 Yo, MSF, I'm fresh out the US, came direct flight, Las Vegas, super jet lag, here's the thing, given the political situation with a certain candidate that rhymes with Rump, I'm going to use this opportunity to officially announce I am seeking asylum in the UK. Is Jeremy Hunt still your secretary of health? Maryland this time of year, is that? Look, Hannah Montana, all right? I don't know if you all know her, she's American, superstar, Disney. When we go into our careers in healthcare and you guys are in the humanitarian space, you were all Hannah Montana. You want to change the world, you want to use your unique gifts to help people in the field. This is health 1.0, okay? But somewhere, some IT guy decided to build you some tech to make things better. And one day you look in the mirror and that reflection has changed. And all the time you realize you were just a twerk in progress, waiting to happen. I'm here all week, MSF, tip your nurse. Health 2.0, okay? This brave new world of medicine as machine with technology to save us has not succeeded outside of the humanitarian space. Luckily you guys are still struggling to get to 2.0. And so this talk is going to be about how do you bypass the worst of 2.0 and get to 3.0, which is going to be dope. That's what we're going to talk about. And this is not health 3.0. This is my dad. Why am I still wearing these glasses? I don't need him to read or do I. So this is my dad and you guys are probably like, what? There's no way. That's what I thought. Because look at, there's no phenotypic resemblance between these two characters at all. I did genetic testing. This is my dad, all right? Beyond the shadow of a douth with a p-value that's very significant. Indian immigrant internist came to the US with $10 in his hand. And obviously when you have an Indian dad who's a physician, those of us with immigrant parents know you're going to be a doctor. There's no getting around it. It's not like I had a choice, right? In fact, those of us know with immigrant parents from the developing world, there is no test they will not criticize. Even a blood test. Easy. The standards are high, people. I'm just saying. So this being my dad, when I was growing up, I loved to make people laugh. I loved to teach. I loved music. And so of course, weird Al Yankovic was my idol. I wanted to be him when I grew up. Creepy and weird, especially when you have the posters on your wall. You never get a date. But I told my dad this is what I want to do. And he looked at me and he said, being a professional clown won't put none on the table, OK? Why don't you come to the clinic and see what I do? See what a real man does to real people to help, OK? And so I had no choice. I did. And what I saw was health 1.0. Here was a guy you trained in India. Didn't have all the expensive tests in the labs and all that. Had touch and intuition and the desire to help people and connect. Here was a guy who was connected to his community, who was paternalistic as heck, right? Because that's health 1.0. It wasn't fettered by data and evidence and technology. It was about a deep relationship, but it was a very hierarchical relationship. And so I saw this and I actually, I fell in love with it. I mean, this was a guy who would lick a person to see if they had cystic fibrosis. You know, and you don't want to know. You don't want to know how he diagnosed diabetes. But, you know, he was deeply suspicious, is deeply suspicious of technology. And I remember telling me, you know, there's all this stuff, ultrasounds and all that. I had no wonder the Americans are spending 2.8 trillion on the health care with a T and getting versed outcomes in the developed world. They are thinking the money is growing on wines only. And I said, well, but you know, but he said, always trying to think outside of the rectangle, OK? Don't do it. What do you need to do? You remember that time I tried to do technology and your uncle Sorab in Pune. And I built that app to date for doctors, the dating app, because a doctor should only date another doctor. And it allowed you to connect with doctors around the world, across the borders. Nobody bought it. And then we got sued. And I said, dad, that's because you call the app doctors without borders. That's a thing already. And with that, I decided to go into medical school. And it felt like this. I don't know if it's like this where you guys trained. But where I trained, the medical system is stuck. It's bypassed the Enlightenment. It's stuck in the Greek era where the first two years you memorize a bunch of facts and spit them out on a test. And the second two years, it's about kissing the ring of the authority figure. It's an apprenticeship so that one day you'll be the ring that's kissed. What a wonderful recipe for innovation and creativity. It's really glorious. And so everything was beaten out of memory. I had an attending physician at UCSF where I trained. We'll call him Flanders for the sake of this talk because that was his real name. And I no longer care. And you can't reach me, Flanders. I'm across 5,000 miles of Atlantic, okay? And he said, at the