A physician’s journey to reduce medical error: Steve Charlap - SOAP Health

It was a pleasure speaking with Steven Charlap, MD, MBA, he is on a mission to reduce diagnostic errors and SOAP Health provides an eloquent solution which addresses pain points for patients, clinicians and payors.

It’s incredibly rare to meet solution which cater to all three of the above. I’m grateful for the opportunity to learn from Steven Charlap, MD, MBA and be an investor in SOAP Health.

We talk about:

1. His childhood
2. Meaning in life
3. How to hire the best people
4. The future of AI in medicine
5. EMR design
6. And more!

Transcript

Thanks so much for being here today, Steve. I'm really looking forward to this conversation to get started. Our childhood shapes us in some capacity. There are things we learned from our childhood which contribute to our success, and there are things we have to unlearn from our childhood for us to succeed.

Talk to me about your childhood, and if you could frame it in the way of, what are some learnings which have helped you and what are some things you had to unlearn?

Yeah, that's a thorny question. I, I had a very interesting childhood because my mother was a Holocaust survivor and she inexplicably decided to share her horror stories with me, uh, which were quite haunting to a small child.

And I often got nightmares of, uh, Nazis chasing me. And I think one of the big takeaways from her Holocaust stories was The Will to Survive, which I think inspired the entrepreneurship in me. Because she was in Hungary and the marching orders from her father was wherever you were. Be clever in finding means to escape, and I think that cleverness and, and finding a solution to every problem to survive, uh, might very well be foundational for me.

And then the other big thing is my mother was very big into prevention. Uh, back in the 1960s, she used to take me to the library where she would read the latest edition of Prevention Magazine. While I would read Curious George and on the way home she would share, uh, everything she read. And then she would use me as her experiment of cod liver oil and back in the day chicken, liver and all kind of vitamins.

And she, in fact, she used to feed me a breakfast that most people wanna bf when they hear that was a combination of cottage cheese, orange juice, applesauce, and wheat drum. Uh, my wife likes to say, I have no taste Pal. I think it's clear. Why not? But I would say that, um, those were two of the valuable lessons.

A third valuable lesson actually came from my brothers. I had two older brothers and one brother said to me, with your attitude towards school, I don't see you getting higher than C and any cost that you take in college. And the other brother said, I want you to know that it's possible to get an A in every single class that you take in college.

And that became kind of a linchpin of, it was easy to fail, but it was possible to succeed. And I would say those three influences, uh, were very powerful. And then the last one, growing up, I would say poor, not poverty level poor, but poor enough that my father wouldn't ask the landlord to increase the heat because he thought he would increase the rent.

So I would have sore throats. Throughout every winter and my room would be absolutely freezing. So growing up poor, uh, definitely inspires you to, um, not be poor anymore. Thanks for sharing that.

I, I recently read Mansur for Meeting by Victor Franco. Have you read that book and what are your thoughts on it if you have?

I mean, I read it a long time ago. Look, there were many different perspectives that people walked away from that type of traumatic experience. Some found meaning, some just survived. Um, quite frankly, I don't know if my mother ever found meaning other than to survive. Uh, she raised a family with three boys.

Um, each of us successful in our own way. But, uh, yeah, I, I don't think I have a strong opinion. It's been too long since I read it. How has

money changed your happiness and your life? When I moved to Canada with my parents, the four of us lived on about $40,000 a year. Now I make well into six figures, but I am not sure if I'm any happier, especially when it comes to buying nicer things, spending more money.

Yeah. Look, I discovered a long time ago that, uh, money doesn't, money doesn't bring happiness. The lack of money can bring pain and dismay. If your refrigerator breaks and you can't afford to replace it, uh, that's a big deal. Uh, but when you get to a certain level of comfort, additional money doesn't add to your happiness.

I think happiness ultimately is an intrinsic point of view. I was accepted into the University of Pennsylvania applied positive Psychology program. Run by Martin Seligman, who's considered the father of positive psychology of the happiness movement. And, uh, I ended up not, uh, matriculating, but I read all the cost material.

So I have a very good sense of what happiness means from a clinical perspective. And he symbolizes it with an acronym called perma. P e r m a p stands for positive emotion. E is engagement r's relationships, M is meaning and a is accomplishment. And, and I think he's pretty spot on with that acronym, and I think about that all the time.

I also think about, uh, the, uh, serenity prayer. You know, Lord, give me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference. So coming back to your question about money. I think, again, at a certain level, additional money is not going to give you any satisfaction if you don't have meaningful relationships, if you don't have purpose, uh, if you don't have positive emotion in general.

So money is important to get to a certain level, but beyond that, uh, it's amorphous.

Let's talk about decision making. Let's talk about structure and intuition and decision making and the framework of when you are trying to pick who you want to work with in terms of a job you're applying or people you're hiring or bringing on.

Yeah. Something I struggle with is either giving people too much freedom and not enough structure, or being too controlling, so to say, a how do you. How do you decide who to hire, who to work with, and B, what is your management style in terms of after they've been brought on?

Yeah, so I would say it's a evolution of sorts from when I was a young man to today, but let me just go back for a second now in the concept of intuition.

I don't know if you read the book by Daniel Canman, thinking Fast and Slow, and the One by Tib, uh, fooled by Randomness. I think both of those books do a very good job of making you step back and say, intuition will only go so far. In fact, I recently saw a study about doctor's intuition about how well a surgery you would go, and it turns out the intuition wasn't particularly meaningful.

So I'm not a big believer in relying on intuition anymore. I think intuition can point you in a certain direction. But analysis ultimately helps you make the decision in terms of hiring people. People are very interesting. Uh, I remember one of the first people I hired for, as a controller with a guy with a Warton mba who was so upbeat in the interview, so, so incredibly upbeat.

