self_made_human
amaratvaṃ prāpnuhi, athavā yatamāno mṛtyum āpnuhi
I'm a transhumanist doctor. In a better world, I wouldn't need to add that as a qualifier to plain old "doctor". It would be taken as granted for someone in the profession of saving lives.
At any rate, I intend to live forever or die trying. See you at Heat Death!
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A friend to everyone is a friend to no one.
User ID: 454
It's 2026, the US has Waymos in Phoenix, SF, LA and slightly more limited availability in Austin, Atlanta, Miami, Dallas, Houston...
That is a lot of of people (50 to 60 million people nominally served). And that is today.
It's one thing to say self-driving isn't going to happen when they're puttering around in a DARPA course and knocking over half the cones. A whole different kettle of fish today, when a good fraction of your country can step out and order one through Uber.
It's like claiming we can't land humans on the moon after we have manned spaceflight and rovers on the surface. While we have hundreds of billions of dollars (or pretty much all the positive growth in the US stock market) and thousands of the world's smartest people, some of them drawing literal billion dollar salaries working diligently to make it happen, as is the case with AI.
I would not bet against it. Maybe it's more academic for you, you've probably had a decently long and well-remunerated career. On the other hand, I face a very real threat of being deported after outliving my welcome and then coming home to a ship that is simultaneously on fire and sinking. Oh well, at least I can probably make it through my psych residency before things get that bad, the ladder is rapidly ascending beneath me every time I look down. We can argue about timelines, it might take 5 years. It might take 10. It won't take 20, I'm confident of that much, and I really put a lot of thought into this.
I wish I am wrong, and you are right. But if wishing were horses, I'd have made PETA very mad by making a living life raft to the States already.
self_made_human
amaratvaṃ prāpnuhi, athavā yatamāno mṛtyum āpnuhi
5hr ago
Huh. I would expect the exact opposite, but I've left search on since pretty much it was an option and haven't checked. Can't say it's been an issue in practice.
self_made_human
amaratvaṃ prāpnuhi, athavā yatamāno mṛtyum āpnuhi
6hr ago
Not really. My personalization settings tell it I'm a psychiatry resident and a transhumanist. I have some stylistic instructions, such as to never do calculations without tool-calls, but nothing that should make it act in an unusual manner. There is nothing in recent chat history that should change this, I do have memory enabled. It's on the default tone and personality settings too.
self_made_human
amaratvaṃ prāpnuhi, athavā yatamāno mṛtyum āpnuhi
6hr ago
I can't say that I've ever intentionally tried to get someone to do that experiment in front of me, but I have, on request, reviewed the advice given by various LLMs and haven't really seen any egregious errors in a longtime.
Poor information will degrade performance in anyone, including human physicians. Our usual approach is to assume honesty and then update towards the possibility that someone is lying or mistaken when further evidence comes in. Of course, it depends on what exactly someone says and how they present. If a clearly twitchy, disheveled guy shows up and claims to have never done alcohol or drugs, I would be rather suspicious. If you have herpetic lesions on your cock and claim you've never slept with anyone but your wife, I will not take your testimony entirely at face value.
I am obviously at an advantage asking ChatGPT questions, because I have at least a vague idea of the kind of information that is important to disclose even outside psychiatry, I know the kind of issues that would make a cardiologist or ophthalmologist sit up straight and lock in. Yet it will consistently ask me for clarification or for more information to narrow down the answer-space, and I have no reason to assume it wouldn't do this for a layperson. In fact, it might even be more thorough, because it might (correctly) assume that there's more room for error or misunderstanding in that scenario.
Right now, a Doctor-LLM cyborg is probably superior to either alone, at least in realistically messy scenarios. But even just the LLM will, at least with the exact same information and affordances, perform quite well. Most of the edge cases can be covered by the assistance of a mid-level or a junior doctor.
I can tell you that my bosses are too old to have learned to rely on AI as heavily as I do, so assuming they don't, I can match their performance while using it. Similarly, a smart med student might be able to match my performance if I was stripped of AI assistance while they got to use it. This gap is, as far as I can tell, becoming increasingly narrow with time.
self_made_human
amaratvaṃ prāpnuhi, athavā yatamāno mṛtyum āpnuhi
7hr ago
I am sorry to say this, but you are woefully underestimating the ability of AI.
