3/29/2017 A.I. Versus M.D.

A.I. Versus M.D.

The New Yorker (http://www.newyorker.com/magazine/2017/04/03/ai-versus-md) by
Siddhartha Mukherjee

OneeveninglastNovember,afty-four-year-oldwomanfromtheBronx
arrivedattheemergencyroomatColumbiaUniversitysmedicalcenterwitha
grindingheadache.Hervisionhadbecomeblurry,shetoldtheE.R.doctors,
andherlefthandfeltnumbandweak.Thedoctorsexaminedherandordered
aCTscanofherhead.

Afewmonthslater,onamorningthisJanuary,ateamoffourradiologists-in-
traininghuddledinfrontofacomputerinathird-oorroomofthehospital.
Theroomwaswindowlessanddark,asidefromthelightfromthescreen,
whichlookedasifithadbeenlteredthroughseawater.Theresidentslleda
cubicle,andAngelaLignelli-Dipple,thechiefofneuroradiologyatColumbia,
stoodbehindthemwithapencilandpad.ShewastrainingthemtoreadCT
scans.

Itseasytodiagnoseastrokeoncethebrainisdeadandgray,shesaid.The
trickistodiagnosethestrokebeforetoomanynervecellsbegintodie.
Strokesareusuallycausedbyblockagesorbleeds,andaneuroradiologisthas
aboutaforty-ve-minutewindowtomakeadiagnosis,sothatdoctorsmight
beabletointervenetodissolveagrowingclot,say.Imagineyouareinthe
E.R.,Lignelli-Dipplecontinued,raisingtheante.Everyminutethatpasses,
somepartofthebrainisdying.Timelostisbrainlost.

Sheglancedataclockonthewall,asthesecondstickedby.Sowheresthe
problem?sheasked.
https://www.instapaper.com/read/887212636 1/21
3/29/2017 A.I. Versus M.D.

Strokesaretypicallyasymmetrical.Thebloodsupplytothebrainbranchesleft
andrightandthenbreaksintorivuletsandtributariesoneachside.Aclotora
bleedusuallyaectsonlyoneofthesebranches,leadingtoaone-sideddecit
inapartofthebrain.Asthenervecellslosetheirbloodsupplyanddie,the
tissueswellssubtly.Onascan,thecrispbordersbetweentheanatomical
structurescanturnhazy.Eventually,thetissueshrinks,trailingaparched
shadow.Butthatshadowusuallyappearsonthescanseveralhours,oreven
days,afterthestroke,whenthewindowofinterventionhaslongclosed.
Beforethat,Lignelli-Dippletoldme,theresjustahintofsomethingona
scanthepremonitionofastroke.

TheimagesontheBronxwomansscancutthroughtheskullfromitsbaseto
theapexinhorizontalplanes,likeamelonslicedfrombottomtotop.The
residentsracedthroughthelayersofimages,asifthumbingthrougha
ipbook,callingoutthenamesoftheanatomicalstructures:cerebellum,
hippocampus,insularcortex,striatum,corpuscallosum,ventricles.Thenone
oftheresidents,amaninhislatetwenties,stoppedatapictureandmotioned
withthetipofapencilatanareaontherightedgeofthebrain.Theres
somethingpatchyhere,hesaid.Theborderslookhazy.Tome,thewhole
imagelookedpatchyandhazyablurofpixelsbuthehadobviouslyseen
somethingunusual.

Hazy?Lignelli-Dippleprodded.Canyoudescribeitalittlemore?

Theresidentfumbledforwords.Hepaused,asifgoingthroughtheanatomical
structuresinhismind,weighingthepossibilities.Itsjustnotuniform.He
shrugged.Idontknow.Justlooksfunny.

Lignelli-DipplepulledupasecondCTscan,takentwentyhourslater.Thearea
pinpointedbytheresident,aboutthediameterofagrape,wasdulland
swollen.Aseriesoffurtherscans,takendaysapart,toldtherestofthestory.A
https://www.instapaper.com/read/887212636 2/21
3/29/2017 A.I. Versus M.D.

distinctwedge-shapedeldofgrayappeared.Soonafterthewomangottothe
E.R.,neurologistshadtriedtoopenthecloggedarterywithclot-bustingdrugs,
butshehadarrivedtoolate.Afewhoursaftertheinitialscan,shelost
consciousness,andwastakentotheI.C.U.Twomonthslater,thewomanwas
stillinawardupstairs.Theleftsideofherbodyfromtheupperarmstothe
legwasparalyzed.

IwalkedwithLignelli-Dippletoheroce.Iwastheretolearnaboutlearning:
Howdodoctorslearntodiagnose?Andcouldmachineslearntodoit,too?

Myowninductionintodiagnosisbeganinthefallof1997,inBoston,asI
startedmyclinicalrotations.Toprepare,Ireadatextbook,aclassicinmedical
education,thatdividedtheactofdiagnosisintofourtidyphases.First,the
doctorusesapatientshistoryandaphysicalexamtocollectfactsabouther
complaintorcondition.Next,thisinformationiscollatedtogeneratea
comprehensivelistofpotentialcauses.Thenquestionsandpreliminarytests
helpeliminateonehypothesisandstrengthenanotherso-calleddierential
diagnosis.Weightisgiventohowcommonadiseasemightbe,andtoa
patientspriorhistory,risks,exposures.(Whenyouhearhoo eats,the
sayinggoes,thinkhorses,notzebras.)Thelistnarrows;thedoctorrenes
herassessment.Inthenalphase,denitivelabtests,X-rays,orCTscansare
deployedtoconrmthehypothesisandsealthediagnosis.Variationsofthis
stepwiseprocesswerefaithfullyreproducedinmedicaltextbooksfordecades,
andtheimageofthediagnosticianwhoplodsmethodicallyfromsymptomto
causehadbeenimprintedongenerationsofmedicalstudents.

