 All your data, as long as you want to be getting a virtual medical coach, all your data will be continually inputted and assimilated and fed back to you in terms of guidance. And as soon as we get the text part straight, it'll also be the entire medical literature pertaining to you. Boom, what's up everyone? Welcome to Simulation. I'm your host Alan Sakyan. We are on site at Scripps Research Translational Institute in the beautiful Torrey Pines, California. We are now going to be talking about deep medicine. We have Dr. Eric Topol joining us on the show. Hello. Great to see you, Alan. Thank you so much for coming on. Really appreciate it. It was, you did such a great job on Sam Harris's podcast and I was really grateful that so many of my friends have been constantly pushing me. Like, have you had Eric on the show yet? Get Eric on the show. See if you can make it happen. So you have a lot of fans around the world that love your work and for those that don't know, Eric's bio. Eric Topol is a world renowned cardiologist, executive VP of Scripps Research Institute, one of the top 10 most cited medical researchers and author of several books, most recently, Deep Medicine. How AI can make healthcare human again. And you can find all the links in the bio below to Scripps profile page, Wikipedia page, Twitter, as well as the link to Deep Medicine, the book. Alright, Eric, let's start things off by asking you, what are your thoughts on the direction of our world? Well, Alan, it's a big question, a lot to unpack there, but I think of it as in the world of medicine and life science and I'm really excited about it. I think that we're on the cusp of a real extraordinary, unparalleled time. It's very much in contrast to some of the other problems we're confronting, but this is largely because we've been accumulating data up until recent times. We didn't know what to do with the data. And of course now with deep learning, machine learning and these different types of artificial intelligence, we're going to take this to a level that I think many of us might not even have envisioned happening more quickly than what I think even some of the most optimistic folks could have foreseen. So having been a student of medicine and life science for a few decades, this to me is really enthralling. I'm excited to unpack the nuance of it with you. One of the things that is so important is having structured data. That's one of the most important things. And the other one is having the stream of relatable biometrics that we take from the body actually be effectively processed to predict pathologies, to augment our health, all this type of stuff. How do you foresee that most effectively happening? Well first on the structured data is really a limitation today because that works really well for images because using algorithms to discern an interpreted image, it's already a structured substrate. It's a perfect input. It's speech as well. But when you get to text, that's where you start to see a drop off because a lot of text is unstructured. And we're just starting to see a turning point there, there was this really remarkable work published in Nature on material science where with unsupervised learning, being able to start to get these embedded texts and trying to recognize text. Right now the idea that, like for example, IBM Watson put out that a doctor could read 5,000 articles and then go see patients while we're not there yet because most things that are published in the literature are unstructured and you still need ability to read and comprehend. We haven't got machines there yet but that's kind of the last of the three with images leading to the charge speech, not somewhat behind but not that far behind and then text is certainly the one that's trailing. Now the other thing you asked about, which is about... The biometric stream being most effectively for predicting the pathologies and for augmenting our health. Yeah, I mean this is an explosion of being able to, well, interpretation, classification is really sharp and again that's relying a lot on images. What we don't have so well really is prediction and when you look at it, we got a lot of shots on goal with we'll predict the person is going to live in the hospital or they're going to be admitted from the hospital, perhaps actually the best paper on prediction study just came out recently, in fact I had the privilege of writing the editorial for Nature, it's only the second paper that's been published in Nature for AI in medicine and it was about kidney injury and it happens very frequently in patients in the hospital, one in five which is alarming and it's a big deal because if somebody has significant kidney injury they could go on to requiring dialysis and possibly transplant or even dying. So we want to be able to predict it because those are the people that we want to have exquisite control of their fluids and their blood pressure and what medications or contrast dye, all these different things that could happen to them and so since we have this very high prevalence of one in five, if we can get that down to one in a hundred it probably never be perfect that would be exciting so that's a more granular prediction rather than someone going to die or not and that's the first time we've seen organ injury prediction but it has to be something that's actionable so one of the problems we have is we've got these things that are prediction like Alzheimer's well okay but what are you going to do about it so that is an issue today is we're being able to predict things it's fuzzy it's not as nearly as high an accuracy as an image interpretation but it's obviously a lot of work's going into it most of the work is retrospective going backwards in computer data sets that are all pristine assembled and the data are all cleaned up they're not in the real world prospectively where you're trying to make predictions and seeing whether they really come true so that is a more challenging thing and very few prediction studies fit into that group of going forward and that's what we desperately need Eric what would you say is the what some of the some of the most important principles and skills for us to embody for keeping our homeostatic capacity in the youthful state for as long as possible to increase our longevity yeah well that's a great question if we knew you know that'd be fantastic I wish I knew you know I think that we're learning