Latest / StartUp Health NOW Podcast / What it takes to trust health innovation: A conversation with JAMA Network Editor in Chief Dr. Kirsten Bibbins-Domingo

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What it takes to trust health innovation: A conversation with JAMA Network Editor in Chief Dr. Kirsten Bibbins-Domingo · StartUp Health NOW Podcast

• 0:00
  I think i- it is not useful for those who sit in the clinical s- to throw stones at the other side because if you can go directly to patients, you're also meeting a need for patients. Mm. Right?
• 0:12
  Because I think in general, people care about their health. W- there's plenty of evidence to suggest that people do care about their health.
• 0:19
  They care about the health of their families, and there is a need being met that is not being met in the healthcare system, and, and that's okay.
• 0:29
  So how do we become part of that conversation working in partnership with others?
• 0:35
  [upbeat music] Welcome back to Startup Health NOW, the podcast where we celebrate the entrepreneurs and innovators who are transforming health. Our final fireside chat of the day is with Dr. Kirsten Bibbins-Domingo.
• 0:51
  I'm really looking forward to this conversation. Kirsten is the editor-in-chief of JAMA and the JAMA Network, and also professor of epidemiology and biostatistics at UCSF.
• 1:04
  She is a general internist, cardiovascular disease epidemiologist, prevention scientist, and nationally recognized leader in health equity.
• 1:13
  Earlier in her career, she served on the US Preventative Services Task Force, and her work is focused on prevention, population health, cardiovascular disease, health disparities, and real-world interventions that can improve health before people become patients, which is exactly what we're tying together here today.
• 1:35
  So the theme of this fireside chat is about convergence, so we're gonna try to tie this all together. Please join me in welcoming Dr. Kirsten d- Bibbins-Domingo. [clapping] How are you? I'm good.
• 1:52
  Thank you so much.
• 1:53
  So I've really been looking forward to this conversation 'cause you have such a vast perspective in so many arenas that I think matter to civic health and what we're really talking about today, the theme of prevention, how we stay healthy during this journey of life.
• 2:08
  I thought just to kick things off, we'd benchmark where we are. Where are we? How are we doing? Where are we doing well? What's surprising you? Where are we today in this crazy time we're living? Yeah.
• 2:20
  I'm sorry I was not here earlier, and I really enjoyed hearing at least the last few panels, and it's really great. So we're in an environment here in the US where we are spending a lot of money on healthcare.
• 2:33
  We unfortunately h- have very low health measures compared to many other countries who spend far less than we do. We are in the center of disruption, as you all know, in terms of new technologies. We have lots of ideas.
• 2:49
  The question is, can they translate into better health for people, for patients, and ultimately for the population? And I think that's the conversation we all need to be having.
• 2:59
  You all are having it in the setting of new technologies, people who are building companies, and I think what we wanna be doing at our journals is figuring out how to have the discussion among the many sectors that play a role in advancing health to make sure we actually achieve those better health outcomes.
• 3:18
  As you kinda think through the arc of your career, medicine, research, public health, prevention, health equity, and now JAMA, what's not changing enough? And also, where's the shining examples of progress?
• 3:32
  Yeah, I think that one of the reasons that I took a leave of absence from UCSF and from my standard academic life, I'm still a practicing internist at the public hospital there, is that it was clear to me we have a lot of people doing important things in silos, and the impact on patients, on the lives of individuals and on health doesn't quite happen.
• 3:54
  And that might happen because there's too much friction for patients. It might happen at the policy level. It might happen because the people who ultimately have to pay for things don't have it.
• 4:05
  It might happen if you are wealthy, but it doesn't happen if you have more limited resources.
• 4:11
  And there were a lot of ways that we both wanted to promote the evidence of what works, but also stimulate the conversations across many people in these different sectors to really arrive at solutions.
• 4:25
  So I don't think we talk to each other enough. No, it seems like there's a lot of silos still. Yes. And that, I've been in healthcare 20 years now, and that word never seems to go away. No, it doesn't.
