Dr. Eric Topol: Pushing Medicine into the Future

Harlan Krumholz: Welcome to Health and Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howard Forman. We are physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This week we’ll be speaking with Dr. Eric Topol. But first, what’s got your recent attention, Harlan?

Harlan Krumholz: Yeah, I’m really excited about having Eric on the program, someone I admire a lot and has made such great contributions. So that’s going to be a great conversation. Howie, I wanted to come back to this issue about salt. I’ve mentioned it before on the program. There were a couple big trials that were done, one in particular that asked the question about whether or not salt substitute, that is, instead of using regular table salt, sodium chloride, they wondered whether or not, what if you gave people a salt that was made of potassium, potassium chloride instead? And would that reduction in sodium chloride, table salt, with the substitute potassium chloride have a beneficial effect on blood pressure or cardiovascular outcomes? And this is the kind of thing, I remember I mentioned it to you before. I remember my grandfather using salt substitute when I would sit at the table with him when I was a boy and yet not really talked about much, I don’t know any doctors who prescribe it, at least it’s not really part of the curriculum. And we don’t actually don’t talk enough about nutrition and diet in medicine as it is. But this is one area that I think has been neglected.

But this trial, the large trial came out very positive. It was positive inclined towards salt substitute. It was good evidence. And then subsequently there was another study that brought together all the published studies and again sort of reinforced this issue about the salt substitute. So in that context, there was also a study that came out just this week in one of the leading cardiology journals that took a look at the association of the frequency of adding salt to foods with patient outcomes, with what happened to people after that. And I often bring up this UK Biobank, this massive study that’s being conducted in the United Kingdom, where over 500,000 people have come together, regular citizens have come together and have agreed to be tested in a wide variety of different ways and then followed over time.

And this is just an ingenious study. Rory Collins, a friend of mine and someone who is another cardiologist who’s done terrific work in clinical trials in a wide range of other areas within cardiology, is leading this. And it’s become a massive resource for the entire world to take advantage of to demonstrate a whole range of different kinds of studies. So there was a group of investigators at Tulane University and at Chan, the School of Public Health at Harvard, who got together, made use of this UK Biobank, and they did a study where they were able to pull together 176,000 people in the UK Biobank who were initially free of having any heart disease. And so they were looking at people with no heart disease.

Now, look at their habits, and let’s see whether any of these habits correspond to what happens to them subsequently. And the habit that they focused on in particular was this issue about adding salts to food. And there’s a question within the UK Biobank about whether you use table salt, regular table salt, always on your food, usually on your food, sometimes on your food, or never and rarely on your food. And then there are a couple of other questions about diets. There’s actually something called the DASH Diet that the NIH had tested early on and an NIH-funded study had tested maybe 20 so years ago, which was using sort of the things that we think of as healthy today, a kind of Mediterranean type diet, lower on the salt. And it found very favorable outcomes—and lower blood pressure, by the way—as part of those better outcomes. But also better, fewer events.

And they found that, yeah, there was a gradient in the DASH Diet too. The more that you were following that DASH Diet, the lower your risk. But on top of that, if you didn’t add salt to your food in general, you got even a bigger boost out of it. So this study’s very interesting because I think we get kind of casual about diet. We get maybe a little nihilistic about it. And we think about salt a lot in the case of heart failure because those patients can be very salt-sensitive and a salt load can push them over to requiring hospitalization or medical attention if they take too much. But this seems like in average people who don’t have heart disease, even in that group, it may be that the amount of salt used, it can precipitate risk, can cause risk.

Now, food studies are notoriously difficult to do and there’s a lot of behaviors that tend to track with the kind of things we look at in food, so there needs to be more study of this. Of course, salt’s been a subject of a lot of different studies, but I think this may really get us looking at how people should be using salt, how much they should be using. And then of course, knowing about its ability to sort of be in processed foods. Processed foods can carry a lot of salt. So there may be issues around that as well. So anyway, I thought this was a very interesting study. People may want to know about it. I think it just goes along with the general thing that we tell people, which is, everything in moderation. But when it comes to salt, maybe moderation or touch less might be good for your health.

