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Becker’s Healthcare Podcast
Rethinking Healthcare as Technology Shifts Care to Consumers with Dr. Joel Selanikio
00:39:54
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- [00:00]
A
This is Scott Becker with the Becker's Healthcare Podcast. I'm thrilled today to be joined by a brilliant physician leader who's also a technology leader. We're joined today by Dr. Joel Salonicchio. And Joel's a speaker. He talks about GLP1s. He talks about healthcare, he talks about women's health. He talks about a lot. Joel, can you take a moment and tell us a little bit about yourself and your background? I don't know if you're a Georgetown Hoya fan, but you'll tell us if you are, but tell us about you and your career. Sure.
- [00:38]
B
Well, I'm a. You know, the easiest thing when I meet people and they ask what I do is I say I'm a pediatrician because everybody likes pediatricians. And you know that you don't have to explain any further. But really, my, my. Although I am trained as a pediatrician and I do work couple days a week in the clinic, most of my work for quite a long time, for a couple decades, has been in technology and healthcare. I used to work for the cdc. I started with CDC after I finished my residency and did a lot of work in international vaccinations by a very indirect route that led me to focus on data collection and data analysis related to immunization. That led me to early technology work. This was back in the. I know, Scott, you of course, won't remember this, but the Palm Pilot days, way before your time, I'm sure. And I eventually wound up leaving CDC and with a friend of mine from the American Red Cross, we started a company that created data collection software that's been used for, for quite a while now by global health. And because of the work in technology and because my background in, in clinical medicine and epidemiology, I've increasingly begun putting those two things together for about the last 10 years because my work with the technology company, which is called Magpie, and this is unusual, I guess, for a pediatrician, I wound up attending a lot of meetings and a lot of conferences out in Silicon Valley and began to get some basic idea. Again, unusual, I think, for pediatricians at least maybe outside of the Stanford community, of how technology works. And increasingly I've been trying to communicate my ideas about what's happening with technology and health and healthcare. And I definitely separate those two, health and healthcare over the last 10 years and what's about to happen. So, for example, looking at things like AI in healthcare and AI in consumer health, which I think is actually by far the more important, the more important topic and the Biggest growth area. But I think lately I've been talking to a lot of healthcare organization boards, I've been talking to a lot of physicians, I've been talking to a lot of technology people about a couple. Well, I think a couple very important statistics that I think are almost entirely unknown within healthcare. And one of them is that people always think of healthcare as being this enormous. It's $5 trillion, it's constantly grow. And you know, I started looking at that because initially I had started thinking, you know, consumer health technology seems like it. It lets consumers do a little bit of stuff on their own that they used to do with the doctors. You know, you can look up stuff on Google and doctors, of course, like to make fun of Dr. Google, but it prevents some appointments. You know, some people who might have gone to the doctor for that knowledge get it from Google instead, or now they might get it from ChatGPT. And I thought, you know, this must be. You should be able to see this in the data. And I started looking into healthcare spending and healthcare spending growth in the United States. I went to the CMS website first. I started looking at health care spending, and of course, as we all know, it's gone nothing but up for the last 50 years. And then I started looking at the first derivative of healthcare spending, which is healthcare spending growth. And I found that that's been falling for 50 years, that the rate of health care spending growth has been dropping for 50 years. Just to give you an example, you know, what with the public spending on health care in the 60s, in 1970, if you look back at the previous 10 years, the 1960s, you'd find that health care spending had gone up by 83% per capita in the United States. If you look 20 years later in 1990, in the previous decade, in the 80s, it had gone up by 65%. If you look most recently in the last 10 years, it's gone up by 28%. And that was unexpected to me. It was so unexpected when I was sitting there with my Excel spreadsheet and looking at that data that I contacted some economists that I know and said, explain this. Did you know this? Does anybody know this? I was surprised to find a graph that was going down. And the economist I talked to said, oh, yeah, yeah, everybody knows that. And I was like, well, everybody doesn't know it in healthcare what's causing that? And no one really had a satisfactory answer. And I thought, okay, that's consistent with. But it's certainly not going to prove that technology is pulling things away from health care and that is materially affecting the growth in healthcare spending. So that's sort of one mystery the other or one unknown within healthcare. The other one that I have found quite amazing both in the content and in the fact that it is completely unknown within healthcare, is that a Harvard study that looked at primary care for insured American adults, and this was published I think in 2020, it looked at 2008-2016, found a 24% overall decline in primary care visits for insured American adults. The amazing thing to me about this is I have never found a primary care doctor who was familiar with the study. And having spoken to probably at least 100 healthcare system CEOs or C suite level executives over the course of the last five years, I've never found a healthcare executive who's heard of it either. And I've never found anyone who came up with a satisfactory explanation for this. Now, the authors of that Harvard study said, well, we think that we can explain about 25% of the 24% decline through things like urgent care. You know, stuff that shows up in billing. You know, someone's billing for something and it's just not the traditional healthcare system that's billing for it. It's urgent care. It's things like that. Maybe direct to consumer stuff, someone generates a bill. But the other three quarters we're not sure. But we think it might be because people are getting more comfortable, especially young people with kind of taking care of their health themselves more on their own. This is back in 2020 and since then that sort of dropped. Everybody ignored the finding. The authors have apparently have some new data that just kind of confirms that the trend continues and healthcare ignores that or is unaware of those two findings. And to me, to get back to your original question, I spend a lot of time now thinking about why that's happening. I think it's connected to technology and talking about that with healthcare executives.
