Refuse to let your doctor record you

His doctor asked him about using drugs and he made a joke that was something like "I only use coke" - meaning coca-cola. Of course his doctor knew he was kidding about drinking too much soda because he eats/drinks too much sugar. So they had a little laugh and moved on.

BUT now it's in his medical transcripts. My mom said it "transcribed" it as something like "the patient responded he has used cocaine recently".

I guess his doctor doesn't go in and actually fix things or even read over what the transcription says...

Also both of my parents have accents and have reported really weird transcriptions that don't match what they actually said.

So now my mom has told my dad he can't make jokes with the doctor anymore because even if the doctor knows he's joking it's going to get noted down as a "fact".

I know a medical professional who does a similar evaluation process to what is outlined in your second link to human written charts. They then use that feedback to guide the department on how to improve their charting.

So, don't presume that those error rates cited in those studies should be compared to a baseline rate of zero. If you review human-written charts, you will often also not have an error rate of zero.

From the 2025 study: Conclusions The CAISs demonstrate high levels of summarisation accuracy. However, there is great disparity between the currently available CAIS products and, while some perform well, none are perfect. Clinicians should therefore maintain vigilance, particularly checking omitted psychosocial details and medications, and scrutinising plausible-sounding insertions. Purchasers and regulators should be aware of the significant performance disparities identified, reinforcing the need for careful evaluation and selection of CAIS products.

This is exactly what I say and how we teach our people to use it. At the end of the day the human is responsible for the accuracy. We do have providers who decline to use AI because they don't want to double check it, and that's fine by us.

> On the gripping hand, people who work in the management end of the US healthcare industry can't be trusted with healthcare or information security to begin with.

No, this blanket statement is far to overly broad. Health insurers are by far the least trustworthy. Provider organizations are a very, very different group. In my 12 years I have never had a PHI breach or leak that wasn't a human making a mistake. No hacks, no credential breaches, no backdoors or zero days, no network infrastructure penetrations. Two former employers had breaches years after I left which I think speaks well to my track record. I take security incredibly seriously. Our patients are the most important part of my job.

It’s been a year or so since I last read The Mote In Gods Eye/The Gripping Hand but I randomly was thinking of this morning. Very funny that I would see a reference to it the same day.

One of my lifelong guiding quotes: The first principle is that you must not fool yourself, and you are the easiest person to fool. - Richard P. Feynman

> We see a win and assume the win is long term, with no downsides, and dependent on the new information/change.

Not me. I've had a hard life and I've worked incredibly hard to get here. I'm a little more loss-averse and focus on what can go wrong, not what went right. It's far too easy for us to become complacent. All in all I'm not your average CIO at all. I'm extremely technical, got my experience as an IT consultant for years and learned business by doing. Since moving from consultancy to employed life, I took the time to get several certifications and even did an MBA about a decade ago.

No, you got an inaccurate diagnoses because your doctor didn't do their job. It's the provider's job to check notes, and this would have gotten that provider a visit with their clinical director at my org.

If I got a copy of the raw recording I might consider it. Maybe. Having that audio recording would be valuable to me.

It's very irksome medical providers I visit have signs posted prohibiting audio and video recording by patients. My medical appointments aren't exceedingly complex, but a reference audio recording would be handy.

I suppose I could exercise civil disobedience and just record anyway since it's not illegal in my state. Still, it irks me.

Which would you prefer, your doctor remembering everything, or making verbal notes into a microcassette tape recorder that is transcribed by a human later (sometimes the doctor, sometimes someone else)? What if your doctor had a medical assistance in the room and spoke out loud and that medical assistant wrote down everything, is that ok?

> or a fucking AI that sits in between me and my doctor.

It sits next to the doctor helping them focus on you by transcribing the session, it doesn't do anything the doctor can't and definitely doesn't do anything the doctor SHOULD. No decision making is done, only transcription and summarization which is then checked by the doctor. We do not let AI make decisions.

Ship's sailed on that level of privacy anyway the second you bill an insurance carrier in the US. I am willing to take this particular risk if something I said two years ago pops up to help explain what I am currently experiencing. I understand not everyone is me and I am lucky to be in relatively good health and not have anything going on that might put employment, etc at risk so I can understand where some people may want to refuse. But the knee-jerk "FUCK NO BECAUSE PRIVACY" is almost as bad as writing a post based on a side plot in The Pitt when said side plot was 110% heightening the stress between Dr. Robby and Dr. Al Hashimi, not a goddamn double-blind study of the effectiveness of AI transcripto-bots.