Howard Forman: Yeah, I was sort of surprised, I mean, just looking at the study, that how many people always add salt to their food. I’m not one of them. I do use salt occasionally, but pretty rarely honestly. But as you point out, we get salt because we add it. We also get salt inside foods that we buy that are processed. And what you’re telling me is that over decades of accumulated evidence, salt is not good for an awful lot of people. And so your grandfather decades ago may have been making some good decisions.

Harlan Krumholz: Yeah. And I’ve always been a little skeptical of this. I kind of thought maybe there are people who are salt-sensitive and others who aren’t. And my mind’s opening again to the possibility that maybe this is an important risk factor for everyone and we need to know more about it. But all things being equal, if you can get by with less salt, probably not a bad thing to do.

Howard Forman: Yeah, I like that.

Harlan Krumholz: Hey, let’s get onto Eric now.

Howard Forman: Dr. Eric Topol is Professor of Molecular Medicine and executive vice president of Scripps Research. He founded and directs the Scripps Research Translational Institute and is a practicing cardiologist. Dr. Topol’s research has focused on individualizing healthcare using genomic and digital data as well as artificial intelligence. He is one of the top 10 most cited researchers in medicine ever. In 2016, he was awarded a $207 million grant from the NIH to lead part of the Precision Medicine Initiative, a research effort launched under the Obama administration to individualize medicine. Prior to Scripps, Dr. Topol led the Cleveland Clinic to becoming the number one center in heart care. In 2002, he also founded the Cleveland Clinic Learner College of Medicine. He is the editor in chief of Medscape and a bestselling author. He has been elected to the National Academy of Medicine, has been recognized as the most influential physician leader in the U.S. by Modern Healthcare.

He also writes an amazing Substack newsletter called Ground Truths—we’ll link to it in our description—that gives frequent interpretations of new data and scientific publications. Dr. Topol received his bachelor’s degree at the University of Virginia, his medical degree at the University of Rochester School of Medicine. I’ve known of you for decades now but came to know you best through your tireless efforts at spreading evidence and good information in pushing back at misinformation during the pandemic. So first, welcome to the podcast, but then, what would you like our listeners to know right now that they may not be hearing enough of from the mainstream media?

Eric Topol: Well, as far as the pandemic, I think it’s right now being kind of put aside prematurely. There’s still lots of concern regarding potentially a whole new family of viruses out beyond Omicron and also the chance that there’s further evolution within Omicron to cause trouble. I mean, we’re certainly seeing that in certain trouble spots around the world, and China is in for some serious trouble right now. So for everybody just to kind of think it’s over, I think, unfortunately, that’s really premature. Not letting our guard down is really important. We know, for example, the importance of reinfections. And if it’s really true that 94% of Americans have been exposed to the virus, that means there’s still a lot in store, chance for reinfections. And long COVID is perhaps the biggest thing that doesn’t get enough emphasis. And you and your colleagues at Yale have been really leaders on that front.

Howard Forman: Tell me a little about, you started college at the age of 15. What did you think you were going to do when you were 15 years old? I think your father was an accountant. Tell us a little about that and how maybe your family illnesses even motivated you toward medicine.

Eric Topol: Yeah, well my father was an insulin-dependent diabetic. And I watched him throughout his life have all the complications, every complication you can imagine of diabetes. He went blind at age 49 despite some of the early retinopathy treatments at the time. So actually, I was thinking I’d become an endocrinologist or a diabetologist. And only when I went to UCSF [University of California, San Francisco] did I get converted to cardiology. But yeah, my family, both sides, a lot of premature deaths in the 50s. My mother died in her young 50s of cancer. So I saw all the bad stuff of what health ravages could do within my family. So that certainly motivated me towards a career in medicine, as you mentioned. But as far as starting college at a young age, I was a misfit. I was a total misfit. I remember going in the registration lines at UVA and they were handing out condoms and I said, “Well, what is that?” So I didn’t know up or down. So yeah, being young when you’re starting at college courses, it’s got pluses and minuses!

