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Why AI will not replace radiologists -

Towards Data Science

Hugh Harvey

13–17 minutes

In late 2016 Prof Geoffrey Hinton, the godfather of neural networks,

said that it’s “quite obvious that we should stop training radiologists”
as image perception algorithms are very soon going to be
demonstrably better than humans. Radiologists are, he said, “the
coyote already over the edge of the cliff who hasn’t yet looked
down”.

This kick-started a hype-wave of biblical proportions that is still

rolling to this day, and shows no signs of breaking just yet. In my
opinion, although this wave of enthusiasm and optimism has
successfully brought radiology artificial intelligence to the forefront
of people’s imaginations, and immense amounts of funding with it, it
has also done untold harm by over-inflating the expectations of
policy and decision makers, and is having tangible knock-on effects
on recruitment as disillusioned junior doctors start believing that
machines are indeed replacing humans and so they shouldn’t
bother applying to become radiologists. It is hard to imagine a more
damaging statement occurring at a time when the crisis in radiology
staffing, especially acute in the UK, is threatening to destabilise
entire hospital systems.

You see, without radiologists, a hospital simply can not function. I

would conservatively estimate that over 95% of patients who enter
a hospital will have some form of medical imaging, and as the
number of patients grows, so does demand for imaging services.
Not only that, but as imaging becomes recognised as the crux of
most diagnoses, most treatment pathways and most outcome
measurements, we are already seeing what looks like an almost
exponential rise in demand for medical imaging, and ergo —
radiologists. This is starkly counter-balanced by sensationalist
headlines along the lines of “machine beats radiologist” which only
serve to further misinform the general public on the real state of AI
currently, misleading them into thinking radiologists’ days are
numbered.

However infatuated or convinced you are about the possibilities of

AI and automation, it is simply not realistic to expect it to entirely
replace human radiologists in the near future, if at all. My estimate
is 10 years until we see AI in routine NHS practice — and my
opinion here is now a matter of parliamentary record! I know this
may be controversial given the amount of hope and hype currently,
and maybe even surprising from someone like me who has
essentially dedicated their career to AI in radiology, but I believe it
is absolutely crucial to have sensible discussions on the future of
the profession, rather than listen solely to silicon valley evangelists
and the media who, let’s admit it, haven’t a clue what it is
radiologists actually do, and just love to overplay the power of what
they are peddling.

In this article I’m going to attempt to break down the three main
reasons why diagnostic radiologists are safe (as long as they
transform alongside technology), and even argue why we need to
train even more.

Reason 1. Radiologists don’t just look at images.

If there is one thing that I would like to scream at anyone who says
AI will replace radiologists, it is this — radiologists do not just look
at pictures! All of the media hype about AI in radiology pertains to
image perception only and, as clearly visualised in my diagram
below, image perception is not the totality of what a human
radiologist does in their day job. Additionally, the above graphic
only depicts a diagnostic workflow, and completely omits patient-
facing work (ultrasound, fluoroscopy, biopsy, drains etc), multi-
disciplinary work such as tumour boards, teaching and training,
audit, and discrepancy review that a diagnostic radiologist also
does on a regular basis. I know of no radiologist who only does
diagnostic reporting as a full-time job. (There’s even the separate
profession of interventional radiology, more akin to surgery than
image perception, also a profession suffering a workforce crisis,
that is less likely to benefit from AI systems).

Simplified schematic of the diagnostic radiology workflow, with

examples of where AI systems can be implemented. Image
copyright @drhughharvey.

The diagnostic radiology workflow can be simplified into its

component steps as visualised above: from patient presentation
and history which leads to decision-making on whether or not to
image, and what type of imaging to perform, to scheduling the
imaging, and automating or standardising image acquisition. Once
imaging is done, algorithms will increasingly post-process images
ready for interpretation by other algorithms, registering data sets
across longitudinal timeframes, improving image quality,
segmenting anatomy and performing detection and quantification of
biomarkers. At present, diagnostic reasoning seems the toughest
nut to crack and is where humans will maintain most presence. This
will be aided by the introduction of smart reporting software,
standardised templates and machine-readable outputs making data
amenable to further algorithmic training to better inform future
decision-making software. Finally, communication of the report can
be semi-automated via language translation or lay-translation, and
augmented presentation of results in a meaningful form to other
clinicians or patients can also be accomplished. And this is only for
starters…

While artificial intelligence can absolutely play a part in each of the

steps in this diagnostic workflow, and even replace a human in
some of them (like scheduling) it simply cannot replace a radiologist
entirely. That is unless we miraculously develop a complete end-to-
end system that has oversight and control over the entire diagnostic
pathway. This to me is a pipe dream, especially given the current
state-of-the-art in AI systems which are only just barely making it
into clinical workflows at present, none of which are anywhere close
to replacing radiologists’ image perception work in any significant
sense.

Reason 2. Humans will always maintain ultimate

responsibility

In 2017 not one single human being died in a commercial airplane

accident. This amazing success story is in part due to the
implementation of high-tech systems that automate many of the
safety oversight tasks normally conducted by human staff,
including, but not limited to, collision avoidance systems, advanced
ground proximity warning systems, and improved air traffic control
systems. It is also in large part due to better training, awareness of
safety issues and alerting/escalation of concerns by human pilots
and other ancillary aviation staff.

Where automation has evolved over the past couple of decades,

humans have been given more freedom to communicate safety
issues, with more time to react to increasing amounts of useful
information, all supported by a cohesive environment of industry-led
safety awareness. The most crucial fact, however is that there has
been zero decrease in the number of commercial pilots — in fact,
quite the opposite. Airlines are reporting a shortage of trained
pilots, and there are growing concerns over a predicted need to
more than double the global number. You see, as safety improves,
costs reduce, flying becomes more popular, passenger numbers
increase, it stands to reason that more planes will be required.

