Medical Innovation 101

Seventy-five. Today I have 75 patents. And those are, second only to my children and my grandchildren, the things I'm most proud of.

I've given some lectures on this. I gave a lecture at MIT Sloan School of Business 15 years ago, and in it I coined a term: "intercepting the strategic vector." There was a book written in the 1980s by John Naisbitt called Megatrends). I look for trends, and then I look for conventional wisdom.

And then I do what I call orthogonal thinking. I try to take a perspective that's orthogonal — 90 degrees — from that conventional wisdom. The fish are all swimming in this direction; I want to swim in that direction. Because if I do that, I'll come up with a unique solution, a unique answer to whatever the problem is.

As a physician, you'll see problems — in your workflows, in your therapies, in your diagnostic modalities. You saw them in your training, you saw them in medical school. And now you get the opportunity to say, "Is there some way to do this better?" That's the way innovation occurs. People who understand the problems decide they're going to take an unconventional approach to them. I've now systematized that; I always do it. At first I stumbled into it, by making that series of bad decisions I told you about.

You get to the point where you don't want to fail. I didn't want to disappoint my parents, my wife, my children. Embarrassment and fear are great motivators when it comes to working 26-hour days — and, unfortunately, they're not good for your family life. I have an incredibly tolerant wife, who's a physician herself, an academic physician. I even have a son who's a physician. But I've systematized the notion that whatever problem I recognize, first I try to figure out what's a unique way of approaching it, a unique solution.

The second thing I try to do is ask: is it practical yet? Does the technology exist, does the infrastructure exist, to implement whatever crazy idea I have? There are a couple of Silicon Valley mantras that are good here, and one of them is: to be early is to be wrong. If I'd tried to implement my idea of a personal ECG device communicating directly to the physician in 1995, I would have failed. It took the iPhone, 3G communications, practical digital wireless around the world — 15 years later — before my idea could be implemented. I had to be able to recognize that.

I plug myself into clinical medicine around the world. I ask my friends: what's the long pole here? What's the hard putt? And I'm fortunate enough that at AliveCor we have some really outstanding investors. One of them is Qualcomm, which makes the chips that go in almost every cell phone that doesn't have a fruit on it. Another is Omron, whose blood-pressure machines you'll find in any pharmacy, literally all over the world. They're investors and partners, and they give me insight into technologies that are coming, and technologies that already exist, that I wouldn't have had myself.

While I've systematized it for myself, I think everyone has to take their own unique perspective on how they innovate. But I do believe innovation is something you can learn. I learned it spontaneously — I was not an innovator when I was 20 years old. I learned it out of necessity.

I have a lot of young people come to me — physicians like you, medical students, graduate students, attendings in their 50s — saying "I want to do what you did." And I go: no, no, no, you don't want to do what I did. It's worked out for me, but I could have failed many times. I have failed many times. I just failed small. But I could have failed big, and then it's back to plan B. So I tell people: do it smarter than I did. If you're going to start a company, you'd better have your best friend who knows what they're doing — someone with an MBA who knows how to run a business, who understands finance, marketing, human resources, manufacturing, all the things I had no clue about. You don't want to jump off that board thinking you're jumping into a swimming pool when you're actually jumping into the Grand Canyon. You don't want to do it with your eyes closed. So I think you can learn it, and I think almost anyone can be an innovator in almost anything they do.

It doesn't mean they'll be an entrepreneur, but you can innovate in almost everything. And again, it comes down to taking that unique perspective, coming up with a different answer — and if you believe it's the right answer, sticking to it.

First of all, I'm very blessed. My leading investor and chairman of my board is a very famous venture capitalist named Vinod Khosla, a co-founder of Sun Microsystems. Vinod famously said, ten years ago, that 80% of what doctors do will be replaced by AI. Of course, I immediately went to him and said, "Hey, Vinod — am I in the 20%?"

He's continuously looking to the future, to innovations. AI is clearly going to play a major role. As he says: I may get the timing wrong, but I'll get the direction right. We overestimate short-term achievements and underestimate long-term ones. Absolutely true. We may think self-driving cars are here tomorrow — they're not, but they will be here.

So I famously tell my four children — and I want them all to do their own thing — but there are only two jobs in this world I wouldn't want them to pursue: truck driving and diagnostic radiology. Both are going to be taken out by AI at some point. Delivery trucks go from point A to point B; they don't stop for lunch, they don't meander. That will ultimately be done by trucks with no people in them. And diagnostic radiology — well, there's the mantra: physicians won't be replaced by AI, but physicians who use AI will replace those who don't. What you want is what I call the highly specific screen. I want AI that really knows normal, and anything it doesn't call normal, that's what I want to look at. I want absolute confidence that when it calls something normal, it's basically 100% specific. It may not be sensitive at all, but if it's 100% specific, it makes me much more efficient — as a diagnostic radiologist, or as any physician.

