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Enhancing the reliability and accuracy of AI-enabled diagnosis via complementarity-driven deferral to clinicians


Predictive artificial intelligence (AI) systems based on deep learning have been shown to achieve expert-level identification of diseases in multiple medical imaging settings, but can make errors in cases accurately diagnosed by clinicians and vice versa. We developed Complementarity-Driven Deferral to Clinical Workflow (CoDoC), a system that can learn to decide between the opinion of a predictive AI model and a clinical workflow. CoDoC enhances accuracy relative to clinician-only or AI-only baselines in clinical workflows that screen for breast cancer or tuberculosis (TB). For breast cancer screening, compared to double reading with arbitration in a screening program in the UK, CoDoC reduced false positives by 25% at the same false-negative rate, while achieving a 66% reduction in clinician workload. For TB triaging, compared to standalone AI and clinical workflows, CoDoC achieved a 5–15% reduction in false positives at the same false-negative rate for three of five commercially available predictive AI systems. To facilitate the deployment of CoDoC in novel futuristic clinical settings, we present results showing that CoDoC’s performance gains are sustained across several axes of variation (imaging modality, clinical setting and predictive AI system) and discuss the limitations of our evaluation and where further validation would be needed. We provide an open-source implementation to encourage further research and application.

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Fig. 1: CoDoC training and deployment architecture.
Fig. 2: Performance of CoDoC in breast cancer prediction compared to that of a standalone predictive AI system and clinical readers.
Fig. 3: Performance of CoDoC in breast cancer prediction on a US mammography dataset (US Mammography Dataset 2).
Fig. 4: Performance of CoDoC in TB prediction.

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Data availability

The mammography datasets from Northwestern Medicine and St. Clair Hospital were used under licenses for the current study and are not publicly available. The tuberculosis datasets from the Stop TB Partnership and icddr,b were used under a license for the current study and are not publicly available. US Mammography Dataset 2 can be requested via email to for research purposes, and access shall be granted within a week’s time. The Github link where the code is also hosted contains details on how to obtain access to the data required to reproduce results for the UK mammography dataset and the associated timeline. These datasets only consist of the data required to train CoDoC (a database of predictive AI confidence scores, clinician opinion and ground truth disease label for each case in the tuning/validation/test set). For the UK Mammography Dataset, the images and data used in this publication are derived from the OPTIMAM database (, the creation of which was funded by Cancer Research UK. The full database including medical images used to train the predictive AI can be requested at; this request will be reviewed by the OPTIMAM steering committee (

Code availability

The code is available at


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We would like to acknowledge the multiple contributors to this international project: Stop TB Partnership hosted by UNOPS; Cancer Research UK; the OPTIMAM project team and staff at the Royal Surrey County Hospital, who developed the UK Mammography OPTIMAM imaging database; our collaborators at Northwestern Medicine and all members of the Etemadi research group for their continued support of this work; St. Clair Hospital; and B.A. Klepchick, J.M. Andrus, R.J. Schaeffer and J.T. Sullivan. We thank the National Cancer Institute (NCI) for access to NCI data collected by the National Lung Screening Trial. The statements contained herein are solely those of the authors and do not represent or imply concurrence or endorsement by the NCI. We also thank L. Peng, D. Webster, U. Telang and D. Belgrave for their valuable feedback and support throughout the course of this project; D. Tran, N. de Freitas and K. Kavukcuoglu for critically reading the manuscript and providing feedback; R. Pilgrim, A. Kiani and J. Rizk for work on partnership formation and engagement; R. May and E. Sutherland Robson for assistance with project coordination; S. Baur and S. Prabhakara for mammography domain expertise; and M. Wilson for early engineering work. The work by S.M., M.B. and N.P. was done at Google DeepMind/Google Research.

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Authors and Affiliations



K.D., J. Winkens, S.G., N.P., R.S., Y.B., P.K., T.C. and A. Karthikesalingam contributed to study conception and design. J. Witowski, S.M., S.S., M.S., T.S., G.C. and A. Karthikesalingam contributed to data acquisition; K.D., J. Winkens, M.B., S.G., N.P., R.S., M.D., T.S. and T.C. contributed to data analysis; K.D., J. Winkens, M.B., S.G., R.S., C.K., S.M., Z.Z.Q., J.C., K.G., J. Witowski, P.K., T.C. and A. Karthikesalingam contributed to data interpretation; K.D., J. Winkens, S.G., M.B., N.P., R.S., S.A., L.C., M.D., J.F., A. Kiraly, T.K., S.M., B.M., V.N., S.S., M.S. and T.C. contributed to the creation of new software used in this study; K.D., J. Winkens, M.B., S.G., R.S., P.S., Z.A., C.K., A. Kiraly, Z.Z.Q., J.C., K.G., J. Witowski, P.K., T.C. and A. Karthikesalingam contributed to drafting and revising the manuscript; and K.D., J. Winkens, M.B., S.G., R.S., P.S., Z.A., P.K., T.C. and A. Karthikesalingam contributed to paper organization and team logistics.

Corresponding authors

Correspondence to Krishnamurthy (Dj) Dvijotham or Jim Winkens.

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Competing interests

This study was funded by Google LLC and/or a subsidiary thereof (‘Google’). K.D., J. Winkens, S.G., R.S., P.S., Z.A., S.A., Y.B., L.C., M.D., J.F., C.K., A. Kiraly, T.K., B.M., V.N., S.S., M.S., T.S., G.C., P.K., T.C. and A. Karthikesalingam are employees of Google and own stock as part of the standard compensation package. S.M., M.B. and N.P. are previous employees of Google, N.P. is a current employee of Microsoft and S.M. is a current employee of OpenAI. Z.Z.Q. and J.C. are employees of the Stop TB Partnership and collaborated with Google to support this research effort. K.G. and J. Witowski are employees of the NYU Grossman School of Medicine. K.G. and J. Witowski collaborated with Google to support this research effort.

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Nature Medicine thanks Pranav Rajpurkar and the other, anonymous, reviewer(s) for their contribution to the peer review of this work. Primary Handling Editors: Joao Monteiro and Lorenzo Righetto, in collaboration with the Nature Medicine team.

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Additional information on datasets and images from breast examinations.

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Dvijotham, K.(., Winkens, J., Barsbey, M. et al. Enhancing the reliability and accuracy of AI-enabled diagnosis via complementarity-driven deferral to clinicians. Nat Med 29, 1814–1820 (2023).

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