#440: From the 16th Century to AI, with Dr David Neal

0:27David Neal, welcome to L-Tip Podcast. How are you doing, man? yeah i'm very well thank you it's great to be here long time listener first time guest well it's interesting you say that did you know you are not a first time guest i i'm not we recorded do you know you were episode two of this podcast oh my goodness how could i and you know what the date do you know what the date of that podcast was the 22nd of October 2018 you were episode two with Vesalian your company back then your startup pre pre-covid pre-covid pre-covid pre-kids pre-pre moving to Holland moving to the Netherlands yeah wow um it was a long it was a long time ago it was a long time ago yeah and I was thinking back and like it's crazy that we've known each other for that long but I can remember first meeting you in Cambridge and being so wildly impressed with you and what you were up to and all the things that you were doing and then you started the startup and I can even remember then like and again we can explain this for the listeners but for Salian you had a take around the public not understanding statistics and a software idea around a jeep which at the time you know pre-ai pre-LLMs pre-loads of integrations with all sorts of you know epic system and all that sort of stuff thinking about okay we can do this thing where we integrate with primary care and we can actually display statistics in an evidence-based way in an academic way that means that patients can can get more to grips with statistics and by the way that not being a problem sorry being a problem that still hasn't been solved like the lack of understanding around statistics that still play exists but i can even remember like all of the sort of guerrilla marketing stuff that you were doing in regents park or one of the london london parks to figure out user research and that sort of stuff you've been wildly impressive since the day i met you david but it's it's it's obviously been a long time what do you remember about those days back then that's very kind of you to say yeah i was also very impressed by you because you came as um uh national medical director's clinical fellow right that correct yeah at the time yeah so yeah i when i was studying medicine in cambridge i uh was not your typical student i was the very like i was the weird one that thought that stuff like public health was interesting uh that that like but that's only because i think that everything is interesting around healthcare because i think um i didn't get into medicine i wasn't one of the sort of people that decided they wanted to be a neurosurgeon when they were four and then like their entire life after that is kind of geared to that i'm the opposite type of type of person because i had like this vague idea that maybe i could figure out how people work and uh if i could do that maybe i could use that understanding to try and like maybe help people kind of live healthier happier lives and so that that's why i applied to medical school in the first place and then i got to medical school and cambridge is fantastic as an academic environment it's a fantastic place to study medicine um but the first two years you just do solid like theory like you know wet labs uh biochemistry and all this stuff which is i think still important to know but i was sort of oh my goodness when are we actually going to talk about people and like what people need and how we can help people and how healthcare works um and that kind of sparked in me something which i guess had always been there this really divergent interests in like everything from psychology which i then did my like part two and so i got my degree in behavioral neuroscience uh in public health which is then what led me to like go to the world health organization and do an internship there and set up polygea this kind of community interest company which still exists still going strong uh which um you know gabriel lambert another fantastic student who'd studied history as a bachelor set up so i think generally like there's a group of people who uh who i've had the pleasure of working with over the years who are the type of people that think that innovation and progress happen at like the intersection of things that don't necessarily belong together um like you know history and uh psychology or you know technology and medicine things that actually when you think about it don't like don't necessarily go together separate worlds separate understanding separate languages separate ways of understanding like the world and the systems that we live in and govern healthcare for example but if you can figure out like at the intersection of those two things like what do they mean for each other and how can you kind of do stuff like you know public and private that's you know it's not one discipline it's not even one sector um that's the space that i think where really exciting stuff happens and and there's plenty of examples of like other people that you know throughout history uh current master of churchill college actually which is why i studied in cambridge is sharon peacock and i think she's a great example of like that kind of thinking and that way of being um so and a lot of entrepreneurs and innovators so i think a lot of other guests on the health care health tech podcast in the past will share a similar kind of worldview um and i definitely share it too right but that's what i remember from cambridge being like being a sort of like a bit of an odd one out that uh was part of like a smaller group of people that just were really like pushing at the boundaries of like sure but yeah we're learning medicine but how are we learning like actually how different things fit together to kind of make progress and innovate it's such an interesting worldview that I definitely share and I people often say like oh I remember a while ago actually I've been talking years ago that when entrepreneur first was in its earlier days of people you know joining it and wanting to start healthcare companies a lot of people I say a lot a few people reached out and asked me you know I'm I'm at the pre-idea stage is what they actually said because that apparently is a stage of a stage of being an entrepreneur you can still call yourself an entrepreneur if you're at the pre-idea stage like I can remember a couple of these calls um and it was quite it was quite funny at the time um but my reflection on it was that exactly what you've just said that there are these places that healthcare butts up to but doesn't cross that actually when you start looking at the intersection of those places there are so many ideas because actually one of the problems to solve is actually learning things on both of those sides it's interesting to me that you said history as well like history and medicine and I'm thinking like okay how can you how can you that but then my mind starts wandering to like well history repeats itself what are the principles what what what can history teach us what can and then obviously it can it can go from there but obviously technology broadly is one of the things that healthcare butts up into but then you can go really specific in that and that's I guess the more common thing to do but for me it was creativity and communication and it was thinking okay well the communication side of the world isn't going very well in healthcare because that's what I felt intuitively the whole time from as from from the super narrow things of if i pick up the phone to a cardiologist and try and explain a patient to them as an f1 why are they so mean to me what's the point in that like just just just like a real basic thing like that but then also if i see a patient in this hospital why doesn't the hospital down the road know about them and understand them why isn't an allergic reaction here not communicated over there that's also a communication issue and that's what sort of initially gave me my thesis around communication it's what i say thesis that's a very grand term for what was basically this thing is vaguely interesting to me let me follow it um it's yeah as i say pretty grandiose to call that a thesis but this really like well thought out plan to start a communications agency in 10 years um it wasn't that but but no i appreciate what you're saying though about like medicine and is super interesting yeah spotting the spotting the things that have been left behind or forgotten about is only possible when you step outside like that single perspective that you're in so uh you have to be able to look at things from another perspective to be able to see well hang on a minute what about this so like you said you can look at health care and be like well hang on a minute what about and so for me and i think there's two like i've had two of those big kind of moments where like looking at things from different perspectives I've had the chance to step back and say well hang on a minute what about and one of those was certainly like when I was doing my foundation program and it was around the time or you know just shortly after that you had the big implementations of the electronic health records um in hospital settings and so there was a lot of like new software new technology coming in and everything there was a lot of stuff being i guess pushed you get teaching sessions where someone buys you an m &s sandwich and comes to tell you about some kind of innovation that the some new software or app or something that's going to completely change your world as a clinician and you're sitting there thinking like okay but this doesn't actually solve a problem that i have right now or it doesn't actually solve a problem that my patient has right now or sure like i can see the point but like why have you made it look like it's from like windows 95 like none of the buttons work so that kind of realization of like oh oh my goodness like technology is suddenly like this huge deal in healthcare because the EHR has digitalized all of our workflows and that opens up the door to everything being technology like a technology for everything right um but But where is the, like, the, I guess, the psychology of the technology?

