FHC #224: Austin Chiang on burnout, misinformation and the future of med-tech

0:11Dr. Robert Pearl: Hello and welcome to the Fixing Healthcare podcast. I'm one of your hosts, Jeremy Corr, also host of the Popular Books of Medicine podcast and CEO of Executive Podcast Solutions. With me is Dr. Robert Pearl. For 18 years, Robert was the CEO of the Permanente Group, the nation's largest physician group. He is currently a Forbes contributor, a professor at both the Stanford University School of Medicine and Business, and author of the best-selling book, Check GPT-MD, How AI-Empowered Patients and Doctors Can Take Back Control of American Medicine. If you want more information on the book and a broad range of healthcare topics, you can go to the website, robertperlmd.com.

0:41Dr. Robert Pearl: Our guest today is Dr. Austin Chang. He's an interventional GI physician and assistant professor at Jefferson Health. In addition, he serves as the chief medical officer for endoscopy at Medtronic. He's the author of Gut, an owner's guide, and his expertise is relied on by over 700 ,000 social media followers. Hi, Austin.

0:59Jeremy Corr: Welcome to Fixing Healthcare. Thank you so much for having me. I'm excited to be here. This is Season 11. It explores what's bothering most Americans about medicine today. In your multiple roles, you interact with a huge number of individuals from diverse backgrounds, including hundreds of thousands of people through social media. As a result, you hear hundreds of complaints and many personal stories. Let's begin by you're telling listeners the three most common or the biggest ones that you're hearing, and then we can dive deep into each of them. So, I mean, there are a lot of issues with healthcare.

1:43I mean, it's a big ecosystem with many facets to it. I would say from a clinician, you know, physician perspective, I hear a lot about burnout and, you know, administrative burden that I think a lot of my colleagues are experiencing and are leading them to consider other, you know, unconventional or alternative career paths than, you know, just purely practicing full time. So I hear that a lot. The second thing I'd probably say has always been a passion of mine in trying to tackle is misinformation and just generally how to improve upon how the general public receives their medical information.

2:32And, you know, that has shifted over time from more traditional media sources to social media and how we kind of navigate that. And I think the last thing, you know, if I had to put my med tech hat on, would probably be, I feel personally that there is a disconnect between, you know, a clinician understanding of how medical innovation comes about. And I wish there was, it wasn't so siloed so that we could help accelerate innovation with the clinician voice incorporated into the process a little bit more. So that's another passion of mine now is trying to share my insights, kind of bridging the gap so that people can understand how to contribute to this whole process of innovation and how they can bring their knowledge, practicing medicine and apply that toward developing new technology and rolling out new innovations.

3:35So those are the three that I probably start with.

3:38Jeremy Corr: I love the framework, the challenges of the clinician, the challenges for the patient, and then obviously the opportunities of technology. So let's dive deep. Let's start with the clinician, which you mentioned first. What do you see as the leading contributors to burnout? What are people telling you? But I'd say equally importantly, how are you interpreting it? Yeah, I hear a lot about kind of the general sense that there's greater administrative burden. And I think part of what that might be is that over time, you know, there's maybe more time spent in documentation and other adjacencies, rather than actually taking care of patients and spending time with patients.

4:30Now, I think that if I had to take a step back even further, what I feel that reflects is maybe a little bit of a loss of autonomy by the clinician. You know, the sense that some of the decisions that they're making for the patients are out of their hands these days and maybe driven by, you know, what the payers are determining for them, you know, the prior authorization process, things like that. And then on top of that, I think it's been compounded by other issues like staffing shortages and reimbursement pressures. And, you know, the fact that medicine today is very complex and it's only becoming more and more complex and hard to keep up with over time.

5:20So all these things combined, I think, are making it harder and harder for clinicians to practice.

5:28Jeremy Corr: Let me take a somewhat controversial position around it. And I would agree that what you're hearing is the same things that I'm hearing. I have monthly musings that have about 80 ,000 readers and I survey them and they say the clinicians in the survey respond in the same way about the administrative tasks and prior authorization and loss of autonomy. But let me offer the thought that all those places, all those approaches that are so frustrating are not are not unexpected. They're actually features designed to address the growing unaffordability of medical care. And that when clinicians had autonomy and had fewer regulations, they still didn't do much to flatten that curve.