about this there is of course a big boom in the science of aging and learning the biology which we didn't know about even you know a few years ago I think turning that into commercial entities is troubling because they are often way ahead of where the science or the proof lies but you know one of the things that's exciting to me is this food is medicine story yes because if we could what we eat if we were using that instead of medicines or augmenting effects of medicines so that I mean that would be ideal and we're just chipping away at that now so that to me is one of the signposts that we're really making progress so whereas up until a few years ago it was just everyone should eat the same diet and we don't have any real good story in fact we don't have data to back that up the studies in nutrition have been very shaky most of them are not randomized trials they're observational so they have all sorts of issues of limitations and so we've been left in the lurch and we've had guidelines and food pyramids and they're all really basically you know kind of a cockamamie mess you know no one knows what really they should be eating lots of perverse incentives to yeah fake foods and we can get a little into the fake physicians as well but just perverse incentives all around in lack of inclusive stakeholder so that I used to give you food for your optimal health because it would also help our tribes health and whatnot and now it seems in many ways that we deliver food for self-dealing purposes so that I can earn more money no matter what the quality of food is and similarly with a physician that is potentially getting a little bit of under the mud under the table money for things that the patient doesn't need and that when there's a lack of inclusive stakeholder between the outcome of the patient as well as the physician and these time blocks are whatever 20 minutes to see a patient and there's the electronic health record and the keyboard the focus on that instead of that deep empathy with the patient I mean there's so many of these variables that we need to really figure out what is most optimal for health care yeah yeah well and we know that a diet is as part of that story I mean obviously exercises part of it you know being at the right weight and being fit is important but the diet part has been the the zone of uncertainty and what's changed there is that using AI we've cracked the case that each person has a very unique individual response and in fact even identical twins are very different and the reason for that is partly because of the gut microbiome which is just blossom in terms of being such a big player in determining our health but also you know all these other factors like you know your your physical activity your sleep your stress level your medication so once we get all that data on each person and you have a glucose sensor on you can find out what foods are the ones that are driving if you have any which is not uncommon these very big spikes in glucose which are undesirable we don't know fully in a healthy person who has glucose spikes we don't know the long-term significance of that and whether we should do everything we can to prevent them up late them or at least reduce them and now we're also seeing the same with these triglyceride spikes so the point being is that although we don't have outcomes to say oh well if you eat these certain foods for you these this is your Alan your personalized individualized diet if you stay on that that will prevent cancer or heart attack or autoimmune disease we don't have that yet what we have are these intermediate markers like this is your glucose and if you stay away from these certain foods and and shift more to these you can keep your glucose flat or you can keep your triglyceride flat and that probably will translate over time but the point is we didn't know that a few years ago so we're making progress it's not a commercial story yet in my view but maybe in the next few years it may start to be so diet is is a biggie but I think in terms of the aging process for the most part it's very difficult to affect that you may have some soft modulation but you know we don't know anything that really is you know there's been all these false starts there was reset veritrol and they're all these things that were to affect a person's and people just obviously they cryotherapy I mean all sorts of things and none of them have actually the science to back them up in people and in a mouse you can do almost anything and get them in mice to live longer so that is not a representative model for humans are endeavor into more precise personalized medicine and nutrition is huge and also the serious amount of of data we're now having from the microbiome and it is very complex to figure out how to keep humans healthy for as long as possible yet that is one of the most important things because as we get older it's like we have a library and that we want to keep adding books to the library and see the new connections that are made the new creative potential that can arise later in our lives versus like what happens in neurodegenerations just like the library gets burned down and well you're bringing up a key point and it relates to this whole deep medicine umbrella concept the point is where we're going to go is that all your data as long as you want to be getting a virtual medical coach all your data will be continually inputted and assimilated and fed back to you in terms of guidance and as soon as we get the text part straight it'll also be the entire medical literature pertaining to you about a condition that you're at risk for or that you actually have and you're trying to manage better already we're seeing this for diabetes now starting to emerge but eventually it's going to be in the next five years for your general health and so you'll have this avatar that will communicate with you on your phone or your smart speaker or whatever and I'll say Alan you know you haven't slept right the last several days and everything indicates you know you're a much higher stress level and that's why we're seeing your blood pressure starting to get out of whack and this is like 11 o'clock spray some lavender they play some seductive music and it may play your favorite song but it also might say you know what the reason is you just haven't been getting any exercise and you're not you really got to get back on track and be like your