Into the Impossible With Brian Keating - Eric Topol: AI Doctors, Medicine's Future, and The Delta Variant (#173)

Starting point is 00:00:01 Any sufficiently advanced technology is indistinguishable from magic. And today we are very fortunate to be joined by a renowned scientist and also a local, a local San Diego, who is benefiting as I am from the end of May Gray, June gloom, July we didn't fry. It's finally clear. It's August 2nd. And I'm joined by Dr. Eric Topal. How are you today? Dr. Toffle. Brian, it's so great to be with you. Thank you for having me with you. I've followed you for years. Obviously, you're renowned scientist, cardiologist, executive vice president at Scripps Institution, which is not to be confused with Scripps Institute of Oceanography. I made that mistake in the past. We had on Lucola Lejiani, who's at Scripps Institution, works on Origin of Life. We talked about Origin of Life, Primo Levy. This is Life Month on The Into the Impossible podcast. But before we get into, into all these physics and kind of nerd out on physical sciences. I want to do what I do, Eric, with all my guests who write books and you've written at least three that I've read,

Starting point is 00:01:10 I like to play a game called judging books by their cover. Because what other prior do you have to go on when you see a book? And so I want to ask you, this book, Deep Medicine, I have your other book. The patient will see you now in another room. But this book, Deep Medicine, what is the origin of the title and the subtitle and the cover design, which seems to have a menacing Android with Apple. Right. Well, deep medicine was easy because this is about how deep learning the subtype of AI will affect the future of medicine and health care. And, you know, I think in many ways, one of my influencers was Gary Kasparov, who had a book Deep Thinking. And it's a natural.

Starting point is 00:01:53 It's deep everything. As you know, Brian, all the different methods. and acronyms, everything surrounding the deep learning era is deep. And the playing on words here is that rather than everybody thinking about the AI impact, it's much more about restoring humanity going deep in terms of the human connection. And that's what I think is the counterintuitive notion. So then that picture of the Android with the Apple was trying to capture that sense, is that we can make with AI medicine better, healthier, and restore the human connect,

Starting point is 00:02:34 which is the whole notion that most people haven't realized that the gift of time, that if you harness what AI can do between all the different things like the assimilation of the data, processing the data that no human being can actually keep up with anymore, So that and the idea that, for example, doctors and clinicians are at keyboards typing and not even looking at patients. And, you know, why that? You would use voice and natural language processing and get synthetic notes.

Starting point is 00:03:09 And there's a long, long list of things that would make that patient doctor relationship back to the way it was supposed to be, back where it was years ago when I first got out of medical school. Yeah. And I want to also point out that I know that you have many awards and honors, in addition to your leadership at Scripps Institute, institution. But I want to also point out that you were named, if I'm not mistaken, 2017 Sharpie highlighter man of the year for all your highlights that you do in your tweets. I decided I would start emulating you when I heard you speak. You are perhaps the most prolific highlighter in human history. and I say that based on your meeting you in real life and seeing you on Twitter where you're been a godsend to many of us who are data driven and like to think about data, et cetera,

Starting point is 00:04:01 more or less continuously. And I do want to get into the opportunities that you presented to me and to the audience back at scripts when you gave a lecture when this book came out. But also, yeah, as you mentioned, and the patient will see you now, you kind of had this, this depiction at one point I remember in the talk you gave, you know, of like a doc, you know, in the olden days it was like a doctor looking at a chart and the patient sitting there talking and now it's like a doctor typing into a computer. And I think about that with education in that, you know, a thousand years ago in Bologna, Italy, the first university was started. And you're also a professor

Starting point is 00:04:34 of scripts as well. And those first professors, you know, think of how much has changed. It was a man with a piece of rock scraping on another piece of rock, you know, writing down something. And then there were students were transferring it to their pieces of rock or papyr, I don't know what they had back then, to be honest, Eric, but the point is nothing has changed in education. Like, if you were explaining it, you know, maybe, yeah, we have these devices and now the kids are recording instead of typing notes or writing notes by hand. But it strikes me as how little has changed in hundreds, if not thousands of years. And, you know, we're kind of at this level as I had on Carl Wyman, who won the Nobel Prize in 2001, who's now turned his

Starting point is 00:05:16 life to educational overhaul. And he said, you know, he claimed we're at the point in education that's equivalent to bloodletting with leeches. But I want to ask you, what is medicine at? How come medicine is so resistant? Is it all lawyers? Is it because of lawyers? Why is it that we haven't, we don't have an artificial intern in the room with all my doctors? Yeah, great question, Ryan. You know, I think one of the big reasons why medicine is so sclerotic, so difficult to change. And as you say, many things are a throwback to more than two millennia, the era of Apocrites, where the doctor knows best about everything and is in command and control of everything. And so letting go is difficult.

Starting point is 00:06:03 And it's not just a legal thing. It's much more, you know, it's this thing of I'm in charge. I'm trained to be in charge. And also, I'm going to live in an analog world. part of that analog world was that the first foray into the digital world in medicine were these electronic health records, which have been an object, you know, a total fiasco because what it's done is it basically really undermine that relationship, as you've already touched on. And the problem is that that's not a good proxy for where digital and where things

Starting point is 00:06:43 like AI can take us. And so a lot of physicians where they were forced to change, their health system said, you must use electronic records, we're getting rid of paper records. And it just, it was all done for billing purposes. It wasn't done to, you know, provide better medical care. So with that, the first chance to adopt the digital era in health care, it backfired in many respect. So between what you mentioned, the medical legal issues, the control issues, the bad experiences, sour experiences, it's been hard to get any real substantive change in medicine. And I look at the work of your colleague and friend Atoil Gawande in his book, The Checklist Manifesto. You know, there it was kind of rationalizing systematizing. And I'm a private pilot.

