HIPPOCRATIC CAPITALISM AN ETHICAL MARRIAGE OF HEALTH AND TECH.
I'M DR. BRIAN JACKSON.
I'M A MEDICAL DIRECTOR AT ARUP LABORATORIES AND AN ASSOCIATE
PROFESSOR OF PATHOLOGY AT THE UNIVERSITY OF UTAH.
I'D LIKE TO START OFF WITH A QUESTION: DOES MEDICINE NEED A
DOSE OF SILICON VALLEY CULTURE.
A LOT OF PEOPLE BELIEVE THAT MEDICINE WOULD BENEFIT THAT THE
HEALTHCARE INDUSTRY WOULD BENEFIT FROM LEARNING HOW TO DISRUPT
ITSELF LEARNING HOW TO MOVE FAST AND BREAK THINGS AND LEARNING HOW
TO EMBRACE FAILURE AS A VIRTUE.
I'D LIKE TO SHARE TWO STORIES OF HEALTHCARE COMPANIES WHO TRIED
TO EMBRACE SILICON VALLEY STYLE CULTURE WHERE IT DIDN'T WORK OUT SO WELL.
MY FIRST EXAMPLE IS INSYS THERAPEUTICS.
IT'S A BOUTIQUE PHARMACEUTICAL COMPANY WHO EMBRACED SILICON VALLEY
BRO CULTURE; THE SORT OF AGGRESSIVE, YOU KNOW, HYPER SALES
FOCUSED, CONQUER THE WORLD AT ALL COSTS, CULTURE THAT WAS IT UBER A FEW YEARS AGO.
DURING THE TRAVIS KALANICK ERA, WHEN THEY DIDN'T BELIEVE THAT
RULES REALLY APPLIED TO THEM.
SO THIS PHOTO IS FROM A RAP VIDEO THAT INSYS PRODUCED FOR ONE OF
THEIR SALES CONFERENCES.
YOU CAN ACTUALLY FIND THAT ON YOUTUBE.
THE GUY IN THE MIDDLE IS THE VP OF SALES DRESSED UP AS A BOTTLE OF
SUBSYS, WHICH WAS THE PRODUCT THEY WERE SELLING.
SUBSYS IS FENTANYL SUBLINGUAL SPRAY.
YOU MAY KNOW THAT FENTANYL IS AN EXTREMELY POWERFUL FAST-ACTING
NARCOTIC, AND YOU MAY OR MAY NOT KNOW THAT SPRAYING IT ON YOUR
TONGUE MAKES IT EVEN FASTER ACTING.
SO THIS IS A POWERFUL DRUG.
IT'S ALSO A GREAT PRODUCT FOR A VERY NARROW GROUP OF PATIENTS FOR
VERY NARROW MARKET. MAINLY CANCER PATIENTS WITH SEVERE PAIN THAT
CAN'T BE CONTROLLED THROUGH ANY OTHER DRUGS.
SO FOR THOSE PATIENTS THIS DRUGS GREAT, BUT THE PROBLEM FOR SUBSYS
THE PROBLEM FROM THEIR PERSPECTIVE FROM THE PERSPECTIVE
INSYS, WAS THAT CANCER PATIENTS WITH INTRACTABLE PAIN, WERE A
FAIRLY SMALL MARKET. AND SO SELLING TO THAT GROUP ALONE WAS NEVER
GOING TO SATISFY THEIR BILLION DOLLAR DREAMS OF WORLD CONQUEST.
SO INSTEAD INSYS SENT OUT THEIR SALES FORCE TO PUSH THE PRODUCT
AGGRESSIVELY NOT JUST TO ONCOLOGISTS WHO TREAT CANCER
PATIENTS, BUT ALSO TO FAMILY DOCTORS, ORTHOPEDISTS, OTHER
SPECIALTIES, AND THEY PROMOTED THE USE OF THIS PRODUCT FOR PATIENTS
WITH ANY SORT OF PAIN. BUT THESE WERE PATIENTS, THE FOLKS WITH, YOU
KNOW, BACK PAIN, HIP PAIN, OTHER NO NON-CANCER PAIN, THESE PATIENTS
ABSOLUTELY SHOULD NOT HAVE BEEN ALLOWED ANYWHERE NEAR A PRODUCT
LIKE THIS BECAUSE IT'S INCREDIBLY UNSAFE AND ADDICTIVE
FOR THOSE PATIENTS.
SO HOW DID THIS BUSINESS STRATEGY TURNOUT FOR INSYS IN THE LONG RUN?
WELL, IN THE SHORT RUN IT ACTUALLY TURNED OUT QUITE WELL,
THEY BROUGHT IN ABOUT A HUNDRED FIFTY MILLION DOLLARS IN REVENUE IN 2017.
BUT IN THE LONG RUN IT ALL CAME CRASHING DOWN.
THE FEDS WENT AFTER THE COMPANY AS WELL AS ITS TOP EXECUTIVES
INDIVIDUALLY FOR VIOLATING FDA RULES WITH THEIR SALES AND
MARKETING TACTICS. THAT IN TURN FORCED THE COMPANY TO BANKRUPTCY.
AND SO ALL THE INVESTORS LOST THEIR MONEY.
THE TOP EXECUTIVES WENT TO PRISON THE FELLOW ON THE RIGHT HAND SIDE OF
THE SCREEN,
JOHN KAPOOR WAS SENTENCED RECENTLY IN JANUARY TO FIVE AND A HALF
YEARS IN FEDERAL PRISON. SO CLEARLY CREATING THIS SORT OF
HYPER-AGGRESSIVE QUOTE-UNQUOTE SILICON VALLEY STYLE CULTURE DID
NOT TURN OUT WELL EITHER MEDICALLY OR FINANCIALLY FOR THIS PARTICULAR
COMPANY. HERE'S ANOTHER EXAMPLE, ONE THAT YOU MAY BE FAMILIAR WITH
IF YOU'RE ASSOCIATED WITH THE LAB INDUSTRY.
