J Basser: 0:07

Welcome ladies and gentlemen to another episode of the Exposed Vet Jay Bass Productions. Today is the I guess we say it's the second day of October 2025. The year has gone by at lightning speed. Today our co-host is Mr. Barry Furley. He's down in Tennessee somewhere. How are you doing, Barry? I'm hanging in there like a loose tooth today. Oh, you had to bring that up again, didn't you? Anyhow. Today we've got uh Bethany Spangenberg. She is the owner of the company called Fowler for Vet. Uh Bowler for Vet is a company that does independent medical opinions, independent medical evaluations for VA disability issues, among other things. And today we're going to discuss using artificial intelligence. Mainly for Nexus Letters, then we'll get into some side discussion too as to what's going on with this stuff. And uh Bethany, how are you doing?

Bethanie Spangenberg: 1:12

I'm doing well. Staying busy, ready for the transition into fall, and just staying keeping like trying to run around, keeping schedules straight with the kids. So a lot a lot of moving parts.

J Basser: 1:27

Well, life does have a lot of moving parts. It does. But you were talking about using AI for Nexus Letters and things like that for um, I guess you do some stuff for uh about vet, but uh I know it's use it's getting more and more popular.

Bethanie Spangenberg: 1:48

It is, and that's actually I had a um conversation recently with another business owner, and they were talking about AI, and that's kind of what prompted, you know, the idea of having this, especially because the same same week I saw a question on a forum about using AI for Nexus letters, and I'm like, you know, we really need to have that discussion. They've talked about it at Nova a couple sessions, um, brought a lot of understanding for legal use. Uh, and so I I really feel like there's a gap there that we need to fill when it comes to the medical expert side for Nexus letters and AI.

J Basser: 2:30

I can see that because I still noticed there's a lot of um, there's one company that's based their whole business model is is using AI. You've probably seen that.

Bethanie Spangenberg: 2:40

Yeah, I have. Um that kind of worries me a little bit because of my experience with AI and the things that I've seen and the products that I see it put out. Um, you know, AI has been fabulous, and I'm actually really impressed with where it's at, but I don't think it's targeted for VA disability claims just yet. I think we'll they'll get there, but you know, there's some things I feel that AI will never replace. Um, but I think there is a place for it when it comes to veteran disability and maybe even in the use of Nexus letters. So for this presentation, I actually wanted to see if you use AI, the really the skill that really comes in is learning how to use that particular type of AI. You need to know how to write your prompts. And your prompts will make or break the output of what you're getting. And so what I tried to do is I actually had AI create the content for this presentation today. So when we go through this presentation, I'm going to talk about some things where yes, I agree, no, I don't agree, and then even point out some things that maybe AI made mistakes on, and that will be an example for the limitations with AI. So just keep that in mind as we go through here. Uh we are actually seeing veterans give us an example of a Nexus letter as like to reference or to use as evidence. So they'll go into, I'm going to talk mainly about Chat GPT because it's the most common right now. Um, but I see veterans going into ChatGPT, they'll create what they think is the right Nexus letter, they'll drop it into their Valor for Vet folder, evidence folder for us to look at as medical experts. And right off, I know it's AI, I know where they got it from, and it doesn't quite hit all the legal points that I would have hit as a medical expert doing this for the last 14, almost 15 years. And so again, that's that's what emphasizes the importance of talking about this today. So again, these slides are created, the content is created by AI. And you can plug the content into your slides, but even PowerPoint will create digital um presentations that are that are like pleasing. So for example, this circle on the edge of my presentation, this setup, I actually had a type of AI help me that is plugged into PowerPoint to create this slide. So even your your standard presentation software is using AI, your Photoshop uses AI, Grammarly is a type of AI, and they're expanding. Our phone lines that we use at Valor for Vet are AI, and I'll talk a little bit about that later on in the presentation. But what is a Nexus letter and why AI? So Nexus Letter is very important for veteran disability claims. It takes that current service connection, excuse me, that current disability and tries to relate it to service. So it's the part that connects these two items. And majority of veteran disability claims need a Nexus letter of some sort or a Nexus statement with a supporting rationale in order for a veteran to get service connected. The challenge has been, and it has always been, getting a Nexus letter from a qualified individual where the quality meets the VA standards and it's at a reasonable price. Doing this for as long as we have, we know that majority of the cost associated with the Nexus letter is coming from that veteran directly. So if a veteran is working with an attorney, the attorney may upfront that fee, and then the veteran has to pay that fee on the back end if they're successful. So we know at the end of the day, our market needs to target the veteran's pocket. And if you look at $1,500 for one Nexus letter, you have to really weigh, okay, is $1,500 worth me getting a Nexus letter for an ankle condition, or should I use that for something like sleep apnea where it may have a longer term or a better benefit for the cost? And so a lot of the doctors that practice medicine, unless you've been taught by the VA, unless you were taught by somebody else, the skill of writing a Nexus letter is also a niche, and they're they're hard to find someone who's experienced enough to put out the quality that is needed. So if we use tools like ChatGPT, is it to the rescue, as this presentation suggests? So, yes, it can draft Nexus letters quickly, but there are certain limitations when it comes to some of the language, the medical research, the legal language, the at least as likely as not, the more likely than not kind of phrase. And then the big question is is can AI help experts create strong letters? The VA will accept. And so we can, but I don't think that that's I don't think it's a one and done. I don't think we plug it into Chat GPT and it spits everything out. I think we have to one, know our prompts, and then two, we have to have the clinical knowledge to really put it back like into like a Nexus letter that flows. So there's a lot of challenges in that.

J Basser: 8:43

I just hit the nail on the head because you know, if you're sitting here and you're a writer and all of a sudden you get a claim, and you get this statement, a personal statement or whatever from this veteran who's got a tenth grade education. Okay. But he sounds like a Philadelphia lawyer with uh a PhD. Yes. It makes a big difference.

Bethanie Spangenberg: 9:06

And you know, the other thing is too, is you know, because you brought it up, yeah, it's later in my presentation, but because you brought it up, I'm gonna go ahead and talk about it. There is there are times when our providers will write a Nexus letter and they are using medical jargon. And if you think about it, our audience is not medical professionals, our audience is the raiders or the people deciding claims at the VA. And somewhere, I can't remember the statistic, it's like more than 50% of the raiders at the VA have a high school education. And so, you know, what audience are you writing this Nexus letter for? So if I have a Nexus letter where my provider is talking about a left shift when it comes to white blood cells, they're not going to immediately know what a left shift is. And so we use Grammarly to help us kind of dumb it down in a layman's language. Um so then that way there is understanding of what what language or what explanation and rationale that we're trying to support. You know, you can get into a lot of these numbers and spit out these numbers for lab counts, kidney count, like your kidney function, um infection numbers, type things like that. But to a layman, they may not understand it. Well, with Grammarly, we can take that information and we can kind of put in that that layman um explanation so we can really talk to the reader that is reviewing that Nexus letter.

J Basser: 10:47

Yep, simplicity. Yeah.

Bethanie Spangenberg: 10:51

So your audience is who you're writing to. Yes, you're right. If a state a veteran who has an eighth grade education is writing this really detailed statement, you're like, okay, this this isn't this is not. And it's actually very like if people are paying attention, it's actually very easy to see that. So all right, let's move on to the next slide.

J Basser: 11:15

Okay, go ahead.

Bethanie Spangenberg: 11:18

All right, maybe and go. Okay, there we go. So these are the top questions AI found about Nexus Letters and AI. Will the VA accept it? So content and a doctor's signature will matter most. Absolutely. So a VA will accept it if the content is appropriate to your claim. It discusses the veteran's medical information, the rationale supports the veteran's claim, including the details of the medical history, and it's written or signed by a PA, DO, nurse practitioner, physician, a PhD, uh, a psychologist with a PhD. So, yes, AI can write it and then the doctor can sign it. I just yesterday had a VSO bring one to me, and they're like, hey, so and so did this Nexus letter. Um their VSO helped them write it. Will you take a look at it and sign it? So I I actually know this individual pretty well. So I was like, oh, let me take a look at it. So I looked at it and I'm like, this is absolutely terrible. They were trying to connect their tinnitus secondary to migraines, but the medical history discussion was only about the veterans' tinnitus, and it did not discuss the veteran's migraines at all. And you you can't have that. If you're trying to talk about how two conditions are related, both conditions medically must be discussed. And then you get down into the rationale, and the rationale was like all this great medical literature, but it had nothing in how it pertained to that veteran. And so I even question, you know, did you? I mean, first of all, your VSO, I should give you a little bit more, you should actually have more understanding of what a Nexus letter needs. And then two, if you actually did use AI, that was terrible because as far as a quality standard for what we put out, that's not even close. And so, you know, even VSOs aren't quite getting what is needed in a Nexus letter, and that's upsetting to me.

J Basser: 13:49

But did you break up the red pin?