Buttherealartofdiagnosis,Isoonlearned,wasntsostraightforward.My
preceptorinmedicalschoolwasanelegantNewEnglanderwithpolished
loafersandastarchedaccent.Hepridedhimselfonbeinganexpert
diagnostician.Hewouldaskapatienttodemonstratethesymptomacough,
sayandthenleanbackinhischair,lettingadjectivesrolloverhistongue.
https://www.instapaper.com/read/887212636 3/21
3/29/2017 A.I. Versus M.D.

Raspyandtinny,hemightsay,orbase,withanejaculatedthrum,asifhe
weredescribingavintagebottleofBordeaux.Tome,allthecoughssounded
exactlythesame,butIdplayalongRaspy,yeslikeananxiousimpostorat
awinetasting.

Thetaxonomistofcoughswouldimmediatelynarrowdownthediagnostic
possibilities.Itsoundslikeapneumonia,hemightsay,orthewetralesof
congestiveheartfailure.Hewouldthenletlooseavolleyofquestions.Had
thepatientexperiencedrecentweightgain?Wasthereahistoryofasbestos
exposure?Hedaskthepatienttocoughagainandhedleandown,listening
intentlywithhisstethoscope.Dependingontheanswers,hemightgenerate
anotherseriesofpossibilities,asifstrengtheningandweakeningsynapses.
Then,withthelanofaroadsidemagician,hedproclaimhisdiagnosis
Heartfailure!andorderteststoprovethatitwascorrect.Itusuallywas.

Afewyearsago,researchersinBrazilstudiedthebrainsofexpertradiologists
inordertounderstandhowtheyreachedtheirdiagnoses.Weretheseseasoned
diagnosticiansapplyingamentalrulebooktotheimages,ordidtheyapply
patternrecognitionornon-analyticalreasoning?

Twenty-vesuchradiologistswereaskedtoevaluateX-raysofthelungwhile
insideMRImachinesthatcouldtracktheactivitiesoftheirbrains.(Theresa
marvellousseriesofrecursionshere:todiagnosediagnosis,theimagershadto
beimaged.)X-rayswereashedbeforethem.Somecontainedasingle
pathologicallesionthatmightbecommonlyencounteredperhapsapalm-
shapedshadowofapneumonia,orthedull,opaquewallofuidthathad
accumulatedbehindtheliningofthelung.Embeddedinasecondgroupof
diagnosticimageswerelinedrawingsofanimals;withinathirdgroup,the
outlinesoflettersofthealphabet.Theradiologistswereshownthethreetypes
ofimagesinrandomorder,andthenaskedtocalloutthenameofthelesion,
theanimal,ortheletterasquicklyaspossiblewhiletheMRImachinetraced
https://www.instapaper.com/read/887212636 4/21
3/29/2017 A.I. Versus M.D.

theactivityoftheirbrains.Ittooktheradiologistsanaverageof1.33seconds
tocomeupwithadiagnosis.Inallthreecases,thesameareasofthebrainlit
up:awidedeltaofneuronsneartheleftear,andamoth-shapedbandabove
theposteriorbaseoftheskull.

Ourresultssupportthehypothesisthataprocesssimilartonamingthingsin
everydaylifeoccurswhenaphysicianpromptlyrecognizesacharacteristicand
previouslyknownlesion,theresearchersconcluded.Identifyingalesionwas
aprocesssimilartonamingtheanimal.Whenyourecognizearhinoceros,
yourenotconsideringandeliminatingalternativecandidates.Norareyou
mentallyfusingaunicorn,anarmadillo,andasmallelephant.Yourecognizea
rhinocerosinitstotalityasapattern.Thesamewastrueforradiologists.
Theywerentcogitating,recollecting,dierentiating;theywereseeinga
commonplaceobject.Formypreceptor,similarly,thosewetraleswereas
recognizableasafamiliarjingle.

In1945,theBritishphilosopherGilbertRylegaveaninuentiallectureabout
twokindsofknowledge.Achildknowsthatabicyclehastwowheels,thatits
tiresarelledwithair,andthatyouridethecontraptionbypushingitspedals
forwardincircles.Ryletermedthiskindofknowledgethefactual,
propositionalkindknowingthat.Buttolearntorideabicycleinvolves
anotherrealmoflearning.Achildlearnshowtoridebyfallingo,by
balancingherselfontwowheels,bygoingoverpotholes.Ryletermedthiskind
ofknowledgeimplicit,experiential,skill-basedknowinghow.

Thetwokindsofknowledgewouldseemtobeinterdependent:youmightuse
factualknowledgetodeepenyourexperientialknowledge,andviceversa.But
Rylewarnedagainstthetemptationtothinkthatknowinghowcouldbe
reducedtoknowingthataplaybookofrulescouldntteachachildtoridea
bike.Ourrules,heasserted,makesenseonlybecauseweknowhowtouse
them:Rules,likebirds,mustlivebeforetheycanbestued.Oneafternoon,
https://www.instapaper.com/read/887212636 5/21
3/29/2017 A.I. Versus M.D.

