From Physician to Patient to Reinventing Medicine

This transcript has been edited for clarity.

From theheart.org | Medscape Cardiology, this is The Bob Harrington Show. Dr Robert Harrington is the Arthur L. Bloomfield Professor and chair of medicine at Stanford University. This podcast is intended for healthcare professionals only. Any views expressed are the presenter's own and do not necessarily reflect the views of WebMD or Medscape.

Robert A. Harrington, MD: Hi. This is Bob Harrington from Stanford University on theheart.org | Medscape Cardiology. Those of you who have listened to this podcast series over the years know that one of the things I routinely like to do is talk with physician-authors. Sometimes it's people who are prominent essayists and other times it's people who have written books.

I do it for a couple of reasons. Number one, I'm a very dedicated reader. I'm always reading. I always have a stack of books either at my bedside or on my iPad. I really enjoy the pleasure that reading brings to me, whether it's fiction, biographies, or historical novels. It really does give me a break from my day job, if you will, to really concentrate on the imagination that others bring to their work.

I particularly have enjoyed interviewing physician-authors because I'm fascinated by that. Many of us in academic medicine spend our lives writing, but we write in a very prescribed format. We write science papers, editorials, viewpoints, and review articles. The work it takes to produce an original book, I think, is extraordinary, and I admire greatly my physician-author colleagues.

Today is no exception to that. It's really a pleasure for me to be introducing a friend and colleague, Dr Jag Singh. Jag is a cardiologist at Massachusetts General Hospital, and he's an electrophysiologist. He's Roman DeSanctis Professor of Cardiology at the Massachusetts General Hospital, and he's a professor of medicine at Harvard Medical School. Jag, thanks for joining us here on Medscape Cardiology and theheart.org.

Jagmeet P. Singh, MD, PhD: Thank you, Bob. It's an absolute honor and a privilege to be here.

From COVID-19 Patient to Author

Harrington: I have a preprint copy here of Jag's book, Future Care: Sensors, Artificial Intelligence, and the Reinvention of Medicine. It's an absolutely fabulous read. I always like to ask the question, why did you do this? You're an accomplished academic, you're a busy clinician, and you're a physician-scientist. Talk to me about why you did this and why you tackled this, because many of us think about writing books but few of us do.

Singh: The book had been bubbling in my system for several years. I think I thought of writing it about 7 or 8 years ago. I started writing it about a year prior to COVID-19 and then it was catalyzed by the whole COVID-19 situation to lead to where it is now.

The reason for writing it was largely because we're going through this digital transformation right now. At this point in time, I think healthcare is really unsustainable the way it is. There are so many issues plaguing it on a daily basis — not just in the United States but all over the world.

I feel that advancing the theory of digital transformation, advancing the use of sensors with virtual care that is powered by predictive analytics with sustainable workflows, could really transform care as a whole. It ended up being a confluence of some of my research work in the past and then, eventually, obviously, my clinical work. Add to that my little experience as a patient, and it all kind of brought together the book, which I think really deals with how healthcare can be transformed.

Harrington: Sometimes authors — and in this case, this is true — are geniuses at underselling. I think you're underselling the prologue, where you said something to the effect of it starting with your COVID-19 journey. If you don't mind, talk a little bit about that because I found it incredibly moving. I remember March 2020 when we didn't know what was going on, where we were trying every day to gather information from Italy and from China.

On the West Coast, we were trying to gather information from Boston and New York which were hit early. That was a scary time. We didn't know what we were dealing with. We didn't know the treatments. We didn't understand all these issues around oxygenation. Yet, you were thrown into that. Talk about how that really informed what you were going to do.

Singh: I saw COVID-19 from both sides. I saw it as a patient and as a physician, but my initial experience was as a patient. I was probably among the first clinicians in Boston maybe, and certainly in Mass General, to get afflicted by COVID-19 that required hospitalization and a day in the ICU, teetering on whether I needed to go on support or not. I was glad not to.

It gave me a different perspective about care. I now look at everything from a different vantage point, and I think many of my personal experiences helped change the tone of the conversation for this book, too. As I told you, I started writing this book a year before COVID-19.

The entire tone of the book really changed and the humanistic appeal of the book changed as I began writing it after I experienced COVID-19. I realized that we can talk about all these technological revolutions, but if they don't have a humanistic appeal, they're really meaningless. If they don't impact care, they're really meaningless.

