EP. 36: INVESTING IN THE FUTURE OF MEDICINE

WITH JUSTIN NORDEN

Nov 8

WITH JUSTIN NORDEN, MD, MBA

A physician and venture capitalist discusses how he strives to impact health care by advocating digital health innovations.

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Episode Summary

While digital technologies now permeate nearly every aspect of our lives, their application to improve medicine remains limited. Still, recent advances in artificial intelligence, telecommunications, and other technologies hold enormous potential to transform how healthcare is delivered. At the forefront of exploring this potential is Dr. Justin Norden, a physician and investor at the venture capital firm GSR Ventures, where he focuses on investments in digital health companies. With a background in computer science, Dr. Norden previously worked on the healthcare team at Apple and helped launch the Center for Digital Health at Stanford University. He joins us in conversation to discuss how he discovered investing and entrepreneurship as a way to tackle problems in medicine, clarify misconceptions about digital health and venture capital, and explore how technologies are shaping the future of medicine.

Justin Norden, MD, MBA, MPhil is a Partner at GSR Ventures, where he focuses on early-stage investments in digital health, artificial intelligence/machine learning in healthcare, and enterprise technology.
Prior to GSR Ventures, Justin was founder and CEO of Trustworthy AI, which was acquired by Waymo (Google Self-Driving). He worked on the healthcare team at Apple, co-founded Indicator (an natural language processing-based platform for biopharma decision making), and helped start the Stanford Center for Digital Health. Additionally, Justin is an award-winning machine learning and bioinformatics researcher with 30+ publications/presentations.
Justin received his MD from Stanford University School of Medicine, where he served as student body president; his MBA from the Stanford Graduate School of Business, where he served as president of the healthcare club; his M.Phil in Computational Biology with distinction from the University of Cambridge; and his BA in Computer Science with distinction from Carleton College.
In this episode, you will hear about:
• A brief introduction to venture capital - 1:48
• How Dr. Norden’s experiences during medical training led him explore entrepreneurship and healthcare investing - 3:22
• How Dr. Norden’s passion for computer science influenced his medical education - 7:30
• What it was like to leave a clinical career - 10:18
• The past and current state of technological advancement in medicine - 20:28
• Co-host Dr. Johnson’s concerns over the ways technology has, at times, impeded the delivery of health care - 28:38
• Dr. Norden’s vision for the ideal balance between humanism and technology in medicine - 34:31
• How Dr. Norden considers the reconciliation between the profit motive of companies and the preservation of what makes medicine meaningful - 38:28
• How Dr. Norden decides which digital health companies to invest in - 44:57
• Advice to young clinicians who are curious about healthcare innovation - 50:09
Transcript
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] Our guest on today's episode is Dr. Justin Norden, a physician and investor at the venture capital firm GSR Ventures, where he focuses on investments in digital health companies. Justin is a computer scientist who previously worked on the health care team at Apple and helped launch the Stanford Center for Digital Health. He joins us in conversation to discuss why he decided to forego clinical training after medical school share, how he discovered investing and entrepreneurship as a way to tackle problems in medicine, clarifies misconceptions about digital health and venture capital, and explore how technologies are shaping the future of medicine. Justin, welcome to the show and thanks for being here.
Justin Norden: [00:01:46] Thank you so much for inviting me.
Henry Bair: [00:01:48] So uniquely among all of our clinician guests, you are the first we've had who decided to forego medical residency entirely after finishing medical school. We will, of course, explore that decision. But first, can you tell us what venture capital is and how it differs from other forms of investing? Although most people have heard of venture capital, I suspect many have a rather vague or incomplete idea of what it is.
Justin Norden: [00:02:17] Sure, sure. Venture capital at the most basic is working with entrepreneurs and giving money to companies before they have real financial metrics to really deserve that capital and deserve that funding. So practically, what does that mean? It means working with founders and people towards the idea stage, maybe concept when they have something very early and then giving them money to build it out, flesh it out, and grow it into the potential for what you see it could be how do you fund people and ideas for what they want to build instead of fully fledged businesses?
Henry Bair: [00:02:54] Can you tell us what kinds of companies and technologies you invest in?
Justin Norden: [00:03:00] As you might guess, given kind of the clinical background. I focus on health technology companies and so what new ideas around how we can use data, how we might be able to interact with patients, how we might be able to help clinicians, how we might be able to develop drugs, what are ways we can use new technologies to fundamentally change how we're delivering clinical care or making that clinical care possible?
Tyler Johnson: [00:03:22] So as a person who has spent a lot of time reading a lot of application essays, some for medical school, more admittedly for internal medicine residency, because that's where I've done the most interviewing. But it's just to say that I know pretty much anybody who gets into Stanford Medical School, part of their application is going to be a very high minded, idealistic essay about why I want to be a doctor, which almost always focuses, at least in part, on some version of I want to help people or I want to help humanity or whatever. So, you know, most people, not everyone, but most people when they write that essay, I think have at least in part a thought that they really want to be sort of down in the trenches, person to person, stethoscope on the chest, helping a sick person to feel better. So I guess I'm I'm going to go ahead and make a presumption that that was playing at least some part in your decision to spend a zillion dollars and a zillion hours to go to medical school and become a doctor. How did you get from that point A to the "No, actually, I want to help turn ideas into companies" Point B. Like how did that ideological shift happen? What did it look like for you?