Iwatchedmyseven-year-olddaughternegotiateasmallhillonherbike.The
rsttimeshetried,shestalledatthesteepestpartoftheslopeandfello.The
nexttime,Isawherleanforward,imperceptiblyatrst,andthenmorevisibly,
andadjustherweightbackontheseatastheslopedecreased.ButIhadnt
taughtherrulestorideabikeupthathill.Whenherdaughterlearnsto
negotiatethesamehill,Iimagine,shewontteachhertherules,either.We
passonafewpreceptsabouttheuniversebutleavethebraintogureoutthe
rest.

SometimeafterLignelli-Dipplessessionwiththeradiologytrainees,Ispoke
toSteenHaider,theyoungmanwhohadpickeduptheearlystrokeontheCT
scan.Howhadhefoundthatculpritlesion?Wasitknowingthator
knowinghow?Hebeganbytellingmeaboutlearnedrules.Heknewthat
strokesareoftenone-sided;thattheyresultinthesubtlegrayingoftissue;
thatthetissueoftenswellsslightly,causingalossofanatomicalborders.
Therearespotsinthebrainwherethebloodsupplyisparticularly
vulnerable,hesaid.Toidentifythelesion,hedhavetosearchforthesesigns
ononesidewhichwerenotpresentontheother.

Iremindedhimthattherewereplentyofasymmetriesintheimagethathehad
ignored.ThisCTscan,likemost,hadothergraysquigglesontheleftthat
werentontherightartifactsofmovement,orchance,orunderlyingchanges
inthewomansbrainthatprecededthestroke.Howhadhenarrowedhisfocus
tothatonearea?Hepausedasthethoughtpedalledforwardandgathered
speedinhismind.Idontknowitwaspartlysubconscious,hesaid,nally.

Thatswhathappensaclickingtogetherasyougrowandlearnasa
radiologist,Lignelli-Dippletoldme.Thequestionwaswhetheramachine
couldgrowandlearninthesamemanner.

https://www.instapaper.com/read/887212636 6/21
3/29/2017 A.I. Versus M.D.

InJanuary,2015,thecomputerscientistSebastianThrunbecamefascinated
byaconundruminmedicaldiagnostics.Thrun,whogrewupinGermany,is
lean,withashavedheadandanairofcomicexuberance;helookslikesome
fantasticalfusionofMichelFoucaultandMr.Bean.Formerlyaprofessorat
Stanford,wherehedirectedtheArticialIntelligenceLab,Thrunhadgoneo
tostartGoogleX,directingworkonself-learningrobotsanddriverlesscars.
Buthefoundhimselfdrawntolearningdevicesinmedicine.Hismotherhad
diedofbreastcancerwhenshewasforty-nineyearsoldThrunsagenow.
Mostpatientswithcancerhavenosymptomsatrst,Thruntoldme.My
motherdidnt.Bythetimeshewenttoherdoctor,hercancerhadalready
metastasized.Ibecameobsessedwiththeideaofdetectingcancerinits
earlieststageatatimewhenyoucouldstillcutitoutwithaknife.AndIkept
thinking,Couldamachine-learningalgorithmhelp?

Earlyeortstoautomatediagnosistendedtohewcloselytothetextbook
realmofexplicitknowledge.Taketheelectrocardiogram,whichrendersthe
heartselectricalactivityaslinesonapageorascreen.Forthepasttwenty
years,computerinterpretationhasoftenbeenafeatureofthesesystems.The
programsthatdotheworktendtobefairlystraightforward.Characteristic
waveformsareassociatedwithvariousconditionsatrialbrillation,orthe
blockageofabloodvesselandrulestorecognizethesewaveformsarefed
intotheappliance.Whenthemachinerecognizesthewaveforms,itagsa
heartbeatasatrialbrillation.

Inmammography,too,computer-aideddetectionisbecoming
commonplace.Pattern-recognitionsoftwarehighlightssuspiciousareas,and
radiologistsreviewtheresults.Buthereagaintherecognitionsoftware
typicallyusesarule-basedsystemtoidentifyasuspiciouslesion.Such
programshavenobuilt-inmechanismtolearn:amachinethathasseenthree
thousandX-raysisnowiserthanonethathasseenjustfour.Theselimitations

https://www.instapaper.com/read/887212636 7/21
3/29/2017 A.I. Versus M.D.

becamestarklyevidentina2007studythatcomparedtheaccuracyof
mammographybeforeandaftertheimplementationofcomputer-aided
diagnosticdevices.Onemighthaveexpectedtheaccuracyofdiagnosistohave
increaseddramaticallyafterthedeviceshadbeenimplemented.Asit
happens,thedeviceshadacomplicatedeect.Therateofbiopsiesshotupin
thecomputer-assistedgroup.Yetthedetectionofsmall,invasivebreast
cancersthekindthatoncologistsaremostkeentodetectdecreased.(Even
laterstudieshaveshownproblemswithfalsepositives.)

Thrunwasconvincedthathecouldoutdotheserst-generationdiagnostic
devicesbymovingawayfromrule-basedalgorithmstolearning-basedones
fromrenderingadiagnosisbyknowingthattodoingsobyknowinghow.
Increasingly,learningalgorithmsofthekindthatThrunworkswithinvolvea
computingstrategyknownasaneuralnetwork,becauseitsinspiredbya
modelofhowthebrainfunctions.Inthebrain,neuralsynapsesare
strengthenedandweakenedthroughrepeatedactivation;thesedigitalsystems
aimtoachievesomethingsimilarthroughmathematicalmeans,adjustingthe
weightsoftheconnectionstomovetowardthedesiredoutput.Themore
powerfuloneshavesomethingakintolayersofneurons,eachprocessingthe
inputdataandsendingtheresultsuptothenextlayer.Hence,deep
learning.