We have to become more efficient. It's very hard to train someone like you — it's expensive, it's time-consuming — and yet, around the world, we need more physicians and more nurses. So we have to improve efficiency.

A few years ago I heard a statistic that just blew my mind: 50% of the population of the world will be born and die without ever seeing a doctor. I was like, no, no. That's a US–UK perspective. That's not the perspective from the middle of China, South America, Africa, New Guinea. Those people don't have a minute clinic a block away. There are well over a billion people who don't have access to doctors, and somehow we have to help with that. Today we still have people dying of the complications of rheumatic fever — something we've been able to cure with penicillin for 70 years. We have rapid strep tests, we have antibiotics that cure strep throat, and yet people are still dying of rheumatic fever. It's like malaria — people are still dying of malaria, of TB, things we can cure. Millions died of COVID in the last two years, and we have extremely effective vaccines. So we need to spread the knowledge and spread the wealth.

And that, my friend, is very fertile ground for innovation.

First of all, they're techno-optimists: they believe the future will be better and that technology will enable better futures. It won't be a Terminator-type future — AI isn't going to come after us. And they're slow to say no to an idea; they want to research it. Eric is a scientist; Vinod is an engineer — you could call that applied science. But both have their finger on the pulse of progress, whether it was Sun workstations or any of the investments Vinod has made, or Eric figuring out that Vioxx had bad cardiovascular outcomes and becoming famous for pointing that out — to Merck's chagrin and the FDA's chagrin. The reality is they're always questioning, always challenging.

To those around them, that can feel intimidating. But you should see it as a tremendous asset. You need to challenge yourself, as well as having people like them challenge you and your ideas. A simple adage from one of my coaches many years ago: the strongest steel is forged in the hottest fire. You have to challenge your ideas — they have to survive those challenges if they really are valuable. These people challenge the status quo and believe tomorrow will be better, and that technology can be part of that.

You probably don't.

People love to talk about sensitivity and specificity. They don't want to talk about prevalence, and positive and negative predictive accuracy. If you put those tools in the hands of people who are 30 years old — and, by the way, health-conscious, fitness kinds of people — most probably any alert you give them is a false positive. It doesn't matter how good you are. That's just the facts. Prevalence for a condition like atrial fibrillation rises exponentially above the age of about 65. It goes up exponentially, so that people over 80 have a 10–15% prevalence of AF. But the problem is they also die, so as you get older you have smaller and smaller absolute numbers. While prevalence goes up, actual numbers come down. These are all things you have to consider when you look at value.

This is near and dear to my heart, because at AliveCor the average age of our customers — most of whom buy directly, from Amazon or our website — is 63 years old. That's not an average app user. Those people aren't on TikTok all day, or Tinder, or whatever app you're using. They're patients. And we know more than 50% of our devices are bought on the recommendation of a cardiologist. That's true in England, too — there are some very famous cardiologists in England who tell their patients to buy a Kardia — and true in the United States and elsewhere. So there's selection.

That doesn't mean we don't have potential issues. A very well-known cardiologist called me into his office ten years ago, scowling, and I knew I had a problem. He said, "Dave, I gave one of your devices to one of my patients, and he sent me 20 ECGs the first day." I said: you and I both have a problem. You need to better select and educate your patients, and I need to handle the data better so it's not such a burden to you. We spent a lot of time and effort at AliveCor working on both — helping physicians educate and select the right patients. We don't want to create cyber-hypochondriacs. We don't want to burden the worried well.

We want to help patients, and we do want to empower them. Because what's one of the biggest problems in medicine? Whatever your therapies are, almost the biggest problem with any chronic condition is compliance. It doesn't matter if it's anticoagulation — you put someone even on a new direct anticoagulant, forget warfarin, you put them on Eliquis, and they stop taking it. They're scared, they want to go skiing or ride a bike, things they're told they can't do on these medicines. Blood-pressure medicines, for a variety of reasons — sometimes personal performance — people stop taking them. Compliance is a huge issue. And an empowered patient is a more compliant patient. Eric Topol's book The Patient Will See You Now turns the old paradigm — "Mr Smith, the doctor will see you now" — 180 degrees. It makes the patient a partner. If your patients consider you a partner and a friend, they take what you say to heart, they're more compliant, and they have better outcomes. It all goes together.

