Can we chat?

By Warren R. Heymann, MD, FAAD
March 29, 2023
Vol. 5, No. 13

Flying back from the annual AAD meeting in New Orleans, I reflected on the past few days with newly acquired knowledge, joy (how wonderful it was to see my mentors, mentees, colleagues, and friends), pain (sore feet from 15,000 daily steps to get to and from the sessions in new yet-to-be broken-in shoes), warmth (hearing attendees applaud at the mention of DermWorld Insights and Inquiries during a lecture) and distinct disquietude because ChatGPT entered virtually every conversation. ChatGPT (OpenAI, San Francisco), is an artificial intelligence (AI) chatbot that was released in November 2022. ChatGPT automatically creates text based on written prompts from users and is capable generating various forms of writing, including essays, poems, song lyrics, and academic manuscripts. (1) ChatGPT is here and our world is not the same. AAD 2023 was likely our last meeting that will not be all about the bot. ChatGPT is changing at breakneck speed, so that studies based on its use and influence are yet to be written. Much of the current literature on its use is speculative. For a more detailed view of AI in dermatology, please see the prior commentaries by Drs Lee and Motaparthi, respectively. (2, 3) I guarantee you that these words are mine.

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When ChatGPT became available, I had to try it. In an upcoming DWI&I devoted to depressed veins in frontal fibrosing alopecia (FFA), I asked ChatGPT to write an editorial on vascular changes in FFA after composing my commentary. Instantly, the words pranced across the computer screen. The essay offered a good summary of FFA, but there was no direct discussion of the striking veins. I was actually relieved — I did a better job than the software — for now. That exercise was performed with ChatGPT version 3.5. Now there is version 4.0 — I do not need to have my ego bruised by repeating the experiment. According to Metz, “GPT-4, which learns its skills by analyzing huge amounts of data culled from the internet, improves on what powered the original ChatGPT in several ways. It is more precise. It can, for example, ace the Uniform Bar Exam, instantly calculate someone’s tax liability and provide detailed descriptions of images.” (4) Ultimately, all of us will be outperformed by a newer version of the bots.

What are we supposed to do?

Prepare, discuss, modify, grow, and repeat as necessary. ChatGPT (or its congeners) will affect every aspect of our lives, and like every tool, has the potential to enhance, exhilarate, confound, and devastate. The first step is having faith in the product. I drive a Tesla, but I do not have complete trust in autopilot software to use it — reports of fatalities petrify me. How can I possibly comprehend the magic behind algorithms that review infinite data in nanoseconds? It is easy to become complacent — when GPS became available, I was distrustful. I continued to hone my navigational skills (go north 3 blocks, turn right at the Shell station, proceed 0.3 miles, and the WaWa will be on your left across from the nursery), but now I listen to that sweet robotic voice, and follow her lead. What a pity — I’m complicit in the progression of my cerebral disuse atrophy. According to Thorp, Editor of Science, “More worrisome are the effects of ChatGPT on writing scientific papers. In a recent study, abstracts created were submitted to academic reviewers, who only caught 63% of these fakes. That’s a lot of AI-generated text that could find its way into the literature soon.” He emphatically states that AI and ChatGPT is tantamount to plagiarism, and in his journals, authors must certify that ChatGPT (or equivalent AI) cannot be utilized in the manuscript. (5) Elsevier’s policy allows AI to improve readability but not for content — ChatGPT cannot be an author. (6)

Face it — all of us will use ChatGPT (or its AI equivalent) in some capacity. Bots aced the medical boards and bar exam — impressive — but is it enough for a medical student or an attorney to just ask a question and have an instant treatise? Of course not — they need the knowledge base to dissect information with relevance and accuracy. Teaching our students and residents proper techniques to assess the validity of results is critical, but how? Developing anti-ChatGPT software is intriguing, but I anticipate an escalating arms race of advanced bots and anti-bots ad infinitum.

For journals that permit the use of ChatGPT, how will editors decide what content or percentage of a submission would be permitted to be written by ChatGPT? What are the ethics of not using the software if it can actually result in better patient outcomes? What should the penalties be if guidelines are not abided to, yet the bot’s conclusions are valid? 

How will clinicians utilize this tool? An expedited, weighted, exhaustive literature review of defined clinical conundrums is obvious. Will seasoned dermatologists trust the recommendations for diagnosis and therapy? What if the results are poor? Do the software engineers bear any responsibility? (I’m sure the answer to that question is no — caveat emptor!) On a more sanguine note, could bots alleviate the tedium of practice — school notes, prior authorization, chart reviews, etc.?

June 13, 2013 was personally momentous, as our practice dove headlong into our electronic medical record (for the challenges of that time, please read my DermWorld editorial “EHR and the Senior Dermatologist”). A decade later, despite all my initial fears and trepidations, the capabilities and actions of our EMR systems are legion and perpetually updated. I cannot envision ever going back to paper. A decade from now, bots will be integral in our practices. Now is the time to ask legal, ethical, and moral questions. I will take the optimistic approach and say that dermatologists will scale new heights with this revolutionary software. I asked ChatGPT how it should be used in dermatology:

ChatGPT is an Artificial Intelligence tool that can be used to assist dermatologists in their practices by providing them with relevant information and guidance on various dermatological conditions. For example, ChatGPT can help dermatologists to identify skin lesions, recommend treatment options, and provide patient education.

