What a digital health doctor learned from recertifying his boards – The Health Care Blog

By JEAN-LUC NEPTUNE

I recently received the good news that I passed the American Board of Internal Medicine (ABIM) recertification exam. As a reminder, the ABIM is a national physician rating organization that certifies physicians practicing internal medicine and its subspecialties (each other specialty has its own certifying body such as ABOG for OB/GYN and ABS for surgeons). Physicians practicing in most clinical settings must be board certified to be credentialed and eligible for work. Board certification can be earned 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 continuing the LKA approach. For my fellow ABIM-certified physicians who are wondering why I did the 10 years vs. LKA, I’m happy to have a side discussion, but a lot of it was a career timeline question.

It should be noted that board certification is different from the United States Medical Licensing Examination (USMLE) which is the first in a series of licensing hurdles that physicians 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-negotiated process (I am active in New York and inactive in Pennsylvania) and has its own set of requirements that one must meet in order to practice in any 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 a lot of standardized tests, and acquire a lot of certifications (which cost a lot of money, BTW) to be able to practice medicine at USofA.

What I learned while preparing for the ABIM recertification exam:

1.) There are SO MANY THINGS TO KNOW about being a doctor!

To prepare for the exam, I used the New England Journal of Medicine (NEJM) review course which included approximately 2,000 detailed case studies covering all subspecialty areas of internal medicine. Considering that each case involves mastering dozens of pieces of medical knowledge, the exam requires a doctor to memorize tens of thousands of distinct pieces of information for a single specialty (remember that medical vocabulary alone is made up of tens of thousands of words). Furthermore, individual facts mean nothing without a mastery of the underlying basic concepts, models, and frameworks of biology, biochemistry, human anatomy, physiology, pathophysiology, public health, etc. Then there’s everything you need to know for your specific specialty: medications, diagnostic frameworks, treatment guidelines, etc. It’s a lot. There’s a reason it takes almost a decade to become proficient as a doctor. So every time I hear a non-PhD say they’ve read articles on XYZ and “I think I know almost as much as my doctor!” ”, my answer is always “No, not at all. Not even a little bit. Stop it. »

2.) There are so many things we DON’T KNOW as doctors!

What particularly struck me during my review was how often I encountered a case or presentation where:

• We don’t know exactly 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 know how the treatment works.
• We don’t know which treatment is most effective, or
• We don’t know which diagnostic test is best.
• And so on, and so on…

It is estimated that there are over 50,000 (!!) active journals in the biomedical sciences publishing over 3 million (!!!!) articles per year. Despite all this generation of knowledge, there is still a lot 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 medical culture can tell you that doctors possess a deep sense of humility that comes from knowing that you actually know very little.

3.) One day soon, the computer doctor will SURELY be smarter than the human doctor.

The whole time I was preparing for the test, I kept telling myself that I wasn’t doing anything that a sufficiently advanced computer couldn’t accomplish.

If you abstract from what most doctors do (diagnose disease and prescribe treatment), it’s pretty clear at this point in the history of artificial intelligence development that a computer will be able to do MOST of what a doctor does very soon.

Establishing a diagnosis is conceptually quite simple: gathering information about a patient’s presentation and evaluating complex patterns involving a patient’s history, signs, symptoms, and various tests. Although human doctors are capable of recognizing hundreds and thousands of patterns, our human abilities are limited by our limited memory, prior experiences, and access to information. However, existing AI systems have access to virtually unlimited information and more powerful pattern recognition algorithms and will soon be able to identify disease types better than even the best doctor.

Prescribing a treatment is also quite simple: based on the characteristics of that patient, the disease, the nature/stage of the disease, the patient’s preferences, etc., recommend what the literature (clinical guidelines, studies in peer-reviewed journals, etc.) shows to be the most effective treatment and will produce the least harm. As humans, there are only so many newspaper articles we can read and only so much information we can store in our brains. AI systems can access the knowledge accumulated by all of humanity and will soon be able to review ALL literature in an instant to guide treatment decisions.

Newly published research already shows that AI systems can match or exceed the performance of human doctors. Many people will quibble and say that machines don’t really reason, which is true for now, but the technology to reason is probably not that far away. Given that these technologies are improving at an exponential rate, it is clear that an indisputably better machine will eclipse the cognitive performance of human doctors in a very short period of time – AT MAXIMUM 10 years. I am convinced that there will soon be a day when patients will ask their doctors “what does the AI ​​system recommend?” »

4.) What the computer can’t do yet is BE HUMAN (at least not yet).

In studies that show a computer works on par with a doctor, what is often overlooked is that the computer works from a well-summarized case presentation (like the ones I used to study for boards) with all the relevant data. What these studies forget is that one of the most important roles of the physician is to interact with another human being to access the information needed to make a diagnosis and recommend treatment. It is rare as doctors that we are given a good summary with all the relevant information. Often the other human is emotionally distraught, or under the influence of a substance, or lying, or unconscious. Much of what we are able to do as human doctors is tell a story using our human senses (sight, smell, touch, hearing – fortunately not taste) to inform our judgment. Much of medical training is learning about human psychology, human culture, and human history, which we then use to inform the science we have mastered.

Another important aspect of being a human doctor is our role as advisors, advocates, and managers of care for individual patients and for larger patient populations. Ultimately, patients need someone to help them understand a serious diagnosis or to help them make difficult choices about treatment options. The modern medical system has evolved to become more of a transactional model in which doctors and patients are often deprived of deeper human interactions, but new technologies offer the opportunity to perhaps reduce the administrative burden on doctors and patients, so that more time can be devoted to person-to-person therapeutic interactions.

One day we’ll have machines technologically advanced enough to fully mimic human beings (interestingly, the original Nexus-6 “replicators” from Blade Runner Tyrell Corporation exist in the fictional year 2019.) but for now, nothing does it better than humans.

5.) Technology can help us become better doctors right now.

What many people don’t know is that the day-to-day job of being a doctor pretty much sucks. For every hour of direct clinical care provided, the physician spends an average of 2 additional hours on administrative tasks. Most doctors aren’t committed to spending their careers entering data into horribly designed EMRs, waiting for insurance pre-authorization, or asking patients for the same information over and over again. I am thrilled that my role at Commure gives me the opportunity to contribute to technology that improves the lives of doctors and patients.

Ambient tracing is a transformative technology that helps physicians reduce the administrative burden of documenting care by up to 80%, reducing physician burnout and allowing them to rediscover the joy of caring. Co-Pilot technologies put all the medical research ever published at a doctor’s fingertips in a way that reminds me of how access to the Internet (and sources like UpToDate) changed the way we delivered care 25 years ago. Finally, agentic AI helps reduce the “secular” work of the doctor by automating and routinizing repetitive tasks that do not deserve human attention.

I know that the introduction of new technologies has many people fearing for the future of employment, which is a reasonable concern in these uncertain times. That said, there is so much care we are NOT providing because we simply don’t have the resources, and I think the story of the next few years will be about using technology to catch up to what we should have been doing in the first place. I encourage my medical brothers and sisters to resist fighting technology and instead work to make technology meet our needs. The development of the modern EMR has come at the expense of the physician in order to improve the lives of other stakeholders who are not at the bedside. We cannot allow this to happen this time.

(AI Certification: I certify that this essay was written WITHOUT the use of any artificial intelligence assistance, but with some modifications by my very human wife.)

JL Neptune is a New York-based internal medicine physician and executive medical director of Commure.