Health2049 Season One Recap

Health2049 co-hosts Bisi Williams and Jason Helgerson look back at season one to discuss inspirational stories and innovative ideas in healthcare. With 19 podcast guests from diverse backgrounds, this season was jam packed with a variety of viewpoints that opened up new perspectives on the way forward into an industry ripe for disruption. What were the common themes? What surprised our co-hosts? What voices were missing? Find out as they reflect on the season and share their insights about the future of healthcare.

To learn more about our Health2049 podcast co-hosts, please visit our hosts page.

Show Notes

• What common themes weaved throughout season one? [02:35]

• Jason points to the episode “The Optimistic Technologist” with Dr. Nirav Shah, Chief Medical Officer of the digital health company Sharecare, in which he described in detail how artificial intelligence can give us the opportunity to live a better life. [05:05]

• In the episode “The Commentator Who Dreams,” Roy Lilley, the Founder of the Academy of Fabulous Stuff, described an example of a highly efficient and respectful patient-centered experience that’s possible with technology that exists today. [06:05]

• Bisi discusses wellness in the future as she comments on her episode “Using Wonder to Imagine the Future of Healthcare” with experience designer Barbara Groth. [07:45]

• Innovative business strategist Dervala Hanley imagines a future healthcare system that offers personalized medical plans for each individual in the episode, “The Inclusive Strategist.” [07:45]

• What podcast guests had differing points of view for the future? [09:35]

• With decades of experience in public policy, Nancy-Ann DeParle, Co-founder of Consonance Capital Partners, expressed her vision for the future of healthcare payments in the episode “The Obamacare Architect.” [10:17]

• In the “The Equitable Visionary,” Dr. Jerrica Kirkley, Co-founder of Plume that serves the queer trans community, offered a surprising perspective on paying for healthcare in 2049.[11:25]

• Dr. Natalie Landman, Executive Director at the ASU Center for Healthcare Delivery and Policy, shared payment alternatives in “Defining Health Economics.” [12:24]

• In the episode “Exploring Healthcare as a Public Utility,” Dr. Jeffrey Kaibin Lin asks what’s the point of new innovations if everyone doesn’t have access? [13:14]

• What perspectives surprised our podcast hosts? [14:07]

• Dr. Monica Lypson, Vice-Dean of Education at Columbia’s Medical School, pointed out that we aren’t training medical students for the future in the podcast episode “The Innovative Educator.” [15:20]

• How can artificial intelligence be more beneficial than an in-person doctor visit? [17:12]

• The importance of compassion and community as tools for healing. [22:20]

• In the episode “Reprioritizing Bedside Manner,” Dr. Theophil Stokes, Chief of Neonatology at Walter Reed National Military Medical Center, shared profound personal experiences about empathy. [24:40]

• The diverse backgrounds of the podcast guests featured in season one. [27:03]

• Roy Lilley bluntly stated that medical providers don’t respect the patient’s time. [27:37]

• Dr. Rushika Fernandopulle, Co-founder and CEO of Iora Health, in “The Compassionate Disrupter” provided an empathic patient-provider point of view. [28:58]

• Two innovative healthcare companies that demonstrate a value-based payment system. [30:50]

• What healthcare perspectives and voices were missing from season one? [33:20]

Bruce Mau, CEO, Massive Change Network

How can we use fact-based optimism to design a new healthcare system? Internationally renowned designer Bruce Mau imagines an intelligent ecosystem of life and health with a diverse ecology that integrates market and social methods. He shares that design goes beyond medical innovations, and can be applied in developing solutions to health disparities, creating health care accessibility and regulating artificial intelligence.

Bruce Mau is a brilliantly creative optimist whose love of thorny problems led him to create a methodology for whole-system transformation. Across 30 years of design innovation, he’s collaborated with leading organizations, heads of state, renowned artists and fellow optimists. A serial entrepreneur since the age of 9, he became an international figure with the publication of his landmark S,M,L,XL, designed and co-authored with Rem Koolhaas. He is the author of MC24, founder of Bruce Mau Studio and co-founder and CEO of Massive Change Network, a holistic design collective based in Chicago.

Show Notes

• Bruce Mau shares his background in implementing design to solve problems. [02:11]

• Health care will be fundamentally reconceived based on a series of structural challenges. [03:01]

• The all powerful doctor era is over as the patient becomes more empowered. [05:13]

• Most of health care is routine knowledge that could be run by artificial intelligence. [07:09]

• We need design applied to a new level of artificial intelligence governance and regulation. [09:26]

• Using fact-based optimism in solving health care issues. [10:44]

• How do we solve health disparities both within and between countries?   [12:23]

• How do we create accessibility for new health care innovations? [14:42]

• How should we fund scientific research in the future? [17:04]

• How do we solve health care challenges as our world population grows? [18:33]

• What are the impediments to change? [20:54]

• How do we normalize change? [21:42]

• How will we use the opportunity to advance quickly? [22:53]

Transcript

Jason Helgerson: I'm Jason Helgerson, and you're listening to Health 2049.

Bruce Mau: For me, it's a diverse ecology. It's not a monoculture. It's not about a singular solution. We can see innovation and contribution and development using market methods, and we can see innovation and development using social methods. There's a new kind of axis developing that is not about left and right. It's not about social versus market. It's actually about forward and backward, an advanced world and a world that is moving forward or retrograde and moving backward.

Jason Helgerson: [01:46] This week, we'll be talking to someone whose optimism and big ideas know no bounds. This week we challenge internationally recognized designer Bruce Mau to think creatively about the state of healthcare 30 years into the future. So without further ado, let's meet Bruce Mau. Bruce, welcome to the show.

Bruce Mau: [02:04] Thank you, Jason. Delighted to be here.

Jason Helgerson: [02:06] So, Bruce, please tell our listeners a bit more about your extraordinary career.

Bruce Mau: [02:11] Well, I'm a designer. I started over 30 years ago as a graphic designer, so I have some perspective. But over those decades, my work has expanded really to design outcomes of all kinds. So I've designed cities and carpets, brands and businesses, social movements and institutions. I've really applied the power of design to solve problems of all sorts.

Jason Helgerson: [02:38] And I know one of your major projects in your career was coming up with a 1000 year plan for Mecca. So if there's anyone qualified to talk to about what healthcare could and should look like 30 years in the future, I think it's you, Bruce. We're so pleased to have you here today. So I'm going to start out with the same question we ask all of our guests what does healthcare look like in 2049?

Bruce Mau: [03:01] I think healthcare will be fundamentally reconceived based on a series of structural challenges that apply to every healthcare system, whether that system is market-based like we have in the US or socialized like most of the rest of the world. Every year we add new capacities and possibilities, new drugs, new products, procedures, new technologies, new replacement parts, we add, and we never subtract. The potential for intervention is ever expanding. The status quo is under constant attack. At the same time, technology is working to miniaturize or dematerialize everything, driving down cost and connecting every device to the Internet of things.

On top of that, we're developing an AI functionality that will take much of the conventional knowledge requirements out of the practice of healthcare. Embedding the knowledge in the devices themselves. As the cost of genetics decreases, healthcare will become increasingly personal and individual. Additionally, with all of that connectedness comes a new potential for data analytics, where we really can learn from tracking our behavior and our genetics to produce health outcomes that we want and need socially, economically and ecologically, using a much more consumer facing interface. 

Finally, there will be a lot more of us. We'll be approaching 10 billion people on the planet, and the stress on the ecosystem will challenge us everywhere to change everything and live differently. So I imagine a much more interconnected, intelligent ecosystem of life and health rather than the medical system as we know it today.

Jason Helgerson: [04:36] Interesting. So, as I said up front, Bruce, you are a man of big ideas, and your idea for healthcare in 2049 encompasses the entire system on a global basis. But I'm hoping that maybe you can take us down from say, that 50,000 foot level down to the ground floor and describe for the audience an experience I think we all have. We all know what it's like to go to a doctor's office. And so I'm wondering what you think that experience will be like in 2049, given your overall system changes that you see coming our way.

Bruce Mau: [05:13] Well, I think that depends very much on where you are. I think overall, the biggest difference will be an empowered citizen. If you think about what is happening globally in our possibility, we're really shifting power to the citizen to the individual. I remember reading a book called "The Pearl," I think it was by Steinbeck when I was in high school and it was about a doctor who was all powerful. That era is over. What we're really seeing is the distribution of power to the individual.

Suddenly the individual really has access to knowledge in a way that was really impossible for most of history. That changes the experience pretty fundamentally, where more and more of the potential for intervention in the health experience is actually resting on the patient, on the citizen and the healthcare doctor's office experience is much more of a collaborative experience than it is today.

Jason Helgerson: [06:14] Interesting, in healthcare we often talk about this concept of patient-centered or person-centered care, but yet least in my view, has always been that it couldn't be farther from the truth that whether it's a doctor's office, a hospital, or almost any other mode of delivery of care is almost all built around the provider of the service and services provided at the convenience of the provider. But the world you're describing is one where the patient, the person is the center, they're an empowered decision-maker.

So one, I think your vision is exciting. But my only question for you is it's doability. We look back in my lifetime, 50 years on the planet, the mode and the method of healthcare and the relationship between the doctor and patient hasn't fundamentally changed in my lifetime. What gives you confidence that the fundamental relationship between the doctor, the system and the patient will fundamentally change over the next 30 years?

Bruce Mau: [07:09] I think, mostly because it's already happening, even though I think you're right that the kind of status quo is holding on. But there is a tsunami of massive change happening. Most of what I described is already here. It's just not implemented yet at mass scale. So it's not accessible. But over a decade ago, I did a project called Massive Change, and we did 20 person years of research to try to understand how our capacity to design the world is changing. And what we discovered is so profoundly optimistic that it is really stunning that we don't believe what we are capable of and what we are, in fact, doing. According to Ray Kurzweil, living in the 21st century will be like living through 20,000 years of human progress.

So the kind of change that is coming and is already happening, I think, is really profound. If you think about what just happened with the coronavirus. The Pfizer vaccine was designed in two days. AI is already making all sorts of routine knowledge actionable on an everyday basis, and most of healthcare is routine knowledge. Now there's a lot of friction to let go of that, because so much status and economy is attached to it. But that's an inevitability. I mean, that is just happening. And like it or not, that's really what we're going to experience.

Jason Helgerson: [08:32] Interesting. And I know there's been a lot of talk about the potential of AI in healthcare. I think not quite yet realized to the degree to which particularly the advocates for the new technology would like. But certainly we already have examples of artificial intelligence being able to diagnose certain conditions or to read, say, imaging more effectively than human beings. Do you see that as a major development here in the sense of really empowering patients when they don't have to see the doctor as this all powerful omnipotent or omniscient individual, the super scientist who has to answer the questions that no one else can answer and that they'll be able to access technology to get some of those answers themselves. Is that what you see is sort of will really change the power dynamic here?

Bruce Mau: [09:26] I think that's a big part of it. I think that when you distribute that possibility, when it's really accessible, when it's really fully developed. For me, AI has a kind of two sided. On the one hand, I think the opportunity to do what you just described is really important and would be profound in transforming not only the experience, but the economy of healthcare. 

The other side is that I think AI and data should not be used by the existing system. We need a new level of governance and regulation that currently really doesn't exist. Our crisis in governance is holding us back in profound ways, and so we need design applied to governance as much as it is applied to the experience and the technology.

Jason Helgerson: [10:13] Interesting, because there are certainly while there are many advocates for these new technologies and tremendous excitement about their application in healthcare, there are also those who have serious reservations and concerns. And I think you have begun to highlight some of those the fear of how this new technology could be used to discriminate against people to exacerbate the inequalities that exist in healthcare access and outcomes. But it sounds like you're more optimistic.

Bruce Mau: [10:44] Absolutely. That's fact based optimism. One of the projects that I just published in MC 24 by a man named Max Roser from Our World in Data, looks at the last 200 years and represents that by 100 people over that time. In other words, if you look 200 years ago, if you look at the important metrics like poverty, extreme poverty 200 years ago, only 6% of the world did not live in extreme poverty. Now only 10% still do.

Now, when I say only 10%, it's still a huge number, but what's interesting, when you really look at the data, when you look at the graphs that Max Roser did, you can see very clearly where that line is going and it's going inexorably in the right direction. The same is true of infant mortality, of basic education, of vaccination, which 200 years ago was zero. Today, it's 86%. So you can see what we're accomplishing. And it's clear that globally we are already doing it and already committed to that.

Jason Helgerson: [11:47] Interesting. So I'll push back a little bit on your optimism in this sense is that disparities exist both within countries and between countries in terms of many of the outcomes that you mentioned. While I agree with you that we've made significant progress and don't dispute your statistics, we still have very significant disparities. What gives you confidence that those disparities exist today will no longer be a salient factor in the healthcare system of 2049? You seem to be quite confident that all boats will rise.

Bruce Mau: [12:23] That is optimistic perspective, but again, it's fact-based optimism. In other words, we've been doing that all along, and we continue to do it, and we will continue to work on smaller and smaller pockets of extreme challenges that we face. And I think that's clear. For instance, just a few weeks ago, at the beginning of this year, Plan S was declared. And Plan S is a commitment by a large group of major funders of scientific research that all of the science that they fund will be accessible on an open platform without cost.

So no more will the science be behind paywalls. And what that does is it broadly distributes possibility in a way that hasn't happened in the past. And I think that that's just part of the global movement that we call massive change. It passed without notice, for most people, they were not aware of Plan S, but it is a profound structural, fundamental change in the knowledge culture of the world. And it means that everywhere anyone can gain access. And that really is the revolution that we're living through.

Jason Helgerson: [13:40] Yeah, that is super interesting and I think massively underreported because I think that the healthcare world is used to new technologies, new treatments, new drugs being patented. And as a result of those patents, that gives the maker of those new treatments, those new devices, those new drugs the opportunity to charge quite high prices for those treatments. And I'm not going to argue that they did not incur costs, R and D costs and development. But the system that we have today, at least at its bedrock, is this concept, that innovation is rewarded through these patents.

And I think what you're suggesting is a pretty fundamental change and move away from that in which those technologies, those new treatments would not be reserved for that length of time. And as a result, the prices would come down and would be more widely available. But I'd say, Bruce, that's a pretty significant change from what we're seeing today.

Bruce Mau: [14:42] Absolutely. And it's something that I've been troubling about for several years. I was trying to think, how do you distribute access if you think about the scientific project, the kind of real genius and transformation of the scientific project is that it was egalitarian. It was accessible to anyone. Anyone could write a paper invent something, prove something and contribute it to the scientific literature. And your status was not a determining factor in its success. Now, the status and the kind of prejudice was still built into the culture. So you didn't escape that, but you could contribute. 

And I think that is now coming to full fruition. And I think that kind of a future accelerates impact. I like to say that Einstein's are evenly distributed, but they're not evenly supported. And the more that we can support access to possibility, the more great contributions we will have. That's why I'm confident think about 100 design teams working on vaccines simultaneously. That's how we're going to beat this thing. And that really is a new era that just wasn't possible even 50 years ago.

Jason Helgerson: [15:59] Agreed. Although I would say about that, though, is that obviously those design teams, which are a mix of government funded and private, although the Pfizers, the Modernas are private companies, some of those receiving government money, others not. But a lot of those companies had the resources, had the ability to focus on the current crisis because they were profit maximizing, because they had generated profits from previous discoveries they were able to capture those economic rents. And so, in essence, the Pfizers of the world are creatures of that system that I had previously described.

But the world you're describing is a very different one. How do you envision that that research is financed in the future? Do you see it as a government function? Because my concern would be is that if you take away some of the profit-making potential of these developments by making them more widely available and less of a proprietary nature, that you're going to get less investment in that. Unless, of course, the government comes in and makes up for it.

Bruce Mau: [17:04] Of course, I think you're absolutely right. And that's why, for me, it's a diverse ecology. It's not a monoculture. It's not about a singular solution. We can see innovation and contribution and development using market methods, and we can see innovation and development using social methods. We can use social institutions to advance the world and we can use market methodologies and incentives to advance the world. 

What we saw really, when we did massive change was that there's a new kind of axis developing that is not about left and right, it's not about social versus market. It's actually about forward and backward, a 90 degree axis that is about an advanced world and a world that is moving forward or retrograde and moving backward. And I think that's a more important access than the left and right.

Jason Helgerson: [17:57] Interesting. So let's talk about what I would consider potentially a threat or opportunity that the world you described presents, which is that as the technology advances, there will be opportunities for all of us to live longer, including people listening on to this podcast right now. But with that, as you had mentioned earlier on, the population of the world will continue to grow. And so my first question is, do you see those longer lives and the growth in the population as a threat or an opportunity or both?

Bruce Mau: [18:33] I wouldn't frame it as threat or opportunity. I think it's a challenge. There are going to be more of us and we're going to live longer. Those two facts seem inexorable, and that produces a new kind of challenge, because that means we're going to have to reconceive practically everything that we do. I mean, the way we do almost everything today is designed for the short term. It's designed for the top billion people. We leave the bottom 7 billion to their own devices. 

CK Prahalad wrote a book called "The Fortune at the Bottom of the Pyramid." And what he describes in the book is that if you really look at the bottom of the economic pyramid in the world and you go down there and you solve those problems. Often you revolutionize the top of the pyramid. And what he showed is that almost no design application is being directed to that bottom of the pyramid. 

And when we do direct it, if you look at the work of Rebecca Richards-Kortum at Rice University, what she did that was so stunning, is she said, look, I want to take a contemporary doctor's office and put it in a backpack and take it off the grid. So I want all the functionality that I have in a modern doctor's office in Chicago, and I want to carry it into the jungle in Guatemala. That means everything has to be miniaturized. It has to have low power needs, because we're going to use solar power and it has to be low cost. And what she did with her team at Rice was they went systematically function by function and put those functions into the backpack. And one of the devices took a $4000 piece of equipment and made it accessible for under $100.

Now, if you're the maker of that $4,000 piece of health care equipment, it's a bad day for you, but that's possible because we're solving the problem of gaining greater and greater access to possibility. That's an inexorable movement, that's not going to stop. We're going to keep making things lighter, cheaper, easier, smarter, more connected, more intelligent. And all of that is going to make healthcare more accessible.

Jason Helgerson: [20:48] What do you see as the biggest potential impediment to this positive vision of the future becoming reality?

Bruce Mau: [20:54] I would say the status quo. It's the stopping power of inertia, combined with the staggering amounts of money and status that are involved. In other words, there are a lot of people right now who have a pretty sweet deal and a very good life and kind of standing in the community under the existing regime. But the sand on which that edifice is constructed is really shifting underneath them. And I think a lot of those people are going to do everything they can to hold on while the world changes. And that, I think, is true of almost everything.

Jason Helgerson: [21:30] So in terms of overcoming that, it sounds like you're quite optimistic that despite that status quo as being a challenge, that humanity will overcome it within the next 30 years.

Bruce Mau: [21:42] Yeah. I have no doubt about that. You think about everything else that we've done. I think one of the most extraordinary things about the human animal is how quickly we normalize what we change. Think about how short a time we've had the iPhone. I started in the design business when we were still using hot metal type. I started in the Gutenberg era, and the change that I've seen is absolutely staggering. I can't remember how we did things. I can't remember how we did things before the computer was the way that we work.

But we did. We managed to produce things every day of the year, so we normalize how staggeringly inventive and creative and transformational we really are. We somehow project that backwards and forwards. We think, oh, it's always been like this and it's always going to be like this. No, it actually hasn't been like this. It's never been like this. And it won't be like this in the future.

Jason Helgerson: [22:45] Great. So one final question, Bruce, and appreciate you being on the show here with us today. What question didn't I ask that I should have?

Bruce Mau: [22:53] That's a great question. I think the question that I really don't know the answer to is whether we will use all this possibility to advance things quickly or whether we will hold on to the very last minute. I mean, I think that it's inexorable at the same time, the big question that we have to answer is, are we willing to move quickly because lives are at stake?

Jason Helgerson: [23:21] Well, thanks, Bruce. That was absolutely fantastic. Thank you so much for coming on our show. Well, folks, that was internationally recognized designer and big thinker Bruce Mau, who was gracious enough to share his positive vision for health and wellness in the year 2049. As always, thank you for listening to Health 2049. If you enjoyed what you heard, please subscribe to us and share this podcast with a friend. Thank you and see you next time.

Dr. Denis Cortese, Director of the Health Care Delivery and Policy Program at Arizona State University

How can we reduce costs, yet improve the healthcare delivery system? Dr. Denis Cortese, Director of the Health Care Delivery and Policy Program at ASU, says that there’s at least one third of waste in the system. He shares a comprehensive plan from the Mayo Clinic Health Policy Center that shifts health care from a hospital-centered, transactional model to a high-value, patient-centered system.

Dr. Denis Cortese is a champion of high-quality and patient-centered health care. He is currently Director of the Health Care Delivery and Policy Program at Arizona State University (ASU); Foundation Professor at ASU; and President of the Healthcare Transformation Institute, a non-profit organization dedicated to improving healthcare delivery and lowering health care costs. Dr. Cortese is also Chair of the Institute of Medicine’s Roundtable on Value and Science Driven Healthcare, and serves on the boards of Pinnacle West and RAND Health. From 2003 until his retirement in November 2009, he was President and Chief Executive Officer of Mayo Clinic. Prior to that, Dr. Cortese served in other administrative positions at Mayo, and worked in the organization’s pulmonary and critical care areas for nearly 30 years.

Show Notes

• A shift from practicing pulmonary medicine to reimagining the healthcare delivery system. [02:58]

• Three future healthcare domains that could shift the hospital from the epicenter of healthcare. [04:16]

• Comprehensive concepts developed by the Mayo Clinic Health Policy Center for a new healthcare delivery system. [10:53]

• Two elements of health care that need to change with cooperation from the government and other organizations. [16:30]

• Why would this new comprehensive health care system cost less? [19:16]

• The four levels of prevention. [21:26]

• Hospital administrators are trained to keep the hospital as full as possible for profit. [27:33]

• What’s in the way of wellness becoming beneficial to all? [32:22]

• Patients have a shared health care vision that doesn’t match the stakeholders.  [33:23]

Transcript

Bisi Williams: I'm Bisi Williams. You're listening to Health 2049.

Dr. Denis Cortese: When you call a group together, all the stakeholders, it's like bringing in all the orchestra members, but that they are all soloists and they are only interested in playing their music when they want to play it, and they want to play it as loud as possible and that's what happens in healthcare. The stakeholders have come to the table in healthcare, they're there to maximize their sector but whether that optimizes the output for the people is not number one in their mind. And the people who become members of an orchestra are very interested in having beautiful music be produced, and it's not about them. It's about the music.

Bisi Williams: [02:03] My guest today is a champion of high quality patient-centered healthcare. Dr. Denis Cortese is a physician and emeritus President and Chief Executive Officer of the Mayo Clinic. He is currently director of the Healthcare Delivery and Policy Program at Arizona State University and a Foundation Professor. He is also President of the Healthcare Transformation Institute, a nonprofit organization dedicated to improving healthcare delivery and lowering healthcare costs. 

His vision for healthcare demonstrates why synthesis and the creation of a learning model will be a win-win for everyone by eliminating gaps in friction within a designed healthcare system. I am pleased to have Dr. Cortese on our show to talk about his Mayo Clinic experience and how he sees healthcare delivery in 2049. Welcome to the show.

Dr. Denis Cortese: [02:51] I'm glad to be here.

Bisi Williams: [02:52] So how do you make the leap from practicing pulmonary medicine to reimagining healthcare system delivery?

Dr. Denis Cortese: [02:58] That's a very good question. It sort of evolved as I was practicing at the Mayo Clinic, did it for over 40 years, but around in the mid 1980s, an awful lot began to change with regard to focusing on payment for healthcare and the idea of getting more people coveraged. And when we talked about the issue of, what is it we're trying to accomplish, we began to talk about that back in the 80s, when I say we I mean a group at Mayo Clinic, and then we extended that out to a wider population.

And when we began to realize what we're really trying to work towards, we felt that the current payment model of fee-for-service would be a great distraction and in fact, an inhibitor to get to the new future state that you are hoping we will be at by 2049. And we are actually on that journey right now. But that's how it shifted because I began to realize that what was being done external onto the health system with regard to payment models would not get us to where we thought we really could be in this particular century.

Bisi Williams: [04:08] That's fascinating. So without further ado, I'd love to hear your vision for a healthcare delivery system in the year 2049.

Dr. Denis Cortese: [04:16] Well, 2049 is a good year to sort of pick that even though I think we can find examples where we are almost there in some isolated pockets around this country. The idea goes like this, what is it that we want in healthcare in 2049? We asked many people these three questions, and I think the audience could ask themselves or answer for themselves because these questions set the strategy for the goals of what we want to attain. And then I'll explain maybe how we get there. 

The first question is who in the audience would like to be admitted to a hospital tomorrow? And most people don't actually stand up and volunteer to say, yeah, I can't wait to get into a hospital tomorrow. The second question is okay, if you don't want to go to a hospital who would actually like to be sick tomorrow, and you don't see many hands go up for that question either. And the third question is, okay, then you don't want to be sick, you don't want to have to be admitted to the hospital, who would like to consider themselves as a patient? A patient is someone defined by the dictionary as someone who long suffers and long endures.

If those are the goals of our new future, then by 2049, I think physicians will be serving the public and collaborating with them to maintain their activity to maintain their feeling of health. Even if they have chronic illnesses, you can feel quite healthy. I've got five chronic conditions, but I feel pretty healthy, pretty active. We will be involved in preventing illnesses. Well, in the fee-for-service payment model, you only get paid when people are sick. If you get into the business of preventing illness, you might lose money.

So we have to change the way the payment model goes to be able to help more and more preventive activities take place. Of course, we'll still be in the business of curing when possible. So we try to cure when possible. If not, we try to help people live and be active with their illness. And towards the end of life, we would be involved in much more in keeping people comfortable. Since people prefer not to be sick or think of themselves as patients, they really want to avoid hospitalization unless it's absolutely necessary. And there will be lots of cases that will be absolutely necessary.

But the idea is to maybe only go in the hospital once or twice in your life rather than once every three months or four months. We want to be active and feeling healthy as possible. Even people with chronic conditions, medical conditions like myself really want to think of themselves as being healthy and to live longer if possible. My job now, and it will be to serve the primary stakeholder in healthcare, and that is the person, the individual, the people or patients. That's the primary and actually the ultimate end user of our services.

So in my view, there really is basically only one, there should only be one stakeholder in healthcare and that's the individual or the patient. All the rest of us are vendors. All the rest of us are trying to help people to attain the goal they would like to have. In 2049, it's likely we will say something like this, that decades ago, many years ago, we realized making the hospital the epicenter of care was really financially untenable in the long term and that our physician-patient relationship with the people that we're taking care of or as some people would say, the clients or customers. In other words, we have to find a way to make money and be viable by keeping people healthier and keeping them out of the hospital.

That would be the design of the new healthcare system in which hospitals are no longer the center of the universe. But in other words, we will need them, but the whole purpose of what we're trying to do is keep people healthier. And then finally, how would we develop some kind of a healthcare system? What would it look like? 

And I would submit that it would look like a national learning organization where we're all learning together, inside of which there would be a number of domains. I'll just list three of them. It would be the knowledge domain. That's where all of the research takes place, the knowledge generation that domain would be if you just view it as its own system. It's like its own universe. And inside that universe are all the people who are doing the work, and they're funded pretty heavily by the federal government. We've just seen the benefit of having a knowledge domain that is quite functional in the fact that we've generated vaccines for COVID, and we will have to modify those vaccines. I think over time and we were able to do so as fast as we did, because we had been investing in this knowledge domain for decades and building up the basic knowledge on how to generate these kinds of vaccines so that's the knowledge domain.

The second domain would be where the patient resides, and that's where care delivery takes place. But it's where all the interactions take place between the individuals in healthcare and the patients who come to those locations periodically for care that they feel they might need.

And then the third big system or domain is the payer domain. And in that payer domain today, we have hundreds of different insurance models. We have the private sector. Then we have sort of the public domain, which would be the federal plans and state plans close to that is, of course, the VA and the military systems. Those are two other systems that are all funded by the government and applied by the government and supervised by the government. So you get the idea there are multiple various insurance plans in that system. None of them really ever communicate with each other and those of us who have to send bills to those systems have to use different paperwork for every single insurer. 

So that gives you an idea that a new delivery system focused on keeping people healthier, out of the hospital, if we possibly can and keeping them well and comfortable and where we are trying to coordinate the efforts of the knowledge domain with the care delivery system and also the payer system.

Bisi Williams: [10:42] Wow. Okay. Dr. Cortese, that's phenomenal. I mean, that is really a complex system that you talk about. And my first question for you is, why do you think your vision will work?

Dr. Denis Cortese: [10:53] Bisi, I should be clear that this isn't just my vision. This is really a set of concepts that were evolved during about probably about a four year period of time, beginning around 2004. When I was working at Mayo Clinic, we launched a group called the Mayo Clinic Health Policy Center. And we engaged over these years, a couple of thousand people altogether, at a national level, we had multiple of some large meetings, and we had a whole series of small meetings with maybe 20 to 30 people. We called them forums where we debated and discussed many different concepts, out of which we did some voting and we prioritized what would be helpful.

And the ideas that came out became a cohesive set about what a new healthcare delivery system could look like. And the concepts that came out I can just list for you and describe briefly, the first concept is that whatever we have should be a learning organization, which means everyone within the system should know what the system knows with a click of a button and that we can integrate and coordinate. Now, I know that we're a long way from that, but we're a lot closer now than where we were maybe just 15 years ago.

So that's the big overarching concept. Then the first question is, what's the purpose of the system? Why do we exist? Why should we exist? And one item came up for that. And that was to produce value in healthcare. High value healthcare. To create the value, we found that there were at least three or four concepts that needed to be in place to make it work. 

Number one is the idea of integration and coordinated care. Without that base, you just can't build on anything. And integrated care is really what physicians, nurses, delivery systems and hospitals do as they work with each other. How integrated are they communicating among themselves?

The second component is basically the idea of coordination of care. Coordination of care is what we do around the patient. So, for instance, an integrated system would frankly look like a really good orchestra with a whole bunch of different people, each playing their role. They may be doctors, nurses, nurse practitioners. It could be community workers. It could be the allied health staff that are in hospitals or in outpatients. There's a long list of individuals who might, depending on the music we're trying to play for a particular patient, we may have one group of people doing it, and then they might hand off to the next group, whatever it takes to make the right music for that patient.

And then the other component is coordination. How do we actually organize the delivery of the care for that patient? When we studied all this, we found that delivery systems that for the last 50 years have been integrated and coordinated actually were as a byproduct of what they were doing, creating higher value care, getting better results at lower costs. 

Two other components came up and that was the idea of individualized medicine. You have to pay attention to the needs of every patient in a given population to improve the health of that population. So even though we talk about public health and population health, the fact is, you've got to get to every individual in that population to make them really healthier.

Second component, under the idea of individualized medicine is the novel diagnostic, novel therapeutics, genetics, genomics, proteomics, all the new stuff that's coming out this century. And this century, we know that we'll be able to tailor medications and treatments to maybe not the whole group of patients, but to subgroups. Maybe even just one person will have a special kind of treatment that will be developed for them as this century rolls out.

So that's individualized medicine and then the other major category, which is absolutely fundamental and which we have not looked at very hard over the last 50 years or longer. And that's what I call the science of healthcare delivery. In other words, it's not studying basic research or even translational research, developing new products or new ideas. It's really how do we take care of patients in new models of care? How do we do telemedicine? How do we have new models of payment, so it will foster our ability to offer patients telemedicine hospital care at home, direct care at home. We're trying to keep them out of the hospital, out of emergency rooms. 

The fee-for-service payment models do not allow payments for those things I just listed until COVID. Now COVID, we've got special permission to be able to get paid for doing telemedicine. If you can believe it, we needed a COVID to be able to start paying for people to do telemedicine. It's just insane, really. 

So when you look at the science of healthcare delivery, that is a fundamental key, because it's basically the end stage of taking an old idea or a new idea and using it in a new way to improve higher value. It's taking the current active ingredients and applying it in a much more effective way than we've done before.

So those are the fundamentals that came out of. Notice, there's nothing in there about IT or any particular products because those are nothing but tools. You need them to accomplish those big pictures. And then finally, Bisi, there are two other elements that came out that is really not, neither one of these are completely in the control of the delivery system, and we need help from government and other organizations to make it work. And these are the two.

Number one is insurance for everybody. Everybody should have insurance. We think people should own it. In other words, it's not linked to their work. COVID has just proven this in a very strong way, as people lost their job, they lost their insurance. Rather insane, too. That should not be happening in a first world country. Then the other one is if we really want to get high value care, we need to change our payment models so that organizations that get the best outcomes at the lowest costs are paid appropriately enough that they stay in business.

Some significant delivery systems have begun to solve their own problem with this idea of paying for value and getting people insured. And that is, they offered their own insurance companies. Those groups can pay themselves to keep people out of the hospital and do telemedicine and do hospital care at home. So sometimes the providers are taking care of that problem. And it's kind of a shame, actually, that they shouldn't be distracted having to do that, they should be able to just focus and concentrate on patient care, in my view.

So that's pretty much the vision. And it was really an evolution of engaging with many people. But we did one thing that was unique. We had a few people who were involved who were patient advocates, who also participated and made some videos. They gave some audio statements about what they were hoping for in the future, and we actually paid attention to patients. So to me, this was a unique and eye opening exercise for me, so we're still working at it. It's a work in progress.

Bisi Williams: [18:37] I love your vision of this fully integrated work, and two things come to mind. One is communication, the other one is orchestration or design of these systems with things that don't talk to each other and creating unnecessary work and unnecessary burden for those within the system, there's a tremendous amount of friction. 

How much money do you imagine in 2049 when you create, and I'm not going to call it a governing body, but I'm going to just say maybe it's a third way for medical and related services to be delivered. How much money do you think you would need to see it and then to fund it?

Dr. Denis Cortese: [19:16] Okay. That's interesting. But first, let's take the easy one first. If we could snap our fingers and be there today, we would probably be spending, instead of $4 trillion a year, we'd probably be spending $3 trillion.

Bisi Williams: [19:32] Tell me why. What happened to the $1 trillion?

Dr. Denis Cortese: [19:35] Because there's at least one third of waste in our delivery system because we use things that we don't really use correctly. We're doing more testing than we need to because it isn't clear what's the best way to do it. There's so much variation around the country, and people aren't looking at what delivery systems are getting, the very best results and learning, what are they doing? How do they do it? 

We spend more time ringing our hands over the bad results we're getting without really focusing and say, forget the bad results. Everybody has to move and be standardized against the best results that we want. And you begin to pay in such a way that you incent those people to move in that direction. So let's say we save instead of 4 trillion today, we're spending 3 trillion. Okay, if we can magically make that happen. And if we can maintain that degree of a delivery system, we would be spending about you inflate the number in 2049, we'd be spending the same amount. It would be still equivalent to 3 trillion, but it would be at a later time, and all of that depends on individual desires in our country to invest in high value health care, how much do we want to spend for high value healthcare?

So that's the first thing to make that move to move in that direction, which is what you're saying, the seed funding, where is it going to come from? Well, the seed funding. I'm not a proponent of putting more money into the delivery system. We already got 4 trillion sitting out there. 

What I am a proponent of is to look at what goes on in the delivery system in the categories of prevention. And it's a little bit tricky. Now, stick with me on this one. Prevention. There's something called primary prevention. There's something secondary. There's tertiary and quaternary. There's four levels of prevention.

The levels basically go like this. If you have a population of people, we can identify some people who might be at risk for getting something sometime in their life. Maybe we identify it by the way they're behaving, maybe from their genetics or genomics, or just simply the fact that they're human. For instance, we know that people are going to get flu. We know that people are going to be exposed to COVID or other pandemics. We know that people used to get polio and smallpox. Well, a primary prevention technique was vaccines, if you get what I'm talking about. So that's primary. So you focus on those people.

The secondary prevention level is folks that you know that are really at risk for some kind of an illness. They're overweight. They have a tendency towards diabetes. They're not exercising, et cetera. And you know that if we don't intercede at that point, they may actually develop a condition, a chronic condition, so that's a subgroup of the whole population. It's a group of people because of certain identifying features. They're not wearing helmets and things like that. So secondary prevention is focusing on those that are at high risk for developing a chronic illness and trying to prevent the illness from occurring.

The third level is tertiary prevention, which is for people who have chronic illness. Like me. I've got five of them. Other people have asthma, they have diabetes, they may have cancer, cancer in a lot of cases is a chronic illness now, which is good for some people, but they're long suffering. It's a very difficult condition to deal with. Okay, tertiary prevention is how do we keep them functioning? You're not going to cure it. But how do you keep them well and out of emergency rooms and out of hospitals? That's tertiary prevention.

And then the fourth level is when people are really sick in a hospital, how do we prevent complications, side effects, deaths, things that we don't want to happen in the hospital. That would be quaternary prevention, in other words, doing it right the first time and every time and don't get anything wrong. Those are all nice ideals to talk about. But there we are. 

So now, where do we spend that $4 trillion at those four levels? It's at levels, tertiary prevention and quaternary prevention. We're spending all of our money not necessarily preventing, but they're at that level. We're spending an awful lot of money for people to go in hospital. We spend an awful lot of money for the 20% to 25% of the population that has chronic conditions. That's where we're spending our $4 trillion. If we can do a better job at tertiary and quaternary prevention levels, we can save money. And you save money right now.

If you want to do more vaccines or primary or secondary prevention, if you want to do more of that, you need to invest money right now. You're not going to save anything by doing it. The saving of money will come 20 years later. But if you want to invest money now in primary and secondary prevention, you better start saving the money right now in tertiary and quaternary prevention, and keep that money in the system and reinvest that up at the upper levels of primary and secondary prevention.

So that is one sort of a strategic technique for at least making optimal use of your current $4 trillion that you're currently spending. And most of the time when I talk to people and they always ask a question, well, what about prevention? What they really mean is primary and secondary prevention, and I just ask them. I said, where's the money coming from? Who's going to put it in? The answer to my own question is it's got to come from the delivery system doing its job because the delivery system functions at the tertiary and quaternary levels, they focus much more on the sick people and those in the hospital.

And if we did a better job in improving everything we're doing, money will be saved. But if the money is saved and it goes into the military budget, that's not going to do as much good. It's got to be reinvested into taking care of our population. And it's a matter of security. A healthy population is fundamental to a country able to function very well. It's absolutely fundamental. It's the biggest security risk we've actually got. In my opinion. Of course, I'm not biased.

Bisi Williams: [26:15] Not at all. But I think what you talked about here, it's a question of will and mindset, this world that you paint for me. When you look at this third way of cohesively designing the system, it seems to me that the health and related fields that there's a tremendous opportunity for growth and exploration and fulfillment in service to people. 

And I'm going to use a terrible analogy, but I'm going to borrow this from Sir Richard Branson. But, you know, industries that are bloated are ripe for disruption, the wedding industry, for example, like the music industry. And so if a third party decides to come in and pick all that low hanging fruit with the orchestration overnight, those models will collapse. And so do people actually look at the flip side. Like what happens if I'm disrupted? In that sense, the lobbying doesn't really matter if people vote with their feet and their dollars to a more individualized care, where they get what they want when they want, that their interests are taken at heart, and they get good value for the money that they spend on their health and wellness.

Dr. Denis Cortese: [27:33] You're exactly right. But the disruptors, there are two things against the traditional concept of an outside new idea disrupting it and that is the medical profession and hospitals have their own credentialing processes. It's a cottage industry at the present time. So whoever wants to disrupt it probably not have a license to take care of patients. That's one of the problems. 

So the disruption that we're seeing is coming from inside. And it comes like this. You get organizations that begin to view their hospital as not the profit center. It still may be an area that makes money for sure, but it's not all about the hospital. Hospital administrators have no concept on how to manage a hospital if it isn't being filled up and have a full ER, the fact that there are four hour waits, some hospital administrators, they're fine with that. That's good. That means they're making money. A hospital is jam packed. You know, we've been measuring hospital occupancy all through this COVID, and we've been watching how the occupancy has been like 90%. And people say they're all full and the ICU's are running at 85% to 90%.

Well, when COVID is over, start looking at the same data. There's no change. Our data is we try to keep the hospitals full. What happened with COVID is the hospital was being managed to be full and they just flexed and they stopped doing more of the elective stuff that they could put off. But they're still full. And as the COVID numbers have come down, but you watch this in Arizona, it's fantastic. The number of ICU beds being occupied are identical. They're all running in the 85% to 90% range, because that's how we run a hospital. So if you disrupt that, what does a hospital administrator do, they would have to actually manage their expenses, which is not something that they are trained to do. They're trained to keep the hospital as full as possible. 

And so the disruptor comes like this, one, groups like Mayo Clinic, but others have no hospital administrators on their staff. We run the hospitals by our clinical practice. If we need beds, we use them. If we don't, you have them. We just close them down. And we've shifted to doing so many more things in the outpatient environment.

You look at transplantation when we were doing liver transplants, around 1990, liver transplants, for instance, required a hospital stay for about three, four weeks, usually about 30 days, also in the intensive care unit for maybe two of those weeks for recovery. That was about 1990. By 2002, 12 years later, liver transplants, no stop in the ICU out of the hospital in four days, up out of bed the day of surgery and walking around. Liver transplants with much better outcomes. People doing very well.

What made that happen so fast? It's because of the way we were paid. We were paid on a capitated box payment. It's like buying a car. You buy the whole car, you don't buy the engine, you don't buy the wheels. Here it is, that's what you get paid. 

And all transplants, the whole field of transplant grew up with this what we call bundled payments. So the better you did in caring for the people and the better they perform, the better they got out and the better the organ function. And you didn't have to redo an operation. And the better that they survive in the longer term, the more money you'll be able to be making and you get your costs covered. You compete on value. And actually, the cost of transplants have come down from where they were very much like we see with automobiles. This is the kind of stuff that can be done with the right goals in mind. This transplant stuff had all the incentives identically laid out. And that is, patients wanted to be healthier, they wanted to be better, they wanted to live longer. And the payment model was such that we were driven to make sure all of that came true. And the better we did it, the more money we actually kept, because that's all you're going to get paid.

Bisi Williams: [32:00] So I'm going to ask you this question. You can see this vision and it's fully materialized and synthesized. In your view, you've got the three domains which you've explained and how they need to work together. What's getting in our way from orchestrating this vision for wellness that's a benefit to all.

Dr. Denis Cortese: [32:22] I think it's the design of the system of developing policy and engaging, quote, stakeholders, unquote. There is a complete lack, the fundamental problem is there's a complete lack of what we really want as a vision. No President has said it, and we haven't really made a commitment to working towards better results. The overarching idea of value is not there. It certainly is not a shared vision. But most people will say, yeah, that's exactly what they want to do. And because of that, the quote, stakeholders have a great opportunity to just work, to optimize their own deal. And the doctors are just as bad. Each doctor group, when there's new price changes that are going to take place, let's say, in Medicare, they're all in their lobbying for themselves, every one of them.

Bisi Williams: [33:15] It seems to me, though, that we have a shared vision. Nobody wants to go to the hospital, nobody wants to be sick.

Dr. Denis Cortese: [33:23] Yeah, we do. But not among the people who come to the table. This is why our work is so interesting because we brought patients in. If you were to grab 400 patients off the street and put them in a room, you'll get a shared vision in three minutes. But that's not who actually makes the decisions. Look at it this way, if all of the current shareholders came to the table and actually fixed the system and agreed to fix it, many of them, including physicians, would lose something. They're all going to lose something.

When you call a group together, and I have run several of these groups of all the stakeholders, quote, unquote, all the stakeholders, it's like bringing in all the Orchestra members, but that they are all soloists, and they are only interested in playing their music when they want to play it, and they want to play it as loud as possible and do all the grandstanding. And that's what happens in health care. The stakeholders that come to the table in health care, they all want to be there, they all want to sit there. But their driving vision, they're there to maximize their sector.

Whether that optimizes the output for the people is not number one in their mind, because if they did, they would realize that none of them shouldn't even be at the table, they're basically vendors. And the people who become members of an Orchestra, and a really fine Orchestra, are very interested in having beautiful music be produced. And it's not about them. It's about the music.

Bisi Williams: [34:52] Dr. Cortese, I'm so inspired by your vision of health care in 2049, thank you so much for joining us today.

Dr. Denis Cortese: [34:59] Well, you're welcome. Good luck to you and take care.

Bisi Williams: [35:01] And that wraps our show with Dr. Denise Cortese. Thank you for listening. If you enjoyed our show, please subscribe or share with a friend. Until next time, I'm Bisi Williams.

Dr. Jeffrey Kaibin Lin, Public Health Family Physician, Los Angeles Department of Health Services

There’s more to health than medicine, a doctor and a hospital. How do we shift health care to include overall well-being? Dr. Jeffrey Kaibin Lin, a physician at the Los Angeles Department of Health Services, shares his experience working in a Transitions Clinic, the comprehensive services they offer and his vision of a completely open access, equitable universal healthcare system guided by compassion.

Dr. Jeffrey Kaibin Lin, a former art director and designer, is now a public health family physician employed by the Los Angeles Department of Health Services. He provides primary care services in the correctional health setting. He is also clinical faculty with the Harbor-UCLA Family Medicine Residency Program (where he completed his training) and is currently setting up a transitions clinic for individuals returning to community from incarceration. He believes that healthcare is a human right, and is a member of Physicians for a National Health Program, which advocates for a publicly-financed non-profit single-payer national healthcare system.

Show Notes

• What health care looks like today and a vision for 2049. [02:44]

• A view of free and accessible healthcare delivery system similar to a public utility. [05:37]

• How would that system be administered and funded? [06:57]

• A perspective of how design and medicine have the same goals. [10:01]

• What is a Transitions Clinic and how does it help individuals returning from incarceration? [11:22]

• How can medical school be redesigned? [14:07]

• Comprehensive medical training creates more opportunities for physicians. [16:42]

• Advice for prospective med students. [18:43]

• An inclusive approach to qualifying for med school. [19:44]

• When accepting students, where should the emphasis be placed? [23:33]

• It’s not easy to talk about universal healthcare, but it's necessary. [25:54]

Transcript

Bisi Williams: I'm Bisi Williams. You're listening to Health 2049.

Dr. Jeffrey Kaibin Lin: This would require, for instance, it would require people to believe that other people are as equal to them, and other people deserve what you deserve. It requires people to think, I'm willing to allow my taxes to go into a system to potentially pay for somebody else. You just have to believe that.

Bisi Williams: [01:46] Today, we're in for a treat. My next guest describes himself as a visual person. Not only can he design the future, he's also trained to heal people. Dr. Jeffrey Kaibin Lin, a former art director and designer, is now a public health family physician employed by the Los Angeles Department of Health Services, providing primary care services in the correctional health setting. He is also clinical faculty with the Harbor-UCLA Family Medicine Residency Program, where he completed his training and is currently setting up a transition clinic for individuals returning to community from incarceration.

He believes that healthcare is a human right, and he is a member of Physicians for a National Health Program, which advocates for a publicly financed, nonprofit, single payer, national healthcare system. Dr. Lin, it is my pleasure to welcome you to our show.

Dr. Jeffrey Kaibin Lin: [02:36] Thank you.

Bisi Williams: [02:37] I'm so excited to get started. So tell me, what does healthcare look like in 2049 to you Dr. Lin?

Dr. Jeffrey Kaibin Lin: [02:44] 2049 is not that far off, we're talking about 2020, 2021 right now. I think what we know as healthcare today and for many years has been a series of closed doors, a series of denied charges, a series of flaming hoops, paperwork, bureaucracy, phone calls. All of that. None of it feels particularly available or accessible. And I think that is the problem. And I think everyone knows this. Everyone who's tried to get a doctor's appointment or pick up some medications from the pharmacy. Everybody is familiar with this issue of just lack of access or lack of ease.

And so the future, I think this is acknowledged. I think people understand this and it really is working towards a completely open access, equitable universal healthcare system. I think when people talk about the future of medicine, maybe it's about technology and the new robotic surgery or nanopill or something like that. Or maybe there's new medications that come out that can treat all these kinds of diseases. Or there's genetic blood screen that can tell you every single possibility of whatever disease you're going to get in the future. But all those things don't matter if people can't access it, if people can't afford it. 

If there's an exorbitant price for any of these cool new things, none of it matters if nobody can use it. The healthcare slice of the economy is like some crazy exorbitant number, and then people's individual healthcare spending is also really high compared to what they get. And so all that has to change. And so Health 2049 is about completely accessible, completely free healthcare for all individuals, all human beings, regardless of where they're coming from, what their need is major or minor.

There's so much waste as it is right now. So there's plenty of space and resources to achieve that, because health isn't just a medicine and a doctor and a hospital. Health is so many different things. It's behavioral health. It's where you live. It's where you play, it's what you eat, it's who you interact with, it's where you work. It's an all encompassing concept of wellness and wellness, not being necessarily like a soft thing as a separate category of health. But just like how you live and survive in this world happily. And so medicine is almost like this subset underneath that. And we have to change these definitions and silos or categories and make it a more all encompassing vision.

Bisi Williams: [05:26] I think you make a great point when you think about it, from the macro to the micro. I want you to just tell me with this vision and this way of living, how does it make the world a better place?

Dr. Jeffrey Kaibin Lin: [05:37] I think it demands thinking about other people. There's a lot of selfishness. There's a lot of I'm taking care of myself. I'm taking care of my family and that's kind of it. And I think greed leads to inequity and inequity leads to just destruction. So this would require, for instance, it would require people to believe that other people are as equal to them and other people deserve what you deserve. It requires people to think I'm willing to allow my taxes to go into a system to potentially pay for somebody else.

You just have to believe that. And I think sometimes people will drive down the road or highway and not realize, oh, actually, this is a taxation at work or. Oh, good thing there's this traffic light here because even though I didn't really pay for it myself, we all paid for it. And so I think health care as a piece of infrastructure or healthcare delivery as a piece of infrastructure that exists for everybody to use where obviously we're not there. But I think that's what the mind shift has to be, and people would be comfortable with that. You can think of healthcare delivery as almost like a utility.

Bisi Williams: [06:51] So how do you imagine the system of care you describe will be administered and funded?

Dr. Jeffrey Kaibin Lin: [06:57] So I know I'm talking kind of very abstract in some ways, but I mean, the nitty gritty would be you have all healthcare systems, they can kind of be separated. But the patients would be at the center of this. And so an individual person who has some kind of healthcare need, whatever it may be, it could be an emergency. It could be maintenance. And so they need access to some sort of facility. And so these facilities, whether it's an emergency room or a doctor's, office or psychiatrist or whatever, they would be part of a large network.