10:47And, like, where is the design of the technology? Where's the attention for the design and the user experience and, like, work process? What we now have started calling work process redesign. That wasn't a term back then, even, really. So, like, those kind of things. and the second kind of i guess um yeah epiphany or like a moment where i stepped back from healthcare and was like whoa where's the what's happened to this that's where i come back to that point on history because um i was i bored when i was studying for some exams uh i think probably finals and i so i borrowed one of my mom's history books called religion and the decline of magic which is by some oxford don from you know from the 60s and it's got a whole chapter on like magical healing and like healing in general uh in the 16th century and it goes through like all of these different like options that people had in the 16th century for for what they would do if they had a problem with their body what you know medical problem as we would now call it so the royal college of physicians already existed back then so you could go to the royal college of physicians you go to a physician if you were rich enough but you know but you had lots of other options right you have you go to a priest you go to a magical healer some local kind of wise person or apothecary or something but what he does through which is really interesting is he does like an analysis of all of the like how these people worked and by looking at that you're like wow they're like they all basically follow the same meta level it's the same kind of thing that's happening so you find someone with a particular status in your community and you go to them and they pay attention to you.

12:26So you get attention from someone with a special status in your community. You tell them your story, you tell them about what's going on, and they'll ask you a bunch of questions. It involves some sort of physical contact, like touching. So, you know, priests maybe like lay on hands to pray, or magical healers do kind of, you know, some sort of divining what's going on the physicians do some sort of physical examination then they put a name they give a name to whatever your problem is and then they give you a thing that you put in or on your body so this kind of process of like healing was consistent across all of those different kind of healers in the 16th century and then when you think about it and i was doing a gp placement at the time i was like oh yeah that's basically still that's basically still what we do that that that meta process is still sort of the the ritual i guess of healthcare and but if you think about that there's a whole load of things that we pay very little attention to and have paid very little attention to at least in a from a research and kind of science perspective like for example that first step you go to a person who has a special status in your community and they listen to you talk about your problem but so there is attention to that we call that a therapeutic relationship right but getting kind of but a mainstream medical research if you compare that to the amount of funding and money and attention for like does this drug work better than that drug uh accounting for like just deliberately excluding that because that's how rcts work forget about that stuff and just like what's the marginal difference between these two drugs that's like it's and so it's become this like enormous blind spot in modern medicine of but right but hang on a minute what about like all of this general stuff that's happening like what about the relationship what about the communication as you said uh because that's still part of what we do it's still part of the ritual health care but we know so little about that like i can't explain to you no one can explain to you as far as i know why that is beneficial like by what mechanisms is that beneficial how can it be that just by like how how does a placebo effect work right like how does a placebo effect actually work physiologically like i i don't believe that anybody can really explain to you in most like they're sure that maybe there's some theories and there's some hypotheses about that but the extent to which we can explain that in detail compared to the extent to which i could draw you like flow charts of like how different chemical compounds interact in the body in different ways like it's it's night and day it's uh yeah so that was that was my second kind of moment that i really like took a step back and was like oh hang on a minute and and then the interesting thing is that those things then intersect again because on the one hand we're doing lots with technology that is fundamentally changing that kind of process and that ritual of health care whilst we have no idea like how important the different components of the way that it's always worked actually are so this is the thing that i think like is is perhaps one of the most fascinating and unasked questions right now you know could not agree more so this is this is fascinating one of the reasons i was sort of laughing to myself there you know how like i've been starting to watch like a little bit of stand-up comedy and i've been listening to a couple of podcasts from like romesh ranganathan and like a few a few like comedians and they sort of academically dissect comedy but the the fact that you're just so able to point out something that's so unbelievably obvious and in one's face is sort of hilarious of like how what's the mechanism of action of the placebo effect i've never read anything that's actually gone through that and you're right of course it'll be theorized but why isn't that studied at length to find out the the causality there like what and And what is the mechanism?

16:35And can we replicate that mechanism? Because if that was a drug, you'd make billions. This thing that you take, which is actually, ironically, it is a thing that you take. You can give a pill, which is a placebo, which ironically now has this obscene value to the tune of curing the thing. But it's also a pill that can be taken for anything to cure anything. So it's sort of a cure-all. So why aren't we, David, looking at the mechanism of action? That's a great question. Sure. I think you've hit the nail on the head there, right? If you look at the past century, the 20th century, the rise of the medical industrial complex, you could call it.

17:18But basically, you can patent a drug. So it's worth investing your money in owning a particular chemical compound, a particular form, a particular way of producing a drug. because then you can sell that and you can make a return on investment. And that makes sense, right? Whereas the secrets of how a good relationship between the patient and the clinician improves healthcare outcomes, or as you said, can even be curative in the context of a placebo, that you can't own that in the same way. Or at least, and this is why I think it's particularly interesting right now as a question you have not until now been able to own that uh and the second thing i think is that maybe there just wasn't really like the urgency in the same way because like like we were just talking about that ritual of health care hasn't really changed like through even up until the end of the 20th century it hadn't really changed even up until when i was studying and and training and like the the you know the mid 2010s still basically the same template right and i think it's only over the last decade that we are starting to see like real actual disruption of that um think about like if you have like a a full end-to-end process we are now in a place that we can imagine an end-to-end process of healthcare interaction where you never actually uh meet a clinician like a face-to-face for example and but and even like 10 years ago that was still not really like it was on the horizon maybe but it still wasn't there so again maybe the urgency to investigate the stuff was not there because the disruption hadn't reached that level of maybe even disrupting the entire ritual of practice whereas now i think two of those both of those things are changing or have have changed and we're kind of we're after the fact now because the first point like can you make a product of this well this is the interesting thing about any generative ai tooling right an ai agent yeah basically you can um so like and if you want your ai agent or if you want your generative ai tool to be better than anyone else's generative ai tool or your agent right you have to understand this like you're gonna have to like it's an opportunity to create a product that actually harnesses like the key elements the key ingredients if we only know what they are uh of the relational aspects of healthcare in a way that can lead to a product which therefore ought to also be leading to investment because you can get a return on that investment now in the form of a product and the second thing as we just said like um you now can envisage a scenario in which perhaps through the use of a combination of telemonitoring, AI agents, various other kind of technology-based healthcare processes, that we're doing so much process redesign that it could fundamentally disrupt that kind of basic narrative of the ritual of healthcare.