Starting point is 00:07:32 I fly little tiny Cessna's around. But the point being, you know, we've learned because the lessons are written in blood and aviation, you know, that you have to learn from the mistakes of others because you won't live long enough to make them all yourself, as Rickover said. But I guess the thing that strikes to me is even more similar is that like artificial intelligence could be in the cockpit too. In other words, every time I fly, you know, from Montgomery Field or whatever and I fly around to go to, I don't know, Los Angeles or something like that, I have to tune in by hand a radio dial and I have to listen analog single, you know, single channel communication to the weather there because there could be a broken down plane on the runway and so it changes every hour.

Starting point is 00:08:10 And then I have to write that down by, look, what if I had an, you know, and I won't say the word, but it sounds like Alexandria or Cyril. And I had one of these devices in the cockpit with me that was connected because it connected to the internet through, you know, 5G or whatever. And it strikes me as is just, as you say, sclerotic because that would save lives. I mean, there's no doubt that there have been lives lost because either someone didn't check, didn't tune the right frequency, didn't know there was something. something that prevented them from being able to land, for example. And probably in medicine, too.

Starting point is 00:08:41 There's people that, yeah, go ahead. Yeah, well, Brian, you're really apt to point that out because the problem we have with medicine today is, you know, this term precision medicines used a lot. And that doesn't mean much. If you keep making the same mistakes, that's very precise. We need accuracy. And that's actually the short-term big benefit of AI, deep neural. networks are, you start to see all the trends, particularly with medical images, of making things

Starting point is 00:09:12 far more accurate. That is, when you get the processing that can be done through training, neural nets of hundreds of thousands, if not millions of, whether it's mammograms or x-rays, cat scans, I mean, any type of medical image, you can do things that no one would have anticipated in terms of revving up accuracy. And when you add the human oversight, then you've got, kind of the best of both worlds. So that's why medicine is in the mist, I would say in the early mist of a shakeup, because the machine plus the clinician is going to be the new look rather than just the clinician, because accuracy is not anywhere near it needs to be.

Starting point is 00:09:56 In fact, the National Academy of Medicine has documented that each of us will have a serious medical error happen to us in our lifetime. you know, at least one. That's pretty bad. And then when you also think about the 40% of doctors when a patient dies and they have an autopsy, and before the autopsy, they say 40% of the time, that is, they know exactly what was the cause of death. And the autopsy, 40% of time, shows they're absolutely wrong. So we have a lot of eubris, a lot of inaccuracy, and we need help. We need to lean on machines to help us. Yeah, and I think that's something that's, you know, again, in the aviation, the military. They've learned this. I had David Marquet on the podcast last year. And he's talking about his book, Turn the Ship Around and Leadership is Language. And he's told me the most dangerous word, a leader, a surgeon, a pilot, someone can say is the word right, question mark. You know, I say to you, Eric, you know, like, I don't, I'm not going to suffer from COVID, right? You know, it's like, it's, and you're in a position of authority. It's coercive. It's manipulative. It's prone to confirmation by.

Starting point is 00:11:06 And I just wonder, you know, I was harkened back to the Talmud, which is the second holiest book in Judaism. And the Talmud has a famous phrase. I don't know if you ever heard it. The best doctors go to hell. Because we do. And I extend that to Ph.D. doctors of my type. So it's not the worst doctor. It's because, yeah, we kind of have this theme that Atul and you and I've talked about, this kind of aura of invincibility, this expert authority bias.

Starting point is 00:11:33 And, and yeah, how do you walk the tightro? because we need authorities. We live in an anti-scientific age. And yet we have a natural desire to also want to be free and have liberty in this country, unlike other countries. And so, yeah, how do you balance that as a doctor, as a public figure, who's perhaps one of the most vocal, you know, kind of supporters of the scientific method

Starting point is 00:11:54 in the public discourse? How do you balance those, too, the competition for liberty on one side and the competition for following experts when it's warranted? Yeah, it's a very important and delicate. it bounds because what I want to see is democratizing medicine. So many people now can capture their own data and with supportive algorithms, they can do doctorless things. But of course, doctors don't want them to do that for the most part. And so we have to let go. But we also obviously want to have this stuff validated with scientific method, that it really works,

Starting point is 00:12:28 that no one's getting hurt, that it leads to the right screening, whether it's skin cancers and lesions or urinary tract infections, skin, you know, ear infections of children, heart rhythm. All these things can now be obtained with a reasonable accuracy by a person without a doctor. Right. So this is really where this change, this shift is occurring because algorithms don't just help clinicians. They help all people if they're used properly. But we have a problem.

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Starting point is 00:14:03 So we can't be pushing this too hard until we get compelling evidence that it works really well. Yeah, I had Dr. Peter Diamandis on last year, and he's famous for a list of democratization, all these five Ds, you know, probably because his name is Diamandas, has so many D's in it. But, you know, he's obviously on the cutting edge of a lot of medical research, but also on, you know, kind of the exponential, all these different exponentials that come into play. And I think it's fascinating that, yeah, we never has there been, you know, misquote Carl Sagan, and, you know, never has so much data been available as so many people who don't know how to use it. It's like, you know, it's like, you know, it would be great if we could actually have the kind of supervising agent not not, not have to be so hard to come about in terms of a trained doctor. Let me ask you a bigger picture question. I want to take you back to college and you're sleeping on the, you know, chatting with your buddies on the couch in the dorm or maybe you got a beverage of your adult variety. and I want to speculate.

