Digital Healthcare and Medical Innovation with Dr. Nick van Terheyden

Living a Life in Full is a conversation you always wanted to have with that person who gave an amazing TED Talk or the author of one of your favorite books, or that inspirational Olympian you always wanted to know more about. It's graduate level conversations with those making a difference in the world and in the lives of others. This show brings you new ideas and approaches so that you can live a life in full. I'm your host, Dr. Chris Stout and I hope you enjoy this episode. Welcome to another episode of Living a Life in full. I'm Dr. Chris Stout, your host. Today's episode is brought to you by ATI Physical Therapy try physical therapy first. Did you know that 70% of patients that utilize physical therapy first for spine, shoulder or knee pain are successfully treated without the use of any kind of imaging, prescription drugs, or even a physician visit. Experience the ATI difference. Your return to an active lifestyle is their primary concern. They'll work with you to help reduce pain and achieve your goals in a fun, friendly and encouraging environment. They have convenient locations close to home. They can schedule your first appointment within 24 to 48 hours. They offer early morning and late evening hours to fit your schedule. They have beautiful, vibrant, modern clinics. They have personalized communication with you and your doctor. They offer diversified, goal oriented specialty services. Their staff have state of the art clinical training equipment and technology available to them. And they have a department of Research and Data analytics that examines and help improve outcomes. They offer hands on therapy, exercise, strength training and cardiovascular conditioning to help you improve your physical strength, reduce pain and avoid recurrence of future injury. They'll help you address chronic pain or help you recover from an injury or surgery expertly, quickly and conveniently. For more information please go visit atipt.com welcome to another episode of Living a Life in full. I'm Dr. Chris Stout, your host and today I'm very excited. I have a good new friend, Dr. Nick Vanderhayden. Nick is really. You probably have heard about him. If you look in the healthcare medicine tech space, he won't be a stranger to you. He's especially popular on LinkedIn. He's a leader in digital healthcare and innovation. He's the former Chief Medical Officer for Dell and I kind of want to go into some of that. We've got a lot of interesting stories I suspect from him. He's a contributing author to numerous textbooks as well as columns and blogs. He's a very popular keynote speaker and that's worldwide. He's presented at the annual meeting of Health Information and Management Systems Society, the American Health Information Management Association. And perhaps most fun, he's also presented at south by in Austin. He's a graduate of University College of London and the Royal Free Hospital School of Medicine. And I, I really kind of think of you, Nick, as a citizen of the world as well. You've worked in the Middle East, Australia, the uk, Malaysia, New England or part New England, New Zealand, probably New England as well. You've collaborated with Phillips Healthcare, Mount Sinai Medical center, kpmg, Healthcare International, Shell. So really diverse, not just specifically health related entities. He's even aided in the, the first electronic medical records and all that's, you know, well and good. But I think maybe most importantly, he's a soccer, as he would probably call it, a football coach, motorcyclist. And Nick, I very much track you. It's probably a little stalkerish, but I know that you're quite the plank fan as well as a scotch expert. And I know with your medical background that that scotch is probably just for medicinal purposes only. So it's very good to be back in touch. How you doing?

Well, it's a delight to be here and thank you for inviting me. You're right. I do have this privilege of this international background that has offered me an exposure to the world that I wish everybody could have, quite frankly. And I know you travel too. I track you, I stalk others online, and you're one of the folks that I do. And you know, one of the things that I've realized through the course of all of those experiences in different countries, different cultures is the more you expose yourself to other places, I think the wider your eyes become and the wider your acceptance becomes when you start to realize that in reality we're all very, very similar. It's only small, minor differences. And you spend time in another country and you realize that people are focused on the same things that we are. Their children, family, education, and the world that they live in. And if we could form a stronger bond around that, I really believe that the world would be a better place.

Yeah, I totally agree. I think so often we focus on what makes us different versus what makes us similar. And I've had similar guests or guests with similar kinds of perspectives, totally different backgrounds, but they've certainly seen that as part of their experience as well too. It's been, what, about a year since we connected at, was it Exponential Medicine out in San Diego? Is that right?

Yes. In one of the prettiest spots on the planet, right?

Yeah. Everyone's very nice out there too. Yes, that's right. Well, I have just a huge agenda because there's so many things I want to kind of get into and talk about with you. But maybe first off, can you describe for our audience what an incrementalist is and how you see or how you define what incremental medic.

Yeah, so it's something that's really, for me, developed into this enormous appeal of a way of achieving the revolution that we're looking for. And as I like to summarize it, it's evolving, adapting and adopting new and insightful capabilities, not just from healthcare, but from other industries that will add up to this revolution that we're looking for. So in my mind, incrementalism is a decreased risk or risk aversion approach to achieving incredible success. And in part that was driven. As you look at, and I'll pick one of the names that comes up frequently, the Ubers of this world where everybody looks at that and goes, wow, that's, you know, who are the two, three, four, one guy, whoever it happens to be that came up with, you know, name this amazing concept. And when you look back at the history of almost all of these innovations, it turns out that it was never this one sort of eureka moment. It was more a number of sort of small steps, course changes, corrections, improvements, and sometimes an element of, of timing that allowed them to achieve something that we look at and go, wow, that's fantastic. And when I look at incremental healthcare, that's what I'm trying to achieve. Revolution through evolution. We'll get there one step at a time.