And then when he started working, he was kind of a Marose fellow. And I went to him, I said, look, you, you really got me confused here. You were this really upbeat, upbeat guy during the interview, and now you're kind of, uh, depressed. And he said, well, Steve, of course, during the interview I had to put on my best face and I had to make the best impression.

Uh, but right now, you know, this is really me. So once I, one, I realized that the interview process is a process with an end in itself, and it doesn't necessarily reflect who you end up with. Another example was a guy who told me he was, he graduated number two in West Point. And was so positive in the way he spoke in terms of us and we even during his interview.

But then when he joined the company, one of the immediate giveaways were we were playing basketball outside and he got, uh, winded really quickly and I'm thinking, guy graduated number two in West Point. He's just shortly out of the military and he's already outta shape. Yeah, maybe he is a bigger talker than he is.

And the third example was a guy who told me he played division one basketball, joined our company, uh, and turned out to be a lousy basketball player and an even worse billing manager. So people can fool you and you should expect that they're trying to fool you. So I'd like to ask a couple of questions, two or three questions that kind of sets people apart.

One of the questions is, if you don't know where you're going, are you likely to go fast or slower or normal speed? And there's no right answer, but the thoughtfulness by which people answer that question gives me some insight into who they are as an individual. People like me, entrepreneurs tend to say we go fast.

Yeah. In other words, we're gonna rush. We're gonna, we're gonna pick up clues along the way, and we're going the wrong way. We wanna get to where we're going wrong as quickly as possible so we can turn around and go back the other way. Thoughtful, careful, detail-oriented. People tend to say, I slow down.

Yeah. The smartest people say, I stop and get directions, but I, I hardly ever hear that answer, but, but I love that answer. Another question I ask that's really quite telling is, tell me all the ways to get on the other side of a wall, because that's a question that requires not only creativity to. But logic, but also persistence and perseverance.

In other words, what I'm testing in that question is how long will someone try to be creative as long as I give them the opportunity. So one, you know, they'll give me standard answers. I'll go above the wall, go below the wall, go around the wall, but I'll keep pressing them and I'll see how they will good naturedly handle that pressure to come up with yet more answers.

And the ones that are good humored about it, at a minimum, I know that it's gonna be a pleasure to work with them. They may not be the smartest, they may not be the most competent, but they will be the the the easiest to work with. And when you are working on something intensely, working with people that are easy to work with, I think is incredibly important.

The third question I'd like to ask is a brain teaser. And again, You don't have to be a genius to figure out this brain teaser, particularly since I'm helping you, but your willingness to continue to struggle to solve the problem. Just like finding the other side of the wall tells me that you're not gonna be somebody easily dissuaded from achieving your goal.

And the final thing is I look for people who are curious, people who, at the end of that question say, are there any other ways to get around the wall that I may not have thought of? Okay. Uh, how would you have answered that question? I find that the most successful people in the world are the most curious.

When they're listening to somebody speak and they don't understand a word, they never hesitate to ask, what is that abbreviation? Or what did you mean by that? Or, I don't really understand what you're saying. Could you clarify for me? I do that all the time, and some people find it annoying that I pepper them with too many questions.

In fact, when I went to the Mayo Clinic, we were part of a program there, John Aloka stopped calling on me because I kept asking too many questions and he kept saying, Steve, I can't call on you anymore. I gotta call on other people because it's my nature to be curious and want to understand exactly what the opportunity all, all the information in front of me is.

Thanks for that answer, Steve. There, there are a lot of nuggets there and I would love if we have time for you to test me with these questions, cuz I, I think it would be a fun exercise for myself as well. Is it better to be a great visionary or a great operator? And are you someone who follows the philosophy, focuses on your strengths and quote unquote, ignore your weaknesses.

Or do you want to be a more balanced person in the sense, and I use the word balanced on purpose, that you should focus on your weaknesses, so you are more well-rounded. I think you should ignore your weaknesses and just go all in in your strengths. Sure.

So let me unpack that a little bit because there's a whole bunch of stuff there.

Let's talk about strength and weaknesses. I coached basketball teams that won championship, and what I realized was that everyone was not going to be great at everything, but everybody was part of a team and everybody had a role to play. And so I played to people's strengths and whatever they were great at, I tried to make them even better at.

So if you weren't a great shooter, but you were a great defender. I worked on your defensive skills. Yes. We've still worked on some offensive skills. But I just wanted you to be even better in what you were, cause what you're really good at, you're also very confident in that and you're able to execute in, in pressure situations.

And I can't tell you how many times a game was won by a guy who was sitting on the bench who hardly got to play. But I knew defensively would give a a plus effort and I would put him on, let's say the guy who was scoring at will on the other team. And that basically would shut down that guy because this guy knew his role was to ride that offensive player up and down the court.

So that's one thing. Let's talk about vision. Vision is a naturally very interesting word because vision actually means to see things that other people don't see. And I saw a study, uh, a couple of months ago that talked about that creative people. See things differently than other people. For example, when I am often asked a question, my answer might sound like it's nonresponsive to the question I'm being asked.

But what's going on in my brain is that I'm thinking about, not the question you asked me, but the questioning you should have asked me, or you probably wanted to ask me, but you didn't think of it. And so my brain is skipping steps. And so it sounds like my response is not secreted to the question, but in fact it's gone in another direction where, for example, somebody asking me, is the Santa's popular in Florida?

And to me, he's not really asking about the Santa's popularity. He's asking me, is the Santa's gonna be a difficult challenge for Donald Trump? That's what my mind hears. And so I start talking about how DeSantis are viewed and how Trump is viewed. And he is like the guy says to me, I just wanted to know is DeSantis popular in Florida?

And so I didn't answer his question. And in fact, this happens with me with venture capitalists. They ask a question and I'm answering something else because I'm thinking, you're not asking a relevant question. This is the question you should be asking. Therefore, that's the question I'm gonna be answering.

