The following short paper has been submitted to KevinMD.com — America’s most widely read and cited healthcare newsletter in America. It will be posted to Linked-In and other social media newsgroups read by over two million healthcare professionals, and many thousands of patients.
By Neil Anand M.D. and Mark Ibsen M.D.
MARK Twain, AI, and the Perils of Predictive Medicine
Drawing a parallel to Mark Twain’s complex understanding of the Mississippi River, the authors argue that predictive AI tools like NarxCare, used to assess opioid risk, fail to capture the essential nuance and human complexity necessary for good medical care.
They contend that these systems rely on biased statistics and oversimplified metrics, reducing individuals to risk scores and ignoring vital factors like tolerance, genetics, and socioeconomic context, which ultimately leads to harming patients and eroding the doctor-patient relationship.
Comparing AI to Twain’s “lies, damned lies, and statistics,” the text emphasizes the dangers of blindly trusting algorithms that lack human judgment, compassion, and the ability to see beyond data patterns to the individual person.
The core message is that relying solely on AI for complex medical decisions is perilous, akin to a pilot mistaking calm river surfaces for safety without understanding the deadly currents beneath.
TWAIN, THE ANAND- CLEMENT RULE EXPOSING THE RISE OF ARTIFICIAL STUPIDITY (AS): [AI(alg*) =AS]
Mark Twain (Samuel Clemens) spent his youth deciphering the Mississippi River, a system far more complex than any artificial intelligence (AI) algorithm. He learned that real understanding demands nuance, context, and skepticism. Were he alive today, he’d likely see NarxCare, the controversial opioid-risk AI algorithm, as a cautionary tale about the dangers of replacing human judgment with lies, damn lies, and statistics.
NarxCare scores patients based on morphine milligram equivalents and pharmacy shopping patterns, ignoring critical factors such as tolerance, genetics, and socioeconomic context —factors that Twain, the great observer of human complexity, never overlooked. Like river pilots who mistook calm waters for safety, NarxCare’s designers believe prescription data can predict overdose risk with mathematical certainty. But Twain knew better because beneath calm surfaces often lurked deadly currents.
Samuel Clemens’ romantic view of the river faded as he learned its hidden mechanics. In river slang, “Mark Twain” meant “two fathoms deep”, a safe depth for steamboats to navigate, measured by the leadsman’s line and called out to the pilot as a signal of safe passage through uncertain waters.
Similarly, AI strips medicine of nuance, reducing pain care to a combined risk score. Patients stable for years on medication are flagged “high-risk” for crossing arbitrary AI algorithm thresholds. Like a pilot misreading a river chart, AI can’t distinguish danger from routine, a failure of judgment Twain would have derided.
“There are three kinds of lies: lies, damned lies, and statistics,” Twain once quipped. NarxCare inherits its data’s biases, much like AI predictive policing that conflates over-policing with high crime. In some communities, higher prescription rates reflect access or need, but NarxCare interprets this as risk. Twain, who distrusted blind consensus, would have seen this as statistical tyranny.
AMERICA’S GREAT LOST OF GENERATIONAL KNOWLEDGE IN PAIN HEALTHCARE
And then there’s the human cost. Twain’s characters—Huck, Jim, the Duke, and King—were messy, flawed, and human. Artificial intelligence reduces people to categories. A chronic pain patient becomes a red flag. A veteran is labeled “likely to misuse.” A trauma survivor is deemed ineligible for relief. Real people are harmed. Doctors retreat into defensive medicine. Patients lose care. Despair follows.
Twain understood that mechanical systems, no matter how sophisticated, cannot replace human experience and wisdom. Artificial intelligence, like the shifting sandbars of the Mississippi, offers the illusion of control while concealing danger. Twain would warn us, not only because prediction is useless, but because blind faith in flawed AI models is perilous. As Twain said, “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that ain’t so.”
For all its data, NarxCare AI knows far less than it claims. Twain once read the river like a book, each ripple a word, each eddy a phrase.