And if we could just talk the USA across the country who is kind of contracted with this national healthcare program to provide services, different models could be a fee for service. So whichever doctor is going to see you in the emergency room, gets paid a certain amount or compensated a certain amount, or they have some salary. And no matter how many people they see or how many people they treat, they have a certain salary. This salary is paid for through basically taxation. This is individual taxation based on your income.

This is corporate taxation because there are gigantic financial entities that exist in this country which generate trillions of which a one percent or half a percent or .01 percent could be used to fund this healthcare program. And so that's kind of the three chunks. I know it's a lot more complex than that, but just to think that for the patient, there's nothing for them to pay because they've already paid in. They've paid their taxes. It may be retail taxes. It may be income taxes. They've already paid in so they don't have to pay anything else.

Compare one individual who has seven different medical problems and is super sick. That's just the term we use. And then you have another person who runs every day and is super healthy and maybe doesn't have that much healthcare expenditure or healthcare need. These are two very different individuals who need to exist in the same kind of universe. They would contribute the same based on their activity in the economy, if they buy things, if they work, even if they don't work they are still purchasing things.

And so all these chunks, they're still contributing equally. But the person who's super healthy and takes care of themselves and has no need has to kind of buy into the fact that they're cool with that and that they don't need to see a doctor every month for some crazy medical condition, but they're okay with somebody else doing that. And so that kind of unifying, like we're all in this together. We're all building towards something. Some people don't like that. But I think that's the only way to have a universal program is to acknowledge that.

 Bisi Williams: [09:45] So as a designer and a physician, your education is unique because you are trained in the design method of visual culture and communication. And you're also trained in the scientific method of evidence-based verbal culture. Could you describe the difference between the two learning cultures?

Dr. Jeffrey Kaibin Lin: [10:01] You know, I loved being a designer. It was problem solving. It was trying to create things that could telegraph something instantly, especially in advertising. You want to have your eye pass over something and know exactly what that means. And if you look really deep, then there was a lot to look at. And so your goal is what I remember was that okay? You want this to be universal? You want us to speak to as many different people as possible, but on the opposite end, maybe you want design that's very specific for a particular audience.

Hey, that speaks to me personally and individually. I think medical education and healthcare, you're talking about communication. You're talking about making the case for somebody to do something. So when I'm speaking with a patient or a group of patients, I'm trying to make the case for them to maybe take my advice. And that's the same goal that I had as a designer, trying to communicate a message and have somebody get it on the other end. They're not the same, but they have the same goals. They have the same goals of just trying to get a point across

Bisi Williams: [11:14] What is a Transitions Clinic for individuals returning from community incarceration? And why are you setting this up?

Dr. Jeffrey Kaibin Lin: [11:22] Yeah so, the concept of reentry program or main streaming program out of corrections is essentially you have individuals who have been in prison, could be in jail for a couple of days, or they could be in prison for years, and they are released. And like all humans, they should be getting some kind of healthcare interface with doctors, some sort of preventive medicine. And so most prisons do have primary care. They may have an affirmary, they sometimes only have an urgent care setting, but they do have medical need.

There's a high degree of chronic medical conditions, just overall, high blood pressure, cholesterol, diabetes, there's often a lot of substance use there's maybe injury. And so all of these things happen within the walls of corrections. And sometimes when they get released, all of a sudden, that's lost. And so part of the goal of the Transitions Clinic is to make sure that the medical care is continued. But really, it's an excuse to kind of really interface with the inmates who have been patients and get them the social services and kind of comprehensive wraparound services that they it needs.

So, for instance, somebody all of a sudden has to take a new medication, but once they leave, they need to find a job in order to afford this medication. And so part of the transitions clinic is social workers and community health workers who have shared experience, who have lived experience and may have been incarcerated themselves, who are able to work with our patients or what they call our clients and help them ease back into kind of mainstream society. Someone who's been in for 20 years is coming out and now has to use the computer in order to apply for a job and has no idea how to do that.

And so our clinic is based on healthcare needs and regular visits and annual visits and all that. But it really is also about setting them up with maybe housing services, employment services. There may be social services or benefits that are available. We have substance use counselors, and all of it is really trying to ease and help prevent recidivism, but also to just make the transition back to, I guess, like mainstream society as easy as possible under the guise of a doctor's clinic. And I think it's our way of sneaking people back in through the doctor's office.

Bisi Williams: [13:57] I love that. So as a recent medical school grad, let's talk about medical education and how it can be updated or redesigned from your perspective.

Dr. Jeffrey Kaibin Lin: [14:07] Yeah. I graduated from the University of Miami and I was enrolled in a dual degree program. And so I earned a Master's in Public Health at the same time. And I think the trend in medical education is about tracks. It's about kind of interests and focus. And so you can also get Master's in Genetics during your med school. You can also get a Law Degree. You could do bench research, hardcore research and get a PhD in Biochemistry. The word producing itself is problematic, but it is about producing physicians with different toolsets. And I think that's what makes things interesting.

The trend at the time was talking about medical education, which is in the US a four year degree, four years of schooling, kind of shifting between book medicine and clinical medicine. Do you need to spend that much time studying, like books? Or do you need to spend more time interacting with humans? And so the kind of push and pull between what they call clinical medicine and preclinical medicine is trending towards more clinical medicine, meaning more interactions with patients, earlier interaction with patients.

Another chunk is when we talk about a four year education, can it be a three year education? Whereas medical school in the US is kind of something you apply for after college and so it's like four plus four. But then you go to other countries where you apply to medical school as a high school student. And so you have essentially the same amount of time. You may spend six years, seven years, and your college isn't filled with non medical things. Your college is med school for six, seven years. It's just a different model.

I feel like medical school was really good for me because I was in this other track. And so I had a different perspective. We learned about public health. We learned about health systems. We learned about kind of the social determinants of health. All these are not necessarily part of a traditional medical program that's kind of focused only on the science. I think there's a lot of value with the MDJD programs because you're learning medicine, but you're also learning about legal ramifications. There's just so many different ways you can do medicine that I think the medical school should offer those kind of choices.

Bisi Williams: [16:30] So when you talk about a comprehensive program where you can explore all of these differences or use all different parts and sides of yourself, do you think that that creates better physicians?

Dr. Jeffrey Kaibin Lin: [16:42] I think you have to have everything available. I think the face of medicine is something we can talk about. Who gets into medical school when you say the word doctor or physician, what comes to mind? And I think that's changing. And I think that's acknowledged that it's not just like a patrician Caucasian guy in, like, a long white coat with glasses and curly hair or whatever. That's kind of like your TV doctor. But I think physicians are just another person who has a specific role. But you shouldn't have expectations about who they are or what they should be or what they could be.

You have to have a body of knowledge, but you do have to learn basic science. But again, what you end up doing in medicine is so different. There's so many different things you could do in medicine, and you have to be exposed to that. Maybe your med school is very kind of traditional hospital medicine with your cardiologists and your GI doctors and it's a very, just kind of straightforward, but it's not outside of the hospital setting or the clinic setting. Then you don't know that there's other doctors who are flying around the country into war zones, and you don't know that there are doctors who are practicing homeless street clinics on their bicycle, or they are in the jail setting, or they're maybe doing home visits as a Hospice doctor.

These are all very different things that unless your medical education can offer you that you're not going to know about it. So I think it's really like changing the definition and expectations of what a career in medicine is and saying, hey, you don't have to do that traditional thing because there's a lot of need outside of that in many different places.

Bisi Williams: [18:32] So it's 2049 and you're sitting at the kitchen table with your son or daughter, and they're about to apply to medical school. What advice would you give them?

Dr. Jeffrey Kaibin Lin: [18:43] You have to have a driving force in order to just do well. I think you have to have a motivating factor, because med school can be hard and everyone has their own reasons. But you have to have reasons. I don't want to judge people's reasons. Let's just say someone had, I don't know, a ton of college student loans, and they thought, Well, if I become a doctor, I can make a bunch of money, and then I can pay off my college loans. That may be true, but I think the work you have to do as a physician, I would have to ask my kid, they don't have to justify it to me, but they need something to carry them through it, I think, and beyond because once you finish med school, okay, cool. You have to do residency, which is hard and difficult. And then after you do the residency, then you actually have to work. And that's hard, too. So something has to be driving you.

Bisi Williams: [19:37] I love that. And so from your perspective, Doctor Lin, talk to me about the healthcare workforce and its qualifications.

Dr. Jeffrey Kaibin Lin:  [19:44] Currently, I would say it's in transition, but it used to be this concept of best and brightest, and so only the highest scores could somehow translate to becoming a compassionate physician and, of course, that makes no sense. I think there's a lot of gates or thresholds or you have to get a certain score to do this. And it's really hard. And I think it's unfair. The concept now of a holistic review, which seems common sense, is basically okay. It's not just these six numbers and a transcript. It's the whole package. And so the whole package is now becoming important.

I would say across the country, people are kind of embracing this concept of okay, we can't just focus on these numbers. So I used to do admissions, I was on the admissions committee at University of Miami for our medical school, and it was a very complex process of multiple chart reviews, multiple interviews, multiple committee meetings, multiple rankings. It was always this debate between, oh, well, this person's got a really great score, but someone said they're a terrible human being. Oh, but they have a great score versus well, this person failed all these classes but is, like, incredibly compassionate and had really good patient experiences maybe while they were in some kind of clinical setting in preparation for medical school.

Who do you think is going to be the better doctor. Who's going to succeed? And you had a cadre of individuals who would say, oh, well, we're going to go with the high score. And then you had another group was like, that high score is going to be a terrible person.

So I think it's hard to know because you're also saying, okay, let's take this person in four years. What are they going to do? And now global pandemic wise you kind of lose the interview process. That was some way of gauging human interaction and who they are and kind of all the subtleties of just like how an applicant might interact with somebody. You can capture it on video. But that interview day and the interview visit, all that kind of stuff just gives you, like a preview of who somebody is.

Now not to say you're also kind of on your best behavior. But to go back to hard qualifications, I feel like the transcript should demonstrate not necessarily high numbers, but good exposure, because if you haven't seen what a doctor does or have any idea or no clue or you've only seen a certain thing, then that's very limiting. And that goes back to what kind of doctor you're going to end up being. So some people have their exposure because that's what their parents did, or maybe they had their exposure because they were very sick as a child. And so they went to the doctor every month or something, who knows, eventually become pediatricians.

Some people have these stories about what motivates them. But I think you really have to have and be able to talk about the things you've seen and maybe how they've affected you and then how they've influenced you. But also diligence and resilience and so, oh, wow they did fail that class, but they took it again, and they did well. That's more important than I don't know, straight A's to me. I'm in the minority opinion, but that's just for me.

Bisi Williams: [23:20] But I wonder the conundrum, could you not have somebody who has amazing grades and is compassionate? Is that such an attention or is that a possibility?

Dr. Jeffrey Kaibin Lin: [23:33] Yeah, those are great applicants, but I think the emphasis would be on the exposure and not necessarily on the grades. And so the grades would be a bonus for an applicant who was able to talk about, oh, I spent the summer doing this and I spent a whole year doing that and was able to learn something from that and talk about it and maybe be able to express a vision for what they want to do with that experience. And by the way, also did well, that's really good.

And it wasn't always that kind of tension of these polar opposites. But when you have the kind of perfect applicant, let's just say that applicant may have their choice of places to go because everybody would love to have that applicant. And I think that there may be another applicant who's not fawned over by everybody else, maybe didn't have all the chances that somebody else had and really struggled but still tried to apply and has a motivation coming out of adversity, a motivation coming out of I didn't grow up in a two doctor household, but I have an idea of what I want to do and I was able to work really hard to get some exposure.

Maybe I was the first college graduate and maybe nobody else is doing what I'm trying to do, which is apply to medical school. That applicant, to me, is very valuable, not a cookie cutter person, but somebody who has struggled and therefore will do well when they struggle in medical school. Those are my kind of applicants that I really always fought for.

Bisi Williams: [25:25] I love that. And to conclude, I think that you're really talking about what's core to caring is compassion, for the system, for the people within the whole medical industrial complex, which you're kind of breaking down a little bit, which I think is interesting. Is there a question or a thought that I didn't ask you that you'd like to say to our audience in closing.

Dr. Jeffrey Kaibin Lin: [25:54] I think that change is difficult. People are used to doing a certain thing. People have expectations, good or bad about what something is. People are used to paying health insurance premium on their paycheck that some exorbitant amount of money, or they're used to paying $10,000 when they go to the emergency room. These are all things that are our current reality and it takes a lot to say, you know, what it's been like this, it's been entrenched like this, everybody else is doing it like this, but this is inappropriate, and this has to go. I think, a big shift towards just a unified system instead of our patchwork of insurance companies who act as gatekeepers, a patchwork of different hospital systems, none of which talked to one another, a system of pharmacies and pharmaceuticals that are really profit driven. These are things that people know and expect.

Advertising budgets became part of pharmaceutical budgets that diverts from, let's just say, even research and development or distribution or costs. So a drug may cost a lot because you have to watch a commercial for that and not because the medication is better. But that's what we know and expect now, for the last 30 years. Oh, yeah, these are drug ads. Why are there drug ads at all? So what we all are familiar with, and I think it's hard, but these are things that people talk about right now.

There was a state bill in California to have a unified California system, at least not just a US system that didn't pass because an insurance company wants to exist and wants to kind of be the middle man. And so they would hate to lose that role. And they have a lot of political power. Just have to have a little faith. I think that we may be shifting all your expenditures into a new system, but that new system is meant to take care of an entire community or nation or country. I think it's scary to think about a kind of universal healthcare, but I think it's necessary.

Bisi Williams: [28:08] That's a wonderful vision. Thank you for joining me today, Dr. Lin.

Dr. Jeffrey Kaibin Lin: [28:12] Thank you very much for having me.

Bisi Williams: [28:14] I've been speaking with family physician Dr. Jeffrey Kaibin Lin, clinical faculty with Harbor-UCLA Family Medicine Residency Program and until next time I'm your host, Bisi Williams.

John Zapolski, CEO & Founder, Alive Ventures

What does vitality care look like? Entrepreneur John Zapolski, CEO and founder of Alive Ventures, expands the vision of health beyond physical to include social, mental and emotional well-being and shares the value of relationships in defining a life well-lived.

John Zapolski is a humanitarian, serial entrepreneur and designer. His mission in life is to create beautiful solutions for the most vulnerable among us.

John served on the graduate faculty at the School of Visual Arts where he taught strategic innovation in interaction design. He was the visionary co-founder of Fonderie 47, a fine jewelry and timepiece company that removed assault weapons from conflict zones, and upcycled them into meaningful, elegant accessories.

Alive Ventures is his newest company that he is the CEO and founder of. Alive Ventures is a startup studio dedicated to building brands and products that help older adults love, work, and live better. John Zapolski is the poster child for businesses that put compassion at the center of their enterprise.

Show Notes

• John Zapolski shares the roadblocks he encountered in seeking venture capital for Fonderie 47, a company that upcycled assault weapons into elegant accessories. [02:41]

• The creative solution to receiving funding for Fonderie 47. [05:03]

• The story behind his latest endeavor, Alive Ventures, and the simple question that seemed radical. [08:51]

• A vision for health and wellness in 2049. [12:39]

• What does the concept of vitality care look like? [13:15]

• A real-life example of how vitality care could work for a person. [14:36]

• What are the trends that show we are moving into a more holistic healthcare system? [17:39]

• How do we deal with the resistance to changing the system? [20:49]

• What’s a product or business idea that could support a preventative vitality care system? [24:16]

• Switching the mindset from longevity to vitality. [27:47]

• A view on longevity for longevity's sake. [28:51]

• What holds us back from designing a preventative vitality care system? [31:24]

Transcript

Bisi Williams: I’m Bisi Williams. You're listening to Health2049.

John Zapolski: More and more as we come to care about things like mental well-being and the state of our emotions with one another, I can see that expanding into the coming decades to really be about us keeping track of how much vitality did we experience in our lives.

Bisi Williams: My guest today is a humanitarian, a serial entrepreneur, and a designer. Like the Bauhaus, his mission in life is to create stunningly beautiful solutions for the most vulnerable among us. Whether it's removing landlines and then creating jewelry from the wreckage or with his newest company, Alive Ventures, making businesses that help older adults love, live and work better, John Zapolski is the poster child for businesses that put compassion at the center of their enterprise. I'm honored to have John on the show today. Welcome to the show, John.

John Zapolski: [02:21]  Thanks Bisi, it's a pleasure to be with you.

Bisi Williams: [02:23]  Glad to have you. So as an entrepreneur, you work at the intersection of philanthropy, venture capital and culture. Please share with our listeners how you turned a well-designed killing machine like an AK-47 into a fine jewelry company to improve the lives of the community.

John Zapolski: [02:41] You're asking about a previous company of mine that was called Fonderie 47, in English, as some people know it. And the mission of that company was to create stability and prosperity in Sub-Saharan Africa. I started that company after spending some time in Sub-Saharan Africa looking for entrepreneurs to help further their businesses and to raise venture capital for them and came away feeling incredibly inspired by the quality of ideas and the quality of people that I met in a scouting trip.

This was maybe 15 years ago, and when I got back to the Bay Area where I lived, I was really discouraged by how difficult it was to generate the enthusiasm that I thought would be there for investing in some of these companies. And I just sort of wondered why that was. And I started kind of asking that question to the Silicon Valley investors that I knew, and I heard stated in different ways, kind of a common theme, which was that they felt there was too much instability in Africa so that you'd have all of the normal risks and challenges of starting the company, but whenever it might be politically convenient, some local dictator or warlord might come along and start conflict, and that would kind of ruin the business prospects. And I thought that was really unfair. I was teaching in the business school at UC Berkeley at the time and remembered how many fairly mundane or even silly ideas a lot of my MBA students had that I knew that they would go on to easily raise capital for because we were in Silicon Valley. And that just didn't seem fair to me.

And so I found myself over time kind of waking up in the middle of the night thinking about that. And about a year or two later, after selling the company that I had at the time, I just decided to go and see if there was anything that I might be able to do to reduce that feeling of instability and make it easier to invest in some of these companies that I felt were so promising.

Bisi Williams: [04:57]  That's amazing. What did you do? How did you actually figure out the instability question?

John Zapolski: [05:03] Well, what I learned is that there was a proliferation of assault weapons throughout most of the countries in Sub-Saharan Africa, and those were by and large, AK-47, which I think, as an aside, we could have a conversation about as designers as maybe being the most successful design object of all time. Unfortunately, it's this incredibly visually iconic object invested with all of this, meaning whether it's revolution or terrorism or all sorts of different things, but also incredibly functionally durable. And you can bury it in the dirt for ten years and dig it up and throw it in a Lake and shake it off, and it'll still shoot 600 bullets a minute.

So all of these weapons were there, maybe around 15 to 20 million. And for the most part, they just sat unused in people's houses. And indeed, were kind of there to be taken out in populations rapidly armed, if there was some reason for conflict. And what I thought about is if you look at that as not just a source of instability, but really as an unused asset that represented about $5 billion in value, I wondered, could we somehow subvert that and turn it from a source of destruction into a source of value.

And so I set about trying to figure out how could we get people to surrender their weapons. Could we do that in a way that wouldn't result in just more weapons flowing in? And then could we transform that material into something of value that we could sell and then use the money from selling it to create programs that would help local communities develop and grow and prosper. So that's what we did. I worked with a nonprofit group called Minds Advisory Group based in the UK, which had won a Nobel Peace Prize in their disarmament work.

And we created programs that incentivize people to turn in their weapons. They get an individual incentive, plus a community incentive that might be things like cell phone minutes or a bicycle or agricultural tools, and then for their communities, a water project or a health clinic, whatever the community decided they would need and then sort of figured out how to get those weapons destroyed and then try to convert them into what I thought of as the opposite of blood diamonds. That was a pretty complicated process, using some ancient craft techniques, like from Japanese sword making and transforming material, also some high tech Nanoscience.

And then we ultimately used that transformed material the way that other luxury brands would use precious materials. Usually, those precious materials were mined from Africa, leaving destruction in their wake. And we tried to take this destructive material, turn it into a really beautiful object, and then sell it to people in the US and Europe. If you bought a piece from us, you would get the serial numbers of all of the guns that you destroyed as a result of your purchase. Generally, that was between ten and 1,000 guns, depending on what kind of piece. And then we would use the revenue from selling those to go and pay for these projects that we were doing in Sub-Saharan Africa.

Bisi Williams: [08:31]  John, that's just so clever and ingenious on so many levels. I love that project, and I know our listeners don't know this, but, John, you're a young man and your latest endeavor, Alive Ventures designs goods and services for an aging population. How and why did you conceive of this business?

John Zapolski: [08:51]  Well, somewhat by happenstance or my good fortune. I came into contact with the board of directors from a medium-sized foundation based in Southern California called the Scan Foundation. The Scan Foundation is about twelve years old, and their mission is to advocate for and invest in improving quality of life for older adults in America. And they've mostly worked in policy to date, and also in the healthcare delivery system. So they work on things like enacting better legislation to get Medicare to cover things that older adults really want and need.

But the board realized that so much of what shapes the experience of being an older person today isn't just what happens in the policy world, but it's the products and services and experiences that are available to us. And wanting to be very proactive in thinking about how to improve their impact, they connected with me as an entrepreneur who's tried to use venture to work on important social issues and ask what I would do. And that intrigued me. Even though I hadn't really spent a lot of time before that, thinking deeply about the lives of older people, I did recognize that in the public imagination, older people are usually conceived of as frail or sick or alone, and generally a population to be pitied, rather than a population to be respected and looked up to and treated in a really three dimensional, fully human way.

And so we just started with the question of what is it that older people want for themselves? And that actually turned out to be somewhat of a radical question.

Bisi Williams: [10:33] Why is that radical?

John Zapolski: [10:35] Well, most of what ends up getting made for older people, unfortunately, is somebody else's idea of what an older person should want or something that they feel like, if I could just get mom or Granddad to use this thing, it would make my life so much easier and make them less of a burden. But not a lot of time is spent really thinking about it through an entrepreneurial lens, which I think any good entrepreneur starts with the notion that I want to build something that people want.

I just spent time through most of 2019 traveling around the country and going to cities and suburbs and some rural towns and getting groups of older people together and coming up with creative ideas to get them to talk about their lives, talk about what they want, talk about their aspirations. And that was so enlivening for me, and so inspiring. The really basic thing that I learned that sometimes I kick myself looking back at how obvious this should have been, but I'll admit that I didn't realize it at the time, is that what older people want is by and large the same thing that all of us have wanted throughout most of our lives, which is to know interesting people and be connected to them, to feel like there's an opportunity to make a contribution to their families and their communities and society, to find ways to discover and nurture love and intimacy in their lives, to find ways to feel empowered in managing their own lives, staying healthy, staying vital, and all of that seemed like such beautiful opportunities to design well.

I felt like it was really a shame that most entrepreneurs and designers and creative people don't have that on their radar screens as something that would be incredibly fun and incredibly fulfilling to create experiences or services for. So that's kind of what I set out to do and ultimately launching Alive Ventures.

Bisi Williams: [12:30] I think that's amazing and so that is a perfect segue for you to tell us about your vision for health and wellness in 2049.

John Zapolski: [12:39] So my vision for 2049 is that our notion of health and wellness has expanded to include thinking about what it means to live vital lives, not just healthy lives.

Bisi Williams: [12:52] I love that. So I think the idea of vitality care is intriguing, and I just want to go back to a discussion we had earlier. The other day you suggested that we could invest in our aliveness. And so if you could expand on the concepts of vitality and vitality care and aliveness, what would that look like?

John Zapolski: [13:15] Well, I think that most of us have experience with the feeling that comes from having a day where you just feel really alive. And that goes beyond, I think for most of us, feeling healthy, feeling like our body is working. But it also includes feeling emotionally engaged. It includes feeling connected to people that we love. It feels like caring about ourselves and being good to ourselves. 

I think that more and more as we come to care about things like mental wellbeing and the state of our emotions with one another, I can see that expanding into the coming decades to really be about us keeping track of, how much vitality did we experience in our lives, going beyond did my knee hurt today, or am I having some chest pains. And thinking more about, do I feel really fully engaged in my life? Do I feel like I'm able to show up for myself and for the people that I care about with openness, with a healthy way of participating in conversations with being the kind of person that I want to be towards them?

Bisi Williams: [14:36] Yeah, that sounds like a great way to live. And I want to expand on the concept of vitality care and aliveness. I have a scenario for your vision. Let's assume it's the new normal. Let's imagine for our audience that there is a 78 years young man named Kevin who works in middle management at Acme Company. So one day he suffers an unexpected heart attack at work. And until that moment, our Kevin was the picture of health. Can you describe how he or this system might use this idea of vitality care and this aliveness investment to manage his wellbeing post trauma?

John Zapolski: [15:20] Sure. Well, I think that most of the listeners will relate to the idea that today our healthcare system primarily focuses on helping people manage illness or managing catastrophic events that have happened to them. So certainly in this scenario, Kevin has experienced something that is very threatening to his physical wellbeing. Hopefully, Kevin has gotten the kind of medical care that he's needed to come through that and is on the road to recovering physically. But I think we can also very easily all imagine that that event triggers for Kevin a number of feelings that come along with it, too.

Any one of us who've had a traumatic incident like that probably goes through a period of questioning. How am I spending my time right now? Am I focused on the things that are important? How is my family feeling about this? Am I spending enough time with them? Am I close enough to living the kind of life that I want to live? And I think that collectively there are opportunities for us to help Kevin ask and answer those questions in ways that feel very positive. I think that it's not just about his recovery in the hospital, getting his heart fully into shape again, but reminding Kevin that there's space and time to think about all of the surrounding context that might have led to that situation for him, being able to provide support for the kind of daily things that he may not be able to attend to as he's coming back.

But even after he's back to think about, how do we keep you cognizant of all of those thoughts that occurred to you about how you want to be spending your time, how you want to be taking care of yourself mentally and emotionally and not just physically and helping be supportive as he tries to put more of those into practice in his life.

Bisi Williams: [17:20] I think I love the way that you frame that about not only his physical health, but his social emotional health as well. And I'm just curious, why are you confident that your idea of people designing a more holistic approach to their wellness is plausible in 30 years?

John Zapolski: [17:39] Well, I think that's a great question. I think there are some trends that we can look at that are suggestive of that. Years back, when our healthcare system was developing into what it is today, we didn't think so much around what we now call social determinants of health. These are things like our ability to stay connected to community in our lives. And now these are things that our healthcare providers do think about. Most insurance plans or many hopefully do cover things like mental health and wellbeing as part of the services that are offered. So we're starting to see things more holistically when it comes to the factors that affect our physical health, and I expect that will continue.

Also in the commercial realm, we see more and more services that are being created and offered to people in increasingly affordable ways, supporting our ability to connect with people to talk to, if we need to talk. Or take time and meditation and reflection for ourselves so that we can lower the stress that we're experiencing on a daily basis. We're getting more and more information and data about the positive consequences that putting those kinds of things into practice have on the overall state of our health, how they reduce inflammation, how they help us have better nutrition, all sorts of ways in which they help us be more healthy and be more active.

So I suspect that will continue. I suspect more people will continue to innovate around these types of services I think will be available to more people. They'll move out of the province of what used to be exclusively for wealthy people who could maybe go away to an all-inclusive spa and had the luxury of a vacation time to do that, and the dollars to be able to afford it, into services that are delivered digitally on demand for lower and lower prices. And hopefully the health insurance services that we have will continue to pay for more and more of those knowing that those kinds of investments are much less expensive and afford much more impact to our positive health than the emergency room services on the other side of it.

Bisi Williams: [19:59] It's interesting, John that you mentioned investments. And I think what we're discussing today may sound somewhat boujee or out of touch for some of our listeners. Let's discuss the darker reality of change. Even though we know this show is about optimism and possibility, change is hard, and as you alluded to previously, there are some difficult problems that we need to address in order to scale the notion in 30 years of people living their best lives by investing in their own aliveness. Can you talk about that conundrum and how we could solve for those problems to get to a world where we're healthy, emotionally and physically?

John Zapolski: [20:49] Change always has a dark side. And I think in the way that we collectively tend to tell stories about innovation, we often hear a wise entrepreneur's or a lone individual who had a great idea and suffered through whatever he or she needed to suffer through in order to bring this great revolution about. But I think all of us also know that there's resistance to change. There's embedded institutions that stand to lose from things becoming more affordable, from things becoming more accessible to more and more people.

People have political opinions about who should be able to access things and what qualifies you to do that. And I think all of that obviously creates a lot of strife, not just at societal levels, but often even within our own families. So I think we need to be willing to tolerate that. And we need to have an optimistic patience that we can, maybe not solve everything. 

I don't think it's going to change overnight that all of a sudden we go from a place where lots of people's daily reality is that they're working multiple jobs. They're struggling to have enough money just to pay for basic services like electricity or food, to all of a sudden having the time and the wherewithal and the attention span and the dollars to be able to put into managing their own vitality. But that doesn't mean I don't think that we can't, as a society collectively invest in helping people understand the benefits of that more, creating more services that make it easy, integrating simple apps or other kinds of services into our daily routine that just check in that help us connect to those kinds of services more easily and affordable.

I don't think it means that employers can't care about that and start to promote an understanding and even an expectation in their workforce that, just like we don't want you to come to work sick if you have the flu and spread that to the workforce, we also don't want you to come to work if you're so stressed out about something that you need to deal with in yourself, and you just need the time to do that because that energy also has an impact on the morale of the people that you work around. It shows up in the quality of the work that you do.

And so I think there are changes like that that hopefully can build momentum towards a society that in a few decades time is just much more aware of and supportive and even expecting of one another, that these are part of what it means to be a good citizen, part of what it means to be a good colleague, part of what it means to be a good father, mother or brother or sister, friend or spouse.

Bisi Williams: [23:41] You know, I love this discussion about relationships and actually moving the discussion from health and wellness from a transactional affair to really one about relationships that you want the people who you work with in your family to be well cared for, and it doesn't necessarily mean medically, right, social, emotionally as well. So I have a question for you. If you were to design a preventative vitality care system, describe a business or product that would exist in 2049 to support this venture or system.

John Zapolski: [24:16] I think there could be so many different products and services and, in fact, a whole ecosystem of things that work in concert with one another to help us manage our vitality. But, for example, I think that lots of people already today have experienced the benefits that they get in the quality of their day if they just get a five minute phone call with their mom.

Bisi Williams: [24:41] That's so nice, John.

John Zapolski: [24:45] Well, that's one of many things I learned the hard way, starting businesses from a framework that mythologized the life of the entrepreneur as somebody who works 16 hours a day, seven days a week and sacrifices everything in order to make their business work is that it became really easy in buying into that myth to just get pretty far out on the limb myself. And I love my mom. I have a great relationship with her, but weeks would go by and I wouldn't talk to her, and I noticed that the longer that that happens, the more it's kind of like you've got stuff saved up.

And so now, instead of being able to call for a few minutes, I've got to carve out an hour, which I can't find in order to really catch up on things. And it works so much better when there's an attitude that I have space every day to make that call, even if it's just did you have dinner last night, what did you have, how are you doing, what are you going to do for your day today, okay, I love you, I'll talk to you tomorrow. 

I think that so many of us are so overscheduled and so stressed out and we beat ourselves up about that like we're bad people. And I think that if we kind of take a more loving and caring approach to ourselves and to one another, we can see that little nudges that help remind us, hey, take time to do that can be really helpful. I don't mean that to sound naive or overly simplistic. It may indeed sound like that, but I do think that that's part of for me, what makes me feel alive and feel vital and feel connected to people is just remembering to take that time. Similarly, like taking ten minutes sometime throughout the day to meditate or to take a walk is so important. What's that saying about meditation? That if you don't have ten minutes to meditate, then you really need to take an hour.

Bisi Williams: [26:46] Seriously, I've never heard. Tell me more.

John Zapolski: [26:49] I think I heard that from Russell Simmons one time, the hip hop mogul. And I thought that was so true. So if you're so overscheduled that you can't find ten minutes in your day, then you really need to find an hour. So I think there are ways that simple services like that can remind us that it's in our benefit and our responsibility to take time out to care for ourselves. And that by doing that, we're going to be much more effective at caring for the other people in our lives, too.

Bisi Williams: [27:21] Wow, that's really phenomenal. I mean, I love that loving, caring, supporting system that you're imagining for our future. And I'm going to ask you another question. Given all the resources and advances in science and in technology that we have today, what advancements would you recommend we not pursue to make the world a better place in 30 years?

John Zapolski: [27:47] That's a great question. You know what comes to mind for me is now that I work in developing products and services for older people, there's kind of an industry that some people call the aging industry, and some people call the longevity industry. And I don't particularly like the notion of longevity. I don't know if I'm someone that wants to do a lot of life extension. I don't think for myself I want to live to be 150, but I am really interested in improving the quality of life for however long we have. And so I'm not so much of a fan of things that are just trying to stave off life and keep us around for the sake of staying around.

Bisi Williams: [28:34] John, that's fascinating. Tell me more about your view on longevity for longevity's sake, if you will, share with me a little bit more about that for a number of people who may not even thought of extension of life as an option.

John Zapolski: [28:51] Yeah, well, we probably all have some dystopic vision that comes from science fiction or somewhere of like people being cryogenically frozen.

Bisi Williams: [29:03] That's what came to mind for me. I'm not going to lie.

John Zapolski: [29:06] Yeah, and I don't know, that just sounds kind of miserable to me, like the sake of preserving my body, kind of at the cost of the relationships with the people and the activities that I love right now. I don't know if I was frozen and then revived, would my fiance still be around? Would I get to kiss her in the morning? Would my sister be there to call and laugh about stuff, I don't know. 

Those things I think are much more valuable to me in thinking about what is going to define a life well lived, also having an opportunity to engage with the books and the stories and the music that I love and the places that I love to visit once we're able to visit places again. So yeah, those are the things that I think makes me excited and the things that I hope to help other people more fully experience and stay connected to versus just preventing kidney disease from ultimately showing up or them passing away at 80 if they could have lived to be 95.

Bisi Williams: [30:20] You raised an interesting point, so the picture that you paint is of a humane, loving, compassionate world. And I wonder what's stopping us from building this world, this system, and these useful products and prompts today. What's the barrier?

John Zapolski: [30:41] I think the really good news about that is that there isn't a lot stopping us except for our own imagination. I think there's never been more venture capital available. There's never been more recognition that there are hundreds of thousands or millions of talented, creative people who want to put their energy and attention into building things that not only are great and beautiful, but that positively contribute to our own lives and to other people's lives. I think there's a lot of opportunity to get started on those.

I think there's all of the typical things that hold back innovation in general that are present in the status quo. There's institutional resistance to things that might cannibalize existing business models. There may be health services companies that feel like if people take better care of themselves, then they'll be less money spent on incredible expenses that come up at the end of life to try to keep prolonging people's last few months. But I think those are always going to be true.

I think that more of what holds us back is that we don't take the time to think about our own lives or think about other people's lives in these ways. By and large, we're very youth obsessed as a culture, that's nothing new to say. I think that we don't spend a lot of time thinking about ways we might look forward to getting older and to be more in our lives as we age. I think oftentimes we think that life maybe peaks sometime around 40, and then you're over the hill and you're on the decline, so life is going to get progressively worse instead of thinking of it as something that could progressively get better. 

Even if our bodies inevitably decline, our wisdom increases, our knowledge of what we care about, who we like to spend time with, what we really like for our own sake, instead of because somebody told us we were supposed to like that thing or it's popular. All of those things, I think improve with age. And there are lots of ways for us to build services or apps or products or places to live that help us get the most out of those, and we just need to turn our attention towards them.

Bisi Williams: [33:05] That's an awesome answer. Okay, I love your vision for the future and the present. That wraps our show with our guest, John Zapolski. Thanks for listening. If you enjoyed our show, please subscribe or share with a friend. And until next time, I'm Bisi Williams.

Dr. Monica Lypson, Vice-Dean of Education, Columbia University Medical School

Medical training needs to change to adapt to the future. How will technology affect that? Dr. Monica Lypson, Vice-Dean of Education at Columbia’s medical school, shares the opportunities we have to diversify and evolve medical education. She explores artificial intelligence, and ways to develop communication and collaboration skills that support an equitable healthcare system. 

Monica L. Lypson MD, MHPE is the Vice-Dean of Education at Columbia’s medical school.  She also is a member of the practice plans board of trustees. As Vice-Chair, she is committed to creating and supporting the academic careers of all faculty members in the department.  

After graduating from Saint Ignatius, Monica graduated from Brown University and received her medical degree from Case Western Reserve University School of Medicine. She completed her graduate medical training at the Brigham and Women's Hospital in Internal Medicine - Primary Care. Subsequently, Monica went on to complete a Robert Wood Johnson Clinical Scholars program at the University of Chicago and a master’s in Health Professions Education at the University of Illinois at Chicago.  She has also trained to be an executive coach; and is currently participating as an Aspen Health Innovator, as well as the Seeding Disruption Fellowship in the District of Columbia.

Show Notes

• Dr. Monica Lypson shares her professional medical background. [02:56]

• How will medical training need to shift now in order to change the healthcare system in 2049? [03:57]

• The role of the clinician as a communicator. [06:21]

• What will the interaction between the patient and physician look like in the future? [09:32]

• We will need to build patient trust into the healthcare system. [11:23]

• What will the role of specialists vs. primary care physicians be in the future? [13:29]

• Will some medical specialties become non-existent? [15:34]

• Will the health care consumer prefer an artificial intelligence solution in 2049? [17:30]

• What needs to change now in medical training to adapt to the future? [19:12]

• Will the length of medical school training shorten and become less expensive with virtual learning? [22:11]

• Will those entering the medical profession be more diverse? [25:50]

• How will this vision of changing medical training improve the healthcare system? [28:27]

Transcript

Jason Helgerson: I'm Jason Helgerson and you're listening to Health 2049.

Dr. Monica Lypson: I think what we recognize now as typical disciplines in medicine will fundamentally change because one can even argue, do you need physician anymore? So I think getting to 2049 in terms of specialty turf wars, in terms of identity crisis, it's going to be tough. But I do have great hope that a lot of that will have been worked out because primacy will be put on a patient's health, and we will create a healthcare team that is able to focus on that outcome.

Jason Helgerson: [01:59] As the Vice Dean for Education at Columbia University's Medical School, today's guest clearly brings an academic perspective to health in 2049. That said her experiences within the system go far beyond the academic world to include years of experience working within the Veterans Administration and as a practicing general internist. She believes that in order to prepare doctors for success in 2049, we will need to start reassessing how we train physicians today. It's clear that today's training and teaching methods won't satisfy the demands of the future, and today she will share her vision for what medical education can and should be like in the year 2049.

I'm Jason Helgerson, and you're listening to Health 2049. And it's my pleasure to welcome Dr. Monica Lypson to our program. Monica, welcome.

Dr. Monica Lypson: [02:48] Thank you. It's a pleasure to be with you today.

Jason Helgerson: [02:51] Well, first, Monica, can we start off by telling our audience a bit more about your interesting background?

Dr. Monica Lypson: [02:56] Yes, I am a general internist or an adult primary care doctor. That's how I define myself clinically, but probably my more important role is really as an educator, administrator, and leader. I spent most of my career not only developing and honing my clinical skills, but actually really thinking about how do we best educate the next generation of physicians and, quite frankly, all members of the healthcare team. And so I really kind of focused on medical education and health professions education as a goal. And I think a lot of that comes from the background that both my parents were elementary school teachers.

Jason Helgerson: [03:48] So we always start with our guests with this very first standard question, which is, what does health care look like in the year 2049?

Dr. Monica Lypson: [03:57] It's a great question, because believe it or not, the learners that are entering our medical schools today will actually be thriving in their mid careers in 2049. So it's something that we need to think a lot about. And I hope that the healthcare system looks like a system that focuses on health. I think one of the things that will not only ideally save us money, but also really impact our citizenry is to move from really a disease-based model to a health-based model. So that's what I hope for.

And one of the ways that can be executed would be to focus on how do we train the next generation? And I'm going to specifically talk about physicians. But I hope these principles actually apply to the entire healthcare team in the future. We need to train people who are able to not only be master clinicians or focus on the art of medicine, i.e. that healing touch, but also folks that are actually quite nimble in a highly technical, highly innovative healthcare system that might be actually pushing the boundaries of science.

So I think our goals in the future will be really to focus on training. In the past, we focused on how do we actually get people to know a lot? And I think in the future we're going to have to think about systems and training paradigms that really focus on how do we help people manage vast amounts of information and deliver it in a timely and equitable way to our patients?

Jason Helgerson: [05:54] So it sounds like the future you describe and the role of physician in that future is really going to be with a heavy emphasis on communicator, because technology will provide the physician of the future with access at the tip of her fingers. Can you talk a little bit more, maybe dive a little bit more deeply into the role of the clinician as a communicator interface between that technology and the patient?

Dr. Monica Lypson: [06:21] Sure. So I would like to spend a lot of time talking about communication, but I do want to sort of also emphasize what the clinician actually will need to communicate about.

So the communication the person will need to not only be able to digest vast amount of information that are gathered through algorithms, be able to deal with the concurrence or the incongruence of an artificial intelligence diagnosis potentially, and how they might deliver that to a patient. And they need to have a vast sense of understanding, really probability and epidemiologic phenomenon if we really are going to focus on health. They're going to have to really understand and have a facile view of numeracy and probability and understand, more importantly, how to communicate those incredibly technical details to the patient.

And that communication style actually might be different. So the communication style might be how do you actually best send out personalized electronic information? How do you make sure that a patient feels touched and the information is personalized when you're actually doing it at the population based level? So that's one level of communication. And that's a skill we don't actually teach people if you think about it, how to write an email, how to write a letter to a population. How might you communicate? We see currently, we don't do such a hot job. If we look at our current situation about how do we communicate to a population about a health related issue.

And so that's a skill set that I think other disciplines actually have. Might we need to bring marketing experts into the medical school classroom? Might we need to bring communication experts into the medical school classroom to really help the physician of the future, really hone that skill at talking to populations and groups of people. And we still need to focus on I think that healing practice. I don't think that that's going to go away, that patients in need and patients with questions are going to come down and you're going to have to be able to be facile with that one-on-one conversation and really understanding how to deliver news in a way that it is heard, but also in a way that people feel empowered to act on.

Jason Helgerson: [09:09] So maybe we could sort of help our audience sort of wrap their heads around this future state in terms of the relationship, say, between the clinician and the patient, can you describe for us what that future interaction will be like, what the role is, what will it feel like, particularly from the patient's perspective and how it'll be different than it is today.

Dr. Monica Lypson: [09:32] So I would imagine that actually the actual hands on, day to day interaction between patients won't actually be between patient and physician. That hands on in-person interaction, actually, in many ways might be between patient and community health worker, patient and nurse patient and extender at the actual level. I think many and we're seeing this, even some evidence now the physician conversation, because I envision that potentially physicians will take care of vast many more patients because we have technology to be able to do that. And then the best mode of individual communication might be virtual, in some sort of virtual format where I might be following patients at some distance and really need to have a healing touch across a hologram, across a screen, across some sort of virtual reality. I think we are moving to that direction.

Jason Helgerson: [10:41] Interesting. So one of the interesting things about some of the surveys that have come out around COVID-19 has been around, who do people really trust when it comes to information about whether they should get the vaccine or not? And generally speaking, at the top of the list of who people trust is their doctor. And so what you've described is a world in which a lot of the communication isn't so much directly with the physician, but with others. Are you worried at all about patients of the future in 2049, not necessarily trusting these other voices, these other people and still longing to have that direct relationship with the physician? Or do you think things will have fundamentally changed in that regard by 30 years in the future?

Dr. Monica Lypson: [11:23] I actually think you pose an interesting question that I'm torn with. So my very DNA says I hope to have that bedside, that classic bedside interaction with patients, and my ego tells me only a physician can deliver that. But in reality, I think that's why we really have to work on that communication skills at the population and marketing level to really embolden that trust in whoever that extender might be. I think one of the interesting things in the scenario with COVID is it's the physician plus my neighbor. It's actually the two of them together that might promote adoption of a value or adoption of a therapeutic engagement.

So I do think the community health worker, I wouldn't rush her out of the system. I actually think that that's a valuable, if not more valuable member of the healthcare team. But those partnerships patients will need to trust that partnership in an important way.

Jason Helgerson: [12:36] Interesting. So maybe we could dive a little bit into the role of specialists versus the role of primary care physicians. So imagine that, and you're obviously a primary care physician first and foremost, as you identified upfront. One of the things at least I think about is that as more of this technology, artificial intelligence, machine learning, things like complex diagnoses and development of treatment options and even treatments themselves will become things that, frankly, primary care physicians with the right training and access to that technology could do on their own without needing to refer to specialty care.

And so I'm just wondering if you agree with that potential outcome. And do you see that the role of specialists being fundamentally different in 2049?

Dr. Monica Lypson: [13:29] Yeah. I'm going to define the middle road. So I think that the middle road is, you're right, what we know as primary care and specialty care actually will fundamentally change. I actually totally agree with you. I've done some exercises, and one of those terms we came up with was a comprehensivist, that in many ways has that function of what we see now as a primary care doctor and is using the algorithm-based medical approaches to take care of a patient with cancer, per se. And then there might be people who are an immunologist and geneticist.

I think how we have defined the current world of what specialties exist, how those specialties divvy up the landscape will, in fact, fundamentally change. And we will need people that might look like old time primary care or general docs. But I do think that their level of training and baseline and that's why I like comprehensivist, will be much more advanced and will need to take into account a lot of knowledge. And yes, I think I would recognize that person and embody what we think in many ways should be the quarterback and the primary care doctors of days of past.

Jason Helgerson: [15:01] So what you're in essence suggesting is almost a skilling up of primary care physicians, expanding their skill set, empowering them with new tools and additional training. But I still go back to this question is, let's take radiology, we already have supercomputers who are proving as effective today in 2021 as human beings at reading images and scans. Do you see that at least some of the specialties that exist today, I'm not saying totally disappear.

Dr. Monica Lypson: [15:34] I totally agree. Radiology, dermatology pathology, things that are visually recognizable, that a computer could probably do better, we won't need it. I agree with you. Will we need informationist, will we need logarithmist, and that's what I mean. I think what we recognize now as typical disciplines in medicine will fundamentally change because one can even argue, do you need a physician anymore?

Many things could be delivered by other professionals that we already have access to. So I think getting to 2049 in terms of specialty turf wars, in terms of identity crisis is actually going to be tough. But I do have great hope that in 2049, that a lot of that will have been worked out because primacy will be put on a patient's health, and we will create a healthcare team that is able to focus on that outcome.

Jason Helgerson: [16:48] Are you at all worried that the healthcare consumer in 2049 will prefer and in essence, choose, but vote with their feet for not an actual human being physician, but for a bot, artificial intelligence solution that they can access 24 hours a day, 365 days a year, that's powered by the latest greatest technology and is super inexpensive, always there at their fingertips. Do you fear that at all that medicine and the medical industry is potentially a threat from competition from machines?

Dr. Monica Lypson: [17:30] Yes. And we call it now, Doctor Google. This is not that far off. Doctor Google can answer a lot of questions that I don't actually see in my office, but I also know how many times people will bring in the phone or will print out, here I read this, Doc, can you help me figure this out? This is what I think, and they still come for, to get help with  which information is better? How do I make a determination that what I've been told by an algorithm is correct.

I think there will still be a need for a human, but I think the human skill and really that's the healer skill, will fundamentally change in the ways of needing to be able to help navigate that information. But in the fundamental ways of working with the suffering that won't change.

Jason Helgerson: [18:34] So in terms of the future state, as you said that the clinicians currently in medical school are clinicians to be currently in medical school today in training will hopefully still be practicing medicine in the year 2049. And as we've been discussing significant changes on the near horizon, what needs to be done now to change medical education, to ensure that those clinicians and training are really ready and able to adapt to the new technology, the new challenges as well as the new opportunities presented by these new advances?

Dr. Monica Lypson: [19:12] I think we have to also change how we teach. So I think if there's any silver lining in a global pandemic was actually the rapid need to innovate in this current environment. So medical students and other health professional students were actually ripped out of the clinical environment over the course of the year and placed into a virtual learning environment. I think that virtual learning environment is not going away, and what we need to do as educators is make the most of that virtual learning environment. So are we doing multiple simulations and gamification of our learning scenarios?

There's other professions that are doing this. The airline pilot is expected to go into the flight simulator several hours every couple of months to enhance their skills. We should expect that of our clinicians as well. There should be simulations, virtual reality that you are expected to participate in, in terms of keeping up your skills. I think that as we move to this idea of algorithms, I think we are not teaching our learners how those algorithms are created. We are not teaching our learners how to spot bias in those AI creations.

That's how the curriculum needs to change so that we have clinicians ready and able to manage the artificial intelligence and mean learning. We don't want the machine managing us. We want to be able to manage the machines. And I think that that really is a change in paradigm of how we currently educate. How do we change people to really think probabilistically and in Bayesian theorems. We spend a lot of time specifically in academic medicine, focused on these rules, but I don't think that the average practitioner, when they're seeing patients on their day-to-day basis, are utilizing that knowledge that could be brought to bear to improve patient outcome.

Jason Helgerson: [21:27] Do you think that the current approach to medical education in terms of the timeline, the four years of medical school, after four years of undergraduate and then another four, potentially two to four years of residency, people coming out in their early 30s, oftentimes with hundreds of thousands of dollars in school debt. Do you think that model of education is what we'll continue to see in 2049? Or do you think this virtual learning and things like that will allow us to potentially shorten the amount of time that people need to get the adequate training and knowledge to be practitioners in this new world? And do you think we can find a way to train doctors in a way that's cheaper?

Dr. Monica Lypson: [22:11] I'm pausing because the answer is, of course, I don't think that this model is not economically sustainable. At some point, we won't be able to sustain this investment. Really, or we chalk it up to that this is a career of the elite, because otherwise we can't do it. So I think you asked a question that is right on, that in fact, we have to think about that. We have currently models about a three year curriculum. There are several schools that have done this. If we can actually look back to World War II, we've done that before. So a three year medical school curriculum is not unheard of.

I think on the residency training side, the feather in the US healthcare system's cap, is really its graduate medical education system and enterprise, and the way that they train physicians, everybody looks to us globally as a model. But that, too, needs to change. There's a lot of training that's done that is time-based and I have spent a lot of my research and a lot of my efforts focused on competency based education, where you get to move forward as soon as you show that you can handle the work for many of that might be early for others, we might have to delay.