Justin Norden: [00:04:38] Absolutely. So I think we have a fair amount of time together and so I'm happy to try to unpack as much of that as possible because it really was a long journey to make that transition. Like many even choosing to go to medical school, that process starts far before the application. And for me, even since an early age, there was exposure to wanting to be a physician. Saw that my father was a physician. There was multiple physicians on my mother's side. You know, they actually didn't say, Hey, you need to go into medicine like some families do. But when when I showed interest, when I was curious, they were happy to kind of expose me, get me to see what's going on. And so from a pretty early age, wasn't interested in being being a clinician and actually cemented that. You know, like many when a family member got sick. And for me it was an interesting experience where I felt powerless. I was in high school, I didn't know very much. I couldn't really contribute, you know, to the care of someone I cared about who ultimately ended up going on a clinical trial in oncology and getting the care they needed at the National Cancer Institute. And so saw what emerging new science could actually do to someone I cared about as an early experience in high school. Obviously that's not enough. You double down in college and later and you do your clinical shadowing and understanding and was fully convinced by the time I was ready to apply for medical school, this is what I wanted to do. This is what I wanted to see were the first wrinkle I would say happened for later was when I decided to study computer science in college.
Justin Norden: [00:06:13] I was still finishing all my pre-med requirements, but kind of had always this interest in technology and what was possible growing up in Seattle under Microsoft. That was kind of always the predominant company and story of someone who had gone to my high school and dropped out and built Microsoft. That was kind of always the bar for, Hey, if this is possible, if you think big, you know, this is something that can happen. And so while I was kind of going forward on my on my path to be a clinician, this was something kind of always in the background. I thought it was kind of a hobby. I had built my own computer, said, Hey, you know what? I like this computer science thing. I'll just decide to major in it. In college, despite the fact that I thought I would never use it, I didn't think it was relevant. It was just kind of an interest of mine. Before coming to medical school, I kind of doubled down a little bit, getting a master's in computational biology out in England, whereas focused on machine learning and genomics. I was looking at cancer. Cancer data sets are basic data, and I was starting to see, oh my gosh, this hobby of mine might actually start to be useful for what the future practice of medicine might look like. You know, how can we do an oncology was a great field where we're starting to use data in different ways to think about how we can make decisions. So that was kind of a first inkling into how I started to kind of see something different.
Henry Bair: [00:07:30] Can you give us more details about how your training as a computer scientist influenced your subsequent medical education?
Justin Norden: [00:07:39] So engineering was before medical school. So coming into medical school, it's interesting kind of with this background as a data scientist, as a computer scientist, where you are learning to be a clinician, you're learning about differential diagnosis, taking a list of symptoms and trying to incorporate that into what the diagnosis might be. And as a computer scientist, you start running into these problems thinking, This is crazy. How are we practicing medicine in this way? These are things that algorithms could and should be doing so much better. We could aid not that we should take it over and happy to talk about that more later if we get there. But we can aid and understand in a way where these problems were built for computers. We're built for solutions like this. And so for me, going through medical training at Stanford as forward thinking of a medical school as could be, still felt like I was having running into walls thinking that this can't be the way we're practicing medicine. We could do so much more if we use new technologies.
Henry Bair: [00:08:40] Okay. So you are seeing all of these problems in medicine. In what ways did you try to explore them further and try to figure out how you might be able to address them?
Justin Norden: [00:08:50] So I think it was a deeply curious person. And coming into medical training with this background, it was, okay, I have this data scientist background. Who can I find to work with? Who can I find? Who has interesting data that I can work on, research with them, work on quality improvement projects? Just kind of get get my hands dirty. You know, one of the things about medical training is it's always wait, wait, wait, You need more degrees, credentials before you can start, before you can start having an impact. And it was, hey, I think I have this background. I think it's different than most medical trainees, especially at the time. I want to do things now. I don't I don't want to wait. And so we're working in hospital. She projects was one of the ways that was fantastic. As an early medical student, you know, there's always more projects to do. There's data that's not getting looked at. How can I look at process workflow improvements and the emergency department? How could I look at pick you sedation protocols and why are we using all sorts of different drugs when maybe we can make it more standardized? So there was constantly where could I find interesting data sets and start to apply kind of this computer science thinking that would start to change outcomes. Very, very early on there was wearables, data sets. Where are we gathering data on patients, pre-op and post-op surgery? How could we look at outcomes to see if we could predict who might be able to recover faster or even what kind of diagnosis they might have? And so I started looking everywhere across Stanford. Where could I find interesting data, interesting people to solve those problems?
Tyler Johnson: [00:10:18] You took us through sort of getting into medical school and then where the first wrinkles started to appear. And it may not surprise our listeners to know that many people who come out of Stanford Medical School decide to be what the medical students here often refer to as doctors. And Right. So they are a doctor and an investor or a doctor and a researcher or a doctor and whatever. And so it's easier. It would be not surprising to me at all to hear that these wrinkles started getting introduced while you were in medical school. And then you said, Well, I don't want to just be a doctor or seeing patients in the clinic. I want to be a doctor and whatever. But I guess the what is somewhat more surprising to me is that for at least as as it looks right now, for all intents and purposes, you just left the doctor part behind entirely, Right? You're just not going to practice as a physician. Was it hard to give up the idea of being a doctor? And how did you like what sort of took you across the Rubicon to get you to say, okay. Not that you're not going to use your medical training because clearly your medical training will inform your investment analysis and everything else. But at least in the way that most people think about using medical training, which is to be a doctor, to just completely leave that behind. What what was that part of that decision making process like?