Thrunbeganwithskincancer;inparticular,keratinocytecarcinoma(themost
commonclassofcancerintheU.S.)andmelanoma(themostdangerouskind
ofskincancer).Couldamachinebetaughttodistinguishskincancerfroma
benignskinconditionacne,arash,oramolebyscanningaphotograph?If
adermatologistcandoit,thenamachineshouldbeabletodoitaswell,
Thrunreasoned.Perhapsamachinecoulddoitevenbetter.

https://www.instapaper.com/read/887212636 8/21
3/29/2017 A.I. Versus M.D.

Traditionally,dermatologicalteachingaboutmelanomabeginswitharule-
basedsystemthat,asmedicalstudentslearn,comeswithaconvenient
mnemonic:ABCD.Melanomasareoftenasymmetrical(A),theirborders
(B)areuneven,theircolor(C)canbepatchyandvariegated,andtheir
diameter(D)isusuallygreaterthansixmillimetres.But,whenThrunlooked
throughspecimensofmelanomasinmedicaltextbooksandontheWeb,he
foundexampleswherenoneoftheserulesapplied.

Thrun,whohadmaintainedanadjunctpositionatStanford,enlistedtwo
studentsheworkedwiththere,AndreEstevaandBrettKuprel.Theirrsttask
wastocreateaso-calledteachingset:avasttroveofimagesthatwouldbe
usedtoteachthemachinetorecognizeamalignancy.Searchingonline,Esteva
andKuprelfoundeighteenrepositoriesofskin-lesionimagesthathadbeen
classiedbydermatologists.Thisroguesgallerycontainednearlyahundred
andthirtythousandimagesofacne,rashes,insectbites,allergicreactions,
andcancersthatdermatologistshadcategorizedintonearlytwothousand
diseases.Notably,therewasasetoftwothousandlesionsthathadalsobeen
biopsiedandexaminedbypathologists,andtherebydiagnosedwithnear-
certainty.

EstevaandKuprelbegantotrainthesystem.Theydidntprogramitwithrules;
theydidntteachitaboutABCD.Instead,theyfedtheimages,andtheir
diagnosticclassications,totheneuralnetwork.IaskedThruntodescribe
whatsuchanetworkdid.

Imagineanold-fashionedprogramtoidentifyadog,hesaid.Asoftware
engineerwouldwriteathousandif-then-elsestatements:ifithasears,anda
snout,andhashair,andisnotarat...andsoforth,adinnitum.Butthatsnot
howachildlearnstoidentifyadog,ofcourse.Atrst,shelearnsbyseeing
dogsandbeingtoldthattheyaredogs.Shemakesmistakes,andcorrects
herself.Shethinksthatawolfisadogbutistoldthatitbelongstoan
https://www.instapaper.com/read/887212636 9/21
3/29/2017 A.I. Versus M.D.

altogetherdierentcategory.Andsosheshiftsherunderstandingbitbybit:
thisisdog,thatiswolf.Themachine-learningalgorithm,likethechild,pulls
informationfromatrainingsetthathasbeenclassied.Heresadog,and
heresnotadog.Itthenextractsfeaturesfromonesetversusanother.And,by
testingitselfagainsthundredsandthousandsofclassiedimages,itbeginsto
createitsownwaytorecognizeadogagain,thewayachilddoes.Itjust
knowshowtodoit.

InJune,2015,Thrunsteambegantotestwhatthemachinehadlearnedfrom
themastersetofimagesbypresentingitwithavalidationset:some
fourteenthousandimagesthathadbeendiagnosedbydermatologists
(althoughnotnecessarilybybiopsy).Couldthesystemcorrectlyclassifythe
imagesintothreediagnosticcategoriesbenignlesions,malignantlesions,
andnon-cancerousgrowths?Thesystemgottheanswerrightseventy-twoper
centofthetime.(Theactualoutputofthealgorithmisnotyesornobuta
probabilitythatagivenlesionbelongstoacategoryofinterest.)Twoboard-
certieddermatologistswhoweretestedalongsidedidworse:theygotthe
answercorrectsixty-sixpercentofthetime.

Thrun,Esteva,andKuprelthenwidenedthestudytoincludetwenty-ve
dermatologists,andthistimetheyusedagold-standardtestsetofroughly
twothousandbiopsy-provenimages.Inalmosteverytest,themachinewas
moresensitivethandoctors:itwaslesslikelytomissamelanoma.Itwasalso
morespecic:itwaslesslikelytocallsomethingamelanomawhenitwasnt.
Ineverytest,thenetworkoutperformedexpertdermatologists,theteam
concluded,inareportpublishedinNature.

Theresoneratherprofoundthingaboutthenetworkthatwasntfully
emphasizedinthepaper,Thruntoldme.Intherstiterationofthestudy,he
andtheteamhadstartedwithatotallynaveneuralnetwork.Buttheyfound
thatiftheybeganwithaneuralnetworkthathadalreadybeentrainedto
https://www.instapaper.com/read/887212636 10/21
3/29/2017 A.I. Versus M.D.

recognizesomeunrelatedfeature(dogsversuscats,say)itlearnedfasterand
better.Perhapsourbrainsfunctionsimilarly.Thosemind-numbingexercises
inhighschoolfactoringpolynomials,conjugatingverbs,memorizingthe
periodictablewerepossiblytheopposite:mind-sensitizing.