And we learned that technique from K through twelve that have been doing competency based education since the 60s. So we actually have many of those fundamental principles, we just haven't put them together in a real way. I think we're going to have to ask a real financial question of, is the federal government, right now Centers for Medicaid and Medicare going to continue to support graduate medical education. I think that's a policy question. And if it does, we're going to have to show the public that it's worth their money.

So the public is interested in the outcomes of the learners. What are those learners doing to improve their health and the healthcare system? So I think that that is coming much sooner than we think.

Jason Helgerson: [24:30] All right. So my next question is actually, I think the best question I have for you today and the reason it's the best is it because it came from you, this suggestion for what you wanted me to get to, which I think it's a great question which really gets at the heart of as medicine, the practice of it, and the way in which physicians are trained and other allied professionals are trained is changing, as we talked about with this new state of health care, that is going to be upon us very near future.

What kinds of individuals will actually choose to enter the health professions? Why will they choose it? Especially given the fact that it's going to be much more algorithmic. And do you think that that future state will allow for a more diverse healthcare workforce than we have today? Clear evidence that when you are able to find particularly for people of color, they can find a provider who they recognize, whose opinion that is of the same race that they are, that there can be much better health outcomes as a result of that.

And yet we have really an inability overall to attract people of color or not attract but actually help them actually get into and then succeed in medical school. Do you think that who we see in the medical profession will be different and perhaps even more diverse than it is today?

Dr. Monica Lypson: [25:50] I hope so. I spent a lot of my time making it. So I think your point is, well, passion. I think if we start to focus on health as the optimal outcome, that we will continue to have a massive amount of learners who are more than capable to do the job as clinicians.

 I think we've been talking lately about medical school enrollment in the Fauci effect. So you would think in the mast of a global pandemic where potentially as a healthcare worker, your health is at risk, and we're having vast amount of applicants to medical schools and other health professions. So the call for the altruistic meaning of being a healer, I think, is not going to go away. I think what we need to do is start to think about who is best to deliver that news. And I'm back to the communication skills of I don't think we really have tapped into who are the best people to fulfill the future of medicine. What is their mindset? How do they best work in teams? Are they reflective and can bring a population health lens to what they do?

I think if we focus on those outcomes and look for people who bring that skill set, we will by nature, diversify those who we think are eligible to participate in this guild, that I have such an honor to participate in. If we continue to focus on it's, just the test score and it's just who's had more access as a kid to certain opportunities, and that's what gets you into medicine, then we will continue to look like we do. But I think if we're going to create a system that focuses on the patient and the population by nature, we will have to diversify that workforce.

Jason Helgerson: [27:57] All right. So we come to the end of our session, and we always like to end with a question which is now that we've had a chance to wrap our arms around your vision for not only health and healthcare, but also for medical education in the year 2049, we always like to ask our guests to take a step back in terms of looking at your vision. If your vision for what the system could and should be is actually accomplished, how will it make the world a better place?

Dr. Monica Lypson: [28:27] So my bias is that health is a right and what we know is that people can't fulfill their full opportunity unless they are healthy. And so building a better health system that focuses on health will actually improve our citizenry, improve their economic opportunities, improve their ability to be the best person that they can, and people will still have acute disease that we need to intervene on. And that's why we still will have a healthcare system as well. But I think improving health overall is the best thing that we can do to really uplift and improve all of the outcomes of all of our citizens and get them to the point where they can take advantage of any opportunity that comes their way.

Jason Helgerson: [29:22] Fantastic perfect point to end on. Thank you, Monica. And that was Dr. Monica Lypson and her vision for healthcare in the year 2049 as always, thank you for listening to Health 2049. If you enjoyed what you heard, please subscribe to us and share this podcast with a friend. Thank you and see you next time.

Dr. Jerrica Kirkley, Co-Founder, Plume

Health care is rooted in 400 years of oppression. Can technology transform the system? Dr. Jerrica Kirkley, family physician and co-founder of Plume, shares an optimistic realism approach that shifts from the one-size-fits-all healthcare model to envision care that is identity-centered and addresses the needs of the trans community and other marginalized groups. 

Jerrica is a queer trans woman, doctor, and startup founder based in Denver, Colorado. With her co-founder Dr. Matthew Wetschler, she started Plume, an app-based gender-affirming care service for trans folks, to increase access to gender-affirming medical care across the country. She hopes to use her platform to not only provide much-needed medical services but to transform the way the world thinks about healthcare and gender.

Show Notes

• Dr. Jerrica Kirkley shares her journey into the healthcare system as a family physician.  [02:52]

• An optimistic realism approach that envisions transformation in six key areas in health care. [06:23] 

• The healthcare system follows a one-size-fits-all model that’s rooted in 400 years of oppression. [08:02]

• How can technology along with a community and identity-centered approach create breakthroughs in the system? [15:12]

• What are the positives and potential negatives of technology in healthcare? [20:45]

• How will we pay for health care in 2049? [22:28]

• What role will artificial intelligence play in 30 years? [26:25]

• Hospitals will change as health care focuses more on prevention. [30:06]

• Achieving the vision of person-centered care would lead to healthier, happier people with a better quality of life. [32:16]

Transcript

Jason Helgerson: I’m Jason Helgerson. And you're listening to Health 2049.

Dr. Jerrica Kirkley: Realistically, we have a healthcare system that is quite literally rooted in 400 years of oppression, built from the beginning and largely, that oppression focuses on lines of race, gender and sexuality among many others. But that's kind of what's brought us to where we are today. So we've built a health care system that does, like a pretty good job of taking care of a fairly monolithic community. And for a long time, we've just been trying to fit everybody else into that one-size-fits-all model. And so I think, as a patient walking into that, if you don't fit that nice, neat box that the healthcare system was designed from the beginning to really address, then you start to hit a lot of friction points.

Jason Helgerson: [01:56] This week's guest is making waves in the world of transgender health. Not only is she a doctor, but she is also a startup founder at Plume, an application-based healthcare services company focused on meeting the needs of transgender individuals. Through Plume, our guest aims to increase access to gender affirming medical care across the country, if not the world, she imagines a future where transgender individuals no longer face any stigma or inadequate access to affordable care.

Given her work to date as well as her own personal journey, I can't wait to hear what she envisions for health and health care in the year 2049. I'm Jason Helgerson, and you're listening to Health, and it's my pleasure to welcome Dr. Jerrica Kirkley to our program. Jerrica, welcome.

Dr. Jerrica Kirkley: [02:44] Thanks, Jason. Yeah. Really happy to be here. And thanks for having me on.

Jason Helgerson: [02:47] So, Jerrica, tell us a little bit more about your interesting background.

Dr. Jerrica Kirkley: [02:52] Yeah. So I'm a family physician by training, I guess, professionally. And I think back to just when I first started thinking about getting into health care and going to medical school, for me, it really looked like finding a career path that allowed me to engage with, I think a lot of different communities and especially to be able to engage with communities who were particularly underserved and just didn't have the resources that a lot of other communities had. So I saw healthcare as a vehicle to do that.

And that was really my draw of getting involved in healthcare at all. Recognizing there's obviously many ways to do that type of work and family medicine just kind of matched a lot of that. It was a community of health care providers who were oftentimes rooted in social justice oriented causes within medicine and the community and society at large for a long time, really dating back to the civil rights movement. And so that was the specialty I picked to be able to have a lot of skills to address sort of a wide breadth of needs when it comes to different communities.

And that was kind of my professional pathway. But yeah, I also have my own experiences with healthcare. And as a trans person myself have felt that pretty intimately in different ways. And after finishing training and then getting into practice, I wound up in a community health center setting. It was sort of where I always wanted to be getting back to the community, providing primary care. And then I just noticed a lot of barriers coming up, really for everybody. But that were particularly emphasized and significant for trans folks.

That sort of led to the founding of Plume, but that's, I guess, sort of a broad overview of who I am and where I come from. But beyond being a medical practitioner, I really love educating folks. And I've done a lot of teaching on gender affirming care and other things within medicine for a long time. I'm a parent, mother and just enjoy, I think, all things outdoors in nature and being physically active. 

Jason Helgerson: [05:06] Great. Well, Jerrica, one of the things that I found very compelling about your company when I first got to know was that you would provide potential investors with a vision for the company in the future that took us through 2030, I think was the year, which I think is a longer horizon than many in the healthcare world are taking. But obviously the purpose of this show is to think even further into the future. And so I'd like you to sort of describe for us what you think healthcare looks like in the year 2049, roughly 30 years in the future.

Dr. Jerrica Kirkley: [05:39] Yeah. Easy question. I know I thought long and hard about this, and I think my approach to answering this question is something along the lines of optimistic realism, which I guess is where I live most of the time because I was thinking, okay, well, that you could take a very utopian, just like everything that seems would be needed or wanted. And for me, that's a little hard to do. I think just living in the world that we're in. So I was like all right. Well, how do I see things moving and sort of mixed with how I'd want to see them move and be in 28 years.

That was the high level approach. What I do see is really healthcare moving along six key buckets or lines. And to me, that looks like culture really being a big one. And I can break down how I see each of these moving. But then I think there's policy, there's education, there's technology and then payment and care models, and a lot of these go hand in hand, and there's a lot of overlap. But that's sort of what I've seen historically and sort of the things that I see changing as we go.

Jason Helgerson: [06:52] So why don't we start breaking those down because I think one of the things we always like to get our guests to describe is thinking about the system, but also from the perspective of the patient to help our audience really kind of get their heads around the future. And I like your realistic optimism. We believe here on this show, we say we don't want Pollyannas, but we also don't want pessimists. We want this to be about what the future could and should look like. So I think your perspective is exactly correct. So give us a little bit more flavor for that future state. 

Dr. Jerrica Kirkley: [07:30] For sure, I always like to start with the culture piece, because I really see that being the focal point where all of these other things come into play and the driver of all those things, whether it's policy, education, technology, payment reform or just how we facilitate care, I think it all is driven from how we approach it culturally. And I'll explain what that means and getting to the patient perspective in this.  

Realistically, we have a healthcare system that is quite literally rooted in 400 years of oppression. I mean, built from the beginning and largely that oppression focuses on lines of race, gender and sexuality among many others. But that's kind of what's brought us to where we are today. So we've built a healthcare system that does a pretty good job of taking care of a fairly monolithic community. And for a long time we've just been trying to fit everybody else into that one-size-fits-all model. And so I think as a patient walking into that, if you don't sort of fit that nice, neat box that the healthcare system was designed from the beginning to really address, then you start to hit a lot of friction points. 

An example of what the work we do at Plume as a patient, we have a healthcare system that is based around insurance and largely fee-for-service billing with health insurance companies. But if I, as a trans person, try to get healthcare, there's a good chance that it'd be hard to find a health insurance company that one even covers the services that I need. But then I have to find a clinic that can deliver those services, whether the health insurance covers the cost or not. It just keeps going from there. 

So for maybe certain individuals, it can be easy just to plug in. You get your health insurance, you go to your local clinic and you get what you need. But it's not the same for everybody. So that's kind of the framing that I'm getting at and where that takes us is instead of this legacy system of really disease-based care, where it's just like we're teaching our medical trainees and then we're doing this in practice to treat hypertension and treat diabetes, treat HIV, whatever it might be. I think we have to take a step back from that. And again, free focus on that patient. And what I mean by that is the identity of that patient, the community of that patient.

And these are not necessarily new themes. We have community health centers that came out of the 1960s because black Americans just literally did not have a place to get health care, because a lot of the clinics were white only. And that's why these health systems and clinics were formed. We've done this on some levels, and we have LGBTQ-oriented community health centers and along other lines of identity. But we've yet to see it, I think really applied to a large scale, and yet to see the paradigm truly shift.

So that's why I think that's such a cornerstone is because we have to get to that point where through everything that we do in medicine is really be focused on where that individual is coming from and acknowledging that, hey, we might need to do things a little bit differently depending on who that individual is and where they're coming from. I always like to throw out some examples, because this is already happening and love to highlight folks who are doing that. We're definitely the big thesis here at Plume, where we're focusing specifically on the trans community and reshaping how we deliver healthcare, how we think about healthcare in our minds more adequately and appropriately address the needs of the trans community that has oftentimes fallen through the cracks and just the general legacy system.

But there are startup companies like City Block who are really creatively looking at leveraging value-based contracts in a virtual and in-person environment to focus on urban communities that are primarily black and brown. And FOLX is another company doing broader LGBTQ plus virtual care, Violet and T Buddy, focusing on the mental health needs of trans and queer folks, both trans and queer founded. Euphoria looking at helping navigate just the process of being trans in the world through all the institutions we face and then couple other neat ones.

Perspective and Hurdle are in particular looking at the mental health needs and focusing on the black community and connecting directly to providers with that identity residence in mind. The list goes on. There's emerging marketplaces that are doing this as well. So it's definitely starting. And I think we'll see that momentum continuing and again, because where all this goes is we want better health care outcomes. We talk about that all the time from a policy standpoint and from a public health standpoint. But yet we keep seeing the same numbers.

Why do we see black Americans are the most disproportionately affected by hypertension, that trans folks have the least access to and culturally and we'll say clinically-informed provider and list goes on. So I think until we really start to change that, those outcomes will probably not change. But when we do what we're doing is promoting comfort, we're promoting safety and really buy into the care process. And then I think that's when we really start to see health get better, health improve.

The last two pieces. I wanted to mention are policy and education, because those will also have to change to really achieve a lot of these things. And so the only thing I'll say about those is I think educational systems for healthcare providers will start and they are starting, but really, in 30 years is a good question, where will they be? I think the majority will have a lot of these sort of culturally informed elements of care baked into curricula. But the healthcare education system is perhaps even slower moving than the healthcare system at large. So we'll see where that is. 

But from a policy standpoint, what I foresee are these universal licensing. Because I think where we go from taking the great work that folks are doing in community health centers and really acknowledge identity-based care, how do you get that to everybody? And so I think we need to see the regulatory side catch up and have universal medical licenses for various health practitioners, universal DEAs, the list goes on, more universal standards of care and not having each medical board kind of dictate these nuances and requirements that become an impairment, actually practicing across state lines. So those things I do see happening as well.

Jason Helgerson: [13:57] Yeah, I mean, I so agree with you in the sense that we use the words patient-centered or person-centered healthcare all the time, the words are like ubiquitous. But yet the system couldn't be farther from the truth. I often also say that so much of healthcare, not just the United States, but in other countries as well, we took the Ford assembly line approach and basically implemented it in healthcare and turned patients into just cogs in the machine. And I couldn't agree with you more that the cogs that this system was designed around white individuals with means.

And everyone else expected to sort of fit in to that same assembly line. And I guess in a sense is that what do you see, in order to get to that more person-centered that system with a culture that really begins to see patients holistically and designing care around those needs, as opposed to expecting people to sort of conform to the system. What do you think is the sort of biggest impediments to us getting to that desirable future state?

Dr. Jerrica Kirkley: [15:12] Great question. And I think really it feeds along the lines of the sort of policy, technology and care model change which I'll get into. But before I dive into all those, there's this other sort of cultural piece. And it's just like that how do we feel being in healthcare? And I think if we had to pick one word, unfortunately, if you ask a lot of people and certainly if you ask me, it's frustration, right? I mean, if you're a medical provider and you think about walking into your clinic to see 40 patients and just knowing that, how can you provide the highest quality care with five minute visits and 40 people?

And then as a patient like, oh, gosh, just shuttering at the fact of having to go to a clinic knowing the potential fallout that can occur there or more so afterwards and lack of transparency, you're going to get stuck with a big bill. It's a lot of frustration and fear, honestly, that's super important, because that is sort of some of the defining cultural elements of healthcare right now. 

How do we get the 180? How do we get to where healthcare does actually feel welcoming and not frustrating and at the very least, if not exuberant, but like, oh, this is like an okay place to be. And I know what's going on. And I know what's coming. And there's not a bunch of surprises. And I think to do that, of course, part of that is the cultural shift we were talking about before, but changing the system. And because if you have a system that's built again in fee-for-service and health insurance carries a lot of unknowns and unpredictability, and then you have technology which is built to support those insurance companies that sort of leads providers kind of clicking buttons that feel completely meaningless, because they're purely built to move codes back and forth from a medical provider to an insurance company.

Then it really detaches the provider from the patient. The patient feels sort of left out of contact with their provider, even though they're sitting right in front of them. But it really doesn't feel like there's a relationship there. A lot of this is just re-establishing the patient and medical provider relationship that, in my mind, has been stripped away over the last 40 plus years because of these system elements which have been driving the system.

And so if we start to get into that a bit, let's talk about the technology. Again, we've had these electronic medical records which are really serving a singular purpose, but then started to be advertised as, oh, this is actually, better for care and it makes it more efficient, and we have data. But then we find out that, oh no, it actually slows down care. You have dissatisfied, burnt out medical providers, frustrated patients, and a whole bunch of data that we can't do anything with. And so what I do see is starting to happen now, and I think we'll be in a really good place in 30 years, especially with as quick as this is evolving, is moving away from this classic electronic medical record or EMR to what I would call healthcare delivery platforms, holistic healthcare delivery platforms that can facilitate care seamlessly, whether in-person or virtually via tele-health.

And when we talk about data again, we're capturing gobs and gobs of data, but we just can't use it that well in these systems. And so I think we really need to redefine how we are talking about data, structuring it and collecting it, so that we can actually go back in and look at these population-based trends to inform the clinical care that's happening in the moment and at that clinical site. But also then, of course, to be able to link to data that's being collected elsewhere and really have some just absolutely robust insights into the care of individuals.

And then if you couple that with an approach that is community and identity-centered, then really having breakthroughs. So I think that's where technology can really be leveraged in a way that just hasn't been for a long time and not for lack of having the capacity to do it. But just again, sort of system forces which are pushing it in a particular direction.

Jason Helgerson: [19:45] So you mentioned already, and I love the description that you just provided in terms of this platform and individuals being able to have their holistic needs met. And these platforms able to tailor the health solutions truly around, it really sounds to me much more like a patient or person-centered approach than what we have today. But the role of technology and all of this, obviously, in the show, we have guests who are very optimistic about the role technology plays, but there's also potentially a darker side of how technology and data can and will be used in the future within healthcare.

What do you see as both the positives as well as potentially negatives of this robust data that you envision these platforms having access to? Are there things that government or others or institutions in society need to do to make sure that we get to them more optimistic, as opposed to the darker version of how that data is used?

Dr. Jerrica Kirkley: [20:45] Yeah. Excellent question. With power comes responsibility. And it is exciting to think about, again, just like, sort of the insights that we can glean from that and really start to radically transform care. But there is that other side. And I think if you start to have these sort of big consolidated buckets of data, of course, you think about data security and does that, then open up these opportunities for hacking into that data. And, of course, all kinds of things can come from that, especially if the data is centered on communities which are traditionally marginalized and oppressed.

And that is a super important concern. And a lot of that comes down to data security, and there will have to be a balance. That's something that we've struggled with in the healthcare community for a while now. And we do have electronic medical records that in many ways can communicate with each other to some degree. But even just having visibility to that information as a provider to help with the care of somebody has been really hard because of regulatory forces that are concerned about various things when it comes to privacy and information sharing.

So I think it's going to have to come to a middle ground of some sort. And what that actually looks like is hard to say. But absolutely. I think it's something that we always have to keep in mind in a company like Plume that we're thinking about all the time.

Jason Helgerson: [22:22] So in the future, how do you think we're going to pay for healthcare in the year 2049?

Dr. Jerrica Kirkley: [22:28] Yeah. Well, this is like a question that I can come up with an answer ten different days, and there'll probably be ten different answers. And I don't know if I trust any of them. So where are we now? We have this largely fee-for-service based system that's linked to health insurance, quote, unquote companies that pay for a lot of the healthcare. But what we've seen more recently is that actually they're shifting that burden onto the patient more and more. And also the medical providers providing the care where they're refusing to reimburse many services. If they do, there's high deductibles, there's high copays, there's coinsurance list goes on.

And so it's actually not really doing a whole lot of what it set out to do. And I think that is going to go away. That will not exist in 28 years. I really hope so. At least the fee-for-service aspect of insurance. Now, where that goes is a really interesting question. I see going a couple of ways. 

I do see a lot of energy being generated around this direct care model, which classically we call direct primary care, the more traditional brick and mortar world. But now that's sort of evolving into this direct to consumer health, which are the virtual health care companies like us and many others I mentioned who are coming up, and there's a lot of them. I was talking about a lot of the identity-focused ones, but, I mean, there's something for almost everything now that you can go into a website and see a clinician and get a prescription as needed. Obviously, the population is really coming on to that. I think it's for all the reasons that we discussed.

It's like, okay, well, why do I need to drive across town to go to a clinic that's where I don't feel very comfortable anyway. And I'm going to get a bill and I don't know what it is when I can just come to a provider, have full transparency, know what the cost is, know exactly what I'm getting and talk to somebody who has deep experience in that. And so I do potentially foresee a system that is perhaps largely built in cash pay, kind of direct cash pay.

Will insurance go away completely? Probably not, but moving more towards a true health insurance in the sense that it's covering catastrophic events. But otherwise you are actually paying reasonable cost for the healthcare that you're receiving. There's definitely a lot of energy in these value-based contracts as well. And I think that's interesting. And so maybe it's sort of a hybrid world where we have completely moved away from fee-for-service. But perhaps there are these kind of value-based contracts set up where we're not having to think about codes and billing by procedure or medication. But the health insurance is kind of charging health providers to take care of a population and do it well and get compensated for doing that. And so I do think that could have a role. But that's where I see that moving. 

Jason Helgerson: [25:45] Great. Well, on technology, a topic that's come up over multiple episodes of this program has been the role of artificial intelligence, machine learning in direct healthcare delivery by the time we get to 2049. What role do you see those technologies playing? Do you see them replacing the human position in some tangible ways? Do you see people seeking or wanting those kinds of technologies to support them? Or do you continue to see the human healthcare provider as still the preeminent clinician in the health care system?

Dr. Jerrica Kirkley: [26:25] Yeah. I get this question a lot. And no, I don't think it's going to replace, for sure like any one profession or role when it comes to healthcare providers. I do see it as a really important supplement. I mean, people have been asking that about things like IBM Watson for the last seven years or more and it's obviously not replaced anybody yet. Now a lot of that is just an adoption thing and a comfort thing with that kind of technology. But I do think it can be really helpful.

There's so much of what we do that is very algorithmic. And also I think you couple that with there is just so much happening. And in the sense of research studies coming out in publications and sifting through information and that in and of itself, Ironically, is also delayed. I mean, to get to that point, you're talking about months to years before something kind of becomes a, quote, unquote guideline or standard of practice. I think what will enable us to do is to really accelerate that process where we're not always on our heels and years behind where we can again modify our practice in more real time and having that ability to sift through massive amounts of data that presumably these systems will be collecting in 30 years.

I see it as a supplement to both in real time care, also getting insights into population health dynamics, and then how that changes practice. And so some of the things that we do might be replaced by, you could say AI or whatever that technology might be. But I think there always will need to be a clinician leader to that, if you will, somebody who is and this gets another culture piece. It's never going to be one singular person. I think that's also an unfortunate paradigm that we're in now, where it's like we kind of have this expectation that you can walk into a primary care facility and we're going to do everything for everybody.

I think primary care is amazing. I'm a primary care practitioner myself. It will always have a place and never go away. But we really do need to rethink how we're I think approaching that because it's just not a reasonable expectation for one provider to be responsible for all these different things. We're going to have to lean on other whether it's providers, groups, technology, etc. and care teams. You're going to see more expansive care teams. And I think that's one of the neat things doing a healthcare technology startup is like we live and die by teams.

We have product teams, we have our community outreach teams. We have our obviously clinical teams, our operations teams. And I think traditionally a lot of health centers and hospitals and clinics aren't necessarily thinking that way. So it really provides us a nuanced approach to just problem-solving and approaching patient issues. And so all I have to say, I think it's a supplement. We'll see more coordination and true team-based approaches, which again, another buzzword, patient-centered team-based care. Yeah. I've been in the PCMH world for many, many years, but I think that will actually help promote sort of those ideals that we've been talking about for a long time.

Jason Helgerson: [29:51] So I have to ask, given your background, both of what you've been saying today, as well as your background as a primary care provider, what role do you see the hospital playing? What is the hospital look like in the year 2049?

Dr. Jerrica Kirkley: [30:06] Yeah, that's a great question. I think it will always be that kind of tertiary care place where people are going when the care just exceeds the capacity of the primary care clinic and for more emergency situations. But I have to believe that as these systems change, like we're talking about that, we actually really will see more through preventative care and better managed conditions. And really the hospital now it's serving the role of catching the folks who just have these conditions that are spiraling out of control and have bloated emergency rooms and ICUs and, of course, overlay pandemics on top of that, and it really gets out of control.

So I think we'll see less of that, hopefully where it really kind of starts to hone in on the folks that need the care the most, but sort of weeding out the people that we can prevent these things in the first place. But I think technology will play a big role, too, similar how it can do in an outpatient setting in terms of just being able to manage the data that's coming. In hospital settings it's just tons of data points and metrics all the time in real time. And I think it could be a struggle to sort of put our heads around it, so certainly can help shape that.

And then the coordination piece, this is a huge thing that is a massive problem. It's like when people leave the hospital, what happens and where does that information go? And how is it getting transmitted to the people that need it? And that is a big reason there are a lot of teams who focus to do this work specifically, but like preventing readmissions.

Why do people end up back in the hospital? So I think that's where these healthcare delivery platforms come into place and the communication between them to really have seamless communication and visibility into what's going on. So I think that can be a big change for sure.

Jason Helgerson: [32:16] All right. So our final question that we always ask is to ask you to take a step back and envision we're in the year 2049 and your vision for the future. And these platforms that provide truly person-centered care are, in fact, now not only in existence, but they are the standard of care. And if we achieve that, how will that actually make the world a better place?

Dr. Jerrica Kirkley: [32:40] Where does this take us? And how does this truly make the world a better place? I guess put as simply as possible, it's just happier and healthier people. We have built a system that's inadequately addressed needs, it infuses a lot of frustration itself and the end result is not great outcomes and unhealthy people. 

For me, the flip is you're going to have people that are healthier. If you're healthier, your quality of life goes up, you're happier. And if we're really digging into some of these kind of social injustices which are built into the system that can have, I think, very broad reaching effects culturally beyond what we're doing in healthcare. And I think can really start to create a more cooperative and an understanding world.

Jason Helgerson: [33:30] Well, I couldn't agree with you more. And that was Jerrica Kirkley's vision for health and healthcare in the year 2049. As always, thank you for listening to Health 2049. If you enjoyed what you just heard, please subscribe to us and share this podcast with a friend. Thank you and see you next time.

Barbara Groth, Founder & Creative Director, Nomadic School of Wonder

How do we shift from ego to eco in health care? Barbara Groth, Founder and Creative Director of the Nomadic School of Wonder and Executive Director, Experience Design of Meow Wolf, shares an experiential design approach that taps into the presence and wonder of nature and animals to create daily habits that enhance wellness.

Barbara Groth is founder and creative director of the Nomadic School of Wonder and Executive Director, Experience Design for the immersive art project known as Meow Wolf in Santa Fe, New Mexico.  Barbara has spent thirty years at the intersection of creativity, emerging technologies and human centered design for the likes of Walt Disney Imagineering, Pixar, Google, x, LACMA, LEGO, Vulcan, Bruce Mau Design, the Museum of Science & Industry and the Los Angeles Dodgers.

Since founding the Nomadic School of Wonder in 2015, Barbara leads a traveling troupe of artists, teachers and adventurers who create “adventures in awe” in small towns throughout the world. Each site specific sensory driven adventure is a unique, joyous and spontaneous experience into the unknown. By weaving together nature, art, community and play, the Nomadic School of Wonder aims to restore our limitless imagination, expand our creative potential and deepen our connection to ourselves, each other and to the natural world.

Show Notes

• Barbara Groth shares her journey in experience design from innovative technology to exploring our natural world. [03:35]

• Redefining wellness by tapping into the aliveness of nature. [06:55]

• How can we design our lives to be full of a sense of wonder, purpose and connectedness? [12:29]

• If we create our lives with strategy rather than urgency, how will it affect our health and well-being? [13:52]

• What does it mean to shift your life’s purpose from working to live to living to work? [15:58]

• What role does money play? [17:42]

• Reimagining how a medical professional might write a prescription. [20:01]

• Three things we can do to be more connected and attuned to ourselves and nature to embody living wisdom. [22:56]

• Nature can fill your medicine chest with incredible ways to boost health and well-being. [24:45]

• What are the obstacles to achieving this vision of 2049? [25:28]

• Shifting from ego to eco. [25:56]

Transcript

Bisi Williams: I'm Bisi Williams. You're listening to Health 2049.

Barbara Groth: For me, it's like the three elements presence, awareness and aliveness. I think if you collect yourself, become present, find some sort of ritual or activity that you can do on a daily basis, tuning into the sky, the trees, the water, wherever you are in the world, I think you will find that you will be brought alive in a way that will not only have you enjoying your daily ritual, whatever that might be, but also having all these other side effects, which are the good kind of side effects of lowering your heart rate, your blood pressure, other things that I think are ailments of our overly do do do modern world.

Bisi Williams: I'm excited to welcome Barbara Groth to our show today. She spent 30 years pushing the boundaries of what is possible in the fields of emerging technologies, human design experience, interactivity animation and storytelling for the likes of Walt Disney, Imagineering, Pixar, Google and Paul Allen's Vulcan. She is a multimedia pioneer and award winning producer, director and filmmaker. She is Founder and Creative Director of the Nomadic School of Wonder and Executive Director Experience Design for the immersive art project known as Meow Wolf in Santa Fe, New Mexico. 

Since building the Nomadic School of Wonder in 2015, she leads a traveling troop of artists, teachers and adventurers to create adventures in awe in small towns throughout the world by weaving together nature, art community and play. The Nomadic School of Wonder aims to restore our limitless imagination, expand our creative potential and deepen our connection to ourselves, each other and to the natural world. It is my pleasure to welcome Barbara Groth to our show.

Barbara Groth: [03:08] Hi, Bisi. Thank you so much.

Bisi Williams: [03:11] Barb, I invited you to talk about health and wellness in the future with me because of your success with Walt Disney Imagineering, Deepak Chopra and Meow Wolf, to name a few, you created programs and experiences to benefit large communities that no one has done before. Describe for our listeners the evolution of your practice from tech and innovation to analog and life-centered practice experience design.

Barbara Groth: [03:35] It's so hard looking back on your life and your work and kind of finding that through line it's there. But I think ultimately it comes from ever since I was a kid asking a lot of questions and being curious. And I think it also comes from moments where I felt most alive and most connected to being in the world. And so I think somehow those two combinations of things have been a thread through my work, whether it's teaching design thinking, whether it's designing experiences for health and well-being with Deepak Chopra back in the 90s and early 2000s, or whether it was doing a film on the poet Rumi in Turkey or whether it was designing Turtle Talk with Crush with Walt Disney Imagineering, I think what they all have is kind of a searcher quality to them, in search of these moments or creating the conditions for these moments where we feel most alive.

And I think where it's had its fullest expression in many ways has been in my latest venture from the last six years, which is called the Nomadic School of Wonder. And what we do is we create adventures in awe, and we take people in the before times and in the after times to remote areas throughout the world, and we explore a theme and we explore it through the senses. It's through nature art, community and play.

And so what we found in doing these experiences that are, let's say, low tech, no tech analog, as you refer to, is that we need very little to enliven our senses and enliven our well-being. And I think I've really loved it as kind of a counterpoint to all the work I've done in technology and human-centered design is to really let nature lead the way a little bit more in what we do and look at all living things like centered in the world of all living things rather than just humans.

And so what we found in our work kind of accidentally is that all the things we were intuitively drawn to, whether it be forest bathing or working with wild Mustangs in Utah and in New Mexico was that these things are actually really good for our wellness, that they lower our blood pressure, that they raise our sense of belonging, that amplify our creativity. So for me, it was really kind of like, how do we explore what it's like to really live again? I think it's even more so post pandemic, it's even more important for us to remember, what are those things in everyday life and in the world that bring us more alive. And I think the more we get in harmony with that, the more well-being and the less disease we will have.

Bisi Williams: [06:40] I love that. And so now I want to go on a wonder trek with you and our audience, and I'm excited to learn from you. What is your vision for health and wellness in 2049?

Barbara Groth: [06:55] It's an interesting challenge, when you threw this out, 2049. I'll probably be in my 80s if I'm still around at that time. And so I started dreaming into it personally. And then I also started dreaming into it for the next generation. And I've done a lot of science fiction and a lot of projects about future. And my dream is that the future is going to not necessarily be a more technology heavy, especially technology visible world. I really feel like we're already shifting from kind of the human-centered existence, which really is a bit of more of an ego approach to life on Earth, to kind of more of an all species centered living and honoring the fact that we share this planet with close to 8.7 million other species.

I think we're going to start to once again value and listen to the intelligence of nature, of animals, the living world around us. And I think we're going to use technology, at least this is my hope, you gave me the permission to kind of dream into a vision which is one that I'd like to see and I think we're going to use technology not to dominate nature and animals, but to co-create a shared relational experience based on biodiversity, potentiality, and love. Love sounds very 60s hippy dippy, but I really think that often what we're tapping into when we tap into the presence of wonder and awe and the connection that we feel between people is this energetic, invisible, powerful force that is love, is the energy of love.

So I know it sounds very utopian, but I also think that unless we do kind of reframe how we experience the world around us and how we realize that we are nature, like Andy Goldsworthy says, and how Bruce Mau says we are not separate from or above nature in MC24. I think that until we recalibrate those experiences in our bodies, that we're going to continue to have more and more disease.

So for a vision in 2049, I think that we're going to just create real relationships with the Earth. We're going to tap into the wisdom of trees. I  know this sounds like it's right out of some sort of Disney songbook or something, cue the music, plants and animals. But I really do think that I find that if I just go out my front door, I happen to live near some mountains here in Santa Fe, and I take a walk and I start the walk, maybe not in the best of mood or overthinking something, I go for a walk whether I hold a question or just tune in my senses, I have shifted. I know my blood pressure has dropped during the walk. I know my blood sugar has dropped during the walk, and I know that I'm feeling a sense of connection and what people would refer to as oneness. And often people refer to as wonder and awe when that happens. So I just have a feeling that we're going to go back to ancient technologies, ancient wisdom traditions in cooperation with science. And the more that we know in science, it tends to reinforce what ancient traditions have been saying forever.

So how do we bring those together to solve not only our gnarliest problems, but enhance the way that we live our lives on a daily basis so that our bodies feel more at ease, more in comfort. You already see this now with forest bathing and I just imagine in the future that a RX from a healer, shaman, doctor, I don't know, just whatever that person is going to be called, will include recommendations to go spend some time with the wild mustangs, to sit on a forest floor to simply play.

I'm generalizing here, but I think we've lost our sense of play and adventure and purposeless activity purely for sheer enjoyment. And this is what I learned from animals. When I was doing a lot of the projects for Disney and others, I was kind of known as a play expert, especially around social play. And then I brought home a six and a half pound Chihuahua that told me, you know nothing about play. Let me tell you about play. I think play and how we create more experiences in our daily lives of playful aliveness in our bodies. I think we're going to feel more kind of creativity and ease in our bodies and our minds.

Bisi Williams: [12:06] So let's just talk about that for a little bit. Can you imagine in 2049, for example, you talk about some of the issues that are really profound today about loneliness, isolation and lack of fulfillment. Tell us how you could imagine designing our lives to be full of this sense of wonder and purpose and connectedness.

Barbara Groth: [12:29] I personally think that if I think back 30 years from this moment and 30 years forward, a lot of the same things may be approached differently, but I think one of the most important conditions for our well-being is presencing, and people do that in a number of different ways, meaning that they become fully present. They become aware of their surroundings and aware of their senses. And I think for us that it's done through a number of different ways that you can do that. You can just do that by walking out your front door and tuning in your senses to nature or to your surroundings. You can also do it through art. People do it through gathering and sharing and ceremony. People also do it with animals, whether it be horses or wolves or interspecies way of presencing with a being that is often seen as the other. And then to realize the connection and the nonverbal connection.

Bisi Williams: [13:33] I love that because you talk about time. Time is really important and the question is, what would it mean if we designed our life with strategy rather than urgency? And what does that mean for our health and our well-being?

Barbara Groth: [13:52] Yeah. It's so interesting because we've had this grand experiment where the whole world had to stop time in a way. We had to kind of get off the so-called merry-go-round. And I think our sense of time has shifted by doing that. And I think we have had time to pause and reflect whether we liked it or not.

I think it's that, to me I think the two things when I think about strategy over urgency, strategy, for me, is not just having a very detailed plan of where to go next it's having time to pause, reflect, look at the big picture. Think about really, what are the deeper goals of what we're trying to achieve, whether it's in our lives or in a project at work, and then something that I call the natural next thing is to say, okay, what's the natural next thing that we could do towards that end versus what is the way in which we just urgently do something about it. And I think the difference is the pause, reflect, think a little deeper, maybe take a walk, what I call a wonder walk, a little sensory wonder walk, carry a question, create a beautiful question, carry it, walk with it, and really be attuned for kind of deeper wisdom that will come. And I think that when we don't do that, it takes so little time to do that, when we don't do that, we end up making very responsive choices that are based on often not really what the deeper need is and the deeper desire and the deeper goal.

Bisi Williams: [15:42] I think that's fascinating. You also described work, high pressure environments, highly creative environments and when you shifted your life's purpose from working to live to living to work, can you tell our listeners what that means?

Barbara Groth: [15:58] Let's see, I've always been focused on experiences. In fact, I was told that really early on in my life that I valued experiences over things. And I think it's probably a good thing I became an experienced designer for that reason. I realized as I was creating a number of experiential offerings for different audiences, whether it be at Disney Imagineering or for a museum client or for retail or for something in public space, is that I was often on the creating side.

Then I decided that I was going to move to New Mexico, and I was going to kind of put myself into my own school of wonder and be on the receiving side. And I really realized that it's sort of an exchange that needs to take place. If we're going to design and create these kind of experiences for people, I think we first need to tend to and design that kind of experience in our everyday lives. And I think when we do that, I think we design from a different sense of clarity. And I also think it just allows us to be more creative and more experimental in the work that we do. So how can we design the time of our lives and I think when we do that, then purpose and then feeling like you're more alive in your everyday life.

Bisi Williams: [17:26] Well, that's amazing and I'm just going to push back a bit. What role does money play in this? Does it sound like? Well, it sounds amazing. And I completely truck with you, the question is, is this something for people with means?

Barbara Groth: [17:42] Yeah. I'm hoping that we crack this nut here. I totally get what you're saying, the connection of wealth to health. I really feel like we have been making short term, old school decisions about business. And I think that if we think a little bit more long term, we will actually be creating real wealth rather than kind of wealth that is based on short term gains and greed. I personally feel that the pandemic has really given us an opportunity to rethink about what is enough and what is too much.

And I'm seeing in the younger generations, younger than me, I'm in my 50s. They are really starting to turn back to nature, turn to making a living in a more purposeful way. And I do think we have to figure out a way in which we can create an ecosystem that really has a responsibility to honor all of the living beings within that ecosystem.

I'm not a Nobel Prize winning economics professor, but I have a hunch that if we looked a little bit longer term, if we handled some of these health and well-being issues that I think underneath them all are kind of maybe what drives some of the greed, if we really were to find a way to live more fully alive lives and have community and create connection, perhaps some of the things that drive that greed will be seen for kind of what I often think is kind of a hollowness. I think it's how we redefine happiness, how we redefine what is enough and being okay with that.

Bisi Williams: [19:39] I think that's perfect. That makes perfect sense, when I think about you as an experienced designer and I think about you being in touch with community for your vision, would you help us reimagine how a healer might write a prescription for high blood pressure? What would that experience be like?

Barbara Groth: [20:01] I'm already seeing it today where when Western medicine is at a loss for how to handle something or even some studies that have been happening now is that they realize that, yes, it's what you eat. Yes, it's your exercise. But there are a lot of people, as we all know, that eat crazy things and don't exercise and live long and healthy and full lives. And I think it has to do with how we are relating to the world around us.

And so we do these experiences where we bring people to the wild mustangs. Then we have people that adopt them and actually give them sanctuary and give them a place to live out their lives and create a new herd. Then we bring humans, humans of all different kinds, currently, we're starting to bring humans that were frontline health care workers with the horses to a sanctuary here in Santa Fe, New Mexico called a Chance of a Lifetime Sanctuary. 

Bisi Williams: [20:58] Wait, why do you bring the health care workers to this mustang ranch?

Barbara Groth: [21:03] Well, this is the work of two people that run the Chance of a Lifetime Sanctuary. And they have been for years now working with people with trauma and with the horses. There's something about bringing the horses and the humans together, who have both been through trauma to create resilience, create connection and to actually, there's sort of a mystery of what happens in this communion between the horse and the human. But often what happens is things like your blood pressure is reduced. Your sense of connection and well-being are enhanced.

And so this is a hypothesis that we're just starting with right now. But we just thought there's so many people that have been put through intense trauma over this past year, but probably no more than frontline healthcare workers and essential workers. And so we thought, let's bring them together in very small groups and create a bit of an experiment to see what happened. So we're just embarking on this experiment. But it's based on years of working with women in trauma and other populations and communities with the horses.

Bisi Williams: [22:21] So when I think about this question that you've just answered so beautifully as it relates to your vision for 2049, where we live a more attuned life while we are more connected with nature and attuned with ourselves and we build positive relationships, what you're really talking about, I feel is like a living vision for 2049. And if we were to really push that, what can we do today to embody this living wisdom that you talk about for 2049?

Barbara Groth: [22:56] So for me, it's like the three elements which I put in my living vision for 2049 is presence, awareness and aliveness. I think if you collect yourself, become present, find some sort of ritual or activity that you can do on a daily basis, bring some awareness to that tuning into the sky, the trees, the water, wherever you are in the world, to the sounds of the city. I think you will find that you will be brought alive in a way that will not only have you enjoying your daily ritual, whatever that might be, but also having all these other side effects, which are the good kind of side effects of lowering your heart rate, your blood pressure, other things that I think are ailments of our overly do do do modern world.

So I would say what Thich Nhat Hanh, the Buddhist teacher talks about, which is interbeing, if you can find ways in your life to be with nature, be with other humans, be with animals, be with other living things, I think that you'll see the world in a different place, and I think you'll see your life and your experience of life come more alive.

Bisi Williams: [24:23] Barb, what you describe sounds so awesome. The impact of what you suggest for our health and well-being is enormous. And yet looking at the sky doesn't cost a thing. Sitting next to somebody that you love doesn't cost a thing in a material sense. But the returns are huge.

Barbara Groth: [24:45] Yeah, I actually think it's so accessible. I mean, that's a big part of what we do go to all these wildly beautiful places on the planet with the Nomadic School of Wonder. And then we also do things in the backyard. And I actually think our backyards, front yards, the street, a walk in nature, a walk in the park, can really fill your medicine chest with all sorts of incredible ways of being in a state of health and well-being.

Bisi Williams: [25:21] So Barb, you paint a beautiful vision for 2049. But can you tell us what some of the obstacles may be?

Barbara Groth: [25:29] I would sum up the obstacles under a category called ego. E-G-O. I think that we are, as humans, so referenced by our egos, there's a lot of underlying things there, and our egos are fragile and they're fear-based.

Bisi Williams: [25:50] I love this phrase ego to eco. Can you tell us a little bit more about that?

Barbara Groth: [25:56] Well, it's interesting, I've been seeing this graphic being passed around for, I don't know maybe a few years now, but there's one graphic that says ego and it has a human at the top of all these species, and then eco is a circle with the human inside there, along with your whales and your starfish and your snakes and your sharks and your chickens, in your natural world. And for me, it just so blatantly shows us where we are out of balance. That's really what I mean by how do we shift from ego to eco in terms of our reference point?

Bisi Williams: [26:36] That's beautiful. Barb, I love that. I'm so inspired by your vision. Thank you so much for joining us today.

Barbara Groth: [26:44] Thank you Bisi. So nice to have the opportunity to dream into 2049.

Bisi Williams: [26:50] And that wraps our show with Barbara Groth. Thanks for listening. If you enjoyed our show, please subscribe or share with a friend, and until next time I'm Bisi Williams.

Dervala Hanley, Strategist & Writer

How do we shift our healthcare model from standardized to personalized? Innovative business strategist and writer Dervala Hanley imagines a healthcare system that fulfills the needs of everyone. She draws on real-world examples to show the power of universal design.

Dervala Hanley is a strategist and writer based in Oakland, California. She worked at the design consultancy SYPartners in San Francisco until Starbucks CEO Howard Schultz invited her to join his leadership team. At Starbucks, Dervala designed a groundbreaking partnership with Arizona State University, which covered full tuition for any employee working more than 20 hours a week to take any bachelor’s degree program at ASU with no obligation to stay at the company after graduation. Since launch, more than 10,000 baristas have gone through the program. Similar college programs have become standard throughout the service industry.

Today, Dervala works as an independent consultant, helping organizations and institutions understand each other’s worlds so they can combine their superpowers to open up new opportunities.

Show Notes

• Dervala Hanley shares her experience and the success of the Starbucks ASU program that offered 10,000 baristas access to higher education. [03:39]

• What does health care look like in 2049? [06:44]

• Shifting from a standardized healthcare model to a personalized approach that fits each individual. [08:36]

• Universal design not only helps those who need it most, it benefits everyone. [09:08]

• What is universal design? [11:08]

• What will it take to use universal design to create personalized medicine? [11:54]

• What are the obstacles to implementing universal design in health care? [13:58]

• Two fascinating examples of universal design and how it benefits all. [16:38]

• What could be the impediment to creating this personalized model in health care? [21:58]

• How can we educate people to understand the urgent need to change the healthcare model? [26:01]

Transcript

Bisi Williams: I’m Bisi Williams, you're listening to health 2049. 

Dervala Hanley: We have so many resources that are locked up and are only available to people, kind of going through a very standardized age and set of abilities. And I'm looking for a world that really understands that the very particular body you get to live in and the kind of care it needs for you to play your fullest part in the community, where our society can actually give, extend that consideration to you. And you can extend that empathy to others in return. Where what you learned about your health is something that gives you power and is not something that can be used against you as it often is today.

Bisi Williams: [01:47] My guest today is Dervala Hanley. She's a strategist and writer. She worked at the design consultancy at SY partners in San Francisco until Starbucks CEO, Howard Schultz invited her to join his leadership team. At Starbucks, Dervala designed a groundbreaking partnership with Arizona State University, which covered full tuition for any employee working more than 20 hours a week to take a bachelor's degree program at ASU online with no obligation to stay at the company after graduation. 

Today Dervala works as an independent consultant, helping organizations and institutions understand each other's worlds so they can combine their superpowers to open up new opportunities. Dervala’s work on the Starbucks ASU program helped break down barriers to future success by opening access to higher education for more than 10,000 baristas who went through the program. This idea of offering universal access also informs her vision of healthcare in the future as we will soon learn. Welcome to the show Dervala. 

Dervala Hanley: [02:52] Hi, Bisi. It's so nice to talk to you. 

Bisi Williams [02:54] Can't wait to get started. I invited you to talk about healthcare in the future with me because of your success at Starbucks, creating a program to benefit a large community that no one had done before. So congratulations on that. 

Dervala Hanley:[03:08] Thank you. 

Bisi Williams [03:09] You know, many people make comparisons between higher education and healthcare and what I'm amazed by is the speed of impact that your work with ASU and Starbucks had. Like that's mobilizing tens of thousands of people in a short amount of time in a very complex system to get access to education. Tell me, what did you break down to quickly get critical scale mass adoption and success?

Dervala Hanley: [03:39] That program to me was very interesting because higher education has been something that has been really set up around exclusivity. And it has been set up where the value of the credential that you earn is based on how many other people are excluded from earning it.  

ASU, about 20 years ago, kind of flipped that on its head. We're going to be measured by how many people we include and how well they succeed, their excellence. And there was such a meeting of the minds in a strange way between President Crow of Arizona State and Howard Schultz of Starbucks, who in a consumer world in the eighties had done something similar where you kind of insisted that lots of people would want fancy coffee if they had the opportunity when this was something that was really not considered cool.

And so, they had a similar vision of like, you'd be surprised at how many people are capable of wanting and liking and appreciating this. And you'd be surprised at being able to create an entire industry that follows that if you choose to believe. So, when I think about how President Crow talks about how, in the sixties, the University of California system took anyone in the state who had a B average, and they created one of the greatest higher education systems in the world at that time. Which is very, very different from measuring success, by how many people, how many applicants we turned down. So kind of once you had that meeting of the minds at a certain level of like, let's just talk about who we can include. And let's just look at this ridiculous system of hoops and financial aid, the dancing that people have to do.

We looked at it from a very simple perspective. How much does it cost us to replace the person who leaves? And how much does it cost you to take in a new student? And what if we just directed all of that money toward them and toward their education and could we make up some of the difference?

And so it was looking at, this is the system we're operating in and it's extremely complicated. Like healthcare, the person who pays is not necessarily the end consumer directly. The money is very, very murky between financial aid and the colleges and employer positions and loans and what feels like real money and what doesn’t. It has some of those qualities in common with healthcare. And it has that feeling of the people who probably need it least have access to the best of it. So we just flipped that and said, obviously talent is not evenly distributed, but the best predictor of earning the degree is your parents' zip code. So we're just going to say, what if anyone who wanted to do this could go?  

Bisi Williams  [06:28] Dervala, you crack the nut in terms of collaboration and shared interests between ASU and Starbucks, clearing that pathway. And now what I'd love you to do is to share your vision for health and wellness in the year 2049. 

Dervala Hanley: [06:44] Sure. I'd be happy to, you know, that whole world where institutions really think about who they can include rather than who they can exclude is something that I learned a lot from working with Arizona State University in particular, and also from the work of Todd Rose and his book, “The End of Average.” 

Todd talks a lot about this notion that fit creates opportunity and fit nurtures health. And by fit, he's not talking and I'm not talking about dumbbells or Peloton. I'm talking about a world that rebuilds our systems, rebuilds our institutions to make the simple adaptations that can fit each person's individual abilities and needs at each stage of their life. Because we have so many resources that are locked up and are only available to people kind of going through a very standardized age and stage and set of abilities. But if with some simple tweaks or sometimes some harder adaptations, many more people can be included and for far longer in their lives. And they can rise to make their fullest contribution, whether that's in work in their communities and their families or whatever. 