I love that. I think what it brings to mind for me is thinking about in technology, which will also spend a lot of time talking about the iterative process, you know, the, in some sense, you know, the fail fast concept and the idea of, you know, moving in a direction but being able to mid course correct if need be, not being so, you know, held to the orthodoxy of a certain kind of thing that you can't say, well, this really isn't working, or this is something we need to, you know, to change the dose or change the treatment regimen or something like that, I, I really like that.

And you know, that's exactly right. But for the folks that sort of look at that and say, well, no, no, I'm looking for the big change. I would say that you still get to the big change and you get to it quicker and you get to it with less risk and less cost, because as you try these things, you discover that not everything works. And you know, I wish I could quote the Original author of this. But, you know, for every failure is an opportunity to learn. And, you know, each of those failures adds up to the next step, the innovation. But if you make them small ones, it doesn't matter if it's wrong because you correct and you ascend that ladder of innovation so much quicker.

You know, I growing up professionally as a psychologist and working in psychiatric hospitals and things, it also just reminds me of the ethic of least restrictive environment or least restrictive alternative, that when someone presents with a problem, the first thing you think of should not be, well, let's hospitalize them. You know, what are the things, the, the other kinds of steps that might be involved that keep us from, you know, having to, you know, get the bazookas out to go hunt rabbits or something like that, so.

Right.

And I have to relate back to. I really enjoyed your article of why I joined Base Health. I think you published it. I think it was medium, or at least that's where I picked it up at. Can you tell us about how that came about and what your work is and what they're doing over at Base Health?

Yeah. So I think that the wonderful thing about, you know, again, the connections and the diversity of activity is that it sort of opened doors for me and I had the privilege of connecting with that team some time back. And you know, there's lots of people that are focused on population health, analytics, predictive capabilities. And this particular group stood out to me for a number of reasons. They stood out to me because they were based on science. So I'm a big fan of validation. And in this particular instance, they had taken the PubMed database, 150 odd million articles and said, let's create a knowledge base based on that. And that wasn't just a sort of throw everything in the hopper and produce an output. It was guided machine learning, which I think is a big differ differentiator. There were a lot of clinician inputs to say what makes sense and essentially they came out with about 40. In fact, it's 42, which for those of you that are fans of the Hitchhiker's Guide to the Galaxy, know that that's the answer to the universe. But if you don't, you'll just have to go Google that.

We'll get it in the show notes.

But so 42 diseases that they could essentially identify and predict with what I would describe as incredible levels of accuracy are going to occur in patients before it occurs. And let me define the incredible level of accuracy. A 0.9 C stat level is almost unheard of in predictive analytics. And that's what they're achieving for these 42 diseases. So that's a 90% accuracy level for patients that haven't presented or don't have that disease or have not been categorized or fallen ill specifically.

Wow.

And that for me was just so extraordinarily compelling because what it now does is it changes the equation of medicine to be no longer waiting for you, the patient who quite honestly is relatively unprepared and not well positioned to identify when you have challenges, clinical challenges. And we're asking you to make the decision to come into my office and turn it around and say we can now reach out to you and say we think you ought to come in based on what we know about your data. And it can be relatively minimal content. We'll ask you to come in. It's very much like the engine manufacturers, you know, Rolls Royce contacting the 747 pilot in the air between San Francisco and Washington, D.C. and saying, hey, we noticed something in your data that suggests there might be a problem with engine number two.

Wow.

And you know, there's a little bit of a reaction to that from some folks who go, well, I don't want to be told, you know, that the head in the sand routine, which we all suffer a little bit from. But ultimately, I think we all know that intervention earlier is always better. And what that does is it connects you now the specialized resource, the clinician who is sitting in his office desperate to help people, but is overwhelmed trying to filter out all of the requirements and the folks that are coming through. So it now identifies the individuals most in need of my help as a clinician and allows me to intervene and an opportunity maybe not to prevent, so that may not be possible, but at a minimum, to mitigate that disease. So that's the best possible medicine you could ask for. And it's also the best possible outcome for the patient. And as a byproduct, and I know it's not really a byproduct, but what I would call a residual benefit, this is also a very cost effective approach because instead of treating the catastrophic disease, you end up treating the and preventing the disease from occurring, which is a much more cost effective, lower cost treatment that's extraordinarily compelling.