So that's the problem with vision, is taking something that's com almost outta worldly and something you see that they don't see and making it relevant to them. And in order to do that, that's the second part of your question. It's the detail and it's the communication and it's the demonstrate by leadership that gets people to go along Now, So health is actually conducting an incredible experiment.

We recruited all our senior executives by requirement, requiring a significant investment based on the principle that they would be vested and invested on day one. And it is a working process with the results to ultimately be determined. But I have never pulled rank, even though I'm the majority shareholder, I have never pulled rank, even though I'm the ceo.

And I like to joke that nobody reports to me in the company because everybody is an independent owner doing his and her own thing. And so we will see at the end of this grand experiment whether or not this is truly an effective way to build a successful team.

Talking about teams, why do teams fall apart?

Steve, in your experience, what are three things you would say?

Uh, or, that's a great question because it once happened to me in a basketball tournament. I was coaching girls varsity and we, I lost a team because I made a snide comment about one of the players for a player next to me on the bench. And that was a friend of hers and she repeated it and this girl on the court suddenly did not care what I had to say.

And the rest of the team kind of picked up on that vibe. And we lost a couple of critical games in the tournament instead of winning the tournament. Cause we were the best team. Uh, we came like in third in the tournament. And so losing a team is a lot easier than gaining a team because in one moment, one.

Inappropriate comment, one, inappropriate action could have somebody losing respect for you. And that loss of respect can basically turn into a, a, uh, what's the word? Like a snowball rolling down a hill. So losing teams is not being ethical, not being honest, uh, not respecting other people's perspective, uh, not considering other viewpoints, et cetera.

That said, it's often, as I said, I don't pull rank in soap, but if I feel strongly about something, I may talk your ear off about it. And that can get annoying sometimes. But I definitely wanna make sure that, that my perspective is fully heard and understood, even if not agreed upon.

That's a good way to look at this.

I think a lot of people act out or pull away when they don't feel heard and, and making sure everyone has a voice on the table is important. That being said, oftentimes the best ideas are not the most popular ones. And idea meritocracy is not an idea. Democracy. Tell me your thoughts on that. And would a weighted decision making process, say on a board or, or in an election even where people with more knowledge, more experience get more votes and people with less knowledge, less experience get, get fewer votes?

The fact that someone who's a criminal, who's immoral, unethical, gets one vote and someone who is the most moral person and devotes their life, society gets one vote to me, seems like. Stupid process to elect our leaders. Tell, tell me your thoughts about how to build an idea meritocracy where it may not be, you're not falling.

A purely democratic process of decision making and as more of a weighted decision making process based on experience and knowledge.

Yeah. It kind of reminds me of the concept of Marshall Law where the government has to take control because leadership, exertional leadership is required. It's an unfortunate state of event, but it is sometimes required from a, from a health perspective.

Public health initiatives have been known to have the single greatest impact on health issues, uh, whether it's agreed upon things like fluoridation, vaccination, banning of smoking in public areas, et cetera. Those have had huge impacts on. Cancer rates, uh, et cetera. Beyond that, I've had two situations where I didn't want to exert authority, but I needed to.

One, it is, I founded a magazine at Harvard Business School called the Business Ethics Forum, and the principal behind the magazine was that students should be driving Ed ethical dialogue within business. And it turned out that that year at Harvard Business School, the former head of the, uh, stock exchange named uh, shagged had donated 30 million to Harvard Business School for ethics curriculum.

So the school was very reluctant to have a student basically drive something in ethics before the school had a chance to develop something on its own. So I got a lot of pushback from the administration and in fact, they discouraged any professor from working with me and you needed a faculty advisor. I ended up getting a faculty advisor who had been denied tenure, which still made an eligible and they wouldn't allow me to form my own organization on campus.

So I joined a different organization and worked under their auspices, and I finally put together a student board and we had our first meeting and there was so much debating about what the magazine was going to be. I said, if we continue to debate this, the magazine will never get published. So by Pushed comes to shove, we actually got it published and I got the dean to write the prologue to the magazine.

I got a couple professors to write articles. I got the head of Johnson Johnson to write an article about the Tylenol. Scandal and so on and so forth. But it was by basically exerting authority over everybody else saying, okay, listen, we've talked enough, we gotta stop talking, we gotta start doing that. We got the magazine published and I ended up getting an award from the dean in graduation for that effort.

So that was one situation. Another situation of my first company, we used to charge for dental exams to patients because Medicaid didn't pay for dental exams and people hated getting out of

Steve. Can you also tell me about the Tylenol scandal? Cause I don't know about that. The Tylenol scandal

was somebody, uh, opened up Tylenol bottles and put poison in it and there was a big to do whether or not Tylenol should recall all, whether Johnson Johnson should recall all Tylenol on the market.

And James Burke, who was the c e o at the time, made the decision. They, and they've studied this leadership move for years after to pull all Tylenol product off the market, even at great financial loss because he felt that it was the right thing to do cause they weren't sure which bottles had been corrupted.

And then Tylenol came back with a tamper-proof bottle after that. So that was the, uh, Tylenol scandal. Um, coming back to the example, so we used to charge for this dental exam, $25, and people were upset because these were Medicaid patients, but without that $25, we would've ceased to exist as a mobile dental provider to nursing homes.

And because cost kept increasing, I had to make the unpopular decision to increase it to 35. And virtually every single person in the company said, don't do it, because they knew there was already to. Biggest thorn of contention from customers, but I knew that if we didn't increase to 35, we would not be able to keep the lights on.

And so singularly, and with the old adage from Shakespeare Heavy as the head that wears the crown, I made the independent decision that we had to increase it, and it turned out okay. But there was a couple of times where you just had to basically do what you knew you had to do, even if nobody else agreed with you.

