# Transcript

**[0:00]** Hey, dr. Lopasada, how you doing? I'm fine Chris. I just wanted to say thank you again for for being here

**[0:08]** Your mentorship has meant a lot to me over the years. We're friends. I really appreciate everything you've done for me and I

**[0:15]** Really appreciate the fact that you've taken the time to sit down with me and talk about

**[0:19]** One of the most impactful things in my life and certainly medically for the United States. So thank you very much, sir

**[0:26]** I'm happy to do it. I just want to start with a really simple question

**[0:30]** How did it all sort of start?

**[0:33]** I

**[0:35]** Have to say it was a revelation that happened while I was a resident I was

**[0:43]** Starting to focus my career on coagulation disorders and how to

**[0:49]** Get the correct diagnosis and it turns out that I had one of the

**[0:55]** Internal medicine residents appear who was regarded as one of the best residents who had a patient with an abnormal value of prolonged

**[1:05]** PTT and it was for a case that was a tonsillectomy and

**[1:12]** What he planned to do was to take a fresh frozen plasma

**[1:18]** This was 1984 and give it to the patient preoperatively

**[1:23]** And I had known a small bit of literature about prolonged PTTs in

**[1:30]** patients who are

**[1:32]** About to get a tonsillectomy and it was a result of a deficiency of factor 12

**[1:39]** Not that everybody would know about this, but I did because I was focusing on

**[1:44]** Coagulation and if you lose factor 12, you don't bleed

**[1:48]** now since it was

**[1:49]** 1984 we were in that very difficult circumstance of

**[1:53]** every blood product was like a potential bullet because

**[2:00]** the HIV

**[2:02]** Epidemic was here. We didn't have a test for HIV

**[2:07]** We knew that if you gave a blood transfusion that maybe one out of 20 bags had HIV and

**[2:15]** What that resulted in is death for the patient who received it. So we were being extra careful to try to figure out

**[2:22]** Does this patient really need a blood product?

**[2:26]** so I called this

**[2:28]** Intern and said hey there and we were friends and I said

**[2:33]** Can I talk to you about this patient?

**[2:36]** And when I told him what I just said about factor 12 and not bleeding. He said I

**[2:44]** Didn't know any of this and he said

**[2:48]** Is there a way that we can make this part of a practice so that

**[2:53]** Well-intended docs like me don't make a mistake that could cost somebody a life

**[3:00]** and

**[3:00]** That really spurred the idea that maybe we did need a practice and as I thought about it more I realized that

**[3:08]** Really patient facing doctors couldn't diagnose von Willebrand disease

**[3:12]** They couldn't figure out why a PT or PTT was prolonged and it was a total guessing game

**[3:19]** So I presented to the faculty where I was Washington University. How about this idea?

**[3:25]** Where we could take coagulation and a few other areas and not only say what the test result is

**[3:32]** But do what happens in anatomic pathology and radiology. We will just provide a paragraph

**[3:39]** That says this is what it is. And this is what you should do and everybody said

**[3:45]** No

**[3:45]** That that won't work. We're too busy

**[3:49]** so their first reason not to do it was

**[3:53]** If you don't publish papers, you will lose your job

**[3:57]** So to get a faculty member take time away to do patient service

**[4:03]** You run the risk of never getting tenure and then getting fired

**[4:08]** Wow, I really thought that being a doctor and being in a hospital meant the patients come first

**[4:14]** I realized that was not the perception now. It could be they just didn't want to do it

**[4:19]** Yeah, but that was a pretty reasonable

**[4:22]** Come back and say okay you resident me faculty

**[4:26]** You don't have to worry about this

**[4:28]** But somebody is trying to think how productive is he or she and should we let them do this?

**[4:35]** So do you so do you think so it sounds to me like your friend

**[4:39]** was at least

**[4:41]** Somewhat aware that there was a problem. Do you think it was it a common thing from a clinician?

**[4:48]** So that that's a good question. So that prompt a further discussion about what else don't you know, right?

**[4:54]** Yeah, exactly. And so I said, could you tell me what it would mean if I told you that the

**[5:00]** ANA anti-nuclear antibody was 1 to

**[5:06]** 360 he said not a clue. I

**[5:09]** Said how would you work it up?

**[5:10]** How would you figure out if there was an autoimmune disease if it was lupus or rheumatoid arthritis or show grins and he said

**[5:18]** I would just be checking all the boxes. Yeah, just check them all check them all without any knowledge of what's valuable, right?