20:31So yeah, that's, I think, historically why it's not been addressed. As to why people are still not doing this now, I can't explain that uh but but i find it a real struggle like because i talk about this to to everyone as you can tell i'm quite passionate about this uh and it's not the first time that i've ranted to you about it um but i i find it really hard to to gain traction with this with this narrative because i don't think i haven't really i've never spoken i haven't spoken to anyone that's just been like i don't know what you're talking about uh but like figuring out how to like like reconcile this with the the day-to-day and like the other side where we're really obsessed with like the very specific effects of like like i said is drug a slightly better than drug b or it does implementing algorithm a give you like 10 seconds extra per day compared to algorithm b uh like how do you reconcile like the incentives that there are to have that focus with like the potential to revolutionize like the the way that you're thinking about ai and healthcare and genicai and healthcare i have an answer i think part of it is actually showing that it is an area of extremely high leverage for investors and finance and so and here's an example right if because i i wrote this down so it was so interesting what you said um what if you could own the process that turned and the process that turned a dummy pill into a placebo that worked for the disease what if it's the ritual to use your language of eye of newt and blood of blood like what what if that ritual yeah is creating the physiological conditions within the person that then activate that action to form the placebo effect what what what if that's that's interesting to me and showing that you know you can patent I can I can you know we just onboarded a new client to Somex this morning I can patent the way that I ask those questions the framework in which those sit the way that those results are then displayed to the client and I can put a nice mnemonic around that and I can call that something and patent it as as a as a process and a framework well what if you could figure out what the process and the framework is to create a placebo and that might be different for different patient groups it might be different for different things but if we can accept that the placebo effect is real and perhaps we can find out real in what circumstances and for whom then perhaps we can start figuring out what that process is if you can then convince an investor like hey by the way i can actually figure this out for about five million quid and then we can own the process i think that you know that's super interesting and the chances of you actually owning the process are pretty slim but again like just having an open mind and thinking about the belief there for a minute as well i think about i think about this a lot is stress and what stress can do physiologically and it's a wild cascade of things that stress can do to the tune of basically you know quite a bad autoimmune disease essentially and so what's the antithesis of that what's the anti once the anti-matter to stress is matter like what's the what is the ritual in the process what is the you know the huge parasympathetic activation that you can do and is that the eye of new ritual and I'm not saying that to to make that reductive but I'm that's what I'm sort of exploring right like make it reductive make it reductive that's like so I want to know exactly like is the mechanism of the beneficial effects of this kind of ritual of healthcare practice like the physical contact the attention is that just maybe parasympathetic that you meant just to hook onto something that you said maybe that is an important part of it and if you know that then you can figure out how do we do that in a different context right so absolutely i completely agree with you so if anyone's got five million quids and then the other thing i just wanted to say the thing that i just want to say on this dude is that um i know that i've mentioned this to you before and i actually just reached out just to just to because i felt like it was it was getting uncomfortable how much i was quoting you without actually telling you that i was quoting you but i i can remember us having a chat and you said to me you you said to me an amazing phrase so I was researching a talk that I was doing um for a an event in Australia and I was doing this keynote on the rise of obviously AI in healthcare and blah blah blah but particularly around communication and the what I ended up researching quite a lot was the what is the role of human empathy in a world where we are going towards the fact that you know my son Levi who's one could legitimately if he wants to probably go through a life of never actually seeing a clinician once he gets to the age of you know 16 18 or whatever you can completely conceivably see a world where he never sees a clinician but my question was what do we lose by doing that and I was trying to sort of explore that and I was reading a lot of literature around the role of human empathy and when you do that you learn that technology can do so much but in part the role of technology really is to support human empathy because of things like history taking is better in a in a sort of dose dependent fashion of human empathy which takes time for repeat consultations and disclosure is better essentially now there is a weird spike of disclosure with anonymity so if you have complete anonymity i.e to technology a machine a chatbot an ai it does actually go quite high as well just not as high as if it was a completely empathic relationship if there is such a thing with a human being and so i was exploring all of this stuff and you said this amazing phrase to me which was that for hundreds of years we've assumed the role of humans in healthcare and we're probably about 150 years behind in scientifically and academically analyzing what the role of humans in healthcare actually is it's only now in the modern day with technology where it is that this question has now become relevant in a world where we can replace every human interaction with technology should we and actually in order for us to answer that question we need to decide where is technology best and where our humans are best it's just that with you know 150 200 years behind ever researching that because we've always just assumed our role it's just that this thing is now existentially threatening our role as human beings and in the whole of health care i have quoted you on that so often it is like embarrassing to the point where like i just keep peddling this not as my own thought but probably sometimes when i've forgotten to quote you but um i think about this so often and i don't know what the answer is or where it's going i just to your point earlier of like i'm trying to get people to care about this or like i just know that this is relevant i'm just not sure how to contextualize this in how relevant you know you look at heidi and what they're doing they're acquiring companies now there's heidi evidence that's blown a load of startups out the water there's they're becoming the ai companion to the whole thing and i know the other scribes are working to to take over more in terms of that early stage primary care stuff and like there's there's a lot of places where that communication side is is is really sort of creeping in and absorbing a lot of everything now and um i'm i'm wondering i'm wondering what we lose i'm also wondering like does that matter like okay do we take an element of loss for what is an overall gain like there's so there's so much here but it's difficult because i just talked to technologists mainly who are like just do everything it's fine yeah the challenge is that that uh you're just kind of if you don't like you can ask those questions like uh you'd like to be able to ask the question right like what what might we be losing are we even losing anything to what extent is this replicable or as i said you can even leverage it in in the technology that you're building but the point is we we we don't know like we so you're making blind decisions about this uh like how to build your technology how to implement the technology um so we're flying blind as you said like we're 150 years as you said the ice is we're yeah we're about 150 years behind and i think that as far the furthest that we've got is uh so i've just uh i have impressed an update of a systematic review of studies looking at how what is what is the effect is there an effect and what is the effect of interventions that specifically improve communication to strengthen the relationship, the interpersonal relationship between patients and clinicians.