your conscience how trying to help you to stay healthy now why is that important because first of all it's not for everybody but just like your kind of voice assistant or your you know your daily life assistant to tell you to go to the airport or the traffic's bad or whatever it's going to be for your health the difference here is that this is about preventing a condition a dream that we've never fulfilled before now we've had general prevention like don't smoke cigarettes or you know wear seatbelts or things like that but we even had individualized prediction now we have these things called polygenic risk scores and I can say this person has a much higher risk of heart disease or a much higher risk of colon cancer or whatever several conditions that are common we've got that now before you ever get it that's the whole key is that your coach so you don't ever get a wheeze if you're a risk for asthma or you don't ever get a polyp if you're at risk for colon cancer and on and on so that is exciting but you know it's just the beginning stages we're at the nascent the fact that we can even ideate about it is excited yes but that's where we're headed so then let's let's see if we can then visualize this so then we have this constant stream of data that's coming from our bodies and our health that is likely from different things like the cameras on our devices that are able to like read our our biometrics that way or other things like all the other just sensor suites in general wearables all different types of things then we have that that is constantly being fed into really strong cloud compute potential that has the entire medical corpus ideally this is the future hopefully entire medical corpus that's constantly seeing okay Eric's current states compared to the corpuses of literature and dynamically making recommendations as a virtual medical coach for Eric's optimal health trajectory so on this like tree of possibilities that exists we could get Eric to live until 96 years of age but Eric needs to do these specific steps in order to get to that spot otherwise if there is a bifurcating moment of not listening and getting that two hours of sleep instead of that eight like we asked that they may slowly be shedding days and weeks off of that optimal yeah I don't know that it's gonna be lifespan changing but it may be quality of life changing because if you don't have one of these conditions that you're at risk for that's just one less thing you have to deal with throughout your life you know whether you have to have stents for your arteries or whether you have to you know keep going more frequently for procedures you know we don't have evidence that we have transforming lifespan come in store but I think I mean if you don't have have an asthma attack ever in your life because it's preventable wouldn't that be better than having to take daily inhalers and medicines medicines and worrying about you know could that sort of thing so we're talking really about quality of life perhaps yeah if we ever get to beyond health span if we ever get to lifespan that would be a welcome thing but you know I'm not trying to be too bold in our expectations I rather be setting things even what we're talking about here is quite ambitious day-to-day feeling in peak health yeah that you're you preserve your health rather than having the years that you're around that you're suffering even more chronic conditions because if you're long wrap you're around long enough you're gonna have some problems some conditions if we can minimize that and keep you well preserved then you're probably gonna be enjoying your life a lot more yeah and then Eric why don't we ask you about those perverse incentives that currently exist so the lack of inclusive stakeholder with physicians and patients is a major one the amount of lobbyist money that's being poured into the pharmaceutical industry it's tough because it takes so much money to make something that we hope augments health and then if it's and then so hard to test it because it's so hard to control that single variable in such a complex piece of art like the body what do we do for increasing inclusive stakeholder between physicians and patients increasing empathy and and while simultaneously having a strong electronic health recorders is something like we take the voice and then we parse that for text and then the text auto inputs it into the electronic health record so they don't have to do it and then also on the like fake food sides as well as how do we have more inclusive stakeholder in less self-dealing yeah well firstly what we do need to do is get back the human bond that is the essence of medicine so the relationship between patients and doctors patients in all conditions whether it be nurses physical therapists pharmacists I mean you name it right now that's fractured it's eroded seriously eroded and it's been a steady demise over decades and that's largely because of the big business of health care and farm pharmaceuticals is just one relatively small part of that story so how do we get it back and I think we can in the era of AI as it kicks in you already mentioned one of many strategies which is keyboard liberation keyboard liberation yeah that's basically using voice the conversation which is the most salient aspect of that interaction and synthesizing the note from it turns out the notes you get from the voice conversation are far better than the notes that are currently in these electronic records because those records are 80% cut and pasted from the prior no and that note is erroneous and so what we do is just have a perpetual transmission of erroneous notes whereas the conversation which captures the real-time interaction is essential because it that firstly that is all archive so patients oftentimes you know they don't really can't absorb everything when they're talking to a doctor because it's a lot happening it's about their body and they're all worried and you know oftentimes they may have their spouse with them or a family member and they still it's hard to get it all absorbed so they can have an archive of that conversation yeah to listen to if they want there's no reason why they shouldn't but also more importantly the synthesis of that note the critical elements are then as you say speech to text and very quickly we've learned that within a small number of patients for a given doctor their voice it captures it really