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On the topic of hallucinations/confabulations from LLMs in medicine:
https://x.com/emollick/status/1899562684405670394
This should scare you. It certainly scares me. The paper in question has no end of big names in it. Sigh, what happened to loyalty to your professional brethren? I might praise LLMs, but I'm not conducting the studies that put us out of work.
I expect that without medical education, and only googling things, the average person might get by fine for the majority of complaints, but the moment it gets complex (as in the medical presentation isn't textbook), they have a rate of error that mostly justifies deferring to a medical professional.
I don't think this is true when LLMs are involved. When presented with the same data as a human clinician, they're good enough to be the kind of doctor who wouldn't lose their license. The primary obstacles, as I see them, lie in legality, collecting the data, and the fact that the system is not set up for a user that has no arms and legs.
I expect that when compared to a telemedicine setup, an LLM would do just as well, or too close to call.
I disagree that they can't handle vagary. They seem epistemically well calibrated, consider horses before zebras, and are perfectly capable of asking clarifying questions. If a user lies, human doctors are often shit out of luck. In a psych setting, I'd be forced to go off previous records and seek collateral histories.
Complex comorbidities? I haven't run into a scenario where an LLM gave me a grossly incorrect answer. It's been a while since I was an ICU doc, that was GPT-3 days, but I don't think they'd have bungled the management of any case that comes to mind.
Physical exams? Big issue, but if existing medical systems often use non-doctor AHPs to triage, then LLMs can often slot into the position of the senior clinician. I wouldn't trust the average psych consultant to find anything but the rather obvious physical abnormalities. They spend blissful decades avoiding PRs or palpating livers. In other specialities, such as for internists, that's certainly different.
I don't think an LLM could replace me out of the box. I think a system that included an LLM, with additional human support, could, and for significant cost-savings.
Where I currently work, we're more bed-constrained than anything, and that's true for a lot of in-patient psych work. My workload is 90% paperwork versus interacting with patients. My boss, probably 50%. He's actually doing more real work, at least in terms of care provided.
Current setup:
3-4 resident or intern doctors. 1 in-patient cons. 1 outpatient cons. 4 nurses a ward. 4-5 HCAs per ward. Two wards total, and about 16-20 patients.
?number of AHPs like mental health nurses and social workers triaging out in the community. 2 ward clerks. A secretary or two, and a bunch of people whose roles are still inscrutable to me.
Today, if you gave me the money and computers that weren't locked down, I could probably get rid of half the doctors, and one of the clerks. I could probably knock off a consultant, but at significant risk of degrading service to unacceptable levels.
We're rather underemployed as-is, and this is a sleepy district hospital, so I'm considering the case where it's not.
You would need at least one trainee or intern doctor who remembered clinical medicine. A trainee 2 years ahead of me would be effectively autonomous, and could replace a cons barring the legal authority the latter holds. If you need token human oversight for prescribing and authorizing detention, then keep a cons and have him see the truly difficult cases.
I don't think even the ridiculous amount of electronic paperwork we have would rack up more than $20 a day for LLM queries.
I estimate this would represent about £292,910 in savings from not needing to employ those people, without degrading service. I think I'm grossly over-estimating LLM query costs, asking one (how kind of it) suggests a more realistic $5 a day.
This is far from a hyperoptimized setup. A lot of the social workers spend a good fraction of their time doing paperwork and admin. Easy savings there, have the rest go out and glad-hand.
I re-iterate that this is something I'm quite sure could be done today. At a certain point, it would stop making sense to train new psychiatrists at all, and that day might be now (not a 100% confidence claim). In 2 years? 5?
Do keep in mind how terrible most medical research is, and that includes research into our replacements. This isn't from lack of effort but from the various systems, pressures, and ethics at play.
How do you simulate a real patient encounter when testing an LLM? Well maybe you write a vignette (okay that's artificial and not a good example. Maybe you sanitize the data inputs and have a physician translate into the LLM. Well shit, that's not good either.
Do you have the patient directly talk to the LLM and have someone else feed in lab results? Okay maybe getting closer but let's see evidence they are actually doing that.
All in the setting of people very motivated to show the the tool works well and therefore are biased in research publication (not to mention all the people who run similar experiments and find that it doesn't work but can't get published!).
You see this all the time in microdosing, weed, and psychedelic research. The quality is ass.
Also keep in mind that a good physician is a manager also - you are picking up the slack on everyone else's job, calling family, coordinating communication for a variety of people, and doing things like actually convincing the patient to follow recommendations.
I haven't seen any papers on an LLMs attempts to get someone to take their 'beetus medication vs a living breathing person.
Also Psych will be up there with the procedurealists in the last to be replaced.
Also also other white collar jobs will go first.
I expect this would work. You could have the AI be something like GPT-4o Advanced Voice for the audio communication. You could record video and feed it into the LLM. This is something you can do now with Gemini, I'm not sure about ChatGPT.
You could, alternatively, have a human (cheaper than the doctor) handle the fussy bits. Ask the questions the AI wants asked, while there's a continuous processing loop in the background.
No promises, but I could try recording a video of myself pretending to be a patient and see how it fares.
I mean, quite a few of the authors are doctors, and I presume they'd also have a stake in us being gainfully employed.
I'd take orders from an LLM, if I was being paid to. This doesn't represent the bulk of a doctor's work, so if you keep a fraction of them around.. People are already being conditioned to take what LLMs take seriously. They can be convinced to take them more seriously, especially if vouched for.
That specific topic? Me neither. But there are plenty of studies of the ability of LLMs to persuade humans, and the very short answer is that they're not bad.
Nah most of us Get Too Excited About Making A Difference.
Sidebar- I was watching "In Good Company" at lunch today (podcast in which the manager of Norway's sovereign wealth fund interview the most successful people in the world) and the CEO of Goldman asked Nicolai about the best features in leaders - empathy was one of them! And this was noted in the context of LLMs taking over other parts of the job for many things!
Empathy and leadership are core to being a physician (at least in the U.S.) and if two of the world's most successful people are going to emphasize the importance of that I'm going to imagine we will be well positioned lol.
That's why I'm quite candid about my opinions here, it doesn't make a difference what I tell people on a niche underwater basket weaving forum.
I looked up studies about LLMs and empathy, including in medical settings and vs human doctors, and there plenty. Can't vouch for them.
But I had a quasi-transformative experience that involved one today (in a significant role), and I might write that up and tag you.
Please do!
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