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Imagine this: You’ve been feeling unwell, so you call up your doctor’s office to make an appointment. To your surprise, they schedule you in for the next day. At the appointment, you aren’t rushed through describing your health concerns; instead, you have a full half hour to share your symptoms and worries and the exhaustive details of your health history with someone who listens attentively and asks thoughtful follow-up questions. You leave with a diagnosis, a treatment plan, and the sense that, for once, you’ve been able to discuss your health with the care that it merits.

The catch? You might not have spoken to a doctor, or other licensed medical practitioner, at all.

This is the new reality for patients at a small number of clinics in Southern California that are run by the medical startup Akido Labs. These patients—some of whom are on Medicaid—can access specialist appointments on short notice, a privilege typically only afforded to the wealthy few who patronize concierge clinics.

The key difference is that Akido patients spend relatively little time, or even no time at all, with their doctors. Instead, they see a medical assistant, who can lend a sympathetic ear but has limited clinical training. The job of formulating diagnoses and concocting a treatment plan is done by a proprietary, LLM-based system called ScopeAI that transcribes and analyzes the dialogue between patient and assistant. A doctor then approves, or corrects, the AI system’s recommendations.

“Our focus is really on what we can do to pull the doctor out of the visit,” says Jared Goodner, Akido’s CTO. 

According to Prashant Samant, Akido’s CEO, this approach allows doctors to see four to five times as many patients as they could previously. There’s good reason to want doctors to be much more productive. Americans are getting older and sicker, and many struggle to access adequate health care. The pending 15% reduction in federal funding for Medicaid will only make the situation worse.

But experts aren’t convinced that displacing so much of the cognitive work of medicine onto AI is the right way to remedy the doctor shortage. There’s a big gap in expertise between doctors and AI-enhanced medical assistants, says Emma Pierson, a computer scientist at UC Berkeley.  Jumping such a gap may introduce risks. “I am broadly excited about the potential of AI to expand access to medical expertise,” she says. “It’s just not obvious to me that this particular way is the way to do it.”

AI is already everywhere in medicine. Computer vision tools identify cancers during preventive scans, automated research systems allow doctors to quickly sort through the medical literature, and LLM-powered medical scribes can take appointment notes on a clinician’s behalf. But these systems are designed to support doctors as they go about their typical medical routines.

What distinguishes ScopeAI, Goodner says, is its ability to independently complete the cognitive tasks that constitute a medical visit, from eliciting a patient’s medical history to coming up with a list of potential diagnoses to identifying the most likely diagnosis and proposing appropriate next steps.

Under the hood, ScopeAI is a set of large language models, each of which can perform a specific step in the visit—from generating appropriate follow-up questions based on what a patient has said to to populating a list of likely conditions. For the most part, these LLMs are fine-tuned versions of Meta’s open-access Llama models, though Goodner says that the system also makes use of Anthropic’s Claude models. 

During the appointment, assistants read off questions from the ScopeAI interface, and ScopeAI produces new questions as it analyzes what the patient says. For the doctors who will review its outputs later, ScopeAI produces a concise note that includes a summary of the patient’s visit, the most likely diagnosis, two or three alternative diagnoses, and recommended next steps, such as referrals or prescriptions. It also lists a justification for each diagnosis and recommendation.

ScopeAI is currently being used in cardiology, endocrinology, and primary care clinics and by Akido’s street medicine team, which serves the Los Angeles homeless population. That team—which is led by Steven Hochman, a doctor who specializes in addiction medicine—meets patients out in the community to help them access medical care, including treatment for substance use disorders. 

Previously, in order to prescribe a drug to treat an opioid addiction, Hochman would have to meet the patient in person; now, caseworkers armed with ScopeAI can interview patients on their own, and Hochman can approve or reject the system’s recommendations later. “It allows me to be in 10 places at once,” he says.

Since they started using ScopeAI, the team has been able to get patients access to medications to help treat their substance use within 24 hours—something that Hochman calls “unheard of.”

This arrangement is only possible because homeless patients typically get their health insurance from Medicaid, the public insurance system for low-income Americans. While Medicaid allows doctors to approve ScopeAI prescriptions and treatment plans asynchronously, both for street medicine and clinic visits, many other insurance providers require that doctors speak directly with patients before approving those recommendations. Pierson says that discrepancy raises concerns. “You worry about that exacerbating health disparities,” she says.