• 4:35
  [laughs] And so what do we do about that? Yeah. There's solutions, and later in the conversation I wanna get to best practices, but what do we do?
• 4:46
  I now oversee a set of 13 journals whose primary audience is clinical medicine, right? What do I want to bring to the conversation for them?
• 4:57
  I have a role, and all of our editors have a role in vetting the science and publishing the science, but I also wanna bring the conversation. The conversation for doctors is not what AI is gonna do to healthcare.
• 5:10
  The conversation for doctors is when companies using can go directly to a patient, directly to a consumer, what does that mean? Where is the expertise that we know we have in clinical medicine?
• 5:25
  Where is it that we have to be part of that discussion, right? This isn't a question of either/or, which is what happens when you're in a very siloed environment. It is a question of there are lots of things happening.
• 5:37
  Patients sit at the heart of this that we all want to improve their health, but oftentimes are most burdened by the system. Even if you have means, you're still burdened by a very fragmented system.
• 5:51
  And I wanna bring those people who have expertise in clinical medicine and public health into the conversation, particularly as we have new disruptive technologies, to say, "How can we ensure that health actually improves?"
• 6:05
  Earlier in the day, I don't know if you were here yet, Dr.
• 6:08
  Daniel Kraft presented hundreds of extraordinary technologies about where the future's going, and the whole time I kept thinking, "Where's the trust in these things? Where's the evidence?" Yeah.
• 6:18
  And there's almost these multi-systems. There's the clinical-based system, and then now there's this consumerized system. Exactly right. Exactly right. That's very well said.
• 6:28
  And I think it is not useful for those who sit in the clinical to throw stones at the other side because if you can go directly to patients, you're also meeting a need for patients. Mm. Right?
• 6:40
  Because I think in general, people care about their health. There's plenty of evidence to suggest that people do care about their health.
• 6:48
  They care about the health of their families, and there is a need being met that is not being met in the healthcare system, and that's okay.
• 6:57
  I think clinicians need to recognize that, but I think we need to recognize that in a way that we also understand we've spent a lot of time thinking about the sets of conditions we'd like to prevent, thinking about what the evidence shows for what works with prevention.
• 7:12
  So how do we become part of that conversation, working in partnership with others? That was a big theme today as I heard in the last panels of the partnerships, 'cause those will ultimately be what's most successful.
• 7:25
  As a journal, we also care about evidence, so I'm happy to see that was a discussion amongst many people about what the evidence is for what interventions work.
• 7:34
  But ultimately we wanna know that they work at scale, that they work in the populations that we would like and who need these technologies the most, and that's what we're interested in promoting as well.
• 7:45
  You, you mentioned a minute ago, and I'm curious how this is impacting you at JAMA, what you're seeing, and I- there's many different levels there.
• 7:56
  There's AI in terms of discovery, clinical workflow, patient engagement, research writing, diagnostics, operations, decision support. But from your JAMA standpoint- Yeah... and
• 8:08
  one of the, I think, major issues today is, especially with these large models, people don't know what to trust. Yeah.
• 8:15
  We've heard about hallucinations, of course, and you're this institution that, uh, provides guidance and evidence and trust.
• 8:23
  We're, we're only a few years into this new world of AI, but what's the impact so far, and where do you see this going? That's a, such a good question, and I like that you've grounded it in trust.
• 8:33
  We're very enthusiastic about, about the potential for AI and from a publishing standpoint, the fact that we can get articles, great science from people for whom English is not their first language, that's a major advance.
• 8:46
  That means that it's, that it makes publishing high-quality science more accessible to more people. That's in part because of generative AI. We know that we can be more efficient in how we publish.
• 8:59
  We can produce more derivative types of products from o- original science within, within an editorial model of oversight than we've ever been able to do before. That's- Are you consumerizing it? Or like- Yeah. Yeah...
• 9:12
  ma- I think there's a lot of ways we can make more information available to the many different stakeholders who have to hear the, the results of science. That's all good. What's bad? It's the hallucinations.
