 Good afternoon everyone Welcome to a session with the modest title a conversation on the future of medicine We're very fortunate to have here a tool go on to renown surgeon author of Many books that many of you have probably read perhaps most recently being mortal Before that books about the checklist which also has had a big influence on the practice of medicine Also a practicing surgeon Who continues to operate on individuals who need his skills in endocrine surgery? And a person who writes regularly for the New Yorker thoughtful very influential pieces That comment on the state of health care such as it is and ways that it might actually Get better I'm Francis Collins. I'm the director of the National Institutes of Health in the United States. I'm a physician Scientist I had the privilege of leading the human genome project Back in that exciting decade there where that effort went forward and now as the director of NIH I oversee the world's largest supporter of biomedical research Which covers a whole lot of territory from basic science through translation through clinical trials So we're gonna have a fun conversation and it's not very scripted. So It's hard to say exactly where this might go But I thought it might be interesting for starters a tool Just to read for the group here the final few sentences of your most recent contribution to the New Yorker Which just came out this week And I won't put the context in I'll ask you to do that Tool writes we can give up an antiquated set of priorities and shift our focus from rescue medicine to lifelong incremental care or We can leave more and more people to suffer and die from conditions that increasingly can be predicted and managed This isn't a bloodless policy choice. It's a medical emergency What were you talking? First of all, can I say thank you for having this conversation? I get to have this conversation with one of my heroes so It's a special occasion What I meant by that I would We built medicine and the we built the health care systems around the world At a time when medicine's capacity to deliver value was really around heroic interventions 1930s 1940s 1950s it was penicillin to rescue you after you had a pneumonia that could kill you or Operations to step in if you have cardiac disease and rescue you, you know after you've already developed And maybe they had a heart attack or you have kidney failure and now we can give you dialysis and things like that The capacity of fields that were incremental in nature small steady deposits of of Care over time like primary care. There wasn't that much they could offer to do that would make a big difference in your future But what I'm pointing to is the fact that data-driven health care is arriving and it has already Started crossing the curves that my field like surgery Had a clear immediate value we could provide in people's lives But now you know by the 60s we discovered that high blood pressure We didn't realize this but that high blood pressure was one of our biggest killers leading to not just heart disease, but also to dementia Leading to kidney failure and we discovered and it took time We didn't have it in the 30s and 40s, but we we found the medicines that could control blood pressure And now they're really cheap and easy to provide but We and and as we've added that kind of predictive capability You know the reason we could just discover that hypertension mattered was we could gather the data about what happened to people's and studies like the Framingham heart study looked at an entire community across the course of people's lives and Discover all these things that turn out to make a clear difference Hypertension smoking and so on but that's getting even more sophisticated as we add genomics as we add information showing that the community you live in might matter and a lot of the work I do in Ariadne labs with the research center I run in my writing is about how the quality of care in your health system turns out to be very predictive of your likelihood of survival So what I was describing was a world where the Heroics is still what we reward Are not only our surgeons like me the highest paid people in our profession I'm armed with millions of dollars of equipment when I go to work to do my best work for people but The people who look after high blood pressure Half of the people in the country in the United States and around the world It's a billion people with high blood pressure only 14% are receiving Appropriate treatment for their care even when they've seen doctors there They still have uncontrolled care uncontrolled high blood pressure I can't help but jump in here as you're talking about the heroic model for how we value the way in which care is Delivered to tell you a personal story about my own daughter who's a physician Trained in internal medicine Got expert training in nephrology the study of kidneys went into nephrology practice spent most of her time overseeing Dialysis and got very frustrated with all of the ways in which patients that she had to take care of Had diseases that could have been managed much better at an earlier point diabetes hypertension, but weren't So she reinvented herself gave up dialysis and basically her whole practice is hypertension But she takes care of patients in a holistic way. She gets to know them her appointments are 30 minutes at least She makes about $50,000 a year Fraction a fraction of what she made before so yes the way in which we value the delivery of care As you're telling this story resonates very strongly with watching in my own family what we have done So how do we get to this mess and and how do we change it? Well, it's for logical reasons in some sense when When illness was experienced as a catastrophe that needed rescue It was a fire you built a system to provide fire engines Yeah, and so we had all of our insurance was designed to rest provide for your hospital and Interventional needs and that was the way it was designed and you