Insiders Scoop: Restoring Healthcare with Artificial Intelligence – Dr. Eric Topol

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Name: Eric Topol, MD

Specialty/Interests: Cardiology | Artificial Intelligence | Genomics | Preventive Medicine

Education: University of Virginia (BA) | University of Rochester (MD)

Current Position: Founder and Director of the Scripps Research Translational Institute | Executive Vice President, Scripps Research | Professor, Molecular Medicine, Scripps Research

About Dr. Topol:

Eric Topol is Professor, Molecular Medicine, and Executive Vice-President of Scripps Research, and Founder and Director of its Scripps Research Translational Institute. He has published over 1200 peer-reviewed articles, with more than 300,000 citations, elected to the National Academy of Medicine, and is one of the top 10 most cited researchers in medicine. His principal scientific focus has been on the use of genomic and digital data, along with artificial intelligence, to individualize medicine. He is a practicing cardiologist.

In 2016, Topol was awarded a $207M grant from the NIH to lead a significant part of the Precision Medicine (All of Us) Initiative, a prospective research program enrolling 1 million diverse participants in the US. This is in addition to his role as principal investigator for a flagship $35M NIH CTSA grant to promote innovation in medicine. Prior to coming to Scripps in 2007, he led the Cleveland Clinic to become the #1 center for heart care and was the founder of a new medical school there. Topol was commissioned by the UK 2018-2019 to lead planning for the National Health Service’s integration of AI and new technologies. He has published 3 bestseller books on the future of medicine: The Creative Destruction of Medicine and The Patient Will See You Now and latest Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.

Dr. Topol’s Bestsellers:

 

1 | What do you believe is the root problem facing healthcare?

The root problem facing healthcare manifests when people seek care, specifically mental care: patients don’t receive the care they need and deserve, and this is largely because clinicians don’t have enough time to listen, to be present, and to really render care with empathy. They are rushed and squeezed and as a consequence, patients like myself feel the brunt of that.

The reality is that you cannot deliver care in a matter of single-digit minutes in a significant situation, in almost any situation clinically – what I experienced is emblematic of what is so common. Since I wrote the book, I’ve heard countless similar stories and I’ve heard many over my career, and I hope that we do better in the future. We must do better in the future.

 

2 | What tangible changes do you believe AI will introduce into medicine within the next 10-100 years?

I hope it doesn’t take 100 years! Artificial Intelligence (AI) has tremendous promise. It is in its early days, but if we set our sights on the overarching goal of giving the physician-patient relationship priority alongside the gift of time, and reestablishing that deep relationship, we can ultimately bring that goal to fruition via AI.

Currently, its utility is reduced to increasing accuracy and speed in the delivery of care, and serving as a solution to inefficiencies and workflow issues, but we fail to recognize it as the rescue – the antidote – that it is, with its potential to bring medicine back to where it used to be decades ago. I’m hoping to make that vision prominent in people’s minds so that we don’t lose sight of where we can go with AI.

If we don’t push [to leverage AI as a means of restoring the bond between physicians and patients], it won’t happen because medicine in the United States is run by administrators –  overlords – who want more cases, more patients seen, more scans read, more slides read because that is how revenue is made.

If we bow to that and don’t stand up, then even when we have AI capabilities that are compelling and validated, and more than capable of rehumanizing medicine, they won’t be properly implemented unless we really fight for that goal.

 

3 | What tangible steps can we take to ensure that the time we gain back from AI is leveraged to restore the human bond between physicians and patients, and not just exploited?

We know that when health systems are run by clinicians, there is a greater understanding of this central problem. We want to see competition among health systems where the gift of time is recognized as the number one priority – where the doctor-patient relationship takes primacy over everything else. That hardly exists today.

Most people don’t share an intimate, trusted relationship with their doctors because when they go to see him or her, there is such little time, and as a result, it is so difficult to achieve an adequate level of presence and trust.

Again, this stems from the fact that doctors and nurses are obligated to currently serve as data clerks – they are slaves to the keyboard and constantly typing. This can be fixed very quickly and it will be. This is something that should be occurring right now –  it is in other countries, and soon enough, the data clerk roles of physicians and clinicians will start to diminish. This is long overdue.

 

4 | For physicians who have found themselves inundated with far too great an administrative burden and are vexed with technology, what can they look forward to as medicine changes?

Through the production of synthetic notes via AI natural language processing, whereby the conversation between a clinician and a patient is translated into a note better than any note that exists in the EHR today, which are largely compositions of cut and pasted text, a doctor’s voice can be very accurately captured in notes after a short number of patient encounters. We should also give these notes to patients for editing.

Doing these two things will decompress the work of doctors, partly relinquish the work to AI, eliminate the need for human scribes – of which there are tens of thousands in the United States – and that is only one element of what AI can do.

Today, each person has a considerable body of data, and to review all that, to click through all of those pages of data and labs and images is really time-consuming. However, AI can be trained to do that on an individual level very well and it can synthesize the critical knowledge about a patient so that before you go and see a patient, all of that is available in a summarized and actionable form. This would reduce a great deal of time and it would cut the workload, which is bogged down with seemingly endless pages of data to review.

 

5| What would you like to say to burned-out physician readers who are facing the brunt of today’s healthcare infrastructure and managing moral injury?

Hope is on the way – we can do this. We have to work on [effectively harnessing the power of AI], embrace it, validate it, and implement it. We have to continue to have it under surveillance, but it will likely be the most transformative effect in the history of medicine. We can bring medicine back to the way it used to be, just back to the future, by this counterintuitive sense of leaning on technology such that machines will help clinicians, who will then help their patients far better than they can today.

 

6 | For premeds and physicians-in-training, what disciplines should we immerse ourselves within and what skills should we develop? How can we be prepared to aid the implementation of AI into medicine?

I think it’s notable that the most exciting times in medicine lie ahead of us! I wish I could go back so I could start over because it’s going to be great as [AI] continues to become an integrated part of medicine and make lives easier. I think each person doesn’t need to become fully adept in computer science and deep neural networks; however, familiarity is very important.

I do think that every medical school should have within their curriculum some grounding for AI and subtypes for deep learning and deep neural networks and machine learning. That is really important so students can understand the nuances of what this technology can do, what it can’t do, and why human involvement will always be very important.

I believe that all aspects of medicine are so remarkably alluring. Personally, I decided to go into cardiology, but that is just one of the so many different domains. The great thing about medicine is that you can do many things in a career; you shouldn’t think that whatever you decide is where you will be constrained indefinitely. Fortunately, this helps those who change their minds several times as I did, and secondly, even if you identify with a certain medical role, you can pivot into something else.

Personally, I’m a cardiologist but I’m doing a great deal to help end the COVID-19 pandemic – who thought cardiologists would do much there? The reality is that once you have the basic education and stay ahead with reading, you have a lot to offer beyond medicine and beyond just treating patients. So it really is a noble profession with pluripotent directions – people should realize that once you are trained, you can do so much more than is imaginable.

 

7 | For those looking to further their education beyond medical school, are there certain Master’s degrees currently worth pursuing?

Yes, that is another way to augment the core medical education. Obviously, data science and computer science are very demanding areas right and there is a shortage of such experts in medicine. So many young and talented people are attracted to nonmedical fields – organizations like Spotify and Amazon – but they aren’t joining the healthcare domain. We have a great shortage, and that realm will be a hot spot in the years to come.

 

8 | You once stated that if you could give your 20-year-old self advice, you would inform yourself to tell it like it is. Could you elaborate?

To me, the virtue of telling it like it is is so fundamentally vital. One can land themselves in trouble when telling the truth – for example, earlier in the pandemic, I tried to bring attention to the fact that breakthrough infections post-vaccination are becoming concerning with the Delta strain. A lot of people blasted me for saying that, that it detracted from vaccine uptake, but my statement was founded on solid evidence that was being denied.

Finally, when the problem became widely evident, expert opinion dramatically shifted. Tell it like it is. Sure, you may take some backlash, but if you stand up for the evidence that you see, review and process, you won’t regret it.

My other piece of advice is that you should never accept dogma.  These two points are interrelated. If you see evidence of something new, something that brings question to prevailing dogma, you need to follow that variable, chase it down, and thoroughly examine it.

Don’t be complicit and simply accept that because you were taught something a certain way, it should remain a sacred tradition. You should question things, and that way, you’ll never have regrets. Even if you end up determining that the status quo is valid, it is critical to understand that more often than is recognized, there will be times where you’ll encounter something that is purely wrong. It is imperative to make that discovery, and simply asking questions is good enough. Asking questions is a sufficient start.

 

9 | Are there instances in your medical training where you spoke up, told it like it is, and faced consequences?

Yes, the most vivid and most dreadful experience was the Vioxx affair. In the early 2000s, I questioned Merck about Vioxx, knowing that they were well aware that their drug caused heart attacks as well as strokes to a lesser extent. They were hiding this, and it was obvious upon reviewing the FDA’s files.

One of my trainees brought this to my attention – he challenged dogma, and he understood the fundamental importance of being critical of information and questioning our assumptions. When he came up to me, I was initially reluctant and felt that Merck wouldn’t do that. Well, they sure did!

When we wrote the paper that blew the whistle on Merck, it led to a devastating attempt by Merck to destroy me. They did not go after the fellow because he wasn’t the key player in the situation – I was the one whose reputation they focused on soiling and ruining. They tried for quite some time, and it was indeed a very difficult time.

In the moment, and in retrospect, I’ve questioned many times whether I should have done that because if I hadn’t, I would’ve saved both myself and my family a great deal of trouble – trouble that had a lasting effect. However, there is nothing more important than to tell it like it is and to stand up for the truth.

Sure, both my family and I faced heavy consequences. The situation almost ended my entire career in 2004-5. But in retrospect, it was indisputably the right thing to do, and we need more physicians out there willing to raise their voice in the face of similar circumstances.

 

10 | Are there any particular ethical dilemmas that concern you regarding the future of healthcare?

There are plenty. We are facing the biggest breakthrough in the history of life science: we have embarked upon the genome editing era. This brings the potential to edit [the underlying genetic makeup of] rare diseases and work towards curing them – diseases like sickle cell disease, thalassemia, eye disorders, heart disease, and others that are amenable.

The question is where do we draw the line? Concerns are raised about the whole prospect of editing embryos. Besides AI, genome editing is the most powerful life science tool we have for the future of medicine. We have to keep a constant eye and appraisal on this domain because there are potentially no boundaries and if we start to edit embryos, we are then basically changing species – we are doing something immutable. So that has to be kept in mind – we’ve already seen reckless work done on editing human embryos. That said, there are lots of ethical issues but that one is front and center.

 

11 | From a policy perspective, do you think the role that the government, physicians, insurers, and patients play in healthcare will change in the near future?

Medicine doesn’t change very rapidly. It is very conservative and unwilling to change. In many ways, it can be considered sclerotic or ossified. It takes a rare impact to affect change in this field, and the prospect is bleak if that impact doesn’t improve financial matters for people.

I am not so confident that things will change soon, but we definitely have to fight for change. We have a system that is terribly broken. Our system is accentuating inequities in healthcare, it has lost the relationship between physicians and patients largely, and it is ridiculously expensive. We need to fix these matters, but that won’t happen without a willingness to reboot. And I do not see it yet – I think it is going to be a hard struggle.

This may happen in other countries much more rapidly than in the United States because other countries have universal healthcare and different incentives at play. Taking into account the economic considerations and several other facts, universal healthcare is not something that is likely to be achieved in the United States for quite some time.

 

12 | Do you remember particular instances where you first realized the major deficiencies in our healthcare system?

These deficiencies have always been on my mind – we have a perverse-incentive system whereby we have administrators who are calling the shots. In my first job at the University of Michigan, where I ran the cardio catheterization lab, I had an administrator come down and tell me to stop a procedure or use different equipment – that was a pretty scary thing to experience firsthand. That administrator had no medical training, he was just a revenue-counter and didn’t like the idea of doing procedures on people who couldn’t pay or using expensive equipment that was not going to get fully reimbursed.

That said, we have a conflict here – we have the most expensive healthcare system in the world, and we have many of the worst outcomes of all 38 OECD countries. The most telling thing for me was when I did the review of the National Health Service in 2018-2019 and had a panel of fifty transdisciplinary experts throughout the UK. I learned how their system is so different and how it is very much truly universal, education-centered, and totally different. That was when I first realized what things were essential – not that the UK has eliminated inequities, but the differences are palpable between the United States and the UK. We see the same thing when we look north to Canada. We have to do better.

 

13 | From a policy perspective, what decisions should be enacted to improve our healthcare system?

We should have universal healthcare – every American citizen should have a right to healthcare. This would fix a lot of problems. The systems should align in such a manner that physicians are not incentivized to do unnecessary things that would benefit our patients. I would like to see features of a model that has been proven and is extremely popular among other countries: higher quality care at a lower cost.

At the same time, what is more important to me than the cost of care is the erosion of the physician-patient relationship, which is at a pathetic low in my three decades of serving as a practicing physician. I hope these are some changes we can eventually implement.

 

14 | What books have greatly influenced you?

My favorite book this year is The Code Breaker by Walter Isaacson which really gets into genome editing. One of the best books I’ve ever read is about cancer, The Emperor of All Maladies, by Siddhartha Mukherjee. There is a terrific book about the pandemic and the CDC – The Premonition: A Pandemic Story by Michael Lewis, one of the greatest storytellers of our time. I can go on and on but those are a few that are really outstanding books.

 

15 | What attributes do you believe were the most influential in catalyzing your tremendous contributions to healthcare?

Oh, thank you. I think the main thing for me has been the goal of trying to take whatever I’ve learned and can learn and amplify that through teaching and through writing. Also, in the last decade or more, I’ve realized that the audience needs to go beyond our medical peers, to the public. That was a real wake-up call that drove me to write books for the public, which is something I never expected myself to do.

When I wrote Creative Destruction, and even before that when I started writing Op-eds, I had come to understand that for physicians like myself who are grounded in medicine, practicing, and keeping up to date, we have a lot to offer to the public. That is another role that I’ve very much enjoyed and I wish I started even earlier. Now it’s gratifying to see younger people doing that, but it was very unusual until about the last ten or fifteen years.

Most times, physicians kept their heads down and did what they were supposed to do, and they wouldn’t be sounding off and writing books and piecing together op-eds. Now, things have changed and these multifaceted roles have become more common, which is great.

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