 ThinkTech Hawaii, civil engagement lives here. Likeable signs on a Friday, it is likeable on a Friday. Fact is likeable all the time, depends on how you approach it. Okay, and Ethan Allen is away today, so I'm the host for this. My name is Jay Fidel here on ThinkTech, and we're talking about moving medicine forward technologies at the frontier with a doctor, Dr. Bob Peterson. Welcome to the show, Bob. Thank you. Great to have you here. You are kind of a techno person, aren't you? I am indeed. In fact, you're trained as a techno person. Oh, I went to graduate school in engineering before I went to medical school, that's right. So why don't you stick with the number one, you know, number one education? Why don't you have to go to number two? When I was in graduate school, I was designing control systems for heart-lung machines, and we needed to test them out on animals. So we had to do animal surgery, had to do heart surgery and put in these assist devices on animals, and as the graduate student, of course, you always get all of the dirty work. So I had to do the surgery, and I found out, first of all, it was really interesting, and second of all, they told me I was very good at it, and I kept saying, you should go to medical school. I said, okay, I'll go to medical school. If it wasn't for surgery, I probably would have stayed in engineering, but surgery is really very, very interesting. What's interesting about surgery? Every case is different, but they have similarities and their differences, and it's one of projects that you do. So every surgery is a project. Every surgery, you do it, and then you have an end point, and you can evaluate yourself on how well you did, and as I said, it's always different. In any surgery, there's probably a thousand different decision points that you make, and then some, many of them, of course, are based on experience that you've made those decisions before, but they're always new ones in every surgery, so it's endlessly fascinating. It's fair to say that there's more ways to do it in surgery, in other words, it's not just one way, it's right. You can get home, you can get to a good result in a number of ways. Is that true? Oh yeah, of course that's true, and no two surgeons are the same. I'm a plastic surgeon, and if you ask 10 plastic surgeons to do a specific case, they'll do it 10 different ways, and they'll give you 20 different options. So why did you go into plastic surgery, as opposed to other kinds of surgery? When I was training, my very first rotation in training in surgery residency was with a wonderful plastic surgeon here at Queen's, named Dr. Don Parsa, and he made it seem so interesting that I always kind of kept it in the back of my mind, and as the surgery training progressed, what I discovered is that plastic surgery has the greatest bread of things that we treat, and there's a certain artistry in plastic surgery that I found very interesting, but mainly was the breadth of surgery that we do. We operate on all parts of the body, and we operate on a large number of different types of things. But plastic surgery has its challenges too. For example, there's a lot of plastic surgery operations that are not covered by insurance, they're discretionary, and people, they want the plastic surgery, but there's no insurance to cover it, which leaves you in a position where you have to organize a business model that can capture those cases. I mean, how challenging is that? That's a great question. Medicine now is just facing up to the fact that patients have choices. We in plastic surgery have faced that for the past 25, 30 years. That's been the nature of my practice, and we've been subject to market forces much, much sooner than the other branches of medicine, and organizing a practice to deal with those market forces was very interesting, and it taught me a lot. When I trained, I did a lot of reconstructive surgery, which is insurance reimbursed. It's like a cancer operation. Cancer operation. Breast surgery. Reconstruction. Right. Well, I trained in pediatric plastic surgery, and I did a lot of cleft lip and pallid, you know, craniofacial surgery, congenital hand surgery, burns, things like that. But in cosmetic surgery, you don't have insurance reimbursement. So there's a lot of competition to get those patients, and you have to be very sensitive to the consumer's demands, and that's actually probably a good thing. I mean, medicine has been shielded from the patient's concerns for a long time because of the insurance model and because of the monopoly that medicine has. So it's not much of a competition. You have to do what you have to do. Right. That's right. And so having been shielded from the patient's concerns, doctors perhaps became arrogant or maybe not too sensitive to the patients as much as they could have been. That's changing now, and I think changing for the better. But in plastic surgery, that was a big concern. Patient comfort and satisfaction were critical to doing your job. Because it's word of mouth, isn't it? Yeah, word of mouth. So I was fortunate after my plastic surgery training, I went to China, and I did work in hand reconstruction at a big plastic surgery center in China. Did people who were injured in industrial accidents, that's a good thing. They had a lot more industrial accidents in China at that time back in 1990 than we did in the United States because the worker protections were not nearly as sophisticated as we have here. And one of the things that was very interesting is that they didn't use general anesthesia. Almost everything that they did was using local blocks or spinal anesthesia, something like that. So I was unaccustomed to that. In the United States at that time, especially, everything was done under general anesthesia. So when I came back, I adapted those techniques and I felt that it was safer and also the patients are more comfortable when you do that because we would have to numb them up to do the surgery. And the nice thing is that when you're done with the surgery, they're numb. So I advanced that in my practice and made it so that the need for narcotic pain medications was almost completely eliminated. And so I was swimming. Also the risk, the risk of respiratory secondary problems and the need for equipment to cover those problems and so forth, you can do it in your office instead of having to go to an operating theater with all the equipment. That's right. But the main thing was that the patients were just much more comfortable. And so the final frontier for us was abdominal plastic, a tummy tuck, being able to numb that completely up. And about 15 years ago, I reported a series of 100 consecutive tummy tucks and the average number of pain pills that they took in the first day after surgery was less than one. A bunch of them took a half. Some took none. Some took one. That's pretty good. But the average was about a half. So I thought that was really good. And the nice thing is that we were swimming upstream against the opioid crisis that has developed in the United States because we weren't causing pain. We were preventing pain and then not having to treat it with the opioids that have then gotten out of control subsequently. And that was just a lucky side benefit of doing it that way. Well, it's kind of a modern drift, in other words, after an operation, I would call it a classical operation, a conventional operation, not a cosmetic operation. People or any procedure, people are encouraged to leave the hospital earlier. Right. Right. After childbirth, for example, leave the hospital early. We don't want you here. Right. Not only because of the risk of being in a hospital or a MRSA or whatnot, but because you'll do better at home than hanging around here. That's right. And so this is all very modern and progressive, isn't it? It's the same thing you're talking about. Right. Let's get you out of here. Well, there are two parts of it. One is that if our patients would get up, at the end of the surgery they were numb so that they didn't hurt, they would get up and they would walk out. And then even our timing techs would come walking in the next day and they weren't sore. And the reason is that there's something called the gait theory of pain. And if you block the pain-producing signals before they hit the brain, the brain doesn't pay attention to the fact that there's something painful going on. And you get this tremendous, it's sort of placebo effect, but it's not even placebo because the brain doesn't even know that there's something sore. And so the brain doesn't pay attention to it being sore. And so the requirement for pain medication is much, much less than somebody who wakes up sore, you know. So what we do is we numb up, as I said, we numb everything before we cause anything sore to happen. The downside of that is that it requires time at the beginning of the surgery. The first half hour or 45 minutes of the case, I spend numbing everything up. And it has to be you. And it has to be me. Well, it doesn't, I suppose, have to be me. It could be an anesthesiologist or something, but it is me in our practice. And surgeons are very impatient. They want to pay. Once the patient is asleep, boy, they want to do surgery. Our patients are groggy but awake, breathing for themselves. And we numb everything up. It's not particularly painful to numb things up. So you don't need to be as heavily sedated. And then once it's numb, we do the surgery. And they can stay very lightly sedated during the surgery because it's numb. And then because they've only been lightly sedated, they wake up very quickly at the end of the surgery. I can see how this would help your practice and make you more competitive in the plastic surgery world. But there's more here than just that. You go to a foreign country, you see what they do. They're not entirely behind the curve in China. They're thinking about these things. And they come up with something that actually looks pretty good as against American medicine, which is not necessarily the best in the world these days, actually, and you bring it back. It's sort of an arbitrage of ideas. You bring it back as a piece of technology, actually. You employ it in your practice. And voila, you're using technology that you gain somewhere else, using it to improve the patient's experience and also to leverage yourself in a competitive market. That sounds pretty good. It probably suggested to you at some point that technology, the kind of technology you could find and develop, is a good thing. Indeed. Absolutely. And it still is. There are still things. I still go to China pretty much every year. I have good friends in China. And as you said, when I first went there, they were very resource-poor in terms of their medical care, but they were smart. And they thought about things very carefully, and they did the best with what they had. They've become more resource-rich over the ensuing 25 years, but they still have some really good ideas. And there's things that I see there that I think, wow, I wish I could do that back home because that's a good idea. What stops you? The FDA. In particular, there's something people have been working for years on trying to make a better facelift. And as I said, if you have 10 plastic surgeons, what's the best facelift? You'll get at least 10 ideas, probably 20. And most of them will be the way I do it. That's the best way. But there are some things that are really better. People have been trying to minimize the incisions for facelift for a long time. And there are little thread-lift things that people have tried in the United States. And they've been around for about 20 years, and they've never worked out. And so you put a string from here to here to lift things up, and it'll lift it up for a little while. But what happens is that as soon as you open your mouth or move or sleep or do something, that the thread will either break, it will pull through, or it'll tear the tissue. Something will happen to it. So the threads have really never worked out. The static threads have never been popular in the United States. In China, and there are some people that say, oh, you do this, do this, and try various different things to try and make it work, and it has never really caught on. In China, they did something very ingenious. Instead of having a static suture to lift from here to here, they put an elastic suture. So at rest, it's under slight tension. When you move, it will get under a little bit greater tension. And when you stop, it will go back to its rest tension. A static suture doesn't have any rest tension. And if it does, when you open, you'll break that rest tension. And when you go back to neutral position, there'll be no tension. So why doesn't the FDA approve the elastic suture? The politics and the finances of approval. It's not necessarily a rational decision. No. I think the FDA would approve it, but nobody is willing to put the millions of dollars that it would take into getting the approval because they don't view the market as being large enough to make it worth the investment and to get return on an investment for something that's perceived as having not that large a market to be able to amortize your investment in the approval. This sounds like a problem that goes beyond sutures. Yes. It sounds like a bureaucracy that's slowing us down and going to the question of, is our medicine the best in the world? And the answer is probably no. And this kind of thing stands in the way of technological advancement, doesn't it? Yeah. Let's take a short break. This is Bob Peterson. He's a doctor. He's a plastic surgeon. And he's got a degree in technology and he's got a degree in medicine. And we're going to talk about how this comes together and how, in a perfect world, you can use technology in so many ways to improve a medical practice and pretty much everything else. We'll be right back. And Aloha. My name is Calvin Griffin, a host of Hawaiian Uniform. And every Friday at 11 o'clock here on Think Tech Hawaii, we bring in the latest in what's happening within the military community. And we also invite all of your response to things that's happening here. For those of you who haven't seen the program before, again, we invite your participation. We're here to give information, not disinformation. And we always enjoy response from the public. Join us here at Hawaiian Uniform, Fridays, 11 a.m. here on Think Tech Hawaii. Aloha. Hello. I'm Yukari Kunisue. I'm your host of New Japanese Language Show on Think Tech Hawaii called Konnichiwa Hawaii, broadcasting live every other Monday at 2 p.m. Please join us where we discuss important and useful information for the Japanese language community in Hawaii. The show will be all in Japanese. Hope you can join us every other Monday at 2 p.m. Aloha. OK, we are exploring technology in the medical practice with Dr. Bob Peterson. This is so interesting. It's the kind of show I love. So no limitation on money, no limitation on approvals, OK? Take the FDA out of the picture for now. What's your dream suite? What's a medical practice? What kind of technologies would you bring into, you know, a medical practice to make it work really, really swell? Well, the electronic medical records, if done properly, actually are very useful. Unfortunately, they're also oftentimes a bit of a burden, but as we were talking before the show, one of the things I developed about 20 years ago was a cloud-based medical history product, and it's never caught on. But when you go to the doctor's office, most times nowadays, they still give you a couple of pieces of paper, and you fill out all this stuff, and you write through things down, and it's a waste of your time. People don't read them very carefully. They're more or less accurate. And it would be much simpler if you just went and said, here, here's my identification number. Look it up. You know, print it out if you want it, or download it into my file. What advantages would that provide to the average patient to have that? You wouldn't have to fill out the stupid form anymore. That's the first thing. The second thing is, you know, I personally have had a hernia surgery. I don't remember when it was. I mean, it was a while back. It was years ago. I don't know if it was 2010, 2008, 2012. You know, this is sometime around there. If I had it online, I wouldn't have to remember anymore, you know. When I go to the doctor's office, have you ever had surgery before? Yeah. When? I don't know. A while back. People frequently forget what medications they're on. They'll have maybe a little piece of paper with all their medications. And that can be very important information. That's incredibly important information. Okay, so let's just diverge on that point for a minute. Medication errors are thought to be a major source of problems for people in the United States where the medications will interfere with each other or they'll be additive or, you know, they'll be something. Surprise cumulative effect. Exactly. So, if you were to have all of your medication information on the cloud where it would have your doses that you take, what the medications are, and you would then be able to run an artificial intelligence program on that set of data, and it would be able to say, hey, you're taking two medicines that have acetaminophen in it, and they're adding up to pretty close to a toxic dose. Oh, and by the way, the way that that medicine is cleared is through the liver, through this one enzymatic pathway, and you're taking an antihistamine that also is running through that same pathway and kind of gumming up the drain, so you're at risk of having a too high level of this medication, or that that medication that you're taking is not a high enough dose for somebody your size. Because when we do medications, you know, what's the dose of aspirin, two aspirin, one or two aspirin, like that? Say two aspirin. Is it two aspirin for an 88-year-old, 88-year-old woman who's thin and emaciated and maybe not eating too well, and also for Kanishki? Well, it is. Should it be? Probably not. So, if the program, the artificial intelligence program, which could do drug interactions, but for ones that are interacting and all being drained out through the same plug, it could also look at your weight, and your height, and your age, and your gender. And even your family history. And then, so those things are simple, I mean, and then family history. Not only could it do that, if you wanted to include a link to your 23andMe genetic profile. Oh, wow. Then it could look, for example, to see if you are a hyper-metabolizer genetically of a certain medication or a slow-metabolizer. And I'll give you an example of that. There's a blood thinner that is metabolized by a cytochrome system in the liver called the cytochrome-19 pathway. And genetically, there are different types of people. There are people that are hyper-metabolizers. There are people that are mixed, and there are people that are slow-metabolizers. Well, this anticoagulant drug turns out to be a pro-drug, so the metabolizers turn it into the active drug. So it's called the CYP-219 drug. And if you take that drug in your hyper-metabolizer, your blood will be extra thinned. You're going to be at risk of having bleeding problems, for example, hemorrhagic stroke or any kind of bleeding... Like a hemophiliac. No clotting. That's exactly right. You're going to be similar to a hemophiliac. I personally am a hyper-metabolizer of that drug, which means that both of my parents have given me the gene that makes me a hyper-metabolizer. Both of my parents are on anticoagulants, and my mother was on that drug. So I said, since I know that I got that gene from you, and I know that I got the gene from my dad as well, you may also be a homozygote. You may have two copies of that gene, and you may be at risk. You should have a gene test to see if you are at risk for bleeding if you're taking that medication. And so she did the gene test, and it turns out that she's not a homozygote. She's a heterozygote. So I got the SIP-219, the allele, that makes me a hyper-metabolizer from her, but she had one of those alleles and one of the wild type, the other allele. So she is not a hyper-metabolizer. She has a normal metabolism. So for her, it's okay to take that drug. But that's a very sophisticated analysis that I happen to be able to do because I'm a doctor, and I know that I'm a homozygote for that gene. But the internet could do it just the same way. The internet could do it just as well and much faster. And so if you were to put all of your drug information into a cloud-based program and then allow the internet to look at the drugs, because they're drugs that just are known to interact with each other. Warfarin and aspirin are known to interact with each other in everybody. You don't have to know anything about the person to know that that's a potential risky situation. Then you could also look at the person's weight, their age, their genetic makeup, things that are individual to that person that would maybe want you to alter the drug dosing, maybe space the drugs out a little bit more, maybe switch to another drug that isn't metabolized by the same pathway as another drug that they're taking that's more important. Well for that matter, do some blood testing, or for that matter do some DNA testing and get the complete picture and give you a really smart answer. And not only could it give you a really smart answer, it could give you an answer that's smarter than any human being could give you, because it could be the Watson of drug interactions. It would be able to factor in many, many variables that are too complex for an average person to be able to do, and it would be, if you took a pharmacist and gave them a month to do it, they may be able to do as good a job. But pharmacists have to do prescriptions every day, they don't have the time to do that kind of analysis. But you can do this on an automated basis. You can automate it. And the beautiful thing about it is that once it's automated, the machine doesn't care. The iteration just runs the thing. And you can do that for everybody. That would be a technology that's certainly well within the realm of what's currently possible. It's so obvious Bob. Why aren't we doing it across the board? We have the technology. None of what you're saying, talking about, is all that cutting edge. I mean, it's not all that remarkable. We know these things work that way, and we know we have artificial intelligence. We can build the logic to do exactly what you're talking about. Why don't we have it everywhere? I don't know. I wish we did. We have pieces. Well, part of the problem is that we have pieces here and pieces there. Most people's medical information is in silos, and the privacy laws prevent the silos from interacting. And so to... I thought we got out of that a few years ago with electronic medical records and all this, and it was sort of breaking down out of the silos, but I guess it never really did. Well, it's getting there. But for example, just in Hawaii, we have three medical information systems that cooperate to some extent. You have Kaiser, you have HMSA, and you have the military. And you could have medical records in each of those that are mutually inaccessible. The epic interconnectivity is very helpful. Now I'm at Hawaii Pacific Health, and at Hawaii Pacific Health, I can use the technology to look at people's medical records pretty much across the HPH system, and we can access out to the queen system. But the military is still... But if you had a situation where you put the patient health record information on the cloud, make it available everywhere in the world, have these artificial intelligence processing systems available on an internet site somewhere, it's so easy to do that, software as a service where the site is really smart. The world would be a better place, and patient benefits would be enormous, and medical... Doctor benefits would be enormous. You wouldn't have to pledge through this. You would have instant answers on exactly what to do from very reliable, if not mechanically automated systems. When are we going to get to this? Is it soon? I don't think it's soon, but I think we will. And we were talking earlier about the United States being at the cutting edge. I don't think the United States will probably be the country where this happens first. I think there's going to be Scandinavian countries that are going to beat us to it, maybe other European companies and countries, and maybe Korea or Singapore or some place in the Far East will be there before we are. Well, in order to get to a better place on this, use this technology and many others, we don't have time to talk about all of them, but I would really like to have you back and we can talk about so many more. It seems to me that you have to have patient education, the patients have to understand not only what the medicine is, but what the possibilities are, and get behind initiatives like the one you're talking about. But I get confused and I'm glad you're here because I've been meaning to ask this question of a doctor just like you for a long time. My wife and me, we sit together and we spend a certain amount of time every day watching television. And when we watch television, we see ads for warfarin and a million others, and they are giving us medical advice which is self-interested, it's the drug companies talking to us. They're not talking to the doctors, they're talking to us. As if it's going to make a difference in what we say to the doctors. And I can just see you're walking into a medical doctor's office, maybe this has happened to you. You know, Dr. Peterson, you know, warfarin, I've been studying warfarin because I've been watching those ads until my eyeballs fall out. Why don't you prescribe warfarin for me? Does this happen? Is this crazy? Are they talking to the right people? They're spending billions on these silly ads that play all day and all night. What's going on? Well, you're right, I mean, they're directed towards trying to shift people to the newer, more expensive medications. But in fairness, the new medications are often better. They're just very expensive. And a well-informed patient is a patient who's better able to help take care of himself. So maybe when you see those ads, you say to yourself, okay, they're raising the issue. They're suggesting something to me. And maybe I should discuss it with a doctor. But first, I'm going to do some research. Absolutely. Yeah. And people come in, people are very informed about their own health nowadays. And I think that's a good thing. Yeah. The doctors are there to help guide them. It's great. It's great that you're into technology because after all, medicine is technology. That's right. Thank you, Bob. Great to have you on the show. Thank you. Thank you for having me. Sometime again soon. Yes.