well and the notes are just excellent and they're just going to keep getting better of course because they're it's an autodidactic story just gets more accurate and here we want the patients to edit the notes too because that'll just even add more authenticity and accuracy anyway so that part is starting to take off and different parts of the world and that's just one there's so many other ways that AI that's a natural language processing machine learning but you've got AI to tee up a person's record to go through the hundreds of pages of labs and path reports if there are any scans and all the other things that happen to that person or in their family history their social history you have that a machine to do that for you to do that accurately and tee it up so you don't have to spend hours trying to sort through and miss a lot of stuff because you get distracted or because this is so much stuff then you have of course the ability to have the images interpreted as we talked about through initially through a scan to not miss things or the slide or a skin lesion or you know all sorts of things that the machines are really good at they don't miss things that humans and experts can so you have offloading to machines you've got also the ability for patients taking more charge with their data like you mentioned they may have sensors on they may have their electronic record and they may have their genome and their gut microbiome and all of a sudden they're getting feedback and they're getting more autonomy there's a lot of things that are in medicine today they don't we are we could do without a doctor diagnose a urinary tract infection an ear infection a skin rash and the long long list of common things that are not serious they're not life threatening but they could be just validated through algorithms so patients can do themselves again decompressing the load on clinicians so we're going to see all these things take hold and one of the biggest longer term is that we will gut out hospitals because the hospital is the biggest hit to the health economy the staffing and the facilities and that's a third of the 3.5 3.6 trillion dollars in the U.S. a year so if we obviously we're not going to get rid of intensive care units or operating rooms or emergency rooms or fancy imaging equipment but the regular hospital room would be better served in a patient's bedroom yeah or even anywhere in their home or on the go the reason being is we can exclusively monitor people today and as soon as we get to the point of having that multimodal data getting properly processed then we can say you know what it's safer to have the patient at home at a tiny fraction of the cost wouldn't that be great so that's where some of the biggest changes we're going to see they're pervasive there isn't one specialty in medicine or primary care that isn't affected we're talking about everything from paramedics to palliative care there isn't one walk of life or in the in the whole life story from in vitro fertilization all the way to end of life care that wouldn't be affected so it's a very big impact like I've never seen sort of thing oh and it's so important for us to to democratize the benefits widely quickly and also important for us to pursue this in a way that is ethically and morally righteous and and also that that is we'll get to some more of these things but also that is geopolitically collaborative so let's um let's touch on this you mentioned this there's a big part of what you just said we're architecting new data flows right now for the data to be structured in a way that can easily be readable and that can easily then have all different types of artificial intelligence apple uh um methodologies apply to it in order for us to understand what's actually going on within ourselves so does a does a future with with these new architectures of data flows potentially look like ownership of our own data and then being able to do things like almost in a sense have a valve and be able to like open the valve and let my biometric data flow into like scripts for example and have scripts be able to leverage my biometric data for research purposes right well this is a really big topic about control and ownership of data because the way that it works today is that people don't own their data they have to beg and grovel to get pieces of their data because it's distributed in many different places first of all there's not even a home for person sensor data or their genome or if in the future more and more of their microbiome of their gut and so the environmental sensors there's lots of things that we don't even collect and put in the medical record of today but then each person often has many different interactions with doctors of different places and different even in the same city or town and that data just sits at different places and it's never collated so one of the problems we have in the era of artificial intelligence is nobody has all their data unless they happen to be born in a health system and never left it and all that's you know aggregated perfectly well that's pretty unusual plus even that person doesn't have all their sensor data and their genome and whatnot so we have we're in a flux right now where there's many modes of data and it's fragmented and it's hard to get at it all some of it if we're older is a lot of it's on paper not even digitized so we have a problem because inputs is basically what is the story here for AI and you have limited inputs then your output is not going to be as it's going to be compromised it's not going to be as good as it can be so we are firstly not fessing up that we have a problem and we have to override this somehow or other and then secondly we have a security and privacy issue that's deep in this country we don't have these GDPR standards that Europe adopted we're much more tolerant of hacking and cyber and holding hostage health systems for their data all these sorts of things that are just atrocious and we're doing very little to stop it and also juxtaposed with what looks like to be a very collective approach of like the People's Republic of China yeah well like you know an Estonia people own all their data it's it's in a blockchain type format and you make the call like you said I want to open the valve to give my sensor data to this research program or to give this medical data to a doctor that I'm going to see or I trust you make the call and the reason why that's attractive and that model really was initiated there is that when you have control of the data and it sits at the level of an individual or a family then you don't have the cyber hacking potential if you talk to the guru as a cybersecurity I say keep it in the smallest units as possible the more it sits on big servers the more it's a target because it turns out that the data of our health is far more valuable than our financial data turns out that it's at least 5x in the dark web or more value because it's used for false medical claims in this country it's used to get prescriptions like opiates it's used for identity theft medical identity theft so well our medical data is really valuable when not protecting it enough we don't aggregate it you know it very well and that's needs a shake-up that needs priority and it hasn't gotten it yet so you know we can learn from other places and it's surprising how little attention has been paid to this okay let's let's touch on how you gave these examples of like okay estonia is doing things a specific way china is doing things another way the united states europe etc doing things in different ways now we also mentioned like the importance of democratizing these advancements in healthcare and making them accessible to people being ethical as we do that something that i thought that was really interesting was that you're you had a recent post with kai fuli about june wang's i carbon x and jamey haywood's patients like me right and there was a order from the united states for i carbon x to withdraw its funding and ownership of patients like me well they had to yes they're a through the trump administration there was a order of divestiture whereby patients like me could not be owned by i carbon x a chinese company and they ultimately were after that piece was published they they're in they're ready to close terms to be acquired by united health in the u.s because of this forced divestiture whoa so this was a real bad omen because i carbon x beautifully was a great partnership with patients like me they hadn't done anything wrong in terms of a breach of data of any patients of the 700 000 people in patients like me and the idea was that they were going to be like this voice medical coach they were going to they were working on that that that was to give them you know a large cohort of people with diverse conditions diverse demographics with all the things that they're doing so it was actually i think a bad sign of the times which is in part why kai fu and i wrote that piece because we want to see collaboration this is an opportunity but we're i don't know if we'll ever have it again and what and not only that but the chinese u.s relationship is kind of at a nadir right now a lot of tension the trade war and all sorts of accusations of sciences spies and i mean it's it's really the worst i've ever seen in my career meanwhile we're all like friends you know yeah like we have friends in beijing or shanghai or whatever and they have friends in new york and la and stuff yeah so that's going on in the in the foreground and but in the background we got some serious of concerns now health is interestingly of mutual interest and there's so much complementarity of what china has and what the u.s has and if we could work together well what about all the other countries around the world that could join in but if we're if we're using the planet uh inhabitant health as a goal and yes it's a big goal and that could help improve relationships even outside of health between the countries um so i haven't given up hope for this but i hope at the same time that we recognize at this point you're bringing up this force divestiture is going to uh really need to more polarity it's going to escalate the tension rather than the opposite so um you know it's really unfortunate that this will occur i'm hoping it's just a transient thing that we get back on track we we outlined in the nature biotech uh article how we could go forward and with an open science uh open platform resource way and uh have joint governance and once we get started and develop this infrastructure of data where it's federated learnings this is a type of ai which is really another exciting subtype where you never take the data outside of that country or health system hospital doctor's office it's all machine trained it's like at the edge instead of in the cloud it's all done and so you never have to worry about breaches of privacy and if we did that so that no country would have to worry about their data leaving or being stolen or or hacked using this federated uh type of ai we could we couldn't even actually advance the concept but now that is a an alluring potential it's something that deserves to be tried at least in a pilot way yes the importance of the united states and china to be able to cooperate and maximize flourishing for the rest of the planet together especially with things like the belt and road initiative coming up on the eastern hemisphere and just the united states and china being the top two economies on the planet just that our way of actually being able to really more deeply spiritually work together um is critical it's one of the top most important things um in the world and also within our ethos and so that's why you know we're coming up on um partnership uh interviews and delivering a talk at picking university in beijing in september and i'm really looking forward to that and it's just going to be one of the most critical things that happens in the next um couple of decades is being able to figure that relationship out more effectively all right let's um let's make sure we talk about the heart i think this is really important to talk about the heart in our just entire evolution of our planet and our bodies on this planet and then the organ systems within those bodies and then the heart specifically being such a beautiful organ that gives us a hundred thousand beats a day of of being able to help us live and help us survive and so i'm just very spiritually tied to the heart like i really love it on just like a huge spiritual level and and i'm just curious what are your thoughts on on on the heart and on a spiritual level about um the importance of the heart well you know i've that's my been my career uh you know i i got boarded as a cardiologist in 85 so it's now 34 35 almost years um i think it's uh a phenomenal organ the fact that this pump is is there for you um you know every second and um giving you the nourishment of every cell in your body uh essentially so yeah spiritually i mean that's why there's so much overlap with love and the heart and you know i think there's no question about that connect and uh you know i think that there are obviously every organ is important in the body um this is a central part of life um so i can understand your spiritual correct connection to it i've been very uh lucky to be able to work in this area of trying to preserve people's heart health uh and it turns out you know it's oftentimes a mixed bag of genetics so people do everything they can to take care of themselves and still wind up with heart trouble and oftentimes is bad lifestyle as well it's just kind of a mixture of everything of nature and nurture but um you know overall we've made tremendous strides in heart health over the course of my career uh in fact that's why i got into it in the first place i wasn't even planning on being a cardiologist but i i'm so excited by what was happening when i was training in the early 80s that it was clear that that was going to be a hot area to be in and and that was going to be an area that would be stimulating and and turns out it's been one that probably in many ways have outpaced other areas of medicine in terms of progress doesn't mean that we we still have lots of heart disease but you know people dying of heart attacks today is much less than used to be the case people having less heart damage um many things are far better than they were uh in fact just to give you a quick story on that alan when i was um training if you had a heart attack what we did was we you know gave you morphine for the pain and oxygen and basically you know kind of prayed that you would get through it because we didn't have anything to stop a heart attack in its tracks and so now obviously we we do everything kind of restore the blood supply and most people do have a restored blood supply and people dying of heart attack is you know markedly it's plummeted so that used to be the most common cause of death heart attack and heart disease and now it's still important but over time you know cancer is overtaking it um and you know i think it's exciting to see the progress because you know we think about 30 years is a little almost like a little drop in the bucket of time when you think about the universe and to see that kind of progress in a short time is is relatively astounding yes eric would you say that we all come from the same source uh you know i'm not a real kind of religious person so i don't know i i if you talk about source of evolution yeah i could get into that but you know i really don't yes uh but as far as you know did guy create man and all that i don't know i i i um but all coming from the same source of evolution yeah oh i i am a strong believer in that yeah that principle that we evolve from you know organisms of lesser and complexity and we're continuing to evolve albeit perhaps you know at a different pace but yeah no i that i would agree and and let's go backwards far enough then so then if we go from yeah from humans to single-cell organisms to the to the initial root of evolution on this planet and the star systems and then what we hypothesize is this big bang what about prior to that does this feel like it's just one big creation that's occurred and it's like a big beautiful painting with different strokes and a big symphony of different notes yeah i don't know uh something i think about um and it's hard to know it's just you know we're here for a limited time and we can be you know quite introspective about it but these are some of the unknowns um i wish i had an answer for it and then what do you think about how lots of uh indigenous wisdom around the world is saying that our disconnection from nature our disconnection from this origin story of ours is the reason why we have so many of the issues yeah well you know that's like the religious wars and you know the whole idea of this disbelief anti-science you know the evolution of man and our whole of our biology is somehow it didn't occur i mean i have a hard time with that because i think that that particularly uh the climate right now of anti-science with the idea that you know evolution shouldn't be taught in schools and that sort of thing that really gets me pretty riled up so you know i think that um this is an area where just like the diet there's a lot of tribalism you know about people that are really big on let's say ketogenic diet and people are really big on this or that i mean i'm fasting we have a lot of divisiveness and uh we don't really have tolerance or belief in where there's hard scientific proof i don't think there's any question about the if you trace evolutionary biology you know where we came from but you know there's people that uh negate that uh unfortunately uh it's a it's a very difficult area you know the importance of nuance the importance of multivariability of humility of compassion of having really good thought-provoking conversations but having good dialectic all right and how about then what would you say is the teleology of this whole human experiment well it's a pretty deep question which i did none of these recent ones had i anticipated you know i this kind of like the meaning of life and you know um it's it's it's it's tough to all i know is that you know i try to have input in the time the short time on around to try to make a difference to try to help people to try to connect deeply with my family who i'm lucky enough to have all close together here in san diego and you know it's sometimes beyond that it's hard you know i contemplated i'm sure a lot of people do you know it that having seen so many people who are alive one second and dead the next it gives you a different sense about life and how short it can be and how sudden it can be not there um and that's one thing in medicine it's somewhat unique um that you the evanescence of life yes um and you know it to me that and the fact that you know i've had so much of a burden of disease among my family my parents and relatives it even gave me more motivation to try to make the best of each day um but i still know that however many years that i get to be on this side of the the dirt that you know what it's a small tiny tiny thing in the big picture and even whatever you can have is a that you added to