I agree. And the success rate that you had, that 90% is just unheard of. I think, you know, as we get into more of the genomic and whatnot kinds of things, I think it will just really be that revolution that, you know, people are always wanting to see in health care. And it reminds me, there is a, I did a piece a while back on biohacking and there's a researcher who I just highly respect, Rhonda Patrick. And she has a website called Find your Fitness, I think, and she has a, a very nice tool on her website. I think it Costs all of $5 if someone wants to upload their genetic data into it like a 23andMe report or, or whatnot. And there's another one, Promethease, which I love the name that you can do likewise. I think it's also like five bucks or something. And I, I don't know. She always is like up to date on what the literature is and whatnot in terms of, of genetic expression and polymorphisms and whatnot. But Prometheus looks at, it's like a, it's like a Wikipedia for S&PS so and I think it's actually. Well, it's, it's from. What is it? SNpedia, I think. So it's sort of like the Wikipedia of, of literature around that. And you can, it's very overwhelming. The reports you get from Prometheus and, and Rhonda's are a little bit more understandable. But I've seen people in the biohacking kind of thing. I think your point about, you know, disease mitigation, disease prevention, et cetera, you know, is obviously huge. But I know a lot of biohackers also look at it in the context of how a person might metabolize vitamin B or B12 or something like that. There's also, you know, those kinds of things where people are trying to perhaps have a better level of just general fitness and, and healthiness or their athletes and you know, trying to get an edge or something like that. I just think this whole world of what you guys are doing at Base Health as well as, you know, these other kinds of data sources are really informing patients to, in collaboration with the systems and physicians that are in the know to be able to do that. But I guess my question then is how, you know, how widespread or broad spectrum, you know, if I were to, you know, go to my doctor and say, hey, I've got, you know, my 23andMe data, or hey, I've got my, you know, whatever, you know, 500 pound printout of, you know, all my stuff, are primary care physicians equipped these days to deal with it? Or some are, some aren't, or what's your crystal ball on that?

Yes. So you bring up a couple of really interesting points and I'll tell a story to answer that, but before I do, I just want to highlight the fact that in fact the genesis or the origins of the base health concept was founded around genomics. And the challenge that they had was that there was insufficient data and it was essentially a solution looking for data that was not currently available, which is why they sort of pivoted to looking at other elements. But as soon as we have the genomic data, that gets so much more accurate, which is for me, very exciting as far as the application. You know, tell my story. So I've been sequenced. I went through the 23andMe process before they got dinged by the FDA. So I actually got, you know, the 300 plus insights, which I just found truly fascinating. And you know, I accept that I'm not the average bear. I'm privileged to have had medical training and therefore could sort of read that and interpret it. But in fact, it was a non medical person who put me onto it. And you know, one of the challenges or issues that I hear repeatedly I had discussed with him, which is, you know, it gives you these insights that say, gosh, you're at risk of, you know, X and it's an increase of, you know, some percentage points, which, by the way, we as human beings are just terrible at assessing. We have a really hard time of understanding risk. But put that to one side for a second and say, well, so how do you deal with it? And as he described, and I'll quote him, he said, well, you know, it turns out that I had an increased risk of Alzheimer's. And I said, well, so what did that mean to you? He said, well, it just means that I do more sudoku. And that for me captures the sort of spirit of that today, which is, you know, this is guidance, this is, you are not a product of your genes. We understand that much better than we used to. And you know, clearly the epigenetics and the expression of this is very much up for grabs. So I did the 23andMe, got some insights, and then I actually went for a full genome analysis. And that process I went through as a patient. So I tried to understand it from the patient perspective so that I could relate it to what they would experience. So I had to get a physician order from my physician who very much looked at me as if I was stark raving mad. Why would I want this? You know, but he's gotten used to me. I'm a little bit of a, as they say in the banister of life, I am a Little bit like a splinter up his backside. And you know, I tease a little but you know we have a very good relationship. So he signed off on it and you know, I went through this and the sequencing was done digitally and they, they then took that sequencing and printed out a report and they mailed it to my general practitioner, my family practitioner and his staff scanned it into their electronic medical record. And then I had to go to the practice and ask for a copy of my report and they hit the print button and gave me a printed

copy of my efficiency at its highest.

Well, and you know, to answer your original question, how prepared are we that prepared? So there really isn't the capacity to sort of process this. My physician himself didn't really sort of, he got no value from it. I indeed have, you know, used Prometheus and I'll, I'll give them a shout out right up until the end of this year 2017. They're offering now a free opportunity to submit and store and continue to receive insights. And you're right, it is a little bit overwhelming. I'm not aware of Rhonda's site and I'll certainly take a look at that. So now you can actually continue to get insights and that's really the value because we continue to learn and I think as we start to understand this, we're going to learn better to incorporate this into our healthcare practice. But as of today it is very much on the periphery, on the edge around cancers where there's specific use cases, around pediatrics and rare diseases where we have some unique opportunities to identify and then for targeted instances where the well known one is the BRCA gene that people associate with breast cancer that has a clear association, although even that's not as clear as everybody likes to believe. You know, as, as demonstrated by the bilateral mastectomy that some folks have have elected to go with, although it's not 100% that you will develop. So lots of complexity. But that to me is again opportunity and you know, I would bring it back to incrementalism and say what can I use this for in an incremental fashion? Well, in the case of 23andMe, I'll give you some hardcore examples of incremental improvement. So my 23andMe and indeed my full sequencing showed that I was a Plavix super metabolizer. Plavix is one of the most commonly prescribed drugs in cardiac patients and fully one third of the population is so a super metabolism. It's useless to me give me as much. And so we can save both the cost of giving me the drug and finding it doesn't work and also the potential side, all of those things with a simple test. And that alone for me is worthy of an investment which you know, to me is a small improvement. And I'm not taking Plavix, but at some point I might be and I would put it on my, you know, it's in my medical record so that we don't waste time.