And in fact, as a child, I very much remember the famous short Story Enemy of the People by Henrik Gibson. Are you familiar with that story? No. It's about a doctor in a, I think in a Finland town that is the town's doctor, and the town has these sofa baths that everybody comes from all over to bathe in them because they're supposed to be very healthy.

And the doctor discovers. Not only are they not healthy, but in fact they're unhealthy and he starts telling the leaders of the town. We have to tell everybody and the leaders of the town say, if you do that, you'll put us out of business. Nobody will come here. And he becomes an enemy of the people or the movie 12 angry Men, where one juror believes the person is innocent and everybody else wants to convict, and eventually he convinces them.

So leadership really is sometimes the head, the wears, the heavy crown, and sometimes you have to make very tough decisions. And so sometimes you have to be in the position to be allowed to make those tough decisions.

The doctors of the future will be actors. You studied speech, drama, and film in undergrad. Tell me about that time. Tell me if you agree with that statement and what did you learn from your undergraduate studies that are useful as a, as an entrepreneur, as a c, and as a physician? Yeah, so

I've heard Vino KO speak and I've met with him personally a couple of times.

I also read his 20%, uh, solution paper first before it was edited and and copyrighted. And then afterwards what he said was that 80% of what doctors do can be done by ai and the 20%, which is the empathy and handholding could be done by actors and actresses. Do I believe that to be true? Yes. Because I've gone to many a doctor who has not been particularly empathetic, and I do believe that AI will eventually get to the point where like in chess, it will succumb human capability.

What I've learned from speech and drama, and in fact, I get to use it all the time because I mentor up to nine students every year from Stanford Business School in public speaking. And the main thing that I teach in public speaking, which I took away from my speech and drama training, is passion. Ask yourself, what kind of speaker do you wanna listen to?

Someone mundane, someone monotonous, or someone who is passionate. And, and by passionate I don't mean screaming because anybody can scream. Passionate means excited. Thinking carefully about what you're saying, not running on your sentences, making sure that you are connecting with your audience, making sure that your audience is following, holding onto your audience's attention.

So I do that literally every year. For the last five, six years I've been doing that mentoring. I've mentored now at least, uh, 30, 40 students on improved public speaking, and I try to give them little nuggets and gems. I also tell them when publicly speaking, if you can use a prop because a prop is worth a thousand words, use a prop if you can, to make sure the audience can fully relate to what it is that you're trying to convey.

Those are.

Let's go back to the chess analogy. A AI has beaten almost every, it has been every human in chess, but people don't watch AI playing chess. People watch Magnus, Carl Carlson playing chess. People watch a car, they, they still like watching people playing chess. So bring that analogy to medicine.

Say AI is better than the best doctor. Will people actually use AI or will they still want a human involved for whatever reason? And if so, why would they want the human involved?

Yeah. So I've been giving a lecture that I've given twice, and I'm gonna give it to some Harvard MBAs in a few weeks. It's titled The Rise Four of American Medicine.

What comes Next? And at the beginning of the lecture, I asked the audience a very simple question. If you had the choice between an AI doctor that was always accessible, infinitely patient, sometimes funny, inexpensive. And clinically validated, or a human doctor who you have to schedule at his or her convenience, considerably more expensive and prone to human error, which one would you choose?

And the audience inevitably chooses the human doctor by the time I finish my lecture and I describe the woes that are afflicting doctors today, such as 63% report, symptoms of burnout, 53% report burnout, 27% report depression, one outta 10, report suicidal ideation, nine outta 10. Report being verbally or physically abused by patients in the last year adjusted for inflation.

They are paid less money than they were paid in the 1970s. According to a landmark study by the afternoon, they suffer from decision fatigue all day. They suffer from cognitive bias. So by the end of my lecture, when I ask that question, the overwhelming majority of people say the AI doctor. And in fact, I make a joke that's really not so funny and, and at the expense of doctors, I say, the next time you go to your doctor, put your arm around your doctor and say, don't worry, it'll be okay.

And if you're feeling depressed, say to your doctor, by the way, what's been working for you? So these are meant to be humorous, but they're really not funny because medicine is in a very sad shape of affairs. I know a lot of physicians. This burnout thing is very real. It's taken hold. It's driving them crazy.

I heard one of my closest friends on the phone with his answering service who called them accidentally on vacation, and I've never heard him lose it to this answering service, which to me tells me he really needed a vacation. And so any interruption on that vacation was dealt with very harshly. So it's a, uh, the answer to your question is I believe the future of medicine and the future of every medical encounter is going to begin with interface with ai, and that's why Soap Health built and patented the use of a digital human as an interviewer.

Because if you watch sciences fiction, Unlike previous science fiction like 2001, a Space Odyssey, back to the future Star Trek. When they spoke to a computer, they spoke to the ear. In more recent science fiction, when they speak to a computer, they always speak to an embodiment of the computer. Whether it's a hologram, whether it's a physical robot, whether it's a face on the screen, it's always an embodiment because people relate better to an anthropomorphic computer representation than to a non anthropomorphic.

And just to give you a quick example on, on the most basic level, there was a study done at Stanford where they had a automated garbage collector go around to different tables, and when it got to your table, it would open up and people intuitively understood, throw your garbage in. Then they reran the experiment.

With when you put your garbage in, it beat to acknowledge that you put your garbage in. And people were asked in both cases how they felt about the interaction and they felt much better when there was some form of acknowledgement from the robot. And I think that's also true with ai. We want the AI to recognize our pain.

We want the AI to understand and acknowledge what we're saying. Is one of the reasons why soap health reflects answers back to users to say, I was listening. Did I get it right? And if I didn't get it right, please correct it. Now, how often does your doctor say to you, did I get this right? Or, please correct me if I'm wrong.