Starting point is 00:15:02 When I say life, you know, what is life to you? There's a famous paper monograph by Erwin Schrodinger, Nobel Prize winner for creation of wave mechanics, quantum mechanics. He wrote a monograph. It basically had some cool things in it, like hinted that there might be some crystal inside life that stores information. What is life to you, Doctor? Oh, Brian, that's a tough one. You know, there's a recent book by Carl Zimmer, who's a real good friend in George. Journalists in New York Times that, you know, several hundred pages that gets into this. It's not an easy

Starting point is 00:15:35 answer. I mean, you know, you could say is a virus life like COVID, right? That's my next question. Right. And you could say, well, not really enough it can get into a host, right? And then it's, then it sure is a hell of a life and causing death, but of the hosts. And so it's tricky because if you want to talk about independent ability to sustain itself versus being able to, invade and then basically, you know, hijack a host of any kind. There's lots of fine lines between life here and sublife forms. So I, you know, in the true sense, it would be, you know, that an organism that can sustain itself, replicate itself, perhaps. But I think we have to think more broadly than that. And then when I say artificial intelligence, my friend Max Tagmark at

Starting point is 00:16:29 MIT was on the show. He's a proponent of this concept that he calls Life 3.0. Yeah. Actually, artificial intelligence has all the characteristics that could plausibly, from a physicist's point of view, perhaps, be ascribed to living organism. What do you make of that? Yeah, I think Max's book, 3.0, is actually very provocative. I enjoyed it. I haven't met Max, but I certainly think he's a sharp thinker. I don't want to give AGI, which he forecast will be 24. with his big conference that he pulled together. If that ever happens, if that ever happens, maybe he'd be right.

Starting point is 00:17:07 But right now, I'm not thinking 2045 or beyond that. And I don't know that I would give AGI signing life potential yet. And we'll have to see whether that actually pans out. One of the things I've gotten interested in is kind of taking the words of the great maestro of physics, Galileo, for the first time making the first ever audio book with some colleague Carlo Rebelli and others. And when I had the audio, I actually realized there is no audio book of any of Galileo's works,

Starting point is 00:17:35 which is really a tragedy, so I'm rectifying that. But I said, actually, now I have the text. So could I put that into GPT3 and make artificial Galileo, or as I call them, GALAIO? And start doing things with it. But then it started to dawn on me that, you know, so Einstein, you may or may not know this, he called the realization of what's known as the equivalence principle that if you're in free fall,

Starting point is 00:18:00 you experience no gravitational force. So even if you're near, you know, that's the sensation that you have when you go over a hill or in a plane or something like that. Or if you're in a rocket in deep space, you're moving at 1G, you can't tell you're not in a gravitational field stationary. And Eric, he called that, Eric, he called that the happiest thought of his life. And I started thinking, first of all, could a computer experience happiness, number one? And then number two, could it even relate? What does it mean to feel like you're free falling? And so I agree with you. I'm actually an AI pessimist or GAI.A.I. Like, I don't think that it will be in the same, as I quote, you know, often, you mentioned Kasparov. He was beaten by Deep Blue. I know computers can now

Starting point is 00:18:40 defeat any human in chess. Can they create the game of chess? Can computers eventually come up with new ways of treating, like, come with some new idea. Actually, you have to remove all the mitochondria from every side. I don't know. I'm making it. The last thing I had in biology, Eric, was ninth grade. I dissected a frog. I got it all wrong. The frog lived. The frog actually lived. I don't know how I'm such a failure. But, yeah, I mean, are there opportunities for, like, completely, you know, de novo innovations in the, in either machine learning and from deep neural networks that you talk about in here, or an AI? Is there any possibility we just think so outside the box, literally, the silicon box, that it could really surprise us in the way that Einstein

Starting point is 00:19:19 was surprised in a similar fashion? Well, I think it's speculative. We haven't seen. We haven't seen it yet. We have seen, you know, amazing things that we have to be imaginative, that we can train machines with the right inputs to get outputs that were not envisioned. But what you're getting at is the autonomous aspect of neural nets to be able to do things that, you know, without any guidance whatsoever, I don't know about that. I'm much more skeptical that that's going to be happening. But, you know, there are these people that have. the doomsayers, like Elon Musk and several others that have basically gone that direction. You know, it's possible. I don't think we've seen any good evidence of it. But I also would say,

Starting point is 00:20:07 you know, right now, deep learning is the vogue, you know, it's the main thing that we harp on. But there are lots of new models that are going to be come up with in the years ahead. And, you know, anything's possible. We should be open to potential, you know, and watch for that, but I don't see it. You know, I'm more like you on this, not having heard your views, but people. And one of my favorite chapters in deep medicine is a chapter called deep empathy. Can you explain what that means for people that haven't read the book? What does deep empathy mean? Right. So, you know, you already, in a way, came on to this with this assigning human qualities to machines, which is wrong, because it's no reason to get anthropomorphic with

Starting point is 00:20:59 the machines. So they're not going to have empathy. You just can't do that. I remember in the book I had a table before that chapter about all the things that humans do that machines can't really do, whether it's cry or laugh or have true empathy and on and on. But the deep emphasis, The final chapter, the culmination of the book is how we get back this deep connection between the patient and the clinician. Because it's what it's all about. That's with the essentiality of medicine. And yeah, you can have help with a machine to get, whether, you know, to get the right diagnosis or even to guide towards the right treatment. But all of that is unimportant because when you're sick, you want a human looking after you.

Starting point is 00:21:48 you want to know that a human has your back. And so that's deep empathy, having your back, having a presence, a trust, all the qualities that are humanoid that we don't have enough of today because we don't have the gift of time. One of my favorite tweets that you had pinned on your Twitter profile where you've got nigh on 500,000 followers that are rabid and love it in the best sense. I shouldn't say rabid to a physician. Could be taken the wrong way.