And I'm looking for a world that really understands that the very particular body you get to live in and the kind of care it needs for you to play your fullest part in the community, where our society can actually give, extend that consideration to you. And you can extend that empathy to others in return. And where, what you've learned about your health is something that gives you power and is not something that can be used against you as it often is today. That's a baseline for what I would like to see. 

Bisi Williams [08:25] Wow. Okay. That's great to have a lot. You're describing a very personalized approach that would put more responsibility for change on both the individual as well as the larger community, right? 

Dervala Hanley: [08:36] Yes, I think so. And I think it's like you know we tend, in the United States in particular, to put so much on individuals to do all of the adapting. And I think this is really about saying actually, no, we need to change the systems in the organizations to demand the changes that can actually adapt to fit the individual rather than what we have today, where you're personalizing by contorting yourself. 

Bisi Williams [09:04] That's amazing. Now, why is your vision possible? 

Dervala Hanley: [09:08] I think it's possible because I think a lot of it is possible today. I think it's as much a culture change as it is a scientific change. And I will also kind of say that there's a baseline of healthcare first. And I want to see the 2049 where every person arriving and leaving has access to high quality healthcare, good beginnings,  dignified endings, full lives in between. And that's already possible because we know that Coca-Cola could use 20th century tools, the distribution and mass branding to put soda within an arm's reach of desire for billions of people, then we can do the same thing with clean water and healthcare. It's a matter of will and money and commitment. 

So I think the baseline stuff that I'm talking about both as this standard that every person deserves as they arrive and leave this planet and in between. And then this is the stuff where we actually have the tools and technology to adapt to both first, to understand health on a very individualized basis versus on a kind of a one size fits all and to treat anything or to prevent or to work on prevention on a very individualized basis. So much of that is already possible. We're just not yet able to articulate it and demand it and access it and fund it. 

But I think it's possible in 2049, because I think so much of it is possible now. So when we're talking about things that make it possible for more people to make their fullest contribution. For more people, to be comfortable, to be healthy in their bodies, for more people to feel well for longer, because we're making the accommodations that they need, that is something that goes on to benefit everybody. That's what we learned from the world of universal design in the first place. That what makes it easier for the people who need it most makes it easier for everybody. 

Bisi Williams: [11:00] So tell me, give me an example of a universal design to help our listeners get attuned to what we mean by universal design.

Dervala Hanley: [11:08] So universal design is design that can adapt to meet and fulfill multiple needs. And one example of that one famous example of that started quite close to where I live, coming out of Berkeley, California was curb cuts and there was a concerted campaign and movement to put cuts in the inside walks so that people who use wheelchairs can get up and down. And of course over time we discovered, well, that's also great if you've got a shopping cart, a stroller, if you've got so many other use cases. And I think that's where we kind of learned that when you're making it easier, you're making it easier for everybody. 

Bisi Williams:  [11:46] Okay. I'm going to push back a little bit or ask you this. What will it take to build a world where universal design meets personalized medicine? 

Dervala Hanley: [11:54] I think it's very hard. I think it's an absolute shift in how we see health beyond the health care systems and so forth, but how we see our food system, our education system, our transportation system, our workplaces. This is a very big set of shifts and those have never really taken place without the people who have the most to lose and who are the most vulnerable really putting up a fight.

In the United States, we saw the fight for the Americans with Disabilities Act. We saw just the years and years of campaigning. We saw policy changes to protect people's status in the workplace and so forth. It's a very tough thing that will take a lot of will and commitment from the people who have a lot who have most to lose. And for whom it will be toughest to fight for this, for what I'm talking about.

I also think the other side of where those changes have come from before, it’s like, if you want to see, I think it was Paul Grim, who said, if you want to see what the future looks like, look at what rich people are doing now. So when you get deeper into the thesis of what personalized medicine and the science of individuality can do, you start to see people with means already making use of that today and you start to ask, well, how would you expand that and how would you scale that? And how would you make use of the fact that it's actually the promise of it is that it should in fact be far cheaper than the way we are dealing with illnesses today, which is after they've already been kicked to catastrophic versus heading anything off.

Bisi Williams: [13:32] I love that. And so you mentioned some of the obstacles today. Mostly the most powerful and the most vulnerable, who have a stake, usually the most conservative, whenever there's change coming. But could you describe some other obstacles that you could imagine that are getting in our way of your ideas and perhaps what you might do to help ease the bridge, to just convince them or seduce them to the other side of your idea?

Dervala Hanley: [13:58] I think there are huge systemic changes that need to happen, you know, on a vast scale. Not just in the healthcare system, but also in education, transportation, the workplace, the food system, you name it.  All of the things that really determine our health and how healthy we feel.

The one that's probably most directly within our control is our own mindset around trying to shape ourselves to fit what is asked of us because it's absolutely the standard thing to do. Versus saying, gosh, I would be so much more healthy and thriving if I could just do it this way or do it from here or have this kind of care versus that kind of care.

Often those are not even huge changes to make, but I think that the challenge for us, first of all, is even learning how to know what we're working with. And know what we need and know what would really unlock more within us. And then being able to put that into words, to ask for it. And if that is stuff that is not on the menu today, being able to band together and say, this should be here. We should have these protections. We should have these curb cuts. We should have all  of the pieces, all of the first steps toward this, whether it was, you know, on a very massive scale, the Americans with disabilities act. Or those kinds of protections, it came from people saying this cannot work for me. I absolutely can't partake at all, but I really could, if you would give me this. 

It starts with an individual saying what it is that they need, but when it needs to be bigger than out loud grouping together and saying like, this has to happen, we have to get this done. So I think the first step is like that mindset shift within ourselves of going like, why are we trying to fit into a very unencumbered, able-bodied standard work where your entire value is measured by your productivity and your output versus your humanity, and then saying, well, what do I need to be able to take part as fully as I can to make my fullest contribution? And is there a reason why with all the technology we have today that that cannot be accommodated? And if not, then that's a human change that needs to happen. 

Bisi Williams: [16:17] So beautiful. I'm struck by the notion that we are all healthy in the same way, but unhealthy in unique ways. That idea, that standardization that you referred to earlier is the notion of average is kind of wrong for the 21st century. Could you talk about that a bit?

Dervala Hanley: [16:38] Yeah, I’ll mention Todd Rose, when I was starting out, he wrote a book, I think 2016 or 17 called “The End of Average.” And when I first read it, I was like, well, yes, of course nobody's average, we’re all special. And it turned out that’s not what he was saying, It was kind of eye opening for me that he made the point that It feels like a law of nature, but somebody had to figure out the math and the idea of average in the first place. 

I think it was a French monk, who had worked out the math to figure out like, well, this is the average harvest, and this is the average lifespan and this is the average yield from your flock of hens or whatever. And it was transformative because suddenly we had a tool to say, well, how are we doing this year versus last year? And what happened over the next 200 years was that was the base from which we were able to standardize. That led to factory management, that led to industrialization. But if we'd had not had the idea of average that none of that would have been possible, which is kind of fascinating. 

But what Todd points out is where we went wrong was average can tell you a lot about groups, but it can't tell you anything about an individual. And it's the idea that there literally is not any individual who is average. And that was really just striking to hear. I think in the twenties, they tried to find the average American woman and they discovered that she literally didn't exist. They took all the measurements and they took the average wrist and arm length and leg length and eye spacing and they couldn't find one person who actually was, and it turned out to be absolutely impossible. 

So he said, we have designed our health systems and our school systems and our work systems for this average person and it turns out to be a person who doesn't exist. He gave wonderful examples around the Air Force. They had a standardized cockpit in the fighter jets. First of all, there was an accident rate because nothing ever really quite fit anybody. And when they started to make it adjustable, it turned out that one of their best pilots was a woman who would never have qualified before because she wasn't, she was outside the standard, she was too small. And because they finally made seatbelts that could fit her and seats that could move and so forth. The accident rate went way down because things that adjusted to fit were far safer. And they were able to extend it to find talent that they had never been able to have before.

If you think about that in education. If you think about that in, in healthcare, in particular, I think it gets really exciting to kind of say, not only is this like, okay, we'll grudgingly include you, but like, wow, we were just unlocking and including all these people who could not have been included before. It comes from the viewpoint that people are assets, not liabilities. And a world that can adjust in big ways or in small ways, in a lasting way to actually best fit what it is that you can do and that can actually let you make your contribution to your community and to your world. It's kind of extraordinary what people can do and what can happen and what that actually starts to open up for everybody else. So I think about that fighter pilot, and I think the same is true in health. 

Even coming at it from a very different angle, Nike’s new shoe where a young teenager with cerebral palsy wrote and said, I love your shoes and I'm really upset that I can't ever wear them. And they hired him to come on as a design consultant and eight years later, they just dropped a shoe that you can step into and it clicks closed. 

Not only is he delighted that he can wear this and people with CP are delighted, but it is now something that all kinds of people want not just because I'm pregnant and I can't bend down or I have bad knees and I can’t bend down, but because it's just super cool. Now they're just worried that the sneaker heads are going to drive the price up because this thing actually happens to be just really cool. 

So both on the level of what people themselves can contribute as individuals, when they're invited in versus warehoused. And on the level of like what you create to accommodate people itself creates opportunity and help for many more people who didn't even realize that this was possible and for whom it's just an opportunity that they might not have asked for because it wasn't pressing, but it is real nonetheless. 

Bisi Williams: [21:27] So that concept of fit makes opportunity as you're describing the world in 2049, where you can live where you want, how you want, work where you will and where you want, get healthcare to meet you, I'm envisioning this incredibly compassionate world. To your mind, with the data and information and technology that we have, what could be an impediment to having that? Wonderful moment where we can actually live self-actualized lives. 

Dervala Hanley: [21:58] One thing I do think about is, as I said I think it starts with having the opportunity to understand yourself first as a learner, as a person with a body, to understand your own strengths and challenges in all of those dimensions. And from the health perspective on that, you get your test at the start of your life and it can kind of tell you a lot about this body that you are going to be embodying as long as you're around. And what's some of the possibilities for it are.

I think one impediment is, I would love to see that being like, this is wonderful, now I know what I'm working with and how to keep myself healthy. And these are particular things that I can ideally head off or I can deal with in a particular way because I know that that particular way will work for me.

I think a dystopian version of that is right now that can be used against you. If you know that kind of information, sometimes I think today you are better off trying not to find out that you have something because frankly life is a preexisting condition but people will and can legally discriminate against you because you have a pre-existing condition. There's a law of unintended consequences, which is the more we put in protections, the more people with power over you can try to preempt the protections by not taking you in the first place. Whether that's in your job or in your healthcare. I'm talking about the US specifically in that. But I can imagine that applying in many other cases where it’s like, if I find out that I am predisposed to this, that should be a wonderful opportunity for me to get whatever prophylactic treatment will help me.

But right now it would be very bad for me if somebody found out and said, I don't want you on my payroll when your insurance is paying, for example, preemptive double mastectomy. I think it would be just an enormous transformation if we could get to that point where it's something that really empowers you and that everybody is invested in helping you live with and work with. I think that part of that comes from that business side. I’m talking in the US in our very odd and peculiar system, but it is a real hot potato about who pays for anything that goes wrong. So people are always trying to shunt off anyone with risks. In that world, anyone who discovers they have risks. Why would you want to discover you have risks?

But of course, what ends up happening is it is just catastrophic financially, physically and emotionally, diseases that play out because they aren't caught fast or because you're covered an amputation, but not for the checkup.

Bisi Williams: [25:22] Right. I think that the articulation you talk about is really important. Being able to say what we need and what we want. Most importantly, you're not really talking about enormous technological changes. You're really talking about a mindset, compassion, looking around to see what are the little things that we can do to make life better that really doesn't cost a ton. And so is there a question that I haven't asked you that you wished I would ask you to shade in the little areas of your vision? 

Dervala Hanley: [26:01] I wouldn't put that pressure on you but one thing that I have a question about, but not yet, necessarily an answer for, is right now the kinds of changes that I'm talking about, where it really is In the interests of power to keep pretty rigid systems that people have to fit themselves into. And there's a lot of kind of arbitrary responses to laws and requirements that kind of backfire on the people who are most vulnerable.

I often think about, like, we might say that you have to give healthcare for part-time workers and then what ends up happening is you can only find jobs where they won't let you work more than 20 hours a week, so you end up with three jobs. Making those kinds of changes, it takes a lot, there’s a lot at stake. And the question I think that I'm most interested in on that is how can the people who have less at stake and more energy to make those changes, feel the urgency to actually work toward them as well. Rather than it being the parents of the vulnerable child or the people in the capital fighting for the affordable care act because they are the ones who absolutely will die without it. 

How can people who need it less, fight for those changes, too? And I think about 30 years from now, 2049, we are going to have a very different kind of working life anyway. The jobs that are breaking people's bodies today, hopefully will not exist and we will have all kinds of capacities to do other things. I think that piece of saying, so what will we do with that? What will we do with that time? What will we do with that energy? What will we do with that, with the stuff that only humans can do is just so worthwhile in its own right. And it also is part of that notion of when we have a world that adapts to include people that fit to abilities, creates opportunity and it creates health. 

Bisi Williams:  [28:23] Dervala I'm so inspired. Thank you so much for joining us today on health 2049. 

Dervala Hanley: [28:29] Thanks Bisi. 

Bisi Williams: [28:31] And that wraps up our show with Dervala Hanley, writer, author, and strategist. Thanks for listening. If you enjoy our show, please subscribe or share with a friend until next time. I'm Bisi Williams.

Dr. Griffin Myers, Chief Medical Officer, Oak Street Health

What’s the benefit of a value-based healthcare system? Dr. Griffin Myers, Co-founder and Chief Medical Officer of Oak Street Health, explains that when we flip fee-for-service to a capitated healthcare model, the focus shifts to health outcomes and reconnects the shared values of patient and provider. 

Dr. Griffin Myers, Chief Medical Officer, is a board-certified physician responsible for the excellence of healthcare delivery at Oak Street Health. Oak Street Health is a growing organization of value-based primary care centers serving adults on Medicare headquartered in Chicago. Dr. Myers is also a Co-founder of the company.

Prior to Oak Street Health, Dr. Myers was a Clinical Fellow at Harvard Medical School, where he did his residency in emergency medicine at the Brigham and Women’s and Massachusetts General Hospitals. He previously worked as a Project Leader at The Boston Consulting Group. He is also an Aspen Health Innovators Fellow.

Show Notes

• Dr. Griffin Myers shares his background as a Harvard trained doctor and University of Chicago trained economist. [02:41]

• Why shift from a fee-for-service healthcare payment model to value-based? [03:56]

• Viewing health care from the perspective of the patient and the provider. [08:16]

• A value-based system has the potential to shift the healthcare model from provider-centered to patient-centered. [12:31]

• What will the roles of the health insurance companies and large hospital systems be in 2049? [15:47]

• Will the healthcare system be run by artificial intelligence in the future? [21:31]

• What is the biggest obstacle to achieving a value-based healthcare system? [25:23]

• What could a value-based system look like for patients and providers? [29:25] 

Transcript

Jason Helgerson: I'm Jason Helgerson and you're listening to Health2049. 

Dr. Griffin Myers: [00:08] What I get excited about is a universe in which you sit down with a patient and the economics that that individual provider faces are aligned with the interests of the patient in front of them. And that's going to take some work. I'm confident we can do that. And we're beginning to see some of that. But it's not all at once. So I think the answer is like, yes, it's very good news. It's going to be bumpy, but we will find a new ground state that feels better for patients, is deeply personal and solves their problems, but also feels better for providers.

Jason Helgerson: [01:43] Today's guest is equal part Harvard trained doctor and University of Chicago trained economist. He sees a future in which fee-for-service reimbursement is a very distant memory by the year 2049. In his worldview healthcare, while more complex in some regards, is more patient-centered and others. And overall is greatly improved over our current state.

Unlike many, he sees the healthcare system as being in the seventh inning of the move to value and not the second, which is a common complaint today. His opinion is especially interesting given the fact that he is a co-founder and chief medical officer of Oak Street Health. One of the hottest healthcare companies in the United States that recently went public with a valuation of over $15 billion.

I'm Jason Helgerson and you're listening to Health2049. And it's my pleasure to welcome Dr. Griffin Myers to our program. Griffin, welcome. 

Dr. Griffin Myers: [02:35] Thanks Jason. 

Jason Helgerson: [02:36] Well, Griffin, to start off, could you please tell our audience a bit more about your interesting background? 

Dr. Griffin Myers: [02:41] Uh, sure. Thanks for having me. And on behalf of all of the Okies that I get to work with thanks for having us. So I'm an emergency doc by training and chose that field largely because I wanted to take care of patients, whether or not they could pay me. So, I got into it and passed out cold the first two times I went into a trauma bay, but ultimately figured it out. And I did, I trained at Mass General at the Brigham. And when you called me an economist, I think I got a little bit of a promotion, but I did get an economics degree at the University of Chicago and certainly appreciated learning some of the theoretical frameworks I imagine we're going to use today that I think kind of inform the way that we can use the way that we structure the healthcare system to take better care of patients. 

I serve as our Chief Medical Officer at Oak Street, which my business card hasn't changed in eight years, but the job has changed a ton. But I have a really unique privilege of helping really build and support the medical group that takes care of our patients at Oak Street, work with our many partners, health plans, health systems, and the like, and until pretty recently was still taking care of patients at Oak Street. And now largely have gotten lately, especially spent time, mostly just vaccinating our patients and staff members and community members, but it's great to be here. 

Jason Helgerson: [03:45] All right. So Griffin, we'll start with the question that we ask all of our guests, which is really to sort of tell us what you think healthcare will look like in the year 2049.

Dr. Griffin Myers: [03:56] Yeah. I mean, I think, stepping back it’s good to say, how did we get where we are because that'll kind of tell you how we're going to get where we're going. We ended up with the current system by no fault of any individual. And certainly from my view at least wasn't intentionally the case. 

We created a system in 1964 with the passing of the Social Security Act, which established Medicare with the most administratively simple way for the Federal Government to pay hundreds of thousands of providers on main street, which was a fee-for-service model. And, at the time, I suppose as somebody who'd been really forward-thinking, you could have anticipated the unforeseen consequences, but when you do that you create a game in which you're in the business, largely of sick people. You want return customers and you want to do the things they get paid the best. And so, frankly there is no investment in prevention. We wait for people to get sick, we do things that are relative to their cost of goods sold. We do things that have high margins. So it turns out that specialty care and acute care versus other things and where there are ability to price discriminate, we look for a better mix. 

So in general health systems prefer to take care of commercial patients who pay multiples of what Medicaid and in some cases, Medicare pay. And that's how we ended up here. And so, like I say that without blame. And when you look at the healthcare system as a whole, it's like generally wonderful people with strong values who want to take care of others and make genuine personal sacrifice for the health and wellbeing of strangers. But we ended up with a healthcare system as a consequence that is deeply inequitable and again, is the outcome of that model. 

Where we're going is gonna be the output of the new model. And the new model is one that we call it value-based healthcare and we talk about value-based pricing. In reality, it introduces a price mechanism, which is what economists say allow us to find an equilibrium between supply and demand and creates the right quantity and the right price. And most importantly, in all of that steers capital to its highest and best IE, in the economist parlance, the marginal use.

Right now, I would say all of us would look around the healthcare system and say, we have too much of some things, we have too few of other things. I always kind of joke about this. knowing where I went to medical school and trained, most of my colleagues from those times in my life are specialists. So they kind of all want to punch me in the face when I say this, but in general, I think we can all look at the healthcare system and say, we have far too many hospital beds, far too many dermatologists and ophthalmologists and orthopedic surgeons. And probably not enough primary care, behavioral health, medical, social workers, and the like, and obviously I'm very biased, so I'll just admit that out front, but those are sort of undeniable outputs of the fee-for-service model. 

And so, when we get to a true value-based model, we can talk about what that's going to look like. What that leads us to is a world where we start to allocate resources towards their highest and best use. Which at a societal level would be health disparities, health inequities, primary care, behavioral health, community health, preventative care, social determinants, and that's how we raise all boats. 

I always try to leave an opinion at the door and work on facts and there's pretty good evidence now starting with a Shattuck Lecture that was given at Mass General back in 2007, later published in the New England Journal that shows when you look at what's driving population level health outcomes, under 20% is related to the quality of healthcare, the rest of it's determined by genetics and social factors. In so far as I know, we can't change people's genetics going in, so the way that we're going to make for a healthier population at large is by investing in these non-healthcare related services. They can certainly be provided and supported by great health care organizations at the community level.

Jason Helgerson: [07:40] So you certainly paint a very optimistic picture for what value-based care could mean overall in terms of the system and better alignment of incentives. And almost basically describe a rebalancing of the system and sort of reducing the level of investment in certain areas like specialty care and increasing investment in addressing social determinants of health, primary care, and other community-based services. But could you maybe help the audience sort of wrap their heads around this, and either from the perspective of a patient or from the perspective of a provider, describe what you think that the actual healthcare experience will be by that year 2049. 

Dr. Griffin Myers: [08:16] I mean, there's a few underlying assumptions that I think are just like worthwhile if we're going to go down this path to break. 

I think number one the assumption that we spend too much on healthcare, is not a real one. I think people say we spend 18% of GDP and that's too much. And in a universe where robots are going to be doing all of our work for us and all we're left to do is emote and take care of each other, I could imagine it being way higher. 

I think the second thing is saying that we don't have enough money to achieve the goal, is also just seemingly, not a definitive thing to say. We are a very prosperous nation, the most prosperous in the history of humanity. And the idea that we don't have enough money to take very high quality, very equitable care of everybody with that amount of money. I would just challenge that. 

I think it's very reasonable that we just need to reallocate those resources appropriately. And I don't mean in a top down way. I mean, in an economic freedom way, a way that when you have a functioning price mechanism would allow us to do that. The way to do that is a full shift to value-based payments and starting with global capitation. And then we can talk about sort of downstream, the way those things will look. What that implies is a whole bunch of things, you asked me to focus on a couple, one being, what's it feel like for a provider and another, what it feels like to be a patient.

There was a really good paper published in annals of internal medicine, I want to say back in 2010, that's really insightful. We've got a great table, you don't even have to read the article, that talks about eight different ways to pay for healthcare. And I teach this value-based healthcare course at Kellogg and we look at this table and we do this exercise, which is to say choose one of these ways to pay and then decide what it feels like for a patient and decide what it feels like for a provider. And we do this. So when you look at fee-for-service, time is money. And so what it feels like for a provider is that I know that I need to bill as many things as I can. And by the way, I'm not, this is by no means to criticize individual providers. This is just the incentive they face.

It turns out when you look at large aggregates, this is how folks behave, this is not an indictment of any individual's specialty or specialist or provider at all. It's true in primary care, it's true in specialty care. You're paid to bill things, and so the return on capital is that you bill things and we see that happening. So it means people go fast. They focus on the things that are most billable and the idea of losing a patient to another provider who's therefore going to sort of reduce your demand, you wouldn't do. And on the patient side, you feel the hurry. You do feel somewhat like the object of a procedure rather than a person with a complex and ambiguous life that creates the health outcomes you experience. 

Meanwhile, when you flip that and let's say, instead of doing fee-for-service, you do a capitated model. Well then what matters most is the health outcome. And depending upon the patient's needs, you're going to solve that very differently. And so I would encourage people to look at that table and you can kind of derive what the macro, the micro economic incentive is going to be for that individual participant. And I would say that it works pretty well. 

And we have enough of these models now to see that it works pretty well in fee-for-service, in capitated models, in sub-cap models, you can certainly look at what it feels like to be a hospital that works on per diem versus a hospital that works on DRGs or a fixed payment. And so, again, I don't want to say that once we solve the payment structure, we fix everything. There's still a lot of work to do to reorient our healthcare system and reconnect our healthcare system with our shared values. I think that's a critical, insufficient, but necessary first step.

Jason Helgerson: [11:57] So one of the common complaints, which is a complaint that I have made many times over the years, which is that fee-for-service healthcare ends up with the patient being very much secondary to the provider, in terms of convenience, user experience. Do you think that the move to value-based care is going to fundamentally change that? That ultimately, it'll really mean a truly patient-centered system? Is that what you're seeing is sort of when the incentives are really, truly aligned, that's the kind of changes that the healthcare consumer will begin to feel?

Dr. Griffin Myers: [12:31] Yes, but not immediately. And I also think it's fair to say this current model makes everyone unhappy. Patients receive pretty typically, I would say quality that is not our best and it is highly inequitable. And when you look, providers are miserable and all the literature suggests that you can do as much bagels and yoga, before people start their workday and providers are still truly miserable, and measured in as many ways as you want to measure it. So I'm actually hopeful that this is better for everyone involved. I will say that change management is real and it's going to be challenging. I think, especially for people later in their careers, because they've made decisions based upon the old rules of the game and the rules of the game are changing on them. I think that is justifiably frustrating to a lot of people. 

I also think it would be intellectually dishonest for me to say that it does not create winners and losers. Anytime you reshuffle the deck and you take a fixed set of resources and you allocate that differently, there are winners and losers. 

But at the very end of the day, when you're able to reconnect providers with their values and you have this functioning price mechanism that allows providers to say, I can do what's right for my patient and I don't have to wait for there to be a new billable code for my incentive to line up with the incentive of my patient. 

And I'm sure there are listeners who hear this and are super frustrated and they're like, I don't think this way, this is like econo robot nonsense.That's a very valid point on a microeconomic standpoint to say, I don't feel this in my day to day. I just feel busy. I feel overwhelmed by the number of patients I have to take care of. I feel like I'm underpaid. I feel all those things. Those are outputs of a fee-for-service model.

What I get excited about is a universe in which you sit down with a patient and the economics that that individual provider faces are aligned with the interests of the patient in front of them. And that's going to take some work. As big a believer as I am in globally capitated bottles, and I do think at the highest level of the population level, that's the way it starts, if you are a really talented retinal surgeon, we are going to have to do a lot of genuine innovation and create some real intellectual property to try to solve how we're going to connect that ophthalmologic surgeon with his or her values in a way that aligns his or her interests with that of his or her patient. I'm confident we can do that. And we're beginning to see some of that. But it's not all at once. 

So I think the answer is yes, it's very good news. It's going to be bumpy, but we will find a new ground state that feels better for patients, is deeply personal and solves their problems, but also feels better for providers and reconnects them with their values and allows them not to focus on what is an overwhelming amount of administrative minutia. Trying to get a billable code ready when that's not what they signed up to do. 

Jason Helgerson: [15:33] So let's talk about the big behemoth of American healthcare, health insurance companies and the large hospital systems. What do you see? What is their role? What do they look like in 2049? 

Dr. Griffin Myers: [15:47] You'd have to split them, they are very different businesses and very different tasks. And I call them businesses, for-profit, not-for-profit, that's just a tax status, they’re doing the same thing. And for-profits retain their earnings, not-for-profits have to put their earnings somewhere and they typically put it into it real estate portfolios and bonus programs. But, and I don't mean that pejoratively, it's just there is no difference largely when you look at their behavior. 

I think on the health plan side, I'm personally very empathetic to what it feels like. I think in many cases to work at health plans, and I think frankly, they get a bad rap. These are again, folks who have a deep commitment to taking care of patients and improving the lives of strangers by doing their day-to-day work and the way that they do it is actuarially and by processing the very necessary background stuff that has to happen to get a provider and a patient together in the right moment in space and time. Processing claims is important. There's crucial data in there. Building networks is important. It allows us to measure and refine quality. Actuarial sciences is really important. It's how we price these products and allocate risk across the system. And, those are really important, and I will be a little bit provocative and saying, whenever I hear that 20% of American healthcare is in administrative waste, I think it's pretty unfair. Without going really deep and understanding what health plans do, to call their entire enterprises waste, I  just don't believe that. And I think I have certainly come around to seeing the value that they produce. What I think it looks like in the future, is more tight integration between the work that a health plan does, on the risk-taking side and allocating that risk thoughtfully in partnership with providers.

So frankly, more tight collaboration with providers and helping them understand and transition to these new value-based models. Because it's not just global caps, it's sub caps and DRGs and bundles and all these things. And as you can imagine, that sounds pretty complicated. And, as I suggested to you in our prep, I do think it's gonna get more complicated. 

On the health system side, this is another place that I have a lot of empathy, I'm an emergency doc. I'm not a primary care doc though, I consider myself an honorary PCP given my job. So I'm a hospital trained provider and chose emergency medicine because I wanted to take care of patients, whether they could pay me or not. And EMTALA and related regulations allowed me to do that without worrying about the underlying economics of the patients I wanted to care for and the emergency departments where the hospital world meets the real world. I think it's fair to say health systems have a real challenge ahead of themselves. Because stepping all the way back, we as a society, as a species, our goal should be to do such a great job taking care of each other and encouraging appropriate health behaviors among our neighbors and communities that nobody ever needs to go to the hospital and we put all the hospitals out of business. 

Now that's not realistic, but it should be our goal. And I'm not the first person to say nor will I be the last person to say that we have too many hospital beds in this country. And they are certainly not allocated appropriately. So how do you unwind that? That's a real, that's a real challenge and I think there are a few paths that can be taken. None of them are painless by the way, but I will say, as I get to spend time with my friends and colleagues that work at these great health systems, they have unbelievable values and great leadership. And what I think will end up happening is a transition to more of these community-based services, transitioning much of care outside of big downtown real estate into the community and into patients' homes and in digital settings. And what we do with those buildings, I have some early hypothesis that they'll become a lot of primary care and behavioral health and community health and medical, social work and pharmacy services and other stuff, but it's a hypothesis and it's probably not going to feel every floor of a 25 story hospital building, but in either case that transition will be challenging. 

And what I hope is, and I will just, if you allow me, I think the folks at CMS have done a really smart job laying out, not just a multi-year, but like a multi-decade path for this to happen, starting with the MSSP and then into the next gen ACO and now direct contracting later into Geo, I think Medicare advantage is kind of an early thought it trying to do some of that and allowing more, sort of private private contracts to do that work. So it’s going to happen in a bunch of different ways, but I do think it's fair to say it's going to be a challenging transition. I don't think every organization's going to manage that as well as everyone may hope, but at the very end, what we end up with is a more patient-centric, more equitable, higher quality, more flexible healthcare system based more in our communities. 

Jason Helgerson: [20:35] So maybe we can move on to technology and obviously with 2049 being almost a 30 years into the future, there's a lot of opportunity for technology to further enter into the provision of healthcare services. And obviously the technology that a lot of people are talking about is artificial intelligence. And with some actually speculating that instead of actually talking to humans in the future, we'll be talking to machines when it comes to getting advice relative to our current health status and what we should do to improve our health or to address whatever our chronic illness is and basically that in essence machines that are available 365 days a year, 24 hours a day could potentially replace the human being as a caregiver. Do you see that as a possibility in 30 years time? Do you wonder whether or not the healthcare industry will face competition from machines for the direct provision of care?

Dr. Griffin Myers: [21:31] One of the things I always try to challenge myself on is the limits of our own imagination is as humans constrain us. So I certainly would not say that that's not possible. I will say I'm not particularly concerned that robots will replace all doctors on the timeline you described. I will say my imagination is limited by what that would even mean and what it would mean for the rest of society, were that to be the case in 2049. 

We have great AI solutions today that are materially helping us take care of patients. And I'll give you an example at Oak Street. We talk about this a lot that we have got an unbelievable platform that in a very robust way, delivers very consistent results across very different geographies and very different patient populations with people who are new in our model and experienced in our model, which speaks to the quality of that platform.

The artificial intelligence really takes the wrote evidence-based medicine that we have and provides that right at the point of care and lets our teams get done what they need to do. Things like preventive screenings and evidence-based management of chronic diseases, all teed up and it means that what our teams get to focus on is really two things. Number one is building a deep and meaningful relationship with patients so that when when, for example, there is a behavior change required, or a difficult moment, we have those relationships as human beings in an authentic way to help our patients achieve their health goals. And the second is catch with the robots miss. When you do have a complex case and the evidence doesn't give you perfect guidance and you've got the context and experience to make a decision, get that right. So AI is already playing a huge role in those.

What I get most excited about is not that you'll log into the robot to get your care. What I get most excited about is, today when we develop new clinical knowledge at the level of randomized control trials, we're typically testing A versus B. And if you're going to draw out the options tree of all the things that are required for us to make new knowledge and everything requires very, very expensive, A versus B, double-blind placebo controlled randomized trials. It's a very slow process to build new knowledge for us as humans. And what I get excited about are using these technologies largely giant, robust, diverse datasets, and just to make a plug for value-based care, because once we get away from documenting for the purpose of billing to documenting for the purpose of better understanding our patients, we build far more diverse datasets.

Now we have this ability to use machine learning methodologies to do sort of non-hypothesis based research. We don't have to have a question to answer, we can use the data to go generate insights and then sort of retrospectively use our intuition to say, mechanistically, does this make sense?

And I get really excited that we're going to solve a lot of clinical problems that way in ways that historically would have taken a lot of time, that I I'm hopeful now won't take as much time. That's what I get most excited about. I think we will frankly understand science and human biology better in 30 years and have better solutions to problems. And frankly, the AI will help us apply those better. If you made me put my nickel on the table, we still have humans taking care of humans. And I don't think that's a bad thing. As much as an optimist as I am, I think it's a totally reasonable thing to be very happy with the healthcare system run by humans in 29 years.

Jason Helgerson: [25:01] Alright. So in terms of your vision for the future of what it's going to be like in 2049, what makes you confident that that vision in fact is achievable? And then in addition to that, what do you see as the potential biggest impediments, things that could stand in the way of the value-based healthcare world that you've described so far?

Dr. Griffin Myers: [25:23] This is a perfect example to me of we are getting in our own way. It is us. We are the biggest obstacle and it's totally reasonable and it makes sense. And I blame no one. We know the answer now. I think we all know that the current structure of how we allocate resources in the healthcare system, because economics is the study of the allocation of scarce resources. We have a certain amount of resources, despite how prosperous we are as a society it's fixed. And maybe we can go up or down a little bit, but we have to allocate those. And right now we allocate those resources in a very bizarre sort of prescribed, but well-intentioned fee-for-service manner. We know the answer is not that. And the answer is to change how we allocate that towards, and again, when we call it value-based, that is a whole bunch of terms that really all essentially just say trying to find a mechanism, a price mechanism that allocates resources to their highest and best use according to their price mechanism.

Whether that’s, Michael Porter would call them IPUs or Integrated Practice Units and paying for it that way. Others would call it Bundles, there’s Global Cap, there’s Subcap, there’s DRGs and per diems. All of these are important tools, technologies frankly, that we're going to use to solve that and what gets in our way is change. Change is hard and it's painful and it's human and what is going to be most required to get us there is genuine empathetic leadership, saying to someone, Hey, you used to get paid to do this, and you did well. And because of a whole bunch of things going on in the universe, that's changing and here's what we're going to do in the future. And here's how you can thrive in that future. 

I do think it's going to require being honest about that because some of these, one of the things I always like to say to students, that every dollar we spend in the healthcare system, every single dollar ends up in someone's W2. So when we hear people complaining that the healthcare system is too expensive, really what we're saying is people are getting paid too much. Somebody is getting paid too much. And so what this means to change this is we need great enlightened, thoughtful leadership towards making that transition. And I think that's a good thing. 

I think what this means is, and I spoke to a group of medical students earlier in the week as they are making specialty choices, I said to them, the last thing you should look at when you make your specialty choices is how much money you're going to make, because you have no idea what that's going to be in the future. We're in the sort of the biggest point of change I would imagine in the last 75 years in that regard, and I think there's a rough correlation between how much a specialty is paid today versus in the future. But, and I would say it's positive, but I certainly don't think it's greater than 0.6. 

So people should make these decisions based upon the patients they want to serve and the kind of work they want to do. And those payment mechanisms are gonna change a lot. And they're probably gonna change based upon the practice environment folks are in as well. 

So I say all that to say, you asked me what's the barrier. The barrier is time and leadership and change management. And we will get there. At the very end of the day, I have incredible faith that people who go into healthcare make real genuine, authentic sacrifice to take care of strangers and it's noble and it's an incredible privilege. And I have this unique position of sort of commenting on it at a system level, but I do genuinely feel a big part of my job, especially with the people I get to support at Oak Street is help navigate that change. And I think your podcast is a part of that helping give people a heads up of these are some of the things that are going on and I look forward to working with people to make that happen. 

Jason Helgerson: [29:05] Well, I appreciate that now up to our final question, also question we like to ask all of our guests, which is to sort of take a step back and imagine a world in which your vision for health in 2049 is actually achieved. Why would that achievement be truly important to humanity and why would it in essence make the world a better place? 

Dr. Griffin Myers: [29:25] You know, I think back to my own training and as challenging as so many patient experiences are, and just the fatigue, physical and mental, and sometimes even spiritual exhaustion of what it is to train in medicine and then to take care of patients, the reward of somebody really needing help and feeling like you did something great and unique, that in that moment in time, sure there are other people who are trained, but I did my job well in that moment. That's the reward and you get addicted to that. And literally every single clinician I've ever met has those moments. 

The future that I see is one where yes, the complexity of how we pay for healthcare will be greater, but we're also be more, frankly intuitive and it will be aligned with the work that we want to do. And I think we're going to give people back those moments to do their job, whether you're a surgeon who does something brilliant or heroic, or a doctor who makes a great diagnosis and educate somebody on how to adapt to it or you're somebody who's a non-clinician who is helping make a process simpler, more effective, safer, more consistent. These things are all really, really valuable. And the world that I see is one that once we make a material part of this transition, we'll reconnect to those things. And rather than our work and our values sort of always bumping up against what is required to get this CPT code through is going to feel really different.

And I think Jason, the good news is not only does it mean we focus on higher quality outcomes, but we focus on higher quality interactions, more meaningful relationships with patients. We have time to do that. You know, we address health disparities, yes, out of the goodness of our heart, but also because it's in our interest, it's in our organizational's interest to look for the sickest members of our neighborhoods and make those people better.

Those are all well within the way that these models work. And I always joke about this, but when I was in graduate school, they used to sell t-shirts that said, sure, it works in practice, but does it work in theory? And I think the cool thing is these models allow us not just for it to work in practice, but there is a theoretical mechanism behind why we will go invest in communities and people and conditions that need our help. And we have a healthcare system that’s standing by and a bunch of people who want to do that work. Right now what blocks us is we can't get out of our own way because of our healthcare system of payment structure. And we're going to fix that.

Jason Helgerson: [32:08] Well, that's a very optimistic note for us to end on Griffin. Thank you so much. And that was Dr. Griffin Meyers and his vision for health and healthcare in the year 2049. If you enjoyed what you heard, please subscribe to us and share this podcast with a friend. Thank you and see you next time.

Sean Hobson, Assistant Vice President & Chief Design Officer for Ed Plus, Arizona State University

How can we use design to adapt ideas from an online education model into health care? Sean Hobson, Assistant Vice President and Chief Design Officer for Ed Plus at Arizona State University, explores ways to implement solutions toward a personalized healthcare system focused on health outcomes.

Sean Hobson is the Assistant Vice President and Chief Design Officer for Ed Plus at Arizona State University, where he leads strategic design initiatives to solve complex challenges in higher education. As ASU’s first Chief Design Officer, Sean believes design is at the core of driving meaningful innovation. He has directed some of ASU’s most impactful course redesign efforts, garnering recognition in The New York Times, The Chronicle of Higher Education, and Scientific American.

Show Notes

• Sean Hobson shares an optimistic vision for healthcare in the future. [02:30]

• How can we create transparency in health care? [04:32]

• What are the parallels between the healthcare system and education? [06:19]

• ASU’s commitment to online learning. [07:19]

• Is online learning just as effective as the other programs? [08:17]

• How did ASU scale online learning? [10:12]

• The mother or caregiver at the center of healthcare design. [11:24]

• How can we empower people to shape the technology that determines our future? [13:38]

• Innovative technologies are developed to solve problems, yet they sometimes create new ones. [15:13]

• What is a personalized happiness plan? [16:47]

• How do you measure the success of a personalized happiness plan? [18:07]

• What does this digital tool look like? [19:34]

• What should we not be pursuing in terms of health and education? [22:32]

Transcript

Bisi Williams: I'm Bisi Williams, you're listening to health 2049. 

Sean Hobson: I think in an ideal world, it would fit into the flow of my life rather than having us make adjustments to even figure out, let alone adapt to what the system is providing.

Bisi Williams: [01:34] Imagine what access to higher education and by extension health and wellbeing could look like by designing the tensions between broad accessibility and academic success. Our guest today is charged with doing exactly that. Meet Sean Hobson, Assistant Vice President and Chief Design Officer for Ed Plus at Arizona State University, where he leads strategic design initiatives to solve complex challenges in higher education. As ASU’s first chief design officer Sean believes design is at the core of driving meaningful innovation. This week, we challenged Sean to think creatively about the state of health and wellbeing in 2049. Welcome to health 2049, Sean. 

Sean Hobson: [02:20] Thank you Bisi. It's my pleasure to be here.

Bisi Williams: [02:23] We're happy to have you. So what changes will there be within how healthcare is delivered and received in the future? 

Sean Hobson: [02:31] It's such an interesting question and to be honest, one that I've been laboring on a little bit, since we talked about having this discussion. There's an optimistic future, but then I think there's some challenges. You have big, very comfortable systems and cultures and disrupting those are very challenging. But I think, it's perhaps quite basic and getting back to first principles. When I think about what first principles are, I think about a much more personalized model. And so as with education, when I think about personalized, I think about providing the right tear for the right individual, at the right time.

So while that might seem like a basic principle in a first statement, you wouldn't have to look far to see contradictions towards that. It's a very patient-centered model in one where the interventions are as simple, transparent, and hopefully invisible to the patient, because I think the outcomes for the patient, it's not going to the doctor, it's not getting this type of care, they are most likely life outcomes. Things like happiness, feeling healthy, being productive, living longer, performing better. Those are the outcomes of healthcare, at least in my perhaps naive estimation. So making some of the care transparent in the process I think would be a tremendous, type of evolution.

Bisi Williams: [04:28] So tell me, how you would make the care transparent?

Sean Hobson: [04:32] A transparent experience for my nine-year-old daughter is different for me than it is for my parents. It’s hard not to think about the experience that all three of us have gone through in trying to understand COVID–understand the risks, understand and get access to the appropriate care and the logistics around all of those things including what we're dealing with around getting access to the vaccine. We each have different experiences in that process and the process is anything but transparent.

I think in an ideal world, it would fit into the flow of my life rather than having us make  adjustments to even figure out, let alone adapt to what the system is providing. And so I think it all starts for me around education, helping people understand complex topics, the more connected we are, the more messages we get, the more confusing it all becomes. And I think when you have a state of confusion and there's this feeling that you get around being vulnerable, being unprepared not knowing what to do. I think that's a big part of it. One thing that's attracted me to education is that, and healthcare for that matter I think has a similar type of position, that most problems have education at the core in terms of thinking about solutions.

Bisi Williams: [06:19] I love that. What are the parallels between healthcare and education in your opinion, Sean? 

Sean Hobson: [06:26] I think there are many. When you think about healthcare and education as systems, they have many of the same actors and then they have many of the same bureaucracies and challenges. There's localized challenges, there's national challenges, there's different stakeholders, but when I think about the similarities, it's also this notion that there's a service framework, whether it be the patient or the student, they are ultimately who should be at the center of the design. 

Bisi Williams: [07:09] I think that's interesting, Sean. One of the things I’d like for you to paint a picture, tell us how you revolutionized higher learning online with your work at ASU. 

Sean Hobson: [07:19] Sure, happy to. Everything that we do with respect to online and digital education works backwards from our charter. In essence, it’s that ASU aspires to be measured by who we include and not by who we exclude, reaching learners where they are and finding a way to serve learners who otherwise might not be able to participate in a traditional residential model. And so we've been working through Ed Plus and through ASU online for the last 15 years or so in earnest to design solutions in service of those learners. 

Bisi Williams: [07:59] I'd like you to just tell us a little bit more. I mean, when you started 15 years ago, online learning wasn't really a thing and it was an afterthought. Tell us what is the difference or what is the Arizona State University difference and what directly did you do to make online learning more effective? 

 Sean Hobson: [08:17] I think the biggest difference is that there's no difference at all, if that makes sense. And so online is just a different modality for us. We believe that the outcomes and the quality are exactly the same. We use our same faculty that teach our residential experience. We deploy latest tools and instructional design theories and pedagogies. And so part of what we set out to do is really work on the culture of the institution. 

For each professor that goes through the experience of designing an online course and going through that change process that occurs when you go from teaching a lecture model to an online course and working backwards from the needs of an online student, then there’s change that happens. When you do that over and over again, you start to really affect the culture of the institution. And once our faculty began to really adopt the model and believe in what's possible and see it not as a different methodology and in quality, but as a simply a different modality, then anything is possible. And so once we establish that culture early on, that's what has led to our ability to scale and succeed. 

Bisi Williams: [09:49] I love that you built the culture. When you had the mandate to build online learning 15 years ago, you did so with design and intention, you needed to go and find the people, first of all, who weren't knocking on your door and then you needed to invite them and inform them that there's a whole world waiting for them. And you're just scaling. I mean, you started with how many students and how many students do you have today? 

Sean Hobson: [10:12] We started with about 400 students in four degree programs. This year we'll serve somewhere in the order of 70,000 students across 200 or so degree programs and certificates. And just to clarify, these are ASU online students and so these are students that will start and finish their entire degree without coming to campus except for graduation. That's been tremendous growth, 20% year over year. 

Bisi Williams: [10:48] So when you think about that model and you think about 20% growth year over year, and you translate that to healthcare, first of all, you changed the culture, you made sure that your online wasn't less than, it was equal to. Can you imagine the interface of healthcare delivery, trusted networks, learning for general citizens to figure out how to get the care that they need when they need it and how they need it is. Do you think that's translatable and scalable to have a fantastic digital medical experience given the tools we have?

Sean Hobson: [11:24] It's a great question. Even though we've achieved some success there, it’s nowhere close to what we need in terms of scale. And I think you have that same type of challenge with healthcare. If you look at the complexity and the size of the problem, even our open access model, our online model is still not available to everybody. And so we have a very great model for a subset of the population, but we need to be also building models that scale in the millions and the tens of millions. And I think healthcare has that same type of challenge.

In some cases, when you look at the coronavirus, for example, the urgency is even more prevalent. And so when a platform like YouTube, for example, has more than 2 billion users a month and 90% of them are there to learn something, that’s the type of scaled platform that we need to be developing solutions with and for. And health care needs some of those same things. 

One thing I was thinking about and where might scaled healthcare be happening right now, it occurred to me that the biggest provider of healthcare isn't the doctor or the nurse or the surgeon. It's what happens in the home. So it's the mother, it's the caregiver. And this is around the world, so I haven't seen too many solutions that put the mother at the center of healthcare design.

Bisi Williams: [13:13] I love that. So here's a question and let's think about the mother at the center of care. As technical developments increasingly drive social change, how can democratic societies empower ordinary people, or in this case, parents, mothers, and fathers, to have a say in the decisions that shape the technological pathways that will in turn determine what the future looks like?

Sean Hobson: [13:38] We are in a very interesting and amazing time with respect to advancements in technology. I think we're also in an amazing time with respect to agency. So any individual can have a voice and can have a pathway to making something incredible. Education, again, is at the center of that.

I think too often technology solutions are developed in a bit of a Silicon Valley vacuum or Ivy league vacuum. I think we do need to get more diversity in the design process. And I think when you start to do that in the democratic process you outlined, I think you get more inclusive solutions that may not have some of the profit motivations that we see in some of our scaled technology platforms, but social ones. I’s going to be an increasing set of urgencies around how new technology companies are created and funded that they have a social impact agenda at the core of their of their mission. 

Bisi Williams: [14:56] You know, Sean, I think that's interesting, too. I have another question for you along those lines in that, a while ago, you'd mentioned that sometimes while the innovations and technologies are a boon to a few, sometimes the problems that we mean to solve, create other ones. 

Sean Hobson: [15:13] Yeah. I think we often look to technology to solve problems. In many respects it can, but it also can leave a lot of people out. You know, when I think about the signup process to get my parents signed up to take a COVID vaccine, that little innovation on one hand that provides anybody in the state of Arizona a web form and openings and places to go and general information, is also perhaps leaving out some of its most urgent users, those who may not have the technical literacy or the access to a computer to sign up. That's an example of a conflict in the design process. 

I'm kind of trained this way to work backwards, to approach some of these big challenges from backwards to design. And so I find myself wanting to ask what this kind of desired state in 2049 is, and both from a process standpoint in terms of what these interventions look like, but also, what is the desired outcome for the patient?

Bisi Williams: [16:44] I love that. Can you expand on that more? 

Sean Hobson: [16:47] Sure, and so everybody’s going to have their unique definition here, but for me, the holy grail is happiness. For some, it might be longevity, but if you live to be 120, but you're miserable, what’s the point? I think the way to get there is to have a personalized healthcare plan or a personalized happiness plan. I can assemble that and I can tweak it and I can build it myself because I’ve developed the skills to do that. 

Bisi Williams: [17:24] So tell me about your personalized happy plan. 

Sean Hobson: [17:28] I think it's a thing that you check in on, whether it's every day, every week, when you think about your five-year trajectory there's a lot of things going on in the world. There's a lot of things going on in the daily life of somebody who's juggling a career, juggling all the messages, I think you've got to take stock in where you are. 

Bisi Williams: [17:56] Well, I have a question. So how do you measure it? Do you write it down? Do you paint it? Do you record it? How do you actually keep your data point for your happiness on a daily, weekly, monthly?

Sean Hobson: [18:07] For me it's more of an intrinsic thing. I ask myself how am I doing? I might talk to my wife about it. I might observe how my kids are doing and notice that my happiness could be a reflection on them and how they're doing. I look at my job, my career. Am I doing work that's meaningful to me because I know that's an important trigger for my happiness. And look, this is a constant struggle, it's not that I have some sort of secret happiness algorithm here. It's just that's my long-term objective. And so I think it starts with perhaps looking internally about what those objectives are and then putting together designs and plans to test and achieve them.

Bisi Williams: [19:09] I love what she said about algorithms and test and achieve. And I want to take this sort of intrinsic analog notion and marry it with other tools that we have and when you talk about personalized care, so can you imagine in this future state how the public and you, so going from the micro to the macro would have meaningful input, can you imagine this as a tool? 