- [07:27]
A
Thank you. And talk for a second about that. How much of that primary care changing in how people deal with primary care is. I'll give you three questions. Technology, necessity due to shortages, maybe the third is sort of combined with the second and is accessed that that by design. It's harder and harder to get to a true primary care physician. In some states you can't do it without paying concierge fees. So how much of this is due to technology and by necessity? People moving away from primary care physicians because they can't get into them. It's almost why you see somebody about the ER sometimes, because there's no other easy access point sometimes. But what do you think's driving about what you're doing? Talking about? Because I think you're. The counterintuitive stats that you have I think are actually right on and really fascinating talk about what do you think is driving some of that?
- [08:24]
B
Well, Scott, I think you've hit on exactly the question because you know, one question is why is this happening? But here's a, here's a, I think a more telling question. Why don't we know the answer? Right? You raised certainly a great counter possibility, you know, and people often in healthcare they assume that this is because we need more access, right? We need more clinics, we need more doctors, et cetera. And that that's a reasonable explanation. It's also reasonable to say it's because demand is dropping. Now if someone found that auto sales in the United states over an eight year period had dropped by 24%, it would be all over the news. And you know something, every car dealer in America would know about it and the CEO of Toyota and the CEO of GM would know about it and they would be finding out the answer to the question that you just asked. Right? They would be like, well you know, this might be because we don't have enough dealerships and we gotta build more or it might be because people are taking Uber, like we need to put some money and some time into finding out the answer to this question. But within healthcare that's not what has happened. What has happened is no one knows about it and no one talks about it and, and no one further investigates
- [09:46]
A
in the point is so well taken. And I've heard some discussions recently along these lines. One, I think you're absolutely right. I mean, for example, just the beauty of health care is every single one of us is our consumers. And while you can't extrapolate totally from your own experience, we do know that more recently many of us look at ChatGPT, we go to the urgent care, we think we have a better sense, and we often do, of what's wrong with us unless it's something that's really serious and we take care of it through the practice assistant, the pa, the nurse at the urgent care versus what would have been a one way ticket to the primary care doctor years ago and part of its necessity, we're in our country creating 200,000 nurses a year, where we're creating maybe 8 to 10,000 primary care physicians a year, where we're losing almost that many per year. And the numbers just don't work in terms of long term single primary care physician for a lot of stuff. But what are some of the things that you sort of believe may be causing the change in how people see physicians?
