“Last month in JAMA, bioethicist Ezekiel Emanuel and colleagues argued that AI is already superior to physicians at five cognitive tasks, including eliciting the patient’s story, and that keeping doctors in the loop with AI actually degrades care. The piece flooded my LinkedIn feed: doctors horrified, AI evangelists applauding. The evidence they cite is impressive. But nearly all of the data rests on methods that sidestep real life: in most studies, the LLM was handed a curated case vignette and asked to spit out a diagnosis. The studies behind the history-taking claim barely had AI talk to a patient—two of three analyzed electronic medical records; the third had doctors typing like chatbots to actors. It’s no surprise the models do well; LLMs excel at generating answers from organized information.
[..] the most pernicious problem in US healthcare isn’t a lack of solutions; it is the absence of space for question-formation—the slow, unglamorous work of discovering what a patient is actually asking—before anyone writes a prescription. At the very moment primary care is on life support, receiving less than 5 percent of US health care spending, chatbots are poised to industrialize the transactional medical encounter that patients (and doctors) resent most.
[..] Even Google admits that actors cannot replicate the complexity and unpredictability of real patients. The machines win at answer generation; what hasn’t been shown is their ability to build what undergirds every answer: trust from a person who is sick, scared, and not yet sure what her problem is.
There are questions that emerge only between two people who have time and a reason to be honest with each other—the question beneath the question. Patients will disclose remarkable things to a machine. But discovery is not the same thing as disclosure. The art of medicine includes helping a patient articulate her true problems—medical, social, and emotional—in such a way that this information shapes our treatment plan. It requires time and patience and sometimes awkward silences. That is not something any chatbot has been shown to do.
[..] here is the assignment. Give AI the gruntwork that has hollowed out primary care: the documentation, the prior authorizations, the inbox triage that forces doctors to look at screens instead of the patient. Then pay for human conversations, not just the procedures and prescriptions that follow them. Otherwise, AI will simply shrink the fifteen-minute appointment to ten. Use LLMs for diagnoses—great—if they are so much better than us, but only after the conversation, after trust is built, after the patient has had time to surface her real problem. And teach clinicians—and patients—the skill no model yet replicates: knowing which question to ask, and which question to ask yourself first. Even JAMA’s authors call for urgent work on reimbursement and medical education. At least we agree on the path forward, even if we disagree on the destination.”