know the value wasn't around that steady incremental care So as a result today, we still live in that system where the highest-paid clinicians orthopedic surgeons Interventional cardiologists and the lowest paid pediatricians Internal medicine physicians rheumatologists your daughter And and specialists like HIV specialists and geriatricians and others But one of my points is that we're crossing that line now where we are more and more able not to react But to project and predict What could go wrong for you and one of the things we have wrong with our model about recognizing how to use genomic information And how to use data about you know your own personal life You know what your smartphone can tell you about how well you're sleeping and exercising and things like that And about the quality of care that you're getting in the system One of the things we get wrong is that the the idea that genomics should be will lead to an instant fix that That addresses your problem the future what I try to make clear in this article is how Steady incremental care. That's probably lifelong care Based on what we learn from your data and are able to predict and see that's coming down the line And then reshape your future Will be the most life-saving way we deliver on that data We already know if you have a regular source of care from a clinician who knows you You have a longer life expectancy. You have better quality of care, and you have better health and We have made it so in our financing systems certainly in the US But around the world that we are undervaluing that care to the point that we're leaving millions of lives And the potential improvement in their lives at stake So how do we turn that around because those who are responsible for covering the costs of care are generally not enthusiastic about taking on additional responsibilities unless you can show the evidence that that does in fact improve outcomes Extends not just lifespan but health span and maybe even saves money by avoiding the development of very Expensive disorders that could have been prevented But where's where's the path forward here to try to take a health care system? Which is not known for rapid change and providing the kind of evidence that would change this in the direction that I agree We really need to take the whole system Well, so this is where people focus on policy around incentives, and that's important But what we're all missing we're often missing is what you're talking about evidence and science and what does science mean? In the same way that we want to create science and innovation around creating the next new drug We want to have science and innovation around how we actually make the care of patients Put data together with their ultimate outcomes. So for example your your daughter who does hypertension work Innovations that could dramatically change the outcomes of patients people who have high blood pressure Would include how do I use your smartphone to begin to monitor your blood pressure? log in that information Connect it to a clinician, and it doesn't have to be a doctor. It could be a nurse It could be a community health worker who is able to adjust the medications. Let's say you're having side effects Okay, how do I how do I make changes? Let's say it the medications aren't working your blood pressures are still too high how do we get it under control and Be able to no longer make you go in for a 20-minute visit in person with a doctor When and instead have much smaller contacts more virtually Separately in time and also begin to have some self-care components of that where you can drive the choices And it can be more It's not gonna only be self-care based. I mean one of the one of the key things is it that a data Driven healthcare future is going to be about recognizing that it's both clinicians and Patients who are the customer, and they both need scientific Design of innovations and testing to confirm though that we're creating value creating real Improvement in people's lives. So it's I totally agree. That's the path to get to and then the question is sort of how do we develop? The appropriate research-based efforts to begin to build that case I'll tell you about one and I know you're doing a number of studies Maybe you can tell the group a bit about as well one thing we're doing in the United States is in the next few months Sometime this spring a launch an unprecedented program to try to enlist as partners a million or more Americans In the largest ever study of health and disease you mentioned Framingham earlier Framingham was about 25,000 People started 1948 still yielding really interesting data now that we're up to the third generation of those original Participants, but focused mostly on heart disease and much of it built upon technologies that were invented quite a while ago We have a chance now to take that model and put it on steroids if you'll pardon the use of what is a very unfortunate medical phrase And go from 25,000 to a million, but actually study all diseases So this is anybody who's interested can sign up for this. What would you be expected to do? Well, you would give a consent to make your electronic health records available in a secure system You would give a blood sample which would be tested for all manner of Metabolites and when it gets cheap enough your complete genome sequence and it will be cheap enough pretty soon You would fill out a bunch of personal questionnaires about your own health behaviors your lifestyle other things about social demographics Which you sometimes can't discern from the medical record and you'd be invited to walk around with a lot of wearable sensors That are keeping track of what's happening on a daily basis and what's happening to your sleep What kind of environmental exposures do you have and as a full participant? You will get all this data back about yourself as well So you can see how you compare as well as an opportunity to change your health behaviors with