And if you're going to take lessons from The Pitt about medical record transcription, why isn't it Dr. Santos repeatedly falling asleep while transcribing records?

Why? Doctors have the strictest privacy regulations I know of. It's the one place where I'd be least uncomfortable with a recording, because there's nothing they can do with it other than use it to provide healthcare to me.

> or a fucking AI that sits in between me and my doctor.

The expected arrangement is that the AI would be alongside you and your doctor, so that your doctor can spend time interacting with you instead of playing transcriptionist and dictating your statement into your chart.

You can do that by recording and transcribing (many methods) or your doctor has to write on the fly, or worse, has their head in their computer while you talk in their general direction.

Letting doctors talk and examine and not write is a wholly better experience.

Offsite third parties are the problem here. If this was done automatically without data leaving the room, is there a problem? Do you have the same objections to how your digital notes are stored?

Positive survey feedback certainly isn't a bad sign, but people can get very excited about cool new technologies, even ones that ultimately fail.

Or with assistance from other humans.

The last time I had surgery, every time I met with the surgeon (about six times), he had an intern following him around with a Thinkpad, typing in everything said.

The intern has the ability to understand context, idiomatic expressions, emotion, and a dozen other important and useful things that an AI transcription will never capture.

Imagine your doctor head down writing down everything you say. Now imagine your doctor looking you in the eye and listening intently. Which do you think feels better to the patient? That is "huge". Anything that helps improve patient care with little effort and cost IS HUGE to us. That feeling of the doctor being present and invested helps patient outcomes. THAT is also huge, even if it's a few percent.

We're healing people, we're not looking for a unicorn startup, a few percent improvement IS HUGE to us.

> As a patient sitting with a doctor, I don’t care how standardized the notes are.

Yes you do, better notes mean better care because the next time your seen your records are clean, understandable, and compliant with regulations and best practices. Better notes mean doctors are following protocols. Better notes mean fewer claim rejections, and fewer claim rejections means less money wasted arguing with insurance companies. Better notes mean the data is more easily used for research, as well, which leads to new treatments and better outcomes.

> I don’t care about anyone’s NPS score.

Ever had a doctor with a bad bedside manner? Missed a diagnosis? Skips appointments on fridays? Tracking NPS scores can help with that. Every data point is useful, and patient satisfaction is massive.

> I do want the doctor to connect with me,

Ok, well, most people DO want this, most people DO want to have a good relationship with their doctor where they feel heard and cared about rather than just another widget on a conveyor belt.

> but I also remember not too long ago when doctors did this anyway, without any assistance from robots.

I also remember when doctors weren't constantly overruled by insurance companies. Ever heard of a Prior Auth? That's when your doctor writes a prescription or an order and then the insurance company makes the doctor call them back and say "yes, I did this on purpose, yes the patient really needs this." Then a bureaucrat at the insurance company will decide if the doctor is right or not. Usually those bureaucrats aren't even doctors. That's illegal, but happens every day.

Anything I can do to help my doctors provide better care for our patients, I'll do. I've dealt with scribes for 12 years and I genuinely think these AI scribes are a genuinely amazing use of the technology. We don't have to hire human scribes, and our doctors are freed up to deal with the patient thanks to a documentation helper.

I evaluated quite a number of these tools before we rolled any out. I've been researching these for two years. Dragon with Copilot is not a good tool, for example. There was another we evaluated, I just did a search on them and their story today is wildly different than it was 18 months ago when I discovered they were lying through their teeth about the tech. I see they claim to have secured a $70m round in 2024 (which I know is a lie) and more since, so maybe they can actually do what they say now but I couldn't trust them, so I kept evaluating.

I'm not an AI truster, AI isn't a panacea, but it DOES have uses, and this is one I've seen make a positive difference. I'm not an insurer, I work for providers, my goal is helping my docs provide the best care, so I promise I'm not going to roll out bullshit tech or things that would endanger our patients. My reputation is on the line, and I take that incredibly seriously too.

Every provider is under an Assistant Clinical Director, and they report to the Clinical Directors, who report to the CMO. ACDs see fewer patients than regular providers because they have more admin time. That admin time is used to check charts. We don't review every chart, but a pretty good sampling. I meet with them monthly to talk about tech issues, and that's where I helped them create templates for notes that we can have the system output in that same format. We'll tweak the formats as needed, or the ACDs will talk with a provider about changes in how they handle the patient.

Also, we look at denial reasons. Any time a claim is rejected by a payor for note related reasons it gets a full review from clinical staff other than the original provider.