Harlan Krumholz: I wanted to ask you this. So arguably you’re the leading cardiologist in the country, only Gene Braunwald, I think, sort of rivaled where you were at your peak. You’re still peaking, but in a different way. I mean, you pivoted away from the kind of work that you were doing specifically within the field of cardiology. Not that you don’t retain expertise and contribution, which is substantial, but it’s no longer your main platform. You broadened your platform. And you went to digital. I mean, The Creative Destruction [of Medicine], the book that you came out with, was really, I think, paradigm-shifting in many people’s minds, and then continued on that way to become a public figure. But also still substantively involved in the science in a wide range, genomics and digital health. What was that like for you? I mean, here you are in a very prime position to continue your work within cardiology, and you pivot from a position of strength. I mean, what was going through your mind at that time and how did that happen?

Eric Topol: I guess the best way to say it is, I got bored. There wasn’t enough excitement in cardiology per se, and I could kind of see where the field was going, where obviously genomics was starting to get more momentum in the mid ’90s. And then all the digital potential of our, not just our infrastructure but the sensors and the data, and I started to become much more intrigued by these other opportunities. Because a lot of the clinical trials that you mentioned, Harlan, many that we were involved in were turning out negative. And when you start doing head banging, you go for a year or two on a clinical trial and then it’s negative, you say, “What are we doing here?” So I kind of thought that there was other opportunities and the excitement going on, for example, in cancer, in immune diseases, system diseases, many other things that just seem to be more stimulating that could use the new tools that we were starting to see.

Harlan Krumholz: What were the challenges in that?

Eric Topol: Well, I think you’re pinpointing an important aspect is when you’re delving in a new area and it isn’t your home base, and you really got to get to know it. It’s a lot of autodidactic work. So when I did the Deep Medicine book about AI in medicine, it took three years. And during that time, I did a lot of reading, a lot of research. That was two years of work. But also, when I put the book together as a draft, I sent it to over 20 AI experts around the world. And they became friends, and I got to learn from them. So each time, that’s the same kind of thing I did with genomics. And I mean, digital medicine, there was no digital medicine. So that one was easy. I think the AI one was the most challenging because I didn’t have any grounding in computer science. I did have in genetics in college, and getting back to that, but the AI was formidable.

Howard Forman: You had the benefit of being way ahead of the curve, as you’ve just described, and studying this space and then following it really close and even the startup, I think it was called Western Wireless or something that you have on the West Coast [West Wireless Health Institute]. Are you surprised by how slow the technology is rolling out, how fast it is? Tell us what your impressions are now, looking back at what you wrote. And I’ll give one quick follow-up question. I’m in radiology, and I wrote a piece six and a half years ago about the impact of AI in radiology, and I said it’s not going to happen quickly. And I think I overstated that because it’s happening much slower than I expected in terms of its impact on the field. What are your thoughts?

Eric Topol: Yeah, well that was prescient, Howie. I think the problem we have is the medicine, our community is really kind of ossified, very resistant to change. And in order for that change to occur, many things have to happen. One of them is compelling evidence that is just overwhelming, that you just can’t practice medicine the same way as you used to. And so for example, with radiology, there’s been certainly many algorithms of interpretation. Machine eyes are amazing, but they are not published, they’re not transparent, they’re kind of in the bowels of proprietary data in the FDA review retrospective.

They’re not what you call kind of groundbreaking results that would change how radiologists necessarily would practice. But then the digital thing is much bigger. But the digital thing is, it’s been well over 15 years now. When I came out to Scripps, we started really, I think the first academic digital medicine program. And 15 years later, what do we have to show for it? Not much, because it took a pandemic just to accept that telemedicine existed. And there’s lots of reluctance to accept—we see certain elements of acceptance, but gradually it’s a very slow-moving process.

Harlan Krumholz: So I heard from many folks because who’ve run, people who work with you, because every once in a while I’ll ask about that. “How does Eric keep up that volume of Twitter?” “And does he have a team of people?” “And how is he doing those?” “His visualizations are terrific,” and all this. Time after time, people say, “He does it himself. He actually does the work and does it himself.” Tell us a little bit about your own process. I mean, given how busy you are and everything you’re doing, I mean, that you’re able to devote yourself to that kind of communication and do it so well. I mean, the visualizations with your tweets, for example, I mean, you’re always right on. Tell me a little bit about your process. How do you get that done?

