I get that there isn’t an enormous abundance of ideal 3-day work week jobs in all areas. Your challenge was “show me where they are”. They exist in rather large numbers in many places. It may be inconvenient for you to move to one of those places, but that doesn’t mean it’s an empty set.
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Sure, smart guy. Show me where can I find the job advertisements for the 3-day work week jobs
Go to any job board and set a filter for “part time”.
Are these gaps related to medical knowledge, or admin/procedural knowledge?
What is the most complex task you have personally observed a PCP perform that you feel prevents you from doing the role?
Thankful for your thoughtful and substantive critique. I’ll address it point by point.
On diagnosing rare diseases: The case for PCPs receiving (anything close to) a decade of training is not generally justified on the basis of the ability to identify common issues like hypertension or cold/flu symptoms. The reason I bring this point up is that a crucial function of PCPs is to flag and escalate rare conditions to the appropriate specialists. The word “diagnose” here, I admit, is not quite right—what I mean is “flag”, “notice”, or “indicate”. This function IS an absolutely central role of a PCP, and the evidence does indicate they don’t perform this function well at all.
On physical exams: The reason I point out that physical examinations are ineffective is that “an LLM can’t touch you” is heavily undermined as an argument in view of this fact. Additionally, the fact that ulrasounds and other devices make this facet of their job redundant further attests to the claim that the vast extent of training PCPs receive is superfluous for the service they provide.
On competence deterioriation: Yes, it’s not specific to PCPs. I am considering writing a follow up post on specialists as well, because the story is not much better in their case and is in some ways worse. However, given the splintering of subspecialities, it is a more tangled picture.
On empathy/manner: Yes, specialists are likely worse. I gather you largely agree with the argument nonetheless.On whether CDSS/LLM support systems can be used effectively by a layperson: This is somewhat of an extrapolation, however I stand by it. There are unfortunately not many studies directly investigating this, and the combined LLM software products are largely hiding behind paywalls. However, based on a few facts:
- realtime audio->text transcription exists and is integrated into modern CDSS software
- LLMs can suggest clarifying questions (which improve diagnostic performance when doctors use them, implying they are questions that would not have otherwise been asked, or asked worse)
- LLMs outperform doctors in many (possibly all) hard outcomes, and even moreso in soft outcomes. This is undersold in the literature given many studies are using GPT 3.5-4.
it, is on balance, very likely that a layperson with a brief intro to using a LLM-supported CDSS can outperform a PCP. This may not be the case for people of below-average intelligence, perhaps, but this is a narrow and rapidly shrinking moat. The true moat is almost exclusivley regulatory.On limited usage of CDSS:
Doctors ignore/override CDSS recommendations 46-96% of the time:
GPs identify admin hassle as a major barrier to CDSS adoption.
CDSS increase performance without increasing consult times when actually tested
41% of GPs identify medico-legal liability concerns as a barrier to adoption
On multiple referrals, medications and specialists being a source of value for PCPS: PCPs do not hold this information in their heads; it is a matter of basic admin. I would also add that PCPs are largely quite bad at managing drug interactions. For instance, about 1 in 3 to 1 in 5 prescriptions in polymedicated patients are inappropriate.A person using the same admin process as a PCP plus a CDSS will get the same (and likely better) results. You can argue that PCPs provide value by offsetting this administrative burden, but a retreat to something this trivial is hardly a glowing endorsement of their utility.
I agree, however most people have difficulty “using” PCPs effectively for healthcare as well.
Peoples’ ability to articulate their symptoms doesn’t change much by stepping into a medical office.Whether you’re prompting an AI or talking to a human, ultimately it’s a matter of the words you say and how those words are interpreted.
In this case I think your intellectual humility is preventing you from diagnosing the emperor as naked.
Yes, the information is generalisable. Critical care doctors would be expected to outperform PCPs on a specialised function they perform regularly, and nonetheless have very low sensitivity.
Unless you think it’s plausible PCPs would outperform critical care doctors on abdominal auscultation for detecting haemmorhages, I see no reason why it is irrelevant to the case.
We have digital flowcharts. That’s essentially what a traditional CDSS is.
On the LLM skepticism, it’s possible they have rare hallucinations, but I don’t think it’s likely that spontaneous rambling about goblins is a meaningful concern. In my experience, you have to try pretty hard to get GPT or Claude to have mental breakdown. It’s not usually something that happens for mundane use.The bottom line is whether, all things considered, the results for patients are better.