30:12Interesting. And yeah, so there's original study was by John Kelly, who's at Endicott College and Harvard Medical School in the US. And I worked with him on an update now. And the original study found very clearly that there's a positive effect. And it's statistically speaking, it's a reasonably small effect, but it applies in theory to every patient, every interaction, every care pathway. And so our results are now in press for the update. But suffice to say, essentially what we found with more than twice as many studies is that that effect is still robust and still visible in the literature.

30:51so uh so we can show that there is an effect uh that is potentially very meaningful but and that should be the basis to then say okay so we know there's an effect and now here we need to come up and i have thoughts about setting up an entire research group an entire research line around this to then say like okay here are the follow-up questions to figure out how does this work how can you leverage this if you're building technology and and rethinking you know if you're work process redesign care pathway redesign so i i can come up with you know i've got like 50 research questions to ask on the back of that um but i think that it's interesting right that the the funding and the interest has to come from somewhere to do that i think one of the challenges with research funding in europe is that oftentimes like even fundamental research even funding for fundamental research follows to some extent uh like in industry funding like where there are developments seem to be promising so coming with something that uh i think unfortunately it's still going to be a gradual process of kind of trying to build traction around this as a real need and an urgent question to ask yeah and that and that those those two things there need and urgency i think is important to note because you and I both come from the clinical ground floor as well and I think I particularly when I get when I get passionate about this stuff I definitely run the risk and I've definitely stepped over this line of just being completely tone deaf about like do you realize there's just a massive problem to solve over here and you splitting hairs on like the value of this extra level of empathy with this question like to be honest we just we just want the tech in because it will just solve massive problem all patients can be seen so i i do i i personally always run the risk of like i need to actually check myself and remember that hold on a minute the the is is the goal here the the the perfect consultation at individual level or is the goal here to improve health care at systems level and an argument i was sort of thinking about for a while was well unless there's someone defending the absolute top quality individual consultation and interaction then is it or is it not a slippery slope of letting technology in where it solves a problem economically it's incredibly viable how do you ever then come back from that if you later determine oh we shouldn't have let technology in there because overall it was a bad thing and and i think that that we now need to 10x the cost and put humans back in that's not realistic so uh well you say that but that has happened in that we're talking about just before we started recording we mentioned about fintech and actually that has happened to some extent interesting that there's been a rollback right in certain areas interesting of the kind of the innovation and digitalization has gone too far uh for what is acceptable for customers and then you've seen like there has actually been a rollback so good point i don't think it's impossible but it's but it's interesting because it also raises the other side of what i what i do um maybe we should talk about what i do let's talk about what you do yeah why are you qualified to talk about all of this david yeah yeah yeah well james uh so i'm an assistant professor at amsterdam university medical center in the netherlands uh thanks and uh specifically I'm attached to the Human Factors Engineering Research Group and the eHealth Living and Learning Lab.

34:35And essentially, Human Factors Engineering is kind of, for anyone that's probably most of them that don't know, my first introduction to that was actually during Foundation Program. Human Factors was like something about airplanes crashing and switchies, things lining up. And and it was about like it's about like but it's about how people interact with systems so it's kind of the psychology of how people function in systems or with systems and that applies to technology so if you put human facts engineering it's kind of the idea of like how do we uh make systems and technologies work in such a way that they're working with people's kind of cognitive biases and processes and psychology rather than like against very sensible that way around Yeah, exactly.

35:26So that's kind of the discipline, the academic discipline that I work in, in the context of healthcare. And the eHealth Living and Learning Lab is a multidisciplinary team. In fact, it's multidisciplinary in two ways, because it's people from all different backgrounds. And all of those people also have done multiple different things. So in the same way that I've spent time in an incubator and a startup and in research and in clinical practice, I also have colleagues who have been like computer scientists, but also health professionals or social scientists, but also project leaders in healthcare.

36:02so uh and basically the aim of the e-health living and learning lab is to i guess responsibly accelerate digital innovation in healthcare um and i guess we try and do that by on the one hand kind of bringing a kind of academic and scientific rigor to innovation whilst remaining kind of value focused and value based so it's trying to find a way to uh be be just enough of a scientist basically with respect to innovation so to to not be uh boiling the ocean navel gazing from ivory towers yeah but also to not say like oh well that's what science is so we're not going to do it we're just going to throw stuff at the wall and see what sticks how do we do that i mean yeah it is that is a knife edge isn't it and i think that is that you've you've beautifully articulated everyone's problem with each side of that you know like you're slowing me down you're you're you're speeding me up you're unsafe well there's too many regulations that yeah that is a huge that's a huge not the right level of something i can remember actually when i when i was at the digitalhealth.london accelerator i can remember back then like the my very first foray this is over like 10 years ago like the very first foray into digital health it was a conversation back then what's the right level of academia what's the right level of scientific rigor what's the right level of evidence and we i mean i can naively remember thinking at the time like oh we'll just set up a little work group to figure that out and then we'll just keep going it's like no no no no no no no you can't that's that's not a one-hour meeting oh no we've been fortunate because we're all as i said because we're a multidisciplinary team and each of us has complicated career backgrounds you could say uh we kind of can speak with authority from multiple perspectives great um and that allows us to uh it gives us credibility to actually then bridge those professions, bridge those sectors.

38:20So when we're doing public-private partnerships, like I can actually say like, yeah, I understand what it's like to have an investor meeting and the kind of questions that you get from it. Because as you know, having facilitated those, I've been there. 100%. So people can trust that I know that that's what is important to them. And they can also trust that I know what it is to be a PhD student who's like got a deadline to get a paper submitted uh and all of and at the same time all of the regulatory and and burdens that come with the scientific process and stuff so i think we have exactly exactly exactly i think we have a good strong basis in the team for uh for being able to kind of forge those those bonds and uh and then i think that where we've been the team has only existed for two years so i've been doing this for two years two and a half years and two and a that's how long teams existed and uh um but on a project basis we've been trying to figure out like how how do we do this like how do we achieve this kind of as you said this alchemical kind of knife edge balance um and uh it's been it's been tough and i think we're definitely still learning and we you know you again it's very much a world in which you can't please all of the people all the time uh so but but you can see where we actually then do manage to make make progress and and by bringing everyone together making real kind of meaningful progress yeah i was gonna say how do you do it with examples yeah yeah i mean is it like an accelerator or do you work with specific ones are they are they large companies they small companies like how do you how do you practically go about it we have a couple of different things so we still do kind of um scientific research projects that are kind of true research collaborations where we would work with a company to develop new IP, which, you know, that's kind of grant funding model.