Eric Topol: Well, first of all, the staff is me. You’re looking at the staff. So, it’s 13 years, over 40,000, I don’t remember the current number of Twitter posts. But I try to take each one as seriously as what can it transmit? And I wish, I know both of you are active, but I wish all of us would become much more, whether it’s Twitter, which has got some issues at the moment, whether it’s Mastodon or Post, whatever. But we have to stand up to all the mis- and disinformation and all the shoddy stuff that’s out there. And if we don’t do it, how’s it going to be titrated? So I think that’s the problem. I do think it’s worth the priority of time. Yes, Harlan, you’re absolutely right. It does take some time. But as both of you know, as you do it more and more, it takes less time. You just get very efficient. And if you’re going to read something anyway, all you’re doing is basically sharing it.

Harlan Krumholz: Yeah, I just love, I mean, you highlight the pieces. I mean, you make it easy to extract the information. Anyway, much appreciated from your readers. I’ll just say to you.

Eric Topol: Oh, you’re very kind. Thank you. I mean, I now wonder about all the investment of time put into Twitter if it really deteriorates, as it looks like it is at the moment. But hopefully, I’m optimistic. I’m always thinking something will turn that around. We’ll see.

Howard Forman: Yeah. I want to go back to what you said with social media because the last few weeks have been frustrating. And I am seeing a flood of misinformation—purposeful misinformation—propagating itself. And I take a different tack from you and Harlan. I’ll just continue to fight in the trenches against this at times. But it’s becoming almost impossible, and I worry about it. And you are on Post already, and I think you’re on Mastodon already, and so am I. What do we do? Do we keep fighting the good fight on Twitter no matter what happens? What are you thinking specifically about how you’re going to manage social media?

Eric Topol: I’m kind of thinking there’s parallels to terrorists where you don’t let them get you to cede your space. You got to ante up. I really think it’s important that we don’t just go off to sites with minimal reach where people are not spreading misinformation. They don’t actually need us as much. Twitter, I think is, Twitter is unfortunately, because of its long-term base, it has extraordinary reach. And if we just give up, that’s unfortunate. So I’m going to fight it out. I love what you do, Howie, where you take them all on. You’re not afraid of anybody.

Howard Forman: That’s true.

Eric Topol: You’ll go after Elon, you’ll go after, it doesn’t matter. I think that’s great. It isn’t fun to be piled on, because they’re organized. As you well know, they’re organized and they have some ringleader that says, go after this person or that person who wants to kind of ruin your day.

Harlan Krumholz: I wanted to ask you this. You wrote about almost a decade ago, 2015, I guess, The Patient Will See You Now. I thought, by the way, amazing title, talking about the democratization of medicine, what I think will be an inevitable turn of medicine toward the patient. But even over the time since you wrote that book, slow progress, lots of resistance. There’s paternalism in medicine, the idea that we’re telling people what to do, and that we’re also filtering the information that people can see and use, persists till today. What do you think is going to be the turning point here that’s going to lead us into a new direction? I mean, the direction that you talked about almost a decade ago. It’s there. I know it’s going to be there, but I don’t know when.

Eric Topol: Well, I know you’ve championed, I think, a very much similar path that patients should own their data. And this is, in a digital world, this is an inevitability. The question is when. And it may take decades to get to this natural conclusion that it’s not right for doctors to think they own the record just because they did the notes or that it’s their work product. It’s the patient’s. So that’s kind of the real basis. The core problem is the unwillingness. Even still today, most physicians don’t want to share their notes with patients for ridiculous reasons. But this continues. There’s been little... One thing, going back to the AI and digital, we’re seeing a lot more coaching, and we’re seeing people being able to capture their own data and get algorithmic support. So that will arm patients more, but they are missing getting their data. And the portals largely are totally inadequate.

Harlan Krumholz: Yeah. I think the pandemic may have pushed things forward, but still, not fast enough progress.

Eric Topol: Right.

Harlan Krumholz: So let me, we’re getting toward the end. So I wanted to ask you one final question just as a parting shot for the listeners. And it’s about mentorship. And I was just wondering today, given all the exciting things that you’re seeing ahead, there’s no one who sees the future, I think, as well as you do. When you see medical students and they come and say to you, “Hey, I’m looking at all these exciting things going on and I’m trying to decide where to go with my career now.” What’s the advice you give to those young students now about how they should position themselves for the careers that will last the next 50 years?

