Innovation insight and poetry from a physician-technologist [PODCAST]

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“Medicine is not a business
You fools.

Healing is your blueprint, activated
to complete itself.

A doctor does not broker it,
The best anyone can do is align you
With what you should be,
And stay out of the way.

(Like a teenager setting off an illegal firecracker.)

Mostly, you pay the doctor for the alignment,
And the nurse
To keep the doctor out of the way.

If you’re not ready,
to get on with the business of what you should be,
You come back later.
Or, maybe, next lifetime.

It’s not complicated.
And it’s not a business.
You fools.

The doctor knows what you should be,
when they know what they are,

And if they don’t
And the nurse can’t tell them,
You come back later,
Or, maybe, next lifetime.

It’s simple, but
It’s not easy,
And it’s not a business you fools.

I’ve seen it, GNP and recurring revenue and prayers so many pairs of high-intervention end-of-life care.

It’s cosmic law
That you cannot profit from someone else’s suffering.
You only appear to,
When you do not know what you are.
When you are blind
to the part of yourself that suffers with them.

Which is why medicine is not a business
it’s a relief,
A chance to make yourself right,
Whole.

When you are whole, you come back later if you want or next lifetime,
To heal.”

Drea Burbank is a physician-entrepreneur.

She shares her story and discusses her series of poems, “When you die: a poem,” “Medicine is not a business: a poem,” and “A physician’s pain poem.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Drea Burbank. She is an MD technologist, and she wrote a variety of poems on KevinMD, the first titled “When you die: a poem,” then “Medicine is not a business: a poem,” and “A physician’s pain poem.” She’s going to talk about those, as well as her story and background. Drea, welcome to the show.

Drea Burbank: Thank you so much, Kevin. You’re a huge part of my medical training. I’m so happy to talk with you.

Kevin Pho: Well, thank you so much for reading and following all these years. Now, can you share your story and journey to where you are today?

Drea Burbank: Yeah, I’ll just give you the brief version. I grew up off the grid in central Idaho, sort of like Educated, The Glass Castle, or Captain Fantastic. Then I was a forest firefighter for nine years. After that, I went to med school. After med school, I worked in Silicon Valley doing high tech, and I started a company for what I call delinquency bonds. We are people with high IQ or extreme talent in different industries, and we solve hard scientific and social problems. My specialty is medical futures, but I have people in rocket science, cybersecurity, and a variety of different disciplines.

Kevin Pho: So tell me about some of the problems that you are trying to solve with your company.

Drea Burbank: OK, so we get to do some fun stuff, and it’s not always paid, I’ll be honest. Like in futures, it’s kind of like three-quarters of the work is free and a quarter of the work is paid. So we try to cherry-pick the good problems and then worry about the payment afterwards. Stanford University hired us to make AI more equitable, and we came up with the Impulse app, which is a way to donate, but the money goes to nonprofits. So there was that. And then last year, Hollywood hired us to do COVID-19 testing. They were getting their results back in seven days, and we got them back in 12 hours, because they couldn’t shoot films during COVID if they didn’t get the results back faster.

Kevin Pho: So you’ve taken kind of a nontraditional path after you got your medical degree. What really led you to that?

Drea Burbank: You know, at first I was trying to pick a specialty, and I was obsessed with surgery. I absolutely love surgery, and I was obsessed with how laparoscopic surgery changed general surgery. To me, it looked like this huge sea change. Also, the cardiac surgeons when I graduated were all out of work, because it looked like endoscopic was better than open. So I thought, if I do a 12-year discipline, I need to kind of know what’s going to happen, so that I can pick a discipline that’s going to expand rather than contract.

The more I looked at medical futures, the more I realized, “Oh my God, everything’s going to change.” We really hadn’t implemented functional MRI in psychiatry. We’re not using machine learning in a lot of diagnostics yet. So many things, I think, are going to change, and I got really interested in how things change in medicine, when they make things better and when they make things worse. I did research at Stanford on regulating e-cigarettes, because I was concerned that would make things worse, and actually, we found that doctors are really split on it. So I think how technology is incorporated in medicine is really a nut that hasn’t been cracked yet, and this is before all the burnout from the EHR.