Sean Hobson: [19:34] Well, I think we have some of those tools, but I think the user lacks agency in the process. So when I look at some of the technology platforms that we have out there now, whether it's Facebook, Google, Twitter, or others, they understand a lot about me. They understand my behaviors, they understand my likes, my interests, they understand all these things. And sure I can go into the settings and I can probably change how much of that I share. But part of me is okay with it because maybe they're showing me things that might be useful to me or exciting to me. 

And so I think first understanding that is part of it. So that I know when I buy something based on a behavior on a particular platform, I know the consequences of that, and I got to be comfortable with it, but I think there has to be more of an intentional and transparent and simplified process that allows the end user to personalize it to their benefit. Not necessarily the benefit of the platform itself. 

Bisi Williams: [20:49] I think that's an interesting perspective. And so understanding that the world is complex, that things are uncertain, when you think about access to information and critical thinking, how do you imagine you could imbue it at the early stage, middle stage and end stages of life? What does that look like for you? 

Sean Hobson: [21:13] My thinking on this is very much inspired by Sir Ken Robinson who's an amazing educator and author. He proposes, and I believe that learning is a natural human ability. As children, we have this thirst for learning and we see it as fun and we do this in early childhood through kindergarten and others. And then for various reasons, whether it's structures we've built or individual interactions, some of us lose it and then we need to find our way back. 

I think it's part of how the system is designed, but it's also part of, you could call it a care plan in terms of how you think about getting back to some of those natural instincts or tendencies that you have as a child around learning,

Bisi Williams: [22:19] I love that giving your purview as a technologist, as a teacher and a designer, what in your opinion should we not be pursuing in terms of health and education?

Sean Hobson: [22:32] I think there's a real risk in choosing and deploying technology for technology's sake. Technology isn't typically the outcome, it's the tool and the mechanism in the vehicle to support the outcome. So clarity around that I think is really important. And so I think the appropriate design development, deployment of technology, and support of inclusive and responsible outcomes is really the way to think about some of the evolution that's going to be happening. 

Bisi Williams: [23:19] Thank you so much. It's good to have you, Sean. 

Sean Hobson: [23:21] Thanks for having me Bisi. 

Bisi Williams: [23:23] So that concludes our program today of Health2049 with Sean Hobson, Chief Design Officer for Ed Plus at Arizona State University. Thanks for listening. If you enjoyed our show, please subscribe or share with a friend and until next time I'm Bisi Williams.

Nancy-Ann DeParle, Managing Partner & Co-Founder, Consonance Capital Partners

How does our own well-being affect the community? Nancy-Ann DeParle, Managing Partner and Co-founder of Consonance Capital Partners, draws on her experience in health policy at the state and federal level to share an optimistic view on patient-centered well care for the future of health care. 

Nancy-Ann DeParle is a managing partner and co-founder of Consonance Capital Partners, a private equity firm focused on investing in innovative health care companies in the lower middle-market. She is a director of CVS Health and HCA Healthcare, as well as Consonance portfolio companies Psychiatric Medical Care and Sellers Dorsey.

From 2011- January 2013, she was Assistant to the President and Deputy Chief of Staff for Policy to President Barack Obama. A health policy expert, from 2009-2011 DeParle served as Counselor to the President and Director of the White House Office of Health Reform, where she spearheaded the Obama Administration’s successful effort to enact the Affordable Care Act (ACA) and managed the initial implementation of the law.

From 2006-2009, DeParle was a Managing Director of CCMP Capital Advisors, and a senior advisor to its predecessor, JPMorgan Partners, LLC. She was also a Senior Fellow at the Wharton School of the University of Pennsylvania and a trustee or director of several corporate and non-profit boards, including the Robert Wood Johnson Foundation. From 1997-2000, DeParle was Administrator of the Centers for Medicare and Medicaid Services (CMS). She directed Medicare, Medicaid, and State Children’s Health Insurance Program (CHIP), which provide health insurance for more than 147 million Americans at an annual cost of $1.4 trillion.

Earlier in her career, she served as Associate Director for Health and Personnel at the White House Office of Management and Budget (OMB), as a litigation lawyer in private practice, and as Commissioner of the Tennessee Department of Human Services.

A native of Rockwood, Tennessee, DeParle received a B.A. with highest honors from the University of Tennessee, where she was Student Body President, and a J.D. from Harvard Law School. She also received a B.A. and M.A. in Politics and Economics from Balliol College of Oxford University, where she was a Rhodes Scholar.

Show Notes

• Nancy-Ann DeParle shares her background in health policy in Tennessee state government and then in the Clinton and Obama administrations. [02:54]

• A vision of what to expect from the health care experience in 2049. [09:52]

• How will health care be paid for in the future? [15:16]

• Why should we be optimistic about patient-centered care in the future? [21:14]

• A person’s well-being is not only good for them, but also for the community. [26:17]

Transcript

Jason Helgerson:  I'm Jason Helgerson and you're listening to health 2049. 

Nancy-Ann DeParle:  If I'm the patient, I'm on the team, too. I'm the quarterback, perhaps of my team or the point guard. And I am defining health care for myself in 2049 as an overall state of wellbeing. And if we look at it that way for everyone, it will compel us to be less selfish, to be more engaged in our communities, to think more about other people, to understand that my wellbeing is not only a good thing for me, but it's also a good thing for you and everyone else who lives in the community. 

Jason Helgerson:  [01:49] Today's guest has been one of America's most impactful healthcare policy makers over the last 30 years. In his recently released book, President Barack Obama states he relied more on our guest than anyone else when it came to getting the Affordable Care Act passed into law. In addition to her time as President Obama's top healthcare advisor, she was also the director of the centers for Medicare and Medicaid services during the Clinton administration.

She is now a partner and co-founder of Consonance Capital Partners, a private equity firm that focuses on investing in the US healthcare industry. Her vision for the future is one in which we will see the emergence of a true well care system, which will replace the sick care focus of today. In addition, she is confident that all Americans will be insured by 2049 and that value-based healthcare strategies will lead to a healthier tomorrow. I am Jason Helgerson and it is my pleasure to welcome Nancy-Ann DeParle to our program, Nancy-Ann, welcome. 

Nancy-Ann DeParle:  Thank you. Good to be here. 

Jason Helgerson:  [02:48] So maybe Nancy-Ann we could start by just having you tell our audience a bit more about your interesting background. 

Nancy-Ann DeParle:  [02:54] Well, it goes back several decades at this point, I guess I would say I started my career in healthcare, in a sense, at my grandmother's kitchen table. I grew up in a small town called Rockwood, Tennessee, a town of about 4,000 people in the eastern part of the state, Appalachia. I have a vivid recollection of sitting at my grandmother's kitchen table in 1966 or 67, she had a little shoe box on her table where she kept bills. And I can remember her sitting there with me and looking at the bills and she had bills from the doctor's office and saying, I wonder if this Medicare program is going to help me. It's funny, the things you remember, but of course, when I came to be the administrator of the agency that runs Medicare and Medicaid, the Centers for Medicare and Medicaid Services during the Clinton Administration, I often thought back to my grandmother and her wondering if Medicare would help her, which I think it definitely did. She lived a nice long life, passed away at the age of 98 and like many people who, if they get to be the age where they're eligible for Medicare in this country of 65, there's evidence that Medicare keeps them living healthier, longer. It's one of the few areas, in fact, Jason, where we compare favorably to other developed countries because Medicare has been so important to the senior population.

So like you, I worked in state government in Tennessee, you were in Wisconsin and New York and I was in Tennessee. And then had even more of an education about healthcare from the governor that I worked for Ned McWherter, who came into office with a pledge of doing something to address what he, and we call them indigent healthcare, the lack of healthcare for poor working people across Tennessee. We had a Medicaid program that was, I wouldn't say generous, but middle of the road, we covered everything we were supposed to cover kind of at a minimum, but there were a lot of working Tennesseeins’ who lacked coverage.

So I worked for a couple of years on a task force that the governor set up, I was the Commissioner of Human Services, which we did the eligibility determination for Medicaid. And so I got close to that aspect of it as well as, how do we solve this problem of covering the uninsured, the working uninsured in Tennessee. Out of that came something called TennCare, which was a Medicaid waiver that the state obtained from the Clinton administration. By then I was working in the Clinton administration, so I wasn't involved in implementing the waiver, but sort of in its most basic form, what it did was take the funding that went to this sort of arcane part of Medicaid called Disproportionate Share, the payments to hospitals that serve disproportionate share of low-income people and uninsured people and take that funding and match it up with individuals who lacked coverage.

So we expanded the Medicaid program to a higher level, percentage of the federal poverty level, and it applied also to working people. In the past, Medicaid had been limited to what was then called the AFDC, Aid to Families with Dependent Children, the welfare population, so mostly single moms and children.

So we expanded the population coverage and changed the funding to hospitals by giving the money directly to the patients, as opposed to the hospitals. It was a terribly difficult negotiation with all the different stakeholders in Tennessee, but the situation had gotten bad enough that everyone came to the table.

So I learned a lot from that experience of working to help people get coverage in Tennessee that informed the work that I later did, both in the Clinton administration and certainly working as President Obama's point person on the Affordable Care Act. I learned a lot of political lessons. I learned a lot of policy lessons about how to get things done and how to make progress and keep moving, trying to get, not make the perfect, the enemy of the good. So those are several experiences that I've had. And then as you mentioned, I spent 2009 through 2013 in the Obama administration, starting off as the point person and running the White House Office of Health Reform. And so led the administration's ultimately successful effort to enact the Affordable Care Act. 

I certainly had no idea that it would become as controversial as it became because for 10 years after the failure of the Clinton health effort, which I'd also been involved in, there were all sorts of strange bedfellows, groups from providers to policy people to advocacy groups, everyone at the table talking about ways to solve the problems that we had in the healthcare system, from how to bring down the rate of cost growth, to how to reform the insurance markets, how to get everyone covered. All of these problems of course were inextricably linked and there were some, it seemed, bipartisan solutions that people were supportive of, at least so I thought when I took the job. But as everyone knows, it became very controversial by the time it eventually passed. And a friend has a book coming out called the The Ten Year War and it's an even longer war. If you look back to when the effort to get everyone covered for started, go back to President Teddy Roosevelt, but it certainly has been a 10 year war since the Affordable Care Act was enacted.

Jason Helgerson:  [09:09] Absolutely and unfortunately the war, I guess, continues at least with some continue to advocate for the repeal, but then also, obviously with the new administration in Washington opportunities potentially to expand upon it. But let's think a little bit farther into the future Nancy-Ann and I think to the year 2049, so roughly 30 years into the future, what is your view of healthcare? What does it look like there in that year 2049, given all your experiences to date as a policymaker and in other roles, we think you're ideally placed to paint a vision for us of what the health and healthcare system could and should look like in the year 2049.

Nancy-Ann DeParle:  [09:52] Well, I'll try, it won’t surprise you that I'm an optimist having worked in these policy wars for healthcare for the better part of three decades now. So I'm an optimist and I've approached it Jason, from the perspective of a patient. So what should a patient's experience be? What should a citizen's experience be with respect to their health and healthcare 30 years from now? And so idealistic really I've sort of sketched out what I think their experience should be like. I will say that I'm not negative on where we are now. I've been doing this long enough to see that we've made progress in some areas, but of course we have a long way to go.

So I would see as a patient that when I needed care that it would be simple and convenient to access. And by the way, care and health as a term would be defined holistically as an overall state of my wellbeing that would encompass both physical health, but also mental, spiritual, and social health. It wouldn't be just the way sometimes it's thought of today as a care for an illness, care for sickness, it would be thought of as an overall state of wellbeing. 

If I need care in 2049, I hope it will be simple and convenient to access. I hope pricing of it will be transparent to me as opposed to the way it often is now where it is not transparent, as well as data about people like me who used a particular service or provider and their view of it and how they did, because I think that information helps people make decisions about what to purchase in other aspects of their life. And I believe that price and cost increases in healthcare should be, and will be 30 years from now, more tied to the value of the treatment or the service as measured by the quality of one's life, the improvement that it generates in your activities of daily living. I can think of a lot of different metrics, but there should be some way of valuing it and deciding whether or not a cost increase that is made is worth it or not, whether I’m getting a return on that investment that I'm making as a patient. 

I believe that physical and behavioral care will be much more tightly coordinated, that it won't be unusual if one is receiving treatment for physical care to get asked about potential mental health care needs, or maybe be offered mental health care supports and vice versa, that if one is seeking therapy or treatment for mental health needs, that one's physical health will also be a subject of discussion. 

And as part of that to make that happen 30 years from now, we need to have a much stronger reliance on team-based care, where one's team of providers, because there still won't be specialization, I don't see there being one person who can do everything for an individual with respect to their health care and wellbeing, but there should be much greater collaboration and much greater information sharing among the people who are on my team.

Maybe artificial intelligence helps make that more possible. We certainly have a ways to go with interoperability of the information now, but even if it were interoperable, it's not clear that each member of the team would know what to do with it. So maybe AI helps us there. And speaking of our data and our electronic medical records, consumers and patients should own their health data and it should be easy for them to know what the members of their clinical team, their wellbeing team have to say about their health status and how they can promote their health. 

And finally, genetic testing we'll have figured out a way to use that appropriately, patients who want to use it, we'll be able to use it to identify potential risks that they have and also it could be used to help aid in diagnoses and prevention and treatment amongst the team that's providing care. 

Jason Helgerson:  [14:52] And then Nancy-Ann, and maybe we could talk a little bit about how you see healthcare being paid for in the future. Do you see it as a multi-payer world? Do you see the role of, in the United States, the large government payers, which you were administrator of Medicare and Medicaid, do you see those programs getting bigger, remaining about the size that they are today? How will people have their healthcare paid for in the year 2049? 

Nancy-Ann DeParle:  [15:16] I don't see it becoming a single payer world and that’s perhaps just my blind spot having worked so hard on the Affordable Care Act when this gets to the real politic of where we were in 2009 and where we are today in 2021, I have no idea where we'll be politically 30 years from now, but at least where we've been for the past 50 years, even in 1965 when President Johnson had a veto proof, he had a two thirds of Democrats in the House and in the Senate for a pretty long period of time. And still, it wasn't easy to pass Medicare and Medicaid, which were passed together. 

Fast forward to 2009, we had a majority in the House and Senate as well, it was much thinner, famously we had fifty-eight Democrats in the Senate, and by the time the bill finally came up for passage in December of 2009 in the Senate, we had sixty. If you counted the two Independents in the house, we had a much bigger majority and still ideas like a public option, having the government offer a plan or even expansion of Medicare, a Medicare buy-in were floated, not even single payer, but those kinds of ideas were floated so that the government would have a bigger role and there were not the votes for that. So it's true that the membership has changed somewhat. The point is that even with much stronger majority’s, Democrats haven't had the votes in their own caucus to pass something like that. So can't predict, my crystal ball doesn't really look out 30 years from a political perspective, but I doubt that that will have happened. 

I do think the government may pay for a larger population. It is possible that there will be a Medicare buy-in of some kind for people 55 to 65 or 60 to 65. Those ideas have been talked about, as I said there weren't the votes for that the last time, but maybe there could be as part of strengthening the Affordable Care Act. Some senators have offered that as an idea and President Biden has also talked about it.

So I do think it's possible that a larger percentage of people will be covered through help from government plans, whether Medicaid or from Medicare. I hope Medicaid is a larger share because there are twelve states that as we talk today, still haven't expanded to cover their population that was covered by the Affordable Care Act under Medicaid.

The Medicaid today is not your grandfather's Medicaid. It's a very different program. As you know, even from when you were running it, at least in Wisconsin, Jason, it's been a little less time since New York. And so you resided over some of those changes, but it's more of a middle-class program than it originally started off as, and as it gets expanded I think it will cover more. 

So I see multiple payers, I don't see employers being willing to give up the game when it comes to providing healthcare for two reasons and I hope they don't for two reasons. One, because of the war for talent in this country, which I think is a good thing. I mean, you could argue that well they could just pay people more and in some cases they should do that as well and they are doing that as well. But healthcare is a benefit that people want and employers use their provision of healthcare as part of the way they attract and retain good employees and their families. So that's, I think a good thing that they want to continue doing that. 

And secondly, they have been innovative. So we in the Affordable Care Act included pretty much every idea that had been tried and successfully implemented in the private sector to help constrain healthcare cost growth and improve quality. Some of those ideas were demonstrations in Medicare, others were more widespread. We need to go back and do the 2.0 version like the employer wellness programs that was somewhat muted version of what some private sector employees were doing. But nonetheless, we tried almost everything. We wouldn't have had those ideas had private sector employers not been innovating and working with health plans and providers to require them to meet new standards and to show more value for the services they were offering and do it at a better price. So that innovation, which the private sector has been a laboratory for as well as states, I think is important. So I hope the employers do decide to stay in the game and the evidence that I see is that they want to. So I think the basic contours of a multi-payer system will remain the same.

Jason Helgerson:  [20:57] So your optimistic vision of a more patients that are more person-centered system in 30 years in the future, can certainly see some barriers that would need to be overcome and to get from here to there. But how confident are you that your vision will be achieved? 

Nancy-Ann DeParle:  [21:14] Well, I am pretty confident and the reason is because I see the progress that we've made even in the 10 years since the Affordable Care Act was passed. We talked and I raised the fact that the Affordable Care Act had been controversial in some quarters. And there's still efforts to repeal and replace. I guess we haven't seen one since 2017, really, but it's been a voting issue every single election since it was passed. 

So starting with the 2010 midterms, that has been a key voting issue. But that said, in the background with all the controversy and the ads being run by various people against it, the insurance plans went to work and changed their business model from one that relied on being able to underwrite and pick the risk they would cover in many states, very lightly regulated. They could charge women in some states as much as 25 times more than men in the individual market just based on, I assume it was based on something actuarial, but that's what they did. There was no real community rating in that market in many states. They were allowed to not cover people with pre-existing conditions in many places. No one had true protection against that. It wasn't guaranteed issue all over.

So there were a lot of changes made to change the rules of the road for insurance companies. And they turned on a dime and implemented them, which wasn't easy. But when you see those kinds of changes, when you see some of the models that have gone into place to move us towards paying for value, again, experts disagree about exactly how much of our payment of our healthcare dollar is devoted towards services that are reimbursed based on the value they provide, but it's not zero anymore. It might not be 50%, it probably isn’t. It's probably closer to 20 or 30%, I guess, most of my data's for Medicare, but that's something, we're making progress. We've got the foundation in place and really that's what President Obama, I think that's what his thinking was, is he looked at the bill towards the end and made the decision about whether to make the final push that was so fraught, was that yes, it achieves enough of his ambitions for a healthcare system that lowered the rate of cost growth that improved and reformed the insurance markets that got everyone into the system, or almost everyone, that created some rights and responsibilities, rights to healthcare and responsibilities to get coverage and some help and getting it. 

So that was the foundation. And I think it's made a lot of changes for the better. That gives me the confidence that we can make other changes to move forward on some of these other issues. The convenience to access, I suppose that was the silver lining, if you will and the pandemic that we're still in the midst of as we speak, hospitals and healthcare systems, again, turned on a dime there. 

Some of them had maybe 2% of their visits in a given year would have been tele-health and now it's 60% or somewhere like that. It probably won't settle out at 60%, but a lot of physicians who had no plan to have a tele-health offering were forced to move to that and it found, Hey, this works pretty well. It serves my patients' needs and it doesn't require them to have a carbon footprint and go into my office and search around in a parking lot or a parking garage for a parking space. So all of those things about simplicity and convenience to access, I think are being, if not jumpstarted, at least advanced exponentially by what we're going through right now. So yes, I guess I would conclude by saying I'm very optimistic. 

Jason Helgerson:  [25:39] So in terms of this vision of yours, as a final question, I’m going to ask you to take a step back and think about it from the broader perspective of the nation, of the world, of humanity. If your vision is achieved by the year 2049 of this very patient-centered WellCare system that is integrated in, you use the word team, I use the word team all the time, I like to say that we need to make health and healthcare a team sport, so I agree a hundred percent with you, if we do achieve that state that you articulated, how will it actually make the world a better place?

Nancy-Ann DeParle:  [26:17] I like that, a team sport and by the way, if I didn't say this, if I'm the patient, I'm on the team too. So I'm the quarterback perhaps of my team or the point guard and I am defining healthcare for myself in 2049 as an overall state of wellbeing that I'm in charge of, not totally responsible for, but I'm in charge of helping make sure that I get what I need from my team, that it encompasses not just my physical health, but also my mental and my spiritual and social health as well. And if we look at it that way for everyone and we as a community, look at it that way, then I think it will compel us to be less selfish, to be more engaged in our communities, to think more about other people, to practice the golden rule to understand that my wellbeing is not only a good thing for me, but it's also a good thing for you and everyone else who lives in the community. And I think that’s a good thing. I think that makes the world a better place. If we think about our lives as being part of community and being engaged in a community, I think it's a virtuous cycle because I think that kind of engagement also leads to better mental and spiritual health and social health. It makes me care that we have clean water in my community, not just for me, but for everybody, it's public health. If this pandemic has taught us nothing else, it's that public health isn't something that you put on a shelf that you just take for granted. It's taught us that it belongs to all of us and we're all accountable for making sure that we have an infrastructure and a foundation for the health of the community, the health of a population that includes not just, it certainly includes whether people get vaccinated and whether they're safe drinking water and safe places to play and good nutritious food to access, but it includes housing and lots of other things as well. I just think it's a more community. If we put our wellbeing in the center of things and look at it, not just as our own wellbeing, but everyone's wellbeing. I think it is a positive thing for our community and for our country and hopefully the globe. 

Jason Helgerson:  [29:01] Absolutely. I couldn't agree with you more. And that was Nancy-Ann DeParle's vision for health and healthcare in the year 2049 as always. Thank you for listening to health 2049. If you enjoyed what you heard, please subscribe to us and share this podcast with a friend. Thank you and see you next time.

Dr. Nirav Shah, Chief Medical Officer, Sharecare

Historically, technology in healthcare has created greater inefficiencies. How will that evolve? Using real-world examples of innovations in technology, Dr. Nirav Shah, Chief Medical Officer of Sharecare, sees a future of personalized “team-based care” in which clinicians will collaborate with artificial intelligence.

Nirav Shah, MD, MPH, is chief medical officer of Sharecare, the digital health company that helps people manage all their health in one place. An experienced leader in healthcare and digital health, Dr. Shah also is a member of the U.S. Department of Health & Human Services Secretary’s Advisory Committee, an elected member of the National Academy of Medicine, a senior fellow of the Institute for Healthcare Improvement (IHI), senior scholar at Stanford University’s Clinical Excellence Research Center, and an independent director of public and private companies and foundations. Dr. Shah also cares for patients at Stanford Health Care.  

Prior to joining Sharecare, Dr. Shah served as chief operating officer of Kaiser Permanente in Southern California and as commissioner of the New York State Department of Health.

Show Notes

• Dr. Nirav Shah shares examples of how medical technologies have advanced over the past hundred years. [03:11]

• Four areas in a patient’s healthcare service experience that will evolve by 2049. [05:47]

• Team-based care plus A.I. will work together to eliminate redundancies in the healthcare system so that physicians can spend more time with patients. [09:37]

• What are the human superpowers that computers can’t replace? [11:12]

• Technology in health care has caused greater inefficiencies in the system. How is that changing? [12:47]

• With new technology, how do we ensure that the world of 2049 is more equitable than now? [15:16] 

• What types of healthcare providers will go out of business if they don’t embrace new technologies? [17:15]

• Will the hierarchy of health care, in which the dominant players of today be flipped upside down to be less important in 2049? [19:24]

• Can this technology vision be achieved by 2049? [20:51]

• Hearing aids can now quantify if someone is lonely. [21:43]

• An example of a dry biomarker tracking for a person with a history of allergies. [22:18]

• How can a federated learning model be beneficial and preserve privacy? [24:00]

• Examples of the benefits of data that can be unlocked for public use, while preserving personal privacy. [25:43]

• Seven key areas that can create a healthcare system that makes the world a better place. [28:42]

Transcript

Jason Helgerson: I'm Jason Helgerson and you're listening to health 2049. 

Dr. Nirav Shah: Artificial intelligence is a different member of that team. So how team-based care plus AI will work in the future is that AI will augment the ability of that team that will take away some of the boring and redundant parts of our practice of medicine today, thereby opening up much more time for the human aspects of care. You want your doctor to spend time counseling you, talking with you, understanding what your priorities are. Not necessarily behind the computer typing up a note because that's what's required for billing purposes. 

Jason Helgerson: [01:48] Today's guest has seen health and healthcare from many different and interesting perspectives. He has been a Stanford University researcher, Chief Operating Officer for Clinical Operations at Kaiser Permanente, and as the Commissioner of Health for New York State. Today, he's working on the cutting edge of health and science as the Chief Medical Officer of Sharecare, a health technology company enhancing digital health offerings with innovative AI solutions. To him, the future of health involves utilizing science to the fullest extent possible in order to make the world a better place. I'm Jason Helgerson and you're listening to health 2049. And it's my pleasure to welcome Dr. Nirav Shah to our program. Nirav, welcome. 

Dr. Nirav Shah: [02:30] Thank you, Jason. It's a pleasure to be here. 

Jason Helgerson: [02:32] Nirav, please tell our audience a bit more about your interesting background

Dr. Nirav Shah:[02:36] Well, I think you've pretty much covered it today. I am the Chief Medical Officer of Sharecare based out of Atlanta, Georgia. I live in Palo Alto and practice at Stanford University in internal medicine and find ways to play with my kids and go on hikes with my wife otherwise.

Jason Helgerson: [02:56] Oh, great. So we start where we always start with our guests, which is really to ask you to describe your vision for what healthcare looks like, feels like, what the experience is or will be for those living in the United States and beyond in the year 2049?

Dr. Nirav Shah: [03:11] Healthcare in 2049 is going to be very different than how most people experience it today. Healthcare will be much more digital, mobile, virtual, remote, real-world, ambient and continuous. And let me double click on some of those. When I talk about digital, mobile and virtual, what I'm talking about is today we rely on technologies that were developed decades or even hundreds of years ago, and the opportunity to leapfrog some of the limitations of those devices to what is capable today with our devices is exponential. 

I'll give you a real example, when you use a stethoscope on a person, you can certainly hear the heart rate and a very experienced clinician can catch many different things about how the heart is beating and how it's working based on their interpretation of the sound. Well, today's stethoscopes, now, incorporate ultrasounds and other technologies so that it automatically gives you several more dimensions of data and knowledge in much less time. And that opportunity is not universally available today. It will be tomorrow. 

When I talk about ambient today, we're still thinking about healthcare in very specific ways where it's related to a doctor, placing their hands on you in a clinical visit and then understanding how that disease has affected your body. Ambient means that there will be continuous sensing, without you having to even notice that healthcare is being delivered to you by artificial intelligence, by sensors in the environment that monitor and understand who you are relative to your environment. You know, the more we learn, the more we understand that you are defined by your environment. It's that whole nature versus nurture debate. For example, when it comes to how long you'll live. Your zip code is much more predictive than your genetic code in terms of how things turn out for you. We know that your weight tends to be the average of your three closest friends.

So the challenge is to change everyone's micro environment, to optimize for total health. Both physical and emotional wellness to best be able to achieve what every individual wants to do with their health. 

Jason Helgerson: [05:32] So maybe we can think about this and your vision for the future in 2049. Can you put us in the shoes of the patient, of the individual, of the family and what would their experience be like in terms of the provision or the receipt of health and healthcare services?

Dr. Nirav Shah: [05:47] Today, we're stuck in mostly the play space provision of care. You often have to either go to a hospital or a clinic to get healthcare. Now we're moving towards video visits. But today the reality is we know that place agnostic care can be the reality for the vast majority of care. Of course, if you're getting a surgery, you have to go somewhere for that surgery, but tele-health has already replaced up to 75, 80% of primary care visits because of COVID. And we know that the opportunity in many other specialties is the same. So from today, going to a place and having bricks and mortars define where your healthcare is delivered to being place agnostic tomorrow. 

Today, we often get our health insurance from our employer and that employer based insurance model has worked to varying degrees for the last 50, 60, 70 years. But more and more, we're seeing that government-based insurance, whether it's Medicare, whether it's Medicaid, whether it's the innovation that the bundles of care are creating, that government-based insurance will then probably create a great equalizing factor. And so I'm not a proponent necessarily of Medicare-for-all, but the fact is, and the reality is that more and more of our government is paying for more and more of our healthcare. 

Today, we're still in a model of physician convenient care. Physician convenient care means the care was designed for and by clinicians, doctors, with their convenience in mind. The surgeon wants to have all of her patients in one ward of one hospital so she can run through at five in the morning and examine them on post-op day one according to her needs. And that made a lot of sense when physicians were a scarce commodity. But when you have many other augmentation of physician skills, tele-health, and other things, we can actually move toward a model away from physician convenient care toward person or patient-centered care. We've talked a lot about it, but we don't really even know what that means, yet. And I think that the whole paradigm of care around a person is going to be very different. 

Today we're also focusing on the practice of medicine by focusing on individual diseases and individual organs, as opposed to focusing on the whole person. So you have specialists, you go to for your heart, your liver, your kidneys, and each of them works in relative isolation to try to optimize their organ, relative to the others and relative to your overall health. So you may get medications that compete with one another in terms of what their effects are on your heart versus your kidneys and unfortunately, that leads to a lot of problems. In the future, when we actually focus on a whole person together, it will fundamentally change the prioritization of care and what you get to optimize your total health based on what you want to do with your total health. 

Jason Helgerson: [08:52] Interesting. So obviously today we talk a lot about team-based care, and I often like to say trying to make healthcare a team sport, getting providers from different areas working together as a team and sharing information amongst them so that you can get to better overall patient outcomes. But with the new technologies Nirav, do you see that that team will be less than just a group of individual physicians and providers and more technology, with maybe a single clinician interpreting the results coming out of the super computer, out of that technology that will be the interface with that patient? So instead of a team of many doctors, it will be a team of technology together, maybe even with the single doctor. Is that the future you see?

Dr. Nirav Shah: [09:37] Yeah, that's a great analogy and team-based care, it does tend to provide much higher quality care than relying on individuals or with all the handoffs we see from one person to another, the discontinuity of care when you don't have a team-based care model.

And how I like to think about it is that artificial intelligence is a different member of that team. So think of everything that's boring, routine, repetitive that you don't want to do as a doctor. I don't want to have to type up notes just for billing purposes. I don't want to just check the medications every single time to make sure they're reconciled. And yet these are important functions that can very easily be replaced by AI, technology and digital approaches that never get bored of checking medications. That never forget to do the safety checks of allergies versus what a patient has been prescribed. That don't make mistakes on the misspellings or the spellings of one medication versus another.

So how team-based care plus AI will work in the future is that AI will augment the ability of that team. That will take away some of the boring and redundant parts of our practice of medicine today. Thereby opening up much more time for the human aspects of care. You want your doctor to spend time counseling you, talking with you, understanding what your priorities are, not necessarily behind the computer, typing up a note because that's what's required for billing purposes. If I was in medical school today, I would actually think about those human superpowers that today computers can’t take over, things like critical thinking, communication, collaboration, and creativity. All of these are super powers in the future because it will be the hardest for computers to take over. 

Let me give you an example, you've heard a lot about self-driving cars and how they're going to be driving us everywhere in the very near future. And they do a fantastic job. But today, if a self-driving car is faced with a little pile of snow versus a little pile of glass, It doesn't know what to do. Why? Because what computers don't have today is common sense. They don't have what every baby has, which is exposure to a whole bunch of field simultaneously so they can take things from one area and then apply them to another. That's a very, very hard problem for computers today. 

So when we think about expert systems, they fail when it comes to common sense, humans don't fail with common sense. That's what makes us human. We can pull these threads together in very interesting and thoughtful and ultimately creative ways in ways that computers can't do today. 

Jason Helgerson: [12:30] So Nirav, do you see this new technology and the evolving role of AI, do you think it's going to lower healthcare costs? Increase healthcare costs? Or have nominal effect, meaning the healthcare costs will continue that on the trends that are on today into 2049?

 Dr. Nirav Shah:[12:47] Great question, Jason, and the history of technology in healthcare has been exactly the opposite of technology in just about every other industry. In every other industry when you have new technologies, they usually introduce greater efficiencies, right? When you introduce a computer, people become 20% more productive. Well, you introduce Epic into my workflow and what used to take me 45 minutes to admit a patient, now takes an hour and a half just clicking and pointing all across my electronic health record. So technology has failed us in one fundamental way in healthcare, and that's by increasing the barrier between the patient and the physician. 

The future, however, could be very different. The kinds of technologies that we're now introducing actually augment the skills of clinicians. If you think about it this way, AI is replacing the senses one by one. So for example, in radiology or ophthalmology or dermatology or pathology, when you have an artificial intelligence read the scan before the human, they can catch all the things that humans won't. But then humans will also add value by recognizing patterns in different ways or catching things that today our computers can't.

If you think about it today, let's say a clinician is 93% effective, a computer alone is 85% effective. Together, they are 97% effective in reading these kinds of scans. That augmentation of the senses is the reality and when you do that and you think carefully of the value-based world we're entering where cost, price transparency, and all are driving adoption, those technologies that actually improve efficiency are, I believe, going to be scaled the fastest. 

Jason Helgerson: [14:40] One of the concerns that's often raised about technology and healthcare is the potential for increasing the inequalities that exist today and that in this future state, even more empowered care or technology empowered care, will really create even bigger gaps between the haves and the have-nots of society. Obviously you're an optimist, you see the benefits of this technology. How do you respond to those critics? What do you think needs to be done to ensure that the world of 2049 is more equitable than the world of 2021? 

Dr. Nirav Shah:[15:16] Great question, Jason, and the reality is we're starting to, only just beginning to understand the black box that is artificial intelligence in many cases. We’ve seen how algorithms, trained on a very specific population, can actually serve to disempower certain other populations. If an algorithm is trained on white males, it'll know what to do for white males and it may give the wrong answer when it comes to Hispanic females, for example. And so our first step is understanding the potential for bias and the potential for coming up with the wrong answers. That is widespread now, and many groups are spending a lot of time to make sure that we don't have such biases built into our tools of the future. And, you did say I am an optimist, and I do believe that what will most happen with technology is that all boats will rise.

As you know, for example, access is a problem to healthcare, and either it's like, you'll get admitted to the hospital and then you get Cadillac care with a team of clinicians working on you, or you don't have access to care at all in a rural area, for example. Or with the wrong kind of insurance or under insurance or no insurance and you fall off a cliff. Those are the kinds of realities we face today. There's a big step change between those who don't have healthcare and those who do have access to high quality healthcare. 

If we go toward the future I envision, it'll allow us to actually decrease the inequities because it's not that giant step change between those who have versus those who have not.

Jason Helgerson: [16:54] In your future state, do you see that there'll be winners and losers? Will certain organizations, types of providers be clear winners, whether that's financial or otherwise, and do see others also being losers, meaning that they'll be financially worse or potentially even go out of business, in the future state that you envision?

Dr. Nirav Shah: [17:15] Well, clearly we know that the writing is on the wall that today, for example, the hospital should not be viewed as a revenue center, that hospital beds are like telephone poles, very expensive infrastructure that drives short-term thinking. Folks who don't embrace the fact that healthcare will be in the home, that healthcare will be delivered ambiently, that healthcare will occur wherever the person happens to be, not in the hospital, is going to be a loser. 

So if you're building large hospitals, I would say in general, you're probably spending money on things that don't make the most sense for 2049. I'm not saying that there won't be any hospital beds, but you can almost imagine the hospital of the future as an ICU, on top of an OR, above an emergency room and everything else is delivered in the home. 

Same thing with nursing homes. I think we've seen with COVID-19, that people don't want to be in nursing homes, but that if people are well supported, family caregivers can actually do a better job keeping people where they want to be, which is in their homes. Obviously there's a lot that needs to be done to get away from that nursing home model that we've embraced that is not what most people want, but I think that's an example of a loser. 

I think the winners are those who are most agile and able to change and able to use these incredible sources of data to actually deliver high value, high quality care, wherever that person may be, whether it's at the job, whether it's at home, whether it's at church, wherever they may be.

Jason Helgerson: [18:50] You're really sort of painting a picture of a world in which the hierarchy of healthcare is almost flipped upside down, right? Where the hospitals and large insurance companies, which sort of dominant players in the industry today become much less important, and physicians or physician groups or community-based services empowered with technology, and even just technology companies themselves that are at the lower rungs of the industry today, rising. Is that an accurate description of this vision have for the future? 

Dr. Nirav Shah:[19:24] Yeah, I think so. The reality is always slower than we hope it to be in the sense that we predicted that value-based care would be the norm about a decade ago and we're still waiting. Many parts of the country still don't even know what that means, even though everyone has heard the words.

Same thing, we’ve talked about how AI will become sentient and we'll be able to replace humans in terms of intelligence in five years, 10 years. I don't think it's going to be five years or 10 years, it’ll be 20 or 30 or 40, or maybe never at all in many ways. 

So to the extent that there's a lot of vectors pointing in the same direction now in terms of what the future of the hospital is versus what the future of care in the home is. There's vectors around how integrated delivery systems are doing better, how value-based operators are doing better, how payment mechanisms are changing fast enough now that the whole insurance industry will have to rethink its model in some important ways.

I believe there'll be many changes. I hope that we see them on the ground by 2049, but the common thread is that individuals will be in much more control. That's the hope. 

Jason Helgerson: [20:40] Great. So just along those lines, it sort of begs the question, how confident are you that your vision for health and healthcare in 2049 will actually be achieved?

Dr. Nirav Shah:[ 20:51] You can see there are a lot of optimists making big bets in healthcare today. The last five or six unicorns have been healthcare technology or digital health companies. And you've seen many big news announcements of people making big bets in healthcare, whether it's Amazon Health, or others. So I believe pretty strongly that healthcare will be very different in even 10 years from what most people experience it today. And by 2049, I hope that we're much, much closer to the vision I described at the beginning. 

Jason Helgerson: [21:25] So let's double click into artificial intelligence itself. It's much discussed in a variety of different industries, but a lot of people, I think yourself, included very excited about its potential application in healthcare. Tell our audience a little bit more about how you think artificial intelligence is going to transform healthcare. 

Dr. Nirav Shah: [21:43] You know, artificial intelligence allows us to think in very different ways than we used to be able to in just the near past. I'll give you an example. Today's hearing aids that Starkey makes, can now quantify an individual's level of social isolation based on how many words that hearing aid hears, based on how many different voices, based on the tenor and the tone. It can quantify if someone's lonely or not. Who would have imagined that possible? And that's possible today. 

We now have all of these, what we call dry biomarkers. Biomarkers are little things like you draw someone's blood and you can see what is the risk of going on to have cancer, for example. Dry biomarkers are those that are taken from other data sources and allow you to help predict an individual's outcome.

Let me give you an example, let's say you walk to work every day and you carry your phone in your pocket and you have a history of asthma and allergy. One day you walk through the park and you have bad allergy symptoms. The next day you walk through city streets and your allergy symptoms aren't that bad.

Overtime, the phone's GPS data, by downloading local pollen counts daily, hourly, minute to minute weather and humidity data and where you're going can inform you in real time saying, you know, your allergies are pretty bad today. You may not want to walk through the park on your way to work. That's possible today with some of the work that we're doing.

Imagine a tomorrow in the not too distant future, where you could add other things. The model I'll give you something we call edge computing. All of that data, about who you are, about your personal symptoms, where you're walking, all of that lives on your phone. It doesn't have to leave your phone, that's called edge computing.

The model that predicts your asthma or allergy flare can live in the cloud and then be localized on your phone. The model on your phone gets smarter based on all of your local data. Your data never leaves your phone, but the learnings that AI model.that's smarter, goes back to the cloud and makes the mothership allergy prediction model smarter.

That's a system called federated learning, where we can take data from many different people, and preserve their privacy. Their data never leaves their phones. So they're never vulnerable to hacking or attacks or anything like that because you'd have to hack into every individual phone. On the other hand, with this federated learning model you can get much smarter, much faster and not worry about all those data issues that we worry about today. So federated learning, zero trust is another example. All of these new things that we finally started to apply to health care, and that have been around for a while in other industries, will allow us to preserve privacy and learn much faster and realize a vision of a learning health system in ways that we've talked about in the past, but we've never really done. You will have a digital twin who will go through your life and see what happens if you take one medicine versus another. And warn you before you take the wrong one, and which one's better for you. Those are the kinds of things that are possible today, but that will be scaled by the time 2049 runs around.

Jason Helgerson: [25:08] So are you at all worried? I mean, when we talk about when we're recording this, we're still in the heart of the pandemic and there's tremendous efforts going on around the world to vaccinate people. And survey after survey shows a lot of reluctance amongst people to get the vaccine. And, it sort of, also in just the rise of the anti-vax movement and just a lot of concerns about new technologies in healthcare, it’s potential impacts. Are you at all worried about this, or did you see it as a challenge convincing the broader public around the value of these new technologies so that they become widely adopted? 

Dr. Nirav Shah:[25:43] Yeah. You know, that's a great question, Jason, and I think part of it is that we've had some bad actors in some real examples of where privacy has been violated or an individual's data has been exposed and that's led to mistrust on many levels and it goes back many decades in health care. And I think part of the opportunity here is that rather than focusing on the right to privacy, we may want to think about the right to information.

So for example, if we aggregate and anonymize that data from individuals. Google researchers looked at phone-based searches on things like stomach cramps, and then can use that person's GPS information to see which restaurant they'd been in and then have inspectors inspect those restaurants, which were found to be three times more likely to be unsafe compared to the conventional methods of looking for a food borne illness and which restaurants aren't keeping the food warm enough. That kind of opportunity from the right information allows public health and everyone to benefit while still preserving privacy. There's ways that we can, for example, Ways, this is an app that allows people to crowdsource traffic and accident information allows first responders to know about an accident 30 minutes earlier than their traditional systems. And actually get to an accident because of weaving through traffic better four and a half minutes faster than if they didn't use Ways. Kinsa Smart Thermometers allow you to predict where COVID is up to three weeks before any other system to understand where a hotspot of COVID is in America today. And that's because they have 2 million smart thermometers across America, which is a leading indicator of where fever and symptoms are versus a lagging indicator, which is when a person shows up in a hospital with COVID symptoms when test results come back or when someone dies from COVID.

So these are examples where there are tremendous benefits in data that can be unlocked without aggregating the data by keeping people in the driver's seat and keeping them as the owners of their data. We can do all of this today and we'll be able to do much better tomorrow as we have the privacy principles that are universal and don't lock down data universally, but allow us to unlock that public benefit.

Jason Helgerson: [28:19] So now we come to our last question, which is really sort of taking a step back and thinking about your vision and its broader implications. Why do you see your vision as really important to humanity, important to the world? And also, how does your vision, what you hope will be the case in 2049 in terms of health and healthcare if that is achieved, how will it make the world a better place?

Dr. Nirav Shah: [28:42] It's a big question, Jason. You know, in 2049, I hope that healthcare will first and foremost be equitable. We know the problems of today are because of the incentives and the way that system has been designed to perfectly deliver more and more healthcare and not deliver more and more health. So equitable will be number one on my list.

I think number two is person centric, which I spoke about earlier. It's not about the doctor, it's not about the hospital. It's not about the insurance company, it's about you and what you need and how you want to live your life. 

The next idea is continuous. Today, we're very episodic in terms of how healthcare is delivered and if you think about it as a continuous linear function, you can continue to optimize health by little nudges that you don't even notice. With ambient intelligence around you, that can totally change the trajectory of your life in letting you do what you want to do, how you want to do it and with whom you want to do it.

I talked about privacy preserving and how people should be the owners of that, of their data and all of the data about them. And it's a very different approach than Facebook and others have taken to date. But I think at least in healthcare, it should become the norm. 

Finally, I believe healthcare is a right, not a privilege and ultimately I think it will become free. We're moving away from commercial insurance for employer sponsored insurance is giving ground to more and more government sponsored insurance. And ultimately I hope that all of the quality evidence-based healthcare is actually free. Of course, there'll be a higher version, which, looks a little different, may have a little better branding, but the fundamentals should be free. And, you know, today cost doesn't reflect value. You, as a head of Medicaid in New York saw how two hospitals across the street had three fold differences in the price of a C-section, for example. With no differences in quality, that doesn't make sense and in the future, with a transparent pricing and costing system approach, we will be able to capture value much better. When cost does actually reflect the value. 

I think that we talked about systems approaches and continuous learning today. We have that Swiss cheese model where a lot of medical errors happen because four humans failed in a row to do what they were supposed to do and in the future, when you take a more thoughtful meta or systems approach, we will have all those safeguards in there in ways that we don't today, because it will be cheap, easy, automated, and probably done by robots and others. And that'll facilitate continuous learning in different ways. 

And finally care will become more and more human. It is still all about care. And empathy and compassion. The pendulum has swung a bit away from that because of all the burdens faced on carers, including physicians and nurses and others in the system. And we need the pendulum to swing back and stop moving on the side of actually delivering what people want more and more help.

Jason Helgerson: [31:55] Excellent. Well, thank you so much, Nirav for coming on the show.

Dr. Nirav Shah:[32:00] It was my pleasure. 

Jason Helgerson: [32:02] And that was Dr. Nirav Shah's vision for health and healthcare in the year 2049. As always thank you for listening to health 2049. If you enjoyed what you just heard, please subscribe to us and share this podcast with a friend. Thank you and see you next time.

Dr. Natalie Landman, Executive Director, Center for Healthcare Delivery & Policy, Arizona State University

Why should we design a healthcare model with personal accountability at the center? Dr. Natalie Landman, Executive Director at the ASU Center for Healthcare Delivery and Policy, shares a vision of sustainable solutions and tools that empower patients and healthcare providers to work together to achieve optimum health outcomes.

Dr. Natalie Landman is the Executive Director at the ASU Center for Healthcare Delivery and Policy. Natalie manages the portfolio of center projects, including project definition, launch, and implementation, as well as serving as a liaison to academic, private, government, and non-profit entities in support of the center's mission. Prior to joining the center, she served as Associate Director of the Research Strategy Group in the Office of Knowledge Enterprise Development at ASU, where she was responsible for the identification and development of large-scale research initiatives, and the establishment and promotion of collaborations with clinical and corporate partners. Natalie joined ASU after nearly three years at McKinsey & Company, where she served numerous clients in the healthcare and high-tech sectors on a range of strategic topics. Natalie holds a PhD in Neurobiology and Behavior from Columbia University in New York City.

Show Notes

• Dr. Natalie Landman shares her experience in academic research, health policy, economics, and the healthcare delivery system. [03:30]

• A vision of the empowered patient and physician working together to create the right set of treatments for the best health outcomes. [05:40]

• We need to teach people that they impact their own health. [07:36]

• Four websites that share vital hospital information and assist people in making beneficial healthcare decisions. [08:05]

• An example of how the Ministry of Health in Singapore discloses health care costs with full transparency prior to the patient’s procedure. [10:43]

• Health care should be a right, but people have to have skin in the game. [13:35]

• How can we bring health care costs down by 2049? [16:24]

• What costs do health insurance really cover? [18:20]

• An explanation of how health insurance in the US allows for inefficiencies in the system. [20:02]

• The benefit of universal healthcare coverage. [22:53]

• What’s wrong with employer-based health insurance? [23:30]

• How does employer-based health insurance affect the job marketplace? [25:04]

• The four fundamental things people look for in health insurance. [27:56]

• How can we design a healthcare model with personal accountability at the center? [29:21]

• How can we incentivize physicians? [30:20]

• How can we incentivize health insurance providers? [31:07]

• A fascinating example of how salsa music helped a patient with dialysis–a cheap solution to an expensive problem. [32:34]

• The one thing that Dr. Natalie Landman doesn’t want to happen in 2049. [35:25]

Transcript

Bisi Williams: I'm Bisi Williams, you're listening to health 2049. 

Natalie Landman: I really wanted to take the perspective of the patient because I feel like in a lot of the discussions that we have around healthcare, the patient is often talked about as this third entity out there somewhere, but we're all patients sooner or later. And so I think my vision is really having that dyad. The empowered patient and empowered physician working together to create the right set of circumstances, the right set of treatments, et cetera, so that the patient ends up with the best outcome for them. 

Bisi Williams: [01:33] Let's agree, the United States of America undeniably provides some of the best healthcare in the world and is one of the most innovative nations. The financial investments in health and medical research are the envy of all. And yet there is no such thing as a single unified and coordinated US healthcare system, but rather a complicated and fragmented healthcare marketplace.

My guest today is a firm believer that knowledge is power. She will share her vision for an empowered citizen, working with empowered healthcare providers to achieve optimum health outcomes for each individual. Natalie Landman holds a PhD in neurobiology and behavior from Columbia University. As a researcher, she led a biotech company with technology platforms in Alzheimer's disease and oncology. She's a health economist with deep understanding of the entire medical delivery system from bench research to bedside care. Currently, my guest is executive director at the Arizona State University Center for Healthcare Delivery and Policy.

She is responsible for the design and implementation of its vision, for a sustainable US health care delivery system that provides high value healthcare for all citizens. Her job is to describe, promote and facilitate the realization of a high value health care delivery. Welcome to the show Professor Landman.

Natalie Landman: [03:11] Thank you again, Bisi for a very, very kind introduction. And thank you for having me on the show today. I'm very excited about our conversation. 

Bisi Williams: [03:19] You're welcome and we're glad to have you. Professor Landman, you seem like a unicorn to me. Could you briefly explain your expertise and academic research, health, economics, and health care delivery?

Natalie Landman: [03:30] So I started out as a research scientist, trained in the discovery and development of novel therapeutics for Alzheimer's disease with an extension in toxicology at a later point. When I was finishing up my PhD, I felt increasingly frustrated by the 17 year timeline from bench to bedside and was looking for an opportunity to have more immediate impact.

On patients and patient care and got interested in healthcare consulting was lucky enough to get into a large consulting firm and spend the next three years working with a variety of healthcare delivery organizations, helping them understand their patient populations and hopefully optimize the care for that patient population. Eventually my husband and I decided that it was time to consolidate operations and he had been at the university for quite some time. So I decided to see if I could find an opportunity to combine both my research background and now my consulting slash business background into a what turned out to be kind of an ideal position.

So for the past 10 years, I have been working at Arizona State University with the former executive team of the Mayo clinic and our work kind of falls into three buckets. We teach health, economics, health policy, we do health policy research. And then we also have kind of a pro bono consulting arm where we work with a variety of health care delivery organizations, helping them redesign the care again for the patient population that they serve. So it's been a really, really neat opportunity to get involved across the whole spectrum in healthcare. 