Samant is aware of the appearance of inequity, and he says the discrepancy isn’t intentional—it’s just a feature of how the insurance plans currently work. He also notes that being seen quickly by an AI-enhanced medical assistant may be better than dealing with long wait times and limited provider availability, which is the status quo for Medicaid patients. And all Akido patients can opt for traditional doctor’s appointments, if they are willing to wait for them, he says.

Part of the challenge of deploying a tool like ScopeAI is navigating a regulatory and insurance landscape that wasn’t designed for AI systems that can independently direct medical appointments. Glenn Cohen, a professor at Harvard Law School, says that any AI system that effectively acts as a “doctor in a box” would likely need to be approved by the FDA and could run afoul of medical licensure laws, which dictate that only doctors and other licensed professionals can practice medicine.

The California Medical Practice Act says that AI can’t replace a doctor’s responsibility to diagnose and treat a patient, but doctors are allowed to use AI in their work, and they don’t need to see patients in-person or in real-time before diagnosing them. Neither the FDA nor the Medical Board of California were able to say whether or not ScopeAI was on solid legal footing based only on a written description of the system.

But Samant is confident that Akido is in compliance, as ScopeAI was intentionally designed to fall short of being a “doctor in a box.” Because the system requires a human doctor to review and approve of all of its diagnostic and treatment recommendations, he says, it doesn’t require FDA approval. 

At the clinic, this delicate balance between AI and doctor decision making happens entirely behind the scenes. Patients don’t ever see the ScopeAI interface directly—instead, they speak with a medical assistant who asks questions in the way that a doctor might in a typical appointment. That arrangement might make patients feel more comfortable. But Zeke Emanuel, a professor of medical ethics and health policy at the University of Pennsylvania who served in the Obama and Biden administrations, worries that this comfort could be obscuring from patients the extent to which an algorithm is influencing their care.

Pierson agrees. “That certainly isn’t really what was traditionally meant by the human touch in medicine,” she says.

DeAndre Siringoringo, a medical assistant who works at Akido’s cardiology office in Rancho Cucamonga, says that while he tells the patients he works with that an AI system will be listening to the appointment in order to gather information for their doctor, he doesn’t inform them about the specifics of how ScopeAI works, including the fact that it makes diagnostic recommendations to doctors. 

Because all ScopeAI recommendations are reviewed by a doctor, that might not seem like such a big deal—it’s the doctor who makes the final diagnosis, not the AI. But it’s been widely documented that doctors using AI systems tend to go along with the system’s recommendations more often than they should, a phenomenon known as automation bias. 

At this point, it’s impossible to know whether automation bias is affecting doctors’ decisions at Akido clinics, though Pierson says it’s a risk—especially when doctors aren’t physically present for appointments. “I worry that it might predispose you to sort of nodding along in a way that you might not if you were actually in the room watching this happen,” she says.

An Akido spokesperson says that automation bias is a valid concern for any AI tool that assists a doctor’s decision-making and that the company has made efforts to mitigate that bias. “We designed ScopeAI specifically to reduce bias by proactively countering blind spots that can influence medical decisions, which historically lean heavily on physician intuition and personal experience,” she says. “We also train physicians explicitly on how to use ScopeAI thoughtfully, so they retain accountability and avoid over-reliance.”

Akido evaluates ScopeAI’s performance by testing it on historical data and monitoring how often doctors correct its recommendations; those corrections are also used to further train the underlying models. Before deploying ScopeAI in a given specialty, Akido ensures that when tested on historical data sets, the system includes the correct diagnosis in its top three recommendations at least 92% of the time.

But Akido hasn’t undertaken more rigorous testing, such as studies that compare ScopeAI appointments with traditional in-person or telehealth appointments, in order to determine whether the system improves—or at least maintains—patient outcomes. Such a study could help indicate whether automation bias is a meaningful concern.

“Making medical care cheaper and more accessible is a laudable goal,” Pierson says. “But I just think it’s important to conduct strong evaluations comparing to that baseline.”