Starting point is 00:22:15 But you had a tweet pinned for a long time. And it was just your period, medical period, data. And, you know, it strikes me that you're one of the more, along with Atul and others, you know, very patient focus. But I want to take a step back because I teach a lot of premeds at UCSD and physics. They have to take, you know, Physics One series. And I guess, and, you know, they think it's just to get past the MCATs. I wish that they would actually learn it in a more provocative and actually intellectual fashion.

Starting point is 00:22:45 But, you know, we do have to do that. And so it's what they do. A friend, actually a friend of a friend who is a famous podcaster in England. He's a doctor, Ali Abdal. He has two million followers, you know, on YouTube. Anyway, he did a survey. He dropped out of being, you know, Cambridge trained physician, OBGYN. And he decided he's just going to stop.

Starting point is 00:23:05 And he asked, because he became a millionaire. He became a millionaire from YouTube and from he runs a bunch of courses and how to study for med school. And so forth. And he surveyed a bunch of his friends that are doctors and said, if you became a millionaire, would you keep practicing? And most of the answers, Eric, came back as yes, until the end of the day. In other words, there's so much dissatisfaction. There's so much burnout. There's so much stress among your fellow physicians that I wonder, like, who speaks for them? And is that a crisis? This crisis of meaning or burnout? What do you make of that? Yeah, I know. You're spot on about that.

Starting point is 00:23:39 So we have a global crisis of burnout, the highest rate of clinical depression, suicide, ever in the medical profession, not even just among doctors, but nurses and other disciplines. It's actually horrific. The pandemic has put medicine in a bright light in terms of heroes, if you will, but it hasn't gotten over this problem of loss of mission. So the point being here is that when you only have seven minutes to see patients and 12 minutes for a new patient that you've never seen, before, you basically are violating why you did this for your life. Because you did it because you care for people, you want to care for people, you want to look after them, and you can't. So that's what leads to profound disenchantment, is unable to cope with the system of how you are basically

Starting point is 00:24:37 supposed to be practicing medicine. That has to change. And the overlords, basically in medicine, unlike your walk of life, are managers bean counters. And they want you to see more patients in any given time slots. So that doesn't work out too well. So the only way we get over this is that we have to revolt. We have to tell the managers that, no, we're not doing this anymore. We want to look after patients because if we don't do that, it's hard to break this progressive crisis global disenchantment

Starting point is 00:25:16 and depression. It's been a, it's been building, you know, over many years. And when we think about, you know, kind of how these students come up and the shortage of physicians I had, Michael Saylor, who's a very big proponent of Bitcoin, not that we're going to get into that, but he's one of them for one. And anyway, he started this new university, basically for STEM, and it's called Sailor Academy. And he basically feels like unless you're going to be, you know, like a sculptor or, you know, major in professional golf, I don't know. Well, I'm talking to a doctor, so maybe you can't major in professional. I don't know.

Starting point is 00:25:50 But the point is like for at least for not physical interactions, you know, maybe there is some part of the bedside manner that you can't teach. But, you know, could we, could we, you know, kind of lessen the pressure on the existing cadre of doctors by having just more and more students get into medicine? And by doing so, lower the cost of medical school, make it more affordable, make their more trainer, you know, teachers, et cetera. You know, why have Brian Keating, you know, teach physics when you can have Galileo or Einstein using AI and all the words they've ever spoken. Do you see an opportunity,

Starting point is 00:26:20 would it make the problem worse to have more people become physicians? Would you just have a greater number of suicides and sort of negative mental health outcomes? Well, it's a very good insightful question. The problem is right now, the workforce, the human capital that's being expended is making healthcare unsustainable. So we have to be smarter about that. And the question is, of course, if we got more frontline people like you're alluding to and stop with all these administrators and managers whose role is more questionable, that's one strategy. But the other one is to rely much more on support that we can get from machines that can make each doctor's life so much easier and more accurate. So I think it's a combination of those two, not one or the other.

Starting point is 00:27:11 And so I think that, you know, dovetails nicely into kind of transitioning to rather, you know, current events. Let's call it current events. There's been a perversive worldwide pandemic for the last 16 or more months. I've heard of that. Yeah. Are you familiar with this? Because I have a doctor or friend of mine. I happen to know Eric Topol, so I could put you in touch. But first of all, I want to get you're just as a human being. So I remember in January, 20, 20, I'd just been invited to go to a conference in Tibet of all places. And I was looking forward to to it. I'd never been to China, to Tibet. And I went to dinner and I was next to a friend of mine, my friend Mitch, and he was saying, you might want to hold off on that a little bit because I just heard, you know, China's building this hospital. And there's so much far in advance of America that they built the hospital in seven days. And it could hold a thousand people. And it also doubles maybe as some other. Anyway, I don't want to get into politics. But the point was they were like,

Starting point is 00:28:09 my friend Mitch, who's not like a global policy, medical health pandemic expert, or, you know, doesn't have the trillion dollar NSA budget, CIA budget, whatever, all these three let it, DARPA, whatever, he knew about it. He knew it was not a good idea. He knew it was coming to America and Canada. How come we failed so badly to diagnose this? And it wasn't like we didn't know it could happen. But with all the apparatus, in other words, not just like, oh, well, you know, we had a bad president or a good president, whatever. Again, I'm not political. I'm a political atheist. And I think, I got into astronomy, Eric, just to sign up, because there are no, like, Republican constellations. There's no Democratic asteroid over there.

