on one of the more obscure treatment programs for thyroidal MC were inconclusively more likely to recover faster (by a matter of a few hours) if they were not on life-extension calorie levels.

Dr Obagnale quickly set up a medical trial protocol (there was something similar in the system anyway) and enrolled Anne-Tze in it.

He noted that Anne-Tze's data would be very likely to tip the trial into statistical significance -- which would get her name as a sub-co-author on the journal article that some computer would automatically write up and get published. The article would never be read by any human being, of course, but would be referenced extensively in forms at various therapeutic administrations around the world. Even more amusingly, Anne-Tze would be able to use the publication as an educational attainment datum. Her original interaction (an inability to concentrate at school in the afternoon) would be post-closure super-resolved, for which Dr Obagnale would receive a tiny credit for.

"Done!" he proclaimed a few moments later. "We can use your mother's delegated approval for enrolment in the trial. In fact, we don't even need to raise an incident, we can leave this as a service request and I'll update your configuration details now. Go and eat something from the extended list."

Anne-Tze could have twirled with delight if her shoes hadn't been adapted for grip. She would have to find an excuse to keep up the higher intake, of course, but that would be easy enough to do. She only needed two or three years anyway to establish a normality base line. By then she would be who she wanted to be, not what her parents, friends or medical guidelines told her she should be and carry on just using precedents. "Thank you, thank you, thank you, Doctor Obagnale. Ten stars!"

Those last two words were recorded despite the privacy protocol. Neither the girl nor her mother had ever given ten stars to any doctor before, so algorithmically, today's appointment was a golden outlier.

Protocol dictated that both should politely end the call, but both parties had subtly switched to automatic mode by then leaving two computers algorithmically saying goodbye to each other, wishing each other well and expressing how they hoped to see each other again. Anne-Tze heard her responder start prattling happily in Albanian because she never had been able to understand the instruction manual on how to alter the default language to the Anglo-Chinese dialect that she spoke. In a world of automated translation it hardly mattered.

The positive outcome from the consultation would make it more likely that Anne-Tze would connect with Dr Obagnale next time, but neither auto-responder was programmed to know that, so the two computers confessed how unlikely it was given the number of patients and doctors in the world, and finally hung up on each other mid-sentence after discussing the weather in Antarctica for ten minutes. It would have been longer had the conversation not triggered an easter egg in the software for Dr Obagnale's responder which had been left there by a bored medical programmer some decades previously and left unnoticed by the rarity of the phrase "Ross Ice Shelf penguins" in typical doctor-patient conversations.

Dr Obagnale let himself relax in pleasure for the maximum permitted time -- nearly a minute -- and wondered out loud in his native Hungarian how long it would be before he next was able to prescribe a chocolate bar as part of a treatment. A statistical bot started a calculation based on today's world-wide prescription list, but crashed with a division-by-zero error just before the next call came in. The patient was a gorilla with an indigestion problem which had been assigned to the veterinary- overflow queue. "Good afternoon, PATIENT NAME GOES HERE. Your reference number for this call is SD84101525926...."

Greg Baker ([email protected]), 2012