Not very often. It's a scary

thought to think. It's more likely than not that your doctor is burnt out. It's more likely than not that they're stressed and it's more, much more likely than not that they have been abused in some capacity in the past year. On your LinkedIn, Steve, you say, while at nyu, I studied medicine and was taught that patients have to share responsibility for their health.

Tell me what you mean by this. Where are patients feeling in their health journey and what can they do better? So

back in the 1980s where patient empower was not yet a concept or even a, uh, as they say, a twinkle in somebody's eyes, they showed us a video back at NYU of a nurse attempting to inject something into a patient's iv, and the patient objecting and the nurse insisting and the patient eventually slugging.

The nurse, and I thought they were gonna say, this is inappropriate behavior from the patient. But instead they taught us that the patient had done the right thing because the nurse was attempting to inject the wrong medication. A few years ago I had hip surgery and literally six times nurses tried to give me a medication that had long been discontinued.

And despite my protestations on each and every occasion after the first one, I thought we'd be done. And they came back five more times, over two days, still attempting to give me that medication. So the reality is that most patients are not physicians and are not cognizant or not curious enough to ask the nurse, what are you giving me?

But there's so much human error out there right now that if a patient is not alert, And paying attention, some really bad things could happen. In fact, let's talk about this error thing because it's a big topic. According to the National Academy of Medicine, they now predict that everyone in this country will experience a diagnostic error.

It's estimated that over 18 million errors are made each year, costing over 250,000 lives and nearly a trillion dollars in cost. I lost my brother to an error, a physician. I lost a friend, a physician, to an error, and I almost lost my life to an error. If physicians can't protect themselves against errors, then you gotta believe the National Academy of Medicine is right, that everyone is at risk of errors.

Now, errors not only kill people, but they also create disabilities, and it's believed that for every life loss there are 10 disabilities. That are created and these errors are contributing. The burnout, because it is said for every hundred physicians there are 97 lawsuits. And according to the American Medical Association, 65% of doctors are sued by the age of 55.

That's about two-thirds of their way through the career. Thirds of doctors have been sued, so this error thing is a real problem. So it's not about, you know, going on Google and, and coming prepared and arguing with the doctor. It is about asking questions to really understand why the doctor is proposing the treatment plan or reach the diagnosis that he or she has reached.

Here's one of the big problems in medicine. You leave a doctor, the doctor wouldn't agree with the doctor. You don't come back. Doctor has no idea. He or she got it wrong. We don't close the loop in medicine, which is a big problem, which is one of the other things that SOAP is working on. Is a module that closes the loop.

That is very well said. And I wonder if the ui ux of medicine, the EMRs have made this worse or better recently. I would imagine they're an improvement on paper charts, but as a hospitalist, the way I see the medications is incredibly confusing even to me. Yeah. And I, I think there's, there's so much room for improvement

there.

Yeah. Look, I built the world's first mobile multi-specialty electronic health record some 20 something years ago. And unlike current electronic health records, maybe the more current ones are doing this, we built it to improve productivity, not to comply with some type of regulatory requirement. And the EMRs that were built over since then, many of them were built for meaningful use to comply with all types of regulatory requirements without any real consideration for the physician experience.

And in fact, today I look at these things, and from my perspective, they still look like DOS based applications, even the epics and the CNAs of the world. And you scratch your head and say, couldn't there have been a better ui UX designed to accomplish the same thing? But that would've required more effort.

And I truly don't understand why the U I UX is so poor. One of the, one of the gurus is a group called the Nielsen Group, founded by Jacob Nielsen. He's the kind of godfather of use to face and design, and I read his literature with a religious fervor. Because it is spot on. And, and one of the simplest rules of UX UI is don't make the user think.

In fact, Nissen wrote a book, uh, I don't know, 17 years ago that I read a few months ago called, don't Make Me Think, and it was still relevant. 17, 18 years later. Maybe he was even older than that. Don't make the user think that's, that's the key to good user design

that is, uh, incredibly powerful. Uh, quote, don't make the user think, don't make the physician think, don't make the nurse think.

And I think it's part of the problem is EMRs are trying to build one solution for multiple users where they should be building a diff probably to be frank with you, eight or nine different EMRs depending on who's using it.

Look, I don't wanna give away all our trade secrets, but I, but I'll give away one of them.

I interviewed 25 doctors under a National Science Foundation grant, and one of the things they told me that was very interesting was they skip up to 40% of what patients write on a medical history form. So there are a lot of products out there that are creating dashboards and, and dumping a lot of information on doctors without appreciating that if doctors are not reading a patient's medical history form all that carefully, they're not reading anything all that carefully that's highly detailed.

And so, again, from the principle of, don't make me think, you need to be more clever in the way that you present your data. And I have patented, uh, a way, for example, to visualize family history better than the traditional pedigree. And we use other things that. We've developed that are more creative in the way we put the information in front of the doctor so that the doctor is less likely to scan it and miss it.

I personally experienced in the last couple of years, two doctors who clearly did not read my history form. In fact, I'll give you a quick story. Before my hip surgery, I went to a doctor I'd never seen before because I'm interested in family history and the role it plays in disease. While he was reading my history form, I said, Hey, by the way, you don't have any family history on your two page medical history form, and he's holding the form and you go like this.

He goes, ah, I know he used to be there, but don't worry. I'll ask you all about it. And then proceeded not to ask me a single question about family history. Now, in my case, that's very important because I have extensive family history of cancer, heart disease, diabetes, and knowing that family history could be relevant for somebody undergoing surgery.

I think there's a lot to unpack there. I'm sorry you had that experience, but I, I don't think it's uncommon at all. And the way we collect information from patients before the visit is an incredibly important, and I think what a lot of solutions do, they collect all the informations patients want to give us.

