Doctors are anxious with being replaced only because medical education worked TOO well and the idea of ‘you know nothing’ is engrained that deep in most doctors.

I trained outside the US and I practice medicine in the US, so I feel I speak with some authority when I say the following: A dog can get better medical care in the US than a human being. APPs have made physicians indispensable. Minimum 30% of patients I see in the ER, clinic, or a specialist office are there thanks to APPs mismanaging a patient. Don’t get me started on inpatient consults.

Our hospital recently switched to APPs staffing admissions. Consults literally TRIPLED overnight. Doctors are paid an arm and a leg in the US and it’ll only go up. What happened to radiology salaries as APPs were allowed to slam on the imaging button is happening to more cognitive specialties slowly but surely as well.

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AI and extenders approach patients with a defined narrow context or task and a defined narrow skill set. There are hidden opportunity losses to automating these processes. Over the course of years, some of my most life changing interventions have come from observing patients as they chat with me or as they move into the room and exam chair or from exploring off hand comments or complaints made as asides deemed not relevant by the patient, not elicited by history takers but allowing me to put together the diagnosis or raise an issue which may have nothing to do with the intended exam or chief complaint. Sometimes these are life saving/changing. A Conversation from the observation of ETOH OB, an early diagnosis of Parkinson’s disease, a rash that signals systemic disease, blue lips on someone presenting for a routine exam denying pain or SOB who should really be in an ER for their subacute MI…

In fact I worry most about unidentified emergent conditions that are unrecognized by regular folks, but are seen by well trained physicians regardless of their specialty or patient context. Emmanuel’s comment attests to this.

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At the end of the day, I think AI will replace APPs for the reasons you describe. I also think, and this may be cynical, but someone needs to be reasonable and hospitals and software companies would prefer a doctor be “responsible”. Also, in some states only a physician can “practice medicine” not a company (corporate practice of medicine acts in many states exist). If a hospital or company can’t practice medicine, how can AI?

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Bryan you are spot on , nuance, ambiguity, abstraction and big picture thinking.I used to to say to the residents you have to be “ comfortable being uncomfortable “ clinical medicine is not black and white and despite all efforts of evidence based medicine the calculus of the human body is not a linear graph.

In 2000 Family Physicians were being told at academic conferences “ watch out you are going to be replaced by Nurse Practitioners “ for me it never bothered me I knew they couldn’t do what I did; complex chronic care in the clinic, complex unsnarling of multiple pathophysiological processes in the hospital.It is sad that without careful study healthcare systems have replaced MD s with NP s and yet there has been no noticeable improvement in health or saving of dollars.That is because roles have not been clearly delineated. The same mistake should not be made with AI who is on the nuance , ambiguity, abstraction, big picture? - it needs to be claimed by MD s .MD s who have clinical mastery of patient care learn these skills as colleagues below point out .

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Some of our IM graduates are being offered PCP jobs for 400,000$ with a 4 day work week in areas where NP-run care is rampant.

They were wrong; primary care APPs saved PCP compensation; the same way they saved radiology, nephrology, endocrinology and more. I talk to cognitive specialists often about this given I'm staring down choosing a fellowship; the majority credit APPs for their overwhelming schedules (and their increased bargaining power with admin).

Our nephrologist used to see consults in the hospitals 'for free' (only took the RVU); since she's private practice she saw that getting the patients to her practice was benefit enough. But now that APPs took over admits and her consults tripled, she put her foot down and the hospital quickly added three figures to her salary.

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My concern is that AI misses the real art of medicine, the expertise that an experienced physician has because much expertise in housed in our mental black box. I wrote abut this in my recent Substack article, "AI, Common Sense, and the Art of Medicine" <https://ruraldocalan.substack.com/p/ai-common-sense-and-the-art-of-medicine>.

Our culture has become so enamored of data there is no understanding that much of human thinking doesn't make it into words which can be counted. And that means the real expertise of physicians will not be recognized—or paid for.

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