You also need to weigh every “goblin moment” against the human equivalent—“couldn’t be bothered” “underslept”, “whoopsie daisy”, and so on.
The argument applies to the United States primarily, as well as the majority of high HDI countries, including Canada, Australia, parts of Asia, and most of Europe.
Your response strikes me as dismissing the argument on the basis of a lack of authority on my part. Which knowledge are you actually referring to?I am happy to discuss, clarify and elaborate on specific factual claims I’ve made that you find dubious or under-supported, but so far your critiques have been exclusively aesthetic: “confident assertions”, “salesy”.
The claim is not that merely because med students outscore physicians on foundational physiology tests that they would be better doctors.
It is an inductive extension of the following:
1. Measured performance across nearly all of the aspects of a PCP’s job is very low, with performance on more difficult and nonstandard tasks being the worst.
2. Performance does not increase with experience, but decreases
3. Deferring heavily to CDSS and LLMs reliably produces better diagnostic and presription outcomes than the baseline of a typical PCPThese facts, PLUS the fact that medical students, (as well as nurses) tend to match or outscore PCPs every time we compare them, suggest rather strongly that early medical students are close to, if not above, the performance threshold of PCPs already.
If you think this is unlikely, I would ask: which aspect of the job of a PCP do you think fresh MCAT passers would do worse in than the average PCP, given the above?
In particular, which patient outcomes do you believe would be worse?
It is opinionated, but I don’t think there are many parralels beyond that.
Do you have any factual disagreements?
There is no quantifiable form of “rude”. 11 second interruption times, (that by the way are not explained by irrelevant blathering. From Claude: “77% of patients (258/335) finished their initial statement within 2 minutes, and only 2% (7/335) spoke for more than 5 uninterrupted minutes. In all cases, physicians considered the information they were given to be relevant. So letting patients finish takes about two minutes for ~80% of cases, and the doctors themselves judged the information relevant. The interruptions aren’t saving meaningful time.”), plus an inverse correlation between self reported empathy scores and those of patients, plus enormous (often majority) percentages of patients reporting some form of neglect or dismissal in surveys, plus virtually ubiquitous and unidirectional anecdotes, is as strong of an empirical case for a profession being “rude” I think you are ever likely to get.
It is a free patient-facing nerfed version, I figured linking to a paywall wouldn’t be of interest.
That said, I’m curious to know if you’ve ever tried spoon feeding a PCP symptoms for a slightly atypical presentation of MCAS. If so, how did that go?
Fair pushback. Although I think you are being somewhat too dismissive.
PCPs are trained to diagnose (and certainly indicate/suspect) both rare and common diseases.
The distinction between uncommon and rare is subjective. There is not an official tier system that graduates from “common” to “uncommon” to “rare”, etc. I used the word “uncommon” as a synonym for rare—“uncommon” doesn’t typically appear in literature. I can appreciate this downplays it somewhat. However, the term “rare”, I would argue, exaggerates rarity for the more common members of that category. I don’t think that pointing out a word choice that commits a connotational but not a factual error is a valid basis to dismiss the whole thing.
Banter declares interest and leads to mutual laughs. When you laugh it’s a good excuse to touch/make contact. Contact becomes more and more common, and the “excuses” for making contact become less and less. Eventually once you’re both comfortable making contact and are close together, there’s some lull in the conversation, and you fill this lull by leaning in and kissing them. Once you’re kissing you’re able to escalate physical contact until you eventually have sex.
There’s a measurement issue on the beauty question as well. Height is trivial to quantify, but what is the unit of measurement of beauty?
There are definitely consistent biologically rooted norms of what is beautiful, but this is a very controversial and culturally loaded issue that would make any taxation scheme (or any other policy relying on some measured “beauty” trait) far more difficult to pull off.
Don’t forget: amethyst on the windowsill.
Possible, but seems unlikely. Unless there’s some verified record, the mere fact he may have taken a valid test is very weak evidence that his claimed scores are accurate and not exaggerated.
Just leaving this here on the off chance this comment counts and I can claim the bitcoin.
This comes across as total nonsense.
I disagree. From the 2018 Ouyang et al. paper, application of SPF 70 sunscreen dropped to just 26 when using 1mg/cm^2 application, whereas it maintained at 64 when 2mg/cm^2 was initially applied—so, using the widely recommended (2mg/cm^2) amount appears to massively affect the longevity of the protection.