• 9:24
  It's the fact that everyone is using this at scale and not using the models correctly. But I think what you hit on is the trust, and there's a big hunger for trust that we should not underestimate.
• 9:37
  So I heard the results of a major global survey that one of the big commercial publishers, Elsevier, undertook, and they surveyed across, I think, 100 nations, the trust in AI and as it relates to science and medicine.
• 9:51
  And the interesting thing for me, the countries, where do you think the trust was the highest? Would you have a guess? Um, not with their doctors or healthcare.
• 10:01
  No, which countries had the highest trust in the population? Would you have a guess? I don't know.
• 10:05
  So the countries that are highest were China and India, and by far the US was an outlier in terms of the lowest level of trust.
• 10:13
  And I do think we don't want to underestimate the fact that people are willing to think about these technologies, but there is a mistrust, and that we have to tap into that.
• 10:26
  It's very interesting to me that there's been a lot of interest in AI platforms, both general large language models and those that are focused on clinical, on c- clinicians.
• 10:36
  They're very interested in actually licensing the content directly from publishers like ours, and I think that's in part because we've still built up a system that people trust what is published, right?
• 10:49
  We can-- we're not perfect, but there-- I would have guessed when we had lots of ability to synthesize evidence that people would why not just go to the AI summary from Google about your condition?
• 11:01
  People still read our reviews more than ever before, and I think there is still something about systems that have been in place that we trust. Now, what does that mean? Does that mean we're rejecting technologies? No.
• 11:15
  I think we have to understand that there is still, even in the US at the height of innovation, a population and behaviors that suggest we want to know more, that there's something about this that we can trust.
• 11:31
  It is interesting, as you suggest, people do trust their doctors. They still trust the person who they sit in front of and have a conversation with about health.
• 11:39
  That doesn't mean that all of these interventions can go directly to a patient.
• 11:44
  It means we have to understand what is the trust that really underlies what people want and how people make decisions, and how can we leverage the good of all of these modes and deliver that for better health?
• 11:58
  I love what we were talking about a second ago about just making this information more accessible and available to everyday people. I think that would be a huge benefit to people everywhere.
• 12:09
  So if you do those deals with- [laughs]... Anthropic or ChatGPT, I think it'd be- They haven't come in to offer us anything yet [laughs].
• 12:15
  They really should, because I could see Google, and they have a really cool product, NotebookLM, and I always, if there's something I want to learn about, I'll take journal articles and just pop it in and it turns it right into a podcast- Yeah...
• 12:27
  and makes it very interesting and digestible, and it's how I learn on the fly. And I think a lot of people could benefit from the amazing trusted information that organizations like yours are producing.
• 12:42
  I think it would add a great benefit.
• 12:43
  By the way, I'm gonna open this up to questions, so if anyone does have questions, raise your hand and we'll make this a little bit more interactive since we're going into the networking hour soon.
• 12:53
  But one topic that came up quite a bit today was obesity. Yeah. And I know that you all just hosted, I believe, an obesity summit.
• 13:02
  In the same way we're living in the age of AI, we're also living in the age of obesity, both in terms of it's a challenge for so many people all over the world.
• 13:13
  Also, there's GLP-1s, there's new things, there's just all sorts of issues going on all at the same time.
• 13:20
  What did you learn at your summit, or what are some of the practical insights that you've been thinking about that might be helpful as we think about civic health and prevention?
• 13:31
  We launched JAMA Summits a few years ago, and the concept behind this was that we would pick a topic, we call them thorny issues in science, medicine, or public health, invite thought leaders across multiple different sectors into a room, close the door, the Chatham House rules, so nothing can leave the room, and just say, "Okay, what is it that prevents us from solving this problem in the next one to three years?"
• 13:56
  Or said in a more positive way, how can we make sure that we have impact on the lives of patients, on the health of the population in one to three years in an area?
• 14:07
  Two years ago, we did a JAMA Summit on AI, and this past year we did one on obesity.