However, it’s important to note that ChatGPT is not a replacement for a dermatologist’s expertise and should only be used as a tool to assist in diagnosis and treatment. Dermatology is a complex field that requires years of training and experience, so any decisions regarding patient care should always be made by a qualified dermatologist.

Overall, ChatGPT can be a helpful tool for dermatologists looking to enhance their practice, but it should always be used in conjunction with traditional diagnostic methods and clinical judgment.

I could not have said it better myself.

Point to Remember: Artificial intelligence and ChatGPT are on the cusp of transforming every aspect of our personal and professional lives. All dermatologists should familiarize themselves with this software’s concepts, applications, ethics, limits, and dilemmas and grapple with how this tool should be incorporated in practice. 

Our expert’s viewpoint

David M Ozog, MD, FAAD, FACMS
Chair, Department of Dermatology
C.S. Livingood Chair in Dermatology
Mohs and Dermatological Surgery
Henry Ford Health, Detroit, Michigan
Professor of Medicine, College of Human Medicine
Michigan State University

The commentary by Dr. Heymann on interactive artificial intelligence is beautifully and insightfully written. An AI race between every global technology company operating in this space has begun. Capabilities are exponentially increasing as the almost daily releases themselves allow rapid advances in other domains. 

As of March 22, 2023, typing on my laptop, abject disbelief at the existential power of these technologies unleashed November 30, 2022 has not reached most, similar to the beginning of COVID-19. Remember early 2020 when we were aware of a virus and a ship docked in California, we continued with busy days caring for patients. Within a two-year span AI will have a similar “pandemic level” profound and transformative effect on all societies.  

Unless the powers that be halt the continued release of these technologies…

If you are reading this two months from tonight (May 22) you will likely be an active user of some AI interface, which is being quickly embedded in most email and cloud-based computing services. By the end of 2023, most of what you read, some of what you see and hear can be created uniquely for you based on detailed questions, prompts, and desires. Want to see a video of a rhombic flap on any anatomical location? If you have a detailed description of the procedure, it will be created. This text to video technology currently exists and is exponentially improving. Your clinical encounter notes will be finished within seven seconds of the end of your patient encounter by AI listening to your patient discussion. This exists. It will be shown to the public for the first time in about a month and will transform practice efficiency over the next few years.

One of these “bots,” ChatGPT-4, is breathtaking in its ability to tackle challenging societal questions, have discussions on complex medical scenarios that rival our best physicians, tell me step by step how to troubleshoot almost every piece of software/hardware in my home, and if I had chosen to, could write a better commentary than this. Ironically, I couldn’t quite nail the grammar of that previous sentence. AI has the potential to level the information playing field for the most disadvantaged among us with the power of expert advice on a smartphone (a precious relic name for a powerful hand-held computer/camera/GPS device which is connected to the world via orbiting satellites). Once they are aware, patients will ask it questions and the results will rival an expert-level practicing physician on complex medical questions even with poorly constructed queries. Be prepared.

These changes will be transformative and will pressure our systems. Jobs will be reallocated. And once again we will experience personal stress during rapid change. What should we do? Simple. Go for a walk with a friend or spouse. Hold hands. Write a letter (the recipient will know it is genuine!). Continue to be kind and care for your patients and each other.

1. Zheng H, Zhan H. ChatGPT in Scientific Writing: A Cautionary Tale. Am J Med. 2023 Mar 9:S0002-9343(23)00159-6. doi: 10.1016/j.amjmed.2023.02.011. Epub ahead of print. PMID: 36906169.

2. Lee, J. Dermatology and Dermatopathology Awake: Now is the time to embrace the artificial intelligence revolution. Dermatology World Insights and Inquiries. June 23, 2021. https://www.aad.org/dw/dw-insights-and-inquiries/archive/2021/artificial-intelligence-revolution.

3. Motaparthi, K. Deep learning in dermatopathology. Dermatology World Insights and Inquiries. June 23, 2021.https://www.aad.org/dw/dw-insights-and-inquiries/archive/2021/deep-learning-in-dermatopathology.

4. Metz, C. Open AI plans to up the ante in tech’s AI race. New York Times, March 14, 2023. https://www.nytimes.com/2023/03/14/technology/openai-gpt4-chatgpt.html Accessed March 20, 203

5. Thorp HH. ChatGPT is fun, but not an author. Science. 2023 Jan 27;379(6630):313. doi: 10.1126/science.adg7879. Epub 2023 Jan 26. PMID: 36701446.

6. The Lancet Digital Health. ChatGPT: friend or foe? Lancet Digit Health. 2023 Mar;5(3):e102. doi: 10.1016/S2589-7500(23)00023-7. Epub 2023 Feb 6. PMID: 36754723.

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