Bisi Wiliams: [05:14] So given the fact that you can see everything from soup to nuts, let's just say, in the healthcare ecology system, tell us about your vision for health and wellness in 2049. 

Natalie Landman: [05:27] You know, when you first posed the question to me about 2049, I thought about myself and how old I would be then, and I will be 70 years old. So you guys can figure out how old I am.

Bisi Williams: [05:38] I'm bad at math.

Natalie Landman: [05:40] But I really wanted to take the perspective of the patient because I feel like in a lot of the discussions that we have around healthcare and about healthcare. The patient is often talked about as this third entity out there somewhere, but we're all patients sooner or later. And so I really got to thinking about what kind of care do I want for myself at 70 and for my family. And what I want to see and what I think is feasible, especially with the growing recognition of how much impact we have on our own health as individuals. The growing number of tools that are out there whether it’s wearables, just information on the web, in home lab tests and so on and so forth, I think we really have an opportunity to empower patients to be the stewards of their own health. 

I also think we have the opportunity to empower physicians with more information about their patients. And about what other providers around the country and around the world know about specific conditions and about specific patients and populations.

And so I think my vision is really having that dyad of the empowered patient and the empowered physician working together to create the right set of circumstances, the right set of treatments, et cetera, so that the patient ends up with the best outcome for them. Because an average patient doesn't exist. We're all unique, we all have our differences, challenges, genetics, socioeconomic circumstances, et cetera. So it's really about taking all of those things together and coming to a shared vision, sorry for stealing that term, but really shared a shared vision for that patient. 

Bisi Williams: [07:28] That's amazing. So how will you achieve your vision of this dyad or some of the practical things that would need to happen?

Natalie Landman: [07:36] So I think one is just a general sense of awareness. I think we need to start teaching people that they have a lot of impact on their own health. I think we need to provide them with the tools to make decisions about their health and their healthcare. I think a lot of those tools are actually available already in sort of pockets around the country and around the world.

Bisi Williams: [08:01] For example, could you tell us some of those tools that are available?

Natalie Landman: [08:05] Sure so a lot of good tools to support patients in their healthcare decisions are already available, either around the country or around the world. Now, some patients are simply not aware of them while others don't necessarily have access to them. And of course the tools themselves could stand to be improved upon, but we do have somewhere to start.

One of the things that happened over the past decade or so, is the center for Medicare and Medicaid services started putting out information about the value of different hospitals provide. It's called the Medicare Hospital Compare, it's a website. You can go there, you can type in the name of a particular facility that you are considering, or even several facilities.

I've had conversations with friends who were looking and trying to compare two or three different healthcare facilities for their care because their physician had privileges in each. And so Hospital Compare is one place you can go to take a look and see how different hospitals in your area, or even other parts of the country compare on certain measures on things like complications, things like mortality rates, even at this point on their cost of care. So that's one website. 

Health Grades is another great website where you can go for information about specific facilities and even specific physicians and look at both quantitative comparison. So this is actually data coming in from Medicare and other states on how these hospitals do in different types of conditions.

And for the physicians, you can actually get some patient reviews about how well they have done on X, Y, and Z dimensions. And I'll mention one more, the Rand Institute in California has also created almost like a value calculator, if you wish. Now it's primarily based on Medicare data, but it's better than nothing. It's a good place to start where it allows you to set, they have several leavers in the calculator that allows you to set your priorities. Is it more important for you that the care is safe? Is it more important for you that it's effective? Is it more important for you that it's timely, et cetera, to help you figure out based on your needs and your preferences, where the best place for care might be?

Bisi Williams: [10:25] Those are three fascinating examples of which I didn't know about at all. Those are fascinating resources that we can use today. How do you imagine in 2049 is that we could improve the communication of what doctors are measuring and what patients are measuring? 

Natalie Landman: [10:43] I think first we need to consolidate some of this information into one place. And I know there are arguments about which of these different sites, and there are others like Leapfrog. There are different kinds of rating agencies for healthcare. We could just at least consolidate them in one place and give folks the opportunity to choose for themselves, what’s most important, but at least all the information will be in one area rather than disparate across the web. 

Bisi Williams: [11:15] I love that. And I love that you actually are designing the experience, right? You have parameters from which the consumer can choose, which is also very empowering, clarify some of that. Could you talk a little bit about, from your position, do you think that transparency is an achievable goal in terms of patient-physician communication? 

Natalie Landman: [11:40] I believe so. And the reason I believe that is because I know that it exists in some countries and also here again in some areas. So one example that comes to mind is what happens in Singapore. The Ministry of Health actually published this information about the cost of care for various procedures at various facilities. You can actually go to the website today, type in, let's say, I'm having an appendix removed or some other common procedure and it will populate a table for you with a list of hospitals and the cost associated with that particular procedure.

In addition, this was absolutely fascinating to me, and I wish we would have that here. I  think with some will, we can, they will actually counsel you in advance of a procedure about what the cost of care is going to be, how much you actually have in your health savings account to pay for the procedure so that there is full transparency around the experience.

Bisi Williams: [12:42] That sounds really quite empowering for the patient, the things that you have control over, you can decide who, where and when, and how much you're going to pay. And so when we address the challenges of healthcare and systems, there's some very painful points that we need to address. Would you agree?

Natalie Landman: [13:07] I think I would call them pain points rather than painful points. And I would look at them as challenges and opportunities, rather than sources of pain, per se. There are plenty of solutions. I think there needs to be a will to actually make them work. 

Bisi Williams: [13:26] I think that's amazing. And then I have another question for you ,and your vision in the year 2049, is healthcare privilege or a right?

Natalie Landman: [13:35] I think it should be a right, but people have to have some skin in the game. 

Bisi Williams: [13:42] Tell me more about how people will have skin in the game. 

Natalie Landman: [13:45] If we're looking at sort of all of the determinants of health, of an individual or a population, healthcare delivery, so the actual care that you would receive when you show up in a physician's office or in a hospital, that has a relatively small contribution to your overall health. 

There are different models out there, some say that it's about 10%, if you include things like genetics. If you actually just look at “modifiable factors,” because we're not yet there with, genetic engineering, but if you look at the modifiable factors, which are things like behavior, socioeconomic circumstances, healthcare education, et cetera. Healthcare, again, still plays a relatively small role. I think the biggest I've seen was about 20% of the total. And so again, when we look at the other brackets, we have socioeconomic circumstances, education, and then behavior. 

Now, they're all intertwined to some extent, but behavior is a big one. And I think we all know what we need to do to stay healthy. Eat the right foods, get some physical activity, not drink too much, et cetera, not smoke, wear seatbelts, et cetera, et cetera, but not all of us do that. And frankly, I'm guilty of it myself from time to time, for example, not eating well. And so I think that, while it is a right, I think there still has to be some sense of personal responsibility that's baked into whatever healthcare system we design. You know, you need to have people say, I am in charge of my health, I know what I can do, I know I can contribute. And so different countries again, have done that in different ways. 

Singapore, again, to go back to them, they’re a very interesting model. They actually have a mandatory health savings account that's taken out of your paycheck on a regular basis and the way they set things up, you still have to contribute to your own healthcare expenses. Now the government provides a significant subsidy, but there's still that piece of your skin in the game you have to contribute. And so it puts a little bit of the responsibility on the patient to actually proactively try to stay healthy because they know that some of the money is going to be coming out of their pocket if they get sick. 

Bisi Williams: [16:11] That sounds interesting. So let's talk about the price problem today and what are three or four things that we could do to mitigate the price problem for the year 2049.

Natalie Landman: [16:24] So again, transparency, I think would be hugely important. It would be very, very useful if we look at other areas of healthcare that are “consumer driven,” like LASIK surgery, some types of cosmetic surgery, it's all out there. The information about prices is out there. The information about quality of care is out there. And people shop around and they force the providers into a price range that they will accept. 

Another interesting example was done by the state of California by CalPERS, which is the state pension fund. They did, what's called a reference price. So they said you are part of our system as a patient. Here is how much we are willing to pay for, say, a knee replacement. Now you as a patient have the choice. You can go to the providers that offer it for less, offer it for that, or offer it for more. If you go to the providers that offer it for more, you have to pay the difference out of pocket. So let's say they set the price that we're going to pay $30,000 for orthopedic surgery. You're welcome to go to the hospital, it charges $35k, but you're going to pay the $5,000 out of pocket. What do you think happened? So that was an interesting thing, right? Not all the patients decided that were going to go to the hospital that charged the $30,000, some decided to go to the more expensive facilities. But what was interesting is that, the price started dropping because there was transparency and choice. 

Bisi Williams: [17:57] I mean, that's fascinating. I mean, that seems like a good capitalist model. A good exchange of goods and services with no middle person in between. So that's interesting. When we look at that, can you give other examples, like, for example, is health insurance as we understand it in the United States a bit of a paradox?

Natalie Landman: [18:20] I think we have forgotten a little bit about what insurance normally is for. Insurance in other areas, whether it's home insurance, car insurance, et cetera, is really done for catastrophic events. Whereas in healthcare, we have come to this expectation that if we're getting health insurance, it has to cover everything. Both catastrophic coverage, as well as all the primary care, and sort of preventative care, et cetera, anything that doesn't land you in the hospital. That would be the equivalent of maybe trying to get home insurance for your appliances or for an oil change for a car. I don't know anybody who gets insurance for oil changes. Again, for things that are kind of regular maintenance. And yet in healthcare we've come to expect that insurance has to cover everything from A to Z.

And I have seen people have very generous insurance coverage, use it because it's there, whether or not they need it. Whether or not the care they're getting is providing any additional value. And so I think there's an opportunity to rethink a little bit the way we structure our health insurance marketplace and the types of plans people can have access to. And frankly, I would be fine if we had a variety of plans and there are folks that really want to coverage A to Z. They can get it. I believe we should have choice. 

Bisi Williams: [19:48] I love that you draw between an oil change and a car accident in terms of insurance. Though some people are imagining in the future that there'll be some sort of universal care. Is that something that you entertain? 

Natalie Landman: [20:02] Absolutely. I think we absolutely should have universal coverage. 

Bisi Williams: [20:06] What does universal coverage mean to you? 

Natalie Landman: [20:09] So I would say we need to have everybody in the same scheme. So the US is unique, we have, our insurance is in series. And I’ll explain what I mean by that. So in most countries in the world, health insurance coverage is provided kind of birth to death. Whether you look at the UK, whether you look at Singapore, whether you look at the Netherlands. You name it. It's everybody in the same system, birth to death. Now the types of insurances they go through might change, but everybody's in the same boat.

What we have in the U S is a fascinating accident of history. But what we have is we have private insurance for folks who are young and working, and then we have Medicare for folks over age 65. And so we have private insurance that gets all the healthy folks. And then the government or the taxpayer gets everybody when they're sort of over the hump and are starting to have all these different health issues.

Because if you think about it, if you look at healthcare spending or how much healthcare utilization folks have throughout their life, the majority of it happens toward the end of life. And so what happens is there is no incentive for the private insurers to really do a lot of prevention because they're not going to reap the financial benefits, which are going to come much later when folks are on government provided insurance. So the thought is, let me just get them until they're 65 and then they are the taxpayers problem. So why am I going to invest any money in prevention and health promotion when all the benefits are going to accrue later to the government.

Bisi Williams: [21:55] Wow. Okay. So how did you flip that model? What would be a better economic model? 

Natalie Landman: [22:03] Well, I would say that we need to go again to the, to what everybody else is doing internationally. Just, we have to have everybody in the same scheme from birth to death. So everybody in the same set of insurance options, birth to death, not all the young folks in private coverage and all the elderly under government coverage. I think that sets up a bad precedent. And a bad set of incentives for the system to really concern itself with again, health and wellness 

Bisi Williams: [22:32] The series, the way the system is currently designed now seems to me, that business model doesn't serve very many people at all. How do you imagine the economic model could shift without getting people feeling that you know, that it's a benefit or a right, it’s just good business?

Natalie Landman: [22:53] As I mentioned before, I think everybody has to be covered. So we need universal coverage. I think people should own their own insurance because one of the things that, I'm sorry, I know we said we're not going to talk about the pandemic, I'll just mention one thing briefly. But one of the things that we saw over the past year is that, because we rely so much on employer-based coverage for our healthcare, people were not only losing jobs, they were losing their healthcare and they're losing it in the midst of a pandemic, which is as absurd as it can get. 

Bisi Williams: [23:25] That's insane. So that is a point in our system that we could design right now.

Natalie Landman: [23:30] Absolutely. I think, you know, what we have proposed is that everybody owns their own insurance. And if the employers want to contribute to it as a benefit and help you pay off part of the premium or all of the premium by all means, let them. But your health care coverage should not be dependent on who is employing you, whether you're employed or not. It should be yours. And you shouldn't have to worry about losing it because you moved, you changed jobs. You decided to leave the workplace. 

There’s a whole slew of issues that come with the current system with our employer based coverage. One I've already mentioned, but there are others. I mean, when you move from job to job, there's no guarantee that your employer is going to have the same coverage as your previous one. And that they're going to have the same providers, healthcare providers, in their network that you had previously. So there's a break in continuity of care because you have to now find a new physician who doesn't know anything about you. You have to go through all of that process all over again, assuming that you can find somebody who actually takes new patients and so on and so forth. So it's terrible for a variety of reasons. 

Bisi Williams: [24:44] Let me just interject here. So what I see here is that if everyone owned their own insurance, they would have, they'd be free. They'd have autonomy, in fact, they would be able to make better life choices for themselves and their family, both professionally, socially, and economically, if you had your own insurance.

Natalie Landman: [25:04] Absolutely. I think one of the other things that it creates right now is job blocks. So people are not leaving jobs that they may not be happy with because they have the benefits or they're not taking jobs that they really want because the insurance either isn't there, or it's not as good as their previous job. So it also creates a lot of inefficiency in the work, in the job marketplace. 

Bisi Williams: [25:27] So I want to discuss this inefficiency because what you say is fascinating. So not only will you take control of your own health. You can take control of your finances and you can take control of your time. And when you think about 2049 and all of the technological advancements that we have, and all of the information that we have in terms of measurement, and we have this empowered citizen and empowered care provider. What do you think this means for productivity in terms of economic growth? 

Natalie Landman: [26:00] I think there are tremendous opportunities, because again, I've mentioned that we are, we have a lot of inefficiencies in the job marketplace because people are tied to their insurance.

A typical employer will probably have three to five health insurance options. They may not necessarily be the options that you want, both from a coverage, as well as a financial standpoint. I may not want to have coverage from A to Z because I am healthy. My family is healthy. And so, I would prefer to be which I am on now on a high deductible plan with a health savings account that gives me choice of where to spend my funds, who to see and so on. That might not be available for me with a different employer than I have now. 

Bisi Williams: [26:46] I think that's fascinating. Do you imagine that care will be beautiful? Will people be happy? 

Natalie Landman: [26:53] I'm going to answer it as follows. There's no perfect healthcare system. It just doesn't exist. We've had the opportunity to work with folks in Japan, in the Netherlands, in the UK and Singapore. I've also had direct experience as a patient in Israel, in the Ukraine, obviously in the US, in Italy, there are always trade-offs. So that's point number one. 

If you don't believe me, there was a survey done by the Commonwealth Fund, which is a quite famous think tank in Washington, DC, that a lot of folks quote. They did a survey of citizens in different countries that have different healthcare systems. And there's no way to make everybody happy. Out of 11 countries they surveyed, only four countries had about 50% of the interviewer’s say that they're happy with it. 

Bisi Williams: [27:46] So what are the common things, on a basic fundamental level, for your health and wellbeing, do people look for universally? 

Natalie Landman: [27:56] I think, again, having the comfort, so universal coverage, so knowing that if a catastrophic event were to occur, I am protected. I think having access to providers is fundamental. I think quality of care was important. 

What was interesting, if you look at the four countries that came up on top, two of them were countries that had universal coverage through what folks call, a single-payer or something akin to it, and two countries were actually more of a market based system.

So my conclusion from all of that, and it was a conclusion that was also reached about 10 years ago by the OACD, which is the Organization for Economic Cooperation and Development, which is more of a global think tank was that there is no perfect system and that it's less the structure of the system than how it is managed. That's more important. That's key. 

Bisi Williams: [28:59] So I think that's an interesting transition because one of the things I'd heard is that in order for this system to work, there needs to be accountability. And if you have a system, that means it's end to end design, how do you imagine that we would design governance models for health and wellness with accountability being key?

Natalie Landman: [29:21] So, I think again, we keep going back to the point of transparency. So I think we need on the provider side, I think we absolutely need transparency and accountability on both costs and outcomes. And again, we're doing some of it, but I think it could be done much better. And I hope by 2049, we can have that information at our fingertips.

I think the other thing, and that's again, something that's already going on on the patient side, some groups have gone out and changed health benefit design, in such a way, that if you as a patient, take good care of your health, you get a rebate on your health insurance at the end of the year.

Bisi Williams: [30:02] You could make money by being healthy.

Natalie Landman: [30:04] Exactly. I'd say that's a pretty good arrangement.

Bisi Williams: [30:09] I think, is that the behavioralist and the economist coming out in you? 

Natalie Landman: [30:15] Yes.

Bisi Williams: [30:16] And so you can be rewarded. 

Natalie Landman: [30:18]  Yes. 

Bisi Williams: [30:19]  How could you reward physicians? 

Natalie Landman: [30:20] In a similar manner I think, and again, that's something that's already being done in the country, in a bit of spotty and sporadic fashion. But if you, whether, it's being done both at the individual practice level, as well as, to some extent by the government, if you get good outcomes and you are efficient, you get a bonus. And if you don't. It kind of goes the other way.

Bisi Williams: [30:47] Well, I think that's fair. Right? 

Natalie Landman: [30:49] Right. 

Bisi Wiliams: [30:50] So, again, when we talk about incentives and bonuses, how could you imagine that the current state of insurers, what's their future state? How could they be a benefit to the citizens that they service? 

Natalie Landman: [31:07] And so, maybe instead of spending time on things like claim processing and claim denial, you could have people actually reaching out proactively to patients that are insured under that company and checking up on them and saying, are you doing X, Y, and Z things? Have you followed up with your physician? Being of service and support of the patient to keep them healthy, to keep them active, et cetera. And there are some groups, again, this is what gives me hope for 2049, is that things are already happening.

Kaiser Permanente who happens to be both a provider and an insurer, so their incentives are aligned, proactively does this kind of outreach to their patients. They identify patients who are at high risk proactively. And reach out to them and provide them with services that will keep them healthy. Whether it'd be something like statins, which you know, are not cheap, but they are cheaper than having the person end up with a heart attack and in the hospital. And it's better for the patient, so everybody wins. 

Bisi Williams: [32:18] I love the notion that everybody wins. Earlier you told me a story about a person who was having dialysis and it wasn't successful. Can you just tell that story of what was a problem and how it became successful? 

Natalie Landman: [32:34] Sure. And I think this goes back to that notion of the dyad really of the patient and the provider deciding what's the best course of treatment, rather than having it be decided by some third party. Whoever that third party might be, whether it's insurers, whether it's regulators, et cetera. 

The story went like this, there was a patient on dialysis, as you had pointed out, that was showing up in the emergency room on a pretty regular basis. I believe at least once a month, he would end up in the emergency room, they would kind of fix him up and then send him home. And the story would repeat all over again, about a month or a few weeks later. 

Things changed when Iora Health got involved. They sent in a health coach into the patient's home to kind of see, what are all the other things, those social determinants of health or something else that could be contributing to his poor outcome and what the health coach discovered while she was there was that the patient also had an anxiety issue. And sometimes those panic attacks would happen while he was dialyzing at home. He would then pull out all of his tubes and of course crash because he wouldn't finish the dialysis and ended up in the emergency room. 

Well, she inquired on whether or not he had panic attacks at other times and he said, yes. And she asked him, what does he do to manage them? And he said, I listen to music. And so their solution for this particular patient was to buy a used iPod and download some salsa music for him so that whenever he would dialyze, he would listen to the music. And from that point on, they said they hadn't seen him in the ED for at least six months, if not longer.

Now there is no billing code for used iPod and some iTunes that you could charge somebody for. The reason Iora was able to do that is because they are in a capitated arrangement where they get a per patient fee from the insurer that they work with. And they can do with that money whatever they want, to provide the best care for each patient. They have the flexibility to decide whether it is a new drug that the patient needs. Or, a used iPod or food delivery or whatever it is, that's preventing that patient from achieving their optimal outcomes, because sometimes it's not the healthcare piece. It’s everything else around it. 

Bisi Williams: [35:06] I find that fascinating. And the question I have for you is, given all that's possible, what’s the one thing you don't want to see happen by design or accident in 2049? 

Natalie Landman: [35:25] I think it's that notion of again, telling patients and providers, how care has to be done and what constitutes care. Having some, again, third party who isn't directly involved in that relationship between the patient and provider telling that dyad what the right answer is.

I think that's what worries me. And it worries me for a number of reasons I mentioned because there is no average patient because healthcare is not always healthcare, as we think of it. It is not always the right solution. And also because even if it is healthcare, medical practice changes all the time. And so, I don't want somebody being overly prescriptive of what needs to happen in a given patient physician situation. 

Bisi Williams: [36:10] I mean, that's a relationship I think that we all would love. Right? Wow. That's been a fascinating discussion Professor Landman. And that wraps our show with Natalie Landman. Thanks for listening. If you enjoyed our show, please subscribe or share with a friend and until next time I'm Bisi Williams.

Professor Ricardo Gomes, School of Design, San Francisco State University

How do we design a healthcare delivery system on an experiential level so that it is embedded into our lifestyle? Ricardo Gomes, Professor at School of Design at San Francisco State University, discusses the role of design in health care and his holistic vision of 2049 that focuses on building trust, equity and inclusion into the system.

Professor Ricardo Gomes has been a faculty member in the School of Design at San Francisco State University for over 29 years, and was chair of the department from 2002 to 2012. He coordinates the Design Center for Global Needs and the Nathan Shapira Design Archive in the School of Design. Professor Gomes is on the board of directors of the Institute for human centered design in Boston, and is a trustee of the Beta Beta chapter Epsilon Pi Tau international honor society for technology. He received his M.F.A. and M.A. at UCLA, and received a B.F.A. in Industrial Design at Massachusetts College of Art. He was a Fulbright Scholar in Nairobi, Kenya and conducted post-graduate research and product development of a container system for mobile health care delivery in East Africa from 1982 – 1987. Professor Gomes has lectured extensively, and conducted keynote speeches, presentations, symposiums, and workshops at universities throughout Africa, Asia, Europe, Latin America and the United States.

Show Notes

• Professor Ricardo Gomes shares his career path into health care design, from his humble roots to being awarded a Fulbright Scholarship. [02:54]

• In 2049, how do we build not only trust, but also equity into health care technology? [09:36]

• We need to map a universal pathway now to achieve an equitable healthcare delivery system in 2049. [15:01]

• An interdisciplinary and collaborative design approach. [16:35]

• How do we design and embed health care into our culture starting at an early age? [19:03]

• Community health care builds trust. [24:12]

• How can we humanize artificial intelligence to benefit health care? [26:18]

• What’s the one thing that could hold us back from progress if we don’t start changing it now? [28:32]

Transcript

Bisi Williams: I'm Bisi Williams, you're listening to Health2049. 

Ricardo Gomes: But if we don't map the path to get to 2049, we're just not going to be teleported. We're going to have to actually move through there, means moving from now 2021, what are the inflection points? What are the stepping stones that we will need to have sure-footing to guarantee that when we arrive, we will all arrive together. There will be no first class or second class, they’ll only be world-class. 

Bisi Williams: [01:47] Professor Ricardo Gomes is an award-winning educator, designer and longtime social justice advocate. He's been an instigator and practitioner of progressive inclusive design for decades. From his early days on a Fulbright Scholarship designing mobile healthcare delivery systems in Kenya, to nearly 30 years on the faculty in the school of design at San Francisco State University. He's the coordinator of the Shapiro Design Archive and the director of the university's Design Center for Global Needs, an international research and development center dedicated to promoting responsive design-thinking methods and solutions in local, regional and global issues. It is my pleasure to welcome professor Ricardo Gomes to our show.

Ricardo Gomes: [02:31] Well, thank you, Bisi Williams for inviting me to join and participate. And it's a pleasure to be here today. 

Bisi Williams: [02:40] Well welcome. So I'm excited to get started, Professor Gomes, you began your career in industrial design and have taught architecture and universal design. What made you pursue this field of interest?

Ricardo Gomes: [02:54] It's interesting. I never really thought of myself as a sort of medical-oriented designer, but you've actually caused me to really reflect on my beginning in design. Mainly through the very mentors and, sort of sages or guides that I have benefited from very early on in my life. And by that being about 16 years old was my kind of beginning of the formulation of my design journey.

And actually one of the very first things I did, which literally led to my Fulbright in Kenya in dealing with mobile healthcare delivery, and I come from a very humble grassroots background and trying to impact that environment, that society where design could be a tool for development, inspired and encouraged me to try to be a change agent. Healthcare delivery was presented to me by my mentor and he had very lofty and visionary goals, but we looked at healthcare, we looked at a mobile healthcare trailer and that was my first project I designed at 16 years old and kind of carried it with me at Massachusetts College of Art in Boston.

In fact, the very last project that I did as a student was this concept to design a mobile healthcare delivery unit. And I took that idea with me to graduate school at UCLA. I went to UCLA because, at the time, it was the only program in the country that I was aware of, that had a program in design for developing countries. And I always had an aspiration as an African-American and having roots in Kabul Verde, the Cape Verde Islands off the west coast of Sunnyville and even my Caribbean background from St. Vincent Union Island in Barbados, I always had a dream of how could I contribute or give back and how could I use design as a tool for development, and healthcare seemed to be one of the more immediate areas because I realized not only how it impacted global society, particularly when we look at developing nations or emerging economies or societies, but even in the United States, when we look at the kind of health equity or inequities or disparity, and how can we bridge that in a more effective way? How can design impact that? 

So, I was fortunate to explore this project in depth at UCLA. And to be very honest, I was somewhat naive about the depth and reputation of UCLA and it wasn't until I arrived there, that I realized what a wealth of resources that I was surrounded by. And the first thing I did was realize that it's about collaboration, collective activity and, I brought with me a design vision and I tried to share that with doctors at UCLA in the School of Public Health because I knew at the time, although I had this design vision of creating a mobile healthcare delivery unit, just like I may have a design vision today to share with you about 2049, I knew I didn't know about the nuances of healthcare delivery. I know about aspects of technology and how it may be incorporated to facilitate it. But I knew I had to meet and understand healthcare delivery, particularly public healthcare. 

And so I started taking courses at UCLA in public health. And I was a design major and I was the only design student in this graduate program of public health. I had these amazing professors who had all these projects all over the world that they were conducting. So the whole notion of empathy and observation was something I just knew was the proper way to approach not only design, but about how design impacts society, how it impacts other disciplines, other domains.

I remember I learned so much. I think when you come from a background that is not privileged, you don't make any assumptions. You just try to acclimate and you try to engage because I've always learned through experience more so, more than reading. I was always a very touchy, feely, experiential type person. For me, that type of engagement was tremendously insightful and I followed that kind of learning process almost what you could say was service learning from the outset. So anywhere I went, I found the need to be very humble, have that beginner's mindset be very open to change and to experiences that I was not familiar with. 

Bisi Williams: [08:54] I love that notion of the beginner's mindset. What's interesting here is that beginner's mindset, and that you were already thinking in the future 30 years ago, when you were imagining, right? Mobile medical delivery trucks for the United States 30 years ago and now this is potentially a thing. And so, that's a nice segue into this experience that you have of just being around the world and being of service and using your secret power of listening and observing and then making, could you describe for us your vision for health and wellness in 2049? 

Ricardo Gomes: [09:36] You know, again, as I think the last thing I said was when you don't come from a position of privilege, you don't make any assumptions. And although I recognize the vastness and greatness of technology in innovation, I realized that technology and innovation is not equitably distributed, in that, unfortunately there are many of us who have not benefited equally, or in an equitable manner from health. And so, there's a tremendous opportunity in need for health, particularly when we talk about telemedicine and even the digitization or the digital aspects, or even the artificial intelligence aspects of healthcare delivery and where it may be in 2049. The question is who is going to benefit from it? 

We can look at where healthcare is today, even in and around from the pandemic, to the need for equity, and we can say, how do we build not only trust, but equity in the dissemination of it because unless all of us are able to equally benefit from that, the power and influence of healthcare technology will not be envisioned or delivered. I say that because I've been kind of noting some of where the future is in healthcare, as I mentioned, some of the things from nanomedicines to artificial intelligence, to stem cell, to even sensors and other things that may help to monitor and deliver it. The big thing behind that is who is operating it or who is managing it and how do we make sure that management and operation is diverse and inclusive so that all people are benefits or benefactors because we have a history in which healthcare delivery was not disseminated  in an equitable manner. In fact, it’s not even disseminated in an equitable manner, it was actually done in a way that was very discriminatory or experimental without the consent or knowledge of others. 

Now I’ll quickly just reference to the Tuskegee experiments that went on back in the day. So when we talk about today from COVID vaccines and people who are somewhat hesitant about it, not because they don't think it will work. What is the guarantee that this is going to be administered in a way that will benefit us? 

So when I look at 2049, I think there’s tremendous opportunity, particularly for communities or societies, and I'm specifically thinking and addressing low-income vulnerable communities or even other emerging, developing nations, how do we better distribute that technology? Because if we talk about cloud technology, if we talk about, other aspects of delivering it from telemedicine, where we can look at some of the advantages that we see that our society has engaged in within the last year and we can say, how can this serve a greater community?

Those who are not mobile, those who don't have access to infrastructural state-of-the-art facilities. And so, we talk about, these ways in which we can say there is great opportunity, for medicine in the future and in 2049, which is only a generation away, you know, less than 30 years. So that means people that are being born today in 2021. If they are born and bred and educated in a very inclusive way and not only inclusive way, but a very representational way that better reflects the types of communities and individuals, both race and ethnicity. We can educate, we can cultivate that learning pool that will be in the position in 2049 to deliver in a very diverse, in a very inclusive and very engaging manner.

Bisi Williams: [14:23] So I think that's fascinating. And I just want to tap on one thing, Professor Gomes, which you've done is you see a role for inclusive and universal design playing along with the GRIN technologies, right? Genome, robotics, information, and nanotech. If we design holistically this platform for all of the new wonders and tools with the lens of inclusivity and universal design, can you tell me why your vision for inclusion with the caveats that you've described, how does it make the world a better place?

Ricardo Gomes: [15:01] So at some point we have to acknowledge the inequities in our society. We have to acknowledge where we can make change and impact. If we only talk about the object or the delivery. And we don't talk about what the pathway is to reaching that. I mean, it's one thing to talk about a destination. And so in this sense, we're talking about 2049 as a destination, but if we don't map the path to get to 2049 we’re just not going to be teleported to 2049. We're going to have to actually move through there means moving from now 2021, and how do we advance that? That's why I was talking earlier about the generation aspect. That means anything you do is an investment and that we can project 2049, but we want to really talk about what are the inflection points? What are the milestones? What are the stepping stones that we will need to have sure-footing to guarantee that when we arrive at 2049, we will all arrive together and there will be no, there will be no first class or second class, they’ll only be world-class. 

Bisi Williams: [16:25] I love the world-class. So what should we be doing today from your view, as a design objective, to reach the vision for 2049?

Ricardo Gomes: [16:35] Well, it goes back to what you mentioned about being holistic. It's all about being collaborative and it's all about being inclusive and it's all about being interdisciplinary. No one discipline can function on its own. And so in the case of, where the future is, it's looking at design. I'm speaking as a design educator, and I know the best way that I can educate, and disseminate the benefits and the services. And even a technology-related to design is to show how it is integrated and how there is a synthesis, to the way in which that evolves. 

Design is not a service unto itself. It doesn't serve itself. Even though many designers do serve themselves. You have designers who are designing for designers and not designing for the society, for the government, for the policy, for the environment and you have to realize you really can't separate all those, because if you really embrace the holistic nature of who we are, we realize that that kind of collectiveness, that kind of life cycle loop, has to be constantly engaged. 

And so when I talk about design and how we get to 2049 is to really show that in design education, we can say, that if we start investing now, we start showing where the designs come together. Where are the touch points between the two? Where does one exchange lead to the other? Where's those connections of the dots? That's what we're looking at. So I think we have to look at, where does design play a role in healthcare? Not on a superficial level, not just on a technological level, but on an experiential level and by experiential, meaning not only in delivering the services, but sustaining the livelihood. We have to think about healthcare not only when we need it, but the way in which healthcare is embedded in our lifestyle. 

Bisi Williams: [18:54] Can you talk about the embedding of healthcare in a lifestyle, for example, what does it mean to design and embed? 

Ricardo Gomes: [19:03] Well, this is where the equity comes into place. Most people, particularly those who die younger or more vulnerable to dying younger or not being able to benefit from longevity, they don't have the proper health care.

Why don't they have the proper health care? Because health care is not being monitored. Or they feel like the monitoring of the health care is a cost factor they can't afford. So if we are able to look at wearables or other types of timely monitoring of services, whether it happens in your elementary school, so that you have elementary services. Think of elementary schools, think of the children who are not able to have breakfast and lunch, which is really when you build nutrition and energy and ability to think in a clairvoyant manner, likewise health care so if they're able to get good healthcare monitoring, you know, on a school level that also transcends to their parents. Because the parents are their caregivers. 

So you got to look at again, this kind of holistic, these connections, you can't separate one from the other. And again, when we look at where there are disparities is because the parents can't afford to be good caregivers because maybe they're working constantly outside of the home. Or as a result of that, aren't able to really properly take care of themselves. And so if their life is shorter than that means the livelihood of their children will not be fully fulfilled and in terms of what they do. 

You have to really look at those connections and say, aha, there is a connection between the monitoring of one's health. How do we use health technology to not only monitor and again, that monitoring could easily be done through mechanisms like from video screening and health that will not be such an exclusive feature, but something that can be more inclusive. Now, whether it happens in the home or whether it happens in a community center or some type of health spot. 

I can remember growing up young that I never got a chance to really go to the hospital, but there were always community centers that provided some level of health monitoring or supervision or guidance. And so wherever, health care can be distributed, whether it happens within the home or there's a more communal structure, whether that's in a house of worship or whether that's in school or whether that's in some kind of community center or maybe even where they buy food, just dealing with food and nutrition. And that maybe helps also limit food deserts or food scarcity. So you can say, well, how can we connect all of them? 

I had a notion that you talk about healthcare workers. You talk about midwives. These things are in our cultural background. In Kenya, when I lived there, they have the doctor, they call mgunga. Mgunga is kind of the, some people that don't know will call it a witch doctor. But mgunga is basically a community doctor, someone who monitors the health of the community. And if we can, again, integrate these people, things that are recognized and not only just in terms of cultural kinds of nuances, but ways in which we can better integrate what one does. 

We can think about how people talk about, for example, mental health in 2049. Mental health is probably one of the more critical things that we tend to not monitor well in vulnerable communities, to even consider anything about mental health was considered to be frivolous. But other people who receive it often will talk about going to their shrink or something as a common, as they talked about going to the dentist, but because of cultural taboos or because of the fact that kind of healthcare is exclusive, we can't afford to think of it. 

Bisi Williams: [23:27] You know what, you've just touched on a number of things, Professor Gomes, that I find absolutely fascinating when you talk about this design journey starting from birth, middle school, et cetera, and one is people talk a lot about the medical industrial complex and really how we've designed it around the hospital. And what I hear in your discussion is notion of communities. So we've really taken it away from the final destination and put the monitoring of care, kind of redistribute, if you will, the access and power in a way that meets people where they are. And that builds trust. That builds a place where we can grow. 

Ricardo Gomes: [24:12] Yeah. that's the big word. Right. And also, when you think about community, and again, I want to go back to the community because community builds trust. As you talked about that complex, it seems very remote and insensitive and you think, how can we build more trust? How can we build more empathy in the way in which we deliver? 

And I think it is quite possible because I know, unfortunately I've had, too often, too many experiences in healthcare, in which, body parts that have to be secured or whatever. But I notice every time I go into healthcare, and I'm fortunate to have very good healthcare services and coverage, that there's more empathy. People ask you questions. They want to know how you doing, are you okay? And it's not so much administered in a matter of fact manner. It's more about people are conscientious, not only about the technology and its delivery, but the experience. And that experience means, and this will touch on another area of where a lot of healthcare was going and we wanted to know how do we humanize it, or how do we sensitize it?

When we talk about robotics, the AI experience, how do we humanize it? I mean, we could talk about if it's seamless, then we don't see it as some kind of addendum to what can be the individual service and delivery. And it's like, how do we say, well, if you go through a toll booth on a bridge, you no longer have a toll booth person to smile at you. And thank you. And you put yours in, you just have something that's automatic. It's kind of seamless and perhaps even that person, but where do we create that community? That experience, you know, sometimes that's experience could benefit from being seamless, but then sometimes that experience could benefit from being human.

Bisi Williams: [26:16] I mean do you want to be cared for by a robot?

Ricardo: Gomes [26:18] No, no, I wouldn't. I would not want to be. Particularly, can you imagine what people are going through now when their last hours or last days of experiencing COVID where they can't even see their loved ones, their father or mother or daughter, and even having someone else have to show them a FaceTime image of their departing loved one. It just seems to really make the whole transition process more agonizing. 

So how do we sensitize it? How do we give a face and a smile to that? So again, when we look at AI, when we look at robotics we talk about is how do we sustain, enhance the human element? But how does 2049 or that period open up opportunities so that, and I think this great opportunity because it's just a matter of, if we look at, if we can land a  Mars Rover all the way there, why can't we land. something in a country in Africa or south America or Southeast Asia? Why can't we land something there that is going to impact the health and wellbeing for generations to come?

Bisi Williams: [27:46] Professor Gomes, I think this is great. I mean, you really paint an optimistic picture of the future of health and wellness if we design it correctly through community. And I love your humanizing way that you look at the GRIN technologies, genomes, robotics, information, and nanotech, not as things to be feared, but as things to learn about, understand, and really have our moral and ethical hat on in terms of access and how we distribute these potentially remarkable goods and services. 

I'd like to ask you, what should we be mindful about in 30 years as we design our future? You know, the reality is we can do anything we want. What do you think we should not do? 

Ricardo Gomes: [28:32] Well, that's a good question because, I would say just bluntly, what we should not do is be looking at 2049 as if it was still 2021. Meaning that the players, those who represent, those who constitute the health community n 2049 look more like the patients. 

And again, if we really talk about how we begin to bridge healthcare delivery. We want to see how can that bridge between the healthcare community and the health care recipient be balanced. In other words, I can be receiving care and feel like I'm at home. And by at home, meaning I am in a source of comfort. How do I reduce any anxiety or ambiguity in the comfort zone in which the health care system exists. And so again, I would just avoid the current disparity that exists. 

In healthcare, I can easily, as a professor, talk about the academia. And so academia has the ability to shift and to ensure the representation and equity of it because when you're bringing in academia, you're not talking about discriminating or disputing ones capability because if you're nurturing them, if you're educating them, if you are investing in them, that starts at a very early age. That starts back at the elementary school I was talking about, starts back at the middle school or the period where mentorship begins to take shape and form.

We just can't look at a date, a time and not look at how we arrive on time. And so we can look at where we are today and where 2049, who are the players, who are the cast, the participants in that. And if that doesn't change, that means we don't change. And by that meaning, we still carry with us the old baggage on that journey. We don't kind of shed that old baggage or luggage that was only either holding us down or we really needed to rethink what we wear and how we wear it. So we really need to talk about that journey. And how we accommodate that journey. What is the vehicle or the mode that we take and who is on that vehicle, you know, who is going to arrive at that destination and realize why they're there.

Bisi Williams: [31:39] Professor Gomes I want to get on that train, that design train that you talk about. Where we really look at things from a human perspective, I am a hundred percent onboard for health in 2049 that's community-based and based on trust. Thank you so much for joining us today. 

Ricardo Gomes: [31:59] Well, thank you for having me and providing me the opportunity 

Bisi Williams: [32:03] Professor Gomes, the pleasure is all mine. And that wraps our show with professor Ricardo Gomes. Thank you for listening and if you enjoyed our show, please subscribe or share with a friend. Until next time, I’m Bisi Williams.

Dr. Michael Lindsey, Executive Director, McSilver Institute for Poverty Policy and Research, New York University

Will mental health professionals be replaced by robots in 2049? Dr. Michael Lindsey, executive director of the McSilver Institute for Poverty, Policy and Research at New York University, imagines the potential of innovative technology to increase accessibility and scalability to reach marginalized communities, by reducing stigma and providing treatment or alleviation of symptoms.

Dr. Michael Lindsey is Executive Director of NYU Silver’s McSilver Institute for Poverty Policy and Research and is the School's Constance and Martin Silver Professor of Poverty Studies. A child and adolescent mental health services researcher, Dr. Lindsey is particularly interested in the prohibitive factors that lead to unmet mental health need among vulnerable youth with serious psychiatric illnesses, including depression and suicide. He has received research support from the National Institute of Mental Health (NIMH) to examine the social network influences on perceptual and actual barriers to mental health care among Black adolescent males with depression. He also received NIMH funding to develop and test a treatment engagement intervention that promotes access to and use of mental health services among depressed adolescents in school- and community-based treatment. He is also an Aspen Health Innovators Fellow. 

Show Notes

• Dr. Michael Lindsey describes his background in researching mental health challenges in marginalized communities. [02:38]

• How can we bridge the gap between mental health needs and accessing services? [06:29]

• With innovative complementary services to treat mental health, will traditional talk therapy still be relevant? [08:19]

• How do we train the next generation of mental health professionals to fuel innovation? [14:46]

• In what ways can a healthcare professional maintain a relevant role in the treatment of mental health care in the future? [18:47]

• There’s a lot of opportunity in the future for mental health services to focus on prevention. [21:25]

• In developing innovative technology for mental health, marginalized populations need to be a part of the research to ensure accessibility and scalability. [24:21]

• How will Dr. Michael Lindsey’s vision of mental health in 2049 make the world a better place? [27:46]

Transcript

Jason Helgerson: I'm Jason Helgerson and you're listening to Health 2049. 

Dr. Michael Lindsey: As we're developing the technologies. We need to be thinking about how are we going to ensure that marginalized populations have access to the technology and then further whatever we develop, does it leave marginalized populations out? And so I think we have to keep the foot on the gas pedal, if you will. It's like you can't be so caught up in the innovation that you forget who is going to be using this, who has access to this? 

Jason Helgerson: Today's guest is the executive director of the McSilver Institute for Poverty, Policy and Research at New York University. He primarily focuses his research on child and adolescent mental health and tries to identify the unmet mental health needs among vulnerable youth suffering from depression and suicide.

His unique understanding of the youth mental health world clearly impacts his vision of the future. Will the future of mental health involve tele-psychiatry provided by robots, therapeutic video games, or the creation of pharmaceuticals that will impact not only the chemicals of the brain, but also the coping skills of the individual? I can't wait to hear what he has to say on these and other important topics. And it's my pleasure to welcome Dr. Michael Lindsey to our program. Michael welcome. 

 Dr. Michael Lindsey: Thank you, Jason. It's a pleasure to be here. 

Jason Helgerson: So, Michael, please tell our audience a bit more about your interesting background. 

Dr. Michael Lindsey: Yes, Jason as you mentioned, I direct the McSilver Institute at NYU and we are interested in the root causes and consequences of poverty. One of the ways that I look at that is through the prism of mental health challenges that might encumber individuals in terms of their ability to work, to be successful in schools and successful otherwise in terms of their interpersonal relationships and how they function as a general matter.

And so I then in my work bring to bear interventions to address those issues. So whether you're talking about depression and how it influences the success of kids in schools, or you're talking about PTSD, which might impact how mothers are able to parent their children in terms of being a successful caregiver, or if their challenges in parenting might lead them to then become involved with unfortunately child welfare services for allegations of abuse and neglect.

We tend to do this work in highly marginalized communities in terms of the resources and opportunities for access to healthy food options or employment opportunities that might not be there in those communities. So the context of the work is typically in those highly stressed environments that then might influence mental health in consequential ways that are unfortunate. But the reality is that context can really shape those mental health experiences in terms of how one functions. And so that's basically the crux of my work. 

I am also, as you mentioned, highly interested in the rising rates of suicide among youth in the United States. And the particular demographic that I have honed in on in my work are black adolescents, which we are now starting to see that their rates of engagement and suicide behaviors are rising to the extent that other racial and ethnic groups are actually seeing a decrease.

I've been really concerned about those trends and both through my research in terms of the epidemiological research that I've been doing, the intervention research that I'm doing. And also my advocacy in terms of translating that research into policy at the federal state and local level is really a passion for me. And I've been able to have some influence at those policy levels based on the work that I've been doing. And so that's basically where I am and the work that I do.

Jason Helgerson: Well, thank you. That's exceptionally important background. And certainly I think sets the stage for our conversation today, which is an optimistic conversation about what health and healthcare should be in the future. And we always like to start with each of our guests with that opening question which is; what does health and healthcare look like in the year 2049? So roughly 30 years into the future and obviously you bring a lot of knowledge and expertise to this question, and I'd love to hear your thoughts, Michael.

Dr. Michael Lindsey: It's such an important question and a great one because it gives me the opportunity, Jason, to somewhat dream and be aspirational in terms of what health care looks like in 2049. But I also want to contextualize my thoughts on that in terms of where we are now with regards to research and innovation in the space of work that I do around mental health, intervention and services research.  And so I do think that what we're starting to see now is that we're trying to figure out ways to bridge the gap between need and service use. Because the reality is that most people who need mental health treatment do not receive it. And then when you dig deeper down and look at certain demographic groups, it tends to be the case that marginalized populations are not connected to services and perhaps they need to be connected to services most because they are most challenged by the contextual realities that are shaping their mental health experiences. I think then we're starting to see the sort of evolution of mobile technology and how it might be brought to bear on how one gets connected to treatment, in terms of whether you're building out mobile technology to address stigma or whether you're developing technology that actually provides some form of treatment or alleviation of symptoms.

I think in 2049, you're going to see that sort of work really be the primary means by which we deliver mental health services in our society. Mobile technology then will be transformed into having the opportunity to actually provide the services or the treatment that one might need. So picking up your phone or whatever device of that time, where we would be using, you're going to be able to perhaps use that technology to interface with a therapist-like entity, a robot for example, or some kind of technology, whatever that might be, may actually be the person or the entity that is delivering the mental health treatment to an individual. 

It's somewhat scary in a sense because we've developed this whole emphasis around training, the next generation of professionals, whether you're talking about nurse practitioners, or social workers who tend to be the providers that are delivering these services, what does that mean for them? The question remains, but as technology continues to innovate, I think you will find that these mobile technologies will morph into ways in which care can be delivered. It's going to have to be evidence-based and so we're going to figure out a way to deliver evidence-based treatments and really crystallize ways via that technology.

I also think that again, on this technology strand of thinking, you’re going to have opportunities to build out games and other kinds of virtual programming that allows one to receive mental health care, but in a slightly nuanced way that relates to their participation in that gaming or that virtual experience. As I started out with saying there's so much stigma in marginalized communities, for example, but just broadly speaking related to mental illness in our society. I think then we'll consider ways to offset that by gaming and virtual experiences, that allows one to be a part of that type of programming, but experience the alleviation of symptoms. I think that’s fascinating and some of that is actually happening in mental health services and treatment, particularly as it relates to veteran populations, in terms of the treatment of PTSD and so I think that will be fleshed out even further and we'll start to see more of that. And certainly our innovations and the more knowledge we're starting to gain around psychotropic medication and how the administration of those kinds of biomedically-oriented treatments will be able to address depression or address PTSD.

So now, the way we deliver those services is in partnership, we're complementary to traditional talk therapy. There's a really popular adage or phrase in psychiatry in that pills do not teach skills. And so we say that in the sense of wanting to ensure that we're not just medicating an issue, but we're also providing opportunities for folks to reconcile those issues through traditional talk therapies. The combination of those two treatments are typically how we deliver those services, but it could be the case then that, and I hate to say this because I was raised in the tradition of talk therapy, I am a recovering therapist in the sense that I started off my career as a psychotherapist, but will a person be able to take a pill and not have to interface with a therapist. I think that is a reality that we will be so good at fine tuning those psychotropic medications to the point where it might nullify the need for a therapist to be involved in terms of traditional talk therapy. So those are the things that I think we will see. 

Jason Helgerson: Interesting. I think that's really very helpful, just to sort of summarize what you're talking about here is technology, in essence, to a great extent, replacing human beings and the provision of service, for the treatment of mental illness. The optimistic aspect of that is this opportunity to address the fact that so many people who have mental health issues today are not getting access to clinicians. They're not getting access to talk therapy. They're not getting access for a variety of reasons from stigma to just a lack of human beings to be providers of service. And so I don't want to put words in your mouth, but it sounds like what you're saying is you see technology is really filling that access gap. And it sounds like you're optimistic about what that potentially means, for care for individuals.

Dr. Michael Lindsey: I think you're absolutely right. Great summary, Jason, because I do worry, in most of my career, I have examined the disparities and mental illness, and the receipt of mental health treatment. And so because of that, Jason, I have had to think about these sorts of innovations and alternate ways by which we can bridge that gap.

And so, as I think about innovation, for me, that is at the top of the list, how can we create technologies that bridge the gap? And I think for me, as I reflect on 2049 and where we'll be at that time, that's really prominent for me in terms of my consideration of things, but the reality also is that there is a whole environment and a landscape that fuels if you will, or contributes to how one functions in terms of their mental health. And so I do think that as we figure out ways to increase access to care, broadly speaking, we figure out how to ensure that we're training the next generation of healthcare professionals in terms of innovations and that sort of thing.

I think that all the pieces that I've laid out in terms of how technology will be a driver will have to be parallel with these trends that we're seeing in healthcare and how we train professionals. And so you'll find then that for me, for example, I'm trained as a social worker and I have been trained across the spectrum of psychosocial interventions that relate to various diagnostic outcomes. But even as a social worker, I'm starting to think about innovations and so we're using mobile technology in our work. We're thinking about how AI and predictive analytics can help us to be crisper if you will, in terms of how we identify need.

And increasingly this notion of what I'm getting at is, this notion of interdisciplinary science and how we generate the science, the questions we ask, is going to fuel the innovation that we'll see. And so, in those ways that I remain hopeful and we'll have to figure out how to prepare that next generation.