Partnership, AI, monitoring, democratizing access to technology. Here's the greatest example, and it's long before me. When I was in medical school in the late 1970s, do you know how diabetics got their blood sugar measured? They went into a doctor's office. Do you think any diabetic today would consider that practical — that they could be well controlled by going into a doctor's office to get their blood sugar measured? No. Now we have continuous glucometers, and for several decades you've been able to prick your finger and get a blood sugar, an A1C. Those things have empowered and improved the outcomes of diabetics all over the world.

Same with high blood pressure. You don't have to go to a doctor's office, or stick your arm into a machine at a pharmacy, to measure your blood pressure — you can do it at home with a very economical machine. We just applied that same idea to your cardiac rhythm. There are millions of people with abnormal cardiac rhythms, some of which can be very dangerous. I followed those previous paradigms and applied them to something I knew well.

Well, first of all, a home MRI machine is neither economical nor practical. That's in a science-fiction book somewhere — the movie was Elysium). If you saw it, the people who lived in the orbiting super-city could get in their machines, and it would scan their body, find their cancers, clear their arteries, keep them in ultimate physical shape. Science fiction.

So what do I think? There are things we still need doctors and nurses involved with, because our therapies aren't without potential harm. Take pain medicine. We have some very powerful pain medicines, and they can be abused, they can cause great harm and death. Sometimes you send somebody home with a PCA pump, but it's regulated — it's not like they can juice themselves into respiratory arrest. For the foreseeable future we'll have doctors involved. You're not going to be taking your own chest X-ray at home.

I've got a GE echo device here, a GE Vscan. So I can do an echocardiogram anywhere, as long as I have some gel. I can do an ECG anywhere, listen to the heart anywhere, digitize it, and send it to people even smarter than me who can tell me what I missed. Those kinds of things are going to be available. We'll have AI that teaches relative newbies how to do an echo for whatever organ system. And those costs will come down. There's not much harm you can do with an echocardiogram — unless you swallowed it, and it looks a little big to me.

But X-rays, MRIs, CTs, various therapies — you're not going to be doing your own cath at home, placing your own stent, doing your own ablation. You're probably not giving yourself your own chemo, unless it's some oral medication. So a lot of things will remain in the domain — both therapeutic and diagnostic — needing professional guidance, supervision and interpretation. But more things will move: blood tests, COVID tests. In the last two years we now have home rapid antigen tests, and that technology — kind of like Velcro coming out of the Apollo program — will be applied to a lot of other diseases. We'll have home flu tests, home RSV tests, lots of different tests. Just like you have home drug tests now, so parents can remain paranoid about their kids.

There'll be more things democratized, more things that come down in cost, and ultimately those will be very beneficial and help decrease the cost of healthcare — which isn't inexpensive anywhere. The NHS has a significant budget, significant costs, and is always challenged to be more efficient. That's true of healthcare throughout the developed world. In the developing world, the challenge is just access — getting those people in front of somebody who can help them.

First of all, I don't do that anymore. I could famously tell you that entrepreneurship is something for the young — kind of like having families. When I see somebody close to my age, a man with a younger wife and young kids, I just shake my head. My grandkids — I love to hold them, I have a two-year-old and a one-month-old, I love to feed them, and I love to give them back to their parents. Diaper changes and getting up in the middle of the night, that's not for me. So entrepreneurship is like raising young children: it's for young people.

Today I'm very focused on a very few things, because I've done a lot, and I'm happy with the things I've done. But I'm not dead yet. As I tell people: I'm old, I'm just not dead. And I haven't started forgetting things yet — so both of those are good. I'm still working, but I'm focusing my work on some very specific things. One of these days I'll decide I've done about all I can do, and beyond that all I can do is harm — and at that point my wife and I will find a nice beach somewhere. But that day is not today. At my age, and with the amount of really outstanding people I have around me, I'm focused on very specific, very targeted, very limited things. AliveCor does a lot of things I'm not involved in today, and I'm glad not to have to be.

Yes. I'm ridiculously and impractically optimistic. My wife is the opposite — she thinks everything's going to go wrong. I just don't believe I'm in a situation I can't get out of. That's a valuable talent for an entrepreneur — and, oh by the way, sometimes I'm proven wrong. But I retain that unrealistic optimism, and I think it's allowed me, despite often being told this isn't going to work or you can't do that, to persevere.

There's another old adage: you'll never fail if you don't try — but you'll never succeed either. So I don't mind trying and failing, because every so often, I'll succeed.