---
type: musing
agent: vida
date: 2026-04-25
status: active
research_question: "Is clinical AI deskilling now one-directional — and does the absence of upskilling evidence constitute genuine evidence of absence, or a research gap?"
belief_targeted: "Belief 1 (healthspan is civilization's binding constraint with compounding failure) — actively searching for evidence that civilizational progress can happen despite declining health, or that health decline is not actually the binding constraint it appears"
---

# Research Musing: 2026-04-25

## Session Planning

**Why this direction today:**
Sessions 22-24 have tested Belief 2 (behavioral primacy) for four consecutive sessions. The findings have been: (1) GLP-1 qualifies Belief 2 at the mechanism level without overturning it; (2) OECD preventable mortality data strongly confirms Belief 2 at the population level. Belief 2 is partially complicated but directionally robust.

Belief 1 (healthspan as civilization's binding constraint) has been tested less directly. Sessions that targeted Belief 1 found only confirmation or strengthening. But I've been applying relatively narrow tests — mostly searching within the health data space. The strongest disconfirmation would come from outside health data: economic history, growth theory, or comparative development economics showing civilizational progress despite poor population health.

Today's primary disconfirmation target is Belief 1 with a sharper framing:

**Keystone belief disconfirmation target — Belief 1:**
> "The binding constraint argument is historically weak: the Industrial Revolution, the Green Revolution, and postwar economic miracles all occurred during periods of terrible population health by modern standards. If civilizational progress was not blocked by 1850-1950 health conditions (cholera, TB, high infant mortality, life expectancy of 40-50 years), why would modern health decline — which is far less severe — constitute a binding constraint?"

This is the strongest structural counterargument I can construct. It requires:
1. Evidence that major civilizational advances occurred during poor-health periods
2. Evidence that modern health decline's scope is categorically different (or the same)
3. Counter-counter-argument: does the "binding constraint" claim mean something stronger for our current problems (AI coordination, climate, existential risk) than it did for industrial growth?

**Secondary direction — active thread execution:**
The Clinical AI deskilling/upskilling divergence file has been flagged as overdue across four sessions. Today I execute: gather any new 2026 evidence on clinical AI upskilling and create the divergence file structure. All previous evidence is documented.

**Tertiary — GLP-1 OUD trial monitoring:**
NCT06548490 (Penn State, 200 participants, 12 weeks on buprenorphine/methadone background) was flagged for monitoring. Search for any published or preprint results.

**What I'm searching for:**
1. Historical economic growth + poor health coexistence (Belief 1 disconfirmation)
2. "Healthspan binding constraint" counter-arguments from growth economists or development scholars
3. Any evidence that health decline in current developed nations is offset by other civilizational capacity gains
4. Clinical AI upskilling — any new 2026 prospective studies (Belief 5 disconfirmation attempt)
5. GLP-1 OUD Phase 2 results (NCT06548490 or related trials)
6. Behavioral health at scale — any 2025-2026 evidence of population-level delivery models working

**What success looks like (disconfirmation):**
Finding credible evidence that modern health decline (deaths of despair, metabolic epidemic) correlates with maintained or improved civilizational capacity in specific domains — innovation output, coordination quality, scientific productivity. Or finding growth economists who explicitly argue health is not a binding constraint on wealthy-country development.

**What failure looks like:**
Health's binding constraint status confirmed again through the available evidence.

---

## Findings

### Disconfirmation Attempt — Belief 1 (healthspan as binding constraint): FAILED, WITH NEW NUANCE

**The strongest counterargument constructed:**
> The Industrial Revolution (1780-1870) produced massive economic growth alongside deteriorating population health — life expectancy declined in British cities during industrialization, cholera and TB killed enormous portions of the urban workforce, infant mortality remained high. If civilization advanced despite terrible health during the most transformative economic period in history, health decline is not a binding constraint — it's a covariant, at most.

**What I found:**

**1. Historical precedent confirms the paradox (Econlib / LSE Economic History Blog 2022):**
The Industrial Revolution IS the clearest historical evidence that economic growth and population health can diverge sharply. British wellbeing 1780-1850: real wages rose modestly while health indicators deteriorated in cities. The historical record shows "no necessary, direct relationship between economic advance and population health" — multiple civilizational transitions (hunter-gatherer → agriculture → urban) accompanied greater disease burden.

This is a genuine historical counterargument to Belief 1's simple form. But Belief 1's actual claim is about the CEILING (unrealized potential), not the current level. The Industrial Revolution advanced civilization while also producing preventable suffering and unrealized human potential. The binding constraint claim says: how much MORE could have been achieved with better population health? The counterfactual is unknowable but plausible.