Whenteachingthemachine,theteamhadtotakesomecarewiththeimages.
Thrunhopedthatpeoplecouldonedaysimplysubmitsmartphonepicturesof
theirworrisomelesions,andthatmeantthatthesystemhadtobeundaunted
byawiderangeofanglesandlightingconditions.But,herecalled,Insome
pictures,themelanomashadbeenmarkedwithyellowdisks.Wehadtocrop
themoutotherwise,wemightteachthecomputertopickoutayellowdiskas
asignofcancer.

Itwasanoldconundrum:acenturyago,theGermanpublicbecameentranced
byCleverHans,ahorsethatcouldsupposedlyaddandsubtract,andwould
relaytheanswerbytappingitshoof.Asitturnsout,CleverHanswasactually
sensingitshandlersbearing.Asthehorseshoof-tapsapproachedthecorrect
answer,thehandlersexpressionandposturerelaxed.Theanimalsneural
networkhadnotlearnedarithmetic;ithadlearnedtodetectchangesinhuman
bodylanguage.Thatsthebizarrethingaboutneuralnetworks,Thrunsaid.
Youcannottellwhattheyarepickingup.Theyarelikeblackboxeswhose
innerworkingsaremysterious.

Theblackboxproblemisendemicindeeplearning.Thesystemisntguided
byanexplicitstoreofmedicalknowledgeandalistofdiagnosticrules;ithas
eectivelytaughtitselftodierentiatemolesfrommelanomasbymakingvast
numbersofinternaladjustmentssomethinganalogoustostrengtheningand
weakeningsynapticconnectionsinthebrain.Exactlyhowdiditdetermine
thatalesionwasamelanoma?Wecantknow,anditcanttellus.Allthe
internaladjustmentsandprocessingthatallowthenetworktolearnhappen
awayfromourscrutiny.Asistrueofourownbrains.Whenyoumakeaslow
https://www.instapaper.com/read/887212636 11/21
3/29/2017 A.I. Versus M.D.

turnonabicycle,youleanintheoppositedirection.Mydaughterknowstodo
this,butshedoesntknowthatshedoesit.Themelanomamachinemustbe
extractingcertainfeaturesfromtheimages;doesitmatterthatitcanttellus
which?Itslikethesmilinggodofknowledge.Encounteringsuchamachine,
onegetsaglimpseofhowananimalmightperceiveahumanmind:all-
knowingbutperfectlyimpenetrable.

Thrunblithelyenvisagesaworldinwhichwereconstantlyunderdiagnostic
surveillance.Ourcellphoneswouldanalyzeshiftingspeechpatternsto
diagnoseAlzheimers.AsteeringwheelwouldpickupincipientParkinsons
throughsmallhesitationsandtremors.Abathtubwouldperformsequential
scansasyoubathe,viaharmlessultrasoundormagneticresonance,to
determinewhethertheresanewmassinanovarythatrequiresinvestigation.
BigDatawouldwatch,record,andevaluateyou:wewouldshuttlefromthe
graspofonealgorithmtothenext.ToenterThrunsworldofbathtubsand
steeringwheelsistoenterahallofdiagnosticmirrors,eachurgingmoretests.

Itshardnottobeseducedbythisvision.Mightamedicalpanopticonthat
constantlyscansusingranularperhapsevencellulardetail,comparing
imagesdaybyday,enableustocatchcanceratitsearlieststages?Couldit
provideabreakthroughincancerdetection?Itsoundsimpressive,buttheresa
catch:manycancersaredestinedtobeself-limited.Wediewiththem,notof
them.Whatifsuchanimmersivediagnosticengineledtomillionsof
unnecessarybiopsies?Inmedicine,therearecaseswhereearlydiagnosiscan
saveorprolonglife.Therearealsocaseswhereyoullbeworriedlongerbut
wontlivelonger.Itshardtoknowhowmuchyouwanttoknow.

Iminterestedinmagnifyinghumanability,Thrunsaid,whenIaskedhim
abouttheimpactofsuchsystemsonhumandiagnosticians.Look,did
industrialfarmingeliminatesomeformsoffarming?Absolutely,butit
ampliedourcapacitytoproduceagriculturalgoods.Notallofthiswasgood,
https://www.instapaper.com/read/887212636 12/21
3/29/2017 A.I. Versus M.D.

butitallowedustofeedmorepeople.Theindustrialrevolutionampliedthe
powerofhumanmuscle.Whenyouuseaphone,youamplifythepowerof
humanspeech.YoucannotshoutfromNewYorktoCaliforniaThrunandI
were,indeed,speakingacrossthatdistanceandyetthisrectangulardevice
inyourhandallowsthehumanvoicetobetransmittedacrossthreethousand
miles.Didthephonereplacethehumanvoice?No,thephoneisan
augmentationdevice.Thecognitiverevolutionwillallowcomputerstoamplify
thecapacityofthehumanmindinthesamemanner.Justasmachinesmade
humanmusclesathousandtimesstronger,machineswillmakethehuman
brainathousandtimesmorepowerful.Thruninsiststhatthesedeep-learning
deviceswillnotreplacedermatologistsandradiologists.Theywillaugmentthe
professionals,oeringthemexpertiseandassistance.