Yeah, I really, I think that's such a, a huge big deal. I mean just the whole like, you know, I made mention, you know, with vitamin absorption, things like that, the certain polymorphisms, you know, and not playing nicely with B and you know, you can just take it sublingually if you, you know, can't metabolize it properly in a pill form and you know, those kinds of things. I think it, it brings to me, brings to mind for me the thought of taking the aspect of big data and you know, doing a mashup with that in precision medicine, you know, taking what's, what did the published studies say? What do we find, you know, in large populations. But then, you know, does that, how does, what does that mean for me? And taking, you know, your own genetic data, scrubbing it against that and then being able to, you know, inform treatment decisions and other kinds of, you know, lifestyle routines, things like that. I think that's fantastic.

Right. And what you're also touching on is of course the explosion around the biome which again many of my colleagues would suggest, and I would concur that that's an undiscovered country in terms of where that might take us. Just in terms, you know, we talk about thinking with your gut and there's some, you know, some instances where people talk about this as, you know, it's an organ and so forth. I just think we are scratching the surface and I just back from an AI med conference and saw some incredible data presentations where people literally loaded in this content and the insights and the correlations that we're starting to see from some of this information are absolutely mind blowing. I think we're just not going to recognize the medicine that we've practiced for many, many years now is going to change in a way that you look at and go, wow, is what the hell were you doing when you did that? Yeah, years ago. Right.

Well, yeah, and, and I grew up again back in psych where you know, it was predating the time of evidence based practice, evidence based medicine kinds of things. Just because we had such a, a void in the Literature. And then, you know, I think the literature is kind of, you know, caught up with things. And now it's sort of like this, this flood and being able to really sort of sort and sift through those things. I have a great quote, if I can pull it out of my head from talks I give periodically about evidence based practice kinds of things. And it was sort of like, I think it was a former dean of the College of Medicine at Harvard who said something like 50% of what we teach students in medical school today will be wrong. The problem is we don't know which 50%. And I think that aspect, I think just the whole, you know, considerate. I mean, the, you know, the genomic stuff will just be like, you know, looking at a blood and just be as routine and, and probably more sophisticated, you know, through AI filtering and machine learning kinds of things. I, I remember too, just, I think it was just last year, if I do our research and get this in the show notes. But I believe that it was just 2016 that for the first time words like machine learning appeared in JAMA and New England Journal of Medicine, you know, sort of the, the North American hallmarks of, you know, medical, general medical journals. So, yeah, I think that's also going to be a radical change of what we see in the future. I, I just gave a talk and you know, I was talking about how historically it was like the Turing test of, well, is this computer as good as a human? And when you start to look at radiological kinds of things, you find that, wow, AI and machine learning is better than a human. You know, it's not even meeting the benchmark of being as good as one, but actually eclipsing them. I think, you know, that to your point, I think things will be radically different in practice as well as in training.

Yeah. And the comment I would. So I have a couple of comments around that I agree with you. What that tends to do is to induce a level of panic with folks who say, where's my job going? You know, what's my sort of ultimate future in all of this? And the one thing I would say relative to that is that when you look at medicine, I don't see this replacing the physician so much as augmenting it. So I think artificial intelligence is a suboptimal term, whereas augmented is the. We can't process the knowledge. We can't even visualize it. We visualize that best in three dimensions and there are so many more. And the capacity to process all this knowledge, you know, exceeded us many, many Years ago. So for me, that's one key point. The other one that I would say, and this, you know, this is another shout out to base health and another reason that I really sort of jumped on. This was one of the things that we know in healthcare. We've seen innumerable studies that show that it takes on average 17 years. 17 years. I have to say that again for, you know, established scientific understanding of disease and treatment of disease to reach, you know, pervasive clinical practice. And if that's the case, that means that you're actually getting medicine today. That is from 1990. I'm sorry, 2000, forgive me. 2000. Right. Unbelievable.

Unbelievable.

So do you really want medicine from there? So here's what base health does. So it's an accelerator for the application of that knowledge. And the hypertension guidelines are a good example that just came out relatively recently where everybody got panicked and said, oh my goodness, we got so many more people that are sitting as hypertensives. And in fact, it turns out that that's something that we knew, but we knew that because we're processing the data and the evidence on an ongoing basis than applying it immediately. And that's exciting. That's an opportunity to. We've got all this knowledge, let's apply it. I mean, we could make huge progress in terms of success and outcomes in medicine if we just applied the knowledge that we already have, let alone all the exciting stuff we're discovering.

Right, right here, here. And I like that point. I mean, your point is well taken, the whole augmented aspect aspect of it, because it is just impossible to maintain any kind of clinical practice as well as keep up with the literature. I mean, it is just, there's not enough hours in the day. I saw a study that talked about just specifically focusing on literature, published literature and in legitimate journals with cardiac care. And it was like around 2400 articles a week or something like that. I mean, you just have to, all you'd have to do is, all you could do is just spend your time reading all day long. So, you know, being able to, to have tools and mechanisms to be able to know what the literature says on big data sets as well, and augmenting them in like a meta analytic way and then taking that to your specific patient that you're, you know, in the consult suite with would be huge. I'm so looking forward to that day.

Right, that's exactly right. I mean, it's just, this is a huge, huge opportunity. I just think we're, we're going to look back at, you know, the archaic way we practice medicine, you know, in short order and go, wait, you did what?

