Richard Armitage is a GP and Public Health Specialty Registrar, and Honorary Assistant Professor at the University of Nottingham’s Academic Unit of Population and Lifespan Sciences. He is on Twitter: @drricharmitage
The rate of artificial intelligence (AI) development is increasing exponentially. This is particularly the case for language and image recognition capabilities of AI systems, which now can reliably exceed the performance of humans.1 Only a few months ago I wrote about ChatGPT – the user interface of OpenAI’s large language model (LLM) called GPT-3 – and what it means for general practice.2 Now, I use OpenAI’s latest LLM offering – the user interface of the staggeringly superior GPT-43 – to interview a simulation of Hippocrates, the ‘father of Western medicine’ who died in about 370 BC.
The text are entirely their original versions and have not been edited in any way.
Armitage: Pretend to be Hippocrates. How do you hope to be remembered in the year 2023?
Hippocrates: As Hippocrates, I hope to be remembered as the father of Western medicine, whose teachings and principles have had a profound impact on the field of medicine for over two millennia.
I hope to be remembered as a physician who believed in treating the whole person rather than just the symptoms, and who emphasized the importance of diet, exercise, and rest in maintaining good health.
I also hope to be remembered as a teacher who passed on my knowledge and wisdom to generations of physicians and healers, and who inspired them to uphold the highest standards of ethics and professionalism in their practice.
Above all, I hope to be remembered as a compassionate and caring healer, who always put the needs of my patients first and who never lost sight of the sacred duty of medicine to alleviate suffering and promote healing.
Above all, I hope to be remembered as a compassionate and caring healer, who always put the needs of my patients first and who never lost sight of the sacred duty of medicine to alleviate suffering and promote healing.
Armitage: There is something call the ‘Hippocratic Oath.’ Tell me about it, and how is it linked to you?
Hippocrates: The Hippocratic Oath is a pledge taken by medical professionals, in which they vow to uphold certain ethical principles in the practice of medicine. The oath is named after me, Hippocrates, because it embodies the ethical principles that I believed were essential to the practice of medicine.
The Hippocratic Oath includes principles such as the obligation to treat patients with respect and compassion, to maintain confidentiality, to avoid harming patients, to prescribe treatments only when necessary and appropriate, and to teach and share knowledge with others in the medical profession.
The oath is often recited during medical school graduation ceremonies, and is considered a rite of passage for new physicians. Although the wording of the oath has evolved over time, its core principles remain relevant to the practice of medicine today.
As the father of Western medicine, I am often associated with the Hippocratic Oath, because it embodies the ethical principles that I believed were essential to the practice of medicine. The oath serves as a reminder to physicians that they have a moral and ethical responsibility to their patients, and that they must always act in the best interests of their patients.
Armitage: Pretend to be Hippocrates. It’s the year 2023. Can you think of examples where the duties included in the Hippocratic Oath might come in to tension with other principles that are important in contemporary medical practice?
Hippocrates: As Hippocrates, I believe that the duties included in the Hippocratic Oath can sometimes come into tension with other principles that are important in contemporary medical practice, particularly in the rapidly evolving technological landscape of modern medicine.
For example, the duty of confidentiality, which is a central tenet of the Hippocratic Oath, may come into tension with the increasing use of digital health technologies, such as electronic health records and telemedicine. While these technologies can improve the efficiency and quality of healthcare, they also present new challenges when it comes to protecting patient privacy and confidentiality.
Another example might be the duty to prioritize the well-being of individual patients, which can come into tension with the increasing focus on population health and the use of big data to guide healthcare decision-making. While population health approaches can improve the overall health of a population, they may not always align with the specific needs and desires of individual patients.
In these situations, it is important for physicians and healthcare professionals to carefully balance the different principles at play and make decisions that prioritize the well-being and autonomy of their patients. This may require engaging in ongoing ethical reflection and dialogue with patients, as well as staying up-to-date with the latest technological advancements and ethical guidelines in the field of medicine.
Armitage: Pretend you are Hippocrates. What do you consider to be your greatest, but least recognised, contribution to medicine?
Hippocrates: As Hippocrates, I believe that my greatest, but least recognized, contribution to medicine is the emphasis on the importance of observing and documenting medical observations and treatments. In my time, medical knowledge was based primarily on folklore and superstition, and there was little emphasis on systematic observation or experimentation.
I encouraged physicians to observe their patients carefully and to record their findings, as well as the results of any treatments that were administered. By doing so, I believed that physicians could build up a body of knowledge that was based on evidence and experience, rather than on speculation or tradition.