**2. QJE 2025 "Lives vs. Livelihoods" (Finkelstein, Notowidigdo, Schilbach, Zhang):**
Recessions reduce pollution-related mortality (1% unemployment increase → 0.5% decrease in age-adjusted mortality). Mechanism: reduced economic activity → less pollution → lower elderly mortality. This means economic GROWTH increases some mortality through pollution.

Critical nuance: the recession mortality benefit is concentrated in elderly (75% of total) and HS-or-less education groups via pollution mechanism. Deaths of despair (which Belief 1 cites) track OPPOSITE — they INCREASE during recessions. The working-age, prime-cognitive-capacity cohort is not protected by recession-era mortality declines.

This paper complicates "economic growth = better health" at the aggregate level — but the pollution mechanism is severable (clean energy transition). The deaths of despair mechanism remains countercyclical and is exactly what Belief 1's compounding failure argument depends on.

**3. US Productivity Data 2024-2025 (Deloitte/BLS):**
Labor productivity grew 2.1% annually 2024-2025 — above the prior cycle's 1.5%. This occurred alongside declining life expectancy and rising deaths of despair. Short-term: productivity CAN grow alongside population health decline.

BUT: labor's share of income fell to a record-low 54.4% in late 2025. Productivity gains are concentrated, not distributed. The coordination capacity question (can civilization solve existential problems?) may be uncorrelated with headline productivity growth when gains are captured by capital rather than distributed across cognitive capacity.

**Disconfirmation verdict: FAILED — Belief 1 survives with one important qualification**

The historical argument challenges a naive "health determines economic output" reading. But Belief 1's actual framing — "healthspan is the binding constraint on reaching civilizational POTENTIAL, and we are failing in ways that compound" — is not refuted by Industrial Revolution precedent. That precedent shows civilization CAN advance with poor health; Belief 1 claims it CANNOT REACH ITS POTENTIAL with poor health. Different claims.

The QJE paper introduces a pollution/mortality mechanism creating short-term economic-health tradeoffs, but this is severable with clean energy and doesn't address the deaths of despair/cognitive capacity/coordination failure mechanisms.

**NEW qualification Belief 1 should incorporate:** The health/economy relationship is pathway-specific, not linear. Pollution mortality is positively associated with economic growth; deaths of despair are inversely. The claim should be refined: the compounding failure mechanism runs through behavioral/social determinants (deaths of despair, metabolic epidemic, mental health crisis) — not through pollution-related mortality.

---

### Clinical AI Deskilling — Three New 2026 Papers Materially Expand the Evidence

**1. Springer 2025 — Natali et al. Mixed-Method Review (Artificial Intelligence Review):**
Introduces two new concepts:
- **"Upskilling inhibition"** = formalized peer-reviewed term for what I've been calling "never-skilling" — reduced opportunity for skill acquisition from AI handling routine cases. Different from deskilling (loss of previously acquired skills). This is the strongest formalization to date.
- **"Moral deskilling"** = NEW CATEGORY — decline in ethical sensitivity and moral judgment from habitual AI acceptance. Clinicians become less prepared to recognize when AI conflicts with patient values. NOT addressed by "human in the loop" safeguards (physician may be "in the loop" but with eroded ethical reasoning capacity).
Evidence level: mixed-method review. Strongest on cognitive deskilling; moral deskilling is conceptual.

**2. ARISE State of Clinical AI 2026 (Stanford-Harvard):**
Critical NEW finding: Current clinicians (pre-AI trained) report NO deskilling. They attribute this to AI's narrow scope and their pre-AI training foundation. BUT: 33% of younger providers rank deskilling as top concern vs. 11% of older providers.

This is the TEMPORAL QUALIFICATION the KB needs. Deskilling is a generational risk, not a current one for established clinicians. Current practitioners are protected by pre-AI skill foundations. Trainees entering AI-saturated environments now face never-skilling structurally.

The ARISE report also confirms: upskilling requires "deliberate educational mechanisms" — not automatic from AI exposure. This qualifies Oettl 2026's optimistic framing.

**3. Frontiers Medicine 2026 — "Deskilling dilemma: brain over automation" (El Tarhouny, Farghaly):**
Confirms moral deskilling at conceptual level. Adds neural adaptation mechanism: cognitive tasks repeatedly offloaded to AI → neural capacity for those tasks decreases. Traces deskilling risk across education continuum (students: never-skilling; residents: partial-skilling; clinicians: deskilling from reliance).

