Future of Medicine Book “Curable” – EP09: Travis Christofferson (Author)

In this ninth episode, Travis Christofferson provides an overview of his new future of medicine book “Curable: How an Unlikely Group of Radical Innovators is Trying to Transform our Health Care System”. He covers the great inefficiencies of healthcare and harm it’s doing to swaths of the patient population. He explains it’s too qualitative than quantitative, that incentives are misaligned. He offers hope by urging a shift to being data-driven.

Lee: Hi Travis, welcome to the Hyper Wellbeing podcast.

Travis: Hi Lee, thanks for having me.

Lee: Appreciated. If we jump in straight away with the introduction of your book, you mentioned Michael Lewis’s Moneyball book, it’s a book about baseball and you make a number of references to it throughout your book. Could you introduce Moneyball and say why it was so significant for you?

Travis: Yeah, Moneyball, for your listeners, if they haven’t heard of it, it was a book by Michael Lewis, I believe it came out in 2001, and then subsequently was made into a movie with Brad Pitt. And the storyline is about the Oakland A’s and their data-driven approach to picking players. And it for me it was just a wonderful story because baseball has been around for over a hundred years. It’s got this rich history, it’s a relatively simple game. And you would think that the mechanics of it or the process would be improved to as good as it could be. So the story of Moneyball is this small market team. The Oakland A’s had, I think at that time, the second lowest budget in the major league baseball, it was three times less than that of the New York Yankees.

Travis: And so they were just trying to survive, “What can we do to compete with these guys with so much more money?” And the idea was they basically fired their talent Scouts and switched to a completely analytical driven approach to picking players. And Michael Lewis told kind of a funny story when he was researching the book, he stumbled in the Oakland A’s locker room and he just happened to stumble in, right when the Oakland A’s were taking a shower. And he said, he saw all these Oakland A’s naked and the site was disturbing and the fact that they just did not look like professional athletes, some of them were overweight, kind of misshapen.

Travis: But this was why the talent Scouts were getting this wrong. They were judging these guys on superficial measures rather than the measures that really mattered. And the data showed that these guys were good players. So the year they assembled this team, just based on analytics, they did fantastic. They broke a record with 20 straight wins in a row. They won the their division. Their approach has been proven out. Ironically tonight is a game between Oakland A’s and the Tampa Rays, and the Tampa Rays have the lowest budget right now in major league baseball and I think Oakland is 25th out of 30 now.

Travis: These two very low budget teams are competing in the wildcard spot this evening. They both have had wonderful, wonderful seasons, but both of them, including Tampa Bay have switched to, or have adopted an analytical approach. And what I thought was just so unique for the book, you’re always trying to have these narrative arcs and this was a relatively easy sort of example to give about how data can overcome our biases as human beings. And I try to then go on to show that healthcare is really dominated by these biases and we need to switch more to this analytical model like, the Oakland A’s had done in Moneyball.

Lee: That was a very nice coverage of Moneyball. You’re very good on the pros, even alive verbally. I like your style of writing. Your previous book in fact, “Tripping Over The Truth: How the Metabolic Theory of Cancer is Overturning One of Medicine’s Most Entrenched Paradigms” was one of my favorite books, and I thought it was brilliant actually. Where did the inspiration come for your new book, which is “Curable: How an Unlikely Group of Radical Innovators is Trying to Transform our Health Care System”, which is launching tomorrow, that will be the 3rd of October, on Kindle, where did the inspiration come from?

Travis: Yeah, it was very similar to the inspiration for the first book. Just kind of these epiphany moments that I was lucky to have. With Curable, because of Tripping Over The Truth, I had been given opportunities. And one of the interesting one was to give a talk as a small charity event in the UK. And at this event I met a medical doctor that was part of this new startup called Care Oncology. And what they do is they specialize in repurpose medications. So these are medications that have had FDA approval for a long time.

Travis: And the idea is to use them for new or different disease indications that the data shows they may have efficacy in. And I was so taken aback by this model, that I struck up a deal with them and agreed to help bring it to the United States. We opened up a clinic about a year later, a good friend of mine in my hometown, Rapid City, South Dakota, which is a very small sort of conservative community. And I was given the opportunity to present what Care Oncology did our treatment to the oncologist at the local cancer center.

Travis: And I’d hope they’d receive it well, and it was a 20 minute presentation in front of all the oncologists, the nurses, the pharmacists, and the medical director of the cancer center. And I just went through the data, explain what we were doing, why this model I felt was so good. And for numerous reasons, repurposed drugs have many advantages, one being safety because they’ve been around so long, you know interactions, you know side effects. And the other is you get these big blocks of data that you can look at when drugs have been in the clinic for long periods of time.

Travis: And so I presented this data and this rationale and I had one of the oncologists immediately just start flinging accusations. And towards the end of this, one of the drugs we use is a type two diabetes drug called metformin. And the data is very clear that it shows it can help improve almost in every type of cancer. And it’s a very cheap drug and it’s extraordinarily safe. So the risk reward is very easier to measure it. And he mentioned towards the end of the talk, “Why would you use a type two diabetes drug in cancer?” And then one of the oncologists sitting off in the corner and said, “Well, I use it to help prevent recurrence.” And just in that moment it struck me how far off track medicine has really gotten.

Travis: If you can have two oncologists in the same room, one be fuddled why you’re using this drug and the other embracing it wholeheartedly, how does this situation come to be? And that was really the inspiration to really examine health care and how these huge disparities and variations can exist. And that was the inspiration for Curable.

Lee: Hey, thank you very much. Have you been preparing for these questions? It’s rather concise.

Travis: Well, yeah, when we write the book, it’s easy to just resuscitate what’s already there.

Lee: But there’s a lot more in the book, you danced around it quite nicely. As you know, I see a secondary health care emerging. One that I’ve been dubbing Wellness-as-a-Service in lieu of a better moniker. And being predictive and preventative it’s about risk and probability, particularly individualized. But from what I’ve witnessed for a number of years now, doctors generally speaking, don’t know about statistics, not even absolute versus relative risk. Even when dispensing of of drugs like statins. Let me just skim read something in front of me today from the British medical journal.

Lee: “These criticisms may be fair, but they don’t disguise a broader point that clinicians, whether they’re working in primary care or hospital practice, have a poor understanding of concepts of risk and probability and the increasing exposure to statistics in undergraduate and postgraduate education hasn’t made much of a difference.” Let me jump ahead. “When doctors offer a prescriptive drug or a screening test to large numbers of asymptomatic people, they’re doing something quite different from treating a patient who has sought help because she is sick. There are not so much doctors as life insurance salespeople, peddling deferred benefits in exchange first small ongoing inconvenience and cost. In this new kind of medicine, not understanding the risk is the equivalent of not knowing about the circulation of blood.” Do you have any comment there? Can you comment around that at all if you wish to?

Travis: Yeah, I think that what you’re stating there and the concept is really what’s plagued medicine for the last hundred years at least. And that is this struggle between human intuition and in the power of data. And I tried to show that in the book through the development of this procedure called the radical mastectomy for breast cancer. And the struggle, this ongoing struggle between clinical trial data and a physicians intuition, there’s a quote by Hippocrates way back that was the value of a physician’s intuition is greater than any measurement.

Travis: And that sort of guiding doctrine from Hippocrates himself is really what’s characterize medicine for most of the 19th, 20th century. And when he made that statement of course medicine, was in the dark ages. We had procedures like purging and leaching and things like that. And medicine was really a mystical type of practice. It took a long time for the data to really come. In fact, the first randomized controlled trial, the gold standard for measuring the therapy’s effectiveness was done in the forties. It took a long time for medicine to catch up to the rest of the sciences and it’s still trying to catch up.

Travis: What we’ve done is we’ve built this culture of medicine, where we value a doctor’s intuition over everything else. And what’s happened is the complexity of medicine has just outstripped any single human mind ability to do it effectively. And so I completely agree with what that statement, the concept behind that statement is doctors have this sort of statistical blind spot. And the way we need to fix that is we need to have a framework or a system that doctors operate within that guides them in these critical evaluations of risk reward, absolute risk versus relative risk and so forth. And there’s examples of that happening that I try to give in the book, but I think, as a general strategy, that’s where we need to go.

Lee: And I guess you’re looking for what I’ll call absolute truth, in terms of number crunching, but don’t you think there is great incentive pressure that will co-opt, the results of such systems?

Travis: Of course. Yeah. And that will be the, I guess the battle front of this healthcare reform, is that’s always the struggle is the money part, but if there’s anything we’ve really underestimated, I think for the 20th century it’s human incentives and how powerful, extraordinarily powerful they are. And that is one of the biggest problems dogging healthcare right now is we have this crazy fee for service system where we pay doctors for every procedure and operation, every prescription and so forth. And this incentivizes them of course to over-treat. And that’s one of the biggest problems in healthcare is we have about 30% of all healthcare dispensed is over treatment.

Travis: We need to re incentivize our doctors and there’s pockets of healthcare systems that are doing this the right way. They put doctors on salary and then the data is very clear. It shows doctors that are on salary, immediately change the way they practice medicine. Now they focus on what the patient needs. And so for example, the market tends to solve these problems quicker than any institution. For example, Walmart has noticed this and if they self-insure, if they have a employee that’s got back pain, they will fly them to the Mayo clinic and have them go there instead because at the Mayo clinic where doctors earn salary, if they don’t need an operation, they won’t get one.

Travis: Yeah, I think incentives are a huge part of this.

What we’ve done is we’ve built this culture of medicine, where we value a doctor’s intuition over everything else. And what’s happened is the complexity of medicine has just outstripped any single human mind ability to do it effectively.Travis Christofferson

Lee: It reminds me, Brad Perkins, who was a former chief medical officer, Human Longevity Inc, he stated, let me find your quote from the first Hyper Wellbeing event. “Medicine has traditionally been a clinical science that’s been supported by data. We’re rapidly approaching a time when medicine is about to become a data science supported by clinicians.” And then I invited him as the first guest onto this podcast and then he stated and let me quote him again, “medicine today is qualitative clinical practice. And you know, there’s the only word I’m comfortable with among those three is the clinical part. I’m very uncomfortable with qualitative, being applied to the kinds of high risk decisions that physicians are making on behalf of individuals. And certainly practice is a suspicious term as well.” Any thoughts or comments there?

Travis: Yeah, what that reminds me of is something in the book, qualitative versus absolute data and how deceptive the human mind can be. And the example that just popped into my mind was in the 1980s there was two treatments for lung cancer. There was surgery and radiation, and surgery offered a better outcome. However, it came with a 10% risk of death over the radiation. But if the oncologist presented these two options to a patient, if the oncologist presented the option and said, “Surgery has a better chance of extending your life, however it comes with a 10% risk of death,” only 50% of the patients opted for surgery. However, if the oncologist presented it and said, “Surgery has a better chance of extending your life and there’s a 90% chance you’ll survive,” then about 85% of the patients chose surgery.

Travis: Yeah, the qualitative part of medicine you can see is very pronounced. It’s just these decisions is life, that decision that should be based on peer rationale data, objective data, are often influenced just by our own cognitive bias and how a doctor frames things.

Lee: You remind me there of the book Nudge by Richard Thaler. Are you aware of the book?

Travis: Uh-uh. No, I’m not.

Lee: It’s called Nudge: Improving Decisions About Health, Wealth, and Happiness. You mentioned that societal systems are being improved with better decision making with correction for the failings of the human mind, which is actually what Thaler’s book is about. However, uh, healthcare is not. In this way your book is saying details the direction of what should happen. Yet I think ironically, that healthcare is increasingly divergent from our individual health, it’s increasingly not aligned with our health. It’s an absurd situation where our most valuable asset is not adequately protected by the institution formalized to do so. And anybody who’s unsure should read Elizabeth Rosenthal’s An American Sickness. So do you really think it can be fixed?

… doctors that are on salary, immediately change the way they practice medicine. Travis Christofferson

Travis: Yeah, I do. I’m optimistic about that Lee. And the reason is because there is a lot of arenas of human activity that are being improved by the system’s approach, their becoming remarkably efficient. And of course medicine is lagged. But because of our system, because we’re not uniform, you see these pockets of brilliance, and it’s always been the doctrine. In fact, it’s kind of written in the law that a hospital or a clinic has got to remain this kind of inert framework that allows doctors to practice medicine within. So they’re designed to be invisible, a hospital and so forth. Incorporations can’t impinge on this. It’s called the corporate practice of medicine.

Travis: We have to stay completely clear of doctor decision making. And there was good reasons for this initially when a doctor had a good grasp of all the treatments that were available. But now because of this complexity, it becomes so much more imperative to have the system be a dynamic partner with the doctor, to guide them to pull data from the electronic medical records and show them the best practices. And there’s a brilliant example of this, of a healthcare chain called Intermountain Healthcare in Utah. And the guy driving this, his name’s Brett James. He’s a statistician. He’s also an MD and a surgeon.

Travis: And what James has done is he’s made the system part of the practice, so he will look at the electronic medical records and notice where there’s variation in treatment. For example, he noticed that it’s always been known that antibiotics given near the time of surgery help prevent surgical infections, however, he’s never known the optimal time. So he looked at the medical records and he saw that his surgeons indeed were giving antibiotics, at different times, way before surgery, 24 hours before surgery, sometimes immediately before, or sometimes 24 or 48 hours after.

Travis: So what he did is he just had them continue that in groups. And then he just measured the outcomes in his medical record system and found out that if you give antibiotics two hours right before the first incision, you had much greater outcomes. So this cut the rate of surgical infections in half. And you just go on and on down the list of the process improvements that they’d done at Intermountain. And it’s incredibly dramatic. These equate to thousands of lives saved and billions of dollars saved. And when you look at Intermountain system, if you applied that to the rest of the United States, the way they’ve done it, it would immediately drop result in about a 40% reduction in healthcare costs. So this would essentially solve our crisis if we just adopted this system and did it the right way.

Lee: I’ve not looked at Intermountain. I immediately wonder how they make money from doing what you just described.

Travis: That’s a great question. And they do take hits because they do do it the right way. So they’re not incentivized by overtreatment and so forth. They put their doctors on salary for example. However, because they’re so efficient, they save money in other ways. And Brent James often brings this up, if you do this the right way, you maintain margins enough that you can continue to operate.

Lee: I haven’t shared with you yet because we’ve not spoken before. I believe that given enough time that what we call healthcare today will be a ring fenced to acute care i.e. something major went wrong or an injury. And with the speed of machines going forwards, the semiconductor industry, generally the democracy of the data processing industry, i.e. chips and associated networking, sensors, end up in the hands of  consumers, that prediction prevention and optimization including lifespan extension will fall under a secondary system that I now see emerging. What I mentioned I’ve been calling wellness as a service. Any thoughts?

Travis: Yeah, I guess when you bring up lifestyle, I’ve always noticed in healthcare is sort of this absurd bifurcation of how we approach treating disease. And what I mean by that is we divide up all these disease processes and try to fix them once they’ve manifested. And it’s very obvious that if you try to get to the source and use a preventative type of medicine, you could make much, much more progress. Now that’s easy to say. And I’ll just give you an example how that doesn’t work sometimes. We always thought that if you could diagnose cancer earlier, you could fix it. You’d have this chance to do better, to fix it before, to cure it before it manifested as a malignant disease.

Travis: And we’ve gotten better at it. For example, for thyroid cancer, we’ve tripled the number of early detections, however, the death rates haven’t budged. And so when you clearly look at the data, what’s happened is we’ve gotten very good at finding masses, finding sort of markers that are indicative of precancerous things. However, most of these tumors turn out to be not a threat. They turn out to be very benign. And so what happens then is these patients will be aware that they have a mass or something, a high PSA, and they’ll demand treatment or the doctor will offer treatment. So you get a tremendous amount of unnecessary cancer treatment on early detection.

Travis: So you get this massive block of over treatment without a consument increase in outcome in death rates. So that’s an example of how you, if you do preventative medicine, you have to do it the right way. You have to have some sort of therapy that’s proportional to an early detection type scenario rather than chemo or radiation and so forth. However that’s one example, but I think if you were able to cure cancer tomorrow or cardiovascular disease, it would equate to something like two to three years increase in lifespan. That’s not as much as most people think. The problem there is what happens is an aging body is you just get a buildup of problems and the next problem is waiting in line.

Travis: I think you’re absolutely right. We need to focus on wellness, on preventative medicine and things like dietary lifestyle things. Metformin is an extraordinarily interesting drug to apply in a preventative mindset for cardiovascular cancer and just the aging process in general. I think, yeah, that is where medicine needs to go just because the bang for your buck I guess is so much better than trying to treat, continuously trying to treat problems after they manifest.

Lee: Yeah. I’m quite keen to jump to metformin. I had a decision to make a couple months ago if to start taking metformin or berberine and I decided, “Hey, I’m going to play with berberine first since everybody’s jumping on metformin.” I’m just playing as usual. I test all kinds of molecular agents on myself and do blood draws frequently. Anyway.

Travis: I take metformin as well, and I’m 47, I just turned 48 actually. And yeah, when you look at the data, it makes a ton of sense. The data that really struck me was they looked at, I believe it’s 70,000 patients with type two diabetes compared to healthy match controls. I think the control group is over 90,000 and the diabetic population on metformin lived longer than the healthy population. That’s pretty compelling data that this is a real anti-aging therapy.

Lee: You recently read David Sinclair’s Lifespan book, but when I looked up the studies, the mice were always obese or sick or elderly or on a standard American diet. I couldn’t help but wonder, not only is it mice, but what if it was individuals who are eating a ketogenic diet, say an ancestral diet on they’re doing five day water fasts, occasionally, et cetera.

Travis: That’s a great question. Since then metformin has been shown to improve lifespan of healthy mice. Resveratrol is one that’s really, I think it only applied in obese and aged mice.

Lee: Yeah. I also start taking resveratrol this year, but now I’m going to switch to a fancier micro [micronized] version. But I looked at berberine as I mentioned and it seemed to have less side effects on more positives, had allegedly a larger impact on lipids. I’m still doing testing. I’ve got 40 days left and then I’ll switch over to a gram of metformin per day. But anyway, jumping back to what you were saying, so what you’re effectively we’re saying as far as I understand and put in other ways is that all men when they die have prostate cancer?

Travis: Say that one more time.

Lee: All men when they die have prostate cancer as far as I know. Or at least that’s what I’ve heard. But while it’s still slow growing the medical system either doesn’t detect it, and if it does, it doesn’t tell you if it sees it’s still slow growing. Correct me if I’m wrong but I thought all men, had some level of prostate cancer typically at the point of death from aging?

Travis: Yeah, I think that’s correct. I’m not sure it’s 100% of men, but I think it’s the vast majority including micro tumors throughout our bodies. We are actively, as we age having this never ending battle between tumor genesis and our immune systems and so forth. And I guess, what’s really important is the ability to recognize when it becomes a threat. Or how do you treat, for example, say you have a high PSA, and the data on this is really kind of phenomenal. It’s actually patients that are diagnosed with prostate cancer from a high PSA have a 47 times greater chance of being treated. So chemo, radiation, biopsies and so forth by invasive treatments than they are to have their life extended.

Travis: What that means is you have to over-treat a lot of people before you treat the ones where you actually makes a difference. And so we need to get good, we need to just get better at determining when, what to do in those scenarios. And I think this is where metformin, ketogenic diets sort of fasting, these therapies that are so low risk and probably have a benefit of changing your health and other ways extending your life as well, that seems like a much more proportional response to these early detections, than the traditional way of biopsies and chemo and so forth.

Lee: So there’s one thing I liked about your book, although it’s out tomorrow with the audible one is already out. I had a listen. I liked the fact that, as you know, I’m pushing the prediction, prevention angle. And as you point out there more treatment and early detection isn’t always better. You need to be very careful. And there’s also the issue of the worried well, in other words you start creating a lot more traffic of people, performing imaging and biopsies and so on. Who would have been better just having not being aware in left it. I’m laughing by the way in part, not just because of that, but because I haven’t even got to discussing later parts of your book.

Lee: I’m still in the first part here. I feel we could chat all day. I guess what you’re saying is you want to see quantified treatment, optimal treatment, a surgery or no, and if surgery to have access to evidence based systems for those decisions. But what, by optimization, like anti-aging outcomes as we discussed? Surely prediction, prevention is a data processing task. It’s not like a typical doctor white coat drug dispensary knock on the knee with a hammer type task.

Travis: Yeah, that’s correct. Going back to these guiding data, what you do in certain situations and why this is so difficult for doctors these days is because there’s so many procedures now and what happens is you establish as a procedure is effective, but then the science sort of stops and you don’t get the next level of data about comparing a procedure to a different procedure or when to apply it and the best time to apply it. In the example I used in the book for that was prostate cancer.

Travis: With early detection, you have five treatment options. You have watch and wait, you have surgery and then you have three forms of radiation, sort of standard radiation. And then at the high end, this new proton beam radiation and the proton beam radiation costs $100,000 and the watch and wait costs a few thousand dollars. None of these treatments have been compared to each other. Doctors don’t know which one is best in that scenario, but under a fee for service payment system, you can guess which ones getting prescribed the most, the hundred thousand dollar treatment. And you can see this in many things in medicine.

Travis: I use the example of the radical mastectomy which went on for 50 years and brutalized women and was based on sort of seductive proof or seductive idea that cancer spreading in this slow centrifugal manner. And the further out you cut, the better chance a woman had of survival. But then when they finally did the clinical trial and compared it to a simple mastectomy, it was shown to be no better. And there is many things like that today. Last year they just showed for the first time that women with hormone positive HER2 negative breast cancer, that adjunctive chemotherapy after surgery is of no benefit.

Travis: Now thousands of women that can be spared chemotherapy with all of its caustic side effects. Just because they finally did this big NIH study to show that it had no effect. Optimizing and figure out figuring out when and how to apply these treatments and when are the best, which ones are the best, is still a fluid kind of ongoing process. And we could do so much better if we just captured all that data like they do at Intermountain all the time.

Lee: I like the fact you have a solid, a reference example in Intermountain. And also the start with the book, you remind me that you mentioned Amazon, JP Chase and Berkshire, have done in creating their own, should we call it health care company and I quote, “The parasite of health care dragging their companies down relative to the rest of the world.” Could you introduce just briefly what Amazon, JP Chase and Berkshire are doing and just briefly why?

Travis: Yeah, it’s very clear what they’re doing. The data is right there for anyone to look at. American healthcare, most industrialized nations leveled off at about 11% per GDP. We just kept going and we’re now, we’re I think 18 and still rapidly rising. So this is a massive chunk of our GDP that we’re siphoning off for health care compared to the rest of the world, which by the way, have better outcomes, better lifespan, better infant mortality, less anxiety because most people are insured. We leave such a substantial proportion of our population uninsured, so they’re just doing it better. And this cost, it costs our businesses and that trio, what they noticed is, they operate on a global scale, it just makes America less competitive. We have to pay out so much more money per employee and health care compared to the rest of the world, we become less and less competitive and it’s harder to do business. 

Travis: What they decided to do briefly is just create their own healthcare system from the inside and see if they could do it better. Capitalize on all these system improvements that we’re talking about. Use the examples that are working like Intermountain and see if they can build this framework from within, and have it operate more efficiently. So I use that as kind of a narrative throughout the book to watch and this sort of ongoing story. Because one of the company’s involved, Berkshire Hathaway, those guys have been money balling financial markets for most of the 20th century. That was why I kind of use that as a narrative arc throughout the book.

Lee: I appreciate it. If I jump to chapter two, I’ll try and speed myself up here because there’s quite a few questions I’ve liked to ask you. Chapter two, which is called How Healthcare Became A Culture Of Inefficiency. My favorite quote from that chapter was, “Medicine has been built on the autonomy of the physician’s venerated intuition—but something more is required. Still today medicine more closely resembles a culture than it does a logically structured, evidence-based system. A culture inextricably shackled to the fallibility of the human mind with its myriad biases.” What you’re saying is healthcare needs to become data-driven, predictive analytics, multivariate causation analysis via AI or this is your point?

Travis: Exactly. Yeah. And I think, those are all the things we’ve talked about. About how Intermountain and places like Geisinger, Kaiser, they’re these examples of that quote references about how to diminish the fallibility of the human mind, where the system can effectively sort of put a noose where doctors are making a mistake. That’s how we improve. And this does not mean we need to diminish a doctor’s intuition. This just means that we wrap data around give them these data guidelines then they can focus more on the human part of medicine and user intuition and other ways.

Lee: Well you state the uncomfortable truth is that there are many procedures with only a thin evidence to support them and that they persist because of tradition rather than evidence-based knowledge. But only persist because there is money and patients are in a vulnerable powerless position in a time of need. Surely it’s simply an expression of the apex of capitalism, the protocols of capitalism have been running for a couple of hundred years. It’s not because of a myriad of biases of the mind. It’s underlying protocols have been magnified by a global system and will continue to grow exponentially.

Travis: Yeah, that’s very true. I think it’s really both. I think it’s biases and it’s these capitalistic incentives and the example I used in the book was McAllen, Texas, where people notice that they were utilizing Medicare about twice the rate as the rest of the country. So they were paying out about $15,000 per Medicare recipient compared to the rest of the US which is about $7,000. And so an author, journalist, Gawande, he went down there, he actually wrote a New Yorker piece about this. He went down there to find out why. And when he found out, when he dug deep into this, it was simply a culture of entrepreneurship that the doctors had developed. In other words, these doctors were buying strip malls, real estate. They were competing with each other and that just escalated into this horrible system of fraud, over treatment and kickbacks.

Travis: All these things were going on. And after he wrote this article in the New Yorker, the regulators came down on this place hard and it really changed. And you can see the utilization rates have dropped substantially. Charlie Monger said that one of the worst things you can do and it can happen to a capitalistic society is fraud, allow fraud to continue to propagate. So if you can find these and shine the light on them you can affect change.

Lee: If the economy is not to support health, wellness and wellbeing, then what is an economy for? And I keep persisting with that question and nobody seems to give me an answer. And it appears to me that the economy may be up until, I don’t know, 40, 50 years ago, did track somewhat well with wellbeing; we had enough calories, furniture and so on. But once we had enough calories and items and material goods, it’s often more and more perpetuating, creating problems for it to solve. For example, obesity.

Travis: Yeah, that’s an interesting way to look at it. And I think you’re right once these basic problems have solved, we’re in a unique position to really examine what we’re doing, what everything else means and how we improve and what accounts for a good life and that is inexorably shackled to health. And I think that gets undervalued in our society. We just accept aging in a decaying body and all these things as inevitable. But in truth, that is what makes a life worth living is the maintenance of health and preventing all these things. I think Lee, I’m optimistic. I see as I was writing this book too, what you see is these changes that are being affected.

Travis: You see the old health care system is kind of this legacy system. It’s like Ma Bell, corded phones. It eventually just dies off and gets replaced by the next best technology. And you see that in healthcare, you see these bubbling sort of percolating pockets of innovation, these small boutique health systems that are doing things so much better. Virta health is an example, they just do a strict dietary regimen for type two diabetes online. It’s a ketogenic diet, it’s online coaching and it’s a value based payment system. So if they don’t achieve outcomes for insured patients, they don’t get paid. So I do see the economy, the market system really evolving to solve a lot of these problems. It’s slower than we’d like, but it’s definitely happened.

Lee: To indicate the vastness of the problem, Victor Chapela I’ll link to him in the show notes. He said that the fast food industry, for each dollar it makes, ends up costing $3 in healthcare to fix what it did, and the great majority of Americans and British are eating out; most calories are food that is been eaten out. So you’ve got this model where they’re making a dollar, only for it then to cost a dollar [sic: three dollars] to try to fix what has happened in the healthcare system. I have hope and cryptocurrency and I wish I could get a little bit more time in that space. I was looking at helping a company with an ICO and that’s where my optimism came from. I think money is undergoing a revolution and I think that will conspire with this need for health, wellness and wellbeing. So yeah, the crypto space. Anyway, you mentioned that procedures get institutionalized. So, for example, stents are overused, one in 10 stents are not needed. So over utilization of procedures. That’s a horrific figure one in ten.

Travis: The overutilization is truly horrific in general. One in ten stents, cancer care treatments, again, tons of over-treatment, there was an interesting story that I dug up and it occurred in Redding, California where it was for bypass surgery in any patients who were admitted to this institute in Redding, if they had the slightest perceived out abnormality in their cardiac vessels, they were shuffled off to bypass surgery. And what happened was this culture developed where this sort of colleague reinforcement, they are operating on more and more healthy people, so their outcomes looked better, and they just sort of propagated this belief that they were doing the patients a favor. Now this is an example of overutilization without the money being the driving component. And so once the regulators in the media got word of this, they came down on them like a hammer.

Travis: They were fined I think half of $500 million. But when you look deeper, you found out they truly didn’t believe they were doing anything wrong. They thought this was in the patient’s best interest. So you see the all kinds of sort of rationale behind this over treatment problem. I think Mark Twain’s old adage for a guy with a hammer, every problem looks like a nail. I think doctors have a desire to fix. And so there’s a general tendency to try to prescribe antibiotics, statins, surgery, they’re trying to fix patients when in fact it’s been known since the times of Voltaire, I think Voltaire’s quote was, “The art of practicing medicine is nothing more than amusing the patient, while nature cures the disease.” And William holster who started one of the founding fathers of Johns Hopkins, stated, “Practicing medicine is teaching the masses not to take medication.”

Travis: It’s been known for a long time that medicine is not perfect and there are great cases where it can solve problems and save lives, but this overtreatment problem is a human bias and we just need to recognize that and institute ways to not do it.

Lee: I personally would like to see consumer apps, which guide you in terms of knowing what your choices are. So if you have a particular cancer, instead of what you mentioned is in the physician, the surgeon have an access to predictive analytics, et cetera. I would like to see the all the way to the consumer for treatment options. Thoughts?

Travis: Yeah. And I think that’s where it’s, you know, with wearable devices and systems biology we’re getting so good at being able to just pull out data on individuals and see trends over time that I think that medicine is heading that direction.

Lee: It’s just not a consumer market health care. You’re already in a deeply vulnerable position, an acute position. It’s not like shopping around the mall.

Travis: No, there’s nothing worse, I don’t know about you, but I hate going to any clinic sitting in the waiting room. The whole process is just dehumanizing and I just prefer to stay out of the system altogether if you can.

Lee: I work on that and that’s partly why we’re talking. It must be 17, 18 years ago that I last went to a doctor and that was for a checkup and I, over study, a lot of time, I have learned or came to the belief, that seems to be backed by continuous forms of testing that the best action I think you can take for your health, and we’ll discuss this a little later on if it’s okay, is the food that you eat. A home cooking book is preferential to resveratrol. That’s been my conclusion and been my foundation of the pyramid. Then supplements, ordinary supplements, like magnesium, zinc and so on. Then if you’ve got those two bases, perfect, then add on some, anti-aging [supplements and/or procedures]. But it’s not just overtreatment you speak about in the book you speak about the extreme variation.

Lee: So for example, time ICU at end of life, in some parts of the country might see 80 specialist and other parts 18. And what’s kind of crazy is that people who are in areas where there is less care and therefore receive less care, it doesn’t seem to be a bad thing. In fact, the population is not worse for it. They don’t have lower rates of survival, and your explanation is that medical intervention, be it surgery, chemo, scans, drugs, they all carry risk. So when you over-treat you introduced risk. And alarmingly, you state that physicians are not made aware of their patterns of practice, so they don’t even know that they’re over-treating or using an updated procedure.

Travis: Yeah. Variation in treatment is not something that’s taught in medical school. And the scope of the problem is kind of underappreciated and the data’s good at just pulling that out. You can see it. It’s just everywhere. So within the same clinic, you can have one doctor prescribed twice a number of scans as another doctor. The rates of back surgery from county to county in Washington vary by, I think 15 times, from cities less than 50 miles away, you can have three times a stent put in, in one city compared to the next city. So it’s just everywhere.

Lee: This is shocking. I’m almost speechless. Yes, I’ve heard it from a number of sources, but why that’s allowed to continue? We’re not talking about minor inconveniences here. We’re talking about people’s lives or very wellbeing, their functioning, their health, their families or extended families, their wealth, et cetera. Half a million Americans are going bankrupt each year because of healthcare costs.

Travis: Yeah. I think it’s one in five Americans have medical debt now. The scope of this problem is really underappreciated. This is a over $3 trillion a year industry and the Americans, we are bearing the brunt of this over-treatment. It’s rampant. That’s the front lines of healthcare is how do we bring down these costs? And unfortunately, I think we have to have a crisis before we act. It was really telling us when I was writing the book, right in the throws of the subprime crisis, so 2009, the stock market was crashing, the finance system was melting down and Obama was asked, “What’s the biggest problem in American economics?” And he said, “It’s not even close. It’s healthcare.” I think the people that are on the inside that see these numbers realize the scope of this problem. That’s it’s bankrupting our country.

Lee: 3o% of dispensed healthcare is not necessary, you say in the book.

Travis: Yeah, that’s the number that’s thrown around. I’ve seen higher numbers. I’ve seen numbers as high as 50%. When you add in fraud and do full cost accounting and not just over treatment, the number is, I’ve seen as high as 50%.

Lee: And you stated that globally after cancer and heart disease, the third largest cause of death is prescribed medications?

Travis: Yeah, that’s correct. Drug interactions, over prescriptions of medications that’s a huge problem. And because it is such a large industry with so many people, the numbers are staggering. Medical error I think we lose 200,000 people a year to medical error. I saw a stat that, I can’t remember which year it was fairly recently, but 7,000 people died from sloppy physician handwriting alone. When you see the number of people that engage the system with all of its inefficiencies, these numbers are mind boggling.

Lee: And also is clear at border, I wouldn’t say even borders. I have to say if you’ve got any moral compass, it is evil. When you get to parts of the book when, for example, you stated, “Over 50% of patients with advanced cancers receive chemotherapy in their final months, even though the chance of extending life is exceedingly small.” And then you go on to say, “Study after study shows that end of life chemo degrades what little time people have left and does nothing to extend life.” I can’t excuse beyond the label evil. Thoughts?

Travis: Yeah. And that’s what the Berkshire Hathaway, the two leaders of that company are Warren Buffet and Charlie Monger. And Charlie Monger used the word evil as well about that overtreatment towards the end of life with chemotherapy. And when I researched that, I became a little more sympathetic for the doctor’s position simply because patients don’t want to give up and their families don’t want to give up. And oftentimes they’re the ones that don’t want to give up and want this sort of Hail Mary treatment all the way to the end. Doctors could certainly do a better job of relaying their position and perhaps not even doing it or giving them a rationale not to do it. And the data shows that when you really engage patients with end stage cancer, when you give them palliative care support staff, nursing, engaged doctors, and really confront this idea of death, they take less treatment at the end, substantially less. And they live longer.

Lee: Yeah. That’s so interesting. They live longer. Taking less.

Travis: Right. When you think about a failing body, pouring chemotherapy into it at the very end is probably not going to help. It’s just going to hasten the process of death. You just want these people to have the best end of life where they’re clear, they feel good, they can talk to their loved ones and, and the chemotherapy at the very end is not the right way to do it.

Lee: One of the major structural problems is private insurance took over paying for the cost of drugs and drugs as you state in the book exploded after world war II because the consumer became dis-intermediated from the price of the drugs, by insurance in the middle, the market can’t be kept in check. As you state, devices, medication and other treatments have skyrocketed in cost.

Travis: Yeah. That’s one of the biggest problems I think in healthcare. It’s just this sort of disassociation from the way capital markets traditionally work where you have consumers that, measure the cost and effectiveness of the procedure and then rationally make a decision if it’s worth it or not. When you’re put in an extraordinarily vulnerable situation, you have heart disease, you have cancer, any number of conditions and the doctors telling you this is the best treatment. You don’t price shop. You don’t question that. You do it. Especially when the cost is hidden in insurance premium. So that’s why you see this sort of ratcheting effect of why this escalation has happened in our country and some of these new cancer treatments that are coming out now, CAR T immunotherapies for example, are costing about half a million dollars, $500,000 for a treatment.

Travis: This is where you get to the point where you have no choice but to allocate healthcare, you’re going to have to pick and choose who gets those treatments. This again takes you away from or takes you to this point of trying to find these undervalued treatments in health care. And that’s what I tried to look at in the second half of sort of the book is, what’s sitting right in front of us that we could do right now that’s very cheap or essentially free to change outcomes? And there’s a whole lot of things because the market is not set up to recognize those things.

Lee: That’s chapter three, which is how simple and effective treatments get lost. And so you stated they’re usually off target effects are observed decades later. But then Pharma has a little incentive to carry out trials off patent. You may wish to say, what off target means and why drugs end up off patent and what generic drugs mean. And then maybe you could give an example with metformin.

Travis: Yeah. Traditionally what happens is, once a pharmaceutical company recognizes potential in a drug, they assured through phase one, two, three clinical trials. Nowadays it costs about a billion dollars. And then they’ll win formal approval by the FDA or whatever regulatory body for that disease and then the pharmaceutical sales network goes off and knocks on the doors of doctor’s offices and tells them the virtues of this medication for them to prescribe it. What happens then is over time these drugs lose their patent protection and they become generic drugs. And by that time typically we’ve captured way more data. So you’ve been able to look at these drugs in action in big chunks of the population over long periods of time, decades and decades. And so often what you find out is you’ll see that they’re useful for another disease indication.

Travis: And the pharmacological rationale behind this is very explainable. Most of these small molecule drugs affect about seven different molecular pathways within the cell, yet they are only indicated for one. So you’ll often get this sort of fortuitous side effect, if you will, where they’re treating another disease process. And this is what we call off label use. So generic drugs get used off label a lot. And the example metformin, it’s indicated for type two diabetes. So that’s what it has FDA approval for. But because there’s these massive blocks of data, people have noticed that it’s really reducing cardiovascular disease risk, it’s improving cancer outcomes in a variety of different cancers.

Travis: But now all of a sudden there’s no incentive for doctors to prescribe this. In fact, there’s a disincentive because off label comes with sort of career risk. Doesn’t have formal approval by a regulatory body. So a doctor is going out in a limb by prescribing off label, even though the risk is minimal. So this is just another example about how this misguided incentive system leads to these tremendously undervalued or mispriced therapies in our system.

Lee: It reminds me of Joseph Antoun who introduced me to anti aging. He was one of the early guests on the show. And in the book you state that a slight attenuation of the aging process would benefit society. A 2013 economic analysis showed that by slowing age related diseases by only 20% would save $7 trillion in the USA alone over the next 50 years. And yet the FDA couldn’t go ahead with a trial for metformin for aging. Could you briefly explain why?

Travis: Yeah. We touched on that earlier about how we sort of have this kind of upside down and backwards approach to medicine where we just wait till disease is manifested and then we try to fix it, that is a terrible strategy. Metformin has been shown in almost every multi-cellular creature it’s been tested into, extend lifespan and increase healthspan. So in other words, a lot of the problems we develop as we age, like increasing insulin resistance, prediabetes, cardiovascular risk, it’s able to attenuate almost all of those problems. So there was a trial called the TAME trial that would finally do the test metformin in healthy adults and see what we could do, see how much risk we can mitigate, how we could increase health span and lifespan of this healthy population as they age.

Travis: And the government apparently had no interest in funding this yet this is the perfect kind of place for government to step in because this is a 5 cent pill. It’s almost free. And this could benefit the entire society. It’s like the interstate highway system. No one else is really going to do this besides government and they should because it’s their citizens wellbeing that they should be responsible for. At the time I wrote the book, it was not funded. Now, however, I think a very philanthropic, private donor has stepped in to fund this trial. Finally, I think it’s going to cost about 60 million. But yeah, the benefits of that, if we can attenuate things like type two diabetes, which now one in 10 American adults, over half of adult Americans have either prediabetes or type two diabetes.

Travis: And the cost of that disease is incredible. It’s a pernicious disease that results in nerve damage, all kinds of ancillary problems and healthcare costs over time. So if we can attenuate this with a 5 cent pill, that is healthcare at its best. Now that doesn’t mean we should ignore lifestyle and dietary changes. You just take this pill, of course not, but it’s a first step.

Lee: I agree. And also there’s other cheap treatments like water fasting or the ketogenic diet also highly effective, they’re not going to find a place because where would the money come from in prescribing water fasting?

Travis: Yeah, that’s an interesting one. And just about a 48 to 72 hour water fast before chemotherapy has been shown across the board to dramatically diminish side effects. And there’s very good, cellular mechanistic reasons why this is happening. When you fast, you go into this ketogenic state and what happens when you switch over to burning ketones as a fuel, your healthy cells are made much more robust. You produce much more glutathione and antioxidants, and your healthy cells are able to withstand chemotherapy much better. And on the converse when you do this, cancer cells are made much more vulnerable because you’ve switched them away from a fuel that they love, blood glucose, to this different fuel of ketones that they have trouble metabolizing. So you not only do you see a diminishment and side effects from these patients undergoing chemotherapy, but you see improved outcomes. And this is all from just not eating.

Travis: It’s funny, the doctor that published this data, I’m sorry, he’s a PhD, he had a really hard time getting oncologists to sign onto this. They are loath to have somebody not eat and they don’t want them weakened and they have all these excuses and reasons why they think it’s a terrible idea. But eventually he convinced enough of them to do this small trial. And the outcomes were dramatic. You saw objective measures of chemotherapy, side effects, vomiting, patients that didn’t fast vomited throughout the day or the patients that did fast almost, it almost went to zero. These are simple, extraordinarily simple. It doesn’t get any cheaper than not eating. Because of the way the system is set up, incentive wise, there’s little incentive to study these things.

Lee: And hopefully one day when you have an app on your phone that can point out these treatments and give you data on efficacy, I think the consumer will be in a much more powerful position.

Travis: Yeah. Knowledge is power. Just presenting this to patients.

Lee: But you don’t have to be a patient, you don’t have to be sick first also. There will be a whole economy based around helping you take an actionable step every moment of your life should you wish to do so. People who have got X number of dollars per month, they’ll commit to health and they might as well commit it to not getting sick or feeling more well. And so when people wish to spend, you need something very individualized that says, “Hey, to take action and what is the best bang for buck action?” At the moment it’s a wild west market with consumer genomic tests, gut tests, blood tests, people are lost and searching, but that will get formalized. And it’s a bit like, being able to search via Kayak for airline costs, to be able to rank the airlines by cost.

Lee: There will be an economy in what we’ll call search engines in place that will guide you individually, each step of your life, on a daily basis should you wish for whatever capacity of spending and time that you have to move your health forward. Because health is a continuum. It’s not binary. So especially with the generation now, I think the previous generation looked after their cars more and took their car for servicing and resented spending on their bodies. But I think we see the result of that now.