- [10:55]
B
Well, I don't think it's just how people see physicians, but I think that over the course of our lifetimes we have seen a variety of tasks that used to be done by doctors or used to be done by the healthcare system move into the consumer space. And we're all very familiar with that. I mean Google, of course, in terms of knowledge, I usually think of this as sort of five categories of five migrations out of healthcare. And in terms of knowledge, obviously 20 years ago, all of a sudden you've got all kinds of websites designed specifically to help people and doctors to look up information beneficial to the consumer, beneficial to the doctor. And of course Google, probably the most important knowledge tool, well, maybe up until recently ever developed, you know, you know, post printing press and you know, as I said, you know, if you go to Google and you look something up, you might not go to the doctor. We haven't really quantified exactly what happens with that if we look at diagnosis rather than just knowledge. Well, you know, we've had home pregnancy tests for a long time. Nobody thinks of home pregnancy tests. No one ever asks the question will home pregnancy tests replace the doctor. But the fact is the 20 million home pregnancy tests that are done in the United States every year, and this is, you know, this is not some up to date technology, right? Those are 20 million visits that don't happen. That's 20 million visits that don't get billed. If you look at treatment over the counter drugs, I mean, over the counter drugs are specifically designed to replace the judgment of a doctor with the judgment of a consumer. Right? That's the whole reason for over the counter drugs is to replace doctors for certain health interactions. That is what they do, that's what they're designed to do. And you know, estimates that I've seen, and I think these are pretty rough estimates, are that we would need tens of thousands more doctors if we didn't have over the counter drugs. I think the current FDA is very, very interested in trying to figure out what can the consumer of today, equipped with ChatGPT, equipped with an Apple watch, equipped with a smartphone and a computer, what can the consumer of today, with all those knowledge sources and all those resources, what can we make over the counter today that maybe we couldn't make over the counter when people had to go to the public library to learn about things? Now the answer can't be. Well, it's just the same. Right? The answer has to be, well, yes, of course. People have many more knowledge tools now than they did say, you know, 30 or 40 years ago. So surely we can move more drugs over the counter again. That's a process that's been going on a long time, largely unnoticed. Monitoring. I mean, monitoring has exploded. You know, I'm wearing an Apple watch right now. Many people wear similar things, Oura rings and whoop and all these other different devices designed to monitor stuff. I mean, monitoring used to be. Used to be a big thing that you had to go to the doctor for, except you only monitored certain stuff once or twice a year. That's not only allowing people to see things and understand them at home that they didn't used to. It's allowing them to see things that they could never understand at the doctor. Right. The doctors, doctors were never measuring, for example, let's say, heart rate variability or VO2 max. I mean, I think the American Heart association came out, this must have been 10 or 20 years ago, with a statement saying that we should measure VO2 max. It's a more potent predictor of future health than I can't remember than any of the things that we're doing currently in a doctor's office during a checkup. And that doctors should do it. Now, of course, doctors didn't do it because it requires a lab and exercise test and all the rest of that stuff. So that metric would never even done. I think the thing that's new, I mean, all that stuff that I'm talking about, this is decades old. I think the thing that's really new is the interpretation layer that we never had before. So we've got the knowledge, the diagnosis, the treatment, the monitoring, and now technology that can actually interpret that stuff for us. All those things, they're not destroying healthcare, they're not eliminating healthcare, but they are removing tasks out of healthcare. And interestingly and importantly, those we never hear of a task that is dealt with on the consumer side, they never move into healthcare. They only ratchet out of healthcare. And so again, you know, when you think of, like, why this might be happening, that's why I think it's happening. But a bigger picture is we need a lot more information. And an even bigger picture is why is it that we're not getting that information? In fact, no one's even looking at the question. As I said. No, you know, with the. The example of the car dealerships, I mean, literally 24%, and you and I are sitting on it on a podcast. Hey, saying I wonder why. Scott's got one idea, Joel's got a different idea. Do we have any data? No, no one's looking at the question
- [15:50]
A
and talk about this because two things you mentioned resonate so well and I know you do a lot of discussions and speaking in TED talks around GLP1s and other evolutions, but the GL area is a fascinating area to the point that we're talking about in that in the old days anybody that wanted to get a GLP one would go see their, their primary care doctor or some doctor or specialist in weight management. And now we've taken so much out of the system by going directly to whether it's hims and hers or Rose Sparks or one of the other telemedicine or online providers. And that would be a huge burden on the system if not for these companies. Is that a fair assessment? I can't even imagine how overwhelmed our health system would be if all of that went through the traditional health system versus some of these online retailers. Can you talk about that for a second?