6:25Jeremy Corr: Do you see clinicians accountable for the affordability of American health care? Or do you think whatever it costs, it saves lives and someone should just pay for it, but it's not the purview of the medical professions? Yeah, I think that's a great point. It's, you know, it's always a balance. And, you know, there may be, you know, the amount of oversight and administrative burden, I understand kind of what it's there to serve. And, and it's trying to find, you know, where along the spectrum that probably works best for the current situation. I think that clinicians, yeah, to a certain extent should be held accountable.

7:11And it's difficult because I'm sure there are folks who are very judicious and cost conscious when it comes to, you know, their decision making and others who are, you know, not so careful and thoughtful about how they're, you know, utilizing these resources. So I think it's going to be somewhere in the middle. And I don't think there will ever be a perfect answer that, you know, everyone will be happy with because everyone practices medicine differently. But I think there's also just helping clinicians understand the greater ecosystem of how healthcare comes together and why these decisions are being made is also helpful in allowing them to put things in context so that maybe that element, if it's contributing to the burnout, they can have a little bit more of an understanding of why.

8:10and potentially even how to get involved to affect change.

8:16Jeremy Corr: I've been a big believer that if we could move from a pay-for-volume, a fee-for-service system, to a capitated approach where a group of clinicians, hopefully working maybe with a hospital, are able to take the full accountability for care and be paid a set fee, it's often called capitation, that it would eliminate all of the prior authorization, that it would eliminate all of the excess documentation. It could get rid of all the administrative burdens, but it would create the risk for the clinician. I don't see very much progress in this direction. I'm not even hearing many doctors request it.

9:05Jeremy Corr: what's your view on this reimbursement i'll say opposite poles between a pay for volume and a pay for value oh i mean admittedly i am not you know uh an expert in this area so i'm just speaking from my own personal uh clinician lens um you know i feel like there have been efforts around value-based care. And again, I feel like there might be certain situations where it's very obvious that that makes a whole lot of sense and in other ways that it might not. And any sort of sweeping change, I think, could have, again, situations where it's appropriate and others where we might not see as much benefit.

9:55And it really comes down to, as a system, kind of a healthcare system as a whole, you know, who realizes those benefits at the end of the day? Is it the system as a whole? Is it, you know, do certain institutions benefit more than others? You know, depending on what the patient population is around that region, depending on the available expertise, the demographics in that area. So I feel like it's a very complicated question for such a large country with a lot of diversity along many fronts. So kind of a long answer to your question there. And I don't think I have a 100 % grasp over what one approach could lead to versus the other.

10:53Jeremy Corr: You are an expert in technology. And let me ask you, therefore, building on what we just discussed, if you look at generative AI, I'm sure you saw the study coming out of NYU that the currently available large language models, both in doctor's offices and patients' homes, like ChatGPT and Claude and Gemini, actually perform as well or better than some of the specialized tools like open evidence in studies, both theoretical as well as clinical application. I don't hear very many doctors encouraging patients to use these tools to be able to get care either more effectively or at lower cost. can you see a way that a generative ai tool used broadly not just by not in the clinician's office but also in the patient's home could address this problem by taking some of the load off of the doctor and also by improving people's health and if you do why are clinicians seeming to me to be so reluctant to use these tools outside of administrative tasks?

12:13Yeah, I think so. I think that there may be some benefit to patients. I don't think it will take much convincing of patients to adopt some of these tools. I think as folks become more and more tech savvy and are using these chatbots and chat GPT and whatnot for their other kind of non-healthcare uses, As they get used to that, I'm sure they'll naturally also turn to these tools to seek out medical knowledge. I think that, yeah, I think potentially I know that there are folks out there who are developing tools to help with, you know, processing their prior authorization appeals and find ways for them to better navigate the healthcare system.

13:04I feel that for doctors, as much as it may help patients and empower patients to understand their conditions and be able to navigate their care better, we also have to be careful that it could introduce a lot of confusion. I think medicine is very nuanced and personalized. And when, you know, when a large language model is providing recommendations or suggestions that aren't necessarily taking in all the different considerations that we might necessarily take into consideration when we're, you know, making a clinical decision, bringing that back to the doctor who's taking care of the patient could introduce some frustration.