That living water shaped his vision of America. Today, our rivers are streams and waves of anonymized data, cold and unfeeling, feeding systems like NarxCare and AI predictive policing. These promise clarity but often deliver distortion. If Twain read rivers to understand America, we must learn to read these digital currents and waves with equal care.
Twain’s life depended on tiny observations, a flicker in the current, a shadow on the water. AI mimics this vigilance but without understanding. AI watches everything and knows nothing.
Its judgments are indifferent and often erroneous. It lacks the reflexes and humanity of a pilot who knew life and death depended on subtle clues.
OUR DEMOCRACY IS BEGINING TO DESTROY ITSELF
As Twain mastered the river, he mourned the magic lost to mechanistic understanding. In Life on the Mississippi, he lamented how poetry gave way to measurement. Today, we, too, have traded reality for red flag metrics. NarxCare AI reduces human pain relief to a number. It replaces doctor-patient relationships with AI black-box decisions.
Patterns become pathology. Numbers override nuance. We’re left with Garbage In, Garbage Out, disguised as AI and run by technocrats who’ve never left the river dock. We’ve traded poetry for computer code, and in the process, lost compassion, creativity, and the courage to see patients as people.
Twain’s river teemed with unpredictable, complex lives. That chaos gave his writing soul. Today’s AI algorithms offer no such complexity. A mother in pain becomes a liability.
A veteran becomes a statistic. A survivor becomes suspect. This isn’t help—it’s harm. And who benefits?
Not the patients.
Twain knew freedom involved risk. The rich human tapestry he celebrated is now flattened into spreadsheets. These systems erase complexity rather than reflect it. Huck and Jim found freedom on the river, but only by respecting its dangers and learning its rhythms.
Our digital systems should do the same. NarxCare claims to protect but often punishes.
People lose care not because of wrongdoing, but because an AI algorithm labels them a threat. There is no appeal. No raft. No Huck Finn to escape with.
Freedom in the digital age demands more than computer code. It demands transparency, humility, and safeguards against AI algorithmic violence. Twain warned: “Whenever you find yourself on the side of the majority, it is time to pause and reflect.”
AI algorithms speak in a language few understand, but many obey. They’re maps handed to children expected to pilot ships. Designed by the powerful, enforced on the powerless, NarxCare, like AI predictive policing, wears the mask of objectivity while reproducing old injustices. It doesn’t see people. It sees probabilities. It acts not on what someone has done, but what a machine predicts they might. It replaces care with control.
In Twain’s era, the steamboat symbolized progress. But Twain wasn’t seduced. He was no Connecticut Yankee. He knew technology without judgment was dangerous. The river was alive. It required respect. Misreading it was fatal. AI is our generation’s new steamboat—praised for efficiency, yet blind to nuance. Twain would have seen through it.
He would have recognized the hubris in believing machines can replace wisdom. Heraclitus said, “You cannot step into the same river twice.” AI disagrees. It treats people as static patterns, denying change and redemption.
We must resist this flattening. Real rivers and real people don’t move in straight lines.
Twain’s river carried rogues and saints, all sharing the same current. He knew freedom came with risk, and compassion required understanding. Twain’s river taught him to read America, its beauty, blindness, and contradictions. Our modern data streams could do the same, but only if we approach them with Twain’s skeptical eye. We must ask ourselves.
Who built these AI systems?
Whose stories are excluded? What truths are erased?
What myths are sold as science?
Twain wrote, “The face of the water, in time, became a wonderful book.” Today, the face of AI has become a dangerous fiction. Each metric is a mask. Each score a sentence. If we don’t learn to read it wisely, we risk losing not just justice but the practice of medicine itself.
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Summary
Timeline of Main Events
While the source doesn’t provide a strictly chronological narrative, the main points discussed can be organized thematically to create a timeline reflecting the evolution of the concepts and technologies discussed:
- Youth of Samuel Clemens: Clemens spends his youth learning the complexities of the Mississippi River, developing skills in observation, nuance, and skepticism. This period is presented as formative in his understanding of the world and human nature.