• 14:13
  Now, we invited the companies that make GLP-1s, we invited regulators and the World Health Organization, we invited patients, we invited clinicians, we invited people who are thinking about the food environment, and we closed the door.
• 14:28
  Now, what I thought was going to happen was we were going to argue about is it drugs or is it food? The thing that I was surprised by is how quickly everyone said it is both.
• 14:42
  And we have to think, we cannot dismiss public health, we cannot dismiss the fact that we live in a very obesogenic environment, that there are many incentives in place that really promote unhealthy foods, particularly for people who have less means to think about going to the whole foods and making different choices.
• 15:02
  There was agreement across the board. The thing that was most challenging for this group to think together about was really the fact of the disruption of the AI technologies going directly to consumer.
• 15:16
  So many people who think in their usual ways of thinking about clinical prevention or public health approaches were reckoning with the fact that you can go directly to get your GLP-1s.
• 15:29
  So what does that mean about thinking holistically about what we need to solve this problem? It means we're probably not going to quite get there.
• 15:36
  Because if we are going directly, we lose the traditional levers to think about all the things that have to be in place.
• 15:43
  And so that doesn't mean that we ignore the fact that it is great for patients to be able to go directly.
• 15:50
  But we have to think differently, and especially clinicians who are used to having their expertise because patients come to them and therefore they deliver the expertise. Clinicians will have to think differently.
• 16:02
  And I think that was the most important insight and the most challenging for the room, es- especially for the clinicians or those who live in traditional public health or clinical systems to think about.
• 16:13
  And I do think that is a way in which our prevention paradigm is going to be challenged in a good way, but we have to come face to face with and really grapple with if our goal really is to see improvements in health for individuals and in health for the population.
• 16:30
  W- was there optimism coming out of the summit with, in terms of just making real progress in terms of obesity, diabetes, cardio issues? We're very early in the GLP-1 kind of era- Yeah...
• 16:44
  but we're already starting to learn even unexpected things as it scales and goes out to so many people. Was there optimism or concern, or what's the general vibe? There was a lot of optimism.
• 16:56
  I think there's no doubt that you look at, we had one of the discoverers of the mechanisms that underlie GLP-1s, and the extraordinary biology that's led, that underlies the development of these therapies is, it's remarkable just to think about the discoveries, but also about what else is on the horizon, because there's so much more in the pipeline, and even those who have approached this from the notorious food environment that we're living in really thought about the disruption that these therapeutics can have in engaging more people in the idea that we can talk about obesity, that we can talk about the treatments, and that if we think together, we can actually get at solutions, as opposed to saying it's food or it's drugs or it's individual willpower or over-medicalizing something.
• 17:45
  There was very quickly, I think quicker than I had anticipated, much more optimism that if we think together, even though we might have approached this from different standpoints, we might be able to get at a solution.
• 17:58
  Any questions before I just keep monopolizing? We got one back there. Hi, I'm Nicole Grohman. I'm a registered dietician. I was curious with the conversation around the two pieces of the obesity
• 18:11
  problem, and I put it in quotes 'cause it's so layered, being food or drugs, with the research on intuitive eating, if you're familiar with all of that, and how the conversation around food in our society and the mental health piece of it and healing the relationship with food is a huge factor in weight trends and weight management, weight cycling.
• 18:34
  I'm curious how that was part of the conversation, if at all.
• 18:37
  Yeah, I think that was definitely a component of the conversation, but mostly I think it was around the fact that if we treat this as just a problem for which the drug is the solution, it ignores the fact that even the drug alone requires lots of types of support to make sure that the goal of optimal health is achieved.
• 18:58
  And so in that context, there needs to be support even about the use of drugs. And because if we think the ultimate goal is health, that requires thinking about food and exercise and all of those other things.
• 19:10
  And so unless we're thinking about this together, we're not going to arrive at that goal.
• 19:16
  I think one of the participants who has a video on this says we're just renting weight loss, we're not buying better health, right?
• 19:23
  Because the weight loss is quick, but the sustained use of these drugs is an issue, and that doesn't mean we throw out the drugs.