Whereas there is a, there needs to be a triage process to collect pertinent information and also also package it in a way. Um, but again, this is one of those things where AI will be better than us. There. There's no doubt in my mind that decision fatigue, as you said, as unless we can build a system where I'm seeing maximum 10 patients a day, um, which is a sixth of what I see right now.

Yeah.

Decision. So we've taken, yeah, we've taken a contrarian approach. And I'll tell you why. Because during that 25 doctor survey, I asked them, do they want more information on their patients? And they said no. And I was like, okay, how come? And they said, well, more information means more work and I don't have time to do the work I already do.

Yeah. And then they said something that was somewhat bone chilling and quite a number of them said it, more information might include something important and I'll miss it, and then I'll be held liable for it. So you would think that the key to a good patient intake application is the limit, the information that you collect?

Yeah. Well, that's why I'm a contrarian. I say, no, we should do an exhaustive intake, but we should make sense of the data we collect for the doctor. In other words, we should pull out actionable information from that data and present it to the doctor in an easy means to act upon it, which is exactly what so has built.

So we are going for that information for two reasons. One, because we think it could be relevant to this particular visit to the doctor. Two, because we think it could be particularly important to your overall healthcare. And three, we think from a societal perspective, if we can develop these detailed profiles, what we call precision patient profiles, then we can mine that data for greater insight than anyone is getting from electronic health record data, which is full of inaccurate data if needed for billing purposes.

So patients may not be perfect historians, but given the time and effort, they can be exceptional historians and they can share things that nobody else can share. Only they truly know what they ate for breakfast. Only they know how stressed they are in their marriage. Only they know what cancer their uncle had.

If we don't ask them in the United States, there's no other way to get that information. Only they know how many sexual partners they have. Right? Yeah. A, a technical, uh, interesting anecdote related to that. So one of the things we say that is great about using a digital human is that it's able to elicit more truthful responses to questions that many doctors don't even feel comfortable asking.

I think, uh,

let, let's go back to your practicing medicine and you do an mba. Why did you decide to do an mba, Steve?

So, it goes back to my speech and drama major. Uh, I fell into the wrong crowd in college. People who wanted to be doctors, older brother was a doctor. I wanted to do something creative. But it turned out that I was first in my class when I applied to medical school, so medical school seemed like the logical place to go.

I went to medical school and I was really disappointed about how cookbook medicine was, how little creativity or self-fulfillment in terms of bringing part of yourself into practice. I actually enjoyed interacting with patients and actually a couple of patients wrote letters to the dean saying, this medical student really went out of his way to be nice to us.

So I found some satisfaction in that relationship. When it came time to do my residency, I said, I don't wanna do cookbook medicine. At least surgery is proactive, active. But then I found that unlike the cookbook medicine, surgery was almost like a craftman, like a carpenter, building a house. It was all about the skills in your hands.

And around the same time in, um, a couple years earlier, DRGs, diagnostic related groups in 1982 were introduced, which fundamentally changed the practice of medicine and also permanently did away with doctor golf jokes because until 1982, doctors could see patients in the morning in the hospital, a few patients in the office, and be on the golf course by the afternoon and make about 250,000.

This was in the seventies. Okay. After DRGs, they had to get their patients out of the hospital. In two days. They couldn't round and make a thousand dollars rounding on their 20 patients at $50 a piece. They had to see more patients in the office, no more time for golf. So it really changed medicine and I got tired of hearing during my residency.

Their attending physicians kept complaining about, How medicine was changing and then the funny straw that broke the camel's back. But I already was accepted into, uh, HBS At the time, the chief of surgery said that Harvard MBAs were ruining medicine at a grand rounds, and he completely demoralized the re resident staff.

I saw people walking out of the room going, I knew I should have gone to law school. You know, I'm just mumbling to themselves, just completely demoralized. And I was thinking, you know what, what medicine needs is somebody that understands clinical care and understands the business because what I keep hearing from the MDs is that the business people are rooting medicine.

When I hear from the business people is the doctors don't understand this is a business. So having both of those degrees, my belief was that I could have a far greater impact on the system than I could ever have as an individual doctor Talking about business,

do you think healthcare should be profitable?

I think if healthcare is not profitable, we will not track the best people through healthcare because many smart people go where the money is. It's not to say that there aren't smart people that would, there would still be smart people who go into medicine, but as we know in healthcare systems where it's socialized and you get a flat fee, you're not incentivized to see more patients.

They often don't see more patients, and the the waiting list could be huge and so on and so forth. So I do believe healthcare should be profitable. But that's a loaded question because when we talk about healthcare, we really gotta dissect healthcare. I don't think health insurance should be profitable because I don't think it serves any greater societal benefit.

It did when it first came on the SCR scene, when health insurance first became available, it was to counter the fact that doctors and hospitals were charging too much money, and so health insurance was a cost effective solution to that problem Today, health insurance, from my perspective, is part of the problem.

So the answer is, should pharmaceutical companies be profitable? Yes. Or they wouldn't be induced to be creative? Should they be as profitable as they are? Well, given the numbers that fail, there's a balance there between those who succeed and, and go through all the trials and tribulations versus all those that try and fail.

I invested in a company that had a half billion dollar valuation, was waiting for the results of a big STEM trial. On, uh, using stem cells to improve cardiac function, post heart attack, the results came back negative. Even though it had been fast tracked by the F fda, it had incredible animal studies. The stock went from half a billion to 20 million.

And then right now my stock is worth about a thousand dollars.

Let's talk about, sorry, go ahead.

I lost about 90% on the value of my,

let's go deeper into genetic medicine. When I was graduating undergrad, 2004, translational medicine, genetic medicine was all the rage. I remember working in a lab where they were taking, uh, flu puttin stem cells and trying to differentiate them into cardiac myocytes.