- The Era of Steamboats: Steamboats become a symbol of progress and technology. Twain gains practical experience navigating the Mississippi, understanding the dangers of misreading the river and the importance of judgment over mere measurement. The “Mark Twain” river slang term originates during this time, signifying a safe depth.
- Twain Reflects on the Mississippi: Twain romanticizes the river in his youth, but later, with more experience, gains a deeper understanding of its hidden mechanics and complexities. He laments the loss of “poetry” in the shift towards a more mechanistic understanding of the river.
- Twain’s Literary Career: Through his writing, Twain explores the complexities of human nature, creating characters (Huck, Jim, the Duke and King) who are flawed, messy, and uniquely human. He critiques blind consensus and challenges conventional wisdom. He is attributed with the quote “There are three kinds of lies: lies, damned lies, and statistics.”
- Emergence of Artificial Intelligence (AI) in Healthcare and Policing: Predictive AI algorithms, such as NarxCare for opioid risk and AI predictive policing, are developed and implemented. These systems rely on data and statistics to make predictions and assessments.
- Implementation of NarxCare: NarxCare is applied in healthcare settings to score patients based on factors like morphine milligram equivalents and pharmacy shopping patterns.
- Negative Impacts of NarxCare and Predictive AI: The source highlights the harmful consequences of using these algorithms. Patients are flagged as “high-risk” based on arbitrary thresholds, doctors engage in defensive medicine, and patients lose access to care. Real people are reduced to categories and statistics.
- Critique of Predictive AI (Parallel to Twain’s Views): The authors of the source draw parallels between Twain’s skepticism towards mechanistic understanding and the flaws of predictive AI. They argue that AI lacks nuance, context, and human judgment, similar to how Twain saw the limitations of simply measuring the river. They emphasize that AI inherits data biases and can reproduce injustices.
- Call for Skepticism and Caution Regarding AI: The source concludes with a warning about the perils of blind faith in flawed AI models. It advocates for transparency, humility, and safeguards against “AI algorithmic violence.” It urges readers to approach digital currents with the same skepticism Twain applied to the river.
Cast of Characters
Here are the principal people mentioned in the sources with brief bios:
- Mark Twain (Samuel Clemens): The celebrated American author and humorist. He spent his youth on the Mississippi River, becoming a steamboat pilot. The source uses him as a lens through which to critique modern predictive AI, highlighting his skepticism towards oversimplification, his appreciation for human complexity, and his understanding of hidden dangers beneath seemingly calm surfaces. He is also known for his famous quote about lies and statistics.
- Neil Anand M.D.: One of the authors of the source “Twain and the Perils of Predictive AI.” He is presented as a medical professional who is critical of the use of AI in healthcare, specifically NarxCare, and advocates for a more nuanced and human-centered approach to patient care.
- Mark Ibsen M.D.: The other author of the source “Twain and the Perils of Predictive AI.” Like Dr. Anand, he is a medical professional who expresses concerns about the limitations and dangers of predictive AI in medicine, drawing comparisons to Mark Twain’s perspectives.
- Huck (Huckleberry Finn): A fictional character created by Mark Twain, from the novel The Adventures of Huckleberry Finn. He is presented as a complex and flawed human character, representing the richness and unpredictability of real people that the source argues is lost when people are reduced to categories by AI. He and Jim finding freedom on the river is mentioned as an example of understanding and respecting its rhythms and dangers.
- Jim: A fictional character created by Mark Twain, from the novel The Adventures of Huckleberry Finn. Like Huck, he is presented as a complex human character. His journey with Huck on the river is used to illustrate the importance of understanding the river’s rhythms and dangers for finding freedom.
- The Duke and King: Fictional characters created by Mark Twain, appearing in The Adventures of Huckleberry Finn. They are presented as messy, flawed, and human characters, further illustrating the type of complex individuals that the source argues are misrepresented by AI algorithms.
- Heraclitus: An ancient Greek philosopher. He is mentioned for his famous quote, “You cannot step into the same river twice,” which the source contrasts with AI’s tendency to treat people as static patterns, denying change.