40:19And we apply together and we say like, look, you have the industry positioning. You know how to develop a product. You know how to bring that product to market. We can bring that human facts engineering expertise and we can bring kind of we're embedded in Amsterdam MC. Like it's the largest healthcare provider in the Netherlands. so if you need access to users to do user testing and to actually like we can lower the barrier to doing like really good user-centered design um so that's what we then can bring in um and so that that will really help like this that's a really good uh way of working together but it is quite slow it's not very agile because it's tied to grant funding so the other thing that we do is we do contract research projects so that's where we kind of we don't have a scientific question like you know it's not a scientific funding thing it's not scientific research but we bring all those methods and the expertise that we develop from the scientific research and the scientific projects that we do and the rigor of those methods to a project that is essentially like a design sprint or it's like a customer insights question.

41:28So it's a practical question that anyone from a startup, you know, founder, pre-idea founder might have, as you said, all the way through to, you know, you're an established big player in the space, but you've got this new feature that you're thinking about introducing for this existing product. And yeah, if you want to talk to clinicians, patients, you want to talk to people about, is this something that's actually valuable? Is this actually going to solve a problem? and you need to do that within the next X number of weeks and you want to talk to this many people, we'll figure out how to do that.

42:02And we'll do it in a way that is ethically responsible and is going to have enough scientific rigor that it's actually useful for you. So we're going to try and do our best to give you unbiased answers to get towards the truth, right? Because that's what the scientific process is about as well. But without then saying like, yeah, sure, we'll write a grant application. That'll take three months. then someone will look at it for six months and then we'll do it yeah maybe q q2 of 2030 or something so um so we can do that quite agile as a as contract research um and i guess so we've done it in a couple of ways um so last year we worked with um a company called personalized and our cardiology department here.

42:51And we worked on kind of front-end first kind of design of new AI-powered planning tools for outpatient care. So basically a company with tremendous expertise in algorithm development and deployment and a cardiology department with, you know, as a kind of like a seeing an opportunity potentially to for efficiencies in clinical care and our role is then was then to come in and be like okay how do we translate between the two these two players and set we so we set up the project as let's first do like some front-end design and that like work process redesign to figure out like what do people are going to use this planning software actually want automated what they actually need automated how do they want the workflow to look when there's like automation through ai to some extent um and so we said we did interviews we did focus groups we did like within like six month period we did this whole design sprint to basically prototype most of like all of the core like front-end features uh for this new for this new product that they were going to develop um and the result of that was really interesting because where initially then maybe there was a hypothesis of like we need to automate the whole thing right like the whole end-to-end process of planning can be automated with AI algorithms but it'll be really hard and like computationally it's going to be really demanding but we can do it and then like doing the kind of looking at workflows that people actually were interested in and happy with and was like what is like the 80-20 here and we came back we're like yeah it's not really we don't really need to automate the whole thing end-to-end And like, if we were to make this and this and this, like we've solved, like we've removed 80 % of the, like the pain points in the workflow.

44:43So, you know, so that was, so that's, I think, a really interesting example of how, like, we can facilitate from our team, like collaboration between like bringing the voice of the clinicians to the fore, but without expecting them to just immediately speak the language of developers. Which is great because you're extra resource in that as well, because that if you think about those two organizations trying to speak to each other, they're using all of their resource in order to do so. Whereas you being in the middle and doing that translation and also I imagine injecting your own opinions and figuring things out and thought capital, etc.

45:20Like you're adding resource into that system as well, which is really interesting. What model is this? Because you mentioned that you're in the Netherlands, which is super interesting. that you went out there um why the netherlands is an interesting question and also what is that healthcare system like in sort of enabling this like do we have an equivalent of this in the uk could it be done in the uk like what like what how does this work in the netherlands and and what why are you in the netherlands david uh i'm in the netherlands for love james no uh well partly my wife's dutch and uh you may remember brexit you remember oh that thing yeah it was a while ago um yeah after brexit we relocated to the netherlands it was just a bit simpler uh but but i'd also so actually the full story is we were we were both looking for jobs at the same time so we just started applying in london and amsterdam to see what came up and within a week of each other we got offers within a hundred offices within a hundred meters of each other wow no way yeah that's amazing we'll take that as a sign we're going to the netherlands but actually um yeah so i'm actually a dutch citizen i speak fluent dutch now wow um so that comes in handy for work um yeah but but so the thing about it so what's the dutch system like um So, a healthcare system is an insurance-based system.

46:50So, you have a compulsory insurance people. It's a compulsory kind of premium that you pay. You can get add-ons as an option. And then the insurers are essentially commissioners of healthcare services. So, they receive money from the government and from everyone that's paying insurance premiums. And they then purchase in healthcare. So obviously you have similarly, you know, primary care, secondary care, tertiary care. The tertiary care you have in particular, the university medical centers. So if you think of like Addenbrooke's medical campus, you know, for example, in Cambridge, that's connected to the University Hospitals Trust.

47:38so amsterdam umc is connected to the university of amsterdam and the frey and the frey university in amsterdam so um so it's a teaching hospital it's a it's a very much an academic medical center so we do a lot of research here um and then obviously you just similarly you have kind of get your DGHs as a hospital service as well.