THIS IS THER ENOSIS FOUNDED BY STANFORD DROPOUT ELIZABETH HOLMES
NOW ELIZABETH HOLMES ABSOLUTELY IDOLIZED STEVE JOBS AND APPLE AND
THERE'S NOTHING WRONG WITH THAT. I'LL TELL YOU,
I PERSONALLY IDOLIZE STEVE JOBS AND APPLE.
I LOVE MY IPHONE.
I LOVE MY APPLE PRODUCTS AND I BELIEVE THAT STEVE JOBS TAUGHT US
A LOT OF VALUABLE LESSONS ABOUT INNOVATION.
BUT HERE'S THE THING.
IF YOU ARE GOING TO TAKE LESSONS FROM ONE INDUSTRY SUCH AS CONSUMER
ELECTRONICS TO APPLY TO ANOTHER INDUSTRY SUCH AS HEALTHCARE.
YOU NEED TO BE REALLY EXPLICIT ABOUT WHICH LESSENS YOUR DRAWING
AND HOW YOU'RE DOING IT. IN ELIZABETH HOLMES' CASE THE TWO
PRIMARY LESSONS THAT SHE BROUGHT FROM APPLE WERE NUMBER ONE SLICK
MARKETING AND NUMBER TWO EXTREME SECRECY. ON THE MARKETING SIDE
SHE REBUILT HER WARDROBE AROUND BLACK TURTLENECKS.
SHE HIRED ONE OF APPLES TOP PRODUCT DESIGNERS TO ATTRACT TO
DESIGN AN ATTRACTIVE PLASTIC BOX AROUND THERE TESTING DEVICE.
SHE HIRED APPLES MARKETING AGENCY TO PRODUCE SOME REALLY
IMPRESSIVELY POLISHED ADVERTISEMENTS FOR THEM.
ALL OF WHICH WAS, YOU KNOW, MAYBE A LITTLE BIT SHALLOW, BUT IT DIDN'T HURT PATIENTS.
THE REAL PROBLEM WAS ON THE SECRECY SIDE, WHERE SHE CREATED
TOGETHER WITH HER PARTNER, THIS ULTRA LOCKDOWN ENVIRONMENT WHERE
NO ONE IN THERANOS WAS ALLOWED TO TALK ABOUT WHAT THEY'RE
WORKING ON, NOT ONLY NOT TO SCIENTISTS OUTSIDE THE COMPANY,
BUT EVEN THE PEOPLE INSIDE THE COMPANY AND OTHER DEPARTMENTS.
NOW IF YOU'RE A CONSUMER ELECTRONICS COMPANY, LIKE APPLE
THEN EXTREME SECRECY MIGHT WORK AS A BUSINESS STRATEGY, BUT IF YOU'RE
A MEDICAL DEVICE COMPANY LIKE THERANOS, IT'S A BIG PROBLEM
BECAUSE HIDING AND MISREPRESENTING THE DETAILS OF WHAT YOUR DEVICE
DOES PREVENTS INDEPENDENT SCIENTIFIC AND MEDICAL EVALUATION.
IT ALSO PREVENTS EFFECTIVE REGULATORY OVERSIGHT.
SO HOW DID ALL THIS TURN OUT FOR THEM?
WELL, YOU PROBABLY KNOW THE ANSWER ALREADY AGAIN IN THE SHORT RUN
THINGS WERE GREAT.
THERANOS GOT UP TO A NINE BILLION DOLLAR EVALUATION.
IT WAS ONE OF THE ORIGINAL SILICON VALLEY UNICORNS THAT WAS REALLY
HYPED UP IN THE PRESS.
MISS HOLMES PERSONALLY WAS PROFILED IN BUSINESSWEEK, FORBES,
AND WENT AROUND THE WORLD SPEAKING AT GLITZY BUSINESS CONFERENCES
WHERE SHE WAS CELEBRATED AS THE YOUNGEST SELF-MADE FEMALE
BILLIONAIRE IN HISTORY. BUT THEN JUST LIKE WITH INSYS, IT ALL CAME CRASHING DOWN.
THEY WENT FROM A NINE BILLION DOLLAR EVALUATION
TO ZERO, COMPANY WENT BANKRUPT, ALL THE INVESTORS LOST ALL OF THEIR MONEY
INCLUDING SOME BIG NAMES THAT YOU MAY BE FAMILIAR WITH, AND HERE'S A
SHOT OF ELIZABETH HOLMES WALKING INTO COURT TO FACE SECURITY FRAUD CHARGES.
YOU'LL NOTICE SHE LOST THE BLACK TURTLENECK HERE. BUT MY POINT IS
THAT CLEARLY EMULATING THOSE CERTAIN PARTS OF SILICON VALLEY
CULTURE THAT THEY TRIED TO EMULATE DID NOT TURN OUT WELL FOR THIS
PARTICULAR MEDICAL PRODUCTS COMPANY.
SO BACK TO MY ORIGINAL QUESTION DOES MEDICINE NEED A DOSE OF
SILICON VALLEY CULTURE.
AND I'M GOING TO SAY THAT'S NOT THE BEST QUESTION TO BE ASKING
WHAT WE REALLY NEED TO TALK ABOUT IS HOW HEALTH TECH COMPANIES NEED
TO EMBRACE MEDICAL CULTURE.
SO IT'S REALLY THE OTHER WAY AROUND AND WHEN I SAY EMBRACING
MEDICAL CULTURE, THE NUMBER ONE THING I'M TALKING ABOUT IS
PRIORITIZING PATIENTS OVER PROFITS.
SO TO BE CLEAR HEALTH TECHNOLOGY COMPANIES IF THEY WANT TO BE
LONG-TERM SUSTAINABLE LONG-TERM PROFITABLE
AND SUCCESSFUL, AND NOT LIKE INSYS OR THERANOS.
THEY NEED TO PRIORITISE PATIENTS OVER PROFITS.
NOW, THIS IS A BIT OF A PARADOX.
