By JEAN LUC NEPTUNE
I recently got the good news that I passed the board recertification exam for the American Board of Internal Medicine (ABIM). As a bit of background, ABIM is a national physician evaluation organization that certifies physicians practicing internal medicine and its subspecialties (every other specialty has its own board certification body like ABOG for OB/GYNs and ABS for surgeons). Doctors practicing in most clinical environments need to be board-certified to be credentialed and eligible to work. Board certification can be accomplished by taking a test every 10 years or by participating in a continuing education process known as LKA (Longitudinal Knowledge Assessment). I decided to take the big 10-year test rather than pursue the LKA approach. For my fellow ABIM-certified docs out there who are wondering why I did the 10-year vs. the LKA, I’m happy to have a side discussion, but it was largely a career timing issue.
Of note, board certification is different from the USMLE (United States Medical Licensing Examination) which is the first in a series of licensing hurdles that doctors face in medical school and residency, involving 3 separate tests (USMLE Step 1, 2 and 3). After completing the USMLE steps, acquiring a medical license is a separate state-mediated process (I’m active in NY and inactive in PA) and has its own set of requirements that one needs to meet in order to practice in any one state. If you want to be able to prescribe controlled substances (opioids, benzos, stimulants, etc.), you will need a separate license from the DEA (the Drug Enforcement Administration, which is a federal entity). Simply put, you need to complete a lot of training, score highly on many standardized tests, and acquire a bunch of certifications (that cost a lot of money, BTW) to be able to practice medicine in the USofA.
What I learned in preparing for the ABIM recertification exam:
1.) There’s SO MUCH TO KNOW to be a doctor!
To prepare for the exam I used the New England Journal of Medicine (NEJM) review course which included roughly 2,000 detailed case studies that covered all the subspecialty areas of internal medicine. If you figure that each case involves mastery of dozens of pieces of medical knowledge, the exam requires a physician to remember tens of thousands of distinct pieces of information just for one specialty (remember that the medical vocabulary alone consists of tens of thousands of words). In addition, the individual facts mean nothing without a mastery of the basic underlying concepts, models, and frameworks of biology, biochemistry, human anatomy, physiology, pathophysiology, public health, etc. etc. Then there’s all the stuff you need to know for your specific speciality: medications, diagnostic frameworks, treatment guidelines, etc. It’s a lot. There’s a reason it takes the better part of a decade to gain any competency as a physician. So whenever I hear a non-doc saying that they’ve been reading up on XYZ and “I think I know almost as much as my doctor!”, my answer is always “No you don’t. Not at all. Not even a little bit. Stop it.”
2.) There is so much that we DON’T KNOW as doctors!
What was particularly striking to me as I did my review was how often I encountered a case or a presentation where:
- It’s unclear what causes a disease,
- The natural history of the disease is unclear,
- We don’t know how to treat the disease,
- We know how to treat the disease but we don’t how the treatment works,
- We don’t know what treatment is most effective, or
- We don’t know what diagnostic test is best.
- And on, and on, and on…
It’s estimated that there are more than 50,000 (!!) active journals in the field of biomedical sciences publishing more than 3 million (!!!!) articles per year. Despite all this knowledge generation there’s still so much we don’t know about the human body and how it works. I think some people find doctors arrogant, but anyone who really knows doctors and physician culture can tell you that doctors possess a deep sense of humility that comes out of knowing that you actually know very little.
3.) Someday soon the computer doctor will FOR SURE be smarter than the human doctor.
The whole time I was preparing for the test, I kept telling myself that there was nothing I was doing that a sufficiently advanced computer couldn’t accomplish.
If you abstract out what most doctors do (diagnose a disease and prescribe a treatment) it’s pretty clear at this point in the history of the development of artificial intelligence that a computer will be able to do MOST of what a doctor does very soon.
Making a diagnosis is pretty straightforward conceptually: gather information about a patient’s presentation and evaluate complex patterns involving a patient’s history, signs, symptoms, and various tests. While human doctors are able to recognize hundreds and thousands of patterns, there are human limits to our abilities that are driven by our finite memory, our prior experiences, and our access to information. Existing AI systems, however, have access to virtually unlimited information and more powerful pattern recognition algorithms and will soon be able to identify disease patterns better than even the best doctor.