Starting point is 00:28:45 You know, I love it because I think we need a politics-free space as intellectuals in society. But anyway. I agree with that. Just like there's not a Democratic or Republican virus either. Yes, exactly. So the issue here is that we were flat-footed. And the biggest singular problem, why the U.S. got so deep into a horrible mess, is that we had no testing capability for the first two months of the pandemic here.

Starting point is 00:29:12 And so without testing, we watched unknowingly the diffuse spread of the coronavirus everywhere. And so that was the time when you needed to have, it was basically invisible to us. And the only way to see it would have been to do nasopharyngeal swabs and PCR. So we blew it. And now we're trying to dig out. out and you know it's just really when you get that far behind two months I mean as you know talk about exponential stuff right you're you're in deep shit I mean no you and we are still in many ways from that now had we been all over it you know like Iceland is an example you say

Starting point is 00:29:57 oh well that's just an island country it's only got 300 000 people but hey they were testing people randomly before the pandemic ever reached there that's the way to be right And so you look at the countries that got to zero COVID, and they were basically all over it from the get-go. Now, you could say in the second part of the story, they're all basically naive. They have no immunity. And so they have to also be smart about getting vaccine-induced immunity, but at least to get through and have unscathed. Like, you know, I have a faculty appointment at the University of Auckland and New Zealand. I talk to my colleagues, you know, frequently.

Starting point is 00:30:37 And to think that they basically have had a normal life, never been affected by COVID, except for a few days here and there, because they got all over it from the beginning. And they've stayed all over it. And they're also doing well now in the vaccination phase. So there are ways that we could have done so much better. And it was just mismanaged. And I think you know our public health resources were gutted, you know, systematically gutted over many years. So we were in the poor position to react. And even knowing, you know, when the sequence of the virus was available on January 10th from China, that was the triumph of the American medicine, life science community,

Starting point is 00:31:23 of getting the vaccines, you know, compressed schedule all the way, highly successful vaccines, all the way through clinical trials and rolling out within 10 months. That's amazing. So you have, you know, the best and the worst, right? have what the U.S. is very good at, which is on the life science industry and ingenuity side, but on the public health, pitiful. Yeah, I see that, especially as a parent of young kids and seeing, you know, just kind of the various whipsawing I felt like over the past year and a half and still feeling like, oh, now we've

Starting point is 00:31:56 got this Delta variant. So you talked a little bit about this in a wonderful chat with Sam Harris a couple weeks ago, But I want to ask you, like when they say, you know, this is spreading and we have a new wave, et cetera, how different in terms of viral, if you just took, you know, the PCR of it? First of all, how do they know it's, you know, if someone goes in the hospital in San Diego, God forbid, and they have COVID, you know, how do they actually test and say, oh, this is a Delta person, not versus an, I mean, do they do that? Well, in San Diego, we're very lucky because we have, if not the most sequencing, maybe the second most sequencing of any per in the country. Right. So fortunately, our collaboration at script research with UCSD and Helix and Illumina, we're all over this.

Starting point is 00:32:39 So we do sequence the samples. And interestingly, to that point, Brian, when we had the original virus and then the alpha variant and the other variants before Delta, we could hardly ever sequence. the virus in the samples, it was so little there. Now, every one of them can be sequenced because there's so much. And the key thing here is that it's a thousandfold more viral load. So when you get the chance of overriding vaccines even can occur, but moreover, the people who are unvaccinated are just spreading this like no other previous version of the virus. It's just so super contagious, unfortunately. And that's why it's causing real havoc and not as much yet in

Starting point is 00:33:21 California, hopefully, but it certainly is in many other states in the country. And looking at the, you know, the data and seeing, you know, the prevalence of both of hospitalization with and without vaccination, I think it's really clear. And I, you know, I got the vaccine at UCSD. I think we had one of the best response. I was never more proud to be at UCSD. You know, we had, we had vending machines with test swab kits. I could get it whenever I wanted. We had, you know, distance. We had mask. We did it all. As soon as a vaccine was ready, I was one of the first people. I got my wife.

Starting point is 00:33:53 And now it's like, I don't even know where to get one, you know, if you wanted to get one. It seems like, you know, perhaps we have to revitalize that whole campaign. But I think UCSD and the chancellor and the med school and everybody and scripts as well did a phenomenal job. And I want to thank you and the role that you played and also our chancellor, as I said. And I'm not just saying that because he's my boss. But, but anyway. No, he's a good, he's a good man. But I also think we're very lucky that we work together in San Diego.

Starting point is 00:34:19 There was no sense of rivalry. And the county, the San Diego County, I mean, three and a half million people, second largest in California. We got on this. And so it isn't perfect, but we actually are a model county like Seattle, Kings County, and a few others around the country that have managed this reasonably well. I mean, you know, you've got wastewater surveillance there on campus. We're trying to stay ahead of it. You know, the one thing I regret here is that we didn't get the rapid home testing to every household in San Diego to show the rest of the country that that would be so striking in terms of helping to manage. So anytime you're going out, you would be clear that you're not infectious.

