Digital Exhaust #208
Silicon shrinks and Bill Gates' prediction of the end of doctoring
Good morning. Thanks for opening. Here are a few things I found this week:
Big behavioral telehealth
Epic Cosmos (the research data arm of Epic) has released new data on telehealth utilization drawn from a whopping 296 million patient encounters through 2024.
A few takeaways:
Leading the pack is behavioral health which uses telehealth at 3x the rate of most specialties, with almost one-third of their visits delivered virtually.
Endocrinology and obstetrics are heavy users with utilization of around 10%.
Pulling up the rear are the cautious pediatricians (waving) where only 5% of visits are via telehealth.
These numbers are static between 2023-2024.
Some of this makes sense: In behavioral health virtual care is bridging the access gap in areas underserved by mental health professionals. There is also the obvious privacy and stigma issues that are resolved virtually. This provider gap is also closed in obstetrics by which makes it popular. Endocrinology is a numbers-driven specialty well-suited for remote care.
I narrate this in a YouTube Short, if you're interested.
The Silicon Shrink
On the podcast I sat down with Daniel Osterhauer about his new book, The Silicon Shrink. I loved this interview. We talk about the collision course between AI and psychiatry. Lots of interesting issues: Digital phenotyping, surveillance psychiatry, and how psychiatry AI will never really take off until we can figure out how to classify mental illness. Really interesting discussion around this evolving space. Please listen on Apple Podcasts, or wherever you get your 'casts — Do me a huge favor and rate Freerange MD if you like what I'm doing.
In related news, it seems chatbots can get stressed and fatigued. Not sure this is a concern of mine right now. But I’ll be worried when they unionize.
I was on the Fire Chief Podcast with Dr. Lee Sheinbart, a show for Chief Medical Officers, discussing the moral responsibility of doctors to create and share information in the public space.
The end of doctors. Again.
Bill Gates suggested this week that doctors will be replaced by AI. This is old news. Vinod Khosla, founder of Sun Microsystems, predicted a similar fate for doctors in 2012 (in fairness, he suggested computer algorithms would replace us, not AI).
I always say that pontificating on all the things AI will do is a parlor trick. But it takes real thinking to identify the things AI should never do.
And as I wrote in 2012, I prefer to define the physician’s future as marked by redefinition rather than displacement. Alot of what we do will be really different — The timeless things will remain.
We’re not dead yet.
When experienced doctors leave
Howard Luks is an orthopod and a good friend. He is one of the OGs of physician blogging and social media. He said this on X and it really resonated with me.
When experienced doctors leave, we don’t just lose hands—we lose capable minds. The kind of expertise that comes from decades of patient care is not easily replaced. Medicine relies on crystalline and fluid intelligence—the ability to see patterns, anticipate complications, and adjust when the standard answer isn’t correct.
New graduates, nurse practitioners (NPs), and physician assistants (PAs) may possess up-to-date medical knowledge (crystalline intelligence), but they often lack the fluid intelligence (wisdom) that comes from seeing thousands of complex cases over decades. This gap matters when guidelines don’t fit the patient in front of you.
The system will try to respond with more staffing, training, and coverage, but you can’t fast-track experience. If we don’t address why seasoned providers are leaving—burnout, moral injury, loss of autonomy—we won’t just face a staffing crisis. We’ll face a wisdom crisis, and the cost will be paid by patients and the system itself.
This gap between crystalline and fluid intel is super worrisome to me.
Howard also a killer website covering orthopedic stuff and longevity. Check it out.
And thanks for making it this far. I appreciate your support. In the event you are not a subscriber I would love to have you as part of the tribe.
I think you're my people. :) I love how you look at the industry as a whole and the trends within it. Thanks for your work.