- [16:45]
B
Sure. Well, I mean, I think to me this, the term I usually use to describe the effect of these on and some other things on the healthcare system is demand elimination. Right. So, you know, there is, as you point out, tremendous demand. Although one thing I, you know, one quibble I'd have is I wouldn't say that previously anybody who wanted to get a GLP would go to their doctor. Previously anybody who wanted or ought to get a GLP didn't go to their doctor because as we pointed out, there's not enough capacity to deal with that. So, you know, the unmet demand for those medications is huge. And obviously this is why you see companies like the ones you mentioned, like Hims and Hers and Ro moving into this space to do that. So this I think is a little bit different from the migrations that I talked about. Because in that case what you're seeing is the disruption of health care, right? In the kind of Clayton Christensen sense of disruption where there is a new technology. Let's say the Internet has been developed or the smartphone has been developed, or the smartwatch or all those things have been developed. And those things are providing perhaps a lower quality but a much more accessible and much cheaper version of something that you previously got in the healthcare system. Again, classic kind of low end disruption going on. And you can look at that from over the counter drugs. You know, getting going to the drugstore to get Claritin is not the same thing as going to see an allergist by any means, but it's good enough and it's a lot cheaper. And so people do it with the GLPs. And another example of that I think would be the, with the GLP is a great medication example. Another example I think is going to be autonomous driving and I'll touch on that in a sec. But with the GLPs, I think what you're talking about is these companies are not disrupting healthcare. They haven't invented a new technology. We're just talking about people who have different business models. So it's not a new technology that has somehow made it, that has disrupted in the Christensen sense you're talking about just companies that are doing that now. How long, I wonder, until these GLP medications wind up being, you know, the pills particularly wind up being over the counter? You know, we, we have, you know, in the United States, tons of people are on statins. They're not over the counter. In the UK they are, right? There are versions of statins that are, or one version of statins that is over the counter. In the uk they've looked at that equation and decided differently. But I think one crucial point about the, the HIMS and hers, et cetera, is at least that stuff is to some extent trackable. But it points to the lack of integration or the lack of aggregation of the data around this. Again, GLPs, as you point out, this is an enormous thing, an enormous need, or I should say obesity is an enormous need in the United States. Not to mention all the other things that the GLPs may in fact have a beneficial effect on. But where's the data for this stuff? Well, we know the stuff that happens in the healthcare system, we can look at billing. Some of the stuff that happens in the, over the, you know, in the, in the direct consumer stuff, some of that is, is billed in a way we can see it. Some of that stuff is locked away in the records from those different companies. So we don't actually even have a real idea of what the extent of this is. So, you know, okay, we've already looked at, well, there seems to be a hemorrhaging of people out of primary care. No one's looking at it. There seems to be a hemorrhaging of people or at least a movement of demand from health care to these non traditional providers. For the GLPs, who's putting all that data together? And I mean, it would be a job, Scott, to put all that data together. You've got to go to a lot of different sources. Healthcare seems to be focused in both instances only on looking at things that generate a code and that can be measured within the traditional billing system. They're not really looking at these other things. I think healthcare is also. They're also biased toward looking at things that involve a provider. So I would say the difference between the technology stuff I talked about at first and the glps is where, let's say looking at direct to consumer stuff, healthcare is aware of the direct to consumer stuff. I think that's because it involves a provider. Healthcare can pay attention to something where there's a doctor, Even if the doctor's over the phone or the doctor's over a video consult, or even the doctor's doing something asynchronous, There's a doctor who's got to be involved to make that decision. There's a white coat someplace that's involved, and healthcare gets white coats and stethoscopes. The stuff that's happening with the technology doesn't involve that and isn't measured, and nobody pays any attention to it at all. So again, we get back to this issue of there's some important questions that no one appears to be making any effort to answer. Your question. This question of exactly how big is the direct to consumer, exactly what kind of a threat does it pose to the traditional health care system? How much of it is need that health care could never have met? And therefore, you know, it's not a big deal because we weren't meeting that anyway. What will the direct to consumer companies do next? Will it then become a. Will they then become disruptors because they'll start to do more stuff and pull more stuff out of the health care system? You know, these are all important questions that nobody seems to really have a very good handle on. I think another thing, another thing that health care really doesn't have a handle on is what happens when obesity is drastically reduced. The only thing I've gotten in talking to executives about this in the last year or two as the direct to consumer stuff has really, you know, blossomed, is the effect on bariatric surgery. Like, hospitals are already seeing an effect, you know, decreased scheduling and bariatric surgery because people are losing weight in another. Another way. What no one seems to be discussing, I mean, at all, is all the other stuff, all the other activity, all the other billable revenue that occurs within the hospital that is related to obesity. Right? We're talking everything from, you know, kidney issues, dialysis, you know, hip replacements, cardiac evaluations, you know, all those different things. What is going to be the effect on healthcare? And if obesity drops by, let's be conservative, you know, 20% or 25%. Another big question. No one seems to be paying any attention to looking at that question or modeling it. Again, I'm talking to CEOs. People are like, wow, that's really interesting. Oh, you guys working on this? Who's got the time?