GeoreyHinton,acomputerscientistattheUniversityofToronto,speaksless
gentlyabouttherolethatlearningmachineswillplayinclinicalmedicine.
Hintonthegreat-great-grandsonofGeorgeBoole,whoseBooleanalgebraisa
keystoneofdigitalcomputinghassometimesbeencalledthefatherofdeep
learning;itsatopichesworkedonsincethemid-nineteen-seventies,and
manyofhisstudentshavebecomeprincipalarchitectsoftheeldtoday.

IthinkthatifyouworkasaradiologistyouarelikeWileE.Coyoteinthe
cartoon,Hintontoldme.Yourealreadyovertheedgeofthecli,butyou
haventyetlookeddown.Theresnogroundunderneath.Deep-learning
systemsforbreastandheartimaginghavealreadybeendeveloped
commercially.Itsjustcompletelyobviousthatinveyearsdeeplearningis
goingtodobetterthanradiologists,hewenton.Itmightbetenyears.Isaid
thisatahospital.Itdidnotgodowntoowell.

Hintonsactualwords,inthathospitaltalk,wereblunt:Theyshouldstop
trainingradiologistsnow.WhenIbroughtupthechallengetoAngela
Lignelli-Dipple,shepointedoutthatdiagnosticradiologistsarentmerely
https://www.instapaper.com/read/887212636 13/21
3/29/2017 A.I. Versus M.D.

engagedinyes-noclassication.Theyrenotjustlocatingtheembolismthat
broughtonastroke.Theyrenoticingthesmallbleedelsewherethatmight
makeitdisastroustouseaclot-bustingdrug;theyrepickinguponan
unexpected,maybestillasymptomatictumor.

Hintonnowqualiestheprovocation.Theroleofradiologistswillevolve
fromdoingperceptualthingsthatcouldprobablybedonebyahighlytrained
pigeontodoingfarmorecognitivethings,hetoldme.Hisprognosisforthe
futureofautomatedmedicineisbasedonasimpleprinciple:Takeanyold
classicationproblemwhereyouhavealotofdata,anditsgoingtobesolved
bydeeplearning.Theresgoingtobethousandsofapplicationsofdeep
learning.HewantstouselearningalgorithmstoreadX-rays,CTscans,and
MRIsofeveryvarietyandthatsjustwhatheconsidersthenear-term
prospects.Inthefuture,hesaid,learningalgorithmswillmakepathological
diagnoses.TheymightreadPapsmears,listentoheartsounds,orpredict
relapsesinpsychiatricpatients.

Wediscussedtheblack-boxproblem.Althoughcomputerscientistsare
workingonit,Hintonacknowledgedthatthechallengeofopeningtheblack
box,oftryingtondoutexactlywhatthesepowerfullearningsystemsknow
andhowtheyknowit,wasfarfromtrivialdontbelieveanyonewhosays
thatitis.Still,itwasaproblemhethoughtwecouldlivewith.Imagine
pittingabaseballplayeragainstaphysicistinacontesttodeterminewherea
ballmightland,hesaid.Thebaseballplayer,whosthrownaballoverand
overagainamilliontimes,mightnotknowanyequationsbutknowsexactly
howhightheballwillrise,thevelocityitwillreach,andwhereitwillcome
downtotheground.Thephysicistcanwriteequationstodeterminethesame
thing.But,ultimately,bothcometotheidenticalpoint.

https://www.instapaper.com/read/887212636 14/21
3/29/2017 A.I. Versus M.D.

Irecalledthedisappointingresultsfromoldergenerationsofcomputer-
assisteddetectionanddiagnosisinmammography.Anynewsystemwould
needtobeevaluatedthroughrigorousclinicaltrials,Hintonconceded.Yetthe
newintelligentsystems,hestressed,aredesignedtolearnfromtheirmistakes
toimproveovertime.Wecouldbuildinasystemthatwouldtakeevery
misseddiagnosisapatientwhodevelopedlungcancereventuallyandfeed
itbacktothemachine.Wecouldask,Whatdidyoumisshere?Couldyou
renethediagnosis?Theresnosuchsystemforahumanradiologist.Ifyou
misssomething,andapatientdevelopscancerveyearslater,theresno
systematicroutinethattellsyouhowtocorrectyourself.Butyoucouldbuildin
asystemtoteachthecomputertoachieveexactlythat.

Someofthemostambitiousversionsofdiagnosticmachine-learning
algorithmsseektointegratenatural-languageprocessing(permittingthemto
readapatientsmedicalrecords)andanencyclopedicknowledgeofmedical
conditionsgleanedfromtextbooks,journals,andmedicaldatabases.Both
I.B.M.sWatsonHealth,headquarteredinCambridge,Massachusetts,and
DeepMind,inLondon,hopetocreatesuchcomprehensivesystems.Iwatched
someofthesesystemsoperateinpilotdemonstrations,butmanyoftheir
features,especiallythedeep-learningcomponents,arestillindevelopment.

Hintonispassionateaboutthefutureofdeep-learningdiagnosis,inpart,
becauseofhisownexperience.Ashewasdevelopingsuchalgorithms,hiswife
wasfoundtohaveadvancedpancreaticcancer.Hissonwasdiagnosedwitha
malignantmelanoma,butthenthebiopsyshowedthatthelesionwasabasal-
cellcarcinoma,afarlessseriouskindofcancer.Theresmuchmoretolearn
here,Hintonsaid,lettingoutasmallsigh.Earlyandaccuratediagnosisis
notatrivialproblem.Wecandobetter.Whynotletmachineshelpus?

https://www.instapaper.com/read/887212636 15/21
3/29/2017 A.I. Versus M.D.