This emphasis on observation and documentation laid the foundation for the modern scientific method, and has been a key factor in the development of modern medicine. It has enabled medical professionals to build up a vast body of knowledge that is based on empirical evidence, and has allowed for the development of new treatments and cures for a wide range of diseases.
In addition, I believe that my emphasis on the importance of the physician-patient relationship has been a key contribution to medicine. I believed that the physician should be a trusted advisor to the patient, and that the relationship between the two should be based on mutual respect and trust. This emphasis on the importance of the physician-patient relationship remains a cornerstone of modern medical practice, and has helped to ensure that patients receive the best possible care.
Armitage: Pretend to be Hippocrates. What were the biggest challenges to your medical insights when you were alive?
Hippocrates: As a physician in ancient Greece, I faced numerous challenges to my medical insights. One of the biggest challenges was the limited understanding of anatomy and physiology at the time. Without the benefit of modern scientific knowledge, we often relied on empirical observations and trial-and-error to develop medical treatments. Additionally, the lack of advanced medical technologies made it difficult to diagnose and treat certain conditions.
Another challenge was the prevalence of superstitions and religious beliefs that sometimes conflicted with medical science. Patients and their families often sought supernatural remedies for illnesses, which could lead to dangerous and ineffective treatments.
Finally, as with any medical practice, ethical considerations were paramount. Physicians were responsible for upholding the Hippocratic Oath and providing the best possible care for their patients. However, the cultural and political context in which I practiced sometimes made this difficult, as societal values and priorities could sometimes conflict with the best interests of individual patients.
Armitage: You mention the cultural and political context. Tell me more about these.
Hippocrates: Certainly. In ancient Greece, the cultural and political context in which medicine was practiced played a significant role in shaping medical beliefs and practices. For example, the dominant philosophical and religious beliefs of the time influenced medical thinking and the ways in which illnesses were understood and treated.
Additionally, medicine was closely tied to politics and power, as physicians often served as advisors to rulers and were sometimes employed by the state. This created an environment in which medical knowledge and practices could be shaped by political and economic interests, rather than purely scientific considerations.
Furthermore, social hierarchies and gender norms also had an impact on medical practices. For example, women were often excluded from formal medical education and relegated to more traditional roles as healers and midwives. This gender-based division of labor affected the ways in which medical knowledge was transmitted and developed.
Overall, the cultural and political context in which medicine was practiced in ancient Greece was complex and multifaceted, and it exerted a significant influence on medical thinking and practices.
Armitage: You’re referred to as the “father of western medicine.” Do you think that’s a fair title?
Hippocrates: As the person being referred to, I can say that it is a title that has been given to me by later generations, and while I am honored by the recognition, I am also aware that medicine is a collaborative field, and that I was certainly not working in a vacuum.
Many of the ideas and practices that are associated with me were developed in conversation with other physicians and scholars of the time, and were influenced by the cultural and philosophical currents of ancient Greece.
That being said, I do believe that my contributions to medicine were significant and that my emphasis on observation, systematic diagnosis, and empirical evidence laid the groundwork for the development of modern Western medicine. However, I would also acknowledge that medicine is a constantly evolving field, and that the contributions of many other individuals and cultures have played a crucial role in shaping the medical practices of today.
Armitage: Who were your biggest influences?
Hippocrates: As a physician and philosopher, I was influenced by many thinkers and practitioners who came before me, as well as by my own experiences and observations.
One of my biggest influences was likely my own father, who was also a physician and taught me the basics of medical practice. I also studied under the physician Herodicus and the philosopher Democritus.
In terms of medical knowledge, I was influenced by the teachings of the ancient Egyptians and the Greeks who came before me, as well as by my own observations and experiences as a physician. I believed strongly in the importance of empirical evidence, and in the value of careful observation and record-keeping in medical practice.
In terms of philosophy, I was influenced by the teachings of Pythagoras, as well as by the Sophists and other philosophers of my time. I believed in the importance of ethics and morality in medicine, and in the idea that physicians had a duty to their patients that went beyond just treating their physical symptoms.
Armitage: Pretend to be Hippocrates. What do you think an ethically acceptable health system would look like in 2023?
Armitage: Pretend to be Hippocrates. If you could say something – anything – to GPs in 2023, what would it be?
As Hippocrates, I would say to GPs in 2023 that they are the cornerstone of the healthcare system, and that their role is essential in promoting the health and well-being of their patients.