Uh, so similar to the company you invested in, why hasn't genetic medicine worked out? Why, why hasn't that taken home? Sure. Why ha, why aren't we using stem cells and when we are using some sort of stem cell therapy for arthritis and, and joint injections, the evidence is lackluster and the studies have not shown clear benefit.

So let me tell you a historical story. In 1907, a physician got up at a major health conference in Boston and said blood chemistry testing is essentially worthless in nine out of 10 patient cases. It does not inform medical decision making. In the article that I read that it goes on to explain that the reason the doctor was so apathetic, if not antipathetic to blood chemistry testing was that he and most doctors at the time did not know how to use blood chemistry testing.

In practice. And even more importantly, it was the blood chemistry labs that were pushing the testing, not the doctors demanding it. And very similarly today with genetic testing, the overwhelming majority of American physicians do not know how to use genetic testing in practice. Pure and simple. So when a patient comes to them with 23 and ME results, they reject it outta hand.

One, because 23andme has limited value in its results, and two, they have no idea how to use that in practice. And patients who come with other genetic test results, whether it's from the En Vita or colors, or myriad, or ambs or, or who, or whatnot, the same thing. They don't know how to use it. And what happened with blood chemistry testing at the turn of the 20th century was it took several more decades until blood chemistry testing became part and parcel of routine medical practice.

And I believe that we are making the same mistake again, which is one of the reasons that Soap Health developed in particularly risk assessment around hereditary risk factors for cancer and heart disease and type two diabetes. Why? Because speak to virtually any cardiologist in the United States today, and he or she will tell you that they hardly, if ever, use genetic testing in cardiology practice, even though we know genetics plays a significant role in cardiomyopathies.

Arrhythmias, hypocholesterolemia, et cetera. There was a study a few years ago where 97% of doctors said they wanted, they were interested or very interested in a point of care cancer assessment tool. Do you know how many doctors have a point care cancer assessment tool right now in the us? Virtually no one.

There's only one other company other than SOAP that has developed a cancer risk assessment tool in the primary care setting using patient reported family history to identify people who require specific genetic testing. And we are waiting on a huge grant from the National Cancer Institute that wants tools that doctors are going to use for cancer risk assessment in the primary care setting.

So think about today, doctors don't have a financial incentive to prevent cancer. They don't have a financial incentive to earlier detect cancer. And among the top two misdiagnosis in the United States is missing early cancers. And I'll give you a perfect example. We're taught in medical school. When you hear horses think of, well, I'm sorry, when you hear hoof beats, think of horses not zebras.

Well, unfortunately, the horses are often not the ones that are gonna kill you. It's the zebras are gonna kill you. Not that cancer and heart disease are zebras because they are the top two killers in the United States. The difference between missing an early cancer and a late cancer is catastrophic cost, catastrophic pain and suffering.

Maybe the difference between life and death. It's life changing. And yet you come in with a sore throat. The doctor's not thinking leukemia and lymphoma as they shouldn't be. But if you have a family history of lots of cancers, or you also have weight loss and fatigue, which is sore throat, and the doctor spends more time collecting that kind of detail, identifying risks, they're more likely to identify that you are at increased risk.

So coming back to genetics, the fundamental issue is that unless we can move physicians, unless we can educate them all, which is highly impractical and unrealistic, we need to hand them tools that baby feeded them, that do the intake, do the assessment, make it easy to order the genetic test, give them the result of the genetic test with specific.

Clinical recommendation so that they can incorporate it with minimal effort for increased reimbursement. Because at the end of the day, I don't wanna say doctors have become mercenary, but making a good living is top of mind. And in the recent Medscape, uh, review, the number one thing the doctors said would address burnout was increase compensation, number one on the list.

And the way they increase compensation is to improve medical complexity. And if you're a patient, you want improved medical complexity because that means the doctor has a more holistic view of you as a patient, which means they're likely to treat you more effectively and more holistic also means earlier detection of disease.

If you look in malpractice suits, it's been shown the number one reason why diagnosis are missed is because risk factors were not considered, which is why SOAP has built the world's first risk and symptom assessment tool because ignoring risk is something you ignore at your own risk. Steve, what is

proudest achievement and what is your biggest failure?

My proudest achieve manage, I'm gonna say is my children. My children are, uh, adults. They give me great pleasure. I was somewhat of a helicopter parent in high school, and then I, I landed and never took off again when they got to college. So I, I made academics a top priority. I. And as a result, all my children went to Ivy League schools.

My daughter went to Harvard. My son went to a joint degree program, university of Pennsylvania, and my youngest daughter went to Barnard Columbia. Uh, so that's my greatest achievement. My greatest failure was my preventive medicine clinic where I was hoping to create a new model of primary prevention in the United States that would change the trajectory of disease.

And I invested 2 million of my own money with a friend, and we built a beautiful primary care center. It was delivering clinically the type of results that everybody in every country would want to take notice of, except here in the United States, the reimbursement was so insufficient that we lost money on making people healthier.

And then my brother got sick. And I ended up closing that down and going back to school to study genetics. But that was my greatest failure and my kids are my greatest success, even though they probably got their intelligence from their mother, I just, I just gave them the, the motivation, but their mother gave them the praise.

Incentivizing prevention is a very difficult problem to solve, specifically because the behaviors we're incentivizing, stopping smoking, healthy eating exercise don't come to fruition in terms of financial savings 40, 50 years down the line

because it isn't about money prevention. Prevention is ultimately about self-awareness, uh, using things like motivational interviewing, tapping into intrinsics motivation.

There are companies, for example, that provide financial incentive around, uh, opioid addiction. So I do believe that you can, financial incentives can drive certain improvement in behavior, but you also have to tap into intrinsic motivation, which is why my second business called MD Prevent had a health certified PhD psychologist on the team.