beginning of the rotation, there are no stupid questions. Flanders was a liar because I asked a question to which he responded in front of the entire team, Demania, you speak and then think. I would like you to reverse that. Or better yet, just think. That's how we're treated for innovative questions and ideas. I mean, all for asking. If essential hypertension is so freaking essential, why do we treat it? And so I gradually somehow survived medical school, got into Stanford and then was met with an interesting transition. Health 1.0 was starting to go to health 2.0. Now, health 2.0, especially in the Silicon Valley, was driven by very confident, some might say arrogant tech entrepreneurs who felt that Moore's law, the idea that things get cheaper and faster, technologically speaking, over time exponentially, would apply to healthcare. So maybe we should change the model from medicine as an apprenticeship, as a cottage industry, to medicine as a machine. And so what does that look like in healthcare? I call it Les's law. So what happens when we get fancier MRI machines and CT scans? It gets more expensive. What happens when we get fancier brand name drugs? It gets more expensive. What happens when we put an EHR in the field in South Sudan? I'm gonna argue it does this, unless you do it right and we have not done it right. And so what happens here in the brave new world of health 2.0 is we are all reduced to a commodity. The paternalistic relationship is flattened, but now the doctor is just an arbiter of information. And as my dad said, now these patients, okay, I'm spending all the time looking at the computer. I can't develop the relationship. And what is happening? They are getting the second opinion from this idiot Dr. Google. Now I don't know who he is, but I have read his notes and he's a quack. And so we're all commodities, including patients. And then we wonder why 80% of our patients look like this. So for people who aren't familiar with this character, this is Winnie the Pooh, adorable children's, you know, story figure. I'll tell you what I see. I see most of my patients at Stanford in the inpatient hospital environment. I see an anxious concerned affect concerning for depression, not otherwise specified with anxiety features. I see a black necrotic nose concerning for likely cocaine ingestion bilateral. I see central obesity concerning for early metabolic syndrome with insulin resistance confirmed and supported by the complete absence of fingers and toes. Every single extremity concerning for diabetic polyneuropathy with auto amputation. And despite his name, he hasn't. Concerning for diabetic gastropathy with constipation. And with this litany of glucose related complaints, Mr. Pooh, who may well as enough be a Syrian refugee in the middle class that you're seeing in a camp now, presents with his auto amputated right paw deep in a jar of honey. Now in our current system with my current EMR, I say, oh, Mr. Pooh, you're fat diabetic, you should walk. By the way, here's five different medications. Here's six different specialists you're going to see. Here's seven different days we're going to admit you to the hospital to amputate that last little bit of toe and eight different specialists we're going to free to. And by the way, here's a glucometer. Check your sugar four times a day. Don't eat crap and come back. See me in a month. Bye. And then I turn around and spend the rest of the hour charting in an electronic health record that's two clicks away from becoming sentient and destroying all of us. Okay. To please a bean counter somewhere has nothing to do with Mr. Pooh. And what happens when Mr. Pooh comes back in a month if he comes back? He's on five medications. Actually, no scratch that he's on one medication. He's taking five times. He's using his glucometer to text his homies with with some success. And he weighs five pounds more and his auto amputated right paw is still deep in the jar of honey. And what are the team? What are the intern and the resident say? They say, oh, you can't cure stupid. That's how we treat Mr. Pooh in our especially in America. That we cannot take care of them. Why? Because we're not trained. We're not giving the resources to look at the entire 100 acre woods. Like when you guys go into the field, what's going on in the community? Killian gave an amazing talk about getting to the bottom of this. Do we have the time in the incentive to do that? No. Do we have an EHR that enables that understanding and cohesion? No. We have a cash register in the United States. And that's the mistake that you guys are going to avoid when you when you build yours. All right. And so what happens with Pooh? No one's able to ask, hey, where's Christopher Robbins? He's your homie. He's your support. He's totally AWOL. What hole in your life is the honey filling? Is it a cultural thing? Is it the fact that you live on $2 a day? Is it the fact that you're illiterate? We can't ask those questions. We don't have the tools to manage that. No one's asking Piglet. Is there caregiver abuse? Right? No one's asking Mr. Pooh. Have you been dipping into Tigger's