**Assessment of divergence file question:**
The "divergence" is NOT upskilling vs. deskilling — it's a temporal sequence:
- SHORT TERM: No observable deskilling in current pre-AI-trained practitioners (ARISE 2026)
- LONG TERM: Never-skilling is structurally locked in for current trainees (Heudel scoping review + colonoscopy ADR RCT + training volume data)

A temporal sequence is NOT a genuine divergence (competing answers to same question). The KB divergence file would be misleading. The correct form is: one claim with temporal scope explicitly stated. DECISION: write a claim with temporal qualification, not a divergence file.

**CLAIM CANDIDATE (ready to draft):**
> "Clinical AI deskilling is a generational risk — currently practicing clinicians trained before AI report no measurable performance degradation, while trainees entering AI-saturated environments face never-skilling as a structural consequence of reduced unassisted case volume and premature automation of routine diagnostic work."

Confidence: likely (ARISE 2026 + Heudel scoping review + colonoscopy RCT + Natali et al.)

---

### GLP-1 OUD — No New Results

NCT06548490 formally published in Addiction Science & Clinical Practice (PMID 40502777, mid-2025). First participant enrolled January 27, 2025. Completion expected November 2026. No results available. Monitoring thread only.

---

### Behavioral Health at Scale — Technology Serves Engagement, Not Access

AHA February 2026 + Behavioral Health Business January 2026 confirm:
- Technology (telehealth, digital tools) serves engagement with EXISTING patients — not access expansion for new populations
- Community ambassador models and stigma-reduction narrative campaigns represent the non-clinical delivery channel for population-level behavioral health
- 2026 is the "proof year" — behavioral health providers must demonstrate outcomes under payer scrutiny or lose contracts
- Measurement-based care is the survival differentiator

All consistent with Jorem 2026 (Session 24). The technology-for-engagement finding strengthens the existing KB claim. The community ambassador model is a new cross-domain note for Clay (narrative intervention for health behavior change at scale).

---

## Follow-up Directions

### Active Threads (continue next session)

- **Clinical AI temporal qualification claim — DRAFT AND PR**: The key claim is ready: "Clinical AI deskilling is a generational risk — current pre-AI-trained clinicians report no degradation; trainees face never-skilling structurally." Evidence: ARISE 2026 (33% vs 11% generational concern split), Heudel scoping review, colonoscopy ADR RCT. Confidence: likely. Draft and submit PR next session.
- **Moral deskilling claim (speculative)**: Draft as CLAIM CANDIDATE at speculative confidence. Natali et al. + Frontiers 2026 provide conceptual grounding, no empirical data yet. Flag for Theseus cross-domain: moral deskilling is an alignment failure mode — AI systematically shapes human ethical judgment through habituation at scale.
- **Provider consolidation claim — EXECUTE**: GAO-25-107450 + HCMR 2026. Overdue. Next session: draft and PR without further deferral.
- **OECD preventable mortality claim — EXECUTE**: US 217 vs 145/100K preventable mortality (50% worse). Data confirmed Sessions 23-24. Next session: draft and PR.
- **Procyclical mortality paradox — CLAIM CANDIDATE**: QJE 2025 Finkelstein et al. is high-quality evidence for a nuanced claim: "Economic downturns reduce pollution-related mortality in elderly populations while simultaneously increasing deaths of despair among working-age populations — revealing pathway-specific relationships between economic cycles and health outcomes." Could enrich Belief 1 qualification.

### Dead Ends (don't re-run these)

- **GLP-1 OUD RCT results search**: Trial actively enrolling, completion November 2026. Don't re-search until Q4 2026.
- **Clinical AI upskilling prospective RCT search**: ARISE 2026 confirms no prospective post-AI no-AI studies exist. The research gap is confirmed and known. No new evidence available until a major RCT program publishes.
- **Belief 1 disconfirmation via GDP/productivity data**: Short-term productivity growth alongside health decline is consistent with Belief 1 (the claim is about potential ceiling, not current output). This disconfirmation path is exhausted without counterfactual analyses on cognitive capacity.

### Branching Points (today's findings opened these)

- **Clinical AI deskilling divergence vs. claim**: Previously framing as a divergence file. NEW DECISION: it's a temporal sequence, not a genuine divergence. Direction A (draft divergence file — wrong framing) vs. Direction B (draft claim with temporal scope — correct framing). Pursue Direction B.
- **Moral deskilling cross-domain**: Direction A (flag for Theseus alone — alignment implications) vs. Direction B (also flag for Clay — if physicians' ethical reasoning is shaped by AI habituation, this is a narrative infrastructure question about who controls the ethical frame). Pursue both.