- [23:34]
A
But isn't that the truth on so many things? We're just on a discussion about the one big beautiful bill, you know, OB3. And we hear so much from CEOs and leaders of health systems and physician leaders. They are dealing with so many different things right now that actually taking a longer view of some trends or trying to figure out exactly how to prepare for OB3 or for something else almost takes a backseat to trying to make sure that you're taking care of patients, filling your work needs, handling things, then looking at some of these bigger questions as to where might things go and how much do you see that, Dr. Cellenicchio? And also, let me ask you a second time question. When you look at all this, are you optimistic about the future because some of these changes or do you think it's a sprawling mess or both?
- [24:27]
B
Well, one, I'd say whose future? This future of the health care system, the future of people's health, the future of these, you know, of direct to consumer companies. Right. These are all different, these are all different questions with different answers. So, you know, I often will say that I look at the future of health care and I see it as being better. I think technology tools like AI, et cetera are already and will continue to make healthcare better. No question about it. There's big advances that are barely deployed and I think they'll have, they'll make beneficial changes within healthcare. I also think that healthcare will get smaller and for the reasons that I mentioned, it's going to get smaller because a lot of the stuff that we do right now because we had previously been unable to successfully address obesity, a lot of that stuff is going to go away. You know, right now we see with bariatric surgery. But if I say, oh well, I think that, you know, I think knee replacements are going to go drastically down. People look at me like I have two heads, but it's the same thing. I think that the stuff that's being pulled out by, you know, all the sort of low level stuff that's being pulled out by consumer health technology, that's obviously not going to slow down, that's just going to, you know, all that technology right now is, as people sometimes say, is the worst that it's ever going to be. Right. This snowball just keeps rolling. I think, you know, you make a great point and it's one that I've heard, as I said from the CEOs, you know, who's got the time, we don't have the time to look for this. You're a CEO of a big healthcare system. You're a busy person. I think healthcare though as a whole has got to start thinking about is there anybody that can look at this? Because otherwise, you know, otherwise you're, you're blockbuster, right? Otherwise your blockbuster, your Kodak, you know, you are having your lunch eaten by these up and comers or by these technologies and you're too busy to pay attention to these things that again will materially affect your results. You know, I read some of your newsletters, your many newsletters and you know, a persistent theme of course is hospital closings and hospital financial problems. I have never ever seen any of the financial problems, except more recently with bariatric surgery attributed to any of the things that we've been talking about and we haven't talked about, for example, autonomous driving. I, you know, my wife's thinking about, about buying a Tesla. I went, I've been in the Waymo taxis, but I never actually, this seems remarkable to a guy who, you know, thinks about technology a lot. I'd never actually driven a Tesla before. So we went and did a test drive yesterday and you know, you think to yourself right now, I think Waymo and some of the insurance companies, I think Swiss Re had said, you know, that Roughly they see 90% fewer accidents with Waymo than they do with human driven cars. You know, let's suppose they're way off and it's only a 50% reduction in accidents. What's the amount of revenue in the hospital system that, that happens from accidents? What percentage of that revenue is simply going to disappear? Not because there's a disruptor or a company that's doing it better or that's pulling accident care out of the health care system. Right? Just like with the GLPs, you know, nobody's, it's not like somebody's pulling, you know, all those downstream from obesity cares out of the healthcare system. They're just making them disappear. So with all these different things, there are, there is I think an enormous potential. I mean I would say it's, it's a certainty that there will be some drastic revenue reduction dress drastic activity reduction in healthcare. I think that Healthcare will deal with the stuff that it continues to deal with in a better way because of these technologies. So again, better and smaller. But if I could do something about this, the thing I'd most like to do is find out how we can get some, you know, third party organization to, you know, or academics or something to be looking at these questions and getting better answers to what's going to happen.