Starting point is 00:35:04 And we need that now more than ever because some vaccinated people are unknowingly infected. And what do you make of it, though, I have, you know, people on, you know, other side. just to have some potential pushback on some of the messaging that's been gotten. You know, if you have a vaccine, if you're vaccinated, rather double vaccinated, it's worked well. You know, why should you have to wear a mask? And I hear that a lot. And I just wanted to get your personal take on it. Because I know you've been kind of atheistic politically too in that you've pushed back on Big Pharma in the past famously against Merck and Bioxx. And now, you know, more recently kind of just criticizing some of the current CDC messaging. What do you make of that? If you

Starting point is 00:35:46 were talking to somebody who's bright and just say this is the first, just stating in fact, this first vaccine that you have to, you know, wear a mask after you got vaccinated and efficacy and efficiency, as you point out in your interview with Sam. What do you make of a well, here you bring in a little physics with the aerosol transmission, right? And when you have a thousandfold more viral load, the chance of you being able to override a person who is doubly vaccinated is higher. We're seeing it. We're seeing these so-called breakthroughs and not just that they get a positive test, but they get symptoms and some get, you know, quite sick. Obviously, the chance of it is much lower than, far lower than if you're

Starting point is 00:36:26 unvaccinated. But it's all about the fact that this virus is distinctly diversion. It's distinctly worse and different and more challenging. It's daunting compared with every prior version. And the other thing is it also has this quality of immune evasiveness. So whereas the prior versions of the virus, the vaccine held up really well. Here, one dose is like placebo. You know, if you don't have the second dose, you got a lot of vulnerability. So basically, the vaccines are leaking. The viral load is overwhelming people.

Starting point is 00:37:05 And the other thing is, which is unanticipated, now we'll get into the weeds of life science. We thought that our B cells and T cells were going to kick in these on-demand reserve cells and that we'd be good for years, like, you know, 10, 20 years. Now it looks like we're only good for a matter of months and we have to get boosters. And so it's becoming much more complicated. In terms of those boosters, you know, I've had friends of my actually physicians just saying like, oh, yeah, I just, I'm going to go down and if this is misinformation, please correct me. But, you know, that they would get another boost.

Starting point is 00:37:37 They would just go and get another COVID shot, COVID vaccination. Is that advisable? Is that not recommend? I mean, if it's safe, in other words, they're the reasoning that these physicians, I've told me, it's safe. We know it's almost as effective as a vaccine has ever been made in human history, as you pointed out, thanks to this immense ingenuity of people around the world, but especially people here locally. And yet, it's so safe. So why not just get a third, you know, wouldn't it be prophylactic in a sense? Yeah, I mean, I think it's still some unknowns,

Starting point is 00:38:06 like, is this only for people of advanced age and immunocompromise? Is this an across-the-board thing? Is this like what timing? Is it six months, nine months? I mean, there's a lot of unknown. So before we start, you know, getting to third boosters, we're learning from Israel, which has started that campaign of a third, in the elderly population. But it's a little early to jump to that.

Starting point is 00:38:31 Ideally, if, you know, this delta wave could pass pretty quickly, and we won't have to worry about it so much. In some places, its rise is complemented, fortunately, by its rapid fall off. So if we see that, you know, then if the virus isn't circulating high levels, then the need for the boosters will be forestalled, you know, and then we can look at it and think about it in the light of day rather than a panic mode where we have insufficient data right now. I want to ask you a question that my audience had, but also I had.

Starting point is 00:39:06 And actually, it was brought to my attention by Andy Weir, the author of The Martian, and more recently Project Hail Mary, which is about a virus that doesn't take over the earth. It takes over the sun. Anyway, he's a proud dropout of UCSD in the computer science division where our mutual friend, Rajesh Gupta, connected you and me together. I thank him very much. Shout out to Rajesh. He's an unbelievable scientist and influence on me. I want to ask you, is this, as Andy said, maybe the last pandemic? In other words, now that we have MNRNA and we have 3D printing, we have CRISPR, We have, is this the last, you know, that we might be a side benefit of COVID that we won't suffer from a global pandemic again? Well, I'm an optimist, Brian, and I think it's possible that we could markedly reduce the chances that we'll have another pandemic if we have developed stockpiles of universal vaccines against all the candidate viruses.

Starting point is 00:40:10 So basically, because of what we now can do with structural biology and with CRISPR and, you know, all the tools that we have, we can basically take down all coronaviruses and other viruses that would likely yield a pandemic, such that the moment we saw it start in an outbreak, we would be, you know, all over it and have the tools to squash it. So that we would never get in this kind of situation again. But that relies on heavy investment in the life science to have those pan virus, all the candidates. There's a list of like five or six families. And we have the ability now. We're smart enough to know whether it's through natural antibody reverse engineering that people make these incredibly potent antibodies, super antibodies, or whether it's synthetic means. We could do this.

Starting point is 00:41:08 but we have to fund it. We have to put the resources and the intellectual talent behind it. But I do think the chances will be blunt it. It will never be zero. And it could be that the top five virus families that we think are it. And we get a surprise, you know. So that's what we should be aiming for right now is having preparation where we basically have a way to squash this from the get-go. another question from a listener or viewer on YouTube who has a name actually i chose i was going to choose

Starting point is 00:41:44 from my oldest son but his name is stinky piece of cheese and yet and yet he asked a very or she asked i don't know it could be a woman asked a very provocative and interesting question um about the future of technology not just AI but he asked or she asked other than eCG pulse oxymetry galvanic response temperature and blood insulin and other things, oxygenation. What other non-invasive sensors look promising to provide real-time specific patient data for input? Oh, I think it's immense, actually. Just voice is a big one.

Starting point is 00:42:23 There's going to be ability for breath, to, you know, being able to pick up all the organic molecules in the person's breath. I mean, it's just unlimited. We have basically, we have all these exhaust fumes as human machines that we are. Some more than others. Some more than others. Yeah, some more than others that we haven't tapped into yet. So, no, I think that the non-invasive sensor world is going to be rich. And we're just barely scratching the surface. And stinky piece of cheese started with a few there, but there's a whole lot more, really. That's right. And the stinkiness, the breath maybe could perhaps provide vital. clues as to his or her health. Another question from a listener.