Eric Topol: Yeah, I think it’s really good to have particular emphasis, if possible, whether in data science and analytics, computer science, AI. I think this area is just going to be the most transformative that we’ve ever seen. And so for people who at least have a willingness to delve into that, they don’t have to necessarily get a degree or go too deep, but just that familiarity. It isn’t a part of medical curriculum now. It should be, for sure. But we need to groom that and really nurture that field so we’re not left behind as we currently are, relatively. So I hope that area will wind up being one that is really extremely popular.

Harlan Krumholz: Yeah, yeah, I totally agree.

Howard Forman: I just want to take the moment to thank you for giving us your time. And really the contributions that you have made to society, to medicine, to the social media community, cannot be measured. If people are not following you, they should be following you. And just for our listeners, Twitter handle for you is @EricTopol, T-O-P-O-L. And we’re just so fortunate to have you as a colleague and a friend.

Harlan Krumholz: Yeah, I appreciate you, Eric. Like I said, appreciate you, appreciate you taking the time with us today.

Eric Topol: Well, thanks. It’s been a joy to join you. And just that I would make a footnote, what you’ve been doing at Yale throughout the pandemic, no less before and after, but in the pandemic has been extraordinary. I don’t know of an institution that’s made more critical contributions, including both of you, but it’s been great to watch. And I’ve noted that in social media from time to time. Few institutions have surpassed the type of pan efforts that you’ve done. So, thanks a lot.

Harlan Krumholz: And we’re not done. I mean, with this long COVID and all, great work that Akiko [Iwasaki]’s doing and others. It’s really, it’s terrific.

Eric Topol: And look what happened with medRxiv preprint. Oh, man.

Harlan Krumholz: By the way, and tip of a hat to you. You and I wrote early pieces together about that. Again, credit to you for helping with that too. Thanks.

Eric Topol: No, well look, that turned out to be an amazing, important platform. Thank you.

Harlan Krumholz: Thank you.

Howard Forman: Thanks, Eric.

Harlan Krumholz: Yeah. Thanks, Eric. Howie, that was a terrific interview. So let’s turn to you. What’s on your mind this week?

Howard Forman: Yeah, so you and I are temperamentally a little different. I’m really easily triggered by some things. I can also be calmed down, and you’re one of the people that can calm me down about stuff. So I’m going to bring this to you and ask you your thoughts. The former FDA commissioner, Scott Gottlieb, posted an interesting table on LinkedIn this weekend. He stated that GLP-1 agonists, these are the glucagon-like peptide 1 receptor agonist that we talked about with Ania Jastreboff with regard to obesity. He pointed out that that class of drugs now is the largest within the peptide group. Total annual sales, $17 billion. Okay. So that’s all interesting. But what caused me to bring this up and what triggered me, so to speak, was a seemingly innocuous reply to his post that read as follows. Type two diabetes “can easily be treated without drugs, but with lifestyle change: reduce sugar and start physical activity to express GLUT4.”

So I’m going to set aside for the moment a discussion of GLUT4 [glucose transporter type 4]. Maybe we’ll get someone to talk about it. But that’s a glucose transmitter, transporter rather, that helps mitigate hyperglycemia in people who exercise a lot. So put that aside. But diabetes is a disease that has many factors influencing its development, persistence, and worsening. And here I’m talking about type 2 diabetes. It may be the case that there are many cases of diabetes that could be managed by reducing sugar intake and increasing exercise. But it is condescending, to me, to say that it is “easy.” So I went back and looked at this person’s background, the one who posted this, and lo and behold, they’re a relatively young PhD pharmaceutical company executive. And I wanted to get your take on it because I’m wondering if I’m being overly harsh. I did not reply to him on LinkedIn. I decided that this is a war that I’ll fight on a different day. But curious of your thoughts.