I REALIZE THAT. BECAUSE I'M GOING AGAINST 50 YEARS OF BUSINESS
SCHOOL DOGMA AT LEAST U.S. BUSINESS SCHOOL DOGMA. BACK IN THE EARLY 70S
MILTON FRIEDMAN, NOBEL PRIZE WINNER IN ECONOMICS, POPULARIZED
THE IDEA THAT IF COMPANIES JUST PUT PROFITS FIRST AND DON'T WORRY
ABOUT ALL THAT SOCIAL RESPONSIBILITY STUFF,
THEN SOCIETY WILL ULTIMATELY BENEFIT THROUGH THIS MAGIC OF
MARKETS TRICKLE-DOWN EFFECT AND LET ME TELL, YOU IT DOESN'T WORK
THAT WAY IN HEALTHCARE.
I'M NOT ACTUALLY CONVINCED THAT IT WORKS THAT WAY IN OTHER INDUSTRIES
EITHER AT LEAST NOT ALL INDUSTRIES, BUT IT DEFINITELY
DOESN'T WORK IN HEALTHCARE.
YOU DON'T HAVE TO TAKE THIS JUST FOR ME.
IF YOU LOOK AROUND YOU SEE THAT AMERICANS HAVE BECOME INCREASINGLY
CYNICAL ABOUT THE ROLE OF THE FREE MARKET IN HEALTHCARE. ALMOST HALF
THE COUNTRY NOT TO MENTION MOST MEDICAL PROFESSIONALS ARE READY TO
PULL THE PLUG AND PRIVATE HEALTH INSURANCE GET RID OF PRIVATE
INSURANCE COMPANIES ENTIRELY INTERNAL OVER TO GOVERNMENT
AGENCIES. IT'S NOT JUST HEALTH INSURANCE COMPANIES THAT ARE
CURRENTLY HELD IN LOW REGARD PHARMACEUTICALS ARE EVEN IN LOWER
PUBLIC REGARD.
THIS IS A GALLUP POLL RECENTLY WHERE AMERICANS WERE ASKED TO RATE
A NUMBER OF DIFFERENT INDUSTRY SECTORS ACCORDING TO HOW FAVORABLY
OR UNFAVORABLY THEY CONSIDER THEM TO BE AND PHARMACEUTICAL COMPANIES
CAME IN DEAD LAST, BUT HERE'S THE THING, WHEN AMERICANS SAY THAT THEY
ARE UNCOMFORTABLE WITH THE ROLE OF THE FREE MARKET IN HEALTHCARE OR
THAT THEY DON'T WANT FREE MARKET STYLE HEALTHCARE.
I BELIEVE THEY'RE TALKING ABOUT A VERY PARTICULAR TYPE OF CAPITALISM
NAMELY THIS KIND OF CAPITALISM.
SO YOU MAY RECOGNIZE THIS CHARACTER AS GORDON GEKKO.
ITS THE MICHAEL DOUGLAS CHARACTER FROM THE 1987 MOVIE WALL STREET,
WHO IS FAMOUS FOR UTTERING THE PHRASE "GREED IS GOOD."
MY POINT IS THAT WHEN HALF THE COUNTRY SAYS THAT THEY DON'T WANT
FREE MARKET HEALTH CARE ANYMORE.
I BELIEVE THEY'RE REALLY SAYING THEY DON'T WANT GORDON GEKKO
RUNNING THEIR HEALTHCARE COMPANIES.
THEY DON'T WANT THIS STYLE OF GREED IS GOOD STYLE CAPITALISM
DOMINATING HEALTHCARE.
THAT DOESN'T MEAN THAT YOU CAN'T HAVE CAPITALISM IN HEALTHCARE
BECAUSE THERE'S ANOTHER WAY TO VIEW CAPITALISM AND IT'S CALLED
STAKEHOLDER CAPITALISM.
SO HERE'S A SHOT OF LARRY FINK, HE'S THE CEO OF BLACKROCK.
IT'S THE WORLD'S LARGEST ASSET MANAGEMENT COMPANY.
THEY HAVE SOMETHING LIKE SEVEN TRILLION DOLLARS OF INVESTMENTS
UNDER MANAGEMENT. IN RECENT YEARS,
HE'S BECOME SORT OF A POSTER CHILD FOR STAKEHOLDER CAPITALISM.
IN HIS 2018 LETTER TO CORPORATE CEOS OF THE COMPANIES THAT
BLACKROCK INVESTS IN, HE POSED THESE QUESTIONS. OR HE SAID
COMPANIES MUST ASK THEMSELVES.
WHAT ROLE DO WE PLAY IN THE COMMUNITY?
HOW ARE WE MANAGING OUR ON THE ENVIRONMENT?
ARE WE WORKING TO CREATE A DIVERSE WORKFORCE?
AND THOSE TYPES OF QUESTIONS NOT JUST ARE WE HITTING OUR QUARTERLY PROFITS.
NOW THOSE OF YOU NOT FAMILIAR WITH BLACKROCK OR THIS
SECTOR THE INVESTMENT INDUSTRY.
YOU MAY BE A LITTLE SURPRISED TO SEE A BILLIONAIRE WALL STREETER
SPOUTING THESE KINDS OF TOUCHY-FEELY IDEAS.
BUT IN FACT, IT ACTUALLY MAKES BUSINESS SENSE FOR A COMPANY LIKE THEIRS.
YOU SEE BLACK ROCK IS NOT A DAY TRADING TERM.
EXCUSE ME A DAY TRADING FIRM WHO'S TRYING TO STIR
UP VOLATILITY IN THE MARKET AND THEN PROFIT OFF OF IT. BLACKROCK
ACTUALLY HAS AN INVESTMENT STRATEGY BASED ON LONG-TERM
INVESTMENTS. THEY WANT TO INVEST IN COMPANIES THAT ARE GOING TO BE
PROFITABLE OVER YEARS TO DECADES AND THAT ARE GOING TO HAVE LOW
VOLATILITY IN THE MEANTIME. AND IT TURNS OUT THERE'S A LOT OF
EMPIRICAL EVIDENCE THAT SOCIALLY RESPONSIBLE COMPANIES FIT THAT CATEGORY.