**[5:24]** And then we went through a few other scenarios and I realized all they have some idea about is the routine tests and

**[5:32]** These were smart people. I admired these docs. They were well-intended. There was nothing that was going on with them

**[5:39]** that was

**[5:42]** Something that would take away from this was absolutely right by the patient driven by ego

**[5:47]** They were my friends, right? Yeah, they they had every reason to be honest with me

**[5:54]** so they said we we thought we might be able to call pathology, but

**[5:59]** really, you're the only person that seems to be interested in this because

**[6:03]** Everybody else in the residency program is delighted to talk to us about a biopsy

**[6:09]** but if we talk about what to do with a cholesterol of

**[6:14]** 500 they're not going to help us with that. And so

**[6:19]** Really? We don't get help. There's no place for us to go

**[6:24]** So as you

**[6:25]** You now unearth the problem and maybe you'd been thinking about it a little bit before I am sure that there was something there

**[6:32]** But then you on the earth the problem you speak to a few friends colleagues

**[6:38]** You start evolving this idea and then did you try to scale it to the clinicians first?

**[6:44]** Or did you try to scale it to fellow pathologists firsts to see who could do the work and how would it grow?

**[6:51]** Yes, yes, it does. I think I probably

**[6:55]** Realized that I

**[6:58]** Needed the clinicians to tell me it was needed. Mm-hmm

**[7:01]** But I needed the pathologist to be able to provide the service because I wasn't gonna answer every question

**[7:07]** Mm-hmm

**[7:09]** about every single thing in all of medicine, so

**[7:14]** I

**[7:14]** looked around at my colleagues and I

**[7:19]** Would say none of them were interested

**[7:22]** So all the residents right totally uninterested. I asked them why they said obviously you're so focused on

**[7:31]** blood tests

**[7:33]** You realize that the average person who comes in here says I'm learning anatomic pathology

**[7:37]** which pays a lot of money and I'm learning clinical pathology which was in turmoil because

**[7:44]** Clinical pathology used to be the way hospitals made lots of money and then

**[7:51]** The government decided that what clinical pathologists did which was attached some

**[7:58]** Standard interpretation to a high glucose

**[8:01]** Was known by the doctors and that it was not valuable. So

**[8:06]** There was no interest in paying clinical pathologists for interpretive services

**[8:11]** They just wanted the clinical pathologist to organize a lab that got the right answer for the test

**[8:17]** well, that's not being a doctor, so

**[8:21]** There weren't many people who were interested in just

**[8:25]** trying to

**[8:26]** Get the test done. Yeah, I wanted to

**[8:29]** Provide something that was clearly meaningful like a lung biopsy and say what it meant

**[8:34]** So really there weren't many people who were training with interest in all these different areas to learn

**[8:42]** microbiology and and

**[8:44]** Coagulation and hematology and all the other areas clinical chemistry

**[8:48]** So I knew that there were a lot of obstacles and at this early time. I

**[8:55]** Realized that the obstacles mostly included finding pathology

**[9:01]** residents and faculty who really wanted to do this and commit time to it and

**[9:07]** and

**[9:08]** Starting to

**[9:09]** show

**[9:10]** How it can have an impact because I was the only one providing answers and I needed

**[9:17]** Ten of my colleagues to do the same thing so we could say look what happens in all these areas, right?

**[9:22]** Yeah, I'm always kind of

**[9:25]** With this topic at least I'm interested in

**[9:28]** thinking about how

**[9:30]** clinicians

**[9:33]** Probably think about what we provide most of them think that we provide just a lab test and so why is it that you sort of

**[9:42]** Stepped away from that. I mean you gave us an example, but nobody else

**[9:47]** Had that same example, even though they were living through 1984 and five and six and all the same

**[9:52]** Nobody else saw it that way. What was so obvious that it wasn't

**[9:56]** Ordering practice but rather interpretive practice that drove you. How is that obvious to you?

**[10:02]** I think it was a matter of seeing where is the need?

**[10:05]** Yeah, and what do I do as a doctor? So if you're in laboratory medicine, you learn all about the instruments, right and

**[10:12]** The instrument development is a pretty neat thing to watch

**[10:15]** so you say how are we doing coagulation tests and there's somebody there with a stopwatch and a

**[10:22]** Metal hook trying to see if the clot is forming in the tube

**[10:26]** And you look at that and say there's got to be a better way

**[10:30]** But I always thought that it was a different kind of scientist who created an automated device

**[10:37]** That would allow that test to be done without somebody who is subjectively determining

**[10:43]** Whether a clot occurs. I remember

**[10:47]** the bleeding time test

**[10:49]** particularly

**[10:51]** interesting I

**[10:53]** Saw one done. It was on a little boy and it was done by one of the clinical lab scientists called medical technologists at the time and

**[11:03]** and so she took this

**[11:06]** small device pressed a button on top of it and a blade comes down and cuts the surface of the skin on the

**[11:13]** Forearm and then she times how long it takes for the bleeding to stop. That's called the bleeding time

**[11:20]** So I said Danielle. Why are you doing all the bleeding times?

**[11:25]** She said because I am the only one who knows how deep

**[11:30]** to put this little device on the arm, right and I thought this is the

**[11:37]** example of the most

**[11:38]** Unstandardized test and yet we are deciding if people should be canceled from surgery

**[11:42]** Mm-hmm. And so some people are totally in that domain. Yes, that was not me

**[11:48]** I really wanted to improve the outcomes of patients and I knew there was a lot to do

**[11:54]** So that's where the focus was. Did you ever think about the downstream consequences of the interpretation? Like it

**[12:01]** I'm curious to know

**[12:04]** Was the downstream consequences a driver for the decision about where DMTs should reside or was it more like I?

**[12:13]** understand this

**[12:15]** Physiology and therefore a DMT should reside there. Does that does that yeah

**[12:19]** We tried to figure out how to put dividers between DMTs. Yeah, which is what I think you're asking and so

**[12:28]** That has been

**[12:30]** Flexible over the years. So for example

**[12:33]** It started out by laboratory. This is a microbiology DMT

**[12:38]** This is a blood bank DMT

**[12:41]** This is a coagulation DMT and then somebody said well, why is it just coagulation? Why don't you make it hematology?

**[12:48]** Why don't you put anemia is in there, right?

**[12:51]** Well, the biggest reason is I needed to do a deep dive and make this work and I knew coagulation and I didn't know

**[12:56]** as much about yeah generalized anemia

**[13:00]** so that's what happened, but as we

**[13:06]** Proceeded with

**[13:07]** understanding how to divide these areas

**[13:11]** people had come up with tiny areas like there's this thing in HLA that was proposed that one of our national DMT meetings that

**[13:19]** We held and I thought that isn't an area of medicine. That would be a chapter in a textbook

**[13:24]** I wouldn't carve that out

**[13:27]** anyway, but they said that's what we know and it's clinically valuable and

**[13:32]** So is it worthwhile if you do something that is three interpretations a week? I've grown to respect that now

**[13:40]** so I think that your area is almost what you define it and it should

**[13:48]** co-relate with your expertise and

**[13:52]** and as an example

**[13:55]** I've done coagulation for a long time, but I've also learned a lot about lipoproteins. So why not put coagulation