crystal meth stash? He has no teeth, people. And so as a result, okay, and don't even get me started on EOR. I don't even know how you get a scar like that. Okay. All I'm saying is the 100 acre woods needs an MSF intervention stat. And so as a result, I would look at Stanford when I was practicing for 10 years, and I realized 50% of the patients in that hospital didn't need to be there. It could have been entirely prevented if we had the technology, the resources, the training, and the motivation to do what we trained to do, which is teach patients to stay healthy and connect with them as human beings. So as a result, I got very burned out and felt like my career was back here again. And here's an interesting statistic from the U.S., greater than 50% of doctors blame the EHR for the fact that 60% of doctors will not recommend the career to their children. How broken is that? I mean, I'm in a room with some of the most passionate people around that are going into danger-risking life in limb to help other people. And that sacred calling can't be recommended. Why? Because we've broken our system, and the technology is part of the problem. There are other problems that are specific to the U.S., but don't make the same mistakes with the technology. So what ends up happening is I ended up looking at this about year 8. I was super burned out. And I ended up deciding, you know what? Something interesting has happened. Social media has started happening. Technology has changed. Maybe there's an opportunity to reclaim this idea that the word docere, which is the root of doctor, means to teach. Maybe we could use social media to engage patients where they are. And I think increasingly in humanitarian circles, you're seeing that people are on Facebook, on cell phones, et cetera. And that's how they're communicating with each other. What if we did that? We could A-B test different strategies to actually focus and prevent disease, to hear what's going on in the community, like Hilary was talking about, go to the women at the well, right? And so maybe we could do that. And then I realized it's going to fail, because I almost lost my job at Stanford with the minimum use of technology, checking my hotmail account on a work computer. Let's just say the speech recognition software also has a long way to go, all right? You've got mail. Yes, several. They're never going to ask me to speak again. It's just, it's done. It's done. Doctors without Z-Dog, that's what it's going to be called. So this is what ended up happening. I started though looking more and more, and young millennials were coming onto my service at Stanford, and they were using YouTube and Twitter and this thing called MySpace that apparently existed at one point. And I said, whoa, whoa, here's the thing. I love to make people laugh. I love to teach. I love to do music. What if I got a handicap and I started recording videos that educated and entertained patients and providers and satirized the system in a way that we could actually affect change and then used a social media apparatus, Facebook, Twitter, et cetera, to actually engage patients where they are, do A-B testing and have a discourse that humanizes us and connects us to that community. And so I got a thing and I got a PC and I started recording and it was a total disaster. Like every time I tried to upload it to YouTube, the whole PC would crash. Then I got a Mac and 160 videos and like millions of views later, this guy is Z-Dog MD with two Gs because one is apparently insufficiently gangsta, was in the house. And by the way, in the UK, they call me Z-Dog, which is clinically proven to be 30% more cool, in my opinion. And so I created this character really against medical advice because the chair of my department was like, you do this, you're going to lose your job. So I did it as this character, and of course it was me, but they never figured it out till I got on the news. And we did tons of videos. So we did a video called More Than Warts, which is a parody of More Than Words by the band Extreme to promote human papillomavirus vaccine. It was so successful, the Centers for Disease Control in Atlanta use it as an ad on YouTube to target pediatric providers to get them to prescribe the vaccine because they don't do it. And then we did another one on flu vaccination that again, it just makes fun of, I can make fun of Jenny McCarthy and these idiots who, you guys are risking your lives to deliver vaccines to people who want them and people are refusing them. Okay, talk about a first world problem. I heard earlier 64% measles vaccination, that's great. In Marin, it's like 40%. They're just too rich. And so with these videos, what we found is year over year, 35% increased uptake in flu vaccination in the corporate environment where we tested it. And the reason again is that you motivate people's elephants, their hopes, dreams, fears with music and with a message that's catchy in a way that's accessible where they are, which is social media. As opposed to vaccines are safe and effective, you should do, yeah. It's never gonna work. So this thing started to take