Kevin Pho: With your experience in Silicon Valley, and of course having that MD, what are some of the future trends that you see coming down the pipeline in the next year or so?

Drea Burbank: Oh, next year, wow. You know, I never predict in one-year timelines, because with medicine, it’s up to a 100-year adoption for things like hand washing. Penicillin took 50 years. So medicine’s pretty long term; it’s like 10- to 20-year cycles.

I have concerns about the EHR, in that the more that doctors simplify their workload, the easier it can be automated, especially cognitive decision-making. I see a lot of machine learning and AI that is not being developed to work in concert with a doctor. It’s being developed to kind of replace what’s really an oversimplified decision-making process. So my hope is that we would get more visual when it comes to our documentation.

Kevin Pho: So give us an example of that. It’s actually very interesting to me, because as a primary care doctor, electronic medical records are a huge part of my life. You’re saying that most of that innovation isn’t necessarily aimed at making doctors’ lives easier, but in fact is trying to replace the doctor. So give me an example of that.

Drea Burbank: Yeah. So if you’re in another industry, and I do have the benefit in Silicon Valley of seeing insights from other industries, I work with engineering and law and construction and all these other areas. If you want to replace a workforce, whatever, the thing you try to do is get the workforce to put their information into an easily codable format, and then that’s something that can later be replaced by a machine learning algorithm fairly easily.

Machine learning algorithms are basically intuitive, so you don’t necessarily know how they come up with the solutions they do, but they can repeat heuristic patterns. I think the problem is that machine learning algorithms are created from data sets that are coded, so you need to get this intensely coded data set. So I see doctors trying really hard to make their thinking simple enough to get into an EHR. But when I look at that from the other end, I just think that simplified decision-making could potentially be turned into a machine learning algorithm, but it won’t necessarily be very useful. It won’t necessarily actually accurately replace all that hands-on clinical decision-making, all those bedside medicine skills.

Kevin Pho: Now, is there anything that physicians can do to prevent being replaced by this machine learning and AI in the foreseeable future?

Drea Burbank: Yeah, I think there are two things. First off, physicians need to actually organize more effectively. There’s an article, I believe Atul Gawande talked about it, but physicians have been balkanized in many ways. Specialties are kind of fighting against each other for territory, and they don’t tend to organize en masse. I think that the EHR is one of the first areas where physicians can really effectively organize en masse and all agree, “This is not working for us.” So that’s the first thing. Physicians need to organize in larger bodies, and they need to be more cohesive in their statements politically, because a lot of this comes down from health systems and payer systems, and it’s more about incentives.

The next issue, I think, is that physicians need to get more visual with their documentation. When we put our assessments into words, the words can then create this huge natural language processing problem. Then the NLP problem kind of obscures the fact that we’re really dealing with a story about something that we did visually and kinesthetically. The thing that computers can never replace is this visual, kinesthetic thing that doctors do. They put their hands on people, they touch them, they sense heat and redness and all this stuff, and that’s something a computer will never do accurately, I think.

Kevin Pho: Now, what exactly would a visual electronic health record?

Drea Burbank: I think it would look more like Plants vs. Zombies or a video game. If you look at most of our EHRs, they’re drag and drop. You type words into boxes, you click checkboxes, and all those things are just really oversimplified for what we do. I’ve seen a software called Visible Body. It’s an anatomy software, and it’s 3D. You can expand it, you can pick places in the human systems, and you can actually visually put in clinical assessments. I think if we took our bedside assessments and put them into a visual format, it’d actually be much more useful data when it comes to interpreting the human body. It would also preserve this role physicians have of touching people and really using their, you know, thousand hours of touching a thousand people and really feeling that liver.

Kevin Pho: Now, are there any companies, to your knowledge, that are working on something like this?

Drea Burbank: No. I’m obsessed with it, but I never got a big enough resource. If I got a chance, I would totally do this, if somebody let me. But I do think Visible Body Anatomy has made good strides. I’ll give you an example. For Google Maps, in order to have a really good information system about navigating and getting around the road, which is also a machine learning algorithm, you need a map in the computer. So Visible Body, I think, did a good job of getting the human anatomy map in the computer, and I think the doctors need to say, “We want that map. That’s what we want.”