our to our species if you will to our planet to our community whatever you want to call it that you can only go so far you know you kind of um the the ability to make substantive changes is a tall order it's probably impossible you chip away at a little bit do you feel like you came to the planet with a north star with with with an ideal goal and mission that you wanted to achieve here and that you're fulfilling that no i that's probably too lofty um in fact i know it's too lofty no i i think it's really more that um you know i when i was a kid i watched a lot of my relatives die i remember you know being a kid and going to various funerals and then i saw my parents die at a young age and uh you know i had a higher appreciation for if you're lucky enough to be here just to be here no less to do something and then i was just lucky enough to have the ability to go to get the right education and pursue a path that i could feel like this i'm aligned i'm i'm excited i'm passionate about what i do and i'm i'm lucky enough to feel a kind of spurts of creativity and being able to inspire other people so i'm lucky enough to have a great team here that i get to work with and and we try to do the same reverberate our work and ideas more broadly so i i feel exceptionally lucky um but a lot of that happens by accident you know some of it is setting goals but a lot of it is you know you're just lucky to wind up with people who are simpatico who are you know kind of the same what drives them what makes them tick there's a lot of commonality and that makes it happen doesn't ever feel like those synchronicities that are lining up in your trajectory of achieving your goals are potentially there for a reason maybe as lessons or as as experiences to help you level up well you know it's it's it isn't clear you know oftentimes what i'll do is i'll say you know we we we we got to do this this is a big thing and sometimes it'll work and we'll get there other times you know we i remember you know when i was back in cleveland and i started a new medical school there hadn't been one in 26 years and it was really difficult because uh where i worked at cleveland clinic there was no degree granting authority so we couldn't start a medical school you know like that and we had to work with the case western in town which is the university and they already had a health system and the last thing i wanted was another medical school in town and it basically like taken down the burlin wall and we were able to do it and we started this medical school as the first one in 26 years in the united states um wow that took a couple years of dedicated effort i'm really proud of that we were able to do it so that's the kind of thing where if you just keep you know working on it uh and you get can you have to convince a lot of people take down on what was walls of hostility um you almost like be a shuttle um ambassador um that something that is worth it it's worth it because it'll train generations of of um doctors in the future now there's been certainly many things you know go after when there'll be a failure they'll never materialize too so you know you have to offset if you don't try what i've learned though and this happened more over the course of a career is don't do little things i mean it isn't worth the energy you know put your put your resources your time into things that are transformative potentially and transcend yeah yeah because otherwise if you're just trying to do incremental stuff it's usually you're gonna wind up put a time into that and it really isn't going to be worth it and you better better off to fail when it's something you know major uh because at least you gave it a shot and and you know what a lot of those times you're going to succeed particularly if you get to work with people you can't it's very hard to do this alone and you and you really got to get um you know a kind of team collaborative approach but if you do that and you set big goals um that some people might say are beyond reach unattainable impossible even those are probably the best goals yep as long as your sound as long as there is you know unmet need and and a real purpose those are the ones that i like to do likewise so beautifully said and then how about if you were to have the ability to make augmentations right now to to children that are being born into the world let's say it's even like your children that are being born into the world and you have the ability to make augmentations to the child being born what area of their development would you choose to augment first yeah i don't think that i'd want to go there to augmentation i still would be into nature but you know i i had with genetic engineering and trying to figure out exactly which which ways that we can augment metabolism or intelligence yeah i know i i'm not i think there's a big ethical quandary with that yeah because there's no real you know it's a gray zone you know what are you going to do make more athletic more intelligent and more what you know more what we've kind of been doing that though over the years of evolution we ourselves have been genetically pairing for fitness in terms of intelligence or athletics or strength or metabolism or all different well but now it's different because now we have these powerful tools like genome editing and we watch the reckless use of that in china where they're basically the fellow he janaki was getting couples with the father with hiv and saying that we could make sure that the baby will crisper the babies at the embryo listate so that baby doesn't have to worry about getting hiv well you guess what that wasn't going to happen anyway you didn't need crisper and so it basically and the genome editing part was so reckless because there's all sorts of things that can happen outside of the zone of editing no less in the zone that you're trying to edit of a genome so that was a disaster and that was the first foray of an embryo but this is a powerful tool which has potentially lots of side effects and it shouldn't be augmenting at the embryo level in my view it what it should be doing is trying to treat diseases that you don't have disease yeah that's say that once but that let's say that was already that's different than augmenting well let's say eradication of disease is already awesome we're all already on board for that okay across the planet now we have the augmentation side of things yeah well