- [28:26]
A
And you've got this great challenge, Dr. Zelenicchio, between sort of the codex and block branches of the world versus this massive health systems and massive health care economy that shifts a little bit slowly based on how many people and how many payment systems are part of it. And so when you look at these overall, overall issues, they talked about how airlines are going to need less fuel as we become skinnier through GLP1s, but again, it's a cascading timeframe in seeing whether these predictions actually happen or not. And so you're stuck as a leader between all these predictions of the future versus sort of the old adage, if you're a carpenter and you see something, you hammer it, you know, versus a knee surgeon who says, well, this is what I do and I'm not seeing the impact on me yet. Whereas the people that are doing obesity surgery are already seeing that actual impact that the weight loss surgery. People that, that, that do that are already seeing a real impact. And it's a matter of how much is cascades and when enough people actually get lose 10 pounds and stay skinnier and where that, you know, you and I are of the age, at least I am of the age where plenty of friends have had knee surgery or knee replacement. Some of them had been involved in fitness for life and kept themselves in good shape. Some of them had not. It's all over the board, quite frankly. We do know if you have more weight, you're more likely to need a knee replacement, no question. But, but many other people still need it because they just were very athletic for a very long time and knees can't take it. And so trying to predict these things and making decisions based on them is still really challenging, isn't it?
- [30:08]
B
Well, it's really challenging if no one's out there trying to, trying to answer it. Right? I mean, I've had many discussions, you know, many similar discussions with folks and you know, again, get back to that, that decrease in the per capita healthcare spending growth over the course of 50 years, you know, a very, very consistent decrease over the course of that time. Over that same period of time, the country got older and Much, much fatter. And health care, you know, healthcare spending growth still went down per capita, right? They got older and fatter and it still went down. Nobody is working to explain that. And you know, in fact, actually in the last, I think in the last 20 years, healthcare spending actually the absolute spending, not the healthcare spending growth, the absolute spending went down four times. That has never happened before since CMS started collecting data in 1960. So not only, I mean, what would you expect if you saw a graph that showed the growth going down over 50 years, you'd expect, wow, that's pretty consistent. I guess at some point absolute spending will also decrease, right? I mean, at some point it's going to hit the, it's going to hit the X axis, right? Well, it did four times in the last 20 years. It never did before. Is anyone paying attention to it? No. And you know, it's also interesting that we, I think we, the sort of, the bias and the information that people look at, you know, I think I've lost count of the number of times I've seen newspaper, you know, news articles or people speaking at conferences, talking about, you know, well, we got the silver tsunami and you know, we've, we've really got to get more doctors. You know, this, we're going to have a shortage of this many tens of thousands or hundreds of thousands of doctors. And I have tried to trace back where those estimates come from. And in every single instance, those estimates come down to one organization, which is the, what is it? The American College of Medical Schools. I can't remember the exact organization, but it is the trade organization of companies, of organizations, schools that train more doctors.
- [32:21]
A
So, but, but don't you think Dr. Celano, to an extent, you know, it is, is. I think that you're, you're agree with a ton of what you say, and some of these numbers are just a way in how we're going to change how we do business. For example, if you look at the shortages of primary care doctors, it's based on the concept that we'll have the primary care doctor like I did through my adult life, where you had an actual primary care physician you saw a couple times a year and so forth. And that model is just changing and we're never going to get back to that model with 350 million people here. But I do see in the specialist area, I'm of an age, and I hate to keep on saying it makes me sound so old. We've had so many people that we know have died of pancreatic cancer Brain cancer this, cancer that cancer. And what I have found in following close colleagues and family members cancer journey is how short the bench gets in certain specialties in subspecialties really quickly throughout the country. Some place might be known as the best oncology place in the country and you get past doctor number two in the area and they're lost. And that just is what it is. So it seems like so much of the guidance on where we're short physicians has been narrative driven towards primary care when at least in my own experience, where we seem to be the most short is in all kinds of subspecialties. And that's an unpopular thing for the medical establishment to say. But that's where I see the bigger gap. I'm curious as to your thoughts.
- [33:56]
B
Yeah, I mean, I think that's a, I think it's an interesting point and I definitely think that a lot of the primary care stuff, you know, well, again, a 24% decline, right. That wasn't really surprising to me when I saw it. It was only surprising that no one was talking about it. I think, you know, if we say, okay, well, we don't need the primary care physicians, we're going to have the same number of doctors, but they're going to be specialists instead, you know, well, then you have the issues of, well, you know, what's the cost of that going to be in terms of cancer in particularly as I'm sure you know, the rate of cancer in the United States has actually been going down pretty steadily from the, you know, since the 80s or the 90s. I think it's down by about a third. So it's not gonna be cancer specialists, it's not going to be obesity specialists, you know, so the, the thing is, if we're saying, well, I think what's going to save us is we're gonna, we're gonna move those doctors, they're gonna graduate and they're gonna go into specialties instead of going into primary care, which, let's face it, they're already doing okay. But I, I think we have to. Healthcare as a field has to move beyond the hypothesis stage and start looking at the, let's get data that enables us to determine to what extent one of these things is happening versus another thing is happening again. But mind blowing that no one's really followed up that 2020 study looking at the 24% decline and that the primary care docs don't even know about it.
- [35:24]
A
No, I think it's, it's actually. Absolutely. I, I know we've Got to wrap up in a second, Dr. Selenikio. But it is brilliant to visit with you. It's such a brilliant sort of different perspective on some of this and so helpful because it helps me also see, like talking to you gives you some of the sense of sometimes the errors in my own thinking. Because if I predict from my own personal experience in watching this as a consumer that somehow or another we need more rear cancer specialist. Because when I'm seeing colleagues pass away, it's pancreatic cancer, brain cancer, melanoma, the eye cancer, different things that have happened more recently. You know, you give that against the backdrop of the increase in colorectal cancers and other cancers. So I immediately go towards. We got to figure out more specialists because so much of our primary care is getting taken care of in different ways. And you say, well, Scott, by the time we change that, you know, if we don't study this very carefully, there might be dramatic differences in the numbers of cancers. So by the time it's almost like the Maginot Line thing in France, we'll be solving the last generation's problems, particularly when we're trying to develop specialties 10 years out. And it does. Even if we 10 years develop a specialist, it actually takes longer to get the pipeline going correctly, too. So you're really looking a long time in the future, and you have to be careful not to solve the wrong problem. But I think your point is that there's so much anecdotal hypotheses going on that someone's got to do a deep dive into where this might be going. And I think that's a brilliant thought.
- [36:56]
B
Yeah. I think the question is, the question only becomes, you know, who. I mean, you know, Scott, you know, you're a guy who obviously spends a lot of time thinking about health and healthcare. You know, you don't know the answer. I don't know the answer. Why don't we know the answer? We don't know the answer because we're not collecting the data for that. I mean, that's not our job. We have other things to do. It turns out everybody's got other things to do. And so, again, nobody's actually getting the information that's going to let us. You and I have had, again, we pointed out a couple different possible explanations for some of the things that I've raised. We don't exactly know what's going to happen with the GLPs. Maybe somehow it'll be a bust and someone. Someone has to be tasked with identifying, you know, actually Going out and saying we need to find the data sets, you know, with the GLPs, we need to have some perhaps government organization that can go to these, these direct to consumer companies and get the data on exactly how much are they serving, you know, we want to know what that is. Does anybody know how many times somebody got some information from Google or ChatGPT or their Apple Watch and chose not to go in to see the doctor as a result? No one has that data, no one's
- [38:10]
A
collecting that data or any real sense of it. We all, we all know anecdotally how many. We've not gone to the primary care doctor because we ended up going to the nurse practitioner or so, or the urgent care or ChatGPT. But we also know how many times in the last few years family members have gone to the ER for different reasons that we couldn't get the access through a telehealth visit, we couldn't get the access through primary care visit. So I ended up rebounding back to the ER and that's led ERs to be crazily full. But I think your point is so well taken, Dr. Salonicchio. I know we've gotta wrap up Joel Salonicchio, brilliant pediatrician, but more technology and futurist and thinkers. Joel, tell us about Dr. Solonikchio, the name of your company. I know you've got a company called FutureLive, I think it is, but tell us about that for a second.
- [38:59]
B
Well, I mean the company is just me, Future Health is just me. That's the consulting and public speaking that I do. Under that label, under that website, I had a technology company that made software. We recently had shut down that software the year before last, basically just when we started it, nobody else was doing it within the international public health community. In terms of the mobile data collection, when we finished it, we had 200 competitors and we just decided to sell the technology base, sell the stack and get out of that. So the only company I have right now is a company of one.
- [39:41]
A
Well, God bless that. Nothing wrong with that. I love that. Dr. Selenico, what a pleasure to visit with you. Absolutely brilliant. Thank you so much for taking the time.
- [39:49]
B
My pleasure, thanks Kaido.