> Vibe-notes might be more verbose and better sounding (which would explain the NPS and satisfaction metrics), but still not actually match the doctor's actual words or intent.

That's the great thing about these, they listen to the entire visit, they hear everything that happens, make a full transcript, then create a summary. It's not a situation where the doc talks for 30 seconds into a mic then the AI fleshes it out, it's the exact opposite. We're using AI to distill the visit into the note, not expand a small note into a larger one. We're not generating data, we're condensing it. Doctors must read each note, and they are legally liable for the note quality. Doctors are highly competitive and image conscious, so they're actually a great backstop for accuracy. If they notice inaccuracies in their summaries, I ASSUME you I personally hear about each and every one. I'm ok with that, though, the buck stops at my desk.

> Are the AI-generated notes actually compared with ground truth to prove they are accurate?

Yes. A doctor could lose their license, so every provider checks their notes, and our CMO and clinical oversight staff take that extremely seriously.

Nonetheless, I come away from this article with the sense the ambient devices automating documentation of an encounter are still a net win, with caveats about the need for the doctor to polish the note ti reflect his or her own narrative voice.

That article is clearly LLM-assisted if not vibe-written, which is the height of irony given the context.

Note that the CIO is talking about patient satisfaction, which is a distinct target. I agree about the long-run benefit being unclear.

is this a counterpoint? he just seems to be wary of the risk, without a firm position and decided to personally stop using it. people often overestimate their own skills and think their own charting is better than that of others, that doesn't mean the tech doesn't work.

1) in the event you find yourself partially or totally disabled but the records don’t really make a good case for it and your provider has a dismissive attitude about filling out additional documentation to substantiate what they failed to in your records.

You’re not necessarily going to get approved for FMLA, STD, LTD, SS etc based on a diagnosis or test results alone. They will nitpick over say, heart failure, as if that’s magically and spontaneously going to go away. If you’re telling your provider that you’re limited by things like oh I don’t know, “I’m only awake for 2-4 hours before I need to sleep again” or “some days I just can’t do it and sleep 20 hours” but it’s not in your chart… expect denials and clarifications and a huge burden on you to prove why it’s limiting.

2) continuity of care, so you don’t end up explaining everything from the top to a specialist or having them run all these tests and procedures from square one — when there’s months long backlogs , and we already did all this and you need treatment - but - there wasn’t much to work with in your referring chart.

You might not appreciate the “intrusion” if you’re healthy and just worried about your privacy.

If/When things go south and you find yourself fighting these entities for a year or two or three while they nitpick and delay and deny and drag their feet , you’ll be glad an “AI” kept up meticulous records because this is phenomenally stressful and an endless burden on you when they don’t.

So, their AI slop can vomit out all this extra info on why insurance companies should pay them or why your condition is in fact disabling, and now their AI slop can comb through it looking for all that. Because they will try to avoid paying or approving any kind of leave or benefits if it’s not there

And god forbid you hand them a form where they’re being asked to explain themselves. 50/50 on them being eager to help out or rolling their eyes and saying something really nasty about the imposition. And then even when they do that, they almost never file a copy in your chart so your chart STILL doesn’t substantiate your claims. I’m all for an “ai” doing the progress notes in a case where the facility or provider can’t be fucked to do so.

Happily that’s not true of my current provider, who just, does that anyway (?) But I’ve been around enough to know they’re an exception. Even when providers are on your side and mean well, and want to bend over backwards to help you in any way they can — and I want to just acknowledge that’s the situation I’m in today — honestly , sometimes they just forget some of the details when they do their notes.

That’s why some places make the provider do it in real time while they’re talking to you, so they didn’t forget something relevant thirty minutes later. The other side of the coin here may be that some providers find that distracting or off putting to be typing away like a stenographer while they’re examining you…

I think it would be fair to say this can all be tedious and a burden for both patients and providers. There’s just a world of difference between a provider who wants to do this to provide excellency in care, and a provider who wants to do this because they resent it and think it’s beneath them.

USA. I should have said that.

> and stronger consumer protection and privacy laws.

No, they may have stricter privacy laws outside of healthcare, but HIPAA is extremely strict and heavily enforced. In 2018 our legal team asked me if we were GDPR compliant if we accepted cash pay clients from Europe. I said from the healthcare side we're already adherent, and the department you'll have problems with is marketing because HIPAA already meets or exceeds GDPR rules. Same for CCPA in California.

I've been the legal Data Security and Privacy Officer in 5 healthcare orgs, I'm more scared of OIG and HHS than I am of the EU.