Why didn't you do this? Yeah, well, I want to shift gears a little bit. I'm going to come back to tech, but I am just itching to hear a little bit more about your global perspectives and the things that you've done. I mean, you've been in the Middle east and you have been in, you know, all points north, south, east and west. So what kinds of things were you doing? Were you consulting or. Tell us a little bit more about your, your filled up passport.

Well, so I was lucky enough to be born overseas. I was actually born in Africa, west coast of Africa. And you know, what they say is that you can take the boy out of Africa, but you can't take Africa out of the boy. And that's true. I still feel a pull towards that continent. So I think that's in part the sort of underlying driver to all of this.

And then I have to ask, how did you wind up being born there?

So my father was in the oil industry in the days when the oil industry was really, you know, still establishing itself. So one of his primary roles was to go out and build the camps that we then ended up living in.

Gosh.

And you know, anywhere there's been, anywhere there's oil, pretty much they certainly have lived or my family, you know, have intersected. And you know, the good news was it was this just tremendous exposure that was just the norm for us. The challenge was it, you know, it forced me into boarding school at the age of eight, which, you know, some people listen to. And even my mother would say, you know, it was awful, it was, it was terrible for her to say Goodbye to an 8 year old on a plane on their own. But, you know, that was also part of the formative aspects of my background. Made me very independent and, you know, it also gave me a travel bug. Now I have two brothers who I don't think have quite the same travel bug as I do. They've sort of settled. They, they stayed in the UK where we went to school, whereas I sort of continue to move. And you know, I love that intersection with other cultures, other people. I find that, you know, the opportunity for innovation and importantly learning. So I saw a report, I can't quote where it's from. I wish I could because I'd been asked that essentially cited the top three countries for innovation are Israel, Nigeria and the United States.

Wow.

And I think some people sort of, you know, two out of the three they. They go, yeah, I get that. But the Nigeria one is sort of really right. That's. That's kind of surprising. And, you know, it's the most populous of the African countries. And part of what drives innovation, you know, is both stress and lack of resources. If you've got very little, you have to be more innovative. And they don't have as much as we do, and they do more with less. And, you know, that's what I love about the sort of exposure to these other countries is, you know, I would say if I had a criticism of the U.S. there's a tendency to believe that we've got all the problems sorted out.

West knows best.

Yes. Yeah, exactly. And I'm counter to that completely. I find that I learn so much when I go to these other countries, and I delight in it. I truly. It's a privilege. I consider it a privilege I always have, and I wish everybody had the same privilege. I think it's a really important element of growth and expansion.

So for you, I totally want to underline that, emphasize that for you. Was it solo or did you bring your family along or.

Oh, no. So my family. So my son had been in seven schools by the time he got to high school around a little bit. We did. We did eventually stop. And some of that was, you know, again, difficult. I think they would certainly accept that or recognize that. But at the same time, you know, when they did, what's the Flat Stanley? You must know, I did.

I took Flat Stanley to. To the equator.

So, you know, we. When Flat Stanley came back from our trips, he had been around the world because we had all these friends around the place. And my kids were. When they stuck pins in the map from where they were from, it was this concentration of wherever they happened to be. And then there'd be these random pins around the globe, and people go, who's that? Oh, that's the vantage,

of course.

So they got the exposure. And I would say, certainly have similar experiences and, you know, both the positives and the negatives, but, you know, in all things, pull the positives and find that. And that exposure, I think, has been good. My wife has been just incredibly supportive and, you know, part of sort of helping maintain some stability in all of these moves. You know, she was a big part of that. And, you know, I think I was. We were a team in delivering, you know, a family through that sort of experience. My kids lived in Saudi Arabia as children and were the highlight of any of the store visits we ever went to, because I had a Red head, a blonde and a dark head. And you know, the blonde, red was very unusual in that culture. So they were the tension.

I remember years ago my wife and I were at the Cairo Museum and it was, was the same thing. There's like a field trip and there are a bunch of these probably tween age girls that just like, like swamped her. You know, they had never seen such an albino, you know, kind of person walking around. So, so I, I think that's, I think that's a fantastic experience. I mean I, you know, my bias is that, you know, those kinds of exposures and at some level, you know, similar to you with Africa and the UK and, and all those kinds of travel things I think are great. And it looked like, you know, from what I know about you and your family, you know, that you've been very involved in, you know, coaching soccer, football and things like that. So to, to be able to have that kind of balance I think is a wonderful thing. I had a particularly bad year that was not in balance that I reconciled ever since then. But I missed my wife's birthday, my son's birthday, my daughter's birthday, birthday, my birthday and my wife and my anniversary all on the same year. It was just like one of those, just a killer. I think I tallied it up. It was like 200, 000 miles. It was just sort of like a perfect storm of just so many things going on and just, you know, just, just crazy. Just, you know, just stuff hit one thing after another. And while all those activities were good, it just, you know, was not good for family life and, and my kids were fairly young at that point point. So I just, you know, you feel like you miss out on those things. So I, I very much applaud you that, you know, it's, it, it can be, you know, stressful for family, stressful for everybody, you know, to, to pick up and move and make new friends and, and miss the former ones. But you know, it also is not cool to be away from your family, you know, lots of times and those kinds of things. It's hard to balance that out. So I think that's great. So when you and I first met, you had a very compelling, you know, the proverbial, everyone's kind of getting to know each other and all this at a conference or at a dinner or interstitial time in between. And I said something like, you know, where are you from? Or something like that. And you said you were like you lived in United terminals or something or something like that. And it was. You were.