LARRY FINK PUSHING SOCIAL RESPONSIBILITY IN THE
BUSINESSES THEY INVEST IN ACTUALLY MAKES BUSINESS SENSE FOR THIS
PARTICULAR TYPE OF INVESTMENT.
HERE'S ANOTHER QUOTE.
THIS ONE'S BRIAN CHESKY THE CEO AND FOUNDER OF AIRBNB. IN A LETTER
TO HIS WORKFORCE AND INVESTORS A COUPLE OF YEARS AGO.
HE WROTE THAT WE, MEANING AIRBNB, MUST ENSURE THAT OUR VISION IS
GOOD FOR SOCIETY.
THIS MEANS WE MUST HAVE THE BEST INTEREST OF THREE DIFFERENT
STAKEHOLDERS IN MIND.
SO NOT JUST AIRBNB THE COMPANY WHICH IS EMPLOYEES AND
SHAREHOLDERS AND NOT EVEN JUST AIRBNB THE COMMUNITY WHICH IS
GUESTS AND HOSTS, BUT ALSO THE WORLD OUTSIDE OF AIRBNB.
AGAIN, THIS MAKES BUSINESS SENSE IF YOU THINK ABOUT IT BECAUSE AIRBNB CAN
ONLY SUCCEED FOR THE LONG HAUL IF COMMUNITIES IN WHICH THEY OPERATE
ARE ACCEPTING OF THIS BUSINESS MODEL A NUMBER OF CITIES AROUND
THE WORLD HAVE ESSENTIALLY BANNED SHORT-TERM RENTALS OUT OF CONCERNS
FOR THE IMPACT ON THE COMMUNITY.
AIRBNB NEEDS TO BE SENSITIVE TO THOSE KINDS OF THINGS AND NOT TOO
ARROGANT ABOUT THEM IF THEY'RE GOING TO SUCCEED FOR THE LONG
HAUL. SO SOCIAL RESPONSIBILITY AGAIN CAN MAKE BUSINESS SENSE.
AND THEN LAST SUMMER THE BUSINESS ROUNDTABLE, WHICH IS MADE UP OF
CEOS OF MOST OF THE WORLD'S LARGEST COMPANIES.
SOME OF THE PHOTOS ARE HERE ON THE SCREEN, RELEASED A FORMAL
STATEMENT SAYING THAT THE PURPOSE OF BUSINESS IS NOT JUST TO MAKE
MONEY, BUT RATHER IS TO DELIVER VALUE TO ALL OF THESE DIFFERENT
STAKEHOLDER GROUPS: CUSTOMERS, EMPLOYERS, SUPPLIERS, COMMUNITIES,
AND SHAREHOLDERS, BUT NOT JUST SHAREHOLDERS.
SO I'M NOT WHEN IN SHOWING THIS SLIDE AND TALK ABOUT THE BUSINESS
ROUNDTABLE. I'M NOT TRYING TO PRETEND THAT THESE FOLKS ARE
SAINTS. JEFF BEZOS IS NEVER GOING TO BE CONFUSED WITH WITH MOTHER
TERESA, FOR EXAMPLE, AND I'M NOT SAYING THAT THE COMPANIES
REPRESENTED HERE ARE NECESSARILY OPTIMIZING THEIR BENEFIT TO
SOCIETY IN EVERY RESPECT.
BUT WHAT I AM SAYING IS THAT THESE ARE REALLY SMART CEOS WHO ARE
SMART ENOUGH TO KNOW THAT THE ONLY WAY FOR THEIR BUSINESSES TO BE
SUCCESSFUL OVER THE LONG HAUL AND NOT JUST BE A FLASH IN THE PAN IS
TO RESPECT IN ADDRESS THE NEEDS OF ALL OF THESE DIFFERENT
STAKEHOLDERS ACROSS SOCIETY.
SO HERE'S MY QUESTION IF WE WANT TO TALK ABOUT STAKEHOLDER
CAPITALISM. WHAT IS THAT MEAN SPECIFICALLY IN A HEALTHCARE
CONTEXT? SO WHO ARE THE STAKEHOLDERS IN HEALTHCARE THAT WE
HAVE TO PAY THE MOST ATTENTION TO.
AND TO GET TO THAT WE HAVE TO GO BACK TWENTY FIVE HUNDRED YEARS TO
THIS GUY HIPPOCRATES. HIPPOCRATES IS FAMOUS FOR WRITING A CODE OF
MEDICAL ETHICS THAT YOU'VE HEARD OF IS THE HIPPOCRATIC OATH.
AGAIN, THIS IS 2500 YEARS AGO IN
ANCIENT GREECE SO MEDICINE WAS PRETTY BIT DIFFERENT BACK THEN, BUT
THE PRINCIPLES IN THAT OATH HAVE BEEN UPDATED AND MODERNIZED
BY MEDICAL ETHICISTS, AND OVER TIME
THE CORE PRINCIPLES HAVE REMAINED THE SAME. NAMELY THAT THE
TOP STAKEHOLDERS IN HEALTHCARE ARE FIRST AND FOREMOST THE PATIENT AND
THEN SECONDLY THE MEDICAL PROFESSIONALS WHO TAKE CARE OF
THEM ONE ON ONE.
ALL OF THIS IS CAPTURED IN DOCUMENTS LIKE THE BELMONT REPORT
THAT LAYOUT THE MODERN PRINCIPLES OF MEDICAL ETHICS IN MORE DETAIL,
BUT TREATING PATIENTS AS THE TOP STAKEHOLDER BASICALLY COMES DOWN
TO THESE THREE PILLARS OF MEDICAL ETHICS.
SO FOR THE REST OF MY PRESENTATION, I WANT TO TALK ABOUT
HOW TECH COMPANIES WITHIN HEALTHCARE ARE, YOU KNOW ARE
IMPACTED BY THESE PRINCIPLES OR CAN FOLLOW THESE PRINCIPLES.
