Deep Medicine

Well, it was back in the 70s, a long time ago — well before you were born. I went to medical school because I thought I could do some things to change the future of medicine, to make it better. And I was always thinking that maybe beyond the immediate patient story there was potential. So there was a lot of grand aspiration, and it took a while to try to actualize that.

I had a very bad burden of disease in my family — a lot of people dying very young. My father had been an insulin-dependent diabetic as a teenager and became blind in his 40s, basically disabled, and had every complication known of diabetes. So I watched all that growing up, going to all these funerals of relatives who were in their 60s or younger. I had a natural sense that there's got to be something better than what I'm seeing here. Maybe I can help.

I've always been interested in what's the new, new thing — what's going to be transformative. Why waste time on old stuff if there's something on the horizon that could really make a difference? So whether it's biotech, digital sensors, whatever — I've always cued into that. There's that old expression: you want to go to where the puck is going to go, not where it is now. And that's the way it is in medicine too. Not that the historic legacy things aren't important — I have a lot of respect for that — but always looking for the path to a better future of medicine, that's kind of vital.

Well, I don't know about the fax machine — but yeah, they're still around, amazingly enough. There were two things that happened that were like eureka moments.

I was in Cleveland, it was 1999, I remember it distinctly. A contact of mine in California sent me a packet of slides, a slide deck. And the question was about monitoring the heart rhythm of a person over the internet. I said, whoa, this is exciting. As a cardiologist, this is going to be big. It turned out it was a San Diego company.

Then I moved to San Diego back in '06 — I came to La Jolla and Scripps Research to set up a genomics institute. That was the intent, because I've always had a longstanding interest in that since my college days at the University of Virginia. And the second eureka moment, which was even bigger — I happened to go to this conference sponsored by Qualcomm, the big wireless company in San Diego, which as it turned out is the wireless capital of the world. That's why that company with the internet heart rhythm was in San Diego.

So I go to this conference, I'm sitting in the back, kind of sleepy, and this guy gets up at the front of the room. Remember, this is the beginning of 2007. He says, we're going to put a camera in a smartphone. And all these people were arguing that that's a total joke, a waste — it's redundant, we've got all these great point-and-click cameras that are very compact, why would you put a stupid camera in a smartphone? And it all hit me: wait a minute, if you could put a camera in a smartphone, you could take pictures of a skin problem, you could take videos — where is this going? That was the moment I said, we're going to go deep in digital medicine.

So here it was, 13-plus years ago. Instead of being a genomics institute — right when I was getting started — we became a genomics and digital medicine institute. That's the first academic digital medicine program I know of in the US, and we stayed with it. Because you can't understand a human being unless you look at multiple layers, multiple dimensions. The sensors are physiology; genomics and all these other biological layers are biology. This whole notion that just from a DNA sequence you know everything about a person — that's just not right. That was too much to expect from DNA.

Oh, I think I'm still viewed as crazy. I've had all these peers say I'm too exuberant about the value of sensors — one person said I have sensors in my underwear, all kinds of stuff. It's nonstop. The naysayers never give up. But you just keep plugging away. If you know something is real, has real potential, then you have to prove it — and that's the harder part. It's not to say, "hmm, this looks really exciting." The much more challenging thing is to go after the validation, the proof that it really is going to make a difference.

And no matter what you do — no matter how many randomized trials, long-term follow-up, all the impact, all the savings, all the reductions in people's morbidities — there's always going to be people trying to negate that. It's unfortunate. We don't have an unbiased peer group in medicine. So the number one adage is: tell it like it is. Just keep telling it like it is. Because if you try to accommodate the people who are going to dismiss or negate your work, you won't get anywhere.

The first sign is that people are saying you're crazy. That's a good sign. That means you may be onto something. You see, medicine is a very conservative, sclerotic, almost ossified community, resistant to change. The only change in the US that seems to light people up is when it's going to improve reimbursement. Overall, it's not a community that embraces change.

It's very anchored in — whatever we're doing, we've just got to keep doing. Now, on the other hand, we don't want to bring in something that isn't proven and put a patient at risk. So there's a fine balance — not being too fast to embrace a new technology. But there's also a pervasive issue: people in the medical profession generally believe that technology is depersonalizing, that it detracts from humanity and humaneness. And that comes, in part, out of the electronic health record disaster. They've been so bad — doctors became data clerks — it's an abject failure. That has affected the digital transformation of medicine in an adverse way. But we can't let that happen. There are lots of other digital things that are great, and we don't want to lump them all together as part of the electronic health record catastrophe.