Justin Norden: [00:11:38] Yeah, so incredibly difficult is the answer. I think as you alluded to before, this was kind of always something I had thought I would be doing. And, you know, not everyone, especially for listeners, not everyone, loves clinical rotations as you talk to your classmates or not everyone. I actually was someone who loved almost everything that I did and love the clinical rotations and loved, you know, more than anything, the sub where you're the closest in medical school to actually treating those patients. And I did my sub I in internal medicine and got all the way to applying an internal medicine thinking that I thinking that I would match.
Tyler Johnson: [00:12:13] Internal medicine was the right answer by the way. So I don't know, just in case you haven't seen the answer key yet. Just, you know, might be hard to know now, but...
Justin Norden: [00:12:20] Perfect. There are there are a lot of surgical subspecialties and things, you know, that were at play before, you know, as emergency medicine. For a while it was all over the place. But I was truly someone who loved it. I loved being in the hospital doing that. What pulled me out from deciding to submit a rank list and go through with it was a little bit this journey of starting to see a little bit behind of asking why? Why is the system set up this way? Why are we not using more algorithms? Where are these problems coming from? And a big later eye opening moment to me was going through business school. At this point. I had done a little bit of work. I'd done summer internships, I'd worked in a few different areas, started to dip my toe in the water to what seen what things looked like. We started a Center for Digital health at Stanford and so got to see a little bit about what is a what does a normal job look like? What is that when you're not going through school or training, what does that look like? And so started to see how other people function. And I was curious. And then going through business school was a really eye opening experience where what did other very smart, motivated people do who want to have a big impact, who chose not to be a scientist, who chose not to be a clinician, What do they do? How do they see the world? How do they make decisions? And, you know, I realized just how broad problems people could work on, what levers they can pull to try to have the impact that they wanted.
Justin Norden: [00:13:40] And so that to me was a really, really eye opening experience that I didn't expect. I didn't expect when I had applied to business school, I was convinced by some mentors, Hey, this would be good for you. You'll get exposure to other things. But I didn't really understand what that meant. But you know, I had classmates in business school who were planting trees in Bhutan and trying to set up businesses so farmers could be their own entrepreneurs and support themselves to what it meant to be a consultant at McKinsey, to what it meant to be doing private equity in New York. I had no conception of what these jobs and what these things were. And so that was a big moment to me to say, Oh my gosh, there are all these other paths. And then I started to find physicians who were like me, had interests in technology. What were they doing? How are they using their clinical degrees? Were they still practicing? What did that look like? And so that was an opportunity where I just found everyone I could. What were they doing? How do they use their practice? Do they still practice today? What they have gone back and practiced again? Would they have specialized more? Would they have specialized less? And so I had every conversation I could have as I was going through business school and starting to understand this.
Justin Norden: [00:14:46] At this point, I still fully thought I was going to do residency and finish clinical training. But then I started to think what comes next? And I didn't know the answer to that at the time. I knew I wanted to be involved in technology and I am doing what I thought I would be doing in my personal statement, what I thought about how could I combine technology in the delivery of health care to fundamentally change how things were happening? I didn't think this would be what I was doing. When I certainly wrote that personal statement, I didn't know I wouldn't finish residency first. So taking all of those experiences, going to finally applying to residency, thinking I was going and then not was ultimately working on a startup. Ultimately, I had actually someone I had met in Cambridge, a very close friend of mine. We'd been doing research together for six years at this point. Mostly he was a PhD in computer science at Stanford. He was we were working together on research. How could we use new data types to find new insights within health care? And you can't spend that long at Stanford without starting to have an idea. Hey, maybe I could start a company.
Justin Norden: [00:15:47] Maybe this could be applicable. You know, let's see where this could go. And after numerous false attempts like so many have, eventually one of the ideas we're working on while I was still in medical school was around understanding, algorithm safety and trust. And at this point, we had written papers and medical devices to show how likely is it for an artificial pancreas to fail? How do you test this? How do you quantify this? And to me, this was super exciting. This was just my background in health care and backgrounds as a computer scientist to, you know, do novel research and see what where it could go. As we started to turn this into a company. This kind of coincided with when I was applying to to residency. And ultimately we're starting to get traction. We're starting to see what this looks like. And so initially when I made the decision, hey, I'm not going to go to residency right now, it was, well, maybe just I'll wait a year. I want to see this through. I want to see this happening. And started to get a little bit more in the startup world. So ultimately, it was kind of that that said, hey, let me just delay this. I still at that time thought I meant to go back. I would go back. I wanted to go back, but it was this was too exciting. We had made too much progress and said, okay, I can always go back to residency next year.