Travis: Yeah, that’s a utopian, I love that idea. And that’s a good analogy with the way people approach health. Well in the 50s, over half of I think adults smoked. And we’ve come a long way since then. And you see this with, with Care Oncology, we switched to a telemedicine platform because the drugs that are prescribed these repurpose drugs are very safe. And it’s clinically very manageable. You can do it remotely. And when you remove these barriers for people, they don’t have to find someone to watch their kids. They don’t have to take time off work to go and sit in a waiting room and see a doctor, they can sit in their pajamas and just interface with a doctor online. And so we’re seeing technology kind of remove some of these barriers that people have these traditional barriers to engage in-

Lee: The health care market is extremely opaque, the cost depends on the post code for the same procedure and that’s ludicrous. But we need to to not just making that transparent i.e. a procedure or a treatment, but when people are not sick, in fact half the population is sick without knowing it. They’ve got a serious nutrient deficiency or something lurking that’s not good. And certainly any healthy people I’ve taken to the blood lab have something missing. That seems more like 100% they have something wrong and people want to protect their health. You need a market where people can invest a certain amount of time and money and get a known outcome.

Lee: At the moment it’s just hit and miss and guesses and too often people end up at the functional medicine doctors trying to get a resolution and I prefer to even avoid functional medicine doctors in the first place because at the moment people are spending on their phone and apps, but people are going to be spending on anti aging, on longevity, on extending their life it’s going to be a quite sizable monthly fee, that people are generally paying in a subscription basis for them and their family. And I’m 100% sure it’s going to be $1 trillion market at minimum within a decade.

Travis: I think you’re right. I haven’t thought about this sort of incorporation into health care, but that makes beautiful sense. I can imagine a future where you’re getting genomic readouts, and you can incorporate, you can have a data analyzed and see where you’re deficient, what you should do, all of these things-

Lee: Yeah. I’ve been tracking companies doing pieces of this in different spaces for years now. I’m actually working on a book on this topic. I won’t divert within your book, but I noticed the time here, so let me just jump on to chapter five and to speed up here. Chapter five is Nature or Nurture, What Really Matters. My favorite quote from this chapter, hopefully I’m quoting okay here, it came from Audible, “Only a few decades ago. The vast majority of biologists would have claimed an individual’s fate lay in the genes inherited from his or her mother or father. But recent studies have shown that the genes we inherit play a lesser role in our destiny. Only approximately 20% of our life span is hardwired into us by heritable genes alone or nature. Conversely, this means that roughly 80% of our longevity is determined by lifestyle and chance, events or nurture.”

Lee: Genes are not our destiny. And this is a hard one to do briefly. Briefly introduce epigenetics. The whole sort of the genome is hardware, epigenome is software. You can mention how they’re switched on and off. And if you wanted to give an example in the book you mentioned about D3 and eating salmon for lunch. Just a brief introduction to the epigenetics so people who don’t know anything have an idea the fluidity inside the hard wiring.

Travis: Yeah. That’s been quite a transition in biology. After we sequenced the majority of the human genome in 2000 and Clinton announced that it was really thought that the majority, and he quoted, this is a quote, “That the majority of disease would be able to be solved now, now that we’ve finally had the hard copy of what our genome look like.” And at the time the director of the NIH thought that, for example, there’d be about 12 genes related to type two diabetes. So you fast forward to today and sequence of genome is down to about a little over a thousand dollars I think-

Lee: I actually did a whole genome sequence recently for 400 euros.

Travis: [crosstalk 01:09:24] that’s crazy. It’s amazing-

Lee: [crosstalk 01:09:28] and the company gave me a 43 gig file to download. I asked for it.

Travis: Right. And the data capture is absolutely incredible now, but what they’ve learned since then is, there’s very little difference between the genomes between individuals. And you cannot account for disease states by genes alone, the vast majority. So when you crunch all the numbers, what you find is about 20% of our health and longevity is determined by the genes you inherit from your mom and dad. And the majority, 80% is determined by what we call nurture. Nurture is a vague term. What does that mean? Nutrition, sleep, chance, events, all those things, but we never really had an explanation for the way that those events translated into our bodies.

Travis: How did events determine our health? Now we know that the way they do it is through epigenetics. So the way you think of epigenetics is you have 22,000 genes in your genome and epigenetics are just the cellular mechanisms that turn the dials, the volume control knobs up and down on those genes. You’ll have the expression or the translation of a gene turned down or turned up by epigenetics. And these events are determined by toxins you’re exposed to, by diet, by lifestyle, by sleep, and by a lot of things, by your relationships. A lot of things we didn’t appreciate before. And the divergence between our epigenomes starts from the moment we’re born, and the reason we know this is the perfect experimental tool proxy for this is identical twins.

Travis: They are perfect genetic clones of each other, but you can measure their epigenome divergence over time. And this actually starts in utero. One twin might get a little more placenta blood flow and get a higher degree of nutrient exchange while they’re growing. And so their epigenomes will start to diverge from their perfect clone right in utero. This is really where science has gotten extraordinarily fascinating. And we’re learning so much more about how these events correlate to our wellbeing.

Lee: Well tying into this before I go to a what I was actually going to ask there is, you mentioned social genomics. Again a topic I have been taking notes for a few years for this book I mentioned I’m working on. And you state that your social life eclipses diet and exercise and your genomics. In fact you state which lifestyle factors matter the most to our longevity. And I think you mentioned something about 4 million people and you say, I don’t know if it was a study, you said there are top two features, strong social connections and social integration, which is a matter of the amount of social interaction you have in a day. So do you talk to the baker or do you talk to a fishmonger? And I find it hard to believe that trump’s diet.

Travis: Yeah, I did too Lee, I found that fascinating. And I thought it’s really interesting, the first half of the book I dedicated so much to data and how we need to do better with data guiding to our decision making. And then I turned in the book to our individual health. And what does the day to say that perhaps we’re getting wrong? What are our own individual cognitive biases with regard to our own healthcare? And that’s the variables, when you look epidemiological and analyze the data, what variables matter the most to our health longevity? And the data suggests that these two interactions, the social interaction that you have throughout the day and the number of close friends and people that you rely on the most. Who do you ask for a loan, for example? Those two things matter the most to our health and they eclipse diet. They eclipse exercise, even smoking, they’re more important than smoking up to 15 cigarettes a day.

Lee: So rather and pay for blood tests and for the ApoE4 gene for example, we should pay for social events?

Travis: Well, you should do it all. These are data showing the importance of lifestyle factors over a statistical analysis of people for genetics. But you certainly need to know if you have a gene for Alzheimer’s a ApoE gene or something else that you could do something about. On an individual level that data is extremely relevant. However as a broad just talking about the general population, that is true for the general population, that your integration into society or engagement with people is extraordinarily important.

Lee: It’s very blue zone-ish.

Travis: It’s very blue zone-ish. And that’s the one commonality in blue zones is you see this dense architecture. You see kitchen parties, you see extended family. And now we know that this fuzzy interface between perception. When you interact with a human being, this perception goes all the way down to your epigenetics and you look at the genes involved in your immune system. This is where this seems to center. When you’re socially engaged, you see a downregulation of the genes responsible for inflammation and you see an upregulation in the genes responsible for the steering response of adaptive immunity. This is why lonely people have this constant sort of smoldering inflammation that results in tremendous amount of health problems, cardiovascular disease.

Lee: [crosstalk 01:116:18] people who feel that they’re isolated, perceived themselves anyway. It’s a subjective thing. Is isolated. Definitely have higher glucose, higher cortisol, higher insulin.

Travis: That’s right. So that just opens up a whole new door of healthcare of how do we combat this increasing societal problem of loneliness, which is getting worse with each subsequent generation.

Lee: But the doctor doesn’t even know you’re lonely, the doctor’s got eight minutes to dispense a drug. They have an incentive to give you an anti depressant. Sorry.

Travis: I’m sorry to interrupt. I thought that was very interesting where, the first half of the book, if you can have doctors be more data-driven, solve a lot of their problems with data, then they can focus more on this human part. Spend more time with this person, this whole person are they lonely? Ask them questions and engage more in the human side of medicine that the data shows is clearly healthcare.

Lee: That’s like the Eric Topol book about humanizing health care with AI. I forget the title. It sort of had the similar message and it’s like, no, there is no incentives that they’ll go from eight minutes to an hour with each patient. All that will happen if the systems could help they would still have eight minutes? But they would somehow push more [billable items] through. There’s nothing to drive an incentive of more time with patient, et cetera. I didn’t understand most of that book to be honest. I was a bit thrown off by it. I don’t know if you that but-

Travis: Well, yeah, I do. And there is the new book, The Price We Pay by Marty McKay, he gives a wonderful example again because our healthcare system is so un-uniformed compared to like the NHS or Canada’s where it’s a national healthcare system, we get these strange pockets of brilliance. And one example he gave was, this payment system where you give a clinic of primary practitioners a bolus of money per patient, right? If they have a thousand patients that you give them X amount of dollars for the year. Now the incentive for all of these practitioners is to do everything to maintain their health, do preventative medicine is cheaply and as good as possible.

Travis: And what you see in these clinics when they do that, they spend much more time with the patient, this sort of human reaction and go through stuff much more thoroughly because their incentives are now aligned to to do that.

Lee: I see, I’ve over showed the agreed time by a couple of minutes. So let me try and finish off on one more question. I’ll just share a couple areas where my mind is been since 2015 and see what thoughts you have. The event I did to validate things back in the Hyper Wellbeing concept et cetera, back in 2015 the splash page back then stated, and it’s funny looking back in time now, “Connected technologies are knowing us ever more intimately. Our physical and sexual activities, motion and gestures, sleep and reproductive cycles and nutritional intake plus increase in physiological measurements. More recently our were moods, emotions, thoughts, intentions and speech.”

Lee: And it was because I realized that an intimacy battery or had been crossed between man and machine and we should use it for something utopian. And then at the same time I’d built up an appreciation of epigenetics. And so in 2016 I’d made this statement, which I’ll read, “Our most pressing health issues today are caused by the lifelong daily interaction among our genetics, environment and lifestyle choices, a dynamic interplay of our biology, environment, psychology and our behavior interwoven.” Now when you take those two things together, machines knowing us, and our health being self determined, not deterministic as I’d been brought up to believe, it’s a perfect marriage because it’s about our social network. It’s about our effective states, it’s about our physiology, moment to moment, our stress levels.

Lee: Now doctors are not watching what we eat, or recording how we feel moment to moment, or recording our stress levels during the day or our glucose response to lunch. It’d be absurd. And so clearly the future is machine and sensor and AI driven. At minimum for prediction, prevention, anti-aging optimization. Surely the machine is center stage there. Brad Perkins argues other way and says, “medicine will become a data science support by clinicians rather than clinicians supported by data.” Do you have any thoughts there?

Travis: Oh wow. Yeah, that’s a lot of content. But yeah, my thoughts toward the end there was, that’s really what Intermountain, these places that are doing this so well that’s what they’re doing is the data is driving is driving the clinicians, not the other way around.

Lee: I’m going to need to look more into Intermountain.

Travis: That’s a brilliant example of this. And AI is already doing things better. For example, radiology, med students are fleeing radiology at the moment because, Google’s got a program and I think others now that use artificial intelligence to diagnose radiology films, images, and they’re extraordinarily good at it. They just show, they show this program, thousands of these scans in it learns how to diagnose and it’s showing is it’s  much better much than a human being.

Lee: Consumer diagnostics will also grow significantly. That’s an understatement. But it’ll become so powerful in the diagnostics side when you do have a condition at the consumer end. I don’t think people are seeing the decentralization of healthcare. People keep speaking of it as if this system will stay. But there is a new system in play. I think it’s like Tesla versus GM, in health healthcare. I don’t think people are seeing this new sensor driven by the semiconductor industry, computer science, moving to healthcare instead of healthcare becoming digitized. There is something new emerging and as I say, I think it’s a multi trillion market.

Travis: Yeah. And I think this is affecting every industry, this new incursion of, of data and analytics and AI. No industry is going to escape the effect of this. How far it goes? I don’t know. I don’t know where you get too much information for a consumer to even rationally to use or you get this kind of weird thing where you’re not even living your life, you’re just, there’s too much… I don’t know where that balance is going to be struck I guess. But we’re grappling with that in society everywhere about how do we use all this data and what is too much, what is too much incursion into our lives? So it’s an interesting argument and I got some far so probably can do this now, but really kind of philosophical thoughts on this process. But it’s undoubtedly the trend is there.

Lee: Have you read any Yuval Harari books, he speaks of dataism?

Travis: No, I haven’t read those.

Lee: But I see the time here and so I just want to give you the opportunity if you feel like we didn’t cover anything or if there’s anything that you’d like to say, then please do.

Travis: No, I think we did. That was a broad sweep of everything in the book. And I think we covered a lot of ground there. And I think the last message I’ll give people is one of optimism. All these things that we’re talking about, these changes are good and they’ll be a time and this stuff is moving extraordinarily rapidly. These life anti-aging technologies and things like that are the next generation, hopefully even our generation could realistically see a dramatic extension in our lifespans. We tend to evaluate things in a very short time frame as humans. But this trend is moving so rapidly. When you look out in decades ahead, I think there will be substantial change.

Lee: I think this is the era, the next decade is about, what I have termed Human-as-a-Platform and I witnessed the PC when it came. I witnessed the smartphone when it came. I was deeply interested in both revolutions, but I think this is the most exciting revolution as innovation heads towards a body. When you eat an apple, an apple is a set number, lines of code that is executed on the body platform. And we’re moving into this, not just systems biology but human in the world systems. I think I’m incredibly excited about the future when you combine, epigenetics, decentralization of healthcare, anti-aging. It’s a brilliant time to be living and it’s not just stopping yourself getting disease. It’s also changing your affective stays possibly with say nootropics. We end up with dashboards for our minds, emotions, and bodies.

Travis: Yeah, I feel the same way Lee. I’m very excited, optimistic, and I think the best is certainly yet to come.

Lee: I must thank you for the book because I greatly admire someone who can actually get a book out the door. Whereas I’ve been spend four years collecting information and every day I keep adding to it, instead of truncating it down, I keep synthesizing but then expanding. And I’d like to talk to you sometime about how you’re able to do the opposite and actually get something out the door. So thank you very much for the book. It’s out tomorrow on Kindle. People will hear this after the book is out, so I’m sure you’ll greatly interest people in checking the book out.

Travis: Thank you, Lee. It was fun.

Lee: Thank you very much, Travis. Greatly appreciate for your time.

Travis: Take care.