I certainly stand by that sense of resistance to change. I'm an old dog now — fourth decade in the practice of medicine, still very much involved in patient care, although more telemedicine now than ever before. What I've learned is that pushing for change is really hard; you meet up with lots of resistance. Take genomics — in the UK it's been embraced and leads the world. But in the US there's still a tremendous lack of interest and support to use genomics in medical practice. It's amazing, no matter how many studies come out showing it helps people. That's why I say it's sclerotic: you have the proof, and the patients who could benefit don't derive the benefit, because of resistance.

I don't think you can learn anything from the US health system — it's far worse. I went into it with an open mind. My perspective had been skewed by all the negative press in the US: that the UK healthcare is rationed, people are waiting a decade to get care, all this stuff. So I went in there after Jeremy Hunt asked me — and I didn't want it to be called the Topol Review, but that's what they insisted upon. And I learned so much about the system, and got immense respect for it.

Let me isolate a few special things. First, the group within the NHS coordinating the review — Health Education England — was an amazing team. Such great talent, the mind-sharing, the brain trust there. And the striking thing is: as part of your health system, you have an education arm. There's no other place that has that. In the US, training physicians, training clinicians? So that was step number one — I felt like I'd landed on a new planet where they actually believe in the education and training of the workforce.

The second noteworthy thing was the deep embracement of genomics — there had already been training of clinicians in how to use it, and it was the world leader. I knew that from the papers, but to see it in action, to see clinicians well-versed and keen and really into it, was something else.

The third thing: I talked to a lot of people on the streets — this was before COVID — because I wanted to get a sense of what the public thinks of the NHS. I'd ask a cab driver, whoever: what do you think of the NHS? And I didn't find one person who didn't have the utmost regard for the care they got. They might have said, "I'd have liked it quicker" — but to learn it's respected as much as the royal family or the BBC, or more, was illuminating. Because if I asked those questions in the US, people want to reach for a barf bag about the health system.

And I actually got sick when I was there — I had a kidney stone on my last visit and had care on the NHS. It was a new experience to be sick in a foreign country, and it was exquisite. I don't think that was unusual; I think it was the norm. Great clinicians, they really care about their patients. I can't say enough positive about the NHS. I know it's under fire — understaffed, underfunded — but the reassurance is that it's egalitarian, and it does remarkably well. Its outcomes are terrific compared to the US. And the fact that all people in the country have healthcare, whereas tens of millions in this country do not — that says a lot about the difference in attitude towards healthcare as a human right.

There are two ways to look at it. On the one hand, it could actually bridge the gap. Take smartphones and medical apps: you'd be better off giving them to people who are indigent, who can't afford it — along with a data plan for the next two or three years — than paying for one night in an American hospital, which is like $5,000. So why don't we do that? Chips are cheap, software can be free. If we used the tools like that — "you can't afford it, we're going to give it to you" — because having broadband access and apps that promote better healthcare is medicine now, and it needs to be promoted. We're not doing it enough.

You and medical students today are digital natives, you get it. But at least in the US, more than half of doctors are over 50, mostly over 55, and they don't embrace this. They haven't come to that resolve about digital tools and smartphone medicine. We need that to happen.

I don't know if I have another book in me. Deep Medicine took so much out of me, because I tried to learn a new field and project where it can go — and the exciting part is that it could bring medicine back to the way it used to be in the 70s when I first started: a precious relationship between patient and doctor, with amazing trust, presence, empathy and intimacy. We need to get back there. Each of these books took about three years to do, and they take a lot out of me, so I don't know if I can do another.

It's a funny story, actually — breaking into publishing as a new author is very hard. When I was writing Creative Destruction, you have to get a literary agent, and then get a publisher to accept it. The proposal was worse than working on any grant I'd ever done in my whole life — like 15 iterations of a 20-page proposal. It went to every publisher of nonfiction books, and none of them wanted to do it. None. They were not interested. I basically got dejected, because I don't like to fail and I'd put a lot of work in. But then I contacted one of them — the only one who'd expressed any scintilla of interest — and I was able to convince him, like a sales pitch, that the book would be worth the investment. And I did it.

The funny part is that when I first called the agent, I said I didn't want to do just one book — I want to do three. And she was laughing. Well, I did what I said I was going to do. So I feel the trilogy is what I set out to accomplish. Whether there'll ever be a fourth, I don't know. I've been thinking about a book on the pandemic and medicine, but I haven't got to the point of deciding to do it. I've been following it very closely, trying to help get the word out about new studies and new ideas.

First of all, I wish I was a medical student in my 20s — that would be number one, because you're entering the most exciting phase of medicine. You have an opportunity to get medicine back to where it was 40 or 50 years ago. That's extraordinary, because it's been steady erosion all this time.