I threw your hypothetical into ChatGPT, the paid version, and even before it finished thinking (it's doing a lot of thinking, and it all seems relevant) it immediately noted:
The big early split is whether he “can’t move it” because of pain/mechanical disruption, because the limb has lost perfusion or nerve function, or because the problem is actually central, such as spine or stroke. That distinction changes the whole pathway immediately.
Emphasis added.
In the full workup, it mentions:
“Is it too painful to move, or does it feel weak/dead/numb?
Seriously, try this for yourself. Get a paid subscription and try and find a clinical scenario where the evidence you have provided has a definitive answer, which the AI is unable to diagnose even after the same amount of effort a human clinician would devote.
Here's the full conversation, if you want to take a look:
https://chatgpt.com/share/69be7d62-ad60-800b-a335-bf527ee5168e
Someone needs to get clean data to give to the AI for outsourcing to work (for now).
AI can't do a lot of clinical work, because it lacks hands. But it can borrow someone else, say an NP or PA or just a nurse. And then it can do things that would otherwise take a human doctor.
I don't want to undermine our profession, but you have to understand that I value probity over professional solidarity, at least if challenged. When I do disclose how close we are to replacement, it's where it doesn't matter, I don't want to lose my job either, but I can rarely bring myself to mislead when I genuinely believe otherwise. I'm not accusing you of being misleading, by any means, but consider this example a data point that you're not considering how scarily good LLMs can be. We can take this to DMs if you prefer.
self_made_human
amaratvaṃ prāpnuhi, athavā yatamāno mṛtyum āpnuhi
8hr ago
I can't really argue against you, can I? It's been like 25 years and change since I was in the States, and would have been like 6 months if my visa didn't bounce. Perhaps American patients genuinely are more demanding and entitled, I can promise you I have seen more than my fair share of demanding and entitled patients in the UK (while the NHS is free, a doctor is not considered that different to a bus driver). I have seen demographic disasters/marvels that have simultaneously made me lose hope in humanity and rekindled my optimism for medical progress. Like seriously, how the fuck are some of these people still alive?
However, I am confident that there is a severe physician shortage when you leave urbanity. Several states, from memory including Texas and Mississippi, have quite recently massively relaxed the requirements for foreign doctors to come and practice as long as they go to underserved areas. They don't even need to have cleared the whole USMLE, let alone have completed a residency. You bet I follow that kind of stuff like my life depends on it, in a very meaningful sense, it does.
The fact that this happens at all, let alone in like 3 or 4 states (could be more) is suggestive of something. Of course the typical doctor wants to be in the Big City and will fight to go there. In India or the UK, where doctors are more abundant, the sheer competition will force some of them to take up less than ideal appointments, albeit not at major loss to earning potential.
I've worked in for-profit systems, in not-for-profit setups, and plenty in between. I would be rather surprised if the US was qualitatively different and not merely quantitatively so. I would happily take the hassle of insurance and the extra medicolegal liability if I could double or triple my income. I'll take the risk of getting shot or knifed. You guys have it very good, by global terms, at least when done with residency.
This is not really an argument that we should let every dude with half a frontal lobe practice medicine, or that doctors should be paid worse. But I think you heavily discount the risk posed by AI, both present and future. I have had senior doctors, family and otherwise, try and flummox recent versions of ChatGPT. They can't pimp it. It will out-pimp them. It's not going to do surgery for you today, or even next year, but many branches of our profession do not rely on procedural skills to make a living (I say, while crying that I have to do cannulations, catheterization or conduct ECGs because our nurses are useless).
self_made_human
amaratvaṃ prāpnuhi, athavā yatamāno mṛtyum āpnuhi
9hr ago
COMP006, if you care to check. My personal experience is documented in one of the posts in my profile, which links to Substack.
self_made_human
amaratvaṃ prāpnuhi, athavā yatamāno mṛtyum āpnuhi
9hr ago
I have a pedigree of medical practice that stretches back 4 generations, probably longer if we're willing to accept qualifications that aren't formal. I would volunteer, as long as they give me a VPN and part of Kim's food budget. That is probably the best job security I can aspire to with AI breathing down my neck.
self_made_human
amaratvaṃ prāpnuhi, athavā yatamāno mṛtyum āpnuhi
11hr ago
Nah, I am fond of you, even though I agree we have our disagreements. I can't even be mad at the AMA, they're not responsible for my med school being subpar and lazy.