you know i look at augmentation is having a baby in an infertile couple that's augmenting that's augmenting their family i have my granddaughter was an IVF baby and i still feel good that is a miracle yeah and she's really healthy she's just like 15 months old and it was secondary infertility because my daughter had already had a healthy boy but i still think that's extraordinary but to manipulate that embryo further besides just being able to get an embryo that's viable and to term pregnancy you know it's really dicey i mean we IVF now is is is still got lots of failures and it's a tremendous expense it's often you know couples go through multiple rounds there's all sorts of hormonal injections until you see somebody having to go through this you have no idea how complicated and tough it is and this is something that here we're talking about augmenting we can't even get you know just a simple let's just have a natural baby you know that is different than we're going to start doing genome editing of that embryo so i i'm not into that you know interesting i think that i wonder if your children 50 years from now yeah and their children 50 years from now will say that i can't believe that you weren't genome editing back then because because in 50 years it seems to be the trajectory is moving to that to be a norm very similarly to how we're slaughtering billions of animals for food versus growing clean meat children again will be like i can't believe you were doing that back well you know you could be right uh that there will be more there will be some use at the embryo level that you know get out these genes that would cause risk of cancer or alzheimer's or you know whatever disease that's possible i if it's preventing significant diseases i could see that but augmenting i see it as artificial augmentation whereby you know instead of having cosmetic surgery to look pretty now we're caught now we're actually going in to human life and remember any transmit anything that we're doing there is transmittable so we're changing the species all right and so this is now we're now we're playing with not fire we're playing with god we're playing with the human genome and the future of the species so if you if you're going to be doing that and you're going to be transmitting that it better be for something damn good and you know i think diseases okay if they're seriously these and you know and you don't have side effects absolutely you want if you want somebody to get somebody more intelligent you know what well we're trying to solve these grand physics challenges under yeah well i see i have a real different solution than you on this i actually think the human mind is is uh the talent that we have in general is extraordinary i i i meet i meet people who are brilliant all the time and you know far smarter than i'll ever be and ever was and you know i think and we see young people coming up we have high school interns spend the summer here and they make me feel like a complete moron you know they're just incredible so i don't worry about the intellect at all and i don't worry about athletics because we already have hero worship of sports i don't see any good rationale for the augmentation side you're bringing up i i'm keen on the disease burden thing if we can do that but that's a big if big if and you know um right now we're talking about rare diseases not common disease so we'll see yeah okay maybe another latter conversation we can unpack some of the other potential uh conversational points are on this let's let's um visit the last couple um questions which is eric do you think that we're in a simulation a simulation i don't know about that i think we're in a real a reality zone and um i mean you don't want to treat it like a simulation you get one chance you know if you if you think of it as a simulation then that's probably um that's probably not ideal it doesn't have to be mutually exclusive if you see it as a simulation you can see it as a game and it's so important for you to achieve your mission and your goals here so it can actually in ways also maybe even excite you more to achieve your divine purpose by by viewing it in that way so it doesn't necessarily have to be exclusive from being serious about life i'll take your point that's a you know that's your perspective it's okay okay and then what do you think is the most beautiful thing in the world uh i think love of another human being is probably what i put up there um you know i think and of course not just one but uh uh there's a real dearth of that it's why we have so much you know divisiveness and wars and but you know at a at a human level that bond for to each other to me is its beauty it's more beautiful than the most beautiful beach or or place on earth nature um we now have enough of it and when you're in touch with it you say well how could it be better than that so that's what i see is the pinnacle of of beauty we can carry that love with us on a moment-to-moment basis through our breath through our gratitude through our connection to the planet to the ecosystem that sustains us connection to each other yeah no you're right i mean if we had love and we if it got expressed in how we take care of our planet we'd be a whole lot better off than we are right now so yeah i mean if we could just get that um you know to be expressed in many other ways it'd be great we don't have enough of it just to each other no less to get it to be reflected in in our walk of life so yeah i agree with you Eric this has been such a wonderful conversation really enlightening thank you well thank you you made me think thank you so much for coming on the show thanks everyone for tuning in we greatly appreciate it we'd love to hear your thoughts in the comments below on the episode let us know what you're thinking also check out the links in the bio below to Eric's profile page on scripts his wikipedia his twitter and check out his new book deep medicine how ai can make healthcare human again that link is in the bio check that out and have more conversations with your friends your families co-workers people online on social media about deep medicine about these subjects that we were talking about today talk more about it and try and figure out how we're going to maximize our prosperity through that age also support the artists the entrepreneurs the organizations the 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