You rightly point out that we knew nothing at that point in time. I was randomized to the placebo arm of the remdesivir trial. I received azithromycin and hydroxychloroquine — which are banned now — because we didn't know better at that point in time. There were many learning experiences for me, both as a patient and as a physician, that I think helped me understand how medicine should be practiced.

Harrington: I'm really happy to hear that you were in a clinical trial at the time. Thank you for doing that. I will tell you a funny story about hydroxychloroquine. I was the president of the AHA when the pandemic started. We were putting out all sorts of pieces on what we knew. Can you take ACE inhibitors? Is that going to increase the likelihood of infection? Why is it that cardiac patients are more likely to both get infected and to get really sick?

We put out a piece in collaboration with other groups, including your own professional society, Heart Rhythm, on QT-prolongating drugs like hydroxychloroquine and azithromycin, and we said, basically, just be cautious. If you have patients with cardiac disease and you want to give them these QT-prolongating drugs, be careful. That's all we said.

On a Friday, Nancy Brown from the AHA — she's the CEO, as you know — called me and asked, "What are you doing tomorrow?" I said, "Why do you ask?" She said, "Because we have to talk to the White House. They're not happy about our piece on QT-prolongating drugs." That's one of the highlights of my AHA presidency.

Singh: As a follow-up to that, after I got well, I was involved in an AI-based study looking at hydroxychloroquine effects on the QT interval off a smartwatch in France using a cloud-based algorithm. We were trying to really shift care and monitor patients. It's really interesting.

Nurses: The Soul of the Healthcare Nation

Harrington: As you went through this experience and you began to see, as you said, both sides of the bedside, one of the things I noted is that you dedicated your book not to a family member or to a mentor. You dedicated it to nurses. As the father of two nurses, I was really pleased to see that.

Was that out of your COVID-19 experience or out of your long experience as a clinician? I thought it was beautiful, and I'm just curious as to where that came from.

Singh: Thank you for noticing that. Obviously, I work with nurses every day and you often end up taking much of what they do for granted. Then you get ill and you realize they're the only ones who actually are looking after you. I think the care I got from the nursing staff while I was in the hospital for the 10 or 11 days had a profound influence on me.

I always deeply respected nurses, but I think seeing it from the other vantage point really highlighted the role they play in medicine and how much — truly — they are the soul of the healthcare nation. The saying "the happiness of a hospital is dictated by how happy the nurses are at the bedside" also runs true.

We don't give our nurses as much credit as they deserve or recognize how much of an impact they have on all our patients on a daily basis. As physicians, we come in and walk out and leave, but 99.9% of the care is nursing care. That's the principal reason. It's just a dedication. I wish I could say more.

Harrington: You, in a way, did say more. I was struck also that Eric Topol wrote the same thing in Deep Medicine — that sensors and virtual care and the digitization of medicine and AI, if we do it right, can bring back some of the humanity of medicine because maybe it frees clinicians up for the human aspect of things.

You talk about that. It struck me in your prologue that the doctors are talking to you via the iPad, but the nurses are coming in to take care of you. There's that interesting juxtaposition, or a bringing together of the human touch with technology.

Singh: Was it Francis Peabody who said that the secret of the care of the patient is in caring for the patient? That's something I strongly believe in, and that's something my mentor, Dr [Roman] DeSanctis, preaches and lives by on a daily basis.

In the book, I hope I bring out — that despite all of the digital transformation, the human bond is central to effective and real care. That's why the cover of the book has those two hands shaking, despite the digitization of the hands. It means that the human contact and bond really needs to be preserved.

Sensors, Virtual Care, and AI

Harrington: I really think that comes across. I'd like to go through some of the sections, all the patient stories and how they — not just your own but of patients you've cared for and known — enter into the dialogue of the book. People worry about technology replacing the human element — no, let's use technology so that we can accentuate the human element.

There are four sections of the book. Let's see if I can get these right. There was a section on sensors, there was virtual care, artificial intelligence, and then there was, I would call, a policy piece: How do we make our health system sustainable?

Let's start at the beginning: sensors. You're a long-time researcher in the area of sensors. Like all electrophysiologists, you're also a gadget guy. Talk about what excites you with sensors. Where do you see their role here?

Singh: One of the things I feel about modern-day medicine, Bob, is that it's very transactional. When I say "transactional," we see patients at 3-monthly, 6-monthly, and 12-monthly intervals, but we know that patients don't necessarily fall ill at those intervals and that the absence of illness is a continuous phenomenon.