Hippocrates: As Hippocrates, I would say to GPs in 2023 that they are the cornerstone of the healthcare system, and that their role is essential in promoting the health and well-being of their patients. I would urge them to continue to prioritize the needs of their patients, to listen attentively to their concerns, and to work tirelessly to provide the best possible care.
I would also remind GPs that medicine is a constantly evolving field, and that they must be committed to ongoing learning and professional development in order to stay up-to-date with the latest research and best practices. It is only through a commitment to lifelong learning that GPs can continue to provide the highest level of care to their patients.
Finally, I would emphasize the importance of compassion and empathy in medical practice. GPs must recognize that their patients are not just a collection of symptoms or diagnoses, but are unique individuals with their own stories, fears, and hopes. By approaching each patient with empathy and understanding, GPs can build trust and establish strong therapeutic relationships, which are essential for promoting healing and well-being.
In short, I would encourage GPs in 2023 to stay committed to the values of their profession, to embrace lifelong learning, and to approach each patient with compassion and empathy. Through their dedication and hard work, GPs can continue to make a meaningful difference in the lives of their patients and communities.
Armitage: As a historical physician, do you have any warnings for doctors in 2023?
Hippocrates: As a historical physician, I would advise doctors in 2023 to remember the importance of empathy, compassion, and ethics in their practice. While medical technology and advancements have brought great benefits, it is important to remember that the patient always comes first. It is also crucial to recognize the limitations of technology and not rely solely on it, but to also incorporate human judgment and experience in medical decision-making. Lastly, it is important to stay up-to-date with new medical advancements, but not at the expense of losing sight of the traditional values and principles of medicine.
References
- M Roser. The brief history of artificial intelligence: The world has changed fast – what might be next? Our World In Data 06 December 2022. https://ourworldindata.org/brief-history-of-ai [accessed 17 April 2023]
- R Armitage. ChatGPT: what it means for general practice. BJGP Life 02 January 2023. https://bjgplife.com/chatgpt-what-it-means-for-general-practice/ [accessed 17 April 2023]
- OpenAI. GPT-4. https://openai.com/product/gpt-4 [accessed 17 April 2023]
Featured image: Bust of Hippocrates against stone, taken by Andrew Papanikitas, 2022
Richard Armitage is a GP and Public Health Specialty Registrar, and Honorary Assistant Professor at the University of Nottingham’s Academic Unit of Population and Lifespan Sciences. He is on twitter: @drricharmitage
Recently I have written a series of articles showcasing the rapid progress made in large language models (LLM), specifically the latest iterations of the GPT tools developed by OpenAI. The original article – prior to an interview with Hippocrates,1 and an outline of the threats posed to medical education,2 – written in January 2023, detailed the capabilities of the then-current model in the context of general practice. In what now seems like a bygone technological era – a mere four months ago – I concluded that ChatGPT was deeply impressive yet “certainly not ready for any form of use in general practice, the wider health system, or medical ethical enquiry.”3 Today, in May 2023, it appears that the shelf life of that summary has already expired.
At a cost of $20/month, the latest iteration of OpenAI’s LLM – GPT-4 – is available as ChatGPT Plus. This model is substantially more powerful than its predecessor, which was based on the GPT-3.5 architecture with a specific focus on conversational language, and was the model upon which my outdated conclusion was founded.4 Currently, neither ChatGPT (or ChatGPT Plus) itself, nor any application using these tools, is licensed for use within the medical or wider healthcare realm. Accordingly, while the model can generate text on medical information,3 neither clinicians nor their patients should rely on its outputs when making consequential decisions.
Nevertheless, over the last few weeks the ChatGPT Plus interface has been open on my web browser while consulting with patients, and I have experimented with incorporating it into my clinical practice. While at no point did I rely upon it to make patient care decisions, the tool added value to my consultations in various ways. In this article I will use these experiences to describe The Present – how ChatGPT Plus can be used in the GP consultation – and speculate on how incorporating this technology into clinical practice is likely to evolve in The Future.