Prescribing treatment is also pretty straightforward: based on the characteristics of this patient, the disease, the nature/stage of the disease, patient’s preferences, etc. recommend what the literature (clinical guidelines, peer-reviewed journal studies, etc.) shows to be the most effective treatment that will produce the least harm. As humans, there’s only so many journal articles we can read and only so much information we can store in our brains. AI systems can access the accumulated knowledge of all humankind and will soon be able to review ALL the literature in an instant to guide treatment decisions.
Recently published research already shows that AI systems can match or exceed the performance of human doctors. Many people will quibble and say that the machines aren’t really reasoning, which is true for the moment, but the technology to reason is likely not that far away. Given that these technologies are improving at an exponential rate it’s pretty clear that an unequivocally better machine will overshadow human physician cognitive performance in a very short period of time – AT MOST, 10 years. I am convinced that there will be a day soon when patients will ask their doctor “what is the AI system recommending?”
4.) What the computer can’t do yet is BE HUMAN (at least not yet).
In the studies that show a computer performing on par with a physician what is often missed is that the computer is working from a nicely summarized case presentation (like the ones I used to study for the boards) with all the relevant data. What these studies miss is that one of the most important roles of the doctor is interfacing with another human to access information necessary to come up with a diagnosis and recommend a treatment. It’s rare as doctors that we’re handed a nice summary with all the pertinent information. Often the other human is emotionally distraught, or under the influence of a substance, or lying, or unconscious. So much of what we’re able to do as human doctors is pull together a story using our human senses (sight, smell, touch, hearing – thankfully not taste) to inform our judgment. A huge part of medical training is learning about human psychology, human culture, and human history that we then use to inform the science that we’ve mastered.
Another important aspect of being a human doctor is our role as counselors, advocates, and stewards of care for individual patients and broader patient populations. At the end of the day patients need someone to help them make sense of a serious diagnosis, or support them in making hard choices about treatment options. The modern medical system has evolved to be more of a transactional model where physicians and patients are often stripped of deeper human interactions, but new technologies present the chance to perhaps lower the administrative burden on doctors and patients so more time can be spent in therapeutic person-to-person interactions.
Someday we’ll have machines technologically advanced enough to fully emulate human beings (It’s interesting to note that the original Blade Runner Tyrell Corporation Nexus-6 “replicants” exist in the fictional year 2019.) but for now nothing does human better than a human.
5.) Technology can help make us better doctors right now.
What a lot of people don’t know is that the day-to-day job of being a doctor kinda sucks. For every hour of direct clinical care provided the average doctor spends another 2 hours handling administrative tasks. Most doctors didn’t sign up to spend their working careers entering data into horribly-designed EMRs, waiting on hold for insurance prior authorization, or asking patients the same pieces of information over and over again. I’m excited that my role at Commure gives me the opportunity to contribute to technology that makes life better for doctors and patients.
Ambient scribing is a transformative technology that is helping doctors reduce the administrative burden of documenting care, by as much as 80%, which is reducing physician burnout and allowing doctors to recapture the joy of doctoring. Co-Pilot technologies are putting all the medical research ever published at a physician’s fingertips in a way that reminds me of how the access to the internet (and sources like UpToDate) changed how we delivered care 25 years ago. Finally, Agentic AI is helping reduce the “scut” work of being a doctor by automating and routinizing repetitive tasks that are not worthy of human attention.
I know that the introduction of new technology makes many people fear for the future of employment, which is a reasonable concern in these uncertain times. That said, there is so much care that we’re NOT delivering because we just don’t have the resources, and I think the story of the next many years will be using technology to catch up on what we should have been doing in the first place. I encourage my physician brothers and sisters to resist fighting the technology and to instead work to make the technology fit our needs. The development of the modern EMR happened at the expense of the physician to make life better for other stakeholders not at the bedside. We can’t allow that to happen this time around.
(AI attestation: I attest that this essay was written WITHOUT the use of any artificial intelligence aids whatsoever, but with some editing by my very human wife.)
JL Neptune is an internal medicine physician based in NYC who is the Executive Medical Director at Commure.
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