• 19:31
  It means we recognize that this is about an entire set of things that we need to figure out how to support and intervene on for individuals, but also population-wide. I think we have another question over here. Yes.
• 19:43
  Hi, Brenda Schmidt. Curious if you had payers in the room. This seems as- Yeah... though the rise of the direct-to-consumer GLP-1 became an aftereffect of a prior auth in limiting the access. Thank you.
• 19:56
  It's a great question. We did have payers in the room. We also had patients in the room who were talking about the challenge of the insurance issue.
• 20:04
  We also had payers who talked about how they thought about a reimbursement model that worked for them and actually increased access to the drugs.
• 20:13
  Our goal was to try to get at solutions for people who have done this so that we could have the conversations about how do we figure out how to make this work, right?
• 20:23
  Having payers in the room, it's very hard to get payers in the room. When you close the door and you allow them to talk freely, they actually are really important.
• 20:31
  I'd urge everyone to think about this because when you get them in the room, every one of our summits where we've had payers in the room, it's been fantastic because I think everyone understands the problem a little bit differently, including the payers.
• 20:46
  One of the things I wanted to get your take on, I know you have a lot of global experience. I believe you spent time in China.
• 20:52
  What should we be learning from other parts of the world that maybe we could ricochet back here that would impact our prevention, our health, our well-being?
• 21:02
  I think it is interesting to learn both about the similarities. We had scientists from China, endocrinologists participate in our summit. We just recently came back there.
• 21:12
  It is palpable, the interest in the general population in these technologies, frankly. And then it's interesting when you talk to public health practitioners about where the big crises are.
• 21:25
  So a lot of the things are in some ways very different, but a lot of the things ultimately are the same around the financial incentives that still underlie a lot of the forces that shape health at the population level, the importance of trust in what individuals look to, and the elements that are important in trust.
• 21:44
  There are cultural differences, obviously, but some of those things are very much the same.
• 21:48
  And it is interesting to us that when you try to convene and have a conversation, even if people are coming at it from their own different cultural context, some of these core elements are very similar, and we can learn a lot from each other.
• 22:04
  Okay, here's a last question. What would you want to see published in JAMA in, let's say, sometime in the next five years- Oh... that would signal to you we're really making progress in the things you care about.
• 22:17
  You've spent your whole career in areas that impact civic health and prevention, and so what would be really exciting and meaningful that you started to see published?
• 22:28
  What I'd like to see in the next year and two years is things that marry the innovations that we're talking about with real health outcomes. It's very easy to get excited about what's happening.
• 22:38
  It's very easy to find something that addresses, 'cause there are so many pain points, our public health and healthcare system. But I'd love to see really evidence for improvements in health.
• 22:50
  But I hope I don't have to wait for five years for those. [laughs] Right. Right. Would this be a technology or a therapy or medicine? Uh, it doesn't, it doesn't matter.
• 22:58
  I think all of the great ideas that people have in this room, I'd like to see that they improve health for whatever smaller, larger patient population.
• 23:05
  I think overall what I'd like to see in five years, though, is that across the population, we see not only improvements in health, but we also see them across the board, across the many parts of our population that access interventions that are grounded in evidence and that ultimately improve health.
• 23:23
  We're in these extraordinary times, and I don't think people were expecting the GLP-1, kinda like how impactful that would be. Absolutely.
• 23:31
  So if we start to see this type of progress with, in the way we are with AI, but in many different ways, I think we can really make a meaningful impact on civic health. This is our- Hopefully... our dream, right?
• 23:43
  So- [laughs] I agree. Thank you so much. Not at all. Uh, really wonderful. Thank you.
• 23:47
  [outro music] And finally, an invitation to all of the extraordinary health transformers, whether you are a startup, someone building the future of health, or whether you are an investor, funder, or buyer of the solutions out there in the marketplace, this is an invitation to you to join the Startup Health member community.
• 24:10
  Learn more at startuphealth.com. Look forward to hopefully seeing you soon.