Where are you from? And I said, I live on United Airlines.

That's it. Thank you. Because you had a very unique position. Was it with Dell? Is my memory serving me well?

Yep, that's exactly right.

Tell our audience about what you were doing then.

So that was truly a privilege and a tremendous opportunity. So working for Dell and, you know. Yes, that is Michael Dell's computer PC organization. And I was the chief medical officer, which, you know, sometimes. Well, actually, frequently I would get really. They have a chief. What's all that about? And then, you know, when you look at health error, it's awash with technology, and Dell is a primary provider for technology. And, you know, one of the things that I had the privilege was getting to know Michael Dell a little as I worked in that organization. Truly one of the most inspirational folks I've ever had the privilege of meeting at that kind of stature. Somebody that if you didn't know who he was, you wouldn't know that that's who it was. I mean, he's so unassuming, and I love that as a characteristic in people. It was just a delight to sort of work with him, work for him. I sat on a panel in the relatively early days with him. And, you know, he's very passionate about healthcare from a personal standpoint. And, you know, being part of the team that helped deliver and support that was just truly an opportunity. And, you know, to your point of travel, I certainly had that. I think in my peak travel year, or certainly as best as I could tell, I was at about 360,000 miles.

That's way more than home. That's.

Oh, yeah. Well. And, you know, it's funny, there's a. It. No matter how much you do, how brilliant you are, how smart you are, how fast you are, there's always somebody smarter, faster, you know, brighter. And that's true in travel. And I can remember having this conversation, you know, with a. You know, this is. Gosh, I do a lot. And whoever it was said, oh, I do 500,000 a year. Is that even possible?

It's like that George Clooney movie, you

know, up in the air without any of the shenanigans.

Wow, that's. That's fantastic.

And, you know, that was a privilege, too, because it got me into lots of places and. But it did. It had the same downside that you sort of experienced. And it's funny, I'm not doing as much of that now. And I actually, I don't miss getting on the planes as much I do miss being in places and, you know, if you were to ask me what was the one piece of technology that I wish would be invented, I don't think it can ever be invented, in part because of the physics and the underlying, you know, science is the transporter beam start.

That would be very handy, wouldn't it?

Yeah. Because, hey, I'm off to Africa. Okay. I'll be home at 5.

I'll be right back. Tech. Well, speaking of that, that's actually, that tees up a perfect segue because one of the things I want to have a conversation with you about also was we talked about tech. We talked about like from the, you know, the genomic and the assessment and the AI and machine learning and augmented and whatnot. But, you know, at some level, if you even consider sort of like a telephone, there has been telehealth for a while and telemedicine and, you know, tele this and that. So do you think the virtual presence of something like that or where do you see telehealth at today and what's your crystal ball say about it in the future?

So I think it's a key asset we have. We use tele versions in other industries, you know, so the telephone extended our capacity to reach people. The telefax or fax as it's abbreviated to, allowed us to communicate in writing. And I think the same is true in medicine. Medicine has struggled and you know, in part, that's the United States where we have, you know, all these different states where there's licensure issues that, you know, precludes a physician who's licensed in Maryland from treating patient in Colorado. My question has always been, I'm sorry, did. Did medicine change? Do the people have a different genetic structure that I don't understand when you

cross that state line?

Right, I cross that state line. And of course, I'm sort of jabbing at it a little bit because it is frustrating because there's. There's no good scientific reason for this. And I know there's economic reasons and I know that there's vested interest, but ultimately for the patient's benefit, you want access to the best resources. So I think we. And that's being resolved. So, you know, some of that's getting fixed and yeah, just some of the

holdout space I know through, like here in Illinois, where I'm based out of the Illinois Psychological association, is working with other states to have what's like called an interstate compact or something like that where you can, if you have whatever you know, level of licensure to practice in whatever state is your home, that other states are sort of giving a reciprocity to that, you know, type of thing. And, but I know it, sometimes it just gets to the point of ridiculousness, you know, like if, if you're on vacation in another state and your patient in your home state where you're licensed to practice, you know, calls you. I mean, it just, it gets to sometimes the point of ridiculousness. So I'm right. I'm hopeful that, you know, there will be a rationalizing of those kinds of laws and have the law catch up with the technology.