> specific motivations of executives endorsing the tools.

My job doesn't include profit motives, and I'm extremely strict. Privacy and regulatory compliance trumps profit ideas. Yes, this tool absolutely helps us not have to pay for human scribes, but we weren't going to employ them anyway. Human scribes are EXPENSIVE. Usually the alternative was a microcassette recorder, or a digital recorder that produced digital files. Then we'd have to send those files, securely, to a licensed medical transcriptionist, then ensure the recording is destroyer and the transcript comes back, and then the doctor uses that to chart. These tools mean we skip most of that, so it's faster, cheaper, and more secure. It IS good for business, but frankly, so is good patient care.

For me the big things are price, ease of use, and data protection policies. I need to know the data never leaves the US, and I need to know what processors will touch it. Then if it meets those needs we'll do clinical demos and tests to get provider feedback. That's where we learn if it is clinically accurate. About half of them suck in the accuracy department.

What stands out to me the most is that the best companies have tended to be the small guys who have a strong grasp ion the entire stack and have somewhat simple apps. They focus on the tech, and have a minimal UI that just focuses on the main tasks and they don't spend engineering time on fancy pretty bells and whistles. If you see a simple UI, that's a good sign to me. Once you hit the big guys the quality goes down. Dragon Medical One is great for straight text to speech, but Dragon with Copilot for medical is really bad.

Have you seen what that looks like in a hospital system?

In America this doesn't matter, everyone's bills are insane.

> Getting billed for a "dietary consult" because your doctor may have asked you what you had for lunch due to the coding intensity of these scribes is asinine.

For what we do it's also illegal. We can only charge for services the patient consents to, and we're obligated through federal and state regulations to provide transparent pricing and estimates, so we couldn't do surprise billing if we wanted to. not that we do! We actually find it better to avoid trying to capture every single procedure code like that because it drives up rejections and thus collection costs. We'd rather bill and collect the straight procedure with no bullshit.

No, the transcript will never result in a bill that is different than the service the provider rendered.

Which is your right, every patient can ask the provider to not use it.

> is the data from my meeting sent offsite at any stage

Yes, no one stores medical records on-prem any more. EMR systems are not like Quickbooks running on an 8 year old terminal server.

> for example to an LLM service

Yes, that's literally what an AI transcriber is, an LLM.

> (e.g., Anthropic, OpenAI, etc.)?

No. The recording goes (in realtime) to our vendor's infra where it is live transcribed, then summarized and returned. When complete only the finished note is saved, never the recording or transcript.

> Or do the LLM vendors (or any others) have access to the internal data at any stage?

Obviously, you can't pricess data you can't access, but the contractual and regulatory environment means that data can't be used for additional training without lots of consents. We do not participate in training activities at all. I won't allow it.

This is also a good thing. Even in supposedly developed parts of the world like San Francisco it can be difficult to find a PCP that is taking new patients.

At least in my area, it seems like lack of people is a problem. Sometimes it's lack of people because the pay is too low, but more of it it's lack of people because the pool of qualified people is too small. And increasing pay increases healthcare costs, and healthcare costs are already very high. If digital tools allow the available staff to see more patients while delivering the same level of care (and without burning out the providers), then that means more capacity and less times people want to see a doctor, but can't. Similar arguments for same number of patients ans greater level of care. If it's more patients, but worse level of care, then it becomes tricky.

Uh... politics is almost uniformly lawyers and business people.

Also tests are the table-stakes to being a doctor (like leet code and programming).

Insurance company profit margins are capped by law and if anything their incentives are to pay the hospitals less.

US physician salaries are astronomical compared to anywhere else in the world.

We need more doctors now and it takes 12 years to make a doctor and by then the boomer cohorts aging and medical needs will peak.

Finally, even if we could do that, the top of the funnel candidate is substantially weaker with lower test scores and higher need for remedial classes. And for the good candidates, the ROI of medical school is not as good as it once was.

So in your example, they'll continue to double-book, and reduce the total time spent with each patient (since they can be more efficient with each patient) and book more patients per day.

So your statement is factually incorrect: in some common professions, your medical record can make your life significantly more difficult.

I'll be sure to say a prayer at your funeral when you died due to an unknown drug interaction because of the lack of knowledge of your medical history in the emergency department of the random city you happen to be traveling through and get in a car accident.

I don't think people are good at estimating tail risks, let alone the 2nd order effects of them. If you opt out of the AI transcription, do you think the doc will spend a bunch of time doing it by hand for free? No, you'll just have a worse record.