So, last time David had a chance to ask me some of my perspectives on innovation and healthcare. And now it's my turn. So, David it's lucky for me to be paired with you as a partner in installing the Innovation Center. And, as I think about your history in what you've done, you've been a physician, a researcher, you are still are a physician and researcher, and you've done that for a long time and you're really great at it. This is a change. This was different for you, studying five years ago and studying this center with me. So, I'm curious to have you talk a little bit about what's different, and how is this different and what different ways of thinking are required. Because a lot of the people probably are familiar with being a clinician or being in a health system, as somebody who works in a health system and the health care organization. So, what's different? How would you talk about what's different for you? Well, for one thing it's been a lot more fun, thanks to you and to others. But when I think about the lives of researchers, and maybe I should divide this into research activities and clinical activities because I think those have only partial overlap in general. But if you think about the research side, so much of your life is generated or focused on generating research projects that are of intellectual interest and that you hope are also have some impact. And there also have to be answerable to some funder because research takes money and there is no other capital market for that except for the investments that we make typically as a nation in research. And, you have to set this path in motion, this research path in motion of convincing the various stakeholders to make your work meaningful to them, often years and years in advance, and you have to map out the entire journey or no one is going to entrust their money with your mission. And to be honest, that's not how anybody would ever really do anything. And one of the things that I think I've learned and the skills I've honed over the last five years, is the recognition in some sense of how much value we give up because of that purpose that we have in research. And to flip it around to be a little bit more constructive, how much we could change the research process that we currently use for typical grants to NIH for example, and illustrate step by step processes. Almost changing the way we talk about the preliminary studies that we might do in a grant and think about staged evaluations. Now, the trouble is if you were to do that, my guess is that somebody at NIH, for example, would say, well then we'll give you the money for each step along the way and that would be a non-starter because you can't begin a project unless you have some belief that you can continue if it succeeds and that needs to be a little bit in your control. But I'll say that one of the good things that has happened to me as a researcher, is recognizing a completely different set of approaches that can inform my academic research in the same way that the empiricism that is so essential on the academic side is really critical on the innovation side. I can answer a little bit on the clinical side as well which is that I need the clinicians are fundamentally very well suited to innovation. Clinicians are on the ground with their patients have a very, typically, very focused attention on some problem that's formulated typically from the patients perspective. And they are actually well positioned to do this kind of work. What I have found that's interesting, on the other hand, is that if you take an academic medical center like ours, most of the clinicians are also researchers. They're scholars in some sense in addition to being clinicians. And they're used to specifying hypotheses and tests and creating aims and being fairly organized about their research. And then in the clinical enterprise, they're great clinicians. But when they try to innovate in the clinical space, it's almost like paradoxically as if they throw all their research sensibilities out the window. And that was another lesson, I think, is that it shouldn't be that hard to remind the clinicians and in fact, it hasn't been, about how they can take those empirical sensibilities right with them into innovating in clinical practice. I think that's been a great win for everybody here. Your answer on the research part reminds me of why we had to change the name of our innovation grant program to the Innovation Accelerator Program. So, grant means something to people. If you apply for a grant and you win, you're supposed to execute that plan that you submitted. And it's about executing what you said you were going to do as opposed to falling in love with the problem, and then shifting changing directions based on what you learn and not necessarily doing what you said you were going to do in the grant application. Yeah. It would be so interesting if NIH took that approach. Here's what that would look like, they would say, so when we pick up people and projects, we're most excited about the importance of the problem. We're also excited about the passion of the team and the ability of the team to move forward, pay far less attention to the solution. If NIH took that approach for its research grants, they would say this problem, this particular pathway that might be important in pancreatic cancer is critically important. This team has demonstrated their ability to move things forward, let's give them a chunk of money and let them go. We don't see that. Right. Everyone wants to see exactly how they're going to proceed. It leads to a kind of incrementalism in the whole research endeavor which is bad and it doesn't support the kind of incrementalism in the actual day to day research which is good. And so, I've learned from you that these two things fit together, that there is a reason for randomized controlled trials, that there is a gold standard of knowing what really works and being confident that it works, getting rid of some of the biases and some of the things that can pollute small pilots etc. and that there is a value to doing some of the rapid innovation work and the front end. But still it doesn't replace the RCT, the Randomized Controlled Trial. So, what is