Well, in the good old days, and this isn't true anymore, but when I graduated, I took my medical degree from the United Kingdom and I flew to Australia and I handed in my medical degree and they handed me a Australian medical degree. That's reciprocity at its finest. I don't think that's true today quite as easy. And again, there are some good reasons why that's the case, but I think we need to move to that. So there's the underlying issue that the technology put to one side, the issue of the pipes and the challenge of access and so forth. But I think we've managed to achieve a lot with limited capabilities. I've seen some incredible capabilities using text messaging in Africa that allows for surveillance, allows for guidance to people, even allows for store and forward of imaging that can then be read elsewhere and provide insights back into the field in very remote circumstances. The clear sort of opportunity is this virtual presence and augmentation of interaction. There's a number of companies that are doing that both from a sort of procedural standpoint. So extending the rare capabilities of our highly trained individual surgeons that can project out an augmented reality. There's a company called Proximly that does that both domestically but also internationally to allow both for the extension of training as well as support for these individuals in poorly underserved areas. And then there's the sort of capabilities, you know, that if I was to picture what it might look like. Let's pick a Star wars analogy. And you'll know why I do, because of my sort of geekiness around that. But when we saw the communication between the Sith Lord and the folks in charge, they had these sort of three dimensional projection capabilities where it was almost as if they were in the room. And I think we'll see more of that and potentially interactions, you know, maybe augmented with capabilities locally that will allow us to receive care. And in the intervening time, you and I, as patients, I Know what I want? I want to be able to access it from my home. I don't want to have to get in my car, go, go park, go, you know, sit in a waiting room. So I think we're going to see an explosion. And I know it's been a long time, but I really feel like we've sort of hit that sort of tipping point to see that arrive.

Yeah, I think things like the growing, you know, the smart home and the Internet of things and you know, maybe even just, you know, aging baby boomers who are very, you know, tech oriented and tech happy. You know, I think those, those things will also help, you know, create a market for it as well too. And as soon as there's growing markets and inform customers and consumers of healthcare that, you know, I agree. I think it'll help, you know, be a couple of those other, you know, points to make that tipping point happen. So.

Right.

So with that like, you know, back to a little crystal ball gazing and stuff, I mean, with the things we've talked about, you know, I also, we haven't yet exactly spoken about like CRISPR and DNA gene editing and things like that, but you know, kind of what, what do you see as next? I mean, you mentioned this tipping point just now, but you know, what are the kinds of things on the whatever near or distant or both horizons do you see for the interaction of medicine and technology?

Well, I think you touched on it right at the beginning. It's sort of data driven. You know, the artificial intelligence that's superimposed on all of this incredible wealth of information. You know, the idea that we assess somebody's blood pressure once or twice a year versus continuously is going to seem, you know, stone age in comparison to the future where we have the capacity to do that. There's some clear potential of understanding that's been sort of exploding around the genomics, the obvious targets around cancer and specific disease. But it's much more complex than that. And I think without the machine learning and the augmentation of technology to assess and pull in all of that data, the genomics would be much harder to sort of see progress. But, but when you combine those two and you combine the 3 to 10x of the biome from the gut and other organs, I think we're going to see a total revolution in the way that we approach and look at disease. And there's already moves to move away from cancer that's labeled by organ. So stomach cancer versus a cellular level or even a genetic level, because I think that's Much more appropriate. So we'll move to precision or personalized medicine, depending on your preference. And that will be customized and more importantly, it'll be proactive. So it's not going to be, hey, I'm going to go and see my physician because I feel sick. It's going to be my physician notices something, proactively reaches out and says, hey, I noticed something. The following. I think you should change your diet. You know, wow, what a radical thought. Rather than here's a drug to your point, you know, you talk about your sort of prima sort of drivers. This is not about handing out pharma. This is about finding the best treatment and the best treatment, food is a drug and you know, changing that. So I think we'll see this complete change in the way that we practice medicine. That will be just as we look back, I think it will be the same as looking back at surgery, pre anesthesia and pre. Any real understanding. It will be that sort of arcane to look back at the way that we treat disease. Give you one simple example of this as a visual. We know how tumors form. They form in the body and at a cellular level. And how do we treat that? Well, typically we irradiate it or we'll cut it out. I don't, I think that will go away over time and we'll just reverse the cellular process maybe with some molecular or individual molecule style treatments. How different, you know. Yeah, no more surgery, just an injection or just a treatment, you know.

Right. Or maybe even a little Gattaca like, you know, deleting that, snipping that out with our Google Informed Crispr tool in our kitchen before the baby's born. So do you see any, are there in your opinion, any current unicorns out there, so to speak, as they talk about in the tech, not necessarily medical tech world, but in this sense we hear about all these tech unicorns, but what about in the medical technology world? Are there unicorns out there? Is there someone that's really going to be the spark to changing the game?

I don't know. I think again part of that sort of revolution, desire for this sort of exponential. My sense is that we're going to see much more of the smaller stepwise incremental companies, you know, and they'll be as simple as, and I'll pick one as an example that I think is just so extraordinarily compelling that essentially allows you to monitor continuously blood pressure using a non invasive device that's not inflating a cuff, it's just literally like a pulse OX CLIPS on wow. And, and that as a concept now suddenly changes our management and understanding of blood pressure because that's something that you could tolerate and they got FDA approval for that just recently, or at least I think a pathway to it. So I think it's going to be more of those small sort of individual insights that will sort of add up to that unicorn and maybe it will aggregate to a unicorn because somebody will coalesce all the right pieces together to be able to, able to deliver against that.

Yeah, I think that's what you raised. Really a good point. Because I think a lot of times when people create their startups and their companies in the medical health tech arena or area, that they are very specific kinds of things. And when you start to, it becomes sort of like an Internet of things for your body, so to speak. When you connect your blood pressure with your sleep, with your biome, with your, your diet, with your meds, with your whatevers, then that's when you. And then scrub that against the big data of, you know, what we are starting to learn that, you know, that gives you the integrated approach or augmented approach to being able to get the best kind of care. So how. I know we're about running out of time, but just a couple more questions. Do you have thoughts then about what we've just this conversation has been on of then how that plays out in medical school training.