Justin Norden: [00:16:58] And so I said, Let me pull this back and kind of see this through. Since then, our startup ended up getting more traction, ended up also kind of getting involved as an investor, seeing what the venture capital side looked like in health care. Ultimately, we ended up selling that company to Waymo, which is a little bit of a pivot. We kind of got pulled out from our technology and what we're doing into the autonomous vehicle world because we realized people in medical devices weren't yet ready to use the techniques and kind of AI tools that we were building and then transitioned to having been someone who understood at least some clinically kind of going through medical training, some about startups and technology ended up finding the team at GSR Ventures, where it was a team of physicians who had all kind of gone to business school, all had worked in technology and said, Hey, we have this collective vision that technology can change, you know, what the future of health care looks like and you and you should join us. So not intentional is the short answer of kind of how this transition happened. But ultimately, now I like to say I'd love to go back to residency. Maybe it'll be in ten or 20 years when we feel like we fixed health care a little bit more. But that that was the story.
Henry Bair: [00:18:07] So I know I'm asking you to be a little bit vulnerable here, but in the time since you've left clinical training, have there been moments when you miss it? And if so, what kind of regrets do you struggle with?
Justin Norden: [00:18:21] Absolutely. And so if you think about the timing, you know, I had just started working and chosen. I wouldn't go into residency. I started to see what that was like. And then obviously, like everyone were affected tremendously by the pandemic and by COVID. And so there were there are numerous nights and times where I questioned, what am I doing? Why am I not in the hospital seeing patients? You know, maybe I could be more impactful there and certainly question questioned that decision. I think on the flip side of that, what COVID really did was magnify the scope of my decision, because whether on the flip side, what was I working on? I was working with companies like Cancer that were working on illness data across the country with smart thermometers, speaking with the CDC and the White House and multiple states. How should we think about on this response? What should we do? How can we use this data to better manage resource and supply? And so to me, actually, what happened with COVID is it really magnified the decision of instead of being at the front line, getting to see patients and getting to do that, I'm sitting all the way at the other side of what are the things we can do from a technology, from a national response level, from thinking about this.
Justin Norden: [00:19:31] I certainly question question that decision, especially then all the time as I was sitting on Zoom calls at home when I guess that's a normal thing now. But at the time it seemed totally crazy to me instead of being there in the hospital. But ultimately and still to today, I'm comfortable with that decision. I think I chose I don't get to have the immediate feedback and I think the true. Joy of getting to work with patients and people and some of the most vulnerable moments where you can try to be there as someone to help them and, you know, navigate those very, very personal experiences, which is just such a privilege as someone who gets to be in medicine and instead work all the way at the other spectrum of how can I try to make the field better, How can I try to encourage new technologies and things to get implemented in health care instead of actually getting to do it myself? And so it was just an extreme magnitude of the choice.
Tyler Johnson: [00:20:28] So if we can kind of change registers now. So we've talked a lot about sort of your personal journey out from thinking that you were going to be a sort of personal one on one doctor to switching over to venture capital. But now I'd like to talk about so you're at a Silicon Valley venture capital firm that is dedicated, as you put it earlier, to discovering and facilitating the ways that technology can revolutionize medicine. So on the one hand, of course, it's true that if you are involved in modern medicine in a in sort of the Western developed world, it's impossible to ignore many, many ways that technology really has revolutionized medicine. Right. Especially depending on sort of where you want to draw the line at what you count as a technology. Right? Everything from the development of antibiotics up through the development of what are not so novel anymore. But one time novel imaging techniques, CT scan, MRI, ultrasound, PET scans, etc.. Up through in my world of oncology is probably in some ways the is where the effect of technology is the most evident. And you could make the argument I mean, that's, I guess, debatable. But the point is just to say that we have dozens of drugs that are approved, either brand new drugs or that are approved for new purposes every year. So on the one hand, all of that is just to stipulate that the the degree to which technology is revolutionizing medicine is unquestionable. At the same time, however, I have to admit that I personally have become a little bit of a skeptic in terms of in particular the ways that AI is going to revolutionize medicine.
Tyler Johnson: [00:22:23] I think that in part this is because there's a little Luddite part of me that is not even 100% sure that I want AI to revolutionize medicine, depending on exactly what that means and not just from a job security perspective. Just to be clear, right, even though I'm sure there are computers and many people that could do my job better than I do, but I don't just mean from a job security perspective. I mean from a, you know, sort of a philosophical, even ethical perspective. I think there are really deep questions about that. We'll get back to those maybe in a minute. But let's say that we answered all of those questions and that everybody was convinced that it was a good idea. I'm just not sure that I'm seeing it. Like the most famous example in the oncology world is that there was this big hullabaloo five, seven years ago about Watson and MD Anderson, and there was going to be that. And and I was going to obviate medical oncologists because I would do such a better job of integrating the gobs of clinical data and study results and everything else, and then fitting them with all the genomic data and data of a particular patient to come up with the recipe for their treatment. Right. And then there was this big partnership and it was trotted out with a bunch of fanfare, and then it was a total dud right now.
Justin Norden: [00:23:42] Absolutely.
Tyler Johnson: [00:23:43] That's one example. Right. And I'm not trying to like separate on that example, but it's just to say, but but there's a part of me that feels like this is sort of the eternally receding horizon, right? Like we keep like the revolution is always five years off. It was five years off 15 years ago, and it's going to be five years off. 15 years from now is sometimes how it feels. But as someone who knows a lot more about what I'm pretending to know what I'm talking about than I do, I love for you to convince me otherwise. Why am I wrong?