48:07The way that we are kind of being able to do this, what we're doing with the eHealth Living and Learning Lab in Amsterdam, UMC, and there are other kind of teams at other universities in the Netherlands and university medical centers in the Netherlands that are doing similar things. it's a combination of that we actually got a big education grant to set up the team because we're also we also do a lot of education activities so the project i just mentioned we also were doing with a with a student in uh medical informatics which is basically a program in sort of like computer science and human facts engineering but then in a context specifically of health care so uh people kind of the students on that get exposed to what is a hospital what are doctors what do they think about like what's important in health care as well as learning like how what is code uh yeah wow what is usability how do you make user friendly so so we actually got a big education grant because the ministry of health in the Netherlands recognized the need for more for more people in the future who have both of those skill sets so we we set up our projects in such a way that we always include students as well so medical students but also these um like healthcare technology students um so that's helped us to get established and then obviously we do also do the scientific research so we can bring in grants uh and we we also mostly then try and focus on so it's more about the strategy that we've taken to like figure out like what do we as a team want to achieve what we want our impact to be and then figure it out like where are the different sources of funding to make that work and then i guess a bit of luck that various funding opportunities kind of yeah makes sense were available um but as to whether you could replicate that in the uk i think like yeah you that definitely you can uh i think that it's just that you you know you need to have the right team and the right vision uh as i said take that kind of authoritative space within the setting of the hospital yeah and who have that kind of who can speak those languages who can understand and speak with authority from a perspective of both business and healthcare and science uh so yeah exactly exactly this and it's that thing isn't it of just with the goal of just actually getting something done right there's no performative nature or you'd hope not anyway and if there is of course it's just to justify the metrics to get more funding in order to keep doing the thing but it's that it's that that can be frustrating in these types of things is the is that it all ends up resorting to a very performative nature again just talking about the accelerators that have been part of like you know when when you got when you got eu funding um it was the rdf funding at the time you know yeah i can still remember the codes the c26s for you see this you see that like it's it's like yeah and you have and it and it towards the end of it as well like became very pressured on just performing to get those things what can we you know make sure evidence is this rather than just how can you make broad impact and so it always ends up being like to some extent when you're taking that sort of money but it's the same question as in as you know you have when you're looking as an investor at founders right yeah it's true trying to evaluate you're trying to look at startups and propositions and like you want to pick the people that care the most about solving the problem and obviously like those people also have to have the metrics to back them up right because that's part of how you demonstrate and build traction and stuff but you're really trying to sift out the people that are that have that are kind of like that have this kind of like paper tiger of metrics that look good from like the people that you really back to be the people that care most about solving the problem and and to really have the skills to and try to do that so that's how that's how i think of it and i think there are enough of those people around in the uk i'm sure that that this is a model that could be replicated yeah yeah yeah yeah it's almost like it's like what a consultancy should be really i guess a team of those types of people trying to get things done does it feel that way guess you could look at it that way i think it's somewhere maybe between like an internal consultancy service and like a sort of internal product product owner kind of product yeah okay Something in that kind of direction.

52:36Because as you said, we kind of, we span everything from like trying to work more on what our, like what a business and user needs, like through, like them, but then bringing that like through then like a work process redesign. And certainly I know that there are consultants that do that. So it certainly overlaps with like consultancy. but then also then translating that into specifications for products that you can also then use a test and look at implementing so I think in that sense it's reasonably it's also like quite a unique combination of stuff that currently I think I see consultants doing and stuff that I see kind of I guess front-end design people doing so yeah and and there's lots of other ways that we're like giving expression to this as well like I'm uh i'm working with um uh i don't know if you know her kira hennessy at the moment she's um yeah she's a physician also ex-clinician um uh previously with nlc ventures in the other ones oh yeah and yeah and she is busy at the moment raising a fund for a new venture builder um so So it's Valora, Valora Health.

53:53And so this is where we then also like can make this relate, like this ambition that we have concrete because, you know, we, we, Kira, again, as you said, like clinician from the ground floor, you have a different perspective. And so we have, we've been having conversations and talking about this. And so in her pitch for the venture builder, she specifically wanted to build in as an extra like an independent board function that at various like gates in the process of the venture builder looks from the perspective of clinical relevance basically the question of like okay good but like clinically like how relevant is this like how promising is this how relevant is this and so like i've agreed that like you know we've already got an agreement in place when they get the race sorted out like i'm going to be on that board and again so it's again a way of making concrete like how do we commit ourselves uh coming from like a health care and academic setting to then translating all of the things that we all of our expertise and knowledge etc into them real world impact so that we can help lift up those like ideas where we're like yes this this is like yes take this further um i don't like no and And I'm not going to be looking at that from a business perspective.

55:11I'm not going to be running like the net present value calculations or whatever. But I'm going to be looking at that from the clinical perspective and saying like, yes, like as a clinician, looking at this from a clinician or patient perspective, like, yes. And then also trying to sift stuff and say like, OK, I can see that this is I can see that this is potentially, you know, there's an interesting business case here. like if you could get it implemented but the the challenge to implementation is going to be like do our clinicians going to use this for example so so i'm really excited for that and uh and i know that she's making good progress with with that um so that's again another example of like how can we concretely from that like healthcare and academic context yeah have an impact on on the on shaping actually like the future of healthcare technology nice over the last couple of years with you doing this for various companies helping out startups are there any common truths that you think all startups should be aware of or something that generally applies to 80 percent of startups in terms of whether that's a knowledge gap or whether that's a single process that they could and should all do, a method of thinking?

56:35Are there any truths of like, actually, I'm noticing that if everyone did this thing, they'd all probably be slightly more successful or stand more of a chance? I think it's the low-hanging fruit in terms of an answer to that is thinking about uh thinking about adoption of your product or service from day one and that's a very easy like it's a very easy thing to say and and maybe it comes across quite like are you talking from like psychology of the user perspective because that's the angle that you come from generally or are you thinking something else yeah basic not not just the psychology but the but more broadly how is your um how is your innovation your innovative product or service actually going to integrate into the context in which you envisage it being used.

57:24So you must have read about the Tricorder study that was published in The Lancet recently. So the Tricorder is this huge study done in the UK published in The Lancet looking at essentially the use of AI algorithms to detect cardiology, cardiological pathology, cardiac pathology. and uh what they essentially the study was really interesting because they didn't just do like an effect study of like yeah we detected x percent more anomalies or whatever they did that and they found like yeah when people use it it was very effective and so when clinicians use this till this tech this applications technology it works really well we detect more but they also looked in the same study which doesn't happen that much in scientific research but they did that they also looked at like yeah but did people actually use it for the whole duration of the study even in the study context right where normally people's motivation to use it is a bit higher because someone's watching because they've got to report to a researcher at the end of like did you actually use it and even in the study context in a whole bunch of cases people stop using it even though it was effective because for example it didn't have any hr integration yet or it was adding like time like not even not a large amount of time and i think people don't understand time because what you actually mean it's adding like cognitive loads like just extra stuff that you have to think about it's not about the seconds it's about the neurons um but but the extra like burden it's putting on people then people stop using it even though they thought it probably was effective almost like so like i think that's a really like and that's great but tricorder is by no means the first study to demonstrate this disconnect between stuff that's effective and stuff that's used it's only the latest in a very long line of studies that finds exactly the same thing and and so that's in the scientific context but i think a lot of the time if you think about the journey that you're on as a founder and you think about the milestones that you kind of want to hit to demonstrate your investors right and you're developing a product and you want to get like uh you know regulatory approval you want to get all this other stuff and there's you know you've got to reach your like mb go your mbp out you've got to hit regulatory approval you got etc um but that takes it puts your focus very much like short term on like how do i hit the next kind of milestone um and how do i demonstrate this stuff and i get it right because let's say you're doing like software as a medical device you can't go to market unless you've got approval so it's a hard barrier but i would also argue there's no point trying to go to market if you haven't figured out from the beginning like how is your product your service going to actually fit into the to the really complicated landscape of healthcare and that is from the perspective like you said of very much like the individual user perspective and like what is their motivation and incentive to use it under what conditions will they actually use the thing uh as well as from a system perspective right so like what's your like and i think there's to some extent there's more attention for like how for example reimbursement that's also a question about how how your product fits into the system.