As far as what to do — I think you have to think big. You have two levels of contribution. One is to take great care of patients, and that involves not just communication and empathy but true care. We use this term "healthcare," but a lot of the time there's no care in there, it's just business. And then there's another level: can you make a difference at a much higher order of number of people? I'd encourage everyone to do both. The reason it doesn't happen many times is that people don't believe in themselves enough, they don't have enough confidence. But everybody can make a huge difference, and I hope people get supported to make it. Because it's very rewarding to have those two levels of impact — to learn from and help patients, but also to take that and amplify it, whether through research, writing, podcasts, an article about a patient in a magazine, whatever.

I look at it just the opposite. We should nurture the idea that you need to be a public communicator. You need to be able to tell a story — whether it's about a patient, or a paper you've been involved in, or whatever you're thinking about — and communicate it effectively to the public. Too much is emphasized about writing scientific papers and getting them published in medical journals. That's not as important. I learned through the books and writing op-eds that the reach, the ability to change things, is much greater if you're talking to the public. Because the medical community, being so sclerotic, doesn't listen. But the public is hungry for new ideas. If you can communicate to the public, think of them as your audience rather than only your colleagues, and learn to translate things into simple language — no inside-baseball jargon — that's really important. That should be promoted in medical school and in training. It's vital.

Well, partly because I'm a maniac and an info junkie. A lot of it is sharing info — most people read a lot of the same stuff I'm reading, but they don't share it. I'm into data sharing and information sharing.

I was very resistant to getting on Twitter 11 years ago. I thought it was about Lady Gaga, some kooky, worthless thing. And a colleague of mine — it was Linda Stone, I remember it very well, we were at a coffee — she said, "Eric, you really have to get on Twitter, that's how you get your ideas and your voice manifest." So I took her advice, and I started realizing: whoa, wait a minute, I can reach a million people. I can reach 10 million. I can reach 50 million. Over 11 years I've learned how to get the word out and use it in a way that's effective. It takes a while, it's an investment of effort. There are some bad days when people go after me on Twitter for no good reason, but most of the time it's very positive.

I see it as a scientific exchange. I'm not an immunologist, but I learn a lot about immunology from people. I'm not an epidemiologist, but I got up to speed quickly in the pandemic. My knowledge base is greatly enhanced through Twitter. I've made all these friends — a long list of Twitter friends, some of whom I've become friendly with at conferences and beyond. I think it's the number one form of scientific exchange right now, because when a preprint is published — no less a paper — there's immediate discourse. Sometimes it's hostile and ridiculous, too aggressive. But when it's collegial, it's very valuable. It's a pulse on medicine, on science, on life science. I don't regret my investment of time. I've done some 28,000 tweets in 11 years — all for me. If people think I have staff that helps me, that's a joke, I have no staff. Typically I'm editing a paper or writing something and I need a break, so I go to Twitter and then go back. I don't sit on it all day; I work it in when I can.

The number one thing has been reading a lot — being up on what's important in the field you're interested in. I'll never forget, back when I did my training at UC San Francisco, it was before there was such a thing as a PDF. I had to go to the Xerox machine and copy all the articles. I had about 50 boxes of articles I'd copied and read, or tried to read. And here I was moving across the country — what am I going to do with all my boxes of precious articles? It's a little anecdote about how much I value the literature.

When I was in medical school, my mentor Arthur Moss — when I did my rotation with him, we'd go to the library every day, first, before we went on rounds with patients. We'd spend an hour reading journals. Now, I know nobody goes to the library anymore, but that helped cement that reading the medical literature is essential. So many people I know are not up on the literature, and I think it's unfortunate, because it's stimulating. I don't know how you can provide the best patient care in your field if you're not keeping up with the progress.

Wow. The best medical book I've ever read was Siddhartha Mukherjee's The Emperor of All Maladies, about cancer. It won the Pulitzer Prize and took Sid seven years to write. It's amazing, both from the cancer perspective and the biology. He wrote another book, The Gene, which is also superb. I'd highly recommend him — he's one of my favorite authors.

And as far as a non-medical book, the one I'd single out is Garry Kasparov's Deep Thinking. You remember him — the grandmaster chess player who lost to Deep Blue. There's nothing medical in the book, but it makes you think a lot about AI, about the man-versus-machine era we're in now. I like that book a lot — it's probably right on my bookshelf behind me. Those are a couple of my favorite authors.

No, no. I enjoyed the discussion, and I'm really glad to connect with you. It's terrific what you're doing — keep up the great stuff. I'll look forward to following your career in medicine.