Starting point is 00:43:09 Second choice for a name for one of my kids. Zero skull, okay? Zero skull asks, is there any such thing as a typical human? I see online often, and maybe I even see you retweet this. You know, there'll be some study, you know, like coffee, more than three cups of coffee a day, kills, you know, you with 100% certainty in 100 year.

Starting point is 00:43:30 But in mice, you know, it's always in mice. By the way, I've coined another one instead of just say mice, it's just say dust, because dust is responsible for most of the, like, hoaxes and problems in astronomy that we see. But anyway, he's asking, does any human that you've ever encountered or examined meet the physiological, psychological, psychological, sociological definition of a typical human? And if not, is that a problem? Yeah, I think that's the principle of individualized medicine, that every one of us is unique. biologically and atomically, our environment, you know, physiologically, every layer.

Starting point is 00:44:09 We are unique. So that's why in many respects, we try to dumb down medicine with the clinical trial. And the clinical trial, you know, that's the sanctimonious clinical trial where you have 10 people out of 100 derived benefit, right? And then you treat everyone with that treatment. Well, what about the 90 that don't have benefit, right? So we have basically all these pills that people are taking every day, and we don't even know if they benefit because are they like the five or the 10 out of 100 that do benefit? Or are they like the 90 or the 85 they don't.

Starting point is 00:44:45 I mean, we are so stupid. We have to be smarter than this because the waste is profound, right? And it isn't just the cost. It's also exposure to side effects and, you know, taking some pill for the rest of your life and so many. we have to do better than this to understand, and that's part of the deep medicine principle, is deep phenotyping, that we understand each person at this kind of multi-dimensional way. And, you know, we can do that now. We just aren't doing it. Question from a fourth-year medical student named Nicholas Premiano. I can't believe that's his real

Starting point is 00:45:24 name. His real name has got to be, you know, like oblong footballers. And anyway, now, This is a real person with a real picture. Nicholas asks you, and this is related, I think, to your conversation with Sam Harris. You talked about the vaccine reporting system and how it's overreporting adverse events by three orders of magnitude. This is according to him. I'm just taking his word for it. I have no reason to suspect that he wouldn't. But he said, is it okay to exaggerate health issues in the name of greater good of public safety?

Starting point is 00:45:54 And actually, I've thought about this, too. It was admitted not too long ago that some breast cancer, you know, that some breast cancer, advocacy group, you know, advocated that all women get mammograms or some, anyway, there was a controversy about mammograms, I remember, very strikingly, and secondhand smoke. And what you did mention with Sam as an example of like something that, you know, is not really transmissible. Anyway, there was a long ago, the American Lung Association, you know, had statistics like, you know, you're 20 times more likely to die of secondhand smoke. And now we don't really talk about it because it was so successful. And obviously, women getting early screening and surveillance for breast cancer

Starting point is 00:46:28 is a net positive, and people not smoking and not impacting people with secondhand smoke is a benefit. Now, the question I think Nicholas is asking is, you know, to what extent is it okay to exaggerate medical benefits in the name of public health? I know you're not a public health. Yeah, I think you touched on mammography, and that's a great example, because the benefits have been grossly exaggerated. So if you take 10,000 women, the prototypic risk at age 50, and you have them get a mammogram every year for 10 years, you find out that there's a 60% false positive rate. Yeah.

Starting point is 00:47:07 But all these poor women that are told there's something abnormal. Many of them get biopsies. Some of them even get treated and surgery. So you have all these false positives for the very small few people that you've helped, right? A few over the course of a decade. So when you exaggerate things, the implications from a public health standpoint are profound. It's kind of like the algorithm that goes into scale in people and there's a glitch in it and you can hurt a lot of people real quickly. That's what you can do if you exaggerate the benefits or the

Starting point is 00:47:40 harms. Now, when I was talking about the vaccine adverse event recording system, that was the same sort of thing as exaggerating the harms because none of these reported things are reviewed or adjudicated. And so a lot of them have nothing to do with the vaccine. In fact, most. So we have to be accurate, again, with this, whether it's a particular intervention, screening, the results of a treatment like the vaccines. All these things require accuracy. And when they're loose, we got problems. So last question from the audience has to do with whether or not, I don't know why he's asking you this, but he's asking you. is there an anthological, is there a moral imperative rather, for humans to colonize other planets?

Starting point is 00:48:31 Well, that's an interesting question. You know, I listened to Jeff Bezos on his recent little trip, a little adventure, about how important it is and how it will be the way to save the planet and, you know, a lot of theoretical things, right? Maybe, maybe. I can see it as a potential thing. I think the problem, and this is where, you know, I got involved a little bit with the Kelly brothers. The traveling in space for human beings, we're not fit. We're not fit to be. If you go hang out in the ISS for any undue period of time or try to take a little trip to Mars, it's going to really have a big. hit on your body and we don't know who are the right genome and right people that you're going to withstand that hit. I mean, humans weren't meant for this. So there's some trade-offs, Brian. I think there's some benefits potentially, but we haven't weighed the toll it takes on Scott Kelly when he was compared to his brother, Mark, who never left, you know. So it's an unknown and I think

Starting point is 00:49:44 we have some of these, you know, between Branson and Musk and Bezos, we have these incredible I don't think we've carefully considered some of the trade-offs to the human toll on your body. Yeah. No, I agree. And just as a point of reference, I had Jessica Mayer, who's from the other Scripps Institution of Oceanography. I interviewed her live while she was on the ISS, and she seemed to be doing well. She enjoyed her hair kind of floating around, but she answered questions from middle school and high school kids around the county. And then I had Lord Martin Reese, who's the astronomer Royale, and tells the question. her horoscope, I guess. But anyway, he was on the show and he said, yes, Elon told me that he