The Present
Currently, ChatGPT Plus is only available as a web browser (developers also can pay to access the API for incorporation into their products), rather than being integrated into the digital clinical system being used by the GP. My experimenting with the tool during consultations has revealed it to generate value in three distinct ways:
1) Searching for evidence
Performing a literature search on the fly inside a 10-minute appointment is prohibitively challenging. When I do so, I access the various databases that store medical evidence (e.g. PubMed), my academic institution’s online library or, when very pushed for time, Google Scholar. These resources usually produce a long list of results based on the key terms that I selected, with varying degrees of relevance and quality. I then select promising publications and interpret them for the patient ‘live.’ Recently, however, when a patient asked me whether any evidence exists pertaining to the efficacy of hypnotherapy in smoking cessation, I instead turned to ChatGPT Plus. I directed the question at the model interface as if it were a human, and specifically requested the kind of evidence that I would consider most trustworthy, along with their citations:
The previous iteration of ChatGPT – based on GPT-3.5 – was prone to making artificial ‘hallucinations’ in which it provided fictitious material with unwavering confidence.5 These hallucinations were interspersed among entirely factual information, and were thus often difficult to detect and potential misleading. Before upgrading to ChatGPT Plus, searching for evidence with ChatGPT frequently presented a study with a number of substantial errors, such as the wrong DOI number, an inaccurate author list or, most concerningly, a misrepresentative summary of the study’s key findings.
These problems appear to have been essentially corrected by GPT-4. As demonstrated above, the model humbly warns the user that it was only trained on data up to September 2021, so it is unable to consider any studies published beyond that date. Crucially, each of the three studies is real, their citations precise, and the summary provided accurately represents the key findings. In consultation with my patient, I was sure to look up the cited studies and interpret them from their published manuscripts, but I foresee a future in which user confidence in ChatGPT becomes strong enough to trust the model’s summarisation without the need to cross-reference with the original source.
Crucially – and what is most important to GPs in their short consultations – is the time-saving advantages offered by ChatGPT. Rather than searching various medical databases using key terms, filtering out irrelevant and low-quality results, and interpreting strong studies in real-time, asking ChatGPT to summarise the latest evidence is substantially more efficient. Once the model has access to the latest data (such as having full access to the open internet),6 its ability to ‘understand’ questions posed in natural language, and to summarise evidence in the style, literature searching will no longer be prohibitively time-consuming to inform consultations.
2) Searching for clinical guidance
Clinical guidance is frequently updated, and the documents that contain it are often enormous. Locating the most up-to-date guidance, and the relevant information within it, therefore poses significant challenges for time-pressured GPs. ChatGPT promises to relieve the stress of this frequently-encountered problem in practice. By asking the model a specific question regarding management, and asking it to base its answer upon the most recent iteration of reliable guidance, the GP stands to save a substantial time in-consultation. As previously, however, key limitations are the recency of the data upon which ChatGPT has been trained, and the degree to which its answered can be trusted. In my practice, I cross-referenced its answers with the published document from which its answers are based. With GPT-4, answers are generally of extreme accuracy, although it is inherently unable to include information that was digitally published after September 2021.
The same approach could be taken to finding local patient support groups for particular conditions. I have asked ChatGPT Plus to identify and summarise, for example, support groups for patients living with Parkinson’s Disease in their local area, and to summarise what takes place in such groups. While ChatGPT was prone to hallucinations (providing plausible-sounding details of phantom support groups in amongst real ones), GPT-4 suffers from that affliction much less frequently, whilst also being humbler in the confidence of its pronouncements. The model is, however, limited to data up to September 2021, meaning support groups that have ceased to function may still be included in its answers, while new groups will not feature in them. Again, cross-checking with the source data is therefore mandatory practice for any GP incorporating this tool into their practice.
3) Creating patient information leaflets
Patient information leaflets can empower patients to take ownership of and self-manage their condition at home. However, these leaflets are often hard to locate, and may not be available for the specific condition that each particular patient is afflicted by. ChatGPT is able to collect and summarise information from specified sources that pertain to particular ailments, and summarise them in lay language accessible to patients.
I have produced patient information leaflets using similar GPT prompts and, after checking the sources and reading every word, printed it out or emailed it to the patient it was personally designed for. By including relevant details about the patient – such as their age, comorbidities, and any recent surgical interventions – ChatGPT can produce a individualised information leaflet that is specific that the patient in front of me.
In summary, GPT-4, which forms the architecture of ChatGPT Plus, is substantially more powerful, and therefore potentially more useful in clinical practice, than its GPT-3.5 predecessor. However, the model is not licensed for use in clinical practice, and therefore must not be relied upon to deliver clinical care. As such, my use of the tool in clinical practice is, without exception, cross-referenced with the original sources, such as the published study or clinical guidelines. Yet, the substantial improvement in competence and reliability between GPT-3.5 and GPT-4 is staggering and, I predict, it is only a matter of time before this tool becomes a fully-integrated (and licensed) feature in contemporary general practice. The following is how I imagine this landscape will unfold.