the role of traditional research, of traditional academia and how does that fit with the innovation one? Yeah, I think it's a great point. Well, first of all, although RCTs are sometimes the gold standard in clinical medicine. There's plenty of research methods that aren't RCTs but are good enough. But it is true that the evidentiary standards for the kind of discovery that academic institutions are in the business of producing, those evidentiary standards are pretty high. And with good reason. We may take these is as fundamental truths about the natural world we're going to deploy them and all sorts of contexts. We want to be pretty sure that we've got it right at that point. Now, I'm not saying that managers and leaders of health systems have lower standards, but they have a different time horizon for when that information needs to be relevant. And so what I think is most interesting is you can have lower evidentiary standards. Instead of a P-value of 0.05 or 0, maybe your P-value is 0.2 or 0.3 enough to pivot and go to the next step, enough to make a management decision, enough to ramp up an evidence base that then you might later want to really nail down with a big trial that needs lots of people, tiny little P-values, the kind of credibility that a trial provides. I think these are so intermingled. Wouldn't it be great again as I said earlier, if the work you report in your preliminary study section of grant show that kind of earlier work as opposed to what we typically put in grants which is a lot thinner I would say. It reminds me of Mitesh Patel's work in physical activity where, a very logical arm might have been looking at a certain kind of leader board just who's walked the most steps for example. But there was no reason to believe that would work because we thought in the preliminary work that it discouraged more sedentary people. So, if your goal was to make more sedentary people more active, it didn't work. They got discouraged, they looked up their 100,000 steps behind. So it didn't waste an arm. And I think that means you didn't waste a lot of time and a lot of money. That's such a great story. So, we started with this walking trial that was done with little pieces of string and scotch tape and cardboard, learned a ton of things, that allows Mitesh Patel to develop a whole slew of randomized controlled trials that were much more elegantly designed and avoided a bunch of blind alleys. The lesson is to learn something, you have to do something. And you have to start somewhere. But often in the traditional research enterprise, we haven't really like we sort of start once we get the money. And like honestly you make your most informative mistakes happen early on. We should bake that into the process and not hardwire our direction so early on. The fundamental problem within RCT is that they answer with incredible precision, very narrow questions and sometimes not the question you would have wanted answered five years later when you get the results and suddenly unblind your study. Makes sense. So, I've got to ask you. I know it's difficult to say whether you love any of your children more than other children but, so after five years and dozens and dozens of projects, many had good outcomes. What's your favorite project? Is there one project that you can think of too that you think represent the way you want people to think about innovation in healthcare. Well, so you're right the first time, I do love all my children, except that boy of mine I could sense about. So maybe the project we did on making Penn Medicine normal tensive. It's not that it's my favorite but I think it illustrates a lot of the principles of this course. So, the goal there was, we recognized that high blood pressure, hypertension, is of enormous personal and public health significance. It actually doesn't get a lot of attention in the way that obesity or smoking or even depression get. But is the leading remediable risk factor for a premature death not just in the United States but around the world. And there are conventional approaches to taking care of high blood pressure that involve largely going to a doctor typically a primary care doctor, sitting in a waiting room, getting your blood pressure checked, having other things happen, maybe your medication is adjusted, you're given dietary advice, it's quite an involved process. And frankly, even if you have the goal of improving the management of high blood pressure, that's a lot of steps towards that goal. And as we thought about it, and I'll just mention this to explain why I picked this one as an exemplar. We realized that process was defined by the way clinical care is delivered. It wasn't defined by the fundamental goal we had which is making people normal tensive. And if you switch it around a little bit say, well what's the goal? Are we want to get blood pressure down quickly, completely safely, conveniently. You'd never designed the system that you had. If you realize like that was a system that was designed for the doctor's convenience. It was designed for all sorts of other clinical. It's not how you would have designed it for that. And so it allowed us to think about new analogies like, someone on our team came up with the idea that what you really want is the equivalent of Jiffy Lube, right. You don't need a car mechanic to manage your oil change, you just need Jiffy Lube. What's the Jiffy Lube equivalent? Why do we really need doctors and all it? It allowed us to question so many of the processes that were built into something was designed really for a different purpose, and be oriented around a very focused simple goal, a goal that we could focus on, which was lowering people's blood pressure, and getting as many people normal tensive as possible safely with a variety of other bounded constraints. I think that project was one of my favorites because of the problem definition aspect of it. And then of course, it actually worked. I mean, the things that we did it allowed us to innovate in different ways, try different solutions. It was successful in its outcomes. But I bring it up as an example of something that was successful mostly in original approach to it and that was what made that project exciting.