information that you might have wanted to have So this is gonna be very empowering But it's also unprecedented it freaks some people out that we would have this much information in one place But that's how we're going to figure out what really are the factors in health and disease So I'm just curious having heard that much about it. How many of you would sign up today for that kind of a study? Can I see a Okay, it sounds like we'd get a pretty good turnout here and by the way, this is not just a US idea The UK already has the UK Biobank half a million people signed up for this Other countries following suit some of them further ahead than than the US is the latest inventory We did there are 53 studies around the globe that have enrolled or plan to enroll at least a hundred thousand people Now imagine putting all of those data sets together in a way that preserves the anonymity of the participants But allows you to understand similarities and differences in terms of genomics terms of environmental exposure in terms of lifestyle and so on That's the kind of evidence base that I believe could be really powerful The other thing I like about this is that those individuals who are part of this Will also be in a situation to modify their health care and have their health care providers do this as well So this is a pilot project for the transformation of all of health care is for these million people It's going to get transformed a lot sooner And then you can see if the all of us program actually produces the better outcome for them Not just new discoveries, but whether it all comes together in ways that steadily over time Lengthens it lengthens and improves their lives. Exactly. Now some may say well That's just observational study You won't be able to really draw a conclusion about what works and what doesn't but this is also a great platform for them Running randomized controlled trials about interventions if you think you want to see what happens in that particular rigorous way But tell me something about the studies you're doing and we're talking about systems Aren't we systems for for health care and not just picking one parameter and saying we're going to tweak this But trying to understand the whole landscape of how health and disease come. I'll give a quick simple example We run trials now that involve large populations across the United States as well as other parts of the world We've done it in surgery whether it's with the state of South Carolina or in a partnership that involves Scotland or New Zealand and others But the one I'm going to pull out is improving the outcomes in childbirth We focused on randomizing 120 primary health centers across Uttar Pradesh one of the lowest income states 200 million people in North India and We have a hundred sixty thousand births and in half of them They have been randomized to get an intervention which involves going and observing the care Taking the data about the patient and observing the care to see did they do any there are 30 things that are known to be Life-saving at childbirth we know they're underperformed whether it's hand-washing treating bleeding appropriately doing the three things that are demonstrated to Rescue the 10% of babies who are born with difficulty breathing warming the baby skin to skin As the most effective way to to take care of the kids and what we found so far is that by providing Send observers Observe the care Provide the data back and coach them on how to solve problems along the way coach the nurses coach the Medical leadership and even the policy makers that we have had 35 to 75 percentage point jumps in Practices that are all below 10% Adherence and in two months We will then be able to make public around our way to being able to make public what the outcomes are we? I'm optimistic that we'll see significant reductions in mortality It'll be very interesting if improving hand-washing taking hair breathing and and addressing bleeding does not actually improve mortality But this is a place where one in 20 of the kids die When we go to a US setting, we're not at a hundred percent on these 30 known practices So across the world in high middle and low income It's the science of how you deliver on data driven delivery of health care And you've written a lot about that and collected a lot of data about the really major imperfections of our own health care system and the massive differences that occur Across the US in terms of exactly what kind of health care people get your zip code is clearly one of the strongest predictors of What your health is going to look like and that's not something that's written into your genome It's something in your environment and yet it's really a powerful part of this Do you get a sense that the existence of such evidence is actually shifting the attention of our health care system Both in the US and elsewhere from a system which basically pays for procedures Versus one that does expect to see results. Are we are we making progress here? Yeah I think that for the most part the industry in the richer parts of the world are realizing that fee for service is dead That paying fee for quantity of care that each quantity you produce it will give you You know the payment regardless because there's such a wide variation in the results people get Depending on where you go for your care And furthermore that wide variation has no connection to what that cost is And so what we're now seeing is a lot of experiments trying to figure out how to pay for fee for value How to reward or at least neutralize the negative effect of Incentives preventing you from making investments. It's it's a terrible thing that our worst paid people are Pediatricians and others who are just at this moment where arming them with data would allow them to make more of a difference in people's lives so Creating systems that are allowing you to reward the primary care clinicians and others That's going to be crucial for how we move forward But the key part of it is you know what we're observing whether it's in india or our project We have a project in estonia. We have several across the united states Is that there are three things that you end up having to put together You have to put together sound training for the people at the front line You have to put together feedback in the form of data and you have to be able to say show them demonstrated methods for making a better difference in people's lives And that's the connection that puts it all together is can you serve them up with the checklist For what makes the biggest difference in a new cancer patient or and it's going to be a mix of yes this drug but then also a set of Ways of taking care of people including looking after their social situation sometimes Second is Where your gaps are in following that method virtually None of us are measuring remotely carefully how well we're tracking taking care of following those methods And following people and then the third is Not using it to punish people because it's the most complex ambition. We've ever had Is delivering on health care. It's 60,000 different conditions that our 13 organ systems can have We have more than 6,000 drugs 4,000 medical and surgical procedures We're just trying to deploy that capability town by town to everybody alive And so you need data to know how well it's going and use it for improvement not for punishment And what is the consequence of all this for what it means to be a physician because I talk to medical students fairly often. I'm sure you do even more so Things are changing in a direction that makes a lot of sense in terms of building things on evidence But some are complaining this sort of takes the personal art out of it and Requires physicians to be much more paying attention to checklists and bottom line about Finances and are they delivering value as opposed to being the cerebral Know it Based on my past experience. So trust me on this kind of doc that most of us once thought Medicine was going to be what's happening there because if we don't Succeed in recruiting the best and brightest to do this because it doesn't sound like fun anymore Then we're really going to be in big trouble. So we're in this enormous cultural shift of Being in a world where our highest value was autonomy. Yeah The that if you just you know the best way to take good care if medicine is a craft Like any artisan you give them the autonomy to practice the art and don't Look at there. Don't give you know, don't don't interfere me with me and and start looking over my shoulder and saying Whether i'm doing it right or wrong Now that we have data and it indicates some Folks are having really poor outcomes and some are having amazing ones The the pattern that we see is that the places and the people and the ethic that's changing We see this when I was trying to get and I continue to work with surgeons to adopt a surgical checklist And they bristle at it and they bristle at it because the because it's saying someone's trying to tell me how to do my operation Yeah, you're checking on me. The new values are humility The willingness to recognize that no matter how experienced and smart you are the volume of knowledge has exceeded Any one of our capabilities and we're going to miss out on opportunities or and make mistakes any of us will Discipline the belief that doing certain things the same way every time Can be powerful and will help reduce a harm And then teamwork and in teamwork is the big opportunity. So when I talk to young people whether it's young medical students surgeons and others moving on I tell them that one of the most important choices they make is where they're going to work and are they in an environment that actually Enables teamwork and the new opportunity when you're going into this profession now is leadership How you take a team of people The creativity now is not in how I do my little corner of the job, but in how we collectively Measure how far how well we're doing for other people we're taking care of and then recognize their gaps and innovate ways locally nationally internationally to drive Towards that those better outcomes and so the creativity Goes into yes, we're doing certain things the same way every time But we have to learn from it and then change it every few months To get better and better and that is where the creativity and the opportunity comes in So even though it's data driven and that can sound Really like you've turned my brain off. It actually is all about how you use that to turn your brain on It's also about I guess an opportunity to not just be a recipient of the evidence but a creator of the evidence as well Exactly goodness knows we need a lot of physicians to take on that Approach and you're trying to do that internationally. I wonder if you can mention what we talked about earlier, which is Building this capacity whether in asia in southern africa, latin america Yeah, I wanted to go there. So thanks for the suggestion. We're in davos So we are thinking not just about parts of the world that already have a lot of resources about about the whole world and one of the things that many of us Are gathered here, especially at this meeting to talk about is how to build that capacity Both for health care and for research In parts of the world that currently don't have a lot of resources But who could get on that particular pathway and in the process both improve their health care and improve their economies Because this kind of investment clearly pays off in terms of return There is a new coalition that just got formed yesterday Called the coalition for african research and innovation An effort to try between the nih and the gates foundation and the welcome trust And the alliance for accelerating excellent science in africa eisa To see what we could do in terms of shifting the center of gravity From where support has been For health care and for research in biomedicine, which has largely been a colonial model And not a necessarily one that's sustainable or good for the recipients We need to go from sort of a donor model to an owner model Where the countries that have the most to gain By this kind of advance wrap their arms around it with help from all of the other Countries like the us that have the opportunity to do so But it becomes much more driven internally by the opportunities by the needs So the research needs to be in the areas that are most needed in that environment Which might not be what you and boston had come up with in terms of what we think those folks need So yeah, we have to take the same conversation we're having about evidence building And generalize that because what we learn in the us about the right evidence for maintaining health Maybe utterly irrelevant for somebody who is lacking a lot of the connections But has a cell phone that is underutilized in the us and could be incredibly valuable In a setting that allows leapfrogging over all the mistakes that we made and created their own new way of approaching health To give an example If a billion people in the world have hypertension And and only 14 of them have an under have it under control We have the biggest killer in the world heart disease not being addressed Why we have to wait for that solution for how to close that gap To come out of a handful of research universities in the united states and in europe is is a is bizarre because There is no reason that that innovation cannot crop up anywhere in the world You take a group of 10,000 people You recognize they're not being taken care of appropriately and you create ways to capture that information To to try out different kinds of ways of Closing that gap give them the right treatments which are cheap And then see why why are we only getting to 40 percent? How can we get to 60 percent? How can we get to 80 percent? There's one state that's done in minnesota that went that was able to do that kind of work Take the the treated population people with uncontrolled blood pressure from less than half to 75 percent And they became the first state where cardiovascular disease is no longer the number one killer And that's possible in many places in the world So you sound like an optimist that And that's good because that's not the mood these days here at the world economic forum Yeah, we're trying to change that Because there are certainly people not so optimistic who say we're just on the wrong path with health care It's absolutely wrecking our economy because we spent so much on it in the us What is it now 18 percent of our gdp? And yet we can all document that we don't get that great health care for it Do you see this path actually realistically taking place over the course of the next while where we do Transform a health care system in the us and developed countries in the rest of the world based on evidence Are we really going to make this happen or is this going to be a davos talk fest? Yes? I think it is it is happening. It's not clear that the us is going to lead the way And and I think it's you know on the us side. It's up to having Policy makers work together to make sure we continue to contribute But we've got a project for example with the country of estonia and the world bank Where at ariani labs, we're working around primary health care We've defined five populations who are the highest risk population for poor Outcomes of care for example people with heart disease alcoholism And um one hospitalization So this is a group who have some of the highest cost people for the country And they're they usually have jobs and then are at risk if they go on to the second hospitalization or third hospitalization They're out of the workforce. They are Sick, they're often at risk of becoming homeless or becoming purely managed by state costs And they are suffering designing This is a country that has 90 of the of their population already in their data They have the electronic health records to be able to define that population And then recognize that they have gaps in their care No one addressed their blood pressure. No one addressed their diabetes and then they are the the experiment is arm the Primary care clinicians with a community health worker They've paid for a nurse or an equivalent to be alongside their clinic And for people who are in these five categories amounts about five percent of a population of a given clinic that that Community health worker focuses on their care with data to track how well they're doing We're not we're not doing that at at statewide or national scale In a country like the u.s. But there are other places that are beginning to make this happen And that sense of competition among countries around the world innovating in systems innovation I just the last century Laboratory science was the single most important way. We were going to change health outcomes for people new discovery of new treatments today deaths under 75 Even in the richest countries in the world in europe and u.s A third of those people die from diseases where we already have the treatments and they're receiving incomplete and inappropriate care Even though they're inside the system Another half its social determinants of health and it's only a fraction that's lack of discovery So how we drive system innovation the science of systems is what will transform Outcomes in the next century. I'm convinced this is the new science of how you put data to derivative data together And create data-driven healthcare Well tool. I totally agree with you. That's a fantastic opportunity and it is of course A cause for optimism because this is something we can do. It doesn't require a miracle It requires a lot of involvement by all of the participants in the healthcare system Getting away from the paternalistic model towards we all own this and we deserve to have it work better than it does now And we could save a lot of lives and probably save a lot of money You all please join me in thanking dr. Atul go on