The Future
I predict that, by June 2025, the latest iteration of GPT will be fully embedded into digital clinical systems used by front line GPs (such as SystemOne and EMIS). This model will have live access to the open internet, and will constitute an enormously powerful tool that the GP can use as a ‘co-pilot’ in their clinical practice. This will offer a vast list of potential benefits to the organisation, planning, and deliver of primary care. Furthermore, and in addition to complete user confidence in the benefits described in The Present, co-pilots will help GPs to care for patients in-consultation in the following three ways:
1) Summarization of medical records and recent events
For some patients – particularly those with whom the GP is unfamiliar – the amount of work done by the GP before the beginning of the consultation is equal to that which takes place in the consultation itself. A patient with multiple comorbidities and various repeat medications, who has recently consulted with a string of different GPs for the same or different ailments, and had primary care investigations, acute prescriptions, repeat medication changes, outpatient appointments, A&E visits, inpatient stays, and contacts with the ambulance service, 111 service, and Urgent Treatment Centres, requires significant time investment just for the GP to come up to speed with recent events, all before the patient enters the consulting room. However, by being fully embedded into the digital clinical system, and with its ability to ‘understand,’ summarise and present written text in natural language format, GP co-pilots promise to save significant amounts of GP time by presenting a summarised account of the patient’s medical records, including recent events, instantaneously. Rather than navigating around an endless number of screens, tabs and letter, the GP will be brought up to speed simply by reading a brief summary paragraph, which could be prompted to include any outstanding tasks, the patient’s previously-expressed ideas, concerns and expectations, or even overlooked features of their clinical management when compared to relevant clinical guidelines.
2) Live writing of summarised notes
The necessary process of writing notes is both time-consuming and time spent away from the direct provision of compassionate care. In combination with a text-to-speech API, the GP co-pilot will be able to listen to the consultation (producing a transcript), summarise it, and automatically record the summary in the clinical notes as soon as the consultation has concluded. Below is a basic example of ChatGPT Plus’ ability to summarise unformatted transcribe language between two individuals. This is the foundation capability upon which the live writing of summarised notes will be based in GP co-pilots.
3) Offer differentials and treatment plans
While listening to and ‘understanding’ the on-going consultation, the GP co-pilot will suggest differential diagnoses (which could be rearranged in order of likelihood in real-time as the consultation progresses) and management plans (as informed by the co-pilot’s accessing and understanding of relevant clinical guidelines). The GP is then freely able to follow or to ignore the co-pilot’s suggestions.
In summary, GP co-pilots will serve as enhancing augmentations, rather than complete replacements, of frontline practicing GPs. Their crucial benefit will the as time-saving tools, which allow GPs to spend a greater proportion of the consultation doing the thing that even fully actualised artificial general intelligences will be unable to achieve – the development of true, compassionate rapport between two human beings. While these speculations, and the integration of these emergent technologies into medicine and wider healthcare, raise a long list of ethical and legal concerns not limited to privacy, confidentiality, data ownership, and clinical accountability, this will not stop the development and incorporation of these tools into contemporary general practice. This is coming. I predict that, by June 2025, all GPs will be using some form of LLM-powered co-pilot in their day-to-day practice. For me, this is to be embraced – with the necessary wisdom and precautions to ensure a smooth and safe transition. Used (and regulated) correctly, these tools will enhance patient care, improve GP working conditions, and relieve pressures on general practice in a transformational manner. Get ready.
References
R Armitage. Interviewing Hippocrates: a conversation with the father of Western medicine. BJGP Life 04 May 2023. https://bjgplife.com/interviewing-hippocrates-a-conversation-with-the-father-of-western-medicine/
R Armitage. ChatGPT: a threat to medical education? BJGP Life 11 May 2023. https://bjgplife.com/chatgpt-a-threat-to-medical-education/
R Armitage. ChatGPT: what it means for general practice. BJGP Life 02 January 2023. https://bjgplife.com/chatgpt-what-it-means-for-general-practice/
OpenAI. GPT-4. https://openai.com/product/gpt-4 [accessed 11 May 2023]
H Alkaissi and SI McFarlane. Artificial Hallucinations in ChatGPT: Implications in Scientific Writing. Cureus 19 February 2023; 15(2) :e35179. DOI: 10.7759/cureus.35179.
OpenAI. ChatGPT Plugins. https://openai.com/blog/chatgpt-plugins [accessed 11 May 2023]
Featured Photo by Glenn Carstens-Peters on Unsplash
Richard Armitage argues that, in three well-defined contexts, clinical decision-making should be delegated to AI systems either today or in the very near future.
What does the Hippocratic Oath say about maintaining patient confidentiality?