Jason Helgerson: So maybe Michael, we could dive a little bit more into that year, 2049, the role of the human being and the provision of care. We've had these conversations around, eventually artificial intelligence replacing human beings in terms of diagnosis, and the potential of that opening up physicians to be more focused on explaining to patients what their options are and helping them make informed choices and hopefully bringing empathy back into the provision of healthcare where it's often been lost in the past.

But what do you think that technology potentially means in terms of redefining the role of human beings as caregivers? As those providing services, not just in the designing the algorithms or developing the new pharmacological solutions, do you see a role for humans in actual treatment? And if so, can you describe for us what that role looks like? 

Dr. Michael Lindsey: You know, Jason, that is a really great question. And to be honest with you, I think that it's one that we should be thinking about in parallel fashion. And so, as we think about innovations, we should be thinking about what the human condition or the human interaction will be.

So I don't know. I mean, it's a really great question. And actually this may be a good thing now that I think about it, will we be pushed toward prevention in ways that are meaningful, that perhaps it interrupts the trajectory toward more severe illness. And so I think in terms of the human role in all of this, what might be then the case, is that individuals will be providing education, not only about how best to interact with these more technological devices, if you will, but it would be also important to provide education about the mental health issue. And then I think further upstream, we'll be trying to figure out ways to prevent folks from going further downstream into a cycle of severe illness. And so we don't do that enough now, Jason, and I think that a preventative focus might be the lens by which the healthcare professional can ensure that they have a relevant position in the overall discourse of how we provide healthcare. 

Jason Helgerson: I had a conversation, not that long ago with someone, in the United Kingdom, that's very much of the similar mindset that we spend a lot of time quote, unquote treating mental illness and we don't really spend a lot of time building up mental fitness. We talk about physical fitness and the importance of maintaining or improving physical fitness, but there aren't that many programs, platforms, initiatives around building mental fitness. And so you see that the role of mental health professionals in the future will be moving more into that space and, thinking of new strategies, new programs, new initiatives, in order to improve that, so we're not always sort of focused on when problems arise. 

Dr. Michael Lindsey: I totally think that future providers of mental health services will be focused on prevention because, think about it, if you approach it from an entrepreneurial perspective, you often, as an entrepreneur, think about what is the next frontier? What is the space in which there's an opportunity for me to develop something that is niche, but that is going to be bountiful in terms of the rewards? And so if you think about it from even that perspective, entrepreneurially, there is a lot of space in the prevention aspect of how we administer or deliver health care because as you mentioned, our focus has almost been exclusive on intervention. We've waited for the problems to emerge. 

Now, we've done so because when you think about how to best allocate resources the focus has been, let's allocate those resources based on what is emergent, what is happening in the now. And so, I do think then that there is a lot of ample space and opportunity on that prevention side. And we're starting to slowly see this in terms of mobile technology. So right now, if I’m struggling with stress at work or wherever the stress is coming from, I can go to my phone and hit my favorite mindfulness app and do some deep breathing and focused meditation that will alleviate my symptoms. So then how do we expand that? How do we think about that kind of prevention programming in ways that are accessible, but also have great evidence for preventing more intense illness or needs. And so, I do think there's a lot of ample space for that.

 Jason Helgerson: So Michael, I think some of our listeners may be wondering, and oftentimes we talk about technology and health or technology in general, concerns that technology can create inequalities, that there is potential for not enough access that people, particularly vulnerable communities, the communities you care so much about, won't have access to the latest technologies and the health disparities that exist today could potentially get worse. 

But how would you respond to that concern? Is that something that concerns you and with regards to the vision you see forward and what do you think society needs to do to sort of prevent those unintended consequences from what it's otherwise what you described is a very positive view of the future?

Dr. Michael Lindsey: It is my extreme worry, Jason, that such innovations will miss out on opportunities to meet the needs of marginalized groups. It's an extreme worry. The way that I think we can offset my worry, let's take AI for example, and machine learning, predictive analytics, we know that if not managed well, that type of technology can have unintended consequences for marginalized groups.

So you take facial recognition software, for example, that might capture voluminous number of faces, but began to then pick out people of color and might unfortunately render people of color and more sort of serious labeling kinds of position. Now, that technology though, can be developed from an ethical foundation. And so I think in parallel fashion, as we're developing the technologies, we need to be thinking about how we are going to ensure that marginalized populations have access to the technology? And then further, how are we going to ensure that whatever we develop, doesn’t leave marginalized populations out?

And so I think we have to be quite intentional about marginalized populations being representative in the research that we do. And we know that in biomedical research already, that is an issue. How do we ensure that marginalized populations, people of color, are participating and randomized control trials, as far as biomedical research is concerned? 

And so I think we have to keep the foot on the gas pedal, if you will, in terms of asking that question, ensuring that we're developing ways for marginalized populations to be a part of the research, and then to ensure that whatever we develop has scalability, it’s like you can't be so caught up in the innovation that you forget, who is going to be using this? Who has access to this? And look at, for example, in the contemporary context, how vaccination for COVID is rolling out. I saw a New York Times article recently that, you have limousines pulling up into marginalized communities, people jumping out of those limousines, getting in line for vaccinations. We have to be careful and considerate of the populations who might be in most need. And who, might be left out and have an agenda that is focused on inclusion just as much as it is focused on innovation. 

Jason Helgerson: Absolutely. And so, Michael, I've got one last question of thinking about this vision of yours for 2049. How does that vision, if it actually does come to be, how will it make the world a better place? 

Dr. Michael Lindsey: Well, right now, as people are struggling with mental health challenges and they have accessed, let's say psychotherapy, they have the combined approach of being involved in talk therapy that is evidence-based, but they have the combination of the psychotropic medication that is alleviating the symptoms so that they might be able to benefit from talk therapy. But yet, it is uneven in terms of whether or not what we're doing now really works. Do we know that it works with, for example, blacks as great as it works with white populations? Those are the enduring questions that we're asking.

What I'm hopeful for in terms of 2049, is that we know what works. We have brought technology to bear on these issues in such a way, as we have clear cut answers on what works best and that folks who need those supports have access to it. I think to the extent that we can continue to work in parallel fashion, as I mentioned in terms of innovating, but also including, then we'll have the answers to those enduring questions, and we'll be doing things that work, that we won't be shooting arrows in the dark, if you will, in terms of how to best alleviate one's mental illness. We’ll be clear about it. And for that the world will be better.

Jason Helgerson: Absolutely. I couldn't agree with you more, Michael. I think that behavioral health, mental health, is certainly an area where we need more research. We need to apply science in a more rigorous and more effective way. So thank you very much, Michael, for coming on the show today.

And that was Dr. Michael Lindsay's vision for healthcare in the year 2049. As always, thank you for listening to health 2049. If you enjoyed what you heard please subscribe to us and share this podcast with a friend. Thank you! And see you next time.

Albert Shum, Corporate Vice President of Design, Microsoft

How can the patient experience be redesigned to build trust? Albert Shum, CVP of Design & Content at Microsoft, rethinks the use of personal medical data as he explores inclusive design principles to dismantle systemic bias and empower the patient to have control of their health care journey.  

Albert Shum leads a collaborative team creating the future of experiences and devices at Microsoft. An accomplished designer with over 20 years of global consumer brand and design development expertise, Albert has led strategic design initiatives at Nike and Microsoft, scaling design thinking and launching products that influence millions. He is currently the CVP of Design & Content teams for the Windows & Devices Group at Microsoft. His team drives incubation for the Microsoft Web ecosystem, focused on the responsibility of design to create intelligent and inclusive experiences. Albert is also a sought-after speaker and advisor in the areas of design team building, brand development, and strategic design. Albert holds a master’s degree in Product Design from Stanford University, and a Bachelor of Science in Mechanical Engineering from the University of Waterloo. He also attended the General Management Program at Harvard Business School.

Show Notes

• Albert Shum shares his design ethos and the importance of the quality of the customer's experience. [02:58]

• The three inclusive design principles that guided the redesign of Microsoft’s Xbox to enable disabled people to play video games. [05:42]

• A health scare that showed how the patient experience can be redesigned. [8:50]

• What does the patient experience look like in 2049? [11:37] 

• What happens when trust and safety are not designed into the system? [15:29]

• There’s an opportunity to rethink the patient experience around data–how to present it and make it consumable. [16:31] 

• How can we create an experience focused on making the patient feel confident? [18:35] 

• What role does ethics play in design? [21:43]

• Designing for personas only reinforces the systemic biases. How do we dismantle that system? [23:13] 

• How can we bring mindfulness into the experience to encourage healthy habits? [25:42] 

• How does the manufacturing of feelings affect society? [28:01] 

• We are in an era of mass producing feelings and behaviors at an unprecedented scale. How do we nurture a healthy ecosystem? [31:01] 

• What are the important factors when creating visual experiences? [33:24]

Transcript

Bisi Williams: I'm Bisi Williams, you're listening to health 2049. 

Albert Shum: So what I think design can really do, and this is the power of design, we can create visual communication, use our superpower to bring that empathy to understand what the patient experience is going through. So I really see this opportunity to rethink the patient experience around information and data. How do you present information in a way that enriches, but also informs, creates confidence and then confidence builds trust?

Bisi Williams: I'm excited to introduce you to the man that USA Today says is responsible for leading the design renaissance at Microsoft. He leads a collaborative team, imagining the future of experiences and devices. With over 20 years of product brand and digital design expertise, he led initiatives at Nike and Microsoft to scale design thinking and create compelling experiences for millions. His team drives incubation for the Windows Ecosystem, is focused on coherent inclusive design across diverse platforms to bridge the gap between humans and technology. I'm thrilled to welcome Albert Shum, Microsoft Vice President of Design to our show Health 2049. Welcome Albert, 

Albert Shum: Thank you Bisi Williams for that very, very generous introduction. 

Bisi Williams: Well deserved. I invited you to talk about health and wellness in the future with me because of your success at Microsoft creating web experiences, including search and discovery across a suite of products that reach customer’s whole lives at work, home, and school. So I'd like you to take a moment and if you would, please explain your design ethos to our listeners. 

Albert Shum: Definitely. Thank you, Bisi, I think the key word for me there is it's the whole lives of our customers. And so much of our customer's lives are digital now. In some ways, it's not just the digital life, it's almost this blend between the digital and the real world. We spend so much time online. I think the last report I read even before the pandemic, people were spending on average six hours a day online. So digital experience is so pervasive. 

And my ethos is, how do we balance that in a sense of creating value? Are we helping our customers achieve their goals, their purpose, but also how do you use that time to their benefit? And probably for me, the most precious value our customers have is time and how do we think about the time our customers spend online? 

I think in digital experiences, oftentimes we think about engagement. It's really the measure of success. How often are you using some product or service? The focus of that is not just about the time, I've been thinking a lot more about the quality of experience. What are you doing with your time? And the products and service that I'm fortunate to be working on at Microsoft, if you’re browsing the web, if you're on your PC, laptop or on your phone, how do we remove a lot of that friction so that it removes the hassle?

So I think that's one element of how people are spending the time, just saving them time. I think the other part in terms of that quality of using their time is, are we enriching their lives, giving our customers information that informs, that helps keep them safe? The pandemic has really shown that we spend so much time online, sometimes it's also important to step back and allow you to focus, but also take time off and take breaks from being online, which I think back to this health question, what is that balance in all things and are you spending your time wisely to have that digital health almost in some ways?

Bisi Williams: I think that digital health is an interesting concept and I'm going to hold that for one second, and I want to talk about, for me, what I think is a watershed moment in your career was your team's redesign of Xbox to enable disabled people to play video games, too. And can you briefly tell us about that experience and the impact that it had on you as a designer?

Albert Shum: Yeah, that was a great experience and it continues to be an important part of our team's work at Microsoft. It was a time when one of the things we started looking at was around people getting access to technology. Oftentimes there's a lot of barriers, meaning it's not just about how do we provide more technology, but how can people get access to technology and the benefits? And we started thinking about exclusion and reframing it to focus on inclusion in our product experiences. 

The team led by a lot of great people with Kat Holmes and others, we worked on developing this concept, building on inclusive design that the first principle, and it's actually really insightful on how the team developed the principle, is to recognize exclusion. In order to create inclusion, we have to recognize exclusion and reach out to people who are excluded, who might be on the margins. That inclusive design principle allowed us to address and focus on the people who were excluded from the experience, address their needs and then solve for those needs. And then those benefits really translate to everyone else. 

So in the case of the Xbox team, they took those principles to heart and really focused on, you think about who's being excluded, actually they worked first on identifying exclusion in all forms, but they zero in on physical disability. If you have the loss of limbs and you couldn't even hold the Xbox controller, how do you play games? And I think that that really brought a lot of insights. The team started thinking about, there are ways to adapt the Xbox experience for all different abilities. I think they did an amazing job to not just create a product, but really create an end to end experience, talking to members of the community who were excluded, addressing their needs.

Then the second principle of building those solutions and really learning from them, that's when we ended up creating the Xbox adaptive controller, which leads to the third principle, how do we bring those benefits to all? What we found, even as simple as the packaging, having more accessible packaging that we could bring to our products, that really benefited everyone, not just people with loss of use of their limbs or hands.

And so I feel like the inclusive design principle really, not just opened up our products to many who weren't able to access, but also really created new innovations that benefit everyone.

Bisi Williams: I just love that. That's such an inspiring story and to set the stage for your vision of health and wellness, Albert, let's talk about your own experiences with health and wellness.

Albert Shum: Yeah, just a few weeks ago, I had a bit of a health scare and unfortunately I ended up to the emergency room. It's still a bit of a fog, it was like 10 people working on me. Next thing you know, I'm in the procedure room and in between doctors and going to different places. And eventually I was recovering in my room and I had a chance to step back and say, whoa, what happened? And it really dawned on me that the health care experience, okay, fantastic amazing doctors, nurses and technicians that really helped me. Yet, I felt like that fog, that loss of control, it was so hard to figure out what was going on. And even though people were telling me, here’s what's going to happen next, it was the ability to process, I was just back to that state of mind, maybe I was in shock, but that got me wondering, like, wow, that patient experience, that customer experience, it feels like it could definitely be improved, at least on a personal level. That’s something that really dawned on me, as a designer working on user experience. The patient experience is something that I feel like there's so much opportunity. 

 Bisi Williams:  And I just want to ask you one more question about that Al, I mean, up until a few weeks ago, you've never really had any interaction with it, right? What was your experience with emergency services? 

Albert Shum: Yeah, thankfully, again, I feel very fortunate and privileged. I've never even been inside an ambulance. Everyone was very caring, so kudos to all the emergency team staff taking care of me. At the same time, that initial shock, it’s because it's so unfamiliar, it’s literally the language, even. I think everyone was doing an amazing job, like I said. At the same time for me personally, and actually, afterwards talking to my wife, it was harder for her. She didn't have any information with what was going on. So maybe it is that sense of almost being lost. It's about the experience. 

Bisi Williams: I'm so glad that you're here with us today. I'm sorry that happened to you and I'm so grateful that you're well, first of all. I share your gratitude that people kept you in good health and in good spirits. So what I'd love for you to do is share your vision with our listeners for how you can imagine the patient experience for health and wellness in the year 2049.

Albert Shum: Yeah, thank you for this opportunity. When I was laying in that room for a couple of days, I really had a chance to think about it. Maybe not 2049, even just now. If you think about it, it's actually not that far, it’s pretty near. If you think back to 1995, what was going on, I think that's when Amazon, sold the first book. We worked on Windows 95 back then as a company. Obviously things have changed so much in terms of the web and how we access information. 

So similarly, if we could look back and then project to the future, this idea of immediacy is to be able to access information and to be knowledgeable to what's going on. The immediacy we create in the user-centered design process is in making sure our customer, our end users are always in control. I think in 2049, you should be able to access all your health information, it seems kind of obvious. They did a lot of tests on me and actually, I can't go access it and try to figure out if maybe I should go talk to someone else. Or is there a different way to look at the data? 

So the access to your own health information, your data, your fitness. What was going on? How did it happen? Just having that knowledge to act on it, I feel that's going to be much more accessible and open, not so siloed into different areas. Like the emergency room, even looking today, the doctors are different than the doctors that are treating me in the cardiac department, my primary care doctor or other specialists. So all those people that are helping me out, obviously they have an amazing intention, but they're asking me the same questions all the time. And I believe there will be a way where your information just travels with you and it’s part of your digital life. It should be your digital twin and be able to not just look at that information on your health experience, but also to empower you to take care of yourself. 

I think so much of the patient journey is about in the moment, in the hospital, but to me, it's what happens after you're outside of the hospital. That's just as important. How you recover. How you take care yourself. How do you think about physical therapy or even nutrition plans. How you use that information and enable you to live a better life. I think that's really going to be key. So I see that in 2049, and I am always an optimist because I work in design, so I'm optimistic that you will have access to all your health information and you can decide how to use it, where to use it and when to use it. 

Bisi Williams: So Al, you talked about in your vision the individual having agency and some modicum of control and choices. I like to think, and I say this respectfully, that sometimes while there's a tremendous amount of design in medical and related fields, it's kind of a design-free zone in that comprehensiveness you're talking about. So your digital information traveling with you, if you could do it today, what would that look like? Just paint a picture of a user experience as you understand it. 

Albert Shum: Yeah, that's a great question. I've been thinking back to trust and safety, which comes in hand-in-hand. When you're lying on a hospital bed, you’re very vulnerable. And obviously you don't have knowledge and a lot of the terminology. The information presented to you, it's very technical. I don't know how to read an EKG? So, I’m not even at a trust stage. I don't have a choice and once you don't have a choice, it creates anxiety and it's hard to create a sense of safety and wellbeing when you have so much anxiety. 

What I think design can really do, and this is the power of design where we can create visual communication, use our super power to connect with that and to bring that empathy to understand what the patient experience is going through. But how do you present information in a way that enriches, but also informs, creates confidence and then confidence builds trust? That's the level of UX that I always try to design for. It's not about doing one thing, it’s building on things as you go through your experience. I really see this opportunity to rethink the patient experience around information and data and how we could present it and make it consumable. 

It's interesting if you think about UX, where it came from, if you go to the history and my friend Cliff Kuang wrote a great book called User Friendly, he talks a lot about flight controls, very complicated experiences where professionals, during World War II, were making a lot of errors and how visual affordance or shape affordance can really mitigate lot of disasters. I think similarly, how do we present information for patients in a way that's consumable and also helps them make decisions? 

If you look at the history of UX design, going from these typical kind of, how do you control the machine was how we focused a lot of our UX design, to how do we create behaviors and how people feel using the experiences, back to that confidence, that control. I think that's where UX is really heading towards, that it's not just about the features and hey, can I get achieve those tasks, and can I do this with this app or this feature, it's really about how people feel and the feelings we can create in our customers. 

Bisi Williams: Can you describe this experience that you're talking about? Can you accomplish that in 30 years? Could you really have that kind of warm, cool experience that empowers people?

Albert Shum: I like to think so. I definitely think if not sooner, I've see a lot of progress on the technology side that we could personalize information for you. Obviously with all the great work in machine learning, AI, where we can take your information and adapt it and tailor it to your needs. There's a lot of breakthroughs and that's already happening from how it's presented and how patients experience, I really like to think more about that sense of it's this belief that design and beauty, and beauty takes away some of the pain. And if we could bring beauty and beautiful experiences to the patient experiences, I do think that would be transformative. In addition, to allow you to have that agency with the information about you. 

So I see an experience where it's focused on making you feel confident. So imagine walking in the ER, even just the color and the lighting. I know there's been a lot of great research work on this by many companies, that the environment is just as important and what you hear and see and feel in the environment. And I'm going to segue a bit, I have friends at design agencies working on the airplane lighting and how important that is to set the environment and actually really shifts your perception. 

So I feel like the hospital experience is about helping you feel safe and secure, giving you the confidence. Then the personal information should really come with you. Like that idea of the chart is somewhere in that computer, somewhere that you can access. We have so much technology on us, you would think we should be able to access that in a way that's consumable for you.

That patient experience, where you can have a device or some way to access your information in real time, I think that's going to be really key to unlocking that experience where everyone, every patient can feel like they're in power, they feel confident and they trust the experience.

Once you’re outside and recovering, how you take that information with you, as you tailor the experience to help you recover, I feel like that's the part that's been so missing. It's still, here’s the medicine you might need to take and read the label, and then there’s sheets of paper they give you, good luck. So again, I'm not criticizing the current experience. I think everyone’s intent is amazing and they've been so helpful. It's just, how do you think systemically, like the system, like the user experience is no longer these discreet moments. I would say it's about the whole end-to-end patient journey.

Bisi Williams: What I'd love for you to discuss now is what role does ethics play in design? 

Albert Shum: I think ethics is everything now because it's really the consequences. If you're not intentional, the things that you create will have amazing impact because that's your goal. At the same time, it can have unintended consequences. And like we mentioned about time, often we don't step back and say, hey, what could go wrong with this experience? There's a lot of conversation around screen addiction and how people are using time. But if you go deeper on the ethical side, you really have to think about all the different stakeholders and not just the end user. When someone that works in a night shift because that's their job or they don't have the ability to go to a doctor because they’re holding down maybe a couple of jobs in these tough times, giving access and being inclusive is not just a moral responsibility. It's really how we design experiences that is inclusive of all different backgrounds and needs. So I think ethics is such an important part, both in terms of addressing unintended consequences, but also making sure that you're being inclusive and your experience is accessible to all. It’s the complete, it's the holistic design practice that we all want.

I do want to make this point where I think sometimes we idealize, like we design for the ideal. There's a lot of tension and debate about design for personas where it could create the norm and you end up with the norm solution that benefits and reinforces the systemic biases that are already there. In order for us to dismantle that system, I know that's a very strong word, we really have to look at the edges and again push on those ethical boundaries to understand where things are breaking. It’s that tension that oftentimes we don't bring into our design practice or our process, so you don't really think holistically about the total experience. 

I'll make this a bit more provocative, systemic racism is by design. And oftentimes I think designers look at like, well that's the system and we're on the outside versus no, we're part of the system. If we want to create change, we have to break it down and really push on those tensions. 

Like in healthcare, there are challenges and how do we dismantle in a way that doesn't break everything up and throw it away. But that thoughtfulness, back to that empathy to understand all the different stakeholders, be it the patient, the doctor, the hospital administrative staff, the government, and audit different institutions and bring people together to understand that multiverse that we live in, it’s not a binary-verse, it’s a multi-verse, and that’s the richness where it will spark creativity. I firmly believe that's where the good stuff will happen if we can have those multiple dimensions in our designs and think through that plural-verse that we live in today. So, I feel it's a moral imperative for designers to think about this dismantling the system in a way that creates positive change.

 Bisi Williams: Al, that's fantastic because my next question is what role can mindfulness bring into your product ethos for health and wellness?

 Albert Shum: That's a really important thing, it’s around time and what people are spending time on and quality time. Mindfulness is such an important part when we're just inundated with information, we're processing so much. It's the golden age of content. There's so much content out there and it's constant and mindfulness is the ability to actually be able to make time for yourself to look inwards, that inner space. How do you create that mindfulness and what are the practices? Back to UX design and the journey we've been on as an industry, that's so much of what we create in the foreground, it’s literally what's on the screen versus what's inside you. And what creates that behavior are the positive experiences that creates that mindfulness, that creates a balance that lets you know when you are consuming a lot of information. It can create anxiety.

We talked a lot about the reward loop as they're engaged, but also I think there should be a mindfulness loop where it can give you a focus, but also help you step back and refresh and recharge and build healthier habits and change habits back to health. If we don't help people change habits, we're just reinforcing habits and sometimes those habits aren't good. I think it's our job to understand what are some of the not so good consequences of things that we create and help mitigate and address them. So it's a balance.

 Bisi Williams: Al you've just hit it. I think that's very interesting. Professionally you create digital experiences that reach millions, often, billions of people instantaneously, experiences that engage you and make you react. And this is a kind of a new thing, which in 2049, we're going to be grappling with a great deal. In what way does the manufacturing of feelings affect society? 

Albert Shum: That's so important, the manufacturer feelings, which ties into beliefs. And you think about the last 12 months and how we're heightened about information and how people feel about certain content and information. Obviously it's gotten more polarized. So what we've been thinking a lot about is being very considerate, like with the vaccine rollout, it's unprecedented how quickly they were able to develop tests, do trials and now mass produce and distribute it to millions, if not billions of people. 

I think similarly with digital experiences, we have to take the same level of consideration where we are being very concerned about how we try experiences. It’s not a product we're creating, we’re really creating a hypothesis. We're trying and learning from our customers before we roll it out to billions and really iterate and again test those boundaries, those edges, and understand where the tension is before we scale it out instantly to millions, if not billions of people, similar to how a vaccine gets rolled out. Digital experience is viral and that's why it's so incredibly pervasive in our world. 

You could create a piece of content like this podcast and get it out to millions of people instantly. It's amazing. We can have conversations now with anyone around the world, that's so amazing and at the same time, that immediacy that you could do something really quickly, I think back to the ethics, how do you make sure we have the level of controls where we can iterate and flight and try and learn and build on? What can we do as designers? I think similar to doctors in the medical field, there's the Hippocratic Oath. For us to be responsible as an industry, we do have to have more thoughtfulness. What is that oath that we keep, that we hold true above and beyond anything we build to take on that responsibility, that mantle of the things that we create?

Bisi Williams: What you're saying is fascinating and I'm going to push you a little bit here. To what extent do you believe that behavioral science needs to play a role in the work that you do? There are a tremendous number of pleasures, I'm agreeing with you, it’s staggering what we can create, but because you influence the entirety of humanity with your experiences and at scale, in 2049 how do you imagine we're taking care of our physical needs, but also our social and emotional needs as well?

Albert Shum: If you look back at even the formation of design itself, a hundred years ago, like Bauhaus and it was always creating the artifact. You can mass manufacturer chairs and use materials and transform it in new ways. Bauhaus led to this whole new design movement that totally transforms product design and design in general. I think similarly, we are in this era where we are mass producing feelings and behaviors at an unprecedented scale. We’re still learning what that process is. Instead of transforming material, we can transform behavior. I’m really passionate that there's new ways of creating and building. Maybe this is the part that I'm really also on the same journey that we are creating systems now, it's not about the end artifact as much. It's still important, but so much about what we create is the system and designing user experiences in the system, nurturing and taking care of that.

Some people call it the ecosystem, almost like a living thing. I feel like our job is almost like gardeners, more than actually planting new seeds and trying to figure out what's the next area to grow, that's important too, but how do we nurture that so we have a healthy ecosystem and design, again back to that plural-verse, that’s the role of design much more than the artifact. How we take care of the system so that they can create goodness and mitigate some of the harm in the system and the challenges in the system. I think that's the tension that I'm trying to promote in my work and my team's work in the industry because ultimately if we don't, the system will just bias towards what everyone else wants it to do. I know I’m talking in some ways, pretty scary things. 

 Bisi Williams: You're okay. You're among friends. 

Albert Shum: I do think we are a force of change if we only recognize the possibilities to create that change. 

Bisi Williams: So I'm going to ask you this then, because I love where you're going. How does designing with an inclusive ethos improve the long-term impact of what we create? 

Albert Shum: Impact is really important because no longer can you create it and just make more things. I think that’s a key lesson learned even from sustainability and ecology of physical products. We can't just make more things for the planet and just get it up there. So similarly, back to that impact, to really think about the whole life cycle of the experience. To think about impact, not just in this moment, like, hey, I bought this, I downloaded this app, I’m using it. Hey, good. See you later. To really think about the whole life of your customer and end user and what they go through and how the system treats them. How does the system continue to adapt to their needs, to be responsible in a way that it's listening and giving back that agency, that autonomy to the end user always, that's the constant iteration of that experience, that I'm talking about.

It's not about creating the perfect design, getting it out there and it's done. It's this living system that you're creating, where it's adapting, nurturing, and building on your customers, not just needs, obviously we want fulfill their needs, but how they feel, what's their behavior? Are they feeling good about themselves or do they feel good being in control or not? I think those are really important things for us to consider now as we create visual experiences.

Bisi Williams: Wow Al, thank you for your incredible vision of a beautifully designed holistic and powering system for all of us. 

 Albert Shum: Thank you. 

Bisi Williams: And that concludes our show with Albert Shum. Thanks for listening. If you enjoyed our show, please subscribe or share with a friend until next time, I'm Bisi Williams.

Roy Lilley, Founder, Academy of Fabulous Stuff

How can a future with no hospitals improve our health? Roy Lilley, Health Policy Analyst and Founder of the Academy of Fabulous Stuff, taps into his vast experience in Britain’s health and social care system to share his vision of the future of health care and how it can be implemented in both the U.S. and U.K.

Over 50 years ago Roy Lilley started his first enterprise from scratch, built it into a multi-million turn-over business and sold it to fellow directors and managers, in 1989. He has chaired everything from major boards, to hospitals, health authorities, voluntary organisations and charities.

He has been a policy advisor, a visiting fellow at Imperial College London, helped start the Health services Management school at Nottingham University and was a founder of the Federation of NHS Trusts… that became the Confed. In local government; for over 20 years a councillor, chaired all the major committees, became the leader of the Council and Mayor of Surrey Heath Borough Council.

He is the Founder of the Academy of Fabulous Stuff, the only free-to-access repository of best practice in the NHS, the developer of the Fab-O-Meter, a way for measuring morale in organisations, in real time, and for over ten years has written a discontinuous eLetter that, often, over three times a week, reaches the inboxes of 300,000 health and care managers in the UK and overseas.

Show Notes

• Roy Lilley shares his journey in the health care field. [02:41]

• An example of an efficient healthcare supply chain. [07:03]

• Why don’t we have that efficient supply chain in place now? [11:35]

• The real vision for 30 years in the future. [12:55]

• How do we get to a place where there are far fewer or no hospitals by 2049? [13:29]

• Why do we have health inequities? [15:53]

• What are the three things that everybody wants? [17:41]

• What makes a good leader? [19:28]

• Where does that leadership come from–government, private sector, and/or healthcare system? [20:16] 

• Financial incentives for healthcare providers that focus on keeping people healthy. [22:14]

• What role will advancements in technology play in 2049? [26:14]

• The ethical dilemmas that we need to address with innovative technology. [27:17]

• How will a future with no hospitals improve health? [30:05]

Transcript

Jason Helgerson: I'm Jason Helgerson and you're listening to health 2049. 

Roy Lilley: And would we really have the supply chain designed the way it is if we really started with a patient, started with a customer and worked backwards? We don't do it because there's no incentive to do it. There's no money in the system to do it. And hey, the patient's time is free. Our time is important. Our doctors are important. Everybody's important in the system except the patient. So that's why. 

Jason Helgerson: Today's guest is famous for being a straight talking commentator on England's National Health Service. He's often described as a voice for many, when few feel empowered to speak. He celebrates the system successes, but is also willing to raise important issues and is never afraid to speak truth to power. He boasts an impressive resume as a health policy analyst, having written over 20 books on health and health services management. Today he runs the Academy of Fabulous Stuff, which celebrates all the great things being done to improve patient care across his country, given his willingness to always say it, how he sees it, I can't wait to hear what he thinks health and social care will look like in the year 2049. I'm Jason Helgerson Helgerson and you're listening to health 2049. And it's my pleasure to welcome Mr. Roy Lilley to our program. Roy, welcome. 

Roy Lilley: Jason Helgerson thank you. And it's a great pleasure to be part of your program and thank you for inviting me.

Jason Helgerson: Great. Well, Roy, can you tell our audience a bit more about your interesting background? 

Roy Lilley: Well, yeah, fundamentally, I'm a businessman. I left school when I was 15 and by the time I was 16, I was running my first business. And this year I'll be 75 years old and I've run businesses for however long it is. From 16 to 75. I can't do the math and I don’t want to, I get spooked. But I’ve run a lot of businesses. And along the way, I got involved in politics. I was a local authority counselor. I was the leader of my local council for 20 years. So I ran a small local authority in between running a business.

And then I got involved in the healthcare sector, where I became the chairman of what we used to call the District Health Authority, the clue is in the title, it just runs a health service for the district. And when that came to an end, I got invited by the prime minister of the day, it was Margaret Thatcher and she invited me to Downing Street for afternoon tea and a conversation. I wasn't there long enough to drink the tea and she did all the talking, but I walked out the chairman of an NHS trust, a hospital trust. I didn't know what it was, but he sounded like a good opportunity. And effectively, it was running the board for a hospital. And I did that for a few years or then, it coincided really with my retirement. I sold my businesses to the managers who worked in them and that enabled me to retire fairly early. 

Then I did a bit in academia. I helped to set up the Health Services Management School at Nottingham University. I was a visiting fellow at Imperial College London, started writing about health and healthcare. I wanted to kind of make it more accessible for managers to understand. I then started writing what I call an e-letter, which is a push email that goes out to, it's free to subscribe to it, I get about 300,000 readers a week now. It's a commentary on what's happening in the NHS, and a lot of updates and stuff that people working at the front line normally wouldn't get access to. It's just the C-suite, they get all the guidance. I make it accessible for people. 

Then I figured that the way we were going about healthcare was ridiculous. We have an inspection regime here called the Care Quality Commission. And of course, all they do is just stomp around, hacking people off, destroying their morale and looking for things that are wrong. 

So I looked for an alternative and now I run the Academy of Fabulous Stuff. That's the up top, bottom of it. I started it. It’s a repository of best practices based on the concept of positive deviance. In any organization, there’s a line of performance below that is negative deviance, which is what inspectors and regulators look for. Above that, there’s positive deviance where good things happen. And that's what I look for. And I look for the good stuff that people do and say, share your good stuff. Because the only way that we will leverage quality is to share the good things. You will not improve if you just simply look for the worst, because people will game the system, they'll hide their worst stuff. So we run the Academy of Fabulous Stuff, we’re six years now, it's a global thing. We have thousands of people that share their things. We have annual awards and we just generally have a good time figuring out how to run things better. So that's a kind of thumbnail sketch of Roy Lilley. 

Jason Helgerson: All right. Well, great. And I wish we had an Academy of Fabulous Stuff here in the United States. We don't do enough to celebrate the good things. 

Roy Lilley: If you want to do it, I'm happy to share it. I would love to have a US partner to do it with. We do get stuff, things from overseas, Australia, New Zealand, South Africa, right across Europe. So we do get people sharing things. So yeah, if you've got good stuff, come find us. 

Jason Helgerson: All right, so let's talk about the future, roughly 30 years in the future. What does health and social care look like in the year 2049? 

Roy Lilley: I’m at the age now where I probably don't care what it’s going to be in 30 years time. Look, I wrote something the other day that I'm yet to publish, I'll probably publish it next week, but shall I read it to you? 

Jason Helgerson: Yeah, that'd be great. 

Roy Lilley: And then we can have a conversation. So here we go, the afternoon before my hospital appointment, my iPhone pinged with a new message. It was the outpatient service dropping me a link to download an app and a password.

In a couple of seconds, the app was live confirming that I was good to go tomorrow and a little message saying, hoping my appointment went well. I arrived at the hospital in good time. The app had linked to my GPS and it gives me a suggested route to avoid some new roadwork on the motorway. So I got there in good time, it directed me to the outpatient car park and the barrier recognized my registration number in the app and up went the barrier and they let me in. It had connected to my credit card and paid the parking charge, emailed me a receipt and a code to cancel the charge if I was disabled or a pensioner. I left the car and made my way across the car park and into the hospital. I ignored all the sign posting, the app gave me pedestrian directions to the department I was expected at. 

The smiley volunteer on reception asked me for the app and zapped the QR code. It told her who I was, who I was to see and to line up my health record. The clinic was busy, but on time. And when my turn came, the doc asked me to authorize his access to my health records with my pin number, my records and test results snapped onto his screen.

I was in and out in no time. He asked if next time I'd like to have a consultation by video and I use my pin number to agree. And that was that, I haven't been back since. I use the gadgets, I plug into my iPhone to keep across the various tests, and speak FaceTime to the doc, when I need to. 

Now, all I've just read to you is fiction. It isn't true, but what is true is the technology exists for everything I've described to happen now. There's no development required. It all exists and working in one form or another elsewhere in the economy, just not in a healthy economy. Amazon has the technology to recognize a customer walking into a checkout-free supermarket and collect payment for whatever they take out.

I have an app that knows where I am and pays my parking charges, Google Maps gives me directions. And my bank lets me give access to my money to a shopkeeper to buy something, appointments are dropped into my calendar and the cloud stores my information. Video technology keeps me in touch with everyone, fun, friendship, business, and family. 

Roll that together and you get an app that takes care of my hospital visit and you can see, none of this is fanciful. Not as you might’ve thought, we don't have to wait 30 years, we could do it now. We can do this stuff and we should be doing this stuff, but we aren’t. Why? Well, there's no need. We don't have to. There's no driver. If people don't turn up or are late for an outpatient appointment, it's annoying, but, so what. If patients have to wander around a windswept car park in the pouring rain looking for change for the ticket machine, so what. If the public have to wait in a clinic that's over running, hospital time is more important than anyone else's time. And if their notes are missing, so what. If we have to go for three tests on three different days, it’s their time, not hospital time. If we do all that knowing we could do it perfectly while sitting at home, no one cares because no one's figured out a way to make the tariff reimbursement work and anyway, the patient's time is free. 

If we got all our records into the cloud, we could have a password and give it like a pin number to any health professional we wanted to access, when we wanted to. The most common indicators we want to monitor can be done from a smartphone and a gizmo or two. So don't speak to me of innovation and don't talk of tech. Don't waste my time with vaporware and snake oil. Don't talk of digital transformation in the future. We don't need aspirants. We need achievers. No more governance. We need go do. No more artificial intelligence. We need some real brains with real intelligence to make real stuff work. 

Jason Helgerson: Well, Roy, as I said, you are a straight talking commentator, on not just England's National Health Service, but on healthcare in general. And I think the technology you described all exists, but yet it is not applied to healthcare. So let's unpack a bit. Why isn't that better future you described the reality of today? 

Roy Lilley: I think there's several things. Partly it's because the technology would save time and the patient’s time is free. So the efficiencies from the patient's point of view are hugely important to make them feel in charge, on top of what's happening, understanding, but it doesn't really matter to the system. The system exists to earn money. The system exists to, yes play lip service to looking after the patient and putting the patient at the center of everything we do and all that, it’s rubbish. But if we wanted to put patients at the center of everything we did, we'd start with the patient and work backwards.

And if we started with the patient and worked backwards, would we really have any of those things on the way? I mean, what I've just read out really is a kind of tarted up version of a supply chain. And would we have the supply chain designed the way it is if we really started with a patient, started with a customer and worked backwards. We don't do it because there's no incentive to do it. There's no money in the system to do it. And hey, the patient's time is free. Our time is important. Our doctors are important. Everybody's important in the system. Except the patient. So that's why, and really, you know, Jason, I don't believe it. I've written that about the future because you know, everybody wants to know what the future looks like.

I don't want the future to look like that. I really don't. I don't want people, even as slick and as good as that would be, if we did it, I don't want that. Because my real mission and what I really want to happen in 30 years time, is I really want to make the hospital history. 

Jason Helgerson: All right. So let's talk about that, 30 years in the future, a world with no hospitals or a world with far fewer hospitals, how do we get from here to there?

Roy Lilley: Well, and that's the really interesting thing, isn't it? Because as the article I've just written explained something which is immediately doable, it is immediately doable for us to really consider making the hospital history. In my view, most of what we go to the hospitals for is either self-inflicted and by that, I mean our lifestyle, the way we live our lives, the things we eat, the exercise, we don't take the cigarettes we smoke, the booze we drink, all the things that we know are bad for us. We just do because most public health initiatives have failed. And because there is a conflict of interest between a government who wants to take the revenue from the cigarette companies and a bit of government that doesn't want us to smoke. I mean, you can't reconcile the two, you've got to decide if you want the revenue or do you want healthy people? And most governments say, well, we'll have the revenue. And then we'll kind of beat the customers up for smoking. So none of that makes any sense to me. It's lifestyle, partly our lifestyle. And it’s partly the way we run our societies.

Now, if we look at the US, for example, in the 2010 census half of the population of the US qualifies as poor or low income, and one in five millennials live in poverty. Now that's not just the US, I'm not just having a go at the US because in 2013, UNICEF said of the US, it's the highest relative child poverty rates in the developed world.

Now, if we look at the UK, we know better. In the same way that we have an image in the United States of Microsoft, Apple, the Oscars, glitz, Beyonce. We think of the UK as guardsmen, the royal family, the Beatles, all of that, but actually there are 14.3 million families living in poverty. That’s nearly 35% of our children and 49% of the 14.3 million live in persistent poverty. And these are all kids coming to school in your country or mine, where if we ask them, what did they have for breakfast, they’d probably say nothing. And if you ask them, when did they have a new pair of shoes? They couldn't remember. 

So it's the way we run our societies. It's endemic. We engender because of the way people live, poor health, poor lifestyle, the whole approach to the way we live ends up with people backed up in hospital with cancers they don't need to have, with heart attacks they shouldn't be having, the whole approach to life and lifestyle gives us what we call health inequalities. Health inequalities in your country and my country and across Europe, any of these developed nations that call themselves wealthy, they are really not. Scratch the surface and you can see why we're getting sicker and sicker and things are going more and more wrong. So if you ask me in 30 years, how do I see the health system and what do I really want from a health system in 30 years is I want to make the hospital history.

And it's a big stretch I know, am I a dreamer? Well, I don't know, if you don't start with a dream, you don't get anywhere. Everything starts with a dream. So what am I saying? Well, what I'm saying is in 30 years, we have got the time and the imagination and the vision to bring up a whole cadre of new young people in a way that's healthy and in a way that stops them from their lifestyles, from getting sick, the air pollution, where they live next door to motorways, the cars they drive, because good health is a product of the way we live our lives. So when we educate kids, we train people to do jobs, are they the jobs we want them to do? I want people to learn for life, not learn for earning a living or learn for a job. We don't teach the kids right from day one how to live their lives in a healthier and happier way. 

I mean, there are three things that everybody wants. They want a job, and in our two countries, we got people who don't have jobs. They want a safe place to live. And how much of our housing in our two countries is really awful and shouldn't be lived in. And they want to be free to love who they want to love. And those are the three pillars for me, a job, a safe place to live and being free to love who they want to love. If we can organize ourselves in our societies to do that, then we can start to be healthier. Then we can start to make the hospital history. Then we can put some of these big hospital corporations out of business. 

And if you say, well, Roy, you're a dreamer, I'm not. When we introduced ourselves, I said, I've worked for myself every day since I was 15 years old. I had my first business at 16. I have not done that by being a dreamer. I've done that by having a dream. I did want to work for myself. I did want to employ people. I did want to create wealth. I did want to make businesses better. I did have an ambition to run a hospital. I did want to lead a council. I've done all that. I'm not saying I'm exceptional or different, but unless you have a vision, unless you have some idea where you want to go, you'll just wander. 

And right now, I think with healthcare, we just kind of wander around landscape of healthcare, not really knowing what it is we want to do. We want a new cure for this, but we don't want to pay for it. We want a new pharmaceutical product for that, but it's too expensive. We want our hospitals to do this procedure, but the insurance companies don't want to pay for it. We want our hospitals to be run like the Hilton Hotel, but no one wants to pay for that, either. We wander around the landscape. 

We need leadership, leaders are visible, have a vision and share it often. And those are the three things that you need to know about leadership. If we want to reduce illness and sickness we can, but we need the vision to do it and we need the leadership to say to people, we're going to change the way we do things. So that's what I really think. 

Jason Helgerson: All right. So let's talk about where does that leadership and vision need to come from? Does it have to come from prime ministers and presidents, from members of parliament or members of Congress? Does it have to be led by sort of a central government? Or is it possible that that kind of leadership, that kind of vision could come from other sectors, whether it's the private sector or from the front lines of the healthcare system? Where do we need that leadership?

Roy Lilley: It comes from a range of leaders, I think, but fundamentally it comes from national leadership. I mean, you've had difficulties in your country with leadership recently and it doesn't look to me like you've solved it now. We have trouble in the UK with leadership. We've got Johnson who, frankly, his response to the COVID pandemic has been woeful and now we've come out of the European Union, we’re struggling on other fronts, as well. National leadership is very important, but that leadership and that vision cascades into every other part of our society. We have our leaders, we have our members in parliament, you have the Senate and Congress, we have our leaders.

But there are community leaders, as well. There are leaders in the workplace. There are organizations that are leaders. There are some extremely good employers now that do have workplace leadership about the health of their workplace. So the leadership comes from all kinds of levels. It comes from national leadership, regional leadership. It comes from the employer in the workplace and it comes from the hospital system itself. Most hospitals are compensated and paid for the people they treat when they get sick. What would it look like if we pay them for the number of people they kept out of hospital and out of the system. So, leadership, I think comes from a number of levels.

Jason Helgerson: So let's talk about financial incentives and you talk about payments. There's a lot of energy here in the United States around what we often referred to as payment reform. The idea of trying to get the financial incentives right, so that providers of health and social care services are rewarded. They do better financially when people are healthy, not just on an individual level, but on a population level. How important is it to get those financial incentives right in order to achieve that vision that you laid out so articulately of a future in which we don't need hospitals?

Roy Lilley: Well, I think he's really important. I mean, think about driving your car, your car insurance is reduced if you don't have an accident. So we know that works. That's an incentive that works. Our two systems are very different. If you look at the system you've got, you’ve got a federalized system, you've got insurance companies, you've got some state intervention. I mean, it's a real mixed bag of incentives and that in itself looks to me, someone looking at it from a distance, from a sort of helicopter view, that looks to me like a real mess. And that leads somehow or other to be codified, coalesced with one central theme. 

Now in the UK, of course we have our national health service, which is funded by our taxes. It's a socialized system. And I know a socialized system is anathema to a lot of people listening to this, perhaps in the United States. But we really suffer, for as much as our two systems are different, we suffer from the same problems. 

Let me give you an example. Our hospitals are pretty much funded on the work that they do. Now during the COVID pandemic, it’s been horrendous for both our countries and God knows how many people have died and we've lost loved ones. But there are things that have been good during COVID. And the great thing about change is to respect the past and take the best into the future. And if we're going to take the best of COVID into the future, one of the good things that's happened here is that a lot of our outpatient appointments are actually now being conducted by FaceTime or Skype or in some way, a video system.

Now it's been years and years and years and years of trying to do that. I wrote a book 10 years ago on telemedicine. And when I wrote it, everybody said I was balmy. In fact, I must have been because nothing happened. We've had more change during COVID using technology than we've had in the last 40 years. And we had that in four months because we've had to do it. So a lot of people now have had their outpatient appointments conducted remotely. Now here's the problem, hospitals get paid quite a lot of money to do outpatient appointments. It’s on a sliding scale, depending on the complexity of what happens when you get there. But fundamentally they earn money from the fact that they're outpatient appointments. So guess what, they want quite a lot of outpatient appointments and they don't care how convenient it is for the customer because, hey, the customer's time is free.

So suddenly in COVID they couldn't do that anymore. Now, guess what? The patients absolutely love doing it. Guess what? The clinicians, once they got over the shock of it, suddenly realized that they quite liked it as well, because guess what? A lot of the clinicians doing the outpatient appointment clinics were working from home. They didn't go to the hospital either.

And so we've got this win-win. The lose-lose is the fact that now the pay is in our system, the people who commissioned our healthcare here don't want to pay the full dollar for an outpatient appointment because it's being conducted remotely. So guess what? We're seeing the amount of remote telemedicine appointments starting to reduce and we're going back to old ways. So the reimbursement mechanisms are really very important. 

Jason Helgerson: So one more topic I want to cover is technology. A lot of our guests on this show like to talk about technology and the role it will play 30 years in the future. Things like gene editing that could potentially be available by that point, curing chronic illnesses, extending life. What role do you see technology and advances in technology playing? Do you think that those advances will help get to your future state in which we do not need hospitals? How do you see that technology playing out? 

Roy Lilley: I think that's very important. I don't want to give anyone listening to this the impression that I'm a Luddite and here I am speaking to you with a gas lamp, somewhere in London. I'm up for all the technologies that we've got and certainly around the diagnostics and forecasting. I mean, there are difficulties with this. Let’s not run away with the idea that the fact that someone's going to be ill later in life is free. It isn't because immediately the insurance companies are going to say, oh, well, maybe we need to raise your insurance premium because you're going to be ill later in life. So we do need to deal with the medical legal aspects of this and we do need to deal with the complexities that it brings. 

But absolutely, I think these technologies are just going to … once you start, it's like an avalanche, isn't it? It's like a game of Jenga, you pull one stick out and that's the key to the one technology and suddenly the whole lot just kinda cascades in on you. So all of that is really very important. I mean, let's ask ourselves the question, if it was possible that, here we are in the maternity ward with this beautiful little baby that's just been born, if we could take a tiny spot of its blood and forecast how well or sick or not or what it's going to be in the rest of its life and that technology will be with us, if it's not with us already in the next 30 years, do we want to do that? And of course that leaves us with a lot of ethical or moral dilemmas about whether or not we should or could do it. A doctor's going to play God, all these very difficult questions that arise out of this.

But, I'm old enough to remember back in 1969, when the world sat on the edge of its seat and watched something happen that it couldn't believe being done by someone they'd never heard of, in a place they didn't know where it was. And I tell you what it was … it was at the Groote Schuur Hospital in South Africa. The surgeon was Christiaan Barnard, he was a heart surgeon and what did he do? He took the heart of a dead girl and put it into the chest of a very sick and poorly man. And that man lived for a week. There were complications and sadly he died, but within five years, heart transplants had become normal and now they're routine. But at the time, I do remember people saying, this is doctors playing God, this is an ethical dilemma. We shouldn’t do this, and of course, the other complication was that it was a young girl's heart, who died in a traffic accident that'd been put in the chest of a man. And even more complicated back then was the fact that it was a white South African girl, and in those days in the ugly language of what was called a Cape Coloured South African. So it was a white girl's heart in a Cape Coloured guy's chest. I mean, these days who cares, but in those days it was a huge, moral and ethical dilemma. So as much as we look at these technologies and we recognize there are moral and ethical dilemmas, they pile into yesterday. And of course these technologies are important. Of course we should use them. And absolutely yes, they will feed in to helping to make the hospital history.

Jason Helgerson: All right. So one final question for you, Roy, I'm asking you to take a step back from the health and social care system to look at the broader landscape. If your vision of a future with no hospitals is actually achieved, how will this make the world a better place? How will it fundamentally improve the human experience, if we are fortunate enough to achieve your future state by the year 2049? 