13:51and so we do have to be careful there. But yeah, I think that generally speaking, AI is here to stay. I think that patients, we have to expect that patients are going to come in with a greater understanding of what they're dealing with and what the personal conditions are and come to us with these types of questions. And I don't discourage patients from trying to seek out more information, even without these AI tools, right? Many are Googling their own symptoms. And that's, I think, where we as doctors also need to try to anticipate that and be able to respond to that in a way where we can use the tools that are available to us to disseminate more accurate health information and help build upon the understanding that the general public has of the healthcare system and their own, you know, condition.

14:50So a mixed bag once again. But at the same time, I think it's exciting. I think that there are a lot of opportunities there to be able to positively, you know, shape what patient care looks like and what the patient experience is like of the future.

15:08Jeremy Corr: You mentioned that a lot of doctors are pursuing alternative career paths. What are the types of paths you're hearing about? How prevalent do you think it is? What's your prediction for the future? I think it's becoming more and more prevalent. Interestingly, I remember hearing, and I don't know if this is entirely true, this is, you know, a limited experience that I've had in hearing about this, but I've heard that a lot of trainees upon completing their training are considering locum's jobs. And I don't know if this is being driven by, you know, this general sense of burnout or if it is something post-COVID that has helped everyone sort of reevaluate their life priorities.

15:54But it's interesting. I feel like the general sense when I was in training, at least, was that, you know, that wasn't something kind of considered as a primary goal coming out of medical training. But now there are folks who are looking to do that more and more straight out of training and not be confined to an individual practice or institution. I think that these other careers, as people are becoming more understanding of how medicine at the end of the day is also a business and also needs to be, you know, run sustainably. And so I think when folks are looking into, you know, better understanding where they can affect change and be involved, they're looking at the healthcare system as a whole.

16:49And look, I think clinicians are very ambitious people. That's part of what drove them into the field. And, you know, speaking for myself, I think there was always a sense that I want to do a lot of different things and I want to diversify my experience in healthcare. And I feel like my knowledge could be applied in a lot of different ways. And so I think folks are looking to do that in a lot of different ways, whether it's education, whether it's advising med tech or pharma, whether it's getting into the startup world or even in policy and public health. And so I'm excited about this. I get that at one point, maybe we were siloed for a good reason.

17:39We wanted to make sure that there are, and we continue to want to make sure that there are guardrails to make sure that everything is compliant. but when we're working kind of in parallel rather than together it I think slows things down and and we all have blind spots that I think we could afford to learn and incorporate some of that knowledge a bit better so I think it's a good thing that maybe physicians are looking to have some sort of hybrid role like myself or just be a more involved outside of their own kind of, you know, full-time practice.

18:19Jeremy Corr: You are a prime example because you not only continue to practice medicine, but you also are a expert and consultant at Medtronic. How did you make, I don't call it that leap because you still keep one foot in the care to live. But how'd you build that wider stance, let's call it? Yeah, you know, that transition was not something I anticipated, especially at this point in my career. Quite honestly, I had been consulting for several medtech companies at the time, which was sort of par for the course, you know, with a lot of my colleagues and mentors. I just sort of expected to stay in academia and do that.

19:02And then I got a call from Medtronic asking if I'd be interested in this role, which hadn't existed before, because I think previously the endoscopy business wasn't independent. And so it was, I think, great timing. And, you know, when I was offered this potential opportunity, I thought to myself, you know, after some soul searching, you know, what really drove me into GI and medicine in the first place? And a lot of that was the innovation and the technologies and procedures. And I think in some ways, my social media presence was kind of me trying to have more of a population level impact. And when this opportunity came about, I felt like it was an even more tangible way of bringing that to life.

19:57And so I thought, you know, this makes a lot of sense. Why don't I give it a whirl? But at the same time, I wanted to, like you said, keep a foot in the door, stay close to patients, still understand what's going on on the front lines. And then that's why I still maintain that balance today.

20:16Jeremy Corr: And I support that 100%. I have a career that's both been very, very aggressive in terms of the breadth and intensity of my clinical practice, as well as taking on the CEO responsible for almost 12 million people. But I continue to practice for exactly that reason. Because I think as soon as an individual loses contact with patients and with families, you start to dull your acuity, being able to see what is most needed as the next steps. You tend to just do a lockstep kind of approach to the future. And you basically slow down and others speed ahead of you. So I applaud you for keeping your foot in both canoes, even if it's quite difficult and potentially even dangerous.

21:10Jeremy Corr: So let's move on to the second part, though. You spoke about you said misinformation and then you talk about education. And I agree with you. Those are simply two sides of the same coin. How do you see us now being able to educate, I'll say to all Americans, particularly those who span generations from Gen Z all the way through the baby boomers? Yeah, I think that, you know, I'm partial to social media as a great tool for doing that. I mean, there's so many different platforms out there, each with different audiences and catering to different forms of communication in different ways. People like to get their information and learn.

21:56and I always felt that you know through medical training med school and residency and fellowship etc that there's always been the emphasis always been on the science and the and the medicine practice of medicine itself but there's so much more to learn about including how to communicate with patients and you know at least in an academic setting maybe there's a little bit of an emphasis in teaching, but I felt like the pandemic really highlighted how we were poorly equipped to communicate with the general public. You know, we were relying on a select few, but really when it comes down to our own local communities, it was, you know, we had to do a better, we could have done a better job at simplifying the message and doing it in a way that was engaging.

22:52And there's just a lot to think about when you're actually trying to deliver a public health message. And so depending on, you know, what the immediate goal is with the education and who you're speaking with, I think that, yeah, a message has to be catered in a certain way. And I feel like I've done that reasonably well over time. I mean, this is something that I've had to learn well over a decade across multiple platforms in how to communicate with different audiences. You know, if you imagine how I who I'm speaking to over LinkedIn is very different than who I'm talking to on TikTok. And I've had to shape shift a little bit depending on who my audience is.

23:37and, you know, and sometimes package the message in a way that, for instance, on TikTok to be engaging and entertaining so that it will even be able to be picked up by the algorithms. I think if something is boring and not engaging and confusing, you know, people aren't going to watch all the way through and save it and share it and engage with that piece of content. And as a result, it doesn't go anywhere. It doesn't go viral and doesn't reach, you know, the number of people that you'd want it to get to. So I really believe that virality in a lot of ways is not, it's a calculated, you know, strategic kind of outcome versus something that just happens by chance.

24:28and I think that there's a way that, you know, clinicians and health professionals in general could stand to learn a lot more about how to participate in that to get the message across. And there's so much that patients have to pay attention to these days. You know, I think about just even all the different types of, you know, cancer screenings that people are supposed to get. It's confusing, even for those of us who are in medicine and we rely on, you know, our colleagues and our, you know, primary care doctors to help us guide our way through that. But, you know, a lot of people who don't have access to care and still need to understand that they need these types of things, I think, you know, we need to get the message to them somehow.

25:16And that's a challenge. I feel like I've often tried to cater a message to folks who are looking for that message. But really, we have to think of creative ways to get the message across to folks who don't even know that they need something. You know, I think there are a lot of folks out there who don't even know that they need to get to start colorectal cancer screening if they're average risk at age 45, especially if they're not plugged into, you know, the health care system already. So, but yes, I would say, you know, education on social media is a big piece of it. And I think we'll continue to be a big piece of it as social media becomes more and more widely adopted.

26:04Jeremy Corr: How do you advise listeners on these different platforms? TikTok is a great example of that because, as you say, being a little edgy and getting a lot of attention is vital to the algorithm that that particular application uses. How do you advise listeners to discern what is good information from what is misinformation on that type of social media platform? Yeah, it's truly a challenge. I think, you know, that critical thinking piece is difficult to train. And I would say, you know, always try to verify through a primary source what you're hearing on the Internet. Try to, you know, find multiple sources to support that and always check people's credentials.

26:56I think there are a lot of non-healthcare professionals who are trying to put out a certain message to sell a certain product. And so I know that some of these social media platforms have tried to actively introduce tools to help guide the viewer or listener. For instance, on YouTube, I was involved in the process of introducing these special badges that certain creators would have to say that they have been vetted by a third party to make sure that they are credentialed appropriately for whatever subject matter that they're talking about. but it is challenged teasing apart what's fact from fiction and especially in the era of generative AI it can be a challenge even for somebody as experienced and chronically online as I am I think there are moments where I question what I'm seeing is that photo is that video AI are these real sources that are being cited are even if it's a real source, you know, is the data being interpreted correctly?

28:14And I think that's why at the end of the day, despite all the information and knowledge acquisition patients and the general public get through social media, it's important to verify that with a professional in person, because even if it is accurate, even if it is applicable, to most of the people out there, you know, everyone's medical history is different and it may not apply or might be, you know, dangerous to one individual's, you know, own medical condition. So I always say at the end of the day to verify with your doctor in person.

29:01Jeremy Corr: let's move on to the third topic this whole issue of med tech and i agree with you completely that this is going to be the future of medicine technology linking into clinical practice do you want to tell the audience a little bit how innovation happens and how you see us getting out of the silos of today yeah i mean it's a it's a very lengthy process because you know unlike a lot of consumer products that are developed out there. You know, healthcare, things that are used in patient care, obviously need to be, you know, very much vetted, and need a lot of data to show that there's clinical benefit, especially, you know, when there's potential risk involved, because any procedure or any type of intervention in healthcare carries some degree of risk.

29:59And so it is a very lengthy process coming up with an idea to address a certain clinical unmet need and prototyping it and making sure that it's safe for, you know, to be on the shelf somewhere And then demonstrating that it's able to do what it's intended to do, you know, both before even in humans, right, in a more in another sort of controlled laboratory setting before it makes its way to being evaluated in patients. And then from there, you know, it's, again, unlike consumer products out there in this very complex environment of determining who pays for that technology, there needs to be a pathway for that.

30:52And eventually, you know, doctors and other health professionals who are using these tools, it takes time for them to adopt these new technologies because in medicine, I think a lot of us tend to be very risk averse. We want to take care of our patients safely and want to make sure that any new newly introduced technology is safe and beneficial. and so it takes a lot of doctors and a lot of patients slowly to prove that story in the real world and ultimately get that technology or that procedure or technique incorporated into you know our professional guidelines and so end to end this whole process could you know span decades even before it really, before something becomes a mainstream technology or technique that doctors use.

31:50And so it's a very complicated process for sure.

31:55Jeremy Corr: Do you see cost benefit analysis part of the decisions doctors should be doing, or do you think that it should simply be driven by clinical outcomes? Oh, I think ideally it would be driven by clinical outcomes at a population level. I think that absolutely cost benefit is part of what is often considered. I think that often they go hand in hand because if a certain technology, for instance, can prevent cancer and we can demonstrate that in preventing a cancer from even developing, that is cost savings not only for patients kind of going to get their own care, but also, you know, potential surgeries and potential imaging and lab tests and medications.

32:56and, you know, at a population level, that's a huge amount, not just of life saved, but also money saved as well.

33:07Jeremy Corr: I really like the idea of seeing improved health as the best way to lower costs and obviously preventing a colon cancer or finding a polyp early saves a couple hundred thousand dollars of chemotherapy as well as the person's life. So I think that's the right approach for our nation and it has not been in place. You talked about integrating the clinician more into the technological process. What did you mean by that? Yeah, I mean, I think that there have been moments where I feel that my input has helped, you know, maybe drive some of the or shed light on certain areas that maybe previously weren't considered in the innovation process, even at my time at Medtronic.

33:56And, and, you know, I know that, you know, for, even before I was in this role, I mean, device companies always will rely on customer feedback and user feedback and, get input ahead of time to understand what new technology should look like and how it potentially will be implemented and integrated into a workflow. So I think practicing medicine, as you and I know, is very complex and nuanced. without actually doing it firsthand, it's often easy to overlook some of the things that we might notice down to, you know, often like workflow related and what, you know, not even the procedure itself, but just, you know, how it fits into the day and what, you know, our staff, how they feel about it and how it could affect their experience and things like that.

35:07Dr. Robert Pearl: So Austin, you have a background in GI, so I'm going to direct your question this way. You know, when I was a day old, I had to have half my small intestine removed, including ileocecal valve, and I've dealt with like chronic GI issues my whole life that have, you know, gotten worse in recent years. So I'm very aware of what it is like dealing with long-term chronic GI issues. And one of the things that blows my mind is medical information when it comes to the gut, not just for people like me with chronic issues, but for people in general. You'll see people claiming to be gut health or experts in gut health all over social media and recommending completely different things in terms of diets and supplements.

35:43Dr. Robert Pearl: You have some people recommending keto, some people recommending vegetarian diets, etc. Yet for people with conditions like small intestine bacterial overgrowth, IBS, or any other number of chronic gut health issues, again, you see people who claim to be experts discussing these things on social media and how to fix them. Well, at the same time, you have massive groups of people on Reddit or Facebook who have these or other chronic issues who feel like nothing has ever helped them. And they just have a complete loss of hope. And these groups are filled with ads and supplements for ads for supplements and people who claim to be experts who often have no medical background and promise them something they can't even do.

36:27Dr. Robert Pearl: And oftentimes may even cause more harm than good. And so when it comes to gut, the reality is, if I'm not mistaken, we still have a really long way to go into fully understanding the gut microbiome and how to fix imbalances or issues there. I've even heard it said that we understand more about outer space than we do our own human gut microbiome. And many people suffering from issues like this might only get to see a specialist once or twice a year and have a long wait time. And I'm curious, you know, what do you view as the role of both credible physicians with a social media voice like yourself, as well as social media platforms and AI when it comes to people suffering from chronic diseases and the online support groups they're in who are almost desperate to try anything that helps return them to normal life?

37:18Well, I mean, I think that there's, I think the role is incredibly important for clinicians to, you know, if not actively put out information, be aware of what the conversations are, and be able to, you know, respond to some of them. And I'm sure they're hearing in their practices, but, you know, especially for, but the discourse, I think, is often a, you know, an indicator of what, what requires the most attention. I think that what's challenging is that why there's a lot of confusion around some of these topics about diet and whatnot is because it's a great, it's a very gray area. And I think a lot of folks who are not, who are sort of misleading folks online and claiming to be gut health experts without the appropriate credentials, it's it's it's ripe for them to capitalize on those gray areas and and that's frustrating for patients to hear that you know we don't have reliable answers and suggestions for some of these conditions I think you know when it comes to even over-the-counter probiotics I often will tell patients who ask me about them that, yeah, you might experience some improvement in your symptoms, but I can't reliably say that that will be the case because it's not always, not everybody responds the same.

38:52And in some cases, patients, it worsens their symptoms. And so I can't say one way or the other. And our guidelines, I think, because they're so, you know, are taking into account the clinical evidence, the scientific evidence behind it. These trials are very sometimes challenging to design to answer these questions, costly as well. And with the limited scientific evidence available, there's only certain guidelines out there that say a certain kind of probiotic is suitable for a certain condition. I think that generally speaking, we have a very poor understanding of what probiotic to use for what condition, at what dose, what bacterial strains.

39:40You know, so there's a lot of unanswered questions there. But I think that, you know, this is not just something that the clinicians can do on their own. I agree there needs to be a lot more conversation between, you know, patient groups, patients who are experiencing this. other experts outside of GI, including dietitians, you know, kind of especially given the gut-brain axis and the link between these two organs, even, you know, psychiatrists and other types of specialists who, you know, can help address not only kind of the source of the symptoms, but the perception of the symptoms. But kind of going back to the original point, this is a very gray area, a lot of unanswered questions that hopefully we'll get more and more answers to over time.

40:39But that's why without clear evidence in favor or of something or not, you know, that's where when in those moments where we as a medical community say we I don't know, Others are quick to provide simple solutions. And it's challenging to try to dispel, you know, try to guide people away from those simple solutions that may or may not have a benefit and could just be costing people more money.

41:13Jeremy Corr: I know our listeners, we have said if I don't ask you a couple of questions very specific to colon cancer. So let me ask you the first one, which is we're seeing cancers far earlier than in the past and far more aggressive than in the past in younger individuals. Why is that happening? And how should we change our approach to medical practice to be able to best respond to it? Yeah, I'm glad that you're bringing awareness to this. Right now, colorectal cancer is the number one cancer killer for patients under the age of 50. And, you know, I think if you look at the grand scheme of things, the number of young people getting colon cancer still is less than, you know, older people getting colon cancer, but we see the rates rising rapidly.

42:10No one knows for sure exactly what is causing it, but, you know, it's probably a combination of different things, you know, rising rates of obesity, but also, you know, the environmental factors of, you know, what's in our food, processed foods, things like that. but I don't think that we have a clear grasp on exactly what the culprit is. I would say, you know, the one thing that we know has been associated with increased colorectal cancer risk is red meat intake. So limiting that I think is always something that we recommend and just making sure that you maintain a balanced high fiber diet. it.

42:54And, you know, in terms of what to, how to prevent this on a population level, there's been, I think, a lot of discussion and debate around whether or not screening age should be lowered even further. It wasn't too long ago that we lowered the average screening age from age 50 to 45. And given this understanding that rates are rising in younger people, you know, a lot of the, I often get questions about why don't we lower it even further to 40 or 35? And I think the reality is, you know, with every five-year drop in that screening age, it's millions and millions of people that were introducing and expecting to get colorectal cancer screening, which is a big influx of patients for, you know, the number of doctors that we currently have and the capacity of our healthcare system currently.

43:52And so, you know, things may have to shift over time in terms of how we're screening for colorectal cancer. And there's been a lot of conversation within the GI community about, you know, maybe one day our focus is more on, you know, screening through different modalities. I mean, there are already multiple different ways of screening, some better than others. I think the gold standard is still colonoscopy because we're able to locate where the problem is and resect it at the same time. And that is, really, that's the most effective way of preventing something from developing. And whereas some of the other non-invasive tests aren't necessarily as good at that or able to locate, you know, where things are.

44:35But yeah, I think that the shift may potentially one day be that GIs are focused on therapy and doing that, removing those polyps and early cancers. But time will tell. And so it is going to take a lot of thought behind how do we actually handle, how do we actually put this into practice? And how do we, what is the kind of population level? What's the tradeoff between the clinical benefit and the resources required?

45:08Jeremy Corr: Last question, Austin. Gender of AI is being applied in ever more common ways. Certainly robotics is being driven by generative AI. It's a learning tool. It's a stimulus response. At some point, do you believe that it's going to be able to do colon cancer screening, we'll call it colonoscopy, autonomously or overseen by a clinician with less experience and less training, relying on the technology itself? or do you believe that's, I don't want to say never anything because nothing's ever, never, ever, but not in the foreseeable future? What's the future look like? And if it can do that, how should we be shifting training programs now to recognize what might be here, let's say, within 10 years?

46:04That's a great question. I mean, this whole space is moving so rapidly that even, You know, who knows, like, what the type of even enabling technologies that we have, what will allow some of these things to even be developed. I would say not generative AI per se, but, you know, already today, for instance, through our GI Genius device, it's an augmented, you know, assistive tool where it helps doctors. There's, it points out polyps and has been shown to reduce mist, you know, polyps. And so it's not autonomous. And maybe one day, like you said, there's so many parts to detecting colorectal, detecting and preventing colorectal cancer.

46:56You know, there's the actual, you know, colonoscopy piece of it. There's the inspection of the gut lining. like there are a lot of different things that have to and then there's the actual therapy portion where you're removing that polyp or early cancer and then in terms of diagnosis you know there's also ways to probably improve upon yeah how we're detecting it even on the pathology side of things so I think it's to what extent things become autonomous but maybe eventually I don't know if it's an immediate thing, but from my understanding, you know, robotics in, especially endoluminal robotics is a very complicated area.

47:42And the human, especially the colon anatomy is not the easiest to navigate because it's a very dynamic organ. And so I think there might be some time before we actually see AI kind of driving this on its own. in a way that is reliable and safe and actually clinically beneficial.

48:06Jeremy Corr: Austin, it's been great having you on the podcast today. There's a lot of social media that I'm involved in. I follow very closely. And to have someone like yourself with an academic background, with a commitment to the science of medicine, but also having a foot in the canoe of med tech is very hopeful for the future. I look forward to what you and your colleagues at Medtronic are going to do, what you and your colleagues at Jefferson are going to be able to do, and the ways that you can continue to educate literally hundreds of thousands, if not millions of Americans about how to live a longer and more healthy life.

48:46Jeremy Corr: I will appreciate the work that you do, and I can't wait to hear what the listeners have to say, and I'm sure quite a number of them will be tuning into you to learn more into the future. Thank you for being here today. Thank you. Coming from you, that means a lot. Thanks again for having me. It's been an honor.

49:04Dr. Robert Pearl: Bobby, you and Dr. Chang covered quite a bit of ground. What did he say that resonated with you the most?

49:09Jeremy Corr: Jeremy, I found his insights into burnout to be very interesting, and I enjoyed his perspectives on educating patients and advancing medical technology. His view that the biggest driver of burnout was the loss of autonomy made me think about how medical leaders need to approach that challenge. Yes, the application of gender-driven AI tools for administrative functions, these are the ones that provide doctors with more time, that could allow them to improve their lives, but it won't provide the level of control that they are desiring and they need to be the captains of the professional lives. Unless they lead, someone else will.

49:49Jeremy Corr: This reality is why I asked them about both shifting the payment methodology from pay for volume to capitation and applying generative AI tools to empower patients. When I look at the loss of autonomy among healthcare professionals, I'm struck by the fact that no one will give doctors autonomy until they're willing to accept accountability. The days of just trust me, they're over in healthcare. And so far, few physicians have been willing to take that risk. My personal preference to improve clinical outcomes for all Americans are groups of doctors from a range of specialties taking a single payment to provide all the medical care for a defined population of patients.

50:31But if they

50:32Jeremy Corr: aren't yet ready to accept that level of risk, they can start with bundle payments. As an example, in Austin's specialty, gastroenterologists in a community could accept an annual payment to provide all the GI care for, let's say, 100 ,000 individuals, assuming the physicians were willing to commit to achieving a defined colon screening rate and reducing the number of deaths from colon cancer over the next five years. A prepaid pay-for-value agreement would align incentives and produce superior clinical outcomes at a more affordable cost than today. Robbie, what else intrigued you? Jeremy, I found his role at Medtronic fascinating, particularly relative to how Genitive AI could perform some of the work that endoscopists do today.

51:20Jeremy Corr: He noted that lowering the age for screening colonoscopy from 45 to 40, that would save lives, but that the cost of doing the additional procedures would be too high. What would happen if a next generation tool would allow less specialized clinicians to use a Gen AI guided scope to screen for polyps? These are the predecessors of invasive colon cancer. Doctors think about medical care as all or nothing. But this type of segmentation could save tens of thousands of lives at a cost that would be affordable. And it's the type of approach our nation will need in the future. If you want to raise quality, save lives, and make medical care affordable for families, and do all three at the same time.

52:06Jeremy Corr: These clinicians using the generative AI-enabled scopes, they wouldn't do colonoscopies for inflammatory bowel disease, and they wouldn't remove polyps. but they could reassure most of these previously never-screened individuals that their risk of developing a cancer was relatively low, and they also could identify the cohort that would require intense follow-up. And when a polyp was found, it would be removed by a gastroenterologist at a subsequent procedure, massively reducing the risk of an invasive cancer. The approach would also help reduce the backlog of gastroenterologists and increase the percentage of Americans with colon cancer screening.

52:45Jeremy Corr: In medicine, we have this view that unless we can do something optimally, it's better to do nothing. But the data on deaths from colon cancer in younger patients, I think that demonstrates the dangers of that belief.

53:00Dr. Robert Pearl: We hope you enjoyed this podcast and will tell your friends and colleagues about it. If you want more information on physician culture, you can find it at robertperlmd.com. Please subscribe to Fixing Healthcare on Apple Podcasts, Spotify, your favorite podcast app. If you like the show, please rate it five stars and leave a review. Visit our website at FixingHealthcarePodcast.com and follow us on LinkedIn, Facebook, and Twitter at FixingHCPodcast. Thank you for listening to Fixing Healthcare with Dr. Robert Pearl and Jeremy Gore. Have a great day.

53:38Thank you.