RESPECT FOR PERSONS BENEFICENCE AND JUSTICE. THE FIRST OF THESE
RESPECT FOR PERSONS MEANS THAT PATIENTS HAVE THE FUNDAMENTAL
RIGHT TO MAKE DECISIONS ABOUT WHAT GOES ON WITH THEIR OWN BODY AND
WHAT GOES ON WITH THEIR OWN DATA. NOW WITH RESPECT TO THE DATA SIDE,
THERE ARE A LOT OF TECH INDUSTRY FOLKS OUT THERE INCLUDING SOME
BIG-NAME VENTURE CAPITALIST FOR EXAMPLE,
WHO HAVE GONE AROUND SAYING THAT PRIVACY IS DEAD THAT
WE AS A SOCIETY NEED TO GIVE UP ON THE IDEA THAT WE SHOULD HAVE SOME
FUNDAMENTAL RIGHT TO PRIVACY.
AND THAT WE JUST NEED TO GET OVER THE FACT THE BIG TECH COMPANIES
KNOW ALL OF OUR PERSONAL DETAILS.
HERE'S THE THING THOUGH THE FOLKS SAYING THAT ARE NOT WORKING IN
HEALTH CARE BECAUSE IF THEY WERE IF THEY WERE MEDICAL
PROFESSIONALS, THEY WOULD KNOW THAT THE RIGHT TO CONTROL YOUR OWN
HEALTHCARE DATA IE THE RIGHT FOR MEDICAL PRIVACY HAS EXISTED BACK
TO THE DAYS OF HIPPOCRATES AND IT STILL REMAINS A BASIC EXPECTATION
OF OUR MODERN SOCIETY AND A CORE PRINCIPLE OF MEDICAL ETHICS.
SO, GIVEN THAT WHAT DO YOU MAKE OF HEADLINES LIKE THIS ONE?
IN JANUARY OF 2020 THE WALL STREET JOURNAL REPORTERS INCLUDING
MELANIE EVANS HERE ON THE SCREEN WROTE A SERIES OF ARTICLES
DESCRIBING HOW MICROSOFT GOOGLE AND IBM HAVE BEEN SIGNING
AGREEMENTS WITH BIG HOSPITAL SYSTEMS MANY OF THEM SECRET
AGREEMENTS THAT ALMOST ALL OF THEM SECRET AGREEMENTS TO GIVE THE TECH
COMPANIES ACCESS TO LARGE VOLUMES OF MEDICAL RECORDS FOR LARGELY
UNSPECIFIED FUTURE USES.
AND GIVEN THE SCALE OF THESE EFFORTS IS QUITE POSSIBLE THAT YOU
LISTENING TO THIS PRESENTATION HAVE SOME OF YOUR PERSONAL MEDICAL
DATA SITTING ON SOME OF THEIR DATABASES.
WHAT THEY'RE DOING IS PROBABLY LEGAL.
BUT THE REASON IT'S PROBABLY LEGAL IS THAT OUR HIPAA MEDICAL PRIVACY
LAW WAS OVER IT'S OVER 20 YEARS OLD.
IT WAS PRE-INTERNET.
WELL PRE-MODERN INTERNET CERTAINLY.
PRE BIG DATA PRE AI, AND IT'S THE OUTDATED IN TERMS OF
BEING ABLE TO PROTECT THIS GIVEN THE STATE OF MODERN TECHNOLOGY.
SO EVEN IF WHAT THESE FOLKS ARE DOING IS LEGAL UNDER HIPAA THAT
DOESN'T NECESSARILY DOESN'T AUTOMATICALLY MAKE IT ETHICAL.
SO HERE'S A PHOTO OF DR. DAVID FEINBERG.
HE'S A VP OF GOOGLE HEALTH AND HE'S THE PUBLIC FACE OF GOOGLE'S
DATA ACQUISITION EFFORTS IS ALSO THE FORMER CEO OF GEISINGER HEALTH
BEFORE THAT CEO OF THE UCLA HOSPITALS, SO HE'S BEEN IN HEALTHCARE
A LONG TIME. HE'S A DOCTOR.
HE'S AN ADMINISTRATOR. HE KNOWS HIPAA.
HE KNOWS MEDICAL ETHICS.
BUT IF YOU READ THE QUOTES IN THESE WALL STREET JOURNAL ARTICLES
OR IF YOU WATCH ONE OF THE YOUTUBE VIDEOS WHERE HE DISCUSSES THIS AS
A GOOGLE SPOKESMAN, IT'S DISCOURAGING WHEN HE FAILS TO
PROVIDE ANY CONCRETE DETAILS OF HOW DATA ARE PROTECTED IN THESE
AGREEMENTS BECAUSE THEY'RE NOT DISCLOSING THE AGREEMENTS.
HE'S BASICALLY JUST SAYING HEY TRUST US BECAUSE WE'RE JUST TRYING TO HELP.
NOW MY PERSONAL OPINION IS THAT GOOGLE MICROSOFT IBM AND OTHER COMPANIES
AS WELL AS THE HEALTH SYSTEMS OF THEY'RE PARTNERING WITH NEED TO BE
MUCH MORE TRANSPARENT ABOUT WHAT THEY'RE DOING.
I'M NOT SAYING THAT THEY'RE DISCLOSING MEDICAL RECORDS IN UNSAFE WAYS.
I'M JUST SAYING THEY'RE NOT BEING TRANSPARENT ABOUT THE PRIVACY
PROTECTIONS THAT THEY MAY OR MAY NOT BE USING AND THAT NEEDS TO BE
DISCLOSED TO THE PUBLIC SO WE CAN KNOW IF WHAT THEY'RE DOING IS
TRULY ETHICAL.
OKAY, THE NEXT MAJOR PRINCIPLE OF MEDICAL ETHICS IS BENEFICENCE.
AND THIS ONE IS REALLY SIMPLE.
IT JUST MEANS THAT EVERYTHING WE DO IN HEALTHCARE HAS TO HAVE A
REASONABLE EXPECTATION OF BENEFITING THE PATIENT AND NOT
HURTING THE PATIENT.
ONE OF THE MOST IMPORTANT WAYS.
WE ENSURE BENEFICENCE IS BY SUBJECTING NEW HEALTHCARE
TECHNOLOGIES TO EXTENSIVE VALIDATION AND SCIENTIFIC STUDY
BEFORE THEY'RE USED IN CLINICAL CARE.
MAKES SENSE, RIGHT? BUT IT'S IN CONTRAST TO THE HIGH-SPEED APP
AGILE APPROACHES THAT ARE REALLY COMMON IN DOMINANT IN THE
TECH PARTICULARLY THE INFORMATION TECH WORLD. IN THOSE APPROACHES
SO IF YOU THINK FACEBOOK IF YOU THINK NETFLIX THAT THE GENERAL
APPROACH IS IN THAT WORLD IS TO GET YOUR SOFTWARE IN FRONT OF
THE CONSUMER AS FAST AS POSSIBLE RUNNING LOTS OF RAPID INFORMAL
EXPERIMENTS AND THE OBSERVING HOW USERS USE YOUR SOFTWARE BECOMES
THE VALIDATION THAT FEEDS YOUR IMPROVEMENT CYCLE THAT WORKS
REALLY WELL IF WHAT YOUR SOFTWARE IS DOING IS SERVING UP MOVIES OR
SOCIAL MEDIA CONTENT OR SOMETHING LIKE THAT, BUT IS PROBLEMATIC IN
THE HEALTHCARE SPACE.
BECAUSE WHEN YOU WHEN WHAT YOUR SOFTWARE IS DOING IS TRYING TO
SELECT A DRUG TO GIVE TO THE PATIENT OR WHETHER TO ADMIT THE
PATIENT TO THE HOSPITAL OR WHETHER TO SEND THE PATIENT HOME FROM THE
HOSPITAL. THESE ARE REALLY HIGH STAKES LIFE AND DEATH DECISIONS
THAT ARE MUCH HIGHER STAKES THAN DECIDING WHAT MOVIE TO WATCH TONIGHT.
AND IN THAT SETTING YOU HAVE TO HAVE DIFFERENT APPROACHES
TO VALIDATION BEFORE YOUR SOFTWARE IS USED ON REAL PATIENTS.
SO HERE'S AN ILLUSTRATION OF THIS POINT INVOLVES MACHINE
LEARNING FOR CATEGORIZING PNEUMONIA PATIENTS.
IT'S AN OLDER EXAMPLE FROM THE LATE 90S, BUT IT'S STILL USED IN
TEACHING SETTINGS TO ILLUSTRATE THESE POINTS.
SO THIS WAS RESEARCH DONE AT THE UNIVERSITY OF PITTSBURGH AND
CARNEGIE MELLON AND THE UNIVERSITY OF PITTSBURGH MEDICAL CENTER BACK
IN THE LATE 90S.
WHAT THEY WERE DOING WAS USING MACHINE LEARNING IE ARTIFICIAL
INTELLIGENCE APPROACHES TO CLASSIFY PNEUMONIA PATIENTS COMING
IN THE EMERGENCY DEPARTMENT. THE DECISION THAT YOU HAVE TO MAKE ON
THESE PATIENTS THAT POINT IS DO YOU ADMIT THEM AND PUT THEM ON,
YOU KNOW EXPENSIVE BUT POWERFUL IV ANTIBIOTICS OR DO YOU SEND THEM
HOME ON ORAL ANTIBIOTICS, WHICH IS MUCH MUCH CHEAPER, BUT AGAIN NOT
AS POWERFUL. SO IT'S A HIGH STAKES DECISION.
NOW THE RESEARCHERS BUILT SIX DIFFERENT MACHINE LEARNING MODELS
AND THEY TRAINED THEM ON HISTORIC DATA FROM UNIVERSITY OF PITTSBURGH
MEDICAL CENTER AND ALL SIX MODELS DID QUITE WELL IN TERMS OF THEIR
AVERAGE ACCURACY.
FOR ANY SORT OF TECH FOLKS IN LISTENING TO THIS PRESENTATION,
I'M BASICALLY SAYING THAT THEY ALL HAD HIGH AREA UNDER THE ROC CURVE.
NOW AT THIS POINT WHEN THEY GOT YOU KNOW, GOOD AVERAGE ACCURACY
RATES ON THESE MODELS IF THIS RESEARCH HAD BEEN CONDUCTED BY A
COMMERCIAL ENTITY;
THEN THERE'S A GOOD CHANCE THAT AS SOON AS THEY GOT GOOD ACCURACY
NUMBERS THAT THEY WOULD HAVE GONE STRAIGHT TO MARKET.
AND HIRED SALESPEOPLE AND TRIED TO GET THIS IN THE HANDS OF HOSPITALS TO START
USING ON REAL PATIENTS, BUT BECAUSE IT WAS AN ACADEMIC PROJECT
INSTEAD, THEY SPENT THEIR EFFORTS STUDYING THE RESULTS TO SEE WHAT
THEY CAN LEARN FROM THEM.
AND IT TURNS OUT THAT THEY DISCOVERED THAT THE THAT ALL SIX
OF THESE ALGORITHMS WERE MISCLASSIFYING AN IMPORTANT SUBSET
OF PATIENTS. NAMELY PATIENTS WHO HAD BOTH PNEUMONIA AND ASTHMA AND
IT WAS PREDICTING THAT PATIENTS WITH ASTHMA WERE LOW RISK AND COULD
BE SAFELY SENT HOME, WHEN IN FACT, IF YOU'RE A DOCTOR LISTENING
PRESENTATION, YOU KNOW THAT PATIENTS WITH BOTH ASTHMA AND
PNEUMONIA OR ACTUALLY AT AN UNUSUALLY HIGH RISK AND THEY NEED
TO BE TAKEN CARE OF NOW, WHY DID ALL OF THE THE SOFTWARE MODELS FAIL?
WELL, IT'S BECAUSE OF THE WAY YOU BUILD AI. WHEN YOU'RE USING
REAL-WORLD DATA TO TRAIN YOUR MODELS IN THAT REAL WORLD DATA
CONTAINS UNKNOWN BIASES, THEN IT WILL THROW OFF THE PERFORMANCE.
THAT'S WHAT HAPPENED HERE.
THE REAL WORLD DATA FROM UNIVERSITY MEDICAL CENTER WAS ON
YOU INCLUDED ASTHMA PATIENTS, BUT THE DEVELOPERS THAT COMPUTER
SCIENTISTS BUILDING THESE MODELS DIDN'T KNOW THAT ASTHMA PATIENTS
WERE TREATED MUCH DIFFERENTLY FROM NON ASTHMA PATIENTS AT THE MEDICAL
CENTER. AND SO THAT INTRODUCED SOME BIAS THAT THEY DIDN'T ACCOUNT FOR.
MY POINT IS SIMPLY THAT WHEN YOU BUILD ARTIFICIAL INTELLIGENCE
FOR HIGH-STAKES SETTINGS SUCH AS PATIENT CARE.
THEY NEED TO UNDERGO AN UNUSUALLY HIGH LEVELS OF VALIDATION HIGHER
LEVELS THAN MOST OF THE COMMERCIAL AI WORLD IS NORMALLY USES WHEN
COMMERCIALIZING THINGS OUTSIDE OF THE HEALTHCARE SPACE.
OKAY, THE THIRD CORE ETHICAL PRINCIPLE I WANT TO TALK ABOUT IS JUSTICE.
THIS IS MORE OR LESS A SYNONYM FOR FAIRNESS ACROSS ALL
POPULATIONS OF PATIENTS. SO HERE'S A HEADLINE FROM LAST NOVEMBER
NOVEMBER OF 2019 SAYING THAT NEW YORK STATE REGULATORS WERE
INVESTIGATING SOFTWARE SOLD BY UNITED HEALTH FOR RACIAL BIAS.
THE SOUNDS SORT OF CRAZY.
HOW CAN A PIECE OF SOFTWARE BE RACIST?
WELL, LET ME TELL YOU WHAT THE SOFTWARE DID FIRST OF ALL AND THEN
IT WILL START TO MAKE SENSE.
SO THIS WAS POPULATION HEALTH SOFTWARE DEVELOPED BY UNITED
HEALTH AND THEIR OPTIMUM SUBSIDIARY AND IT WHAT IT DID WAS
IT PREDICTED FUTURE HEALTHCARE
COSTS BASED ON LOOKING AT A PATIENT'S PAST MEDICAL HISTORY.
SO WHAT WAS THIS USED FOR?
IT WAS ACTUALLY USED IN A NUMBER OF HOSPITALS MAY STILL BE USED IN
A NUMBER OF HOSPITALS AROUND THE COUNTRY AND HOSPITALS BASICALLY
WANT TO BE ABLE TO KNOW IN ADVANCE WHICH PATIENTS ARE GOING TO BE
REALLY EXPENSIVE IN THE NEAR FUTURE.
LET'S JUST SAY IF YOU KNOW THAT MR. JONES
IS PREDICTED TO HAVE $100,000 IN MEDICAL EXPENSES NEXT YEAR,
THEN YOU MIGHT TAKE A NURSE CASE MANAGER AND TELL THAT PERSON
TO FOLLOW UP REGULARLY WITH MR. JONES
AND MAKE SURE HE GETS HIS MEDICATIONS REFILLED AND THEN HE
SHOWS UP FOR DOCTOR APPOINTMENTS AND THINGS LIKE THAT TO TRY TO GET
THOSE COSTS DOWN.
ESPECIALLY IF YOU'RE A HOSPITAL WHERE YOUR YOU'VE CAPITATION OR
SOME OTHER SORT OF MEDICAL RISK SHARING. SO THAT'S THE BASIC IDEA
OF THE SOFTWARE AND YEAH, IT'S WIDELY USED AND IT GENERALLY ON
AVERAGE IT WORKS QUITE WELL. A NUMBER OF SOME RESEARCHERS HEARD
ABOUT THAT THE SOFTWARE WAS BEING USED THOUGH AND DECIDED TO TAKE A
CLOSER LOOK AND STUDY THIS ALTERS BEHAVIOR TO SEE WHAT THEY COULD FIND.
AND PUBLISHED THEIR FINDINGS IN ONE OF THE NATURE JOURNALS RECENTLY.
WHAT THEY FOUND WAS THAT THIS ALGORITHM EVEN THOUGH IT
WORKED WELL ON AVERAGE, IT DIDN'T WORK WELL ON BLACK PATIENTS.
IT UNDERESTIMATED BY ABOUT HALF WHAT
THE FUTURE MEDICAL EXPENSES WOULD BE FOR BLACK PATIENTS.
SO TO TURN THIS AROUND A BLACK PATIENT AND A WHITE PATIENT WITH
THE EXACT SAME MEDICAL HISTORY.
THE BLACK PATIENT WOULD BE PREDICTED TO HAVE HALF THE FUTURE
MEDICAL NEEDS AND THE IMPLICATION OF THIS IN A REAL WORLD SETTING IS
THAT BLACK PATIENTS MIGHT HAVE BEEN, YOU KNOW NEGLECTED
RELATIVELY NEGLECTED BY CASE MANAGERS BECAUSE OF THE SOFTWARE.
SO THIS IS A PROBLEM.
THE SOLUTION SHOULD BE FAIRLY STRAIGHTFORWARD.
IN THE FUTURE I HOPE THAT UNITED HEALTH AND OPTUM LEARN TO COLLABORATE WITH
ACADEMIC GROUPS TO GET THEIR SOFTWARE VALIDATED EXTENSIVELY
PRIOR TO COMMERCIALIZATION RATHER THAN AFTER COMMERCIALIZATION.
AND IF THEY DO THAT IT WILL AVOID EMBARRASSING HEADLINES LIKE THIS ONE.
THESE LAST TWO EXAMPLES SHARE SOMETHING ELSE IN COMMON, WHICH IS
THE BLACK BOX PROBLEM.
SO BLACK BOX BASICALLY MEANS A PROPRIETARY ALGORITHM HELD BY A
COMPANY AS A TRADE SECRET. NOW BLACK BOXES ARE ALL OVER THE PLACE
IN THE TECH WORLD AND IN MOST CASES, THEY'RE NOT A PROBLEM.
IF YOUR SOFTWARE AGAIN IS, YOU KNOW, IF YOUR NETFLIX MAKING MOVIE
RECOMMENDATIONS IF YOUR FACEBOOK MAKING, YOU KNOW, SOCIAL MEDIA
POSTS SHARING THEN BLACKBOX ALGORITHMS MAY NOT BE SUCH A BIG DEAL.
BUT WHEN THE ALGORITHM IS MAKING DECISIONS THAT HAVE MAJOR SOCIAL
TRADE-OFFS OR HIGH-STAKES DECISIONS, LIKE DO YOU ADMIT THE
PATIENT TO THE HOSPITAL OR NOT, OR DO YOU DIVERT YOUR MEDICAL CASE
MANAGEMENT RESOURCES FROM THIS PATIENT TO THIS OTHER PATIENT?
THOSE ARE THE KINDS OF SETTINGS WHERE WE NEED A LOT MORE TRANSPARENCY.
WE NEED SCIENTISTS TO BE ABLE TO STUDY THE ALGORITHMS TO
KNOW WHETHER THEY'RE BEING FAIR, WHETHER THEY'RE APPROPRIATELY
VALIDATED QUESTIONS LIKE THAT.
SO IN THE MEDICAL WORLD BLACK BOXES ARE GENERALLY NOT ETHICAL
AND WE NEED TO DEVELOP POLICIES TO PREVENT THEM.
SO I WANT TO CLOSE WITH TWO TAKE HOME MESSAGES: THE FIRST TAKE HOME
MESSAGE IS THE ONE ON THE SCREEN, AND THIS IS INTENDED FOR
ANY NON-MEDICAL PEOPLE WHO MIGHT BE LISTENING THIS PRESENTATION IF
YOU'RE A SOFTWARE DEVELOPER AND ENTREPRENEUR OR AN INVESTOR WHO
WANT TO DO HEALTH TECH INNOVATION, THEN MY MESSAGE TO YOU IS THAT
WE IN THE HEALTH CARE WORLD
WE WANT YOU WERE EXCITED ABOUT YOUR INTEREST.
WE HAVE A LOT OF PROBLEMS THAT WE'D LOVE YOUR HELP IN SOLVING,
BUT YOU REALLY NEED TO UNDERSTAND THAT WORKING IN MEDICINE IS
DIFFERENT WORKING IN HEALTHCARE IS DIFFERENT THAN WORKING IN A LOT OF
THE OTHER INDUSTRIES THAT INVOLVE INFORMATION TECHNOLOGY.
AND SO AS YOU DEVELOP AS YOU BUILD COMPANIES AS YOU DEVELOP SOFTWARE
PRODUCTS RECOGNIZE THAT THERE'S A MUCH HIGHER ETHICAL BAR TO GET
OVER THEN YOU MAY BE EXPERIENCED WITH IF YOU'VE BEEN WORKING OTHER
INDUSTRIES. MY SECOND MESSAGE IS FOR ALL OF THE HEALTH CARE
PROFESSIONALS WHO ARE LISTENING THIS PRESENTATION.
YOU MAY BE IN A POSITION EITHER CURRENTLY OR IN THE FUTURE TO
COLLABORATE WITH OUTSIDE TECHNOLOGY COMPANIES AROUND RD
AROUND VALIDATION AROUND OTHER THINGS MY MESSAGE TO YOU IS AS YOU
COLLABORATE WITH OUTSIDE TECH COMPANIES DO NOT NAIVELY TRUST
THESE COMPANIES JUST BECAUSE THEY SAY TRUST ME. YOU AS A MEDICAL
PROFESSIONAL HAVE THE PRIMARY ETHICAL OBLIGATION TO PROTECT THE
INTERESTS OF THE PATIENTS IN YOUR WORLD AND YOU PROBABLY HAVE MORE
KNOWLEDGE ABOUT MEDICAL ETHICS THAN THE FOLKS THAT YOU'RE
COLLABORATING WITH.
SO YOU NEED TO CHANNEL YOUR INNER INSTITUTIONAL REVIEW BOARD.
YOU NEED TO PLAY THAT ROLE OF THE THE ETHICS GADFLY AND YOU NEED TO
MAKE SURE THAT IN YOUR COLLABORATIONS THAT YOU HAVE
FREQUENT CONVERSATIONS WITH ABOUT ISSUES LIKE PRIVACY BIAS
PREVENTION. SCIENTIFIC VALIDATION OF ALGORITHMS TRANSPARENT SHARING
WITH THE SCIENTIFIC COMMUNITY.
ALL OF THOSE KINDS OF ISSUES NEED TO BE FREQUENTLY DISCUSSED AND
DISCUSSED EARLY AND THEY ALSO NEED TO BE WRITTEN INTO ANY OF YOUR
AGREEMENTS AND PARTICULARLY DATA-SHARING AGREEMENTS.
AND WITH THAT I THINK ALL OF YOU FOR YOUR TIME AND ATTENTION
IN LISTENING THIS PRESENTATION, AND I'M CONFIDENT THAT AS WE WORK
TOGETHER WE CAN HAVE GOOD COLLABORATIONS BETWEEN
HEALTHCARE ORGANIZATIONS AND HEALTH CARE PROFESSIONALS AND THE
SOFTWARE WORLD IN THE TECHNOLOGY WORLD, BUT WE NEED TO DO THAT ON
AN ETHICAL FOUNDATION IF WE'RE GOING TO BE SUCCESSFUL FOR THE LONG RUN.
THANK YOU.