Kevin Pho: All right, so let’s talk about some of the poems that you wrote on KevinMD. You wrote “A physician’s pain poem,” “Medicine is not a business: a poem,” and “When you die: a poem.” Now, tell me a little about some of the poems that you’ve written.

Drea Burbank: Yeah, I actually didn’t intend to write poetry. When I was a kid, long before medicine, I got obsessed with using the subconscious to memorize stuff, so kind of accessing my subconscious to increase my cognitive performance. And then, just last year, my subconscious knocked on the other side of the door and said, “Here are some poems,” and it just spit my experience back out to me in the form of poetry, which totally surprised me. I would wake up at 3 a.m. with the poem in my head, and I’d just write it out, and then it was done, and that was that. So all I can say is that it’s definitely from my experience, but I don’t feel like I entirely own it.

Kevin Pho: So tell me about some of the poems you’ve written. Why did you choose some of the topics that you chose to write about?

Drea Burbank: Yeah, and this would be something I’d bring up to other physicians: I found that a lot of the stuff that came back to me was trauma regurgitated, and in a really good and healing way. So I’ll just mention the three poems in order.

So pain: I talked about prescribing differences in Texas, where I worked, and also in the Peruvian Amazon. I found that in the Amazon, people were really happy with Tylenol, and in Texas, you just couldn’t give people enough opiates. It wasn’t safe to give them as much as they wanted, and there was something about the way that we were interpreting pain as a culture that really differed. I thought, you know, it’s such a big part of a physician’s lifestyle, this pain management, and I still think that we don’t feel really comfortable in what we’re supposed to do there. There’s the opiate crisis now. Before, we didn’t give enough, and now we’re giving too much. And how do you talk to somebody about their pain? So that was kind of how that came back at me.

And then “Medicine is not a business: a poem.” Working in high tech, you end up working for the business around medicine a lot, so not necessarily doctors, although I did work with about a thousand doctors once doing a telemedicine company. You tend to work a lot with prescribers, payers, health systems, and buyers, and the way that they talk about doctors sometimes really upsets me. Also, having worked in Canada versus the U.S., I really became obsessed with this idea that medicine is not a business. It’s really never going to be a business. It’ll never be a profitable endeavor; it’s always going to be something else. And also, you can’t barter healing. Every doctor knows you put things in alignment, but you don’t heal the patient; the healing happens on its own. So anyway, there’s that.

And then the last one, “When you die: a poem.” Once again, I think that there’s this liminal space in medicine that a computer will never replace, and it’s in people who are on the front lines of medicine, touching patients, dealing with birth and death. They respect this liminal space, and they have this awe for it, and that awe is mirrored in other cultures: indigenous medicine, Ayurvedic medicine, traditional Chinese medicine. This is a universal healing experience, and it’s why we need doctors. That’s why we need nurses. It’s why we need people who care about people to be there.

Kevin Pho: When you’re working with Silicon Valley companies, you didn’t like the way they talked about doctors; it really upset you. So how did they talk about doctors?

Drea Burbank: So doctors are kind of a black box. If you’re not in the profession, if you haven’t trained as a doctor, doctors are a little bit of a black box, like an AI algorithm. They see what goes in, and they see what comes out. There are two factors about doctors that I think are really important. Doctors are gatekeepers for spending in a health system. If you reduce the number of doctors, you reduce the amount of money that’s spent, by about a million dollars a doctor, by about a million dollars a year a head. So if you want to just save money, you just cut the doctors, and they don’t really care about the workload, because they’re not necessarily looking at the workload.

My friend who is an emergency doctor called me the other day, and he was like, “You know, I’ve got a child in here with a broken eyeball.” And he’s like, “Nobody’s going to come and treat this child this weekend, because there’s no health insurance.” He’s calling from the U.S., and I just thought that would never happen in Canada. But he’s the one that has to face those parents overnight and say, “We’re still waiting on the ophthalmologist,” whereas the person cutting a couple of doctors out of that hospital system doesn’t really think much about it. So there’s that aspect. Doctors are truly understaffed, and they’re intentionally understaffed, because it saves big systems money. So that’s the first thing.