I think sensors provide us the opportunity of really digitizing the human body and allow us to have organ-specific strategies or integrated strategies to look after our patients. Furthermore, they allow us to transform that transactional care into some form of continuous care, where we can predict and prevent disease. I think the soul of this book is more on forecasting and prediction and prevention of disease.

I'm really excited about the fact that there is a slew of wearable sensors and there are multiple implantable sensors, and I personally implant a fair number of them. When these start cross-talking to each other, and with the use of a smartphone, the integrated information that can find its way into the electronic health record, we can really change the life cycle of many disease states.

We can really control conditions, can certainly contain atrial fibrillation, heart failure, and limit the incidence of sudden death. I think sensors really have a tremendous role in the future, but obviously, they need to be integrated with some predictive analytics on the back end, too.

Harrington: The other thing you talk about is the empowerment of patients. Maybe more broadly, I'll just say the empowerment of people, because what's the statistic — that we spend only about 1% of our lives on a yearly basis in active contact with the healthcare system. The rest of the time, we're in the wild of life. What do you mean by that, "the empowerment of people"?

Singh: There are multiple ways of looking at it. I think the simplest way is that healthcare right now is not sustainable because you need constant interaction with the healthcare system, which is not possible. Having self-management strategies put into play is going to be instrumental in how healthcare really evolves.

We already have it happening for things like diabetes. The continuous glucose monitor has changed the landscape of how diabetes is managed. I think the same thing applies to organ-specific sensors that are evolving, whether it is for asthma, COPD, hypertension, atrial fibrillation, or heart failure. Having self-management strategies and clinicians empowering the patients to look after themselves and seek care if there is an issue is probably the way medicine is going to evolve.

There's this whole concept that you know about, Bob, which we call exception-based care, where you kind of follow the patient along with continuous surveillance strategies. When they fall off the wagon or there's an issue, then they come to your attention. It's not something where you have to periodically keep seeing them, which I think is a waste of resources, time, and energy.

Harrington: You mentioned the diabetes story. The pediatric endocrinologists here at Stanford have done some amazing work, showing that, by empowering adolescents and young adults by letting them manage their diabetes with continuous glucose monitoring, you actually get way better control than by letting the medical system manage it. It speaks to the power of people taking control of their own bodies and their own lives. It's really amazing stuff.

Let's go to virtual care. In the pandemic, this is how we all saw many of our patients, at least at the beginning. We shifted from doing less than 10% virtual visits as a system to doing over 80%, literally in weeks. I suspect that at Mass General you did the same.

Singh: We had the same shift in virtual care. Somehow, I'm a little upset by the fact that the pendulum is swinging back and we're moving away from the virtual care end of things. I think much of that is due to regulatory issues. There is clearly the will of the people who would like to be seen virtually whenever they can be, wherever they are, for many reasons.

It saves them many concerns of traveling and waiting in the waiting rooms, getting cross-infected, and all the other things that are associated with it. I think the issue is regulatory. That's why we're having this conversation. I'm hoping that some of these conversations will institute change outside-in if they can't be inside-out.

Virtual care requires a new level of learning. I think there's a concept of the virtualist vs the traditionalist, and I don't think they're two separate entities. I think there's a nice hybrid strategy in between the two that will allow us to look after patients in a combined way, depending on which form of medicine needs to be practiced.

One thing you may have been alluding to with virtual care, and that we saw in our research and published, is that there was a deepening divide at the start of the pandemic in terms of who could get virtual care and who couldn't get virtual care.

That's something that the pandemic heightened awareness of — the fact that we need to be paying attention to the risk for digital inequity because that in itself can lead to health inequity. There are many things we yet need to write on that front.

Harrington: People talk about tech equity and trying to make sure that we're able to reach all members of society. I think that's critically important. More and more, everything has to be phone-based because, for many around the globe, that's how they access the internet. We need to really work on universal broadband as a public policy. That should be like clean water in the 21st century.

The third chapter, which I thought was one of the most fun, was on AI. We talk about the hype and the hope of AI. You clearly have hope for AI, though you are cautious. I enjoyed reading your thoughts on how AI is going to help us with things like predictive analytics. Give us a broad view on the use of AI in healthcare; what are some of the missteps that you worry about?

Singh: I think there are many challenges with respect to AI. First, the role of predictive analytics is largely dependent on the datasets you're using. The acquisition of data itself can be a huge issue — to make sure that the data you are using are representative of the subset of patients you're using the algorithm for.