off and we actually did an Ebola piece earlier and making fun of the US response that it kind of got a life of its own. And the next thing I know, I'm getting an email from the CEO of a company called Zappos. And they sell shoes. They're part of Amazon. But he grew it. This is Tony Shea, the CEO. He grew it from nothing to $1.2 billion U.S. sale based on the idea that if you get human relationship culture right, you can sell shoes online and people will buy them because you can sit on the phone with them and develop relationships. And that's what he did. It was all about culture. People are treated like a family within the organization. He reached out and said, I saw your videos, you need a restraining order. Also, here's the thing, we're investing a bunch of the money I made selling to Amazon to move Zappos to the heart of downtown Las Vegas, which is a demilitarized zone. It's not the strip that you see on the news. This is like an old beaten down drug addicts, homeless people. He said, we're gonna invest $350 million there, move Zappos into the heart of it and try to see if we can accelerate the dividend that happens when people move into tight urban spaces and innovation happens when they bounce off each other and collide. And I said, why are you telling me this? He says, well, because there's 18% of the gross domestic product in the US called healthcare that we don't understand. You're clearly pissed off about it. Quit your job at Stanford. Quit your wife's job as an academic chess radiologist. Move to the desert. I'll give you a little bit of startup money and you have to fix healthcare and improve the culture and make it exportable to the rest of the world. And so I Googled healthcare innovation Las Vegas. This was the first hit. And unfortunately, the next three hits were, some of the worst outcomes in the United States for preventable, like literally developing world level outcomes for preventable illnesses. It was horrible healthcare. No academic medical center. It would have taken billions of dollars to fix this. You guys could literally do an operation here and actually improve the health by an order of magnitude. That's how horrible it is. And so when I told my family we were gonna quit our jobs and move to the desert to try to fix healthcare, they were incredibly supportive. Really supportive. And I told my daughter, look, we're moving from this big house on the hill in the Bay Area of California, beautiful weather to 120 degrees. You're gonna lose most of your toys because we're now gonna live in an apartment in a demilitarized zone. She was incredibly supportive as well. And but we actually did it. Now you guys are some of the bravest people I've ever met. I am a coward. I will not fly on a reject airflot plane with bolts flying off to help people in Africa because I'm a scaredy cat. But this was the bravest thing I ever did in my life. And so it's my small contribution. It's nothing like what you do, but it was my small contribution and it looked like this. Here is turntable health, the plans for our clinic. We dropped into this demilitarized zone of downtown Las Vegas, patient population, substance abuse, poverty, et cetera, no sense of community. And we built a facility who's half of it of the 7,000 square feet was based on getting the community together. We had these big screen TVs with Xbox with the sensors that make you move. So people would have to dance instead of sitting there with a controller. We had a teaching kitchen over here, a yoga studio over here, and then the clinical stuff back here. And it looks like this. This is our yoga teaching studio. This is Nina. She's our licensed clinical social worker. She also... So she deals with mental health in the U.S. She also teaches yoga meditation. So she tells patients, listen, I know you're suffering, you're on these medications. Come to my Thursday class where you'll learn from people in your community who are suffering the same way you are. And the connections that are formed between the community members leads to this healing. They exchange ideas. They hold each other accountable. It's a vastly different approach than anything we use in the U.S. And it actually takes the community into account. Now, to do this, you need a team of people. Like you guys have known in MSF forever. It takes an entire team to make this happen. But the thing is, in medicine, we're trained to be autonomous cowboys, right? We're in charge, the patient listens, everyone else listens. Not in what we're trying to do here. So this is what we do. We create a team with doctors, nurses, social worker, and these guys. So the guy's about to break his hip. That's a health coach. That's Andrew. Now, we were just talking earlier. Kylian was talking about how we can be very paternalistic in the humanitarian space. We come in and we say, this is how you should do it. And the community's telling you something different. We want this and this and this. Now, imagine if you get Andrew, we screen 500 people from the community that Andrew is gonna serve to find two, based on emotional intelligence, empathy, et cetera. Then we look