Medicine is often compared to aviation, sometimes inappropriately

and often inaccurately. However, I feel there are some overlapping
key features for both industries. For starters, both are focussed
primarily on maintaining the safety of humans while getting them
from point A to point B, either geographically or systematically. Both
also traditionally rely on human expertise and high level training to
oversee the processes involved. Both also have seen huge strides
in automation over the past decade, and of course both stand to
benefit significantly from artificially intelligent systems taking more
and more of the cognitive workload and mundane tasks away from
humans. But most importantly — in both industries, humans are
categorically not being replaced.
The reason is simple — legal responsibility. It is almost
unfathomable to imagine the owner of an AI system opting to take
full legal responsibility of a machine output when human lives are
on the line. No airline has come close to flying a commercial plane
entirely without pilots, and if it does, I would bet that the insurance
policies will be so huge it will likely not make it worth it for general
commercial flying (however, I concede it may be seen on private or
military flights, for instance). What we will likely see is ‘drone’
piloting of commercial flights — pilots seated squarely on terra
firma but remotely monitoring everything happening on a plane as it
soars across the globe. In fact, experiments are already being
planned for remote piloting, with mixed reactions from the general
public.

In medicine, it is currently far, far, far easier to simply limit an AI

system to providing ‘decision support’ and leave all ultimate
‘decision-making’ to a qualified human. Not one single existing AI
system that has medical regulatory approval has yet claimed to be
a ‘decision-maker’, and I sincerely doubt that one ever will, unless
the decisions being made are minor and unlikely to be life-critical.
This is because it is impossible for an AI system to ever be 100%
accurate in solving a medical diagnostic question, because, as I
have previously discussed, medicine in part still remains an art
which can never be fully quantified or solved. There will always be
an outlier, always be a niche case, always be confounding factors.
And for that reason alone, we will always need some form of
human oversight.

Reason 3. Productivity gains will drive demand

“If you build it, they will come” is the often misquoted saying from
the movie Field of Dreams (or Wayne’s World 2, depending on your
generation). If we build systems that massively improve radiology
workflow and diagnostic turnaround, we will almost certainly see a
massive increase in demand for medical imaging.

I’ve seen this with my own eyes — when I was a trainee, our
department started a new initiative to try and reduce waiting times
for ultrasound lists. We opened up an evening list with three or four
extra slots for urgent walk-in patients or those that had been waiting
more than 3 weeks. At first, this worked out nicely, with one trainee
being assigned per day to this extra list. It only took an hour
maximum after all. Fairly soon however, we started noticing
requests coming in saying ‘for the extra list please’, and before we
knew it we had to start opening up extra-extra lists, and extra-extra-
extra lists, which in turn just became the new normal. My point here
is that in radiology, if you offer a doctor a slot to scan a patient, they
will find a patient to fill that slot!

As AI becomes the new normal in radiology, as scan times and

waiting lists reduce, and as radiology reports become more
accurate and useful, we will continue to see an increase in demand
for our services. Add to this the ever increasing population growing
in age and complexity, it is to me 100% inevitable that demand
increases, and probably the major reason why I remain bullish on
radiology as a career choice.

We will need to train more radiologists to combat the tidal wave of

imaging being requested and data being produced, and may even
consider dual or triple accreditation in other data-producing
specialities such as pathology and genomics. ‘Radiologists’ may
not even be called radiologists in the far future — at least that’s one
theory I heard talked about at RSNA last year, but that doesn’t
negate the fact that someone human will still be in control of the
flow of data.

What will radiologist’s be doing then?

The radiologists of the next few decades will be increasingly freed

from the mundane tasks of the past, and lavished with gorgeous
pre-filled reports to verify, and funky analytics tools on which to
pour over oceans of fascinating ‘radiomic’ data. It won’t quite be like
Minority Report, but if you want to imagine yourself as Tom Cruise
swiping and gesturing away at a screen of futuristic malleable real-
time data, then go right ahead.

Where radiology artificial intelligence is heading towards is digital

augmentation of radiologists, to the point at which their job
becomes to monitor and assess machine outputs, rather than
manually go through every possible mundane finding as they do
now. Personally, I welcome this with open arms — I have wasted
far too much of my working life measuring lymph nodes on multiple
CT scans or counting vertebrae to report the level of a metastasis. I
would much rather check a system has measured the correct lymph
nodes and identified all the vertebrae required, and sign off on the
findings. Radiologists are going to be transformed from
‘lumpologists’ with crude tools, to ‘data wranglers’ dealing with ever
more sophisticated quantified outputs.

Radiologists will also be empowered to become more ‘doctor’ than

ever before, with productivity gains allowing more time
communicating results to both clinicians and patients. I can
certainly envisage radiologists as data communicators, both directly
to clinical teams on their rounds and tumour boards, and even
direct-to-patient information-giving. The profession at the moment is
only harmed by too much hiding away in dark rooms and, if
anything, artificial intelligence has the capability of bringing
radiologists back out into the light. That’s where it’s true power lies.

If you are as excited as I am about the future of radiology artificial

intelligence, and want to discuss these ideas, please do get in
touch. I’m on Twitter @drhughharvey

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About the author:

Dr Harvey is a board certified radiologist and clinical academic,

trained in the NHS and Europe’s leading cancer research institute,
the ICR, where he was twice awarded Science Writer of the Year.
He has worked at Babylon Health, heading up the regulatory affairs
team, gaining world-first CE marking for an AI-supported triage
service, and is now a consultant radiologist, Royal College of
Radiologists informatics committee member, and advisor to AI start-
up companies, including Algomedica and Kheiron Medical.