OnanicyMarchmorning,afewdaysaftermyconversationswithThrunand
Hinton,IwenttoColumbiaUniversitysdermatologyclinic,onFifty-rst
StreetinManhattan.LindseyBordone,theattendingphysician,wasscheduled
toseeforty-ninepatientsthatday.Bytenoclock,thewaitingroomwaslled
withpeople.(Identifyingdetailshavebeenchanged.)Abeardedman,about
sixtyyearsold,satinthecornerconcealingarashonhisneckwithawoollen
scarf.AnanxiouscouplehuddledovertheTimes.

Bordonesawherpatientsinrapidsuccession.Inauorescent-litroominthe
back,anursesatfacingacomputerandgaveaone-sentencesummaryfty
yearsoldwithnopriorhistoryandnewsuspiciousspotontheskinandthen
Bordonerushedintotheexaminingroom,herblondhairyingbehindher.

Ayoungmaninhisthirtieshadascalyredrashonhisface.AsBordone
examinedhim,theskinakedandfellohisnose.Bordonepulledhiminto
thelightandlookedattheskincarefully,andthenfocussedherhandheld
dermoscopeonit.

Doyouhavedandruinyourhair?sheasked.

Themanlookedconfused.Sure,hesaid.

Well,thisisfacialdandru,Bordonetoldhim.Itsaparticularlybadcase.
Butthequestioniswhyitappearednow,andwhyitsgettingworse.Haveyou
beenusingsomenewproductinyourhair?Istheresomeunusualstressinyour
family?

Theresdenitelybeensomestress,hesaid.Hehadlosthisjobrecently,
andwasdealingwiththenancialrepercussions.

https://www.instapaper.com/read/887212636 16/21
3/29/2017 A.I. Versus M.D.

Keepadiary,sheadvised.Wecandetermineiftheresalink.Shewrotea
prescriptionforasteroidalcream,andaskedhimtoreturninamonth.

Inthenextroom,therewasayoungparalegalwithasprayofitchybumpson
hisscalp.HewincedasBordonefelthisscalp.Seborrheicdermatitis,she
said,concludingherexam.

Thewomaninanotherroomhadundressedanddonnedahospitalgown.In
thepast,shehadbeendiagnosedwithamelanoma,andshewasdiligentabout
gettingpreventiveexams.Bordoneporedoverherskin,frecklebyfreckle.It
tookhertwentyminutes,butshewasthoroughandcomprehensive,running
herngersoverthelandscapeofmolesandskintagsandcallingoutdiagnoses
asshemoved.Therewereneviandkeratoses,butnomelanomasor
carcinomas.

Looksallgood,shesaidcheerfullyattheend.Thewomansighedinrelief.

Andsoitwent:Bordonecame;shesaw;shediagnosed.FarfromHintons
coyote,sheseemedlikeasomewhatmanicroadrunner,tryingtokeeppace
withthesuccessionofcasesthattreadmilledbeneathher.Asshewroteher
notesinthebackroom,IaskedheraboutThrunsvisionfordiagnosis:an
iPhonepice-mailedtoapowerfulo-sitenetworkmarshallingundoubtedbut
inscrutableexpertise.Adermatologistinfull-timepractice,suchasBordone,
willseeabouttwohundredthousandcasesduringherlifetime.TheStanford
machinesalgorithmingestednearlyahundredandthirtythousandcasesin
aboutthreemonths.And,whereaseachnewdermatologyresidentneedsto
startfromscratch,Thrunsalgorithmkeepsingesting,growing,andlearning.

Bordoneshrugged.Ifithelpsmemakedecisionswithgreateraccuracy,Id
welcomeit,shesaid.Someofmypatientscouldtakepicturesoftheirskin
problemsbeforeseeingme,anditwouldincreasethereachofmyclinic.
https://www.instapaper.com/read/887212636 17/21
3/29/2017 A.I. Versus M.D.

Thatsoundedlikeareasonableresponse,andIrememberedThruns
reassuringremarksaboutaugmentation.But,asmachineslearnmoreand
more,willhumanslearnlessandless?Itstheperennialanxietyoftheparent
whosechildhasaspell-checkfunctiononherphone:whatifthechildstops
learninghowtospell?Thephenomenonhasbeencalledautomationbias.
Whencarsgainautomateddriverassistance,driversmaybecomelessalert,
andsomethingsimilarmayhappeninmedicine.MaybeBordonewasalone
JohnHenryinaworldwherethesteamdrillswereabouttocomeonline.Butit
wasimpossibletomisshowherownconcentrationneverwaveredandhow
seriouslyshetookeveryskintagandmolethatsheranherngersover.Would
thatcontinuetobetrueifshepartneredwithamachine?

InoticedotherpatternsinBordonesinteractionswithherpatients.Forone
thing,theyalmostalwaysleftfeelingbetter.Theyhadbeentouchedand
scrutinized;aconversationtookplace.Eventhenamingoflesionsnevus,
keratosiswasanemollient:therewassomethingdeeplyreassuringabout
theprocess.Thewomanwhodhadtheskinexamleftlookingfreshand
unburdened,heranxietyexfoliated.