Harlan Krumholz: Well, look, Howie, I think given all the things going on in the world, you might want to reserve your ire for another target. This person’s (1), they’re not wrong, that you actually can roll back type 2 diabetes with marked behavioral changes. If the person suggests it’s “easy,” they’re dead wrong on that. I mean, there’s nothing “easy” about it. And what we’ve seen is that the ability for people to maintain the kind of drastic behavioral changes that lead to marked reductions in weight, for example, and the ability to roll back. And whether it’s a ketone approach with low carbs or whether it’s just low caloric approach. I mean, these things can work in some people temporarily, but the ability to persist with this over time is almost impossible for most people. That’s not to say we shouldn’t encourage people if they want to try or try to suggest, I don’t want to suggest to anyone that they shouldn’t try those behavioral approaches.

And maybe for some people they can live with them for their lives. But we know that for many people this is difficult. And I think the important thing, and this is a message that Ania, when she was on our program, was trying to get across, was “Don’t blame the victims here.” Obesity is a disease and we need to be really careful about suggesting it’s a lack of willpower or an inability to do the right thing that saddles people with these health problems. But rather, we need to recognize that in the context of our current society, that we have a problem with obesity and it’s a disease problem. And now there are lots of strategies that seemingly can help over the long run. Some require drugs, some even interventions like surgery.

And that doesn’t mean we should stop behavioral approaches as well. But it seems like a multimodal approach, a multidimensional approach is going to be the best way. But getting back to your point, look, this person may have been too flip. It’s a very hard problem for most people, and we really need to be sure that we’re conveying respect, honoring them, and not blaming them or suggesting it’s any weakness in their character as a result that results in this.

Howard Forman: It ties back to what you said in the opening with salt, right? I mean, it’s one thing to say to people, less salt is probably better than more salt, but I’m not sure that you’re going to be able to get patients to change your behavior when you take absolutist views to tell them that you can easily not have to be treated with drugs if you just listen to me and do exactly what I say.

Harlan Krumholz: Yeah. Well this gets also to, I think, the thing that Eric is also writing about around the paternalism of our medical care system and the idea that, hey, if you’re not compliant, if you don’t do what I tell you, instead of trying to understand the circumstance of people’s lives, that can make it very difficult to follow certain regimens. And the fact that these regimens continue to fail should tell us something. Again, Ania’s helped to teach me about thinking about obesity like I think about hypertension, which is, I can encourage people through healthier diets and exercise and try to see if we can take a few points of blood pressure off, but in the end we need to treat it. We need to get people’s blood pressure down. And that’s what helps them. And again, it takes people also being interested in being treated and forming that partnership with our patients so that they understand what’s at stake and they can make choices.

But to suggest any of this is “easy” or that trivial is a big mistake. And if that’s what is inflaming you, I would say that’s justified. But I’ll still come back to you and say, in today’s world, you’ve got ample other things I think that should get your attention that may be equally important. Only just saying to this person, this is what we need to fight against. Because this is a prevalent belief, which is that this is just a matter of telling people, urging them on, telling them what to do, having them modify their behaviors. Decades and decades and decades of failure, I think, has shown us that’s not going to be the right approach. It’s just not.

Howard Forman: Yeah, shaming people is just not a solution. I don’t think we’re ever going to get anywhere in medicine if shaming is part of our strategy.

Harlan Krumholz: Or making them feel just inadequate. Because shaming, maybe it’s the same thing. It’s that inadequacy. They shouldn’t feel like they’ve failed. We failed them if we haven’t been able to work with them to find a strategy that works.

Howard Forman: My point. Yep.

Harlan Krumholz: Okay. Okay. You’re justified. You’ve been listening to Health and Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: How did we do? To give us your feedback or to keep the conversation going, you can find us on Twitter for now.

Harlan Krumholz: For now. I’m @hmkyale. That’s H-M-K Yale, and actually, Eric’s helped me think about this a little differently about saying, yeah, we should ante up and really push forward.

Howard Forman: Me too. I’m @thehowie, that’s T-H-E-H-O-W-I-E. And I’m going to stay there as long as I can. You can also email us at health.veritas@yale.edu. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs, or you can check out our website at som.yale.edu/emba.

Harlan Krumholz: Health and Veritas is produced with Yale School of Management. Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer. They are amazing. Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon.