Tuesday, November 7, 2017

Artificial intelligence will not make family physicians obsolete

Last week, I was speaking on the phone with Dr. Roland Grad, a family physician at McGill University and co-author of the new book "Look It Up! What Patients, Doctors, Nurses, and Pharmacists Need to Know about the Internet and Primary Health Care." We were discussing the (to us, preposterous) notion that there would be no future for primary care physicians because we will all be replaced by cognitive computing / artificial intelligence (AI) systems such as IBM's Watson. Roland told me that whenever someone asks him about this, he points out that Star Trek clearly shows that there will be human doctors well into the 24th century. Even the holographic Doctor on the U.S.S. Voyager is only pressed into service after the entire human medical staff is killed in an accident.

Many of the prospective medical students I interview have asked me about how AI will influence how I practice family medicine in the future. A recent Perspective on machine learning in the New England Journal of Medicine asserted that "the complexity of medicine now exceeds the capacity of the human mind." The authors argued that since doctors can no longer keep all relevant medical knowledge in their heads, and "every patient is now a 'big data' challenge," we will soon need to rely on massive computer-generated algorithms to avoid diagnostic and treatment paralysis.

It's no surprise that neither author of this piece is a family physician. Since I began my residency 16 years ago, and well before that, I knew that no matter how much I learned, it wouldn't be possible to keep everything I needed in my head. I never had to. In medical school I carried around a variety of pocket-sized print references, and in residency and clinical practice I had several generations of Palm Pilots and, eventually, smartphones that allowed me to look up what I didn't know or couldn't recall. The same goes for keeping up with the medical literature. Although I regularly read more journals than the average generalist (nine*), I know that there's no way that I can possibly read, much less critically appraise, every new primary care-relevant study. Drs. David Slawson and Allen Shaughnessy have argued that rather than pursue that hopeless (even for a super-subspecialist) task, clinicians should be taught information management skills, which consist of foraging (selecting tools that filter information for relevance and validity); hunting ("just in time" information tools for use at the point of care), and "combining the best patient-oriented evidence with patient-centered care."

And although Watson and its AI predecessors have made short work of the previously invincible Ken Jennings on Jeopardy! and vanquished world chess champions with ease, it is having a much harder time cracking medicine. Although IBM started selling Watson for Oncology as a "revolution in cancer care" to hospital systems worldwide in 2014 and has spent millions of dollars lobbying Congress to exempt its software from FDA regulation, a STAT investigation found that the system has fallen far short of its hype:

At its heart, Watson for Oncology uses the cloud-based supercomputer to digest massive amounts of data - from doctor's notes to medical studies to clinical guidelines. But its treatment recommendations are not based on its own insights from these data. Instead, they are based exclusively on training by human overseers, who laboriously feed Watson information about how patients with specific characteristics should be treated.

AI will no doubt play a supporting role in the future of health care, alongside smartphone physicals and precision medicine and many other promising innovations borrowed from other industries. But based on past experience, I'm not convinced that any of these innovations will be as revolutionary as advertised. In my own career, doctors have gone from using paper charts that were time-consuming to maintain and couldn't communicate with each other to electronic health records that are even more time-consuming to maintain and still can't communicate with each other. You get my point. Even if IBM or some other tech company eventually harnesses AI to improve primary care practice, here's what Roland and his colleagues have to say in Look It Up!:

Some might wonder whether this new automated world of information will create a medical world that is dominated by artificial intelligence, where doctors - if we even need them anymore - will just repeat what the machines say. On the contrary, as more information becomes readily available, doctors, nurses, pharmacists, and allied health professionals will become more important as the interpreters of that information in accordance with the specific clinical and social history, values, and preferences of the patient and her or his family. 

Right. I couldn't have said it better myself.

* - American Family Physician, Annals of Family Medicine, Annals of Internal Medicine, Health Affairs, JAMA, JAMA Internal Medicine, Journal of the American Board of Family Medicine, Journal of Family Practice, New England Journal of Medicine

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