Justin Norden: [00:24:10] Sure. So let's talk about it. Has the history of let's use an example. But other technologies Have there been promises that have completely and utterly under-delivered in health care? Yes, absolutely. Will there still be promises that completely and utterly under-deliver in the future? Yes, absolutely. At the same time, there are starting to be things out today or things that are possible that I was convinced and ultimately said, How much do I believe this? Do I believe these things are coming? And and do I believe these things are coming soon enough that I'm going to jump in two feet first completely to try to make these things happen. And for me, the answer was yes. So why do I believe that? So, so much has changed. And then we can also go back to Covered for how much it has even pushed the field forward faster where technologies and not just are starting to get adopted in health care in ways that they were never before. Data is starting to get shared in ways it was never it never happened before. And the techniques not only in Watson was first of its kind. They wanted and they wanted to try to tackle one of the hardest problems in clinical medicine. Balaji. And that was a new technique, a new system that they had tried to deploy it to a very hard problem. Now we're starting to see and where we're seeing eye impact things today is taking older technologies and deploying them to very targeted problems. So the easiest example for our eye is currently FDA approved and implemented at certain hospitals is in radiology.
Justin Norden: [00:25:50] We have a very clear problem where at the very clear question, very clear data for how we can come to an answer. And so for reading chest x rays, for reading a CT to determine if there's a stroke for these very, very clearly articulated problems, we're seeing solutions today that are performing, let's call it at par with a human physician, or if a human physician isn't around, able to give guidance or triage to kind of help aid or even change the priority in which a physician might see a patient. And so to me, am I interested in or do I think physicians will be replaced by AI? Absolutely not. Not at all in the near term. And I don't think this and I think, unfortunately, a lot of the hype and media has centered around this. So that's what's been talked about. Oh, Watson is going to completely replace an oncologist. Absolutely not. For me, where I get really excited and look at both for companies and where I think impact is going to be sooner is where is AG going to augment a physician? Where can I start to change a workflow? Or maybe, Hey, I'm more worried about this patient and this other patient. I'm starting to flag something or maybe change some attention to something that might be wrong, that a computer is perfect at, that a computer can make that decision during the night, doesn't get tired and can tirelessly kind of go through that. And we're already starting to see a augment decision making as that gets better and as you kind of are using AI systems in the hospital successfully, which again, Watson was not in many experience were not all of the sudden you're going to start to be able to do things that weren't possible before or I think in one of the reasons I got really excited about technology, take what we do know works that only a fraction of patients can get due to resources or being able to come to a place like Stanford and translate that to other people who have less means or translate that same quality that you can get at Stanford to maybe a rural or even a different country where care like that might not be possible.
Justin Norden: [00:27:47] And that's where technology is also having a huge impact. Today we have solutions like asynchronous telemedicine platforms where you can deliver chat. Instead of having to go see your primary care doctor, you need a medication refill, you need something else. You know, there's a UTI where there's a kind of a pretty standard, well-defined set of symptoms for something that you know isn't a medication that's so toxic, toxic. It's going to cause tons of problems where you can now deliver that instead of having to go through a human physician in a real visit. Can we do this via chat? Can we do this in a different way? And so we're already starting to see kind of deployment benefits of using technology to democratize access to care in ways that weren't possible. So maybe, maybe and maybe that's a little bit more compelling of we're starting to see those changes now. And once we do that, they're just going to start to accelerate.
Tyler Johnson: [00:28:36] Uti for our listeners is urinary tract infection. So. Okay. And again, I, I hope very much to be proven wrong down the road. There's a part of me, though, that still feels like so you used the term "augment our decision-making" frequently. But there is a part of me that feels like- So when Barack Obama was the president, the much of the excitement, at least in the lay press at that time, was in the way was surrounding the way that the electronic medical record was going to revolutionize health care. Right. And there was a big thing about. Right. There was a big federal government push about the way that Obamacare was going to be implemented, that you got rewarded if you were on an electronic medical record and penalized if you weren't. And there was a whole thing about that. And President Obama himself spoke often about the panacea the electronic medical records are going to be an etc., etc.. All of which is to say that if you ask any doctor that I have ever met today and you suggest to them that the EMR has simplified their life and made it so that they can just focus on patients, they'll just like take out a sledge hammer and start hitting a computer somewhere, right? Because now instead what has happened is rather than it augmenting their decision making, really all it's done is pull them away from their patients.
Tyler Johnson: [00:29:59] And we have very good data, even from Stanford, right, where they've outfitted internal medicine residents with location trackers while they're on shift. And it shows that they spend like 75 to 80% of their time sitting in front of a computer, basically caring for a patient, Mr. Epic. And 20% of their time actually in front of patients, which is just to say that, I guess, and I don't mean to pretend that medicine used to exist in some sort of Edenic state where there were no problems and everybody just sat around and sang Kumbaya with their patients all day. But it's just to say that it it feels to me like, like the very term augment decision making, you could make the argument that the electronic medical record has augmented their decision making in the sense that they now sit in front of the electronic medical record all day and tend to that rather than to the people in the in the beds. And so I guess I just I, I wonder. Even to the degree that these things become powerful and that they really do.