Yeah. So that's really contextual, I'll tell you, you know, I get a proud dad moment at this point and say, you know, my daughter got into med school and she'll be starting next year.

Congratulations, fantastic.

It is. And you know, I can't tell you I've certainly not pushed it. So to be clear, this is not, you know, you go do this. This was all driven by her. But I thought about it in that context, very much so. And you know, for me this is just this incredible challenge of how do we prep, how are we going to possibly prep her in this new order of, you know, data processing? And, and if we don't fix this, we are absolutely going to fail them because they will never succeed if they're not appropriately prepared for this stuff. So I would say look to the likes of the Dell medical school. Another thing about Dell, Michael and Susan Dell foundation helped support and build that and they're taking a completely different look at the way that we prep both the medical students of the future. So it's more about teamwork, it's more about information or knowledge engineering and knowledge processing versus rote memorization. So I think adapting to this new world order is going to be one of the major sort of opportunities to really change the system to, to match what these folks need, which is a way of coping in this data rich world.

Yeah, it would be interesting. I need to do a little pardon me homework and take a look. I'd be curious to see what the curriculum looks like at Dell's medical school because that might be an insightful model as to how people are starting, starting to conceptualize that and integrate that in. I think that's a challenge to all medical schools, you know, everywhere.

And many are following now in part through the sort of drive by those individuals, you know, at the Dell medical school, or maybe they were before. I don't want to diminish anything that people have been working on in the past, but you know, there's certainly much more of a move afoot to really change the way that we sort of of deliver medical training, which is good news. I'm delighted by that.

Absolutely. Maybe get a better sharper point on what of the 50%. That's going to be outdated, what that is. All right, well, Nick, this has just been a wonderful conversation and you are such an accomplished individual and your CV is just. I've only been able to kind of scratch the surface of it and just. I certainly value, value the contributions that you do, even just publicly to everyone. I mean, I highly recommend people to follow you on LinkedIn and see the posts that you have. I mean, I just find them so fascinating. And I have to ask, there's another credential that we haven't touched on other than maybe in the intro and that is something to do with single malts. Can you wrap us up with a little bit of that? Maybe I should have started with that and get our priorities straight.

No, I think we should always finish with My mother was a Scot. I'm a proud Scot, proud kilt wearing Scot. And I had the privilege of dabbling into Scottish malt whiskey through my dad and living in Scotland for a while. And I have a. So I call myself a whiskey librarian. I, I truly have this outstanding collection. I'm always looking and capturing any new opportunities. I used to be more of a purist and focused on single malts out of Scotland. But I think one of the great things, much like international travel, you get exposed to others and you discover that there are whiskies from Ireland that are better known, but then there is Japanese whiskey. I've even come across some whiskey from Tasmania of all places. You know, so I do. And then I actually, I have a little video channel when I have time, I record a tasting video for some of these and try and give people a little bit of my sense of excitement. And the side benefit of this is that whenever anything like this comes up online, quite often get tagged in it. Now

you have a variety of specialties. So that's, that's good, that's great. Well, and as I've said, you know that the things that you post and the, the information you curate is so valuable. What are some good ways for listeners to follow you or to learn more about your work? I know you've got a website, I know you Tweet, you're on LinkedIn, but tell us maybe what some of the best places to get to know you a little bit better and to see what you're up to are.

Well, so I would say that the first step is obviously connecting online through whatever your preferred channel. I try and be an equal opportunity user across Facebook, LinkedIn, Twitter and some of the other channels. But the other thing I would encourage, and this is again, one of the privileges and opportunities, opportunities is just because we've connected there doesn't limit us. And you know, I love connections that then expand into both, you know, connections on the phone or through, you know, discussions, but then importantly at events. And I can't tell you the number of people that come up to me and say, all right, but you know, love interacting with you. This is who I am. And you know, for me that's a real privilege. I learn from other people. I mean, you're very kind and generous in the way that you describe my sort of contributions, but it's a two way street in my view and I see others as, you know, part of my source and you know, the network is part of the key assets that I have and I value it, it highly.

That's great. Well, good. Well, I, I really would emphasize, and again underline that because I think that that is, you know, very, very true. You're very accessible, you're very public and I think, you know, whoever would want to learn more and, and get more into these, you know, doing deeper dives of the, the interface between technology and genomics and medicine and really kind of what the, the future holds for healthcare. You're one of the key thought leaders in that and I feel honored to be able to call you a friend and to be in touch and it's just been a pleasure to have you on the show today.

It's been a delight. It's hard to believe that it's been so long since we started, but thank you for having me. I've enjoyed the conversation as I always do with you, Chris, so thanks very much.

Thank you, Nick. Take care.

Thank you.

Living a Life in Full is a production of Stout Media, a subsidiary of Gordian Knott, llc. Assistant Producer Gracie Wong Music Dan o' Brien Sam Rude Graphics Larry Newberry Executive producer and host, Dr. Chris Stout. To learn more, stop by our website, alifeinfull.org for show notes, and please recommend us to your friends and leave us a review on itunes. Thanks.