1:00:36But obviously, again, I think people tend to have slightly more attention for that. But so in general, how do you make concrete as a founder or even as a product owner and one of the big players, how do you make concrete that from day one, you're going to start working on understanding how the product or service fits into the system at the user level and at the system level? Because otherwise, if you're not doing that, you're going to hit all your milestones. all the way until you get through to like the point that you have to actually start scaling and then you're going to be like oh and then you're going to say like you're maybe you're going to go to investors and say like well this is what we need to invest in scaling we need such you know we need this size team to work on like our marketing and sales funnels and we need this many customer success people and you're going to pump a lot of funding into that but if you don't really know or if you're only starting at that point to think about but what is the context are those people fighting against something are they swimming against the tide of the system or are they pushing on an open door like that that's i think i think so maybe on yeah and i think it's you know it's not just for founders right it's not just for product owners it's also for investors to to think about like how do they weight that uh in uh in the way that they think about early stage companies in healthcare as well and in health technology because again like if you're a founder and your early stage investor doesn't care about that uh and says you know no doesn't matter just focus on building your product and getting your regulatory approval yeah then who are you as the as a founder to say like no but actually like so so it's not it's a whole system issue it's not just uh you know it's not just it is but i i do i do think part part of building in healthcare is acknowledging that and acknowledging the fact that the valley of death is littered with the skeletons of amazing products like amazing products like the best products actually that just get beaten out because of a relationship or because of a certain procurement process that just value price over quality or like like and and this and this is the thing it is it's an it it's a pretty unfair system but all of that you're right that lands into like can this actually be adopted and the actually word there just it's messy it's it's the acknowledgement that it's going to be messy so one of the things that i'm thinking about in the context of amsterdam umc is uh i don't believe that there's such a thing as b2b software in healthcare uh certainly not in the context of hospitals i think we have to reimagine anything that might be considered b2b software is b2b to c whereby the hospital is is us we are ourselves i would say doing the b2c part of that so uh and our our customer our end user might be our patients but a lot of the time it's our own staff so it's our nurses it's our doctors it's our you know administrative teams um and i and i think that idea is starting to gain gain some traction and that means that like but if you think about it that way if we if we're saying like okay well then that means we are to some extent as an institution trying to do this b2c kind of you know we have an idea of something that we want to implement a technology an application that we that we want to kind of implement um we have to kind of sell it right we have to kind of sell that to people in the organization um so we like logically we need a marketing and sales funnel We need a way of attracting, engaging, upskilling, educating our customer, our end users.

1:04:27And we're talking concretely at the moment. I'm involved in conversations about trying to set up a digital playground in Amsterdam UMC. Interesting. and that essentially would be uh so it's sort of like thinking like a you know that the apple store for for health software or you know the lamborghini showroom i because because i think uh when you're trying to figure out like okay what can we do with technology what we come up against is like if you're if you yourself are not a tech evangelist if you're not one of like the if you're on the adoption curve you're not you're not an innovator or even an early adopter it's very hard to imagine and like what could i do with it how could my day look different right how could my specific tasks look different with technology um so it's that classic thing right of like henry ford like people don't people want a horse but you've got to try and sell them a car if they want a faster horse and you're trying to sell them a car so i i so we have this idea maybe maybe a lamborghini showroom will convince people of like like what is a car what does it do it's really interesting um and and a space that people can play with stuff and a space a space that is then like it's it's low low stakes it's not directly in your work process uh you come you play you discover and you know it's the same it's not new like this is this is the principle how apple shop the apple store works right like it looks beautiful it's a beautifully designed space where you can just come and play there's no one trying to sell you necessarily saying like this is do this do that whatever it's not you can play and you can discover so i think that's um so and the thing if we do that if we can if we do that in the hospital where we we have this kind of digital playground for people to come in and discover you know we facilitate that that kind of discovery process that playing process that would be a golden opportunity as well for startups or even bigger companies in an early stage again low stakes put something in there see it as an opportunity to put you've got an idea you've got maybe maybe you've got like a really good looking like clickable prototype or something it's not even a full product throw it in the the digital playground let people play with it and and then we're doing two things at the same time we're on the what for our staff we're already getting an idea of like hey what are people doing when they're playing with this stuff like and it's giving them an idea of like what can i what could i do with different kinds of technology and we can also provide those insight insights back to to the people exhibiting in the showroom right to be like well people like this they didn't like that this uh and it's not it doesn't have to be big like scientific kind of research studies but it's just it's a playground for people to come together and say like hey what do we think about this honestly mate i i love i love this because i i think it's so practical and and and it's and it's not a i don't know quantum idea that's gonna change the world in that regard but actually it's the butterfly wings thing of what could actually happen downstream of something that feels manageable like you can bite that off and chew it without it being a problem like that's something that can meaningfully change people's worlds that come and yes that isn't the grand i've got the idea I've got the idea that's going to be everywhere but similarly I don't think healthcare actually works that way and you know venture money means you need venture scale is venture scale possible question mark well does everyone feel the problem the same everywhere well not really therefore is the level of customization required for any product actually resigning most or all of those products to that valley of death anyway and it actually brings to mind like a question for me which is that like is the biggest constraint on the system at the moment the fact that there aren't enough tech evangelists and actually you could even rephrase that is the biggest constraint on the on on the system from a health tech perspective or the success of health tech companies perspective is the biggest constraint on them the fact that there just aren't enough people that understand the space to buy the stuff and actually is that something that can be worked on and it's interesting because the lens that i've actually come across this recently is the prevention space so had um neko health the ceo neko health on the podcast chatted to him i've spoken to a few other people in the in in the prevention space and longevity in inverted commas and i'm trying to like cut the wood from the trees and what's going on in prevention and where does the private sector fit in is the republic sector model can the private learn from the public is that the route would would people prefer to go to a private company knowing that they were contributing to a more public model or at least like contributing insights or data more publicly or like like that's what i'm playing with at the moment but it's interesting when i was looking at the prevention space and looking a lot looking at a lot of the you've got luxury clinics popping up you've got more affordable in inverted commas prevention services like neko and i and i was thinking like really that space is going to be won and lost by who can convince the late majority because at the moment the more clinics that pop up the more services that pop up the more blood tests plus insights that pop up i think all those services are just sharing the same number which is spreading spreading thinner and thinner overall i think but probably increasing in overall number slightly as we go on but i think the number of services popping up is just spreading everyone thinner and thinner because i don't think that they're turning up in those in the right numbers and actually everyone's already got they're only going to the people that know about this stuff anyway i don't think anyone's doing the job of yeah like well enough anyway of convincing a majority and let's put you know politics aside and and is it right or wrong aside but these these these all these services have just firmly placed a fulcrum on a plank of wood that on which stands the entire population and each service at whatever price point has just planted a fulcrum of like on this side of that fulcrum all of you lot can now afford this service would you like it but they're not even going to that pot and you know aside for a moment like is that fulcrum even moral or ethical but like i wonder if the job really is to place the fulcrum but then educate that number and some people the other side of the fulcrum actually by the way and tell them that we're trying to push this down towards you but actually to educate everyone and that's kind of where i got to in the prevention space but actually this conversation is maybe like is that actually is that more broadly like part of the problem here that actually you know a clinician like you or i back in the day would would work our way up and let's say we weren't distracted let's say we weren't doing this stuff we'd work our way up to you know clinical director medical director of the hospital we'd have some knowledge of this stuff but we're not tech evangelists we don't really mind about that stuff so we're actually looking at that pnl thinking about loads of other problems and that's where our priority is whereas the tech evangelist knocking the door saying we can solve every problem that you have and it's like i don't yeah and again we're back to communication now of my thesis of like things like this bringing those people together and actually trying to talk about them educate them and i don't know there's a lot there but i don't know whether i asked the question or yeah of course the problem was solved on there but i completely you're i completely agree that i think um looking at it this way if i just look at it in the hospital context uh uh macroeconomics like our innovation budgets are not going to just astronomically increase over the next decade like that's not happening on the other hand there are there are opportunities that we see through digitalization through deployment of technology different technologies into different work processes that could increase the efficiency with which we can deliver health care which we would like to be able to do but we have to make choices so we have to figure out like there are depending on who you ask and how you calculate it 15 000 to 20 000 people working for Amsterdam UMC okay divided over 10 divisions and a greater number of departments and a greater number of job roles so how do we figure out like how do you figure out where there is like traction under the late majority like you said that we're actually going to make efficient use because the alternative is that you run a whole bunch of and i to be honest i think this is how we've been willing to know you run a whole bunch of pilots with a whole bunch of different things and then the outcome of that is that you end up with a whole bunch of technologies that you have like someone in it that needs to like manage and support and maintain that product even though it's being used by like 10 people somewhere uh and and it doesn't it doesn't scale because probably the way that came about was because it was a nice idea on paper, but didn't land, or because it was a top-down idea that didn't build traction, or because it provides a value to a small but vocal number of people.