Tyler Johnson: [00:31:03] So let's just pretend that you can solve all of the technological and logistical and implementation and all the rest of the problems that are inherent in the way that these kinds of things work. But even if you can do that, how. Like, whose responsibility is it to make sure that it doesn't actually make medicine less human? Right? Because I would argue that a big part of the problem with the electronic medical record is that there's all kinds of drivers, there are all sorts of incentives for all sorts of people and all sorts of places. Right. Which mainly come down to how the health care systems get wring more dollars out of their health care workforce. And they figured out that the way to do that is to optimize the way they interact with the medical record, which is great for making dollars. It's bad for making the experience of being a doctor or a patient more human. So I guess my question then becomes, as we implement these technologies, even if they work, who's going to make sure that it doesn't just further erode the human side of what it means to be a physician?
Justin Norden: [00:32:04] Absolutely. I think this is something we should all be keeping our eyes on. And actually, one of the things that drew me into choosing to go into a position like this so that I could have some say in what that looks like, because I agree with you like everyone else. You know, these electronic medical records have really made experience for patients and physicians. Horrible in many ways. And why is that? Well, it's because they were designed to be billing systems and all of this, as you mentioned, augmentation around clinician workflows and where they're spending their time. This was optimized to increase billing for hospitals and optimize to increase fee for service revenue that's been generated. And to people who haven't dove into it at this point to generate CPT codes that can then be billed for. And so for all the physicians who are practicing at EPIC, you'll get a reminder. Hey, by the way, could you please complete the chart? It looks like some codes are missing on this patient. So what does that actually mean? It means I think you could complete a little bit more with your note so that we can charge their insurance company more. And so for me, as I started to go through my medical training and understand, wait, why is it this way? This system stinks, I could build it better. There's so many ways where we could help with note taking or help with all these things.
Justin Norden: [00:33:25] Improve the patient experience, remove the computer so you can spend more time with the patient. These things weren't happening. Why? Why was kind of the underlying business model of these companies. It was the underlying system for how we get paid in health care. And this was kind of one of the early curiosities for me to just kind of keep pulling back the curtain. Why is this happening? I want to make this project better. Why can we not do it? Why is there pushback from someone in the billing department of the hospital so we can't make this clinical change that seems better for patients and for patients and physicians. And so we needed people who understood the clinical side, the technology side and the incentives behind it if we're going to have some say. And so I think it is going to take everyone who knows those pieces to argue for technology in ways that can make it better. And, you know, call me an optimist, but I think it is possible. And I think especially as our technologies gets more powerful and we're able to prove what they can do, eventually we'll be able to use it to make the physician and patient experience better. When I agree with you largely today, it hasn't.
Henry Bair: [00:34:31] So let's assume again that we have figured out how to solve the implementation and logistical the the funding, the financial aspects of these new digital health technology solutions. In your mind, what then is the role, the ideal role of the physician in this context? Can you paint us a picture of what you hope to see?
Justin Norden: [00:34:58] That's a really interesting question. What I hope to see is that technology in many cases is running in the background. Technology is something that can be running in the background in a visit between a patient and physician and in the background for a patient when they're not in front of a physician. So one of the things I was really excited about, where I did a lot of early research and was in wearable technology and what could we do? A lot of people laughed at me. They said these were useless. They're not solving real problems. We don't know what to do with them. And I said, Yes, yes, yes. But what happens when we have 24 seven data that is accurate that people can trust on a patient in their home and their normal life? There are vital signs, vital signs we haven't discovered yet. They give us insights into their health and their human condition. What happens when we have that? And automatic alerts that can let a physician know maybe it's time to intervene, or maybe we have a different course of the disease. Maybe the drug we've given isn't quite as effective as we thought it might be. And then how could we change practice? And so what I want to happen is I want to see technology running in the background all of the time. Just like in your car, you have sensors that tell you when your gas is low, when there's an issue with your brakes, perhaps when something needs to be replaced or, hey, I would come into a check in sooner because something doesn't seem to be right.
Justin Norden: [00:36:20] How can we have systems running like that in the background that focus the physician and patient time on the things that are most important and most meaningful? And so how can when you do have a visit between a physician and a patient, how can there be a better understanding of what's happened before, what's happened between that visit? So when you're in that when you're in that patient visit, how can you have better understanding of what happened before that visit? And then when you do make a plan for what happens next, there's steps and resources to make that happen. I think one of the things that that broke my heart when I was in the hospital or working in a clinic was seeing something that, you know, we'd make a plan for a patient, we'd give them the access to the right drug, and then I'd hear from my attending physician. Realistically, they're not going to be able to follow through with this plan. We don't know if they're going to get this drug or fill this drug. But we did our part. We did our part in this one point visit. It doesn't need to be that way. Right? There can be systems in place that really kind of offer help, offer support, even just offer a very clear understanding of exactly what the plan should be when maybe the patient didn't take right notes or it wasn't a right plan for afterwards.
Justin Norden: [00:37:26] And so I think we'll move from a point visit what we see for the most part in health care to really continuous relationships where data is kind of transferred more seamlessly. Everyone is looking at the same picture of what's happening with a patient and you're really able to have higher level conversations between a patient and a physician about what do they want for their care. And you don't have to spend the time going through kind of these nuts and bolts simple pieces about what needs to happen, but can talk about how is this treatment working for you? You know, at the end of life, how are we are we meeting your goals? You know, there's the quote unquote right answer for if you have this disease, we'll give you this drug. But then how does that impact you? You know, do you want to have this surgery? Do you want to have this treatment? And so I think it actually will allow the physician patient relationship to be a lot more of what it once was. What people talk about. We're able to talk about the human side of medicine and remove the knowledge regurgitation, which is so much of kind of what we have to do both in medical training and then in the patient visit.
Tyler Johnson: [00:38:28] I mean, again, I will just say that I I'm optimistic by nature, though somewhat skeptical about technology, mostly in the sense that, as I was mentioning before, the thing that worries me is that of all of the powerful incentives that are just there, right. They're just sort of like written into the wiring of the development of technology, the implementation and adoption and all of that of technology. The one impetus that is not there in any sort of inherent or systemic way is to preserve the humanity of medicine. Right. Like, of course, it's one of those things that everybody says it's important. Everybody says that it matters, right. But at the end of the day, you your group invests money, other people's money to try to help companies succeed. And the other people want to know what their return on investment is and the companies want to see themselves succeed. But there's nobody I mean, you may I hope you do sit in the boardroom sometimes and say, Well, yeah, but what about the humanity of medicine? But and again, color me skeptical. But I would imagine that just in the when push comes to shove, that voice is like if you have to if you can do both, sure.
Tyler Johnson: [00:39:48] But if you have to choose between them people are going to follow the dollars. Right. And then the same thing again, when the thing gets adopted, even if you create a tool or help to facilitate the creation of a tool that, let's say, has options for sort of allowing for the preservation of humanity. But if it's a 5% shave off of the margin for the health care system to preserve the humanity and they can get that 5% back by not preserving it, even if you've built the option in, they're going to go with the 5%, right? Because that's because they're beholden to their shareholders and whatever else. And so I guess I am I from a systems perspective, right. Even if you and I hope this is true of you, even if you are willing to be the person that sort of stands athwart the tide of technology and says, well, yeah, but what about humanity? That's not going to be enough because you're just one person, right? There needs to be a way to break into the system, someone to to have that as a consideration or else you end up with what's happened with the electronic medical record as you as you rightly pointed out.
Justin Norden: [00:40:51] Absolutely the incentives in health care. And as you write, there's not a there. Sometimes our bodies or our medical groups try to protect the interests of the physicians and try to make it possible for changes not to be worse or things to happen. But you're right in there's not a clear check in the system. A business will function to try to maximize profit, and that's the explicit goal. And so you have to be extremely thoughtful. And there's always trade offs of, hey, if we find technology that makes our physicians 10% more productive, what might happen as you play that out? Maybe we'll hire 10% less physicians, and the physicians will work just as hard in this new paradigm. And this was something that exactly led me to say, well, okay, how can I have a seat at the table when we see physicians who are so burned out and people who don't want to do this, and I take calls all the time from people saying, Hey, I tried to make this changes in my health care system. I couldn't I tried to change the hospital. How do I do what you do? And I realized, wow, at least get to be at the table and be at least one voice, as you mentioned, of someone with at least some clinical training to say, hey, let's think about this differently. What is the fact that this is happening? And then use that to say, okay, can you use that one voice that I have to have more conversations and who can I who can I influence in my sphere to say, hey, maybe we should think about this differently?
Tyler Johnson: [00:42:17] So so let me ask you then as a follow up question to that, back a little bit to your personal journey. So I really like that idea that you just articulated of you sort of vicariously representing people who are actually in the trenches being physicians only. You're sitting in the boardroom helping to make big time financial decisions, whatever. So let me ask this question then. 40 years from now, you're retiring from a long, successful career in venture capital, investing in health, tech startups and people are throwing your retirement celebration dinner and someone stands up to give a speech about what has defined your career, what the changes that you have made or facilitated have looked like. What does success look like for you? Like what do they say at that retirement celebration dinner that would let you know? Yes, I did what I came here to do.
Justin Norden: [00:43:10] Absolutely. So I think the thing that drove me both into medical school and into the job I am now is impact. How can me, Justin, have the most positive impact on the world? And for me, if you think back at that retirement party, what does that look like? It's, hey, these companies that I got to work with at an early stage and be a true partner or the way I think about it when I invest in a company is I'm signing up to work for the CEO and work with the team to try to make them successful. One of the ways I do that is bring capital. The other ways is through ideas, relationships, work, blood, sweat and tears in any other way. And at that time, at that retirement party, can I have worked with companies that have been successful? One, companies and investments. But two, what a successful investment means is that company reached scale. And the scale we use to at GSR Ventures to think about is $1,000,000,000 in revenue, which is starting to get to the scale where that's having real impact across tens, if not thousands or millions of patients. And if those companies can be successful, I want to be able to stand up at that retirement dinner and say, wow, these companies had a positive, positive impact. So take a company, for example, we invested called Olympics Building will likely be the first FDA approved digital therapeutic for adolescent depression, where there's a shortage of therapists, people, there's a huge mental health care crisis. Can this company reach scale? And the only way to reach scale successfully is they built both a successful business and kind of reaching patients and having a positive impact. Can I work with numerous companies like that? That fundamentally started to change how technology was used within health care and then had the impact and scale that it was adopted across the country or the world. That's what success would look like for me.
Tyler Johnson: [00:44:57] So the scale of the number of dollars and whatever, fine. But like, what's what are the unifying principles that make a company beyond the dollars, right? Because dollars are at best value neutral, meaning ethical, ethically value neutral. Like, what are the unifying principles that make you know that the company was one worth scaling?
Justin Norden: [00:45:22] That's a great question, and I wish there was a commonly accepted metric. Yeah, absolutely. So it's a one there's not a commonly accepted metric across the field for me and how I think about it one way, actually, we think about investments just even from a quick ethical check is if when you're thinking about an investment in a new company, if the company is successful from an investment and dollars criteria, then you know you'll be there at the New York Stock Exchange on TV when the company rings the bell and goes public. Do you want your name attached to this? Do you believe fundamentally, ethically, that this company is bringing something good in the world? So that's a very quick check. Do you believe do you want to stand behind this if this is going to be the defining thing you do in your life, do you want to stand behind this and say this? So that's a quick check. It's not really a metric, but I think it's a good gut check of, hey, do I really want to be associated with this? Do I really believe in this? Do I really believe in the positive impact? In terms of quantifying the positive impact, You can get health economics or policy perspective and talk about qualities or other things like that.
Justin Norden: [00:46:30] I personally am not diving down into that metrics for myself and saying, okay, what is this? But I can say, okay, is this helping people? If this scales, is it a good thing or a bad thing? How do you measure that? It's a very different for a different company, for a digital therapeutic of saying, hey, someone has no treatment or a treatment to a digital based medicine that might help a patient. The marginal extra prescription of that digital treatment, I would argue, is pure benefit to someone who has no other options. So I think it's easy category for something. We're looking at a solution around nurse staffing and improving the nurse experience. If we can use AI to help nurses and 100% of the nurses who use the platform say this is helping me in my day to day life net benefit, that's going to be helpful for the system. And so it really does change and tweak per company you're looking at and thinking about it. But I think the quick gut check and then if there's that at scale, do I still believe in this and do I want to be associated with this is a way that I think about it.
Henry Bair: [00:47:28] So over the course of this conversation, we have mentioned some general categories of digital health. We've discussed artificial intelligence applied to diagnose diseases, which is probably one of the first things most people think of when it comes to digital health technologies. We've also discussed digital mental health interventions and wearables, but what are some other areas of digital health? You are excited about that perhaps are a bit more obscure that those who aren't immersed in this world may be unaware of.
Justin Norden: [00:48:00] So I think AI is again, the big category that kind of draws attention and talks about making the diagnosis or showing someone where the image is on a scan. But then there's so many different technologies that are starting to come out that will change kind of what medicine looks like. So one area, as we talked about, is digital therapeutics. So what does this mean? This means instead of maybe writing a prescription for a new drug, can I write a prescription for an application, maybe a smartphone application that is delivering cognitive behavioral therapy to someone over time that is telling them, educating them about things they should know about their disease and helping them through the course that's happening and fundamentally improving outcomes for these patients. So we're starting to see a category of these digital therapeutics that have been out for a little while and are starting to get more and more traction today. So this is something I think for I think the trainees listening to this now will be around in their career by the time they're practicing, and by the time they're fully fledged, we will have digital digitally based treatment options in addition or in combination with other prescription drugs we might have.
Justin Norden: [00:49:07] So that's one area. I think another big area is kind of help around the access to the medical field. So when previously I might have had to fax my medical records or I might have to drive into the clinic to see someone, we've already seen so much change around online scheduling, texting to get appointments, texting to get answers to things, texting to get your medications refill. So we're starting to see the kind of access points to medicine already fundamentally change. And that will only accelerate as people are going to be more consumers of their health care. They're going to get health care when they want, once convenient for them, when something goes wrong, instead of waiting in line for hours and hours at the emergency department, or instead of waiting weeks, if not months, to see a specialist, we're going to start to see access points to health care look very, very different. And that's going to be augmented by technology. So these are just a few areas where we invest in. We spend a lot of time in and will fundamentally change what the practice of medicine looks like.
Henry Bair: [00:50:09] In the final moments of our conversation, I'd like to ask about some advice you might have. If a medical trainee were to come to you and say, Hey, Justin, I'm really curious about the work you do. I don't know if it's right for me, but I want to learn more and experience it for myself. What would you say?
Justin Norden: [00:50:28] So the advice I give to all medical students doing this or thinking about whether these other paths or have as many conversations as you can. I think we get so siloed kind of in our field, learning more and more about our narrower and narrower area and often don't have enough conversations with people who are very different from them doing something very different or doing something in a thing that they might be interested in. So the advice I actually give to the class we teach at Stanford on digital health and the students there is talk to as many different people as you can. You'd be surprised at how willing people are to have a conversation and how much it could change the course of how you think about something.
Henry Bair: [00:51:06] Well, with that, we want to thank you for your time and the insights and stories you've shared.
Tyler Johnson: [00:51:11] Thanks so much.
Justin Norden: [00:51:12] Thank you so much for having me.
Henry Bair: [00:51:16] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program, notes and transcripts of all episodes at the Doctors Art. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:51:34] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.
Henry Bair: [00:51:48] I'm Henry Bair.
Tyler Johnson: [00:51:49] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.