The second thing, I think, is that physicians are under so much strain. They have higher suicide rates right now than post-combat troops in the military, and they aren’t always nice. When you’re under that much strain, you’re not always the nicest person, and sometimes people don’t really understand why physicians would be grouchy or snap at people. They’ve got so much empathy in the day, and they’re saving all of that for their patients, and then after that, it’s going to be their family, and then after that, it’s going to be other stuff, and then last, they’re saving it for themselves. So yeah, those are the aspects that I didn’t like.

Kevin Pho: Now, you work with a lot of health tech startups, I’m sure, in Silicon Valley, and a lot of them have trouble penetrating the health care system and moving the needle. So if I were a health tech innovator and wanted to introduce a product or service that would have a big impact on our health care system in the United States, how would I go about doing that, knowing that a lot of my predecessors have failed in trying to do that?

Drea Burbank: Yeah, this is one of my favorite topics. There’s something called diffusion of innovation theory, and there are different stages of being an adopter. One of the things I tell all health tech companies is that all doctors are professionally past the chasm. I probably don’t have. It’s better to do it, basically. You have techies. They make a product. Visionaries promote a product. And there’s this huge chasm, where it’s no longer interesting but no longer useful. After that, you have pragmatists, which is all doctors professionally, and then you have late adopters, and then laggards will never adopt it.

So all doctors are responsible to make sure the product is useful before they use it on all of their patients, and it doesn’t matter how personally interested they are in technology. A doctor might personally be a techie, tinkering in his basement, but professionally, for his patients, he’s not going to implement it until it’s useful. So I think all high-tech companies need to know where they sit on that spectrum.

And then I tell them, if they want to innovate in medicine, they need to find safe spaces, like safe use cases that are clinically unsolved. One of the big use cases that I really liked that came out recently, they introduced a new technology in a population of children that had a fatal condition, and there was just no other treatment. So even though it was highly experimental, it was ethical. A lot of these high-tech companies don’t really know what’s ethical, and that’s a good time to partner with a doctor. They need to brainstorm, like, “Where are your unsolved problems, and can my tech fit that?” rather than saying, “You should use my tech because it’s better,” because that’s not something doctors can necessarily do.

Kevin Pho: We’re talking to Drea Burbank. She’s an MD technologist, and she wrote a variety of poems on KevinMD, and she also shares her story, insights, and journey. Drea, if I’m a physician who wants to break into that MD technology space, what is some advice you could give to them?

Drea Burbank: Well, almost all startups need doctors as advisors. Any health tech startup will need a doctor as an advisor, and it can be a fairly small amount of time. The problem is that while doctors might be good at advising on the medicine part of it, they might not really understand the technology part of it. So I’d say it’s two parts. Every doctor who wants to work in tech should read a book called The Lean Startup by Eric Ries. It’s very clear about how technology needs to break things in order to develop properly, and that attitude doesn’t always play well in medicine. But doctors need to understand why it does play well in tech, and this is why we have great tech for skateboards but not great tech for surgery.

So when doctors understand the two paradigms, they can usually code-switch and also help tech transition better. But if they don’t understand the other part, why the other paradigm is OK, they sometimes get, I would say, frustrated or judgmental with how, quote-unquote, irresponsible technology appears to be.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Drea Burbank: Oh, OK. So first off, I would say that all doctors should read diffusion of innovation theory, so they can advocate for whatever kind of technologist they are, whether they’re a late adopter or an early adopter. This way, they kind of know where they fit in the ecosystem.

Two, doctors should consider organizing about the EHR and demanding better clinical software. I believe they deserve it, and they could get it if they organized for it.

And then number three is, I think that poetry has been one of the best releases I’ve ever had. There was stuff that I experienced in medicine that traumatized me, and I thought I would never be able to fully let it go, and for some reason, poems were the best way for me to move on.

Kevin Pho: Thank you so much for sharing your time and insight, and thanks again for being on the show.

Drea Burbank: Thanks, Kevin. A pleasure.

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