Roy Lilley: Well, just think of older people, for example, how many years do they spend towards the end of their life in pain, in discomfort, not being able to do the things they did when they were younger. All of that could go. And in older years, where you sit on a mountain of experience and you're not working and how you can play with your grandkids and be part of their growing up and be part of their family, that’s important for the individuals. It’s important for the economy, because think of the amount of taxes, I mean, we're paying a 106 billion pounds a year here for our health services and that doesn't take into account social care, either. Think of what we could do with those taxes in terms of education and making life more pleasant to live and living spaces better and housing and we could make poverty history, as well as, we can make hospital history. So, all of the things that we enjoy in our younger years, our healthier years and our years where we're spirited and full of imagination, all of that could continue on into our later years where we add to that a great deal of experience and a lot of wisdom.

Jason Helgerson: All right on that optimistic note, we'll bring an end to this podcast. And that was Roy Lilley's vision for healthcare in the year 2049. As always thank you for listening to health 2049. If you enjoyed what you heard, please subscribe to us and share this podcast with a friend. Thank you and see you next time.

Dr. Rushika Fernandopulle, Co-Founder & CEO, Iora Health

We’re on the cusp of big changes in how healthcare will be delivered. What does it look like? Dr. Rushika Fernandopulle, a physician, co-founder and CEO of Iora Health, challenges the status quo as he lays out a detailed approach on how to deliver a highly personalized and accountable ‘health’ experience with a shared care plan.

Dr. Rushika Fernandopulle is a practicing physician and co-founder and CEO of Iora Health, a venture backed, national de-novo primary care group based in Boston MA. He was the first Executive Director of the Harvard Interfaculty Program for Health Systems Improvement, and Managing Director of the Clinical Initiatives Center at the Advisory Board Company.  He is a member of the Albert Schweitzer, Ashoka, and Salzburg Global Fellowships. He is also an Aspen Health Innovators Fellow. He is co-author or editor of several publications including Health Care Policy, a textbook for physicians and medical students, and Uninsured in America: Life and Death in the Land of Opportunity. He serves on the staff at the Massachusetts General Hospital, on the faculty of Harvard Medical School, and on the boards of Families USA and the Schwartz Center for Compassionate Care. He earned his A.B., M.D., and M.P.P. (Masters in Public Policy) from Harvard University, and completed his clinical training at the University of Pennsylvania and the Massachusetts General Hospital.

Show Notes

• What if there is a completely different model of healthcare delivery starting with primary care? [02:10]

• Five different aspects that need to change in the next 30 years in order to advance healthcare delivery. [03:26]

• What is a shared care plan and how can it benefit both the patient and doctor? [06:55]

• Will the most common interaction between patient and doctor be virtual or in person? [09:48]

• What should we teach medical students now in order to achieve a new vision for 2049? [11:57]

• We need a shift in mindset, medical training models and the way we choose prospective medical students. [14:06]

• How do we ensure that we achieve that equitable future? [15:52]

• What role will hospitals play in the future? [18:22]

• Will hospitals become abandoned towers, the same way manufacturing facilities were affected by deindustrialization? [20:34]

• How will health insurance companies evolve to adapt with the changing times? [22:32]

• How do we create a different vision of primary care to attract talented doctors into the field? [25:00]

• Three areas in health care that have already made advancements. [27:00]

• Health is really important on three levels that not only affect the individual, but also our society. [28:38]

Transcript

Jason Helgerson: I'm Jason Helgerson and you're listening to Health2049. 

Dr. Rushika Fernandopulle: I think it starts with simply a commitment that we want to build an equitable health system. And it's not clear we actually have that commitment at the moment, or it's certainly that we're acting on that behalf because it means that we would make very different decisions about how we do that.

Jason Helgerson: Today’s guest is someone who has dedicated his career to bringing empathy back into American healthcare. Currently, he is serving as the co-founder and CEO of Iora Health, where he is literally in the business of building a more equitable healthcare system. He believes that all individuals, regardless of race, income, or zip code, have the right to access highly personalized and accountable care. Given all his work to date, I can't wait to hear what he thinks healthcare should look like 30 years in the future. It's my pleasure to welcome Dr. Rushika Fernandopulle to our program. Rushika welcome. 

Dr. Rushika Fernandopulle: Thank you. It's great to be here, Jason. 

Jason Helgerson: Great. Well, why don't we start with you telling our audience a little bit more about your interesting background.

Dr. Rushika Fernandopulle: Sure, so I'm a primary care doctor, and I think, well over 30 years ago, you know, it's hard to be a primary care doctor and not realize that the system doesn't work. They're largely good people and good intentions, but the system is really not doing what it should do, which in theory, the reason we have a healthcare system it's to actually improve our health and we've gone astray. So I tried doing what everyone else is doing, what I call the incremental change model of trying to tweak the system and working for a big health system and serving on various committees, and trying to go to Washington and work on the policy side, worked for a consulting company. I worked in academics and ran an inter faculty health policy group at Harvard.

And finally came to the conclusion, maybe what we need to do is simply start over and build a new system from scratch. And that's what really led me eventually to building Iora, which is trying to do exactly that. What if there is a completely different model of healthcare delivery starting with primary care? Let’s just build that, get patients to vote with their feet, and that will perhaps change the system. 

Jason Helgerson: Well, great. So given all you've done in the time you've been building Iora and with that building a healthcare system, obviously that gives you a great seat for looking into the future. And so I'm going to next ask you the question we ask all our guests, which is what does healthcare look like in the year 2049?

Dr. Rushika Fernandopulle: Yes. I actually think we're on the cusp of healthcare looking very different. You know, it's funny if you go back 30 years instead of forward 30 to 1980, to be quite honest, not a ton has changed. Like, yes, we have computers and yes, we've got better technology, but the way we deliver it to people is actually fairly similar, I think the next 30 years, it's going to bring a really big differences and maybe a five or six stakes. 

The one is, I think healthcare will be a much more personalized. We are now beginning to learn about genomes and proteomes and microbiome, so the way we do healthcare now is incredibly, you know, that there's population health is maybe the wrong thing to do. It’s a, we do a study and we say that 51% of people benefit from beta blockers, by the way, that means that 49% don't, but we then recommend everyone get beta blockers. We say everyone should get them. Every woman should get a mammogram every year or every two years. And it turns out that some that's probably right for, some people too often, other people it's actually probably not often enough. So I think we will learn and be able to personalize our recommendations to people much better based on who they are. 

Second, I think there'll be a very different role of technology. I think a lot of the routine stuff we do right now in healthcare, what can be protocolized will be done by a computer and AI. There's no reason for it, by the way, that doesn't mean that it's going to replace doctors. There's some Silicon Valley people who talk about that. I think there's a huge role, which we can talk about where human beings still play. But I think we're going to really say, let computers do what they do well and let the people do what they do well. 

Third is, I think care has got to become more accountable. We right now have a healthcare system that's based on transactions and largely a fee-for-service payment model. And so what we do is, we do more stuff to people, not make them healthier, not helping them live better lives. And I think the organizations that start being accountable, already we're seeing this and people like us and others just have such better outcomes, and that customers, patients, will vote with their feet, so much more accountable. I know this accountable care has been a buzzword for a long time and despite the hoo-ha, it's not very present today. Only about one and a half percent of most health systems revenue comes to real accountable payment. I think that will change radically in 30 years. 

Then related to that, I think we'll focus more on health than healthcare. In the end, the goal of the healthcare system should be to make us be healthier, you know? And I think it's very clear that many of the improvements in health have little to do with healthcare. It has to do with sort of social interventions, optimism, sense of purpose, social connection, how we eat, how we move, relationships, stress, and I think we'll start paying much more attention to it. 

And then finally, and maybe this final one is a bit of a hope because I could see us going two ways, but the system is more equitable. And I think we can go two ways. Unfortunately, the way we're going now with our healthcare system is becoming more and more inequitable. The haves have more and the have nots have less. And we see that with COVID. We see that in the way we're giving out immunizations for COVID. We see that with what people now call social determinants of health. We can fix that. We know how to fix that. I think that's going to take some political will and I would like to hope, and we're doing everything we can to say, no, let's actually try and make the system more equitable. So it's really a personalized, a different role for technology, accountable, health-focused and then equitable 

Jason Helgerson: To help our audience, who’s a mix, some of them are deeply rooted in healthcare and others are not, help our audience sort of wrap their heads around this future state that you're describing. If you could, please describe that future world from either the perspective of a patient or a provider.

Dr. Rushika Fernandopulle: Yeah, let’s do it from a patient point of view because I think that's the most important. For too long, we've designed our healthcare system around the provider, no other industry does that. We should be designed around our customer. The customer, to be really clear, are the patients, not the providers, not the health plans, not the pharma companies, it's the customer, the patient. So I think if I was a patient, it's important for most people that you do still have a relationship with someone who is going to quarterback your care. We think primary care is a great way to do this, but you can imagine maybe some other sort of vehicles. But a human being, a doctor who is my go-to person who can help me coordinate everything.

What we do is called a shared care plan, which is a proactive plan designed just for me about what I should be doing and is based on my genomics, my proteomics, my microbiome, my wishes and preferences, my genetics, all those things. And this is what I want to do to improve my health. And it's going to be a plan about how I eat, how I exercise, how I build my relationships, the medicines I take, what I'm monitoring and the like. I think I will have access to both human beings and technology to help me execute on that plan. So, sensors will be picking up on my blood pressure, my stress levels, my activity levels, et cetera, and providing feedback to me and if it’s sort of simple feedback, that will largely be automated. But when it goes off the rails, then the human will get involved and say, hey, I noticed that your blood sugar is going off the rails. Let's talk about what we need to do to make this better. And so over the long period of time, I will be able to sort of improve my health, improve my life based on my goals and the like.

From the provider point of view, this is a much better world. This is why we went into medicine, not to do more stuff to people, not to be fighting with billing and coding, all of that stuff will get automated and hopefully even go away. But it allows us to take care of populations, get to know them and do the stuff that only humans can do. If you ask the question right now for primary care docs, what percent of your day is spent doing things that only you can do with all your training and experience? The answer is probably 20 or 25%, and 75% is just crap that we can have either other people or more importantly systems do. So I think from both the sort of patient point of view and the provider point of view, this is a much better world. 

Jason Helgerson: So in the year 2049, do you see the typical interaction between patient and provider as a virtual interaction in the sense that becomes the default? Obviously for a long, long time the default has been that we as patients go to the provider to receive services, but do you see that default being that sort of virtual visit as opposed to physical, or do you still see the physical visit as the most common interaction that an individual has with the healthcare system?

Dr. Rushika Fernandopulle: I think it's actually the wrong question you're asking because the right question is not about how we do it, it’s how do we meet the need best? And so we're doing this right now. On average, our patients at Iora have 19 interactions with their doctor or their health system in a given year. Of those half of them, about 10 of them, are what we call asynchronous, which is emails or texts. It works really well. We don't have to be on at the same time. It's very efficient. And then half of them are synchronous, meaning we're interacting at the same time. Of those, let's call it again 10 to be a round number, four in person, four are by video, two are by phone. And the principle we use Is, if the right way to do this interaction is in person, then by all means let's do it in person. If the right way to do it is by video, then let's do it by video. If we can do it by a phone call, let's do that. If it's an email or text, let's do that. The reality is that different interactions actually need different things. 

Why do we need to be in person? It's clearly to build a relationship. We think it's important. I think one thing COVID has proven to us is that just the nature of relationships that one can build when we meet in person is very different than simply meeting people on video. And I think anyone who has done online dating probably knows that. So we want to meet people in person at least once.There are a set of conversations which are better in person. Serious conversations about end of life care, we should do in person. We also think there’s some clinical things where I need to lay hands on you. I need to feel your belly. I need to listen to your lungs. And yes, we can do some of that by technology, but some of it requires just laying on of hands. We've done that for thousands of years, it’s important. Now a huge chunk of it is not, by doing by video and text. So again, I think the key is we should drive how we interact with our patients, or our doctors if you're a patient, by what the best way to do it, and the right answer is we will use all of them. That'll be sort of a pallet we can pick from depending on the right way to do it. 

Jason Helgerson: Do you think that the way we train doctors today is consistent with the vision that you have for the future? Or is there a need to change the actual methods, ways and subjects that we're training the physicians of the future around?

Dr. Rushika Fernandopulle: Oh, absolutely we have to change. I think the current way we train physicians is completely outdated. Remember that a typical practice today, your job is, I walk in the door in the morning, I have 31 or 35 or 40 patients booked. I see them for seven minutes. I do the best job I can. I document code to bill it as high as I can. I turn my brain off. I go to the next patient. And I do it all myself. It's largely based on my own knowledge that is stored in my head. That's not what we do. Our job and the job of, I think the healthcare delivery system of the future is that I have a population of people and they are my responsibility. How do I improve their health, keep them out of trouble and do whatever it takes with this whole panoply. Why are we teaching doctors organic chemistry? Why do we require BC calculus? It's ridiculous. I've never used any of that stuff. 

But what we should be teaching is behavior change, how to use data, how to manage teams and how to think about populations. It’s a whole separate set of skills. I think the teamwork thing is really important and then the data thing. So really what we're doing is managing populations and how do I think about that? I'm about to take a recertification test, which is a closed book test for eight hours where they're testing my knowledge. It’s ridiculous because in real life, you look stuff up, you use peripheral brains. This is all available to you at your fingertips. I think that the way we need to cram a bunch of facts in people's heads and then regurgitate it, it’s completely crazy in 2021. We need to evolve all of those and how we look for who is going to be a good doctor. How we train them and then how we sort of test them and keep them up to date, all of those need to change. 

Jason Helgerson: How concerning is it to you that the physicians who are in medical school today are going to be the heart and soul and at the peak of their careers in the year 2049, yet, really aren't getting the type of educational experience that you're describing?

Dr. Rushika Fernandopulle: Well, I think it's a huge problem. This is a bit of turning the battleship. And I think if we want to be ready for where we're going to be in 2049, we need to look ahead, you know, the Wayne Gretzky's way, where the puck is going to be, and really start changing the training models. I think people need to be exposed to different ways of thinking and different training. We need to pick different people. We need to train them differently. As I said, we need to keep them up to speed. And I think very few, if any medical schools are doing any of that or residency's. In the first year of medical school, they're doing some things differently and teaching some of this empathy and teaching some of the teamwork, but then what happens is the second you end up going to internship and residency, whatever benefit you had gets kicked out of you because you're just back in the old turn the wheels sort of system. I think we need to change it from soup to nuts, not just throw a few juicy tidbits into the first year of medical school curriculum. 

Jason Helgerson: So the five aspects of that future state that you described, the one that you said was perhaps aspirational, at least you seemed most concerned about it actually being achieved by the year 2049 was equity. And obviously equity is at the top of the political discussion at the moment, particularly, as you mentioned, as it relates to the rollout of the COVID-19 vaccines. What do you think it's going to take to ensure that we have a truly equitable health system by the year 2049? Is it policy change? Is it new care models? Is it new payment models, all of the above? What do you think is really needed to ensure that we achieve that equitable future you hope is possible?

Dr. Rushika Fernandopulle: I think it's all of the above. It starts with simply a commitment that we want to build an equitable health system. And it's not clear we actually have that commitment at the moment, or certainly that we're acting on that behalf because it means that we would make very different decisions about how we do things. 

Number two is that it requires us to change deep structural things. On the healthcare system part, I'll give a simple example, in Medicare advantage, which is where we work, there's a risk adjustment formula where you get paid more to take care of sicker people. There is no adjustment right now for socioeconomics or race. And we know that folks with poor socioeconomics and in minority groups that are traditionally disadvantaged have harder problems. A simple thing to do is add that to the risk adjustment formula and make it so that if you take care of folks who are disadvantaged, you actually get paid more. Guess what? Lots of people are going to flood into actually taking care of those people, as opposed to now where it's harder to do and therefore you don't do it because you get paid less or the same. 

I think also a commitment about the uninsured. COVID has shown us this idea that we're all tied together and thinking that there are people we can not give good healthcare to and it won't affect the rest of us is silly. COVID is a great example where it affects all of us. It affects the economy. We’re one of the very few industrialized countries that have not made a commitment that everyone in this country ought to get reasonably good healthcare, regardless of whether you can pay for it, regardless of your insurance status.

We're still tying to this crazy World War II era where you link employment to insurance, which makes no sense whatsoever given the current state of the world and the patterns of jobs. I think we need to change that, too. Then there's a bigger issues, the real core problem is actually a systemic inequality that has nothing to do with healthcare. It has to do with education, housing, safety and pollution in disadvantaged communities. I think if we deal with this even bigger thing, we have to fix those things if we really want to make healthcare more health, more equitable. 

Jason Helgerson: Let's talk about the actual infrastructure of American healthcare and start with one of the real behemoths of the system, hospitals. What role do you see them playing in American healthcare in the year 2049? 

Dr. Rushika Fernandopulle: It's a great question. We will always need hospitals. There will always be a set of illnesses, particularly serious ones that will require you to physically be somewhere and have people “working on you,” keeping a close eye on you, to have access to advanced technology, whether it's intubating or pressors or the like. Now I think that will be a smaller and smaller percent. We have seen over and over again a 40% drop in hospitalizations by doing better primary care. On top of that, if you do need the hospital, there are people like Contessa and a number of medically home, which is showing that a good chunk of the things that people are now sitting in the hospital for, even if you can’t avoid it, can be managed in their house, hospital at home, by bringing a little technology to your house. I think what COVID has shown is if you don't need to be in the hospital, you don't want to be in a hospital. You will have a medical error, you will fall or break your hip. If you're an old person, you'll get some dread infection that floats around hospitals.

Do we need hospitals? Absolutely. I think they will be a lot smaller and this is a very controversial point, but they will be a lot smaller than they are now. They will need some percentage of the beds they have, but that number is going to be half or less, not 10% less. I think there are very few health systems, Mount Sinai’s is one that is committed to that. They said they're taking 800 bed towers and shrinking them to be 40 beds. We see very little of it. If I drive around, every hospital is putting up new bed towers. I think that’s misguided given where healthcare is going to be in 2049.

Jason Helgerson: Do you see the hospitals almost like the manufacturing facilities of the middle of 21st century with de-industrialization, what we see now, when you drive across certain parts of America, sort of abandoned old manufacturing places that used to employ large numbers of people? Do you fear at all that in the year 2049, we'll be looking at hospitals and seeing them as those abandoned towers because they're just no longer useful? Is that dystopian view a concern for you?

Dr. Rushika Fernandopulle: The one thing hospitals have is that they're sitting on incredibly valuable real estate. If you go to most places, the hospitals are in really nice areas. You're already seeing some of this in New York and in some parts of Boston, places with high real estate costs, you pull down that hospital tower and you put in place something else that is a better use of that land, whether it's senior housing or multi-use development or whatever. I think hospitals have a fundamental decision to make, the world is going to split into two groups. We have for too long driven healthcare around optimizing for providers. I think what's happening in healthcare, for a whole variety of reasons, is that it's going to be increasingly driven by consumers. It's a lot more consumer choice, whether it's through Medicare Advantage plans or high deductible plans and the commercial side. 

So increasingly you will have two choices. You can either take responsibility for managing the health of populations. Or you can become a commodity provider of services to people like us who do that. And so I think hospitals as an institution, we'll need to start moving and say, you're going to manage populations. We're going to do what our mission statement actually says, which is improve the health of the community, not fill hospital beds. That's a fundamental difference. The successful ones start getting into different businesses, whether it's primary care, wellness, housing and a whole lot of other things which can improve the health of the community, which is much more than just building hospital beds or filling MRI machines or whatever it is. You see the really progressive ones that, the inner mountains of the world actually moving in that direction. 

Jason Helgerson: Let's talk about the other big behemoth of American healthcare, which are insurance companies who obviously play a role in providing healthcare, access, buying healthcare services on behalf of commercially insured, Medicaid, Medicare, what's the role of the health insurance company in the year 2049?

Dr. Rushika Fernandopulle: I think that's very different too. What's happening now is you're having folks like us, which are physician groups, being able to raise capital and being able to build IT systems to be able to take responsibility for the health of populations. I think we do that much better than health plans because we have a real relationship with our patients. We meet them in person, we’re their doctor, we have real clinical information, not claims information, and we have a real affect, we can actually change care. In a world like that where you have organized, well-capitalized provider groups, it is not clear to me what the role of what a health plan is, to be quite honest. You could imagine a health plan starts becoming one of these middlemen who are taking a big amount of value out of the system that will get disintermediated. We've seen this over and over again the last 20 years, think travel agents, et cetera. I think health plans also have a reckoning about either we start really being clear about what the value we're adding and charging for that, but simply being a middleman and then taking a chunk off the top becomes less and less viable. And by the way, you see the smart ones. The great quote “the future is already here it's just unevenly distributed.” United Healthcare is obviously making a huge pitch this way, where they're participating  with their Optum Group and going into all sorts of other businesses, including care delivery, analytics, managing drugs and providing housing. They're doing all sorts of things because they realize that's the future. It's not simply being a financial middleman and taking this sort of big 15% cut off the top. 

Jason Helgerson: Another important aspect, particularly given your vision for the future is the role of the primary care provider in the system. One of the concerns today is a lack of primary care providers, not surprisingly primary care providers are under compensated compared to their colleagues who are specialists. And so 30 years in the future, are you confident that in order to achieve your vision, that we'll be able to attract enough people into primary care to allow these primary care centric models to exist? Will we have to convert specialists into primary care providers or do you see technology increasing efficiency to a point where we won't need the same kind of ratios that we have today in order to be able to provide that a high quality primary care experience?

Dr. Rushika Fernandopulle: Yeah, so the population is not just growing, at least in the U.S., but it's getting older and sicker. There is nothing any of us can do about that, the baby boomers are all aging into the time where they're gonna need more care, not less. I think for the foreseeable future, we're going to continue to need to have primary care doctors. Now, what's interesting is if you look at Europe, look at most of the world, there are twice as many primary care doctors as specialists and we have the exact flip here in the U.S., we have twice as many specialists as primary care doctors. I think that's a big problem. And it's because, as you mentioned, we have skewed the payment models for a variety of political reasons where specialists get paid roughly double what primary care doctors do.

But the other problem, I think, is that the job sucks as a primary care doctor. You need to have your head examined to go into primary care in the current model where you're on this treadmill, or you're not getting paid very much. You don’t have the right support. You have these crappy IT tools that make your life harder, not easier and there is no future. So I think that's why people like us are trying to build a different vision. We have no trouble attracting primary care docs because it's a better vision. And eventually the way the economics work, we'll be able to pay people dramatically more. And so that's where I think the world has to go. We need more primary care doctors. Yes, there are a bunch of folks at the low end of the acuity spectrum who probably could have many of their needs taken care of by either technology or less highly trained people. I think there are people at the high end who actually need more primary care. In the end, do we need more or less? I don't know, we’ll have to figure it out, but we certainly need many. And I think creating a different vision of primary care, it’s a better job, better tools, better economics will actually help us fix that. Now again, I talked about moving battleships, this is a huge change it's going to take years and years to do, but I think we can already start seeing the beginnings of it happen.

Jason Helgerson: All right, I hear you on the challenge of turning the battleship around, but what makes you confident, given all these challenges, that your vision is actually achievable in 30 years time? 

Dr. Rushika Fernandopulle: I think the science is advancing. We’re understanding more and more literally every week and every month about genomics and about personalizing care. So science is advancing no matter what happens. I think there are economic imperatives that this will happen. If we don’t, the system will collapse. If we don't fix this out of control healthcare system we have in the U.S., we're going to bankrupt the country because of Medicare and Medicaid and we’ll bankrupt individuals, et cetera. The system will collapse. And third, the social imperative you had mentioned just more and more focused on inequalities. I think there are more and more people getting this and healthcare is a big part of it. Now, maybe on the pessimistic side is what will make this hard is that we have a very powerful medical, industrial complex who really has built themselves around continuing to do more stuff for people and these are the healthcare providers, the payers, the pharma companies. I think what we're going to see is a battle between consumers in the larger interest versus the medical industrial complex, or maybe the smart ones will decide they're going to align back with the consumers and they will win and the others won’t. Again, I think there are a lot of reasons to be optimistic, but it will not be easy. 

Jason Helgerson: All right, so we always like to end our shows with this final question, which is really an opportunity to take a step back and imagining that your vision for 2049  health and healthcare is actually achieved and to think about it in the broader context of the country, of humanity and really why is achieving that important? In other words, how would achieving your vision actually make the world a better place? 

Dr. Rushika Fernandopulle: Health is really important on three levels. Personally, it's a huge priority, without your health you don't have anything. So who cares how much money you have if you're not healthy. As we start to age, we really care about having a system that'll help us improve our health. 

Number two is society. It's a hugely an issue of productivity. I think societies that are not healthy will not be productive. COVID showing us this. This is a health issue, it’s a tiny little virus that is running havoc with our economy and our mental health. So there is an  issue of productivity. 

Then finally it is ineffective spend that is bankrupting us. It’s spending money on things we don't need or want. I think almost anyone who looks at U.S. healthcare spending thinks that 30%, and some would say up to 50% of what we're spending is waste, and waste is not just things that are not necessary, but they may actually be creating harm for people. They're not just what we need or want, it may be harming us. And so I think we have to fix this problem. If we can, it will make a huge impact on making the world a better place. 

Jason Helgerson: And that was Dr. Rushika Fernandopulle’s vision for health and healthcare in the year 2049. As always, thank you for listening to Health 2049. If you enjoyed what you just heard, please subscribe to us and share this podcast with a friend. Thank you and see you next time.

Dr. Theophil Stokes, Chief of Neonatology, Walter Reed National Military Medical Center

Can physicians of the future be experts of science and empathy? Dr. Theophil Stokes, Chief of Neonatology at Walter Reed National Military Medical Center, believes they can as he shares stories from his experience as a neonatal doctor that proves it’s not only more beneficial to the patient, but also to the doctor and medical staff. 

Dr. Theophil Stokes is the Chief of Neonatology at Walter Reed National Military Medical Center and an Associate Professor of Pediatrics at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. He previously served as President of the Medical Staff, Chair of the Provider Wellness and Healthcare Ethics Committees, as was the Associate Program Director for the National Capital Consortium’s Pediatric Residency and Neonatal-Perinatal Medicine Fellowship programs. He has developed educational initiatives aimed at improving communication between patients and their healthcare providers, and his work in this field has been highlighted in national and international presentations and peer reviewed publications. Dr. Stokes was recognized as a Walter Reed Master Clinician in 2016, and in 2017 was selected as a Regional Finalist for the White House Fellows Program. He is a Fellow of the American Academy of Pediatrics, and is dual board-certified in General Pediatrics and Neonatal-Perinatal medicine.

Show Notes

• Dr. Stokes ponders what health care will look like in 2049 by describing a typical doctor visit in 1849. [2:14]

• What’s missing in medicine today that will be a prerequisite for doctors in the future? [4:43]

• How can we achieve this new vision and how much will it cost? [6:18]

• The defining moment that made him decide to become a neonatologist. [7:33]

• A non verbal exchange with a patient that showed a disconnect between the patient and hospital staff. [11:50]

• A breakdown of a well-intended, standardized medical approach to caring for an emotional patient. [13:33]

• What’s the best way for a doctor to counsel a family in distress? [17:47]

• What are some of the obstacles in teaching empathy to doctors? [25:13]

• What can we do as a society to encourage doctors to take an empathetic approach to care? [28:48]

• What causes the resistance to empathy in the medical field? [29:17]

• An example of a behavior between an emotionally detached doctor and one that is connected, emotionally engaged and present. [31:17]

• It’s time to reanalyze and reassess how people get into medical school. [33:18]

Transcript

Bisi Williams: I'm Bisi Williams and you're listening to Health2049. 

Dr. Theophil Stokes: In medicine, I think for a long, long time, there was a notion that one needed to be emotionally detached in order to do their job effectively. This idea that objectivity is what the gold standard should be I think is a big problem because I don't think our patients actually want us to look at them as objects. I think patients want us to treat them as real people.

Bisi Williams: My guest today is a neonatal intensive care physician by training and a humanitarian, but his overarching interest goes beyond his specialty and extends to the world of physician communication and empathy and the critical role that these factors play in the lives of our patients and their families. Dr. Theophil Stokes, welcome to health 2049. 

Dr. Theophil Stokes: Thank you so much for having me. I'm really excited to be able to talk to you today and looking forward to our conversation.

Bisi Williams: We're excited to have you today, too. I’m going to jump right into it. What does healthcare look like in 2049, from your perspective?

Dr. Theophil Stokes: I love the question and I love being asked to think about it this way. I think to look forward, I want to just quickly look back to 1849, which I know is going backwards, but I'm going to get back to the point here in a second. So in 1849, healthcare was very different, obviously. The things that doctors carried in their bags and the medicine that doctors were able to provide in 1849 was obviously vastly different than it is today. Interestingly, 1849 is the year that the first female physician was trained in the United States of America, which I didn't know until I went back and was reading about 1849.

In 1849, doctors basically came to your house and they had their bag, which had some things that might help. And they also had things that might harm you. They had leeches, they did things like bleed patients in their houses, but the things that they did made us feel better in terms of feeling better–when we say feel that means a lot more than just going from being sick to being well–a lot of how we feel is wrapped up in our emotions and there’s so much more to healthcare in our overall wellness than just treating a disease. The good doctors back then, although they didn't have antibiotics, and the medicines were limited and sometimes even harmful, but they made you feel better because they came to your house. They came to your space. They listened to your story. They were attentive to you as a person. They did this to avoid hospitals, which were cesspools of infection and weren't kind of happy places to go, not that they're happy to go to these days either, but they came to your house, they listened and they got a glimpse of who you are as a person.

So thinking about healthcare in 2049, we fast forward to where we are today and clearly medicine has made huge strides, our technologies are incredible and we have the ability to fix and to cure diseases that would have been unimaginable in 1849, however, some of the things that we've lost, in this quest to improve our healthcare, is that bedside manner, that attentive physician who was present with you as an individual who was able to listen to your story and treat your disease within the context of your life. I mean, literally being in your home, in your bedroom, you can imagine how that would facilitate a healthcare plan that is individualized and attuned to you and attuned to the family living around you.

So my vision for 2049 is that our healthcare system in particular doctors, we as a society will have doctors that are trained, obviously in the highest technologies, understanding the most sophisticated medical technologies and medications, and that'll be a prerequisite of what we expect of our physicians. But in addition to that, we will as a society have made a decision that just being a technocrat, just having a scientific mind is not in and of itself enough to be a doctor or physician and that we will have learned that so much of disease is wrapped up, not just in the physiology, the medicines and the procedures, but also of the way that we feel on an emotional level. Being a good doctor entails to being able to provide care that is attuned to the individual that's sitting before you. And so our healthcare system in 2049, we'll have come back to that place where we're able to combine those aspects from 1849, that bedside manner, those physicians that truly knew you and cared about you, with all of the rapid increases that we're going to continue to have in medical technology. And that's my vision for where we can go and hopefully that's where we're going to be.

Bisi Williams: That sounds wonderful. Why are you confident that your idea of this attuned doctor, physician with bedside manner can be achieved in 30 years? 

Dr. Theophil Stokes: I'm confident because this is what most people already want and it doesn't take any more money. In many ways, it's a lot less expensive to select and train individuals in these kinds of skills than it is to think about all of the money that we pour into research and technology development, which is obviously important, but these are inexpensive things. When we are truly sick, ill and fragile and when we are in need of somebody else to care for us, when we're vulnerable and afraid, these are the things that we all want. I've been with people at the end of their lives or the end of their loved one's lives, and you see this over and over again that when you get to those places, we need people that care about us and we need to feel cared for and we all expect this. It's not something most of us are thinking about until we need it and if we can, as a society, start to have these conversations, this is something that we can easily have. We just have to say collectively, this is what we expect and what we deserve as people. And that is why I feel optimistic about this. 

Bisi Williams: I love your optimism. So tell me what made you decide to become a neonatologist. 

Dr. Theophil Stokes: Yeah, so it's an interesting specialty, it developed kind of later in the game. I trained as a pediatrician, so I went to medical school and then I did a residency in pediatrics. Neonatology is a subspecialty of pediatrics that requires an additional three years of training as a fellow, what they call neonatal perinatal medicine. 

What really grabbed me about this was in medical school at Boston University, I remember I was on one of my pediatric rotations and I was just outside of the NICU, the neonatal intensive care unit, and don't remember all the details, but I got pulled into this case where there was a mother who had been admitted and she was a recent immigrant. She didn't appear to have any family or support. She was all by herself. She was Urdu speaking. I remember there was not a translator available and she was in labor at around 24 weeks gestation into her pregnancy. A normal pregnancy is about 40 weeks long. She was literally just halfway into her pregnancy point where babies that are born at that age are just beginning to have enough lung development to be able to survive outside of the womb. 

And so in neonatology, there's this very unique circumstance that arises in those cases where expectant mothers, who are about to deliver in these extremely premature age ranges, that we as neonatologists are expected to have a conversation with the expectant mother. And essentially what we're doing is we're trying to have an informed consent conversation about if their baby is born this early, do they want their baby to be subjected to all of the things that we have to do in order for a baby to survive at that age. And the reason we have this conversation is because in many cases, babies born that early are unable to survive outside of the womb, no matter how many things we do. So when parents make this decision, it can mean that they're not going to have any time to really hold their baby or to be with their baby because we have to whisk the baby away right after birth and get them to the NICU and do all kinds of procedures that make the baby that very inaccessible to the family. In spite of all of that, many of the babies still will not be able to survive. 

This is what we call gray zone of viability, where it's ethically been determined that it's okay to go ahead and try to do these intensive care things, to try to help the baby survive. But that also for some families, it is ethically permissible to say, you know what, I'm not going to do all those things for my baby. I just want to be able to hold my baby for the little time that we have. And for my baby not to be subjected to that. So we're asking somebody to make a life and death decision about their child that they've never met, that doesn't actually exist. It just struck me as such a superhuman place to be. And I was fascinated by, was it really even possible to have such a conversation? Could people actually, as human beings be expected to really make that decision and how do these neonatologists that are supposed to be having these conversations, how do you do it? Because it just seems like this superhuman feat.

So I was really interested in trying to understand how this could be done. And going back to that woman I described, clearly what I saw there was the way not to do it. There was never anybody there to translate for her. She ultimately had the baby, the baby was resuscitated and taken away from her. I don't actually even know what happened after that, but I just remember being struck by the humanity of that and wanting to understand and to potentially be a part of helping people through what seemed like such a crisis in their lives. So that was kind of the root of how I got interested in the profession.

Bisi Williams: So as a young medical resident, is that the correct term? Were you a resident?

Dr. Theophil Stokes: Sure, I was a resident then, yep, in pediatrics.

Bisi Williams: As a young resident and going through your rotations and you see this woman who we have no means of communication, there’s a language barrier and she's alone. What did you see in her? And what was the experience like for you? I mean, obviously it was a non-verbal exchange. 

Dr. Theophil Stokes: As I think back, I was actually just a medical student, so even lower on the totem pole than a resident. And as a medical student, you're very much an observer. You’re kind of like a fly on the wall and occasionally somebody will pull you in and say, hey, help us do this or something, but in that particular circumstance, I was basically an observer. I remember being struck by this woman's fear and just the look in her eyes of fear of not understanding at all, what was happening and being struck by the lack of support and how alone and afraid this woman was and how wrong that seemed. And also how normal it seemed to the team taking care of her, how this just seemed like something that happened all the time. I couldn't shake how discrepant those feelings were, here you have somebody in the pit of despair who is clearly suffering and then a team of people who sort of seem like this is something that happens every day.

Bisi Williams: When I think about the progression of your life and work, there are sort of seminal moments I feel that get you to this place where you can really look at compassion and empathy and communication as clear markers for a well-trained physician, if you will. These soft skills are really hard skills. 

Dr. Theophil Stokes: That’s right. 

Bisi Williams: Can you tell me another instance in your journey to be a comprehensivist physician, that you realize where as a profession you could do better?

Dr. Theophil Stokes: Yeah. So that was me as a young, nobody medical student with no power and really no voice. But fast forward to, now I am a brand new neonatal staff, so I've done my residency in pediatrics for three years and I've done my fellowship for three years as a neonatologist, and now I am an attending physician and I found myself back at the training program where I actually had undergone my training and so literally on the other side of the glass. 

For the fellows, the doctors in training, we have these training scenarios where we use actors to play the role of patients. And I was sitting on the other side of a one-way mirror looking at a one of our NICU fellows and an actor playing the role of a mom about to deliver her baby prematurely. I remember the actor was really strong and she really embodied the character of a mother who was there. And in this scenario, she was there by herself and alone and afraid. And the objective for the neonatal fellow was to go in the room and to counsel this mother on what it would be like to have a premature baby. I had in front of me a checklist that said, the fellow should talk to the expectant mother about all of these potential complications of prematurity. And as the fellow went through and said the different complications, I was supposed to kind of check off on my box. And if the fellow had talked about all of the complications that could arise, then the antenatal counseling was deemed to be a success and the fellow sort of check that box and it had demonstrated competency. So this was how this was supposed to work. 

Bisi Williams: Wait, let me just stop you there for a second. So as a part of the best in class training, is to talk to a woman who's in the throes of distress at the worst moment of her life and then to have a checklist that you want to talk to her about everything that could go wrong with this little baby inside her.

Dr. Theophil Stokes: That is absolutely right. I'm not exaggerating. This is the way that we were taught to do this. And It seems now talking about it and it seemed then, insane. It seemed particularly insane with watching this actor. She was really good. I watched her as the fellow started to talk and this is how we were taught to say, now, here are the problems that your baby could have. I'm going to start at the head and go down to the toes. And we would talk about, inter ventricular hemorrhage and bronchopulmonary dysplasia and patent ductus arteriosus. We call it PDAs, IDH, BPD, CLD, like, all of this alphabet soup and I kid you not, we were supposed to just go through all of these things. And the idea was, if we didn't say all of those things, that we were not providing adequate informed consent. Our healthcare system has become, I don't want to say obsessed because it's rooted in a good intention, we want people to be informed and to be able to make informed healthcare decisions. But I think we've taken the idea of informed consent, we've sort of taken it well beyond what it was intended to do. 

So this is the model that this was rooted in and, medicine being medicine, there's another obsession of standardizing things and standardization is great with airplane safety and automobiles, because we want to do things the same way every time so that you can make it as safe as possible. And there's definitely a lot to learn about, that can be gleaned from that and that we can use in medicine. However, the idea of standardizing an approach to somebody that is literally in the throws of the strongest emotions you could ever imagine, this is where it all breaks down. And I remember thinking, this may be well-intended, but we are doing this all wrong and we need to take a step back and really think about other ways of doing this. 

Bisi Williams: Could you give us an example now of how you can counsel a family going through a very difficult time? And how you solve the problem and what was the result of your you're listening to a family in distress?

Dr. Theophil Stokes: Yeah, this is a story I think that really exemplifies how patients have to be heard in order to hear. I was coming on call to cover our neonatal intensive care unit one night and my colleague, she was the daytime NICU attending, and she was extremely frustrated because a baby had been born about four hours earlier and it was clear that this baby had a condition known as trisomy 18, which is a very severe genetic anomaly that we're not able to cure. And that babies who have this often die within the first hours or days after birth, in spite of everything that we might try.

And so it was very clear that the baby had this condition. The doctor that was signing out to me, she was really upset because in her words, the parents were just unwilling to accept reality. And that they wouldn't believe that their baby had this condition and they wanted “everything to be done.” So the doctor was upset because the baby was still on a ventilator and was being cared for in the NICU. And the nurses were angry because they felt like they shouldn't be doing this to this baby because it wasn’t justified because this baby was going to die anyways, and everybody was upset.

She said don't worry about this tonight. Tomorrow morning we're going to get an ethics consultation and we'll sort this out in the morning. Then she signed out the rest of the babies and that was sort of a night. It was a quiet night and me being me, I thought, maybe I'll just go talk to this family and try to get a sense of what's going on. So I went to the room, they were up in one of the postpartum rooms and it was just mom and dad and it was quiet and they were a little bit older, I think in their early forties. It was mom's first baby. I asked them, I think I said, tell me about your pregnancy and tell me about what's happening. But basically from there, for like the next 15 minutes or so, they told me the story of their pregnancy. They had been trying to get pregnant for a long time and were unsuccessful and mom was getting older, so they were obviously extremely excited when they got pregnant. There was clearly a lot of joy when they told me the story and I could feel the joy and I experienced with the joy with them. They told me about finding out about being pregnant and their early appointments. And then they went to one of their prenatal checkups around like 16 or 17 weeks and they did this ultrasound where they could see the baby and they were so excited to see the baby. Very quickly, during that scan, it was clear that there were lots of problems and that their baby had a lot of physical abnormalities that were really suggestive of this genetic condition. And so the ultrasound tech that was all excited, all of a sudden got very quiet and wasn't talking to them and then leaves the room and gets the doctor. And the doctor comes in and then breaks this bad news and starts to tell them all of the things that are wrong with their baby. And they came back for their next appointment and it had been confirmed and they were essentially counseled that this is a condition that is incompatible with life and they should think about terminating the pregnancy and that there wasn't really any hope for their baby. They heard this and they got really angry. What they heard was that their baby was deformed, that their baby was some kind of a monster, that their baby didn't deserve to live.

And they got really angry and so they ultimately just stopped going to their prenatal checkups. They didn't show up again until mom went into labor, she had come in that day in labor and had the baby. They were explaining what the delivery room was like and mom's face and dad's face, they just lit up when they started to talk about their baby being born. He cried, he had a strong cry, and he was taken to the warmer. Dad got to trim the umbilical cord. They were just gushing, new happy parents. And I got to be there and feel that joy with them about their son who was born. Who was alive right then and there, who was four hours old and who existed and was alive in the NICU. This didn't take a long time for them to tell the story, this took a few minutes. And I just listened and experienced things with them and felt these feelings with them and probably got a little choked up. And then they eventually asked me, so what do you think is going on with our son? Then I told them that I thought their son had this condition. Essentially what I told them was exactly the same as the doctor had told them earlier in the day. 

The difference now was that they were able to hear this and they were able to process it. They were able to feel like they were hearing this information from somebody that had a vested interest in their family. And so they asked me, what did I think we should do? I talked to them about palliative care, hospice care and how hospice could facilitate them having some time with their son and that they could have some time together as a family. And that we could do all of these things to make his time here meaningful and to protect this time together as a family, as opposed to having them separate, in the NICU and in different spaces. And they were able to hear that. And then they decided that they were going to sleep on it and would make a decision the next morning. And we thought that was a good idea. 

Then I got up to leave and the dad, he gave me a big hug and he said thank you so much for taking care of my son. And I remember being very emotional, but also feeling like, in my head, I'm thinking I haven't really taken care of your son, I haven't done anything. I wasn't at his delivery. I didn't do any of the procedures. And I've come to realize now, that story was again, one of those most meaningful moments early in my career that was clearly demonstrating that, if we are to take care of our patients in the best way that we can, first form an alliance. We have to gain the trust of that family. 

Just by being there and showing them that I cared about what they were going through, they came to trust me in a very short period of time and were able to hear that. They ultimately decided to take their son home in hospice care. I heard that he lived for a few days and presumably, that was as much time as they were going to have, but they had that time together as a family.

It's sort of an example of how, as a doctor, you're not just caring for the patient in front of you, but you're caring for the family and you have to take care of the team that you lead, the NICU, the nurses and everybody. All of that came from 10 to 15 minutes of listening to somebody's story.

Bisi Williams: I'm struck by your role as a practitioner and a teacher, how many hats you wear and your insistence on training doctors that not only have awesome technical skills, but also have incredible empathic human skills. Can you tell us some of the obstacles you may encounter in teaching empathy and care to the doctors.

Dr. Theophil Stokes: Yeah, it's a question that I have thought a lot about over the years and there is not a one size fits all approach to it. It's challenging because empathy, there's a lot of research right now going into first and foremost, can we teach empathy? That being said, I think that there is a lot that we can do to acknowledge the importance of this, not just the importance, acknowledged this as a fundamental skill for doctors to have. 

So when you go to your doctor, you go assuming that they have gone to medical school and learned all of the medicine that they need and that they understand if they're going to do a procedure that you trust that they're going to have been trained to do this well. And that’s sort of an expectation that society has evolved, certainly in our society. I think for too long, there’s maybe not that expectation that your doctor will bring those human skills, the ability to empathize, to be compassionate, to genuinely care about you as a person. That hasn't necessarily been an expectation. So medical training programs, starting from medical school and going through residencies, particular specialties and even subspecialty training, they have increasingly begun to teach some degree of how we can talk to patients and emphasize the importance of that. But it really is not a primary focus. It certainly wasn't when I was in medical school and it isn't a primary focus of our residency and fellowship training programs now. So for instance, a neonatal fellow in our program who's going to be taking care of sick babies, it's an absolute expectation that that person, when they finished fellowship, they will be able to put a breathing tube in to a sick baby or to do a life-saving procedure. We would not let them finish their training without having shown us clearly that they can do that.

We don't have those expectations for our physicians to be able to sit with a family when their baby is potentially critically ill or even dying, and to be able to assist them in making these difficult decisions about some of the treatment options. What is my baby's death going to look like? I mean, these are excruciatingly painful conversations. We do not have an expectation of any sort of a minimum level of competency in these regards that these, have for too long, been thought of as, almost like, I don't want to say fluff, but like the touchy feely part of medicine. A lot of medical school training programs have elective courses in these kinds of areas, humanism in medicine. 

Bisi Williams: Wait, wait, wait, how can empathy and compassion be an elective course for a doctor? 

Dr. Theophil Stokes: Yeah. That is exactly the question we should all be asking. I think it’s one of those things where you don't realize how necessary it is until you absolutely need it. And I think that, fortunately, most of us aren't thinking about these in our day-to-day lives. You don't think about these things until you're faced with some horrible crisis where somebody that you love is sick or dying. And I think that's the problem. So it's on us in our medical profession to really begin to put some focus on this and to have this as an expectation of our medical training programs. 

Bisi Williams: Why do you think that there's so much resistance and could you mandate today for example, the doctors that you train, this is no longer an option, it's part of your training?

Dr. Theophil Stokes: I think as I go along in my career and as I continue to make a case in every way that I can, that this is critically important, we are getting there. It's small steps, but they're real steps. I think that our society could certainly demand these kinds of changes and that if our society said that this is what we expect of our doctors, then we would very quickly be able to reform and to change our practices.

In medicine, for a long, long time, there was a notion that one needed to be emotionally detached in order to do their job effectively. Maybe the most compelling version of this argument would be with somebody like a neurosurgeon or somebody who is involved in a hours and hours, long, delicate operation, where their technical skill needs to be superb and precise and presumably having strong emotions while someone's doing brain surgery is likely not a good thing for that doctor at that particular moment. So that argument can be made effectively. And I think that there's some value there. But I think that has been more broadly applied to all of medicine. There’s this idea that, as a neonatal intensive care physician, I don't want to get too emotional because it's going to impair my judgment and impair my ability to objectively provide care. This idea that objectivity is what the gold standard should be, I think is a big problem because I don't think our patients actually want us to look at them as objects.

I think patients want us to treat them as real people and individual subjects. So this idea of objectivity has just always kind of been assumed to be the gold standard. And for a lot of doctors who spend their lives really thinking about the science and the pharmacology and the procedural techniques, we need those kinds of people. But there's not always an expectation that those people should also have these kinds of abilities to translate what they know into having an ability to really compassionately care for patients. 

Bisi Williams: So Dr. Stokes, in your professional opinion, do you feel that being subjective hurts your performance as a professional?

Dr. Theophil Stokes: I mean that's the irony of this is the doctors that I see that are “burned out” who seem to have really not cared or seem to have stopped caring or seem miserable every day when they go into work, their patients don't particularly like them. They don't particularly like their jobs. They tend to have relationship problems. There is a whole lot of depression, suicide, and relationship problems that are pervasive in medicine. 

And so for me, it's completely the opposite, having those feelings of intense connectedness with my patients is what sustains me. So I go through these difficult experiences and sometimes it can feel totally overwhelming. But to have those moments where I can just as a human being, sit with a family who is going through an overwhelmingly sad situation, be present with them, help bring them some closure and help their family have some time together with their baby who may not have much longer to live. It sounds incredibly sad and yet those moments, I find myself having felt as though I really did something to help this family to be together during the time that they had and to find meaning in the life of their baby, who may not have lived for very long.

That keeps me going and I think that has been my perception amongst people that I talk to in medicine who feel similarly, is that being connected and being emotionally engaged and present with our patients, it makes you feel like you're doing something of value. And that keeps you coming to work and it keeps you feeling good about what you do. And that kind of seems to make sense. So, I don’t buy the argument that a disconnected emotionally detached doctor is a healthy way to protect yourself from all the feelings. 

The other thing I'll say, and I don't mean to say this cavalierly, is that, some people are probably not meant to be doctors. And that is another thing that we don't really do well. So if you get excellent grades in college, you ace all of your science classes, you rotate at Mass General, you have great recommendation letters, and when you have excellent MCAT scores, then you basically get into medical school and it doesn't really matter if you don't have the ability to talk to people or to interact. There isn't really a way of assessing the quality of somebody’s personality, their ability to empathize, these aren't really part of the game. It’s very objective. And so that is a part where way upstream, we really need to reanalyze and reassess how people get into medical school. That's a big change because the way we do it now, that is not a focus of it, to be sure. 

Bisi Williams: Right, and so if you think about our expanding abilities, our technical know-how and yet, at the end of the day, there's a person at the other end of this interaction. It's a human to human experience. On the one hand, I was thinking in 2049, it might be a bit existential for highly trained, intelligent beings, professionals, like doctors to think about some of their work being replaced by machines. But in this sense, I think that there still is a future for very creative, empathic and wonderful medical experiences for doctors as a profession and for patients to be on the receiving end of.

Dr. Theophil Stokes: It does and if we someday need less doctors because there are more technologies that can do some of these jobs, then in some ways that allows us to select a more excellent person, let's look for excellence and look for those attributes that make someone an excellent doctor and focus on that. So in some ways that is another reason to be optimistic.

Bisi Williams: I think we're going to need more doctors, to be honest.

Dr. Theophil Stokes: We're going to need people, yeah, doctors, nurse practitioners, physician's assistants, there's going to be lots of people that have to translate this care. 

Bisi Williams: Dr. Stokes, I am so inspired by your vision for physician training and patient care in 2049. Thank you for your ideas and your humanity and your compassion and your skills. 

Dr. Theophil Stokes: Thank you so much for doing this and for letting me be a part of it.