I was just in a very bad place yesterday, largely to do with the fact that I work in the UK, where I ended up at precisely because I'm still not eligible for the USMLE. That makes the whole situation somewhere between academic and painful to engage with, what difference does it make what I think?
(This standard, applied fairly, would preclude most engagement on this platform. I will cop guilty to mild hypocrisy.)
For what it's worth, I think American doctors are world class, only closely rivaled by places like Singapore or other very rich First World countries. The UK is far more uneven, even if I regularly meet doctors who are both better than me and are at a level I would consider well past competent. India? All I can say is that there are plenty of doctors who are world-class, and I know many who would easily fit in in the US. And a lot of idiots who would find a way to kill a cadaver.
Where am I in the grand scheme of things? Idk. My confidence is shot in many ways, but I think the objective evidence, at least from exam results, is that I am above average with respect to my peers in India or the UK. I am not a senior physician, so I suppose that is good enough. I can handle most things in psychiatry, at least if I have time, Google and ChatGPT to help me. I absolutely can match my bosses if I have those tools at hand, which I do have in most scenarios that aren't academic assessments.
However, the medical training pipeline in the US is a bad joke. Mandatory pre-med? What the absolute flying fuck. I don't need my surgeon to have read Seneca in order to harvest my appendix. Even harder stuff like chemistry or microbiology is a waste of time, the syllabus covers everything we need to know. There is very good reason that the rest of the world doesn't do this.
Then there's the fact that the sheer explosion in mid-levels is because of the doctor shortage. I think that, in objective terms, there is nothing wrong with making tradeoffs between quality and availability. Otherwise we could have only the single most talented med student per year become a doctor, and have them train for 50 years so they can handle their own geriatric care right before the next candidate takes them off for MAID.
If you can't legally do that, since the quality of medical training is sacrosanct, then the system will try very hard to route around doctors. I have no reason to think the US has found the global optimum, and I think you guys are too strict. Obviously, I wouldn't endorse any measures that dilute physician wages to the point nobody bothers, but that is very unlikely to happen anyway.
If you float a bill that says: all global physicians who come from a very specific med school in India, have practiced in the UK, are at least six feet tall and right-handed, are welcome to enter the US? It would have my vote. But I am obviously biased.
Anyway, you needed up coaxing me into a more substantial reply than intended, so I hope both you and @DirtyWaterHotDog are happy. Still not everything I have to say, or could say, but it's something.
All fair points, but you have to consider that I'm pricing them in. I think that the regulatory and legal hurdles associated with replacing human doctors will buy us anywhere from 1-5 years once automation-induced unemployment has really taken off it. It's already started, but I'm talking >25% of the population being laid off and unable to find a job that pays nearly as well.
Even if it "merely" augment humans, the elasticity of demand in medicine is not literally infinite. A world where 90% of the doctors are laid off while 10% supervise mid-levels and oversee LLMs (both as troubleshooters and liability sponges) is almost as bad as 100% of us being laid off.
Once a large fraction of the population is unemployed and baying for relief, how long do you think governments can hold out and keep doctors on a pedestal? The AMA is not all-powerful either. It's even worse in the UK, the NHS is floundering, and Rishi Sunak wanted to keep us uppity doctors in check by replacing us with AI and midlevels years ago. They couldn't pull it off then, but it is an increasingly real possibility now. The very fact that doctors are rare and expensive in the US makes you excellent targets. You can't hold out forever. Once a single country or even a state bites the bullet, and succeeds (or doesn't crash and burn), there's going to be a domino effect.
Hell, even places where doctors are more abundant and cheaper aren't safe, mostly because AI is even cheaper and because they're poor countries without the luxury of swallowing as many systemic inefficiencies as the US system can tolerate. The relevant comparison is the delta in pay between the next lower rung of the ladder + a ChatGPT subscription vs a human doctor (or drastically fewer human doctors). That is a very large financial attractor, and barriers are not airtight or as robust as either of us would like.
Anyway, give it 5 more years and we'll see who's right. It's not like I think that being correct about this will change the trajectory of my life, I can only try and lessen the blow.
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