Bethanie Spangenberg: 13:52

I just said um, no, thank you. It doesn't meet my quality standards. So I didn't want to waste my time trying to tell them what was needed or how to make it better. I just pushed it back and said, no, thank you. I didn't really have the time for that. So, yeah, absolutely. Next question on here Do I still need a doctor? Yes. You need a not necessarily a doctor per se, but you need to have a qualified medical professional. So, how accurate is ChatGPT in any Nexus letter that goes out, whether it comes from Vali for Vet, it comes from one of our competitors, or if it comes from ChatGPT, you have to verify everything that it says, and you have to make sure that it includes the appropriate language. When I first started playing around with ChatGPT, it would try to give me the medical malpractice language as far as what to use in the Nexus letter. And medical malpractice language is not the same as what you use in veteran disability. So you have to make sure that that phrase is in there. Um the next one is is my data private? And this is a big thing that the NOVA presentation really leaned on is you know, are you protecting your veterans' information if you're putting it into an open source data system? They're using your data to make things better, and that data is now, you know, in their system being processed. And so, how safe and secure is that individual's data if you're plugging it into this type of software? Then the last point that, or last question it talks about is could it be biased or missed details? Absolutely. I've seen this firsthand. And even, you know, if you think about what we put into a Nexus letter, there's we got to review the medical records, and then we have to understand the medicine, and then we have to to find research, and then we have to take all of that and put it together. There's actually an AI data system that if I tell it to be biased in one in one way or another, it will go and it will get me research that makes it back research that is biased towards one direction. If I click that button for to make it in support of. So it's interesting because anybody can go in there and use this AI system and it will pull actual studies from different countries, from the US, from the government, in order to support a particular medical opinion. So, in my in my experience, I don't like that. Um, again, that's a quality standard thing for us. It needs to both clinically match and you need to have good studies to support that rationale. And we'll talk towards the end of the presentation. When it comes to studies and research, I have some great information that you can use and actually how you can use Chat GPT to find more research for the claim that you're trying to pursue, which I think is really where the most value comes from, you know, AI right now for Nexus letters. Any questions? Any thoughts before I go into the next one?

Beri: 17:40

I was gonna ask you, I didn't want to sidetrack too much, but that one letter that you got from the VSO, was it even a good uh springboard into what they needed? Was it even useful as a tool to start a good letter, or was it just completely?

Bethanie Spangenberg: 17:56

I mean, in my opinion, I could see a veteran writing it the way it was outlined. When it comes to knowing a VSO knowing what should be in a Nexus letter, I think that they have a higher standard that they should know more about really what goes into a nexus letter. And I was kind of disappointed that the VSO um didn't have that quality that I was looking for. Now, what I ended up telling, because it was one VSO, another VSO, like one VSO wrote it, the other VSO I know. He's like, hey, take a look at it. So, you know, I don't know this person directly, but I know this other person. And I was just like, you know, this is you know, when I rejected to sign it, and I said, you know, you can tell the veteran that you know it doesn't meet our quality standards, and really it's missing the details of this individual's migraine history. And, you know, it it gave the medical stuff on his tinnitus, but it gave me nothing for treatment, how long they've been going on, um, what remedies he tried. All of that was omitted in the Nexus letter. So I guess from a standpoint of a veteran writing it, I'd be like, okay, I I can understand what you're trying to do, but this isn't quite right. From a VSO standpoint, I think their standard should have been a little bit higher.

Beri: 19:22

Right. So it it might be a useful tool from a fetcher that needs to be filed to claim or something to start with, but it needs to be uh worked on.

J Basser: 19:32

I think I've seen that before. Um I think maybe the veterans already search connected for migraines. So he's trying to get his answers based on the context itself. Uh he's taking for granted that the VA knows he's already searched connected for migraines, so he's not elaborating too much on that. So I think that's that's that's where that came from. That's my personal opinion, but I've seen that several times before. But he does need to cover both bases.

Bethanie Spangenberg: 20:03

Yes. Any other questions? No, I will say I also saw another PDF recently um where it was like a standard PDF template, and the like the opinion was like the veteran's claim condition is at least as likely as not related to and had like a blank spot. So it was basically like the doctor would just like write the diagnosis and then mark a check checkbox, kind of like how we see the DBQs now. And then on the back side was like a rationale, and that wasn't the PDFs I've seen online. I I still don't think that they're useful. I don't I don't think they're comprehensive enough. They tried to make it like it's a form, like you can just, you know, um, and still kind of hit all those things the VA needs. And I haven't seen a good PDF out there that that does it, or a worksheet that does it, that you can just take into your doctor and say, hey, can you fill this out? Like I haven't found one, and I don't know that you can quite create one because there's so many theories of service connections and so many factors that go into like obesity as an intermediate step. So you can't take like a standard PDF form or standard worksheet and be like, here, doctor, fill this out, please. And that doctor's gonna not be they're not gonna be able to look at something like that and really know what boxes they're supposed to check. So there's a lot of limitations in getting you know a Nexus letter from your doctor. It's it's hard. So this is where AI may be able to step in at some point, but anyways, next slide. So pros of using AI speed. I would agree it's pretty speedy, especially we write, I use AI to write some emails. When I get annoyed or aggravated and I want to write a snippy email, I will talk to Chat GPT or Grammarly and be like, make this a kind email. And it will take all my negative, annoyed language and turn it into something that's very kind and fluffy. And that has saved me like the headache of um you know, waiting the 24 hours or waiting a certain time period to let yourself like cool down. And it's like, oh, you see it? It's like, oh, oh, you did so good being a nice, a nice little AI bot. Like, so it and it does it, it'll rewrite that email just so quickly and uh you know makes things a lot easier from the writing standpoint. So whoops. Thoroughness helps integrate records and literature. It can be thorough mainly for um when you're trying to discuss certain research. What I mean is you can drop the research into the chat GPT, and you can tell them to summarize it in layman's terms or summarize the study findings in a seventh grade reading level in paragraph format or in a structured format, and it'll go bullet points and make something nice and easy to read if you're trying to understand studies. So I think that's helpful. Um clarity, it can do structured language and required phrasing. The other thing I will say, if we get so sometimes when we look for research, we'll find it in another language. Most of your abstracts for medical research is written in English, but the full study and its results may be in another language. We can actually drop that into Chat GPT and it will give us the summary of the data or a certain section of the study that we're looking for in English. And so as far as talking about language, you know, it can help us with understanding some of that data that comes back on those studies. When it comes to cost of using AI, this is what I want to talk about with our phone lines. Um we have set hours, and during those set hours, if our phone lines are plugged up, then the veteran gets this continuous voicemail of please leave us a voicemail and we'll get back to you, you know, yada yada yada. So we have, and we just recently put it in, and of course it's got some learning to do, but we have AI running our phone lines 95% of the time. And that is because if one of our phone lines is tied up, that bot can still give you basic information related to our services. Now we're trying to teach it to get more detailed. So if a veteran is wanting to know specific details of the status of their reports or the status of the work that we're doing, we're working on how it can look up that data and then provide a summary to that individual. But it's not there yet. But when we look at the phone calls that we're getting after hours, those are customers that are still engaging with our with our company because they're getting answers through that bot. So they'll call in, they'll talk to the bot, then we see them register online, and then they'll go through the process of using our services. The other, so that helps us to keep like a continual phone line available, you know, for somebody who's calling in. And so for us, that's cost effective. Um, it's not necessarily preferred. I know that I don't like to talk to robots, so we have it set up that if that individual calls in and they say live agent, live person, I want to talk to a real person, then it will automatically transfer to one of our agents. So for us, that is a cost-effective way to keep phone lines open, to keep an avenue of information for the services we provide, and we find it cost-effective. So the last pro of using AI is empowerment, and I would agree. I think that when veterans look at um using Chat GPT or similar for Nexus letters, the questions you should should really be asking is if we use the tinnitus example, how can tinnitus be related to migraines? And so it can tell you in the layman's terms, and then you can actually prompt it to help you find research. And that is where I think it is the most powerful for when it comes to veterans. And at the end of the presentation, I actually have a word-for-word prompt a veteran can use to help them find appropriate studies that are strong, that are really supportive of what they're looking for as an example. Any questions here? Not necessarily for the PTSD because PTSD is very specific for the VA, but what I'm talking about is if you have like a chronic back condition and you heard it in service in 1992, and your next time of treatment was in 2022, you've got 30 years there. You've got 30 years that you have to plug in. And so you may ask Chat GPT and say, hey, I injured my back in 92, and I'm trying to write a statement for my disability claim. I suffered from symptoms and saw the chiropractor over these 30 years, but I need to help fill the gap of the lack of medical record evidence, and it will walk you through on what type of information you should include in that statement as far as chiropractor over-the-counter medication, stretching, yoga, uh pool programs at your YMCA, but it will prompt you on all of that supporting information to help you fill that gap. So I do find AI is helpful with writing statements in support of your claim. All right.

Beri: 29:13

I guess the one thing I have noticed, just kind of trying to plug in stuff because uh sometimes I do just a Google search looking for condition or something. And if you use that, it does lay out at least all the steps and the things that you need together, which you know we go over all the time with uh claimants, but they you know it it it spells it out step by step, you know, with the diagnosis and which form to file, and it's it's useful for that. Yeah. I'm just not sure you can use it. A lot of people want it to do the work of form, and it's it's I haven't seen it, it's just not their Yeah, I would agree.

Bethanie Spangenberg: 29:57

Now uh Google has their Their new like AI at the top, so where you can actually like, but if you just use straight up Google for like research, it will give you like the most popular hits, and that's where I think using that AI is more advantageous, advantageous than Google, because when you use AI, you're saying find you know this particular type of study, um, a peer-reviewed article that discusses tinnitus and migraines. And then it will start to scan. So I think it does a better job of narrowing down the specific type of research you're looking for, where Google is more of a broad popularity type hit. If if you plug that AI portion that they just added, you know, a few months ago, several months ago, I guess, then it actually has started to populate some of that more um useful information, I think. So, but I think you're right as far as walking it step by step. Um one another advantage for uh using AI is we use it to check our references. And what I mean is in certain cases, you have to use AMA formatting for writing. And that's in-text citations, and the end of your report, you do medical reference citations, and it's got to be, you know, a certain format. Some of it is full first name, full last name of the author, and you name every single author, and then you name the title and the journal and the publication date. And I mean, there's so much information when it comes to citation in reports that it's hard to keep up with, and it's important that we get that right. So for us, we typically use Chicago style citation where you put the superscript number into the text, and then at the bottom you list it in order. So when we take an AMA citation and we try to turn it into a Chicago style citation, sometimes we're not good at doing that as humans. And even sometimes ChatGP, ChatGPT is not the best at doing that, but we will use that to help us check our citations to make sure the formatting is appropriate, and that's important to you know, give credit to the authors of those studies. All right, let's go on to the next one here. Cons of using AI. It hallucinates. So I want to tell you the story about hallucinations, and I'm not kidding. I would love to teach AI how to write a Nexus letter because it would save cost, it would save time. You know, I think cost is the biggest factor that we've ran into as a company because you can't just buy a franchise of writing Nexus letters. This has literally been from the ground up finding software that works for you, finding stuff that works for your company, and really building something that that works with your your flow, with your um your company's processes. And something that has actually helped us from the very beginning is the team structure. Meaning, if if I take a record review and I say, okay, yes, we can write a Nexus letter, then it goes off to the next person and they have to confirm and verify that yes, the information is here, no, there's not. That is very time consuming and that can be difficult because of cost. So that helps us if we would turn to AI, because we have two humans verifying anything that AI puts out. That that won't change. But I use AI or I look at tools where we can speed things up and make this process easier for veterans. And I have played with writing Nexus letters, and in Chat GPT, it created fake references, fake citations, fake URLs, and it's like, oh, this is kind of lovely. And then you go to double check the work, and it's like, oh no, no, no, oh no. And that's actually very scary. So even when I talk about the prompts later at the at the end of the presentation, it is absolutely necessary that you check the URLs, that you check the titles, because it will create all of that in order to make a pretty response. So, yes, it absolutely will hallucinate and make things up. So you always have to check facts that are in you know, whatever using for Chat GPT or AI. Um bias, we talked about pardon?

J Basser: 34:57

Disclaimer on this one.

Bethanie Spangenberg: 34:59

Oh, right. Um bias. I have not appreciated any societal or data set biases. Um it's maybe that's not really something you know we've really looked at. Um so I don't I don't have an example for that. The cookie cutter risk draft feels generic or impersonal. I tried to teach it how to structure a nexus letter and I could not get consistency. Um I just don't like the way that it's putting stuff out right now. So it just feels, I mean, it looks good unless you know, like, you know, like I said, the experience really gets me here because it's like I've been doing this for how long, and this is like what you're putting out, like you're not there yet, bro. Um black box reasoning may be unclear to defend on an appeal. Uh I haven't really seen that. Um, but I can see where that may apply if a veteran is trying to write it, mainly because they don't have the medical understanding. And so if ChatGPT puts out something that sounds good, but it doesn't clinically make sense, that might be, you know, and and the veteran won't know if it doesn't make clinical sense or not unless they run it by, you know, somebody with an education on it. So privacy and ethics, don't paste sensitive health data into public tools. I I think we've already talked about that a little bit. Any questions before we talk about this next slide?

J Basser: 36:42

I think we pretty much covered it running.

Bethanie Spangenberg: 36:46

So at um Valley for Vet, our our medical experts are not allowed to use uh use AI. They have to explain everything that they want to explain and why this study is important. They can use AI to find studies, they are not able or allowed to use AI to write their report. I'm the one that goes in and does grammarly to make things sound to an appropriate um audience. And I'm also, you know, how they talk about like left brain and right brain people, medical people aren't necessarily the best at grammar and where commas and periods go. And so before we used Grammarly or had that process in there, I would have attorneys just rip like comma here, space here. Uh I mean, just and I'm like, okay, okay, we'll fix it, we'll fix it. So by adding that AI, we've had much less complaints for punctuation and commas and things like that, which sounds silly, but you know, some people are particular. Um when uh case study when AI goes wrong. Again, AI made this presentation. I want to talk about it briefly. Um, not gonna spend a lot of time here. So there is a case that they talked about at Nova where attorneys back in 2023, it was a New York attorney, they wrote a brief using AI, and for some reason the attorney did not check it, which blows my mind. And they submitted it to, you know, to court or whatever, and it made up cases, it made up um a lot of the the findings of the case just to meet what that um individual was trying to find. And so when the judge asked the attorney to talk about these cases, it was like, oh, can't find it, didn't know it. And so that attorney got like fined like $5,000, and that attorney was like, or the judge was like, um, you know, you can use AI, that that's not the problem, but you have to check the work that it does. You have to be able to independently verify the information that is coming out from it. And so I think that was the big takeaway is like, you know, you can use it, it's a tool, but it's not going to replace, you know, your knowledge, your experience, and your education. So um then there's this VA Munch example. Sounds like the VA was trying to use it uh as far as dealing with contracts, and it incorrectly flagged uh $3,500 number as $35 million. And so it ended up canceling in real life some contracts because it flagged it for the expense that it was. And so at that time, they're like, nope, we're done. We can't, this is not ready to launch. It has to be um, you know, has to have the manual oversight until it's perfected. So um hypothetical nexus mishap. Generic letters uh gets a little weight. Yeah, yeah. So right now I don't think it's putting out enough. Um takeaway, always double check AI with human judgment, and I I think that's a good takeaway there. Any questions there?

J Basser: 40:17

Or are you doing a lot? You do a lot of work double checking the uh AI. Yeah. Is it not counterproductive to do that, or is it still about the same time-wise, or is it a little faster? Because once you have to double-check everything, uh it appears that you're gonna put the same amount of time into it that you would without it.

Bethanie Spangenberg: 40:43

Um, so we we're not in a place where we've completely replaced um, you know, I what I found when working with both, and I even tried to pull up some examples for this, but we won't have time to go over it. But what I have found is there's still a disconnect between taking the actual veterans case and the facts of that case and plugging it into the medical research. So if I would give AI the medical information, and then I would give them the studies, they still don't like merge that understanding. Um so right now with what we're using specifically for grammar, it's it's not very time consuming because it's like keep the text, make grammatical corrections, capitalize the word veteran when discussing the veteran, period, and that's it. Um especially with the research part too, because you know, the medical people have to write that in order to properly explain their clinical thought process on that. And um, you know, I almost think it's it's it's not very time consuming for us, but I can't imagine trying to do like the whole thing. Um mainly when we do our quality reviews, we're making sure that the the medical history is um heavy enough to persuade or to feel like the history is complete, that there's any um significant risk factors are also discussed in that medical history because the VA is going to try to deny you and say, well, their obesity is their primary risk factor for sleep apnea. And so if we talk about their obesity and their medical history, then we can say, well, yes, they're obese and their body mass index was 34 at the time of the study. However, the prolonged history with PTSD over 30 years, including the lack of motivation associated with PTSD, are stronger risk factors and contributing to the veteran's sleep apnea. So then, you know, we're acknowledging those risk factors. Um quality review is making sure that the grammar is correct. Um, and then of course, that the studies that are listed are pertinent to the veteran's claim, that it fully explains that relationship, and uh it's lengthy enough. We don't like one or two paragraph rationales. We want something that has three or four medical studies, even more to support a case. If I have a Nexus letter that has two medical literature citations, it's getting kicked back. I want more than that. Does that answer the question, or is that like that was way too much?

J Basser: 43:47

Your goal is you mean your goal is to at least kick in the benefit of the doubt.

Guest: 43:52

Yeah.

J Basser: 43:53

At a minimum. Yeah. But you have to do what you have to do. On problem is, I mean, you know the VM is going to use negative evidence, but you don't have access to that evidence unless you are, you know, accredited or whatever, you're representing a veteran. So it's uh kind of catch-22 in some ways. But as long as you, you know, you present it and you know you stack the deck in your in the best way you can, so that's what it takes.

Bethanie Spangenberg: 44:19

Yeah. We actually um we do get a lot of claims files. So we're um so I'm happy, I'm excited about that. They're big files, but that's that's what we need. The only limitation that I don't like is that sometimes we can still get the C file, but we can't get um VB, uh excuse me, can't get CPRS, the medical records from the VA. And so those aren't directly plugged into VBMS. So, you know, there's still information there that we're not fully getting. So, but if we don't have enough information, we don't have enough information and we reject to write the nexus. And we'll actually tell the veteran, hey, we want more records related to your treatment for migraines. If you provide that to us, we'll take another look at it. No cost to you. We need more of those treatment records. Did you see a neurologist? Did you have a head CT? You know, what have you done for treatment? You we need more from you. Right now we can't write it. We may be able to. If you get more records, get them back to us and we'll take a look at them.

J Basser: 45:25

Well, that's also an issue too when you deal with older vets, because you know, a lot of vets are, you know, especially vets in their 50s and 60s, you know, most of their records are not computerized. They're mostly paper. 2013, I think the VAs get everything computerized. So it's hard, you know, because going through like the old days that used to send the claims folder over to a C and P examiner, here comes this 500-pound block of paper. And you've probably seen that before. And uh, you know, that'd go through each one of them. I I've been sitting with a C and P exam helping the examiner go through the record. So if everything's computerized, you could actually you actually you could actually AI the entire the entire veteran's medical history, you know, from A to Z. And it would probably cook up a whole bunch of stuff.

Bethanie Spangenberg: 46:21

So we have tested a few of those systems. Um the biggest limitation is handwritten records. You're never gonna get rid of hand record handwritten records because of like in service or like if you're you know in the field or if you're at a base that doesn't have a data system or the computers are down. I think we're always gonna see handwritten records within the military file. Um and so that was the biggest limitation with one of the companies that I saw is they they could their systems couldn't read handwritten writing. The other thing is check boxes. So with the DBQs, the um information, if it's positive, then they mark a box. So we had some cases where the AI told us that they had hip surgery, and here it was just reading the DBQ and the history section where it was blank for it to state the history, and here it read it as if that individual had hip surgery. And so for DBQs, it hasn't been great either. So right now we work with a company that does both AI and manual to index the records. Um you know how they do it, their AI, you know, I'm not familiar with, but um, you know, if we have issues, we we kick it back to them to help them um like re-educate or reteach their system. So ethical guidelines for using AI, it recommends that you verify the accuracy, you protect confidentiality, the doctors sign what matches their clinical judgment, that there's transparency, that AI was used as a drafting aid if asked. Um to some extent, I think that's appropriate. I think the limitation is now is that there is some type of AI in every component. So even in Word doc, there's what they call copilot, and I've never used it, but that's a form of AI, and so I I can't use a Word doc without copilot popping in my face every time I open it. So I think if your AI is used to draft more than 50%, then maybe yeah, you you provide that. Um avoid over reliance, so you really have to keep humans in the decision loop. I that's what I think won't ever change, and then bias checks. Um I've never appreciated that from the Nexus Letter side of things, but certainly uh if it's in there, it should be considered.

J Basser: 49:24

So this verify Yes. Go ahead.

Bethanie Spangenberg: 49:29

So bias accuracy and source risks. Um let's see here. There are some AI data systems that you can build or teach, and the limitation is with that is they have to have the most up-to-date information. So, for example, if somebody's trying to use AI in order to keep up with the the CFR and ratings, then every time it changes, they're gonna have to update that into the system. And so we call it Yeah. They call it learning. Yeah. So I'm gonna push through these last few slides here. Um, I would agree that tone, um, there's a difference in the tone between human and AI. The there are certain words that AI likes to fixate on. And so when I read an article online, I'm like, oh, AI wrote that. Because I've seen it so much. Um you want to make sure it has consistency, the rationale, credibility. We've talked about all of that. So, as you can actually see, like in this AI-created presentation, a lot of it is redundant. So we're beating a dead horse with some of this. Predictive analytics, I don't think that this applies for veterans. So I taught or I told the AI to that my audience was veterans for disability claims. Now, this predictive analytics, I actually know some large attorney groups use this. So they're using AI for all of these claims, and they're trying to use some predictions on how the VA is going to come back or what things work or what things don't work, which I think is valuable for those large attorney firms, but not necessarily to you know veterans. Again, protect privacy, verify the information. I think that's pretty redundant there. So I would agree on this conclusion that the AI is an enabler, it's not a replacement. Um, you have to balance the pros and cons, keep human in the loop. I do think that the VA is going to use more AI. I think they have to. Um, in order to keep up with the claims and keep to keep up with government shutdowns, to keep up with budgets, all of that. And then these couple slides here. Yeah. Say that again.

J Basser: 51:59

I'll give you some insight in a minute.

Bethanie Spangenberg: 52:01

Oh, okay. All right. I'm going to push push through these last few things. What I really want to talk about are the types of studies. When we look at medical literature, these are the all the different kinds of studies, okay? Your three at the top are going to be your strongest evidence to use. The four in the middle are going to be mid, and then at the bottom, the last four are things you kind of want to steer away from. Um, ecological studies can be relevant when it comes to like Agent Orange or toxicology type things, but the case studies and case reports, it's usually something that's on one individual person and they're not very strong. So when we take the fact of like the strength of these, if we plug into AI to find a study. So help me find a study for hearing loss and dementia. That was my example. I prefer studies that are Did I spell that wrong? Oh boy. Systematic. I put systemic. Systematic reviews and meta-analysis, randomized controlled trials, or pros yeah, or prospective or retrospective cohort studies. Studies from the Department of Veterans Affairs should be prioritized. Additionally, PubMed or National Institutes of Health are important. Provide a list of five studies if found for each result. Give me the title of the study, a brief summary in layman's terms at a seventh grade reading level, and the URL to link to the study. So you put that, it should be systematic, not systemic. But you plug that into Chat GPT for what you're trying, the two conditions that you're trying to discuss, and you can actually find quality studies that you could submit to the VA for your claim. It'll explain it in layman's terms. And then let's say you get the PDF of that study and you're like, you know what, I really want to verify this again. So you open up a new chat and you attach that study and you put this prompt in here. It says, analyze this medical research article for me in plain language. Please explain only these four things in a way that a non-medical person can understand. The study type, what kind of study it is, and where that ranks in strength of evidence. Relevance, how closely it relates to the medical connection I'm trying to prove, weight for legal use, whether it's strong, moderate, or weak evidence for a Nexus letter, and the recommendation: should I use it as primary evidence, supportive evidence, or not at all? And keep it simple and clear, no heavy medical or research jargon, do not use acronyms or abbreviations. So using that prompt with that PDF of the study, it can give you useful information that you can apply to the veterans disability claim. And that's all the slides. Those last few slides were my slides. Those weren't AI. But like I said, you could see that what it created is redundant. So if I would have gone in there and tweaked it a little bit, it could have a smoother flow. We could talk about, you know, group some of those conversations differently. But I wanted you to see that, yeah, it's great, but you still need the human touch in there.

J Basser: 55:13

Note to agents if you follow this criteria. You can also work using Chat B this AI. You can also type in very similar criteria, and you can actually dig out uh all the BBA decisions you need on certain issues, and all the veterans court issues and the entire history of the veterans court is published that you can also find for whatever you're working on. So that's one good thing to have, and that's that's a good avenue. So but uh given the fact that artificial intelligence is artificial intelligence and it's artificially based, it's based off of information available across the you know the airways and the internet. Every published article, whatever everything's on there is available. Um certain levels of the government do not have access, or not the access, but they do not have the power because once you start going into learning modes of AI, um the power consumption just in order to do uh the updates and things like that, or to write the programs, we don't have enough power, especially you know, in within the government scope itself. It's gonna be 10 or 15, 20 years before very much speed. So I've had that up with only good authority. So uh as far as what you guys are doing and what everybody you know what needs to be done on a general basis as long as you're using already established uh that's all said and said and done, you know. You look at the big picture and then AI's uh it's gonna be probably the biggest thing that the human race has ever come across once it gets going.

Bethanie Spangenberg: 57:05

You know, it's kind of scary because I really do like I see what it does now. I use it for mainly my kids. I'll I'll create like uh birthday cards tailored to things that they like. Like I did a birthday invite with a Cappy Bear wearing a party hat for my youngest. That's what she wanted. And so, you know, I was able to have Chat GPT, you know, create that cute little image, and I printed it on a card at Walmart and you know had it tailored to her and said something that she loved. But um, you know, what does that do for our you know our our artists? What does that do for our you know digital artists? I mean, it's gonna replace so many things.

J Basser: 57:47

It's gonna replace a lot of things. I mean, you know, you sit here and it it's all it's all it's all over Facebook, it's over everywhere.

Guest: 57:53

Yeah.

J Basser: 57:54

You know, there's so much fraud and scams going on using AI, AI generated actors and things like that. You gotta be careful because they're doing all it's uh but I think our enforcement communities need to get their hands on this to get a handle on it because it's gonna get ugly. Okay for every good person that has it. Oh no, they're underneath the eight ball. Not behind it, they're under it. I think it's a magic eight ball. Shake it up.

Bethanie Spangenberg: 58:30

Denied.

J Basser: 58:34

But again, more good, really good content. We'll probably get a lot of feedback on this one. Um if you're using AI, guys, go ahead and keep on using it. I mean it works, but if you're a veteran and you're using AI, make sure that you kind of dumb it down. You don't want to be a high school educated veteran and sound like a PhD when you submit something to the VA, well, they're gonna know something's up.

Guest: 59:00

Yeah.

Bethanie Spangenberg: 59:01

And I do want to mention that even like even if you put in there, like, okay, so let's say you graduated from high school, if you put a 12th grade leaving reading level into Chat GPT, it it's I don't think it's accurate. I think you have to target like ninth, eighth, ninth grade reading level to really hit US high school level. Like I when I try to do it in different things, it get the words get bigger and bigger and bigger, and I'm like, uh-uh. So even if you're a veteran writing a statement and you're trying to get it down to your education, you you need to play with it a little bit. You need to understand your prompts.

J Basser: 59:41

Look at the veteran's age. Go back in history and for example, do a um um do a little math and say, okay, it's got to graduate high school, maybe you run this time. Put the time in there and do it that way. Because education has actually changed that much. Yeah.

Bethanie Spangenberg: 1:00:00

And you're not quitting in the eighth grade to go tend to the farms anymore, so they do.

J Basser: 1:00:06

I mean used to. They probably didn't know how to though, didn't they?

Bethanie Spangenberg: 1:00:11

They sure did.

J Basser: 1:00:12

Yeah, here too. Well it used to be sixteen they quit, but I guess they changed that here to eighteen. I know a lot of folks do that. I know a lot of them still there too and done nothing in their life, you know what I mean?

Bethanie Spangenberg: 1:00:32

Yeah.

J Basser: 1:00:34

Okay. Well, guys, it's uh eight o'clock. We want to thank Beth for coming on. Barry. I'm sorry you didn't get a lot of words at me, but I do appreciate you.

Beri: 1:00:46

Oh, I I appreciate this because I mean nothing and I think those last two slides, you gotta really uh discriminate what you ask that, and it's useful total, but not ready for prime time.

J Basser: 1:01:02

No, it's c it's gonna be complicated. It's gonna be complicated.

Beri: 1:01:06

So it's gonna change a lot of, you know, it's gonna be this AI is gonna be like the telephone, but the TV is gonna be a major thing. It changes society.

J Basser: 1:01:17

Well, I mean, they just now got the degree. The degree programs for AI have just been had just come out. I mean, this is something that uh, you know, a lot of college universities like UK or Ohio State are just starting. You know, some people already have the degrees in it, you know, but uh, you know, they had to go over and above and do extra stuff just to get the degree and certificates in AI.

Beri: 1:01:38

Well, and it changes so much.

J Basser: 1:01:41

And these kids are some of the smartest, these are some of the smartest people that I know in the world, but I'm telling you what, I mean they're geniuses doing this stuff. But with that, uh guys, thank you for coming on. And we'll have another party next week, Thursday, about eight uh about seven o'clock east Eastern Standard Time. And uh we'll have some other party and uh we'll uh we'll drink some water and have another good discussion on something VA related anyways. Hopefully it'll be back to work. So but good news is guys, since yesterday the VA has not denied one single claim. All right. Well, guys, I want to shut her down. You guys have a good evening.

Bethanie Spangenberg: 1:02:26

I am too.

J Basser: 1:02:27

All right.

Bethanie Spangenberg: 1:02:28

Bye.