Starting point is 00:50:25 wants to die on Mars. And I said, I just hope it's not on impact. So we're going to go into the impossible, which is when I do questions only for my members and subscribers. And I don't want to deny my non-members and non-subscribers, the opportunity to hear just your last thoughts about COVID, what this wave is likely to do, any imprecations, any implorations, any implorations, What would you like to leave the vast majority of my audience with today? Well, like I said, Brian, I'm an optimist, and I have watched the other countries where this wave, it was severe, but it passed through relatively quickly, shorter than prior. Partly because the virus is so incredibly efficient, burned through populations, and then it can't find hosts and it retreats, partly because in some places we've had, you know, good vaccination to help give some. line of defense. So I'm hoping that in the next several weeks, it'll be passed. But I don't know what

Starting point is 00:51:26 lurks after that. I don't know whether it'll come back, whether we'll see a worse variant. I'm hoping not. I mean, this is pretty darn bad, pretty damn bad. So let's just hope that we're over the biggest hump, because eventually there is the worry that we could see a virus with even more immune evasiveness and make our vaccines look even weaker. So let's hope that we don't see that. Yeah. So I think we're both encouraging people if they meet the requirements to get vaccinated and take proper precautions.

Starting point is 00:52:01 And not be too, you know, I always think being an optimist is dangerous and being a pessimist is dangerous because they can both lead you to inaction. But I want to thank you, Dr. Eric Topol of the Scripps Institute and institution. I always get the two of them, Scripps Research Institute. That's the way I'll remember it. I want to thank you so much. And if you'll indulge me, five more minutes of questions

Starting point is 00:52:22 just from my members and audience called Into the Impossible, we'll ask them final big philosophical picture questions. But for now, Eric, thank you so much for going Into the Impossible. Thank you. Okay.

Starting point is 00:52:33 First question I ask has to do with the far future for you personally. At the biblical age of 120 when you spring forth this mortal coil, what ethical will, not material will,

Starting point is 00:52:46 What ethics, wisdom would you most like to communicate to your biological but also your ideological errors? Oh my gosh. That's a tough one, Brian. That would take more than our time together to come up with an answer. I wish. Let me think about that one. We'll do that in the future. Maybe we'll do a part two. Okay. Last next question is, if you've ever seen 2001 a space odyssey, there are these monoliths. There are these structures that are kind of like time capsules. I want to ask you, what would you put on it? to a time capsule that you knew would last a billion years to summarize the great technological, medical, you know, scientific heights that humanity has achieved. Is there anything in biology, chemistry, medicine? Well, I mean, you know, we talked about AI, but the genome editing, I mean, you mentioned CRISPR is the biggest thing to happen in life science in my 60 plus years of life. And it's unlikely we're going to surpass that for some time. So the idea that we can,

Starting point is 00:53:46 you know, engineer a genome, whether it's, you know, someone who's alive or an embryo is extraordinary to a sword, just like AI. And as you know, there's fusion of both where you can make AI, the AI can make CRISPR and genome editing better. So the question here is can we, can we use it right? Can we can we make, because we can change the species now. Right. And that's freaking scary, right? It's scary. Yeah. Yeah, there's an old joke where a doctor like yourself, or like Jennifer Doudna says, you know, I can do anything God can do. Oh, yeah, can you make a man out of dust? And she says, yeah, let me just scoop up some dust. And he says, no, no, no, get your own dust. I made it myself. Okay, last question, doctor, has to do with the past, not the future.

Starting point is 00:54:31 If you could go back and tell your 20-year-old self some piece of advice that would give you the courage, as Arthur C. Clark said, to go into the impossible. That's the only way to know the limits of what's possible. What would you give your 20-year-old self? What piece of advice or wisdom would you give yourself to give you the courage to go into the impossible as you have done. Well, you know, it's been, I guess, modus operandius for me, which is, you know, tell it like it is and just be ready that sometimes the people you're telling it to aren't going to like it or you. But at the end of the day, it's the right way to be. Don't try to be a populist. Try to, you know, call the balls and the strikes as they are. And if you do that, you know,

Starting point is 00:55:15 that over your lifetime of your career, no matter what walk of life here, and I don't think you regret it. But it will lead, has led to me, in me, you know, some rough patches, but, you know, that's perseverance in truth-telling is vital. Dr. Eric Topal, a real doctor, not like me. Thank you so much for spending so much of your valuable time going into The Impossible with me and my audience. It's been a real treat. Same for me, Brian. Thanks so much.

Starting point is 00:55:45 Thanks so much. Any sufficiently advanced technology is in distinguishing from magic. Thank you for listening to Into the Impossible with Professor Brian Keating. Please support the show by rating, commenting, sharing, and leaving reviews. We appreciate hearing from you, and it really helps keep our universe expanding. Watch our YouTube channel at Dr. Brian Keating. That's DR. Brian Keating. And join our premieres Tuesday at 8 a.m.

Starting point is 00:56:20 time. Follow Brian on Twitter and Medium and support us on Patreon at Dr. Brian Keating. For exclusive content, visit Professor Keating's website and sign up for his informative newsletter at Brian Keating.com. Into The Impossible is produced with the Arthur C. Clark Center for Human Imagination in the Division of Physical Sciences at the University of California, San Diego, produced by Stuart Volko and Brian Keating. Ambition comes in all shapes and sizes. We roll with your goals because we're built for what you're building.

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Into the Impossible With Brian Keating - Eric Topol: AI Doctors, Medicine's Future, and The Delta Variant (#173)

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