**[14:02]** Which is a clot in a in a coronary artery for a heart attack as a clot involved

**[14:08]** but there's also atherosclerosis which involves lipoproteins, so now we're

**[14:14]** beginning to organize a DMT that we're calling the

**[14:18]** Cardiometabolic DMT that has everything that can produce

**[14:21]** Atherosclerotic vascular disease and the clot that follows from it

**[14:26]** So that one will be large because it will be coagulation. It'll be lipoproteins

**[14:31]** it'll be things related to diabetes because it's

**[14:35]** Macrovascular disease and I can imagine that where we are signing out five to ten coagulation cases a day

**[14:41]** If you start tossing in lipoproteins and a whole bunch of other stuff

**[14:47]** You're gonna end up with 50 cases a day even at a mid-sized

**[14:50]** Academic Medical Center like the one we work in. I I'm I'm curious

**[14:56]** you I think what you've outlined is kind of a

**[15:01]** Clinically minded pathologist, that's that's how you're sort of describing yourself and

**[15:06]** That's where this concept originated, but why didn't it?

**[15:11]** Why didn't it originate from a laboratory minded clinician?

**[15:16]** Yeah, that actually that's a really good question. I

**[15:22]** Think this is the explanation and it relates to a historical event. Yeah in medical training

**[15:29]** when I was a student, I was an MD PhD student and

**[15:34]** my project related to

**[15:36]** how

**[15:38]** platelets

**[15:39]** interacted with the blood vessel wall

**[15:41]** So there I was interested in something that involved platelets and clotting

**[15:45]** so I went to the chairman of the hematology division at Hopkins and

**[15:52]** I said I want to be just like you. How do I do that?

**[15:56]** How do I take care of patients who have bleeding and clotting problems?

**[15:59]** He said you won't be able to be like me anymore

**[16:02]** And I said and why is that he said he metology and oncology are about to merge and my prediction is that

**[16:11]** You're gonna get about 19 out of 20 people who pick hematology oncology to become oncologists

**[16:16]** Because it's surely gonna pay better than hematology

**[16:21]** And I thought really?

**[16:23]** So I asked him how do I become a

**[16:27]** Specialist in coagulation. He said you have to do pathology

**[16:32]** And I said, I don't know if I'm cut out to do autopsies

**[16:37]** It just wasn't my personality

**[16:40]** He said you don't have to do that

**[16:42]** There are two parts two major parts to pathology anatomic and clinical and if you do clinical you could have a practice

**[16:49]** Just like I have a practice

**[16:51]** And so totally unknown to me

**[16:53]** but this guy

**[16:56]** Made decisions and made them quickly. Yeah, and he said if you want to do this

**[17:00]** There aren't many places to do it

**[17:02]** But one is Washington University, which has now gotten developed on training in laboratory medicine

**[17:08]** I know an expert in coagulation

**[17:12]** You could do four years of training two years of science in his lab two years of clinical work. How would you like to go?

**[17:20]** Like right now I have to make a decision pack it up tonight. So I I said, I think that sounds great

**[17:27]** And who was I to decide?

**[17:30]** Relative to this person who knew everything and was respected by everybody next thing

**[17:35]** I knew within a week. I was on an airplane going to st. Louis the Washington University. I gave a

**[17:41]** seminar from my PhD thesis work to the guy in whose lab I would work as a scientist and

**[17:48]** After I got there, I was involved with

**[17:51]** Laboratory medicine and said I was interested in this but I wanted to be a clotting doctor and I started out wanting to be

**[17:59]** the internist

**[18:00]** Who was the clotting doctor?

**[18:02]** But realized I had to be affiliated with a department with a construct

**[18:08]** Yeah, and that was going to be clinical pathology. So

**[18:12]** Knowing that that was the way I was going

**[18:15]** I

**[18:16]** Got into the program

**[18:18]** And then I was often running learning all I needed to know

**[18:24]** I think about not only what are the tests mean?

**[18:27]** What are the results mean but how the tests are done and that made me better at it because there's so many

**[18:34]** interfering factors

**[18:35]** confounding things that

**[18:37]** Make a test not right and like the story about the bleeding time too many variables

**[18:43]** So only done by one person and all of Hopkins Hospital

**[18:48]** Preposterous that people would think that's a good test. Yeah, so I thought pathology was a good home because then I could