Therewasmore.Thediagnosticmoment,astheBrazilianresearchersmight
haveguessed,cametoBordoneinaashofrecognition.Asshecalledout
dermatitisoreczema,itwasasifshewereidentifyingarhinoceros:you
couldalmostseethepyramidofneuronsinthelowerposteriorofherbrain
sparkassherecognizedthepattern.Butthevisitdidnotendthere.Inalmost
everycase,Bordonespentthebulkofhertimeinvestigatingcauses.Whyhad
thesymptomsappeared?Wasitstress?Anewshampoo?Hadsomeone
changedthechlorineinthepool?Whynow?

Themostpowerfulelementintheseclinicalencounters,Irealized,wasnot
knowingthatorknowinghownotmasteringthefactsofthecase,or
perceivingthepatternstheyformed.Itlayinyetathirdrealmofknowledge:
https://www.instapaper.com/read/887212636 18/21
3/29/2017 A.I. Versus M.D.

knowingwhy.

Explanationsrunshallowanddeep.Youhavearedblisteronyournger
becauseyoutouchedahotiron;youhavearedblisteronyourngerbecause
theburnexcitedaninammatorycascadeofprostaglandinsandcytokines,in
aregulatedprocessthatwestillunderstandonlyimperfectly.Knowingwhy
askingwhyisourconduittoeverykindofexplanation,andexplanation,
increasingly,iswhatpowersmedicaladvances.Hintonspokeaboutbaseball
playersandphysicists.Diagnosticians,articialorhuman,wouldbethe
baseballplayersprocientbutopaque.Medicalresearcherswouldbethe
physicists,asremovedfromtheclinicaleldastheoristsarefromthebaseball
eld,butwithadesiretoknowwhy.Itsaconvenientdivisionof
responsibilitiesyetmightitrepresentaloss?

Adeep-learningsystemdoesnthaveanyexplanatorypower,asHintonput
itatly.Ablackboxcannotinvestigatecause.Indeed,hesaid,themore
powerfulthedeep-learningsystembecomes,themoreopaqueitcanbecome.
Asmorefeaturesareextracted,thediagnosisbecomesincreasinglyaccurate.
Whythesefeatureswereextractedoutofmillionsofotherfeatures,however,
remainsanunanswerablequestion.Thealgorithmcansolveacase.Itcannot
buildacase.

Yetinmyowneld,oncology,Icouldnthelpnoticinghowoftenadvances
weremadebyskilledpractitionerswhowerealsocuriousandpenetrating
researchers.Indeed,forthepastfewdecades,ambitiousdoctorshavestrived
tobeatoncebaseballplayersandphysicists:theyvetriedtousediagnostic
acumentounderstandthepathophysiologyofdisease.Whydoesan
asymmetricalborderofaskinlesionpredictamelanoma?Whydosome
melanomasregressspontaneously,andwhydopatchesofwhiteskinappearin
someofthesecases?Asithappens,thisobservation,madebydiagnosticians
intheclinic,waseventuallylinkedtothecreationofsomeofthemostpotent
https://www.instapaper.com/read/887212636 19/21
3/29/2017 A.I. Versus M.D.

immunologicalmedicinesusedclinicallytoday.(Thewhiteningskin,itturned
out,wastheresultofanimmunereactionthatwasalsoturningagainstthe
melanoma.)Thechainofdiscoverycanbeginintheclinic.Ifmoreandmore
clinicalpracticewererelegatedtoincreasinglyopaquelearningmachines,if
thedaily,spontaneousintimacybetweenimplicitandexplicitformsof
knowledgeknowinghow,knowingthat,knowingwhybegantofade,isit
possiblethatwedgetbetteratdoingwhatwedobutlessabletoreconceive
whatweoughttobedoing,tothinkoutsidethealgorithmicblackbox?

IspoketoDavidBickers,thechairofdermatologyatColumbia,aboutour
automatedfuture.Believeme,Ivetriedtounderstandalltheramicationsof
Thrunspaper,hesaid.Idontunderstandthemathbehindit,butIdoknow
thatsuchalgorithmsmightchangethepracticeofdermatology.Will
dermatologistsbeoutofjobs?Idontthinkso,butIthinkwehavetothinkhard
abouthowtointegratetheseprogramsintoourpractice.Howwillwepayfor
them?Whatarethelegalliabilitiesifthemachinemakesthewrongprediction?
Andwillitdiminishourpractice,orourself-imageasdiagnosticians,torelyon
suchalgorithms?Insteadofdoctors,willweenduptrainingagenerationof
technicians?

Hecheckedthetime.Apatientwaswaitingtoseehim,andhegotuptoleave.
Ivespentmylifeasadiagnosticianandascientist,hesaid.Iknowhow
muchapatientreliesonmycapacitytotellamalignantlesionfromabenign
one.Ialsoknowthatmedicalknowledgeemergesfromdiagnosis.

Theworddiagnosis,heremindedme,comesfromtheGreekforknowing
apart.Machine-learningalgorithmswillonlybecomebetteratsuchknowing
apartatpartitioning,atdistinguishingmolesfrommelanomas.Butknowing,
inallitsdimensions,transcendsthosetask-focussedalgorithms.Intherealm
ofmedicine,perhapstheultimaterewardscomefromknowingtogether.

https://www.instapaper.com/read/887212636 20/21
3/29/2017 A.I. Versus M.D.

TheNewYorker(http://www.newyorker.com/magazine/2017/04/03/ai-versus-md)
bySiddharthaMukherjee

https://www.instapaper.com/read/887212636 21/21