1:14:22But that doesn't tie into your bottom line necessarily. It's like, well, actually, this is moving the needle. And as you said, I think we can only move the needle if in the hospital we are implementing technologies that can gain traction with the late majority. And instead of doing a pilot and figuring out, how do we please the innovators and maybe the early adopters and then figure out, is it possible to do this in a way that also pleases the late majority? I think the idea that I have for the digital playground that we're talking about within Amsterdam EMC is how can we proactively be getting the late majority in the door to tell us what they want and what they need and what they accept yes because like and that doesn't just happen because it's like it's a kind of a chicken and egg thing right it's a catch-22 like i can't again i can't tell you like how many gears the car should have if i'm used to working with a horse i have to be able to come and experience that to some extent And first, so this is, I think, it's getting people in proactively to figure out like, yeah, how do we increase, how do we educate people?

1:15:39How do we upskill people on the one hand? And that's the people side, but also not making it just about like we need to educate and convince people to do X. But we're going to do X because we know that this is something that is valuable to people. um so that's the shift that i that i hope that we can work towards and uh yeah and the idea behind this digital playground that we're talking about i love that because it what's run through this whole conversation actually i think is the level the level of practicality that you're applying to i'm not pure academia i'm i'm academia towards a goal and a purpose and i'm gonna i'm gonna try and shave off what doesn't need to happen in order to like prove what needs to be proved to get something done and I really appreciate that because I think a lot of people listening will in fact a lot of people that come on actually you know they talk about the academic world being slow this is what they're saying and some people you know obviously come on and say the academic world is incredibly necessary which it is and you get all those opinions but but broadly it's like oh I left academia because it was too slow I wanted to do a thing and I think that that that kind of drain of people that the innovative academics almost I think this sort of thing that you're describing where you work how you work it's almost like an outlet for those types of people which is people that respect and enjoy and want to do that academic side but but with the goal of practical application and purpose and I think that's such an oasis in the desert for so many people I really do and I can totally see how you've ended up there because from like I mean you're in my in my you're so entrepreneurial like you are an entrepreneur like you've you've done all of those things and you continue to create things in the world in your own vision and you've you found a way of doing it through the organizations that you're now part of that's the same as any entrepreneur it's just that you know you have to start this thing called a limited company in order to do certain things or a community interest company or this or that that's details the people that can imagine something and then go and create it in the world by convincing people and putting their ideas into of the physical reality I think yeah you're 100 % an entrepreneur for me so I think I I love the fact that you've been able to like do all this stuff and and that we can have a conversation about you know 150 years behind figuring out where humans fit in and should we research it and um yeah it allows me the the pleasure of being able to discuss that sort of stuff with you so um oh it's been a pleasure man thank you so much for coming on I need to let you go and um allow to do some more assistant professing because um i've kept you far too long but i imagine those people are going to want to chat to you man but like for those people that do want to get in touch with you i imagine linkedin is probably a good place to start but are there any other places where people can get you or find out more about what you do and how you do it yeah absolutely so ella has a website it's um ella with three l's nice yeah the extra l uh yeah you know how it is with naming things right like you do ella with two l's and there's already like a billion companies that have that so ella with three l's dot amsterdam umc uh dot nl um and uh you can also email me i'm also very happy to receive emails d.n.neil m-e-a-l at amsterdam umc dot nl awesome david it's been a pleasure mate i'm sure we'll speak yeah same likewise it's uh it's great i love talking to you man it's uh it's always interesting and uh yeah good luck with uh good luck with making this into something that is uh logical and uh tells a logical story oh i'm sure that will be dead easy david i think this is a one take so i appreciate you thanks man