at the CV, and then we train them. And so Andrew is, happened to be a paramedic, also was a bartender at the Wind Resort in Las Vegas. He knows the population. You don't have to multiply the drinking history by five to get the accurate result. In fact, you have to remove beers to get the accurate. So Andrew does the heavy lifting and speaks the language of the community. And to support him, then there are four of Andrews to every doctor. So Andrew does the heavy lifting, texts the patient, emails the patient, goes on Facebook with the patient, skypes the patient, holds them accountable, goes running with the patient, goes shopping with the patient. And then the doctor goes room to room, tying it together and practicing that high level intuitive medicine they were trained to do. And so everybody supports each other as a team. And as a result, the tech piece, which is the crucial part we want to talk about in the three minutes we have left, is the whole point of the talk. We looked at all the EHRs, they were all glorified cash registers. And so we said, okay, let's just build our own. So with our partners Iora Health, we got an IT team that served the clinicians on the ground in the community they were serving. And so they built a workflow around us. This EHR is issue based, so chronic congestive heart failure, diabetes, hypertension, substance abuse, in these sort of clouds. Doctors, health coaches, nurses, everybody can write in that cloud at the same time. This isn't episodic care where you click boxes to fulfill an episode of care. It's holistic issue based care that the patient in every room can read and write in their own chart. They can text weight and steps on their little wearable into our chart, and it goes into the chart. And then the health coach follows up and holds them accountable. On the back end is a population health management tool that assigns every patient something called a worry score, zero to 10. How likely is that patient to get admitted to the hospital in the next month? And it's partially algorithmic based on our engine, partially clinician-derived. Then every Wednesday we huddle and we go through all the aids and reach out to keep Mrs. Witherspoon from putting salt into Mr. Witherspoon's food because he's ending up in the ER with edema, which you guys hear spell oedema, which I still don't understand. And it actually, it's actually transformative. And so as a result we use the technology to actually bind the relationship and this is what it could look like for MSF if you get it right. This is what I call Health 3.0. It takes the best of one and two, transcends them and what emerges is even bigger. So it takes the relationship from one and that's sacred autonomy and it puts a team behind it. It equalizes their eye to eye. It's not paternalistic, but also it's not just informative where she has to go to Dr. Google. He has time to learn her hopes, dreams and fears and she has the accountability to hold him accountable as the shepherd for her care and he demands that she release the victimhood of illness and be a team in this. It's very hard, but they need time to do that and look where the chart is. It's a triangle. They use this technology to bring them together to accentuate the human relationship and as a result gray areas thrive. As a result, he's evidence informed but not evidence enslaved. You can have guidelines, but they are that guidelines. You know her hopes, dreams and fears. You know her culture. The health coach tells you about what's going on in the community and the rest of the 100 acre woods and as a result with MSF, if you were to build a system like this and I know because I've seen some of the talks, it's gonna come. You could have 100 acre woods that looks like this. All right. And now Tigger still doesn't have teeth because no one's gonna pay for that. But it is transformative. And so to wrap up, the reason we called it turntable health is because those of us old enough to remember records and those of us young enough to rediscover them, right. Know that it's a piece of beautiful art that you hold in your hand. There's 10 tracks that tell a story. You sit with your friends and you drop a tone arm. It's a ritual, right? It's almost a community ritual. And this beautiful, warm sound, organic human sound washes over you and you're together with your friends. What a human experience. What an analog human experience. That is the heart of medicine. Everybody here knows that intuitively. Even if you work on logistics and IT, you know that intuitively that's the case. So do not let the IT people or anyone build you an MP3 player. All right. Zeros and ones ripped one track off the internet, jammed into your earbuds on a subway isolated from the rest of humanity because that is what health 2.0 is doing in the U.S. And we can't tolerate it. We can take the analog heart of medicine and amplify it digitally with technology that serves this and that will transform everything. So thank you so much for listening. I'm exactly out of time. And in fact, I've probably gone a little bit over but, you know, it is what it is. Thank you so much.