**[18:55]** learn all about the testing and

**[18:59]** I would be a

**[19:01]** Forerunner of many people maybe who went into pathology and became

**[19:07]** clinicians who had

**[19:09]** Consult services just like everybody who went into cardiology and nephrology and

**[19:15]** Rheumatology. Yeah, I you know, it's it's been interesting to from your career perspective

**[19:22]** You've seen the growth of

**[19:25]** The health system as it is today, which is very different than it was when you started not that you're that old sir

**[19:32]** But thank you. Anyway, and so what I've seen even in my career is this

**[19:38]** growth of like the guidelines based and that almost like the committee base of medicine that the health system

**[19:46]** administrators

**[19:48]** Formulate these committees that make medical decisions. Honestly clinical decisions and so

**[19:55]** If the clinicians weren't where the idea was going to start

**[19:58]** How is it that these committees haven't really adopted the DMP concept more readily?

**[20:06]** That's a hard question

**[20:08]** because

**[20:09]** It should be pretty obvious

**[20:11]** That if you have an expert in a room totally focused on your patient and his or her problem in clinical context

**[20:20]** That that is clearly the best way to go. We can do lots of cases

**[20:24]** Yes, I'm not running around the hallways and I'm I'm

**[20:28]** Not doing the same thing in terms of

**[20:31]** writing notes

**[20:33]** Right now we use artificial intelligence and I could do 50 cases a day and I take advantage of the knowledge base that we have

**[20:41]** Through which all the lab data and the clinical information goes

**[20:46]** This is obviously a better answer. However, there is a certain amount of

**[20:54]** Reluctance for anybody in any any business or profession to say

**[21:01]** Maybe I don't know as much as I thought I did

**[21:03]** So if you got even the person who's focused in hematology and you said

**[21:09]** Do you know all about platelet function disorders and the genetics that are associated with them?

**[21:16]** The answer has got to be no

**[21:18]** Because I can tell you that so many disorders which are identified by a single gene mutation

**[21:26]** Have lots of mutations that can produce the disease

**[21:30]** To step out of coag for a minute. There's more than

**[21:33]** 2,000 different mutations in the cystic fibrosis transmembrane regulator gene to produce cystic fibrosis

**[21:40]** You have them all memorized. What is that?

**[21:43]** So the reality is it's learning how to use the information that's out there

**[21:48]** to get it quickly to make sure it's validated and

**[21:53]** Then put the whole story together in the context of the patient

**[21:57]** Anybody who is denying that reality as being the best

**[22:02]** Really is not thinking through it carefully

**[22:04]** you know, I

**[22:08]** You're sort of I think answering this question, but it's it's worth asking

**[22:13]** What part of the DMT concept?

**[22:17]** did you have fairly clear in your mind at the beginning and

**[22:21]** what part of it has sort of

**[22:24]** Evolved over muddling through just kind of doing cases beginning and then recognizing what works and what doesn't

**[22:31]** So I started from the end point. What is Oz?

**[22:35]** Mm-hmm Oz is having a clinical service where everything beyond the routine tests what my friend told me he knew and then beyond