On top of that is integrating these into current systems and then making them scalable. Those are big problems that need to be surmounted. The biggest issue with clinicians right now is the lack of explainability within the AI algorithms and folks not having trust. I think some of those issues are getting sorted out as we get more familiar with AI and the roles it can play.

It's going to be iterative. It's not something that is going to sweep in and change everything. I think folks are going to have to get used to it, get adjusted to the fact, and understand that these need to be interpreted and used in the clinical context with all the available knowledge that we already have, and not just go directly to AI as the solution.

There are many potential missteps that could occur. Hopefully there's enough regulatory oversight and guardrails to ensure that the ethical and privacy aspects are being looked into.

Making Healthcare Sustainable

Harrington: For me, as a clinical researcher, I hope that we take the same approach we would take to any other diagnostic or interventional tool, which is that you need to expose it to the rigors of investigation to see whether it is adding, whether it's adding in a positive way, and whether it is hurtful or harmful. Just because it seems like this black box, there are ways to study it to make sure that it's adding to care, not subtracting from care. I think that comes out nicely in the book as well.

I want to talk about the hardest chapter in the book, which is the last one, on making healthcare sustainable. I'm going to read you one of the last sentences you wrote in the book, which is that you believe "virtual care strategies, aided by sensors and AI, coupled with self-management approaches, will create sustainable disruption and appropriate reimbursement models." Want to tell us what you're talking about?

Singh: I think it's going to be an evolution of how reimbursement evolves. The current fee-for-service structure is not sustainable, right? What it really perpetuates, Bob, is an affinity for volume and high-margin situations so you can make money rather than try to deliver the best possible care.

I think there is a transition toward value-based care. The transition, however, has been fairly slow. At the same time, there are shared savings strategies that are being implemented, where you have a capitated amount, and if you can provide some degree of continuous surveillance for a patient with self-management strategies rolled in, you could potentially change the outcome of those patients. The shared monies from that could be equally distributed in the parties affiliated with that care.

That is one strategy that is evolving and will need to evolve if healthcare really is to be sustainable. There is a future where we will be able to have reimbursement for self-management strategies. The problem is that everybody looks at healthcare from just a year-to-year basis.

The insurance companies, if they were to even create incentives for you to help with these reimbursement models, look at you as just a 1-year customer because you might shift your insurance company. At the same time, hospitals are looking at their feet, hoping that they don't step over each other, and not really looking at the long-term vision of how the life cycle of this patient is more important than that singular episode.

I'm hoping we can evolve to that stage, and I think this is where large academic centers that have their own health plans really can make a change by experimenting, and with experimental models, actually show savings and then institute changes in care, which benefit themselves by their health plans but also then become a template for the rest of the country. I think some of that work is already happening.

Harrington: I love the way you said "experimentation." We don't do enough experimenting with new policies. We tend to assume it's going to work or we have some empirical evidence that it might work, and we push it out for implementation. Experimenting with some of these novel methods is exactly where we might want to go.

You have a foreword by Sid Mukherjee and a blurb by Abraham Verghese. Wow! How does that feel to be among those two great physician-authors?

Singh: Oh, my gosh. I am incredibly thrilled, honored, and a burst of other, additional emotions that may not be adequately emoted in words. To have them endorse the writings and the book is just phenomenal, and I'm very grateful for both of them taking the time to write toward this book.

If I may add, Bob, I'm very grateful to you for writing a blurb for this book. I deeply appreciate that. It means so much.

Harrington: Thank you. I had fun reading the book and writing a few thoughts about it. Thank you for being on our podcast here.

Thank you, the listener. This has been a fabulous conversation with my friend and colleague, Jag Singh, a cardiologist at Massachusetts General Hospital and a professor of medicine at Harvard Medical School.

He is the author of a new book, Future Care. Take a read. It's fantastic. It really does try to get at this issue of the new technologies, how we use them, and how maybe we can disrupt healthcare with technology. Thanks for joining us here, Jag, on theheart.org | Medscape Cardiology.

Singh: Thanks so much, Bob, for having me.

Robert A. Harrington, MD, is chair of medicine at Stanford University and former president of the American Heart Association. (The opinions expressed here are his and not those of the American Heart Association.) He cares deeply about the generation of evidence to guide clinical practice. He's also an over-the-top Boston Red Sox fan.

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