When people came to me and wanted to lose weight, it's very easy to put somebody on a weight reduction plan. It's much harder to understand why they allowed themselves or whether it was medically predisposed or genetically predisposed to becoming obese. And so a health certified psychologist could help figure out if this was emotional eating or if this was genetically predisposed obesity.

Or what it was. And then we had a, uh, master's level trained nutritionist who could work with people. And we had a master's level trained exercise physiologist who could work on that component. And we had a teaching kitchen, in classrooms, in classes, and a gymnasium and all kind of goodies, which is why we burned through money so quickly.

Uh, and here's the funniest part about that story. So there was a grant application that we applied for, it was called The Billion Dollar Challenge. It's something like that. It was part of the Affordable Care Act. And we submitted an application to open up what we call pre-disease centers. So centers for overweight people, people who were borderline hypertensive, people who were pre-diabetic, et cetera.

And we said, we wanna open up these centers where people could almost, from a community perspective, come in to stop progression of disease. And one of the reviewers asked a question that really blew me away. He said, if your program works, who's going to pay for it?

And the irony of that question, among other things, led me to the conclusion that there is no place for preventive medicine in the United States with simply a society that doesn't buy into prevention. Yeah. We have the worried, well who, you know, takes supplements, which was a whole nother thing. People want pills.

And as I dug into supplements, I became decidedly antis supplement, except in, in very specific situations. So anyway, so prevention is a very tough topic and we as a society are not prevention oriented. The only prevention we do sometimes is, is on our cause and our air conditioners because it's gonna cost us a lot of money to fix it.

But here in the US, if we don't prevent disease, it doesn't cost a lot of money. If you have insurance sometimes to fix it,

the lack of an immediate problem or cause by not falling prevention is, is I, I feel like it's almost an impossible problem to solve. I'll ask you one last question, Steve. What's the end goal for you?

Where, when do you feel you have arrived in life in the sense you have accomplished everything you want to accomplish?

Yeah, that's a great question. I. I tried retiring about 14 years ago, and it was literally the worst year of my life. I had no purpose. I had no meaning. My accomplishment was okay. Done. I had sold my company.

Uh, I did not have a positive emotion. I actually became depressed. So one, I don't think we as human beings are meant to be put out to pasture. This particular effort with self health right now is really born out of losing my brother, the brother I shared a bedroom with the brother whose lap I put my head on, long cart trips.

Uh, the brother that, uh, I often went to because he was a physician, anything medical related and losing him so suddenly as I did, uh, really was a shock to my system. And then losing a friend, uh, who also was misdiagnosed with cancer and again, almost losing my life. Has put me on this trajectory where for the first time in my life, I'm working seven days a week.

And for the first time in my life, I am willing to sacrifice important family events for the betterment of humankind because one, I think I'm in the process of creating something that will transform medical practice. Two, my goal is to save the lives of a million people I will never meet in memory of my brother and my friend.

And three, whatever I do from the healthcare system, not only helps society at large, but also helps my own family, my own friends, my own neighbors, colleagues, et cetera. So it's both altruistic and selfish at the same time. And I want to keep going, even though my co-partners put in my employment agreement.

But I have to retire by 76. Um, that's still a long time away and hopefully I can accomplish all my goals by then. That is a noble comment.

I am sorry to hear about your brother. It sounds like you are ensuring the same does not happen to other people and that that is a very noble thing to do, Steve, so I commend you on taking that path.

Yeah. Look, there's no greater personal satisfaction than knowing that you've really made a difference in somebody else's life.

Is there anything else you want to talk, tell our audience to?

Yeah. The last thing I'll talk about, because you know, the premise of this whole discussion is digital health. Is the need for digital health companies to come together. There is too many one-sided efforts, everybody trying to build the next grade company, to get wealthy, to transform medicine with individual or to distinct group efforts.

I've had conversations with companies outside the US and it's so funny. Everybody wants to be the next great success and I just want to succeed and I'm willing to partner with everybody and anybody that shares my sense of mission and has something of value to bring to the table, I'm more than happy to share the pie and distribute it widely to achieve our goals because we're all part of this healthcare system, and if we don't start working more cohesively together, A lot of things that could happen sooner are gonna happen later.

And I say this half jokingly because I'm really only half joking. My greatest upset is that I believe in the not too distant future. People are going to live hundreds of years and I'm going to miss that opportunity. But I believe if people worked together, we could accelerate that. And I believe that staying alive longer is preferable to the alternative.

And also not just staying alive, but maintaining vitality is preferable to the alternative. And there are so many great ideas out there, but too many people are trying to do it alone. And many of them are gonna fail and their ideas are gonna fail with them. And we need to come together and as we discuss at the beginning of this session, somebody has to be the cohesive.

Force that brings those efforts together. So I hoped I inspired you, Rashad, to possibly take this on, but I think this is a very important undertaking that is long overdue. I wish more startups

thought like that. I, I really do. I wish there was more camaraderie and teamwork in this industry. And it is not purely a, a single player game you can played in teams.

So thanks for

saying that, Steve. It's unfortunate. And, uh, maybe cause I'm, uh, older, maybe wiser, I definitely have the gray hairs to, uh, demonstrate that. Um, I've seen time and time again that teams can accomplish much greater things than individuals. And one of the e earliest experiments that is, they gave us styrofoam cups and told us.

Write down everything you can do with a styrofoam cup, and then they put you in groups and now say, put your ideas together, and you come up with so many more ideas for the Styrofoam Cup as a group than you do as an individual. And so it's proven science that, uh, collective effort is more successful than an individual effort.

That's well said. Thanks for coming on today, Steve. This has been a lot of fun, and we will have to do a part two sometime in the future.

All right. Take care, Rashan. Bye-bye.