**[22:43]** that did not

**[22:44]** that has to have an expert and

**[22:46]** We had figured that out for anatomic pathology

**[22:50]** But we did not figure it out for clinical lab tests and for goodness sakes everybody gets clinical lab tests

**[22:57]** And they're getting more complicated

**[22:58]** So it's easy to figure out that somebody's got to step in here and do this just to give you an illustration

**[23:06]** When I was at the Mass General the doc who

**[23:10]** Organized the CPC articles in each

**[23:15]** Issue of the New England Journal

**[23:17]** Dr. Bob Scully told me the story of what it was like when he was a surgical pathologist

**[23:24]** as a newbie this was in the 40s and

**[23:28]** At that time they had to decide what to do about for example a breast lump

**[23:35]** So the surgeons in the 40s said if there's a breast lump you do a mastectomy

**[23:40]** Okay

**[23:41]** So what they'd learned is that if you look at the breast lump after the breast is totally off the body

**[23:48]** That too many times it's not cancer. You didn't have to do it

**[23:53]** so

**[23:55]** the notion that surgical pathology had some merit

**[23:59]** was

**[24:01]** Preposterous to surgeons. Why would you do that? Just take the breast off? Oh

**[24:06]** My goodness, so he said we actually had to convince people

**[24:09]** That it was a good idea to do a biopsy and then make a decision after the biopsy

**[24:17]** So think about all the unnecessary

**[24:20]** Mastectomies and what that meant to the patient how horrible so he said what you're doing is actually

**[24:27]** It's a bigger leap

**[24:30]** You're trying to convince somebody who says I'm a hematologist

**[24:35]** That you know more because you know more about how the test is done. You know about the interferences

**[24:40]** you can do them all pretty quickly and

**[24:43]** They have a hard time doing that and you're gonna get better faster because you're seeing 10 20 cases a day

**[24:50]** When they go through their day

**[24:52]** They might see two and they're not seeing the cases that are done by one of their colleagues

**[24:57]** You're seeing every case in coagulation that is done in this hospital

**[25:02]** So it's true by now

**[25:03]** I've seen more than 50,000 coagulation cases. I've seen the diagnostic

**[25:10]** difficulties in

**[25:11]** virtually every kind of bleeding and clotting disorder you could imagine so

**[25:16]** then I guess

**[25:18]** Do you consider this a failure of medicine? Do you consider it?

**[25:25]** Just the nature of the way that we interact with humans is this like a workflow problem education problem incentive problem

**[25:31]** I mean, what where do you pinpoint the failure?

**[25:35]** From a diagnostic perspective. Yeah, and what does it answer? How does the DMT answer that?

**[25:40]** I think I think that the reason it hasn't gone faster than it has is this is our medical system in America

**[25:53]** I

**[25:54]** My friend in Holland said

**[25:57]** You will never be able to move this forward the way we can here and I said, why is that?

**[26:05]** He said because of your payment system. He said you realize that

**[26:10]** Right now if somebody who does anatomic pathology signs out a case the payment is in the hundreds of dollars

**[26:17]** He said you go down to the emergency room identify

**[26:21]** What's missing for a patient who's losing a unit of blood through a chest tube and is gonna die?

**[26:26]** And you give the right blood products and they pay you 25 bucks

**[26:31]** So nobody's gonna do that. Yeah, he said here

**[26:35]** Everybody gets paid the same

**[26:37]** So it's not an issue and he said that's gonna be a big problem

**[26:42]** And of course that has led most of the pathologists into anatomic pathology until we over

**[26:47]** 20 30 years now have gotten reasonable payment systems working some only very recently for doing

**[26:54]** clinical pathology

**[26:56]** interpretations like going down to the emergency room and

**[27:00]** Before it was just to help now. It's actually you're a necessary doctor and what's your answer?

**[27:06]** So I think that the way American medicine is uniquely set up

**[27:12]** where health care is

**[27:15]** Is a privilege not a right has a lot to do with it. What do you um, I

**[27:23]** Mean I it's hard for me to disagree. I think that that's that makes a lot of sense

**[27:27]** The incentives are why people make certain decisions and then they follow through those incentives

**[27:34]** They're compensated, you know handsomely for that makes perfect sense that they they act this way. Well

**[27:41]** What would you if you were to go back talk to yourself?

**[27:45]** Prior to DMT starting what what would you wish you knew now or then that you know now? I

**[27:51]** suppose the biggest thing is

**[27:55]** understanding the size of the challenge

**[27:59]** Understanding that there are more than ten big obstacles that I would have to overcome. Mm-hmm

**[28:05]** I really thought it would be straightforward. I show you this works your patient gets better his or her patient doesn't and then everybody says

**[28:14]** Oh do what Mike did. Yeah. Thanks Mike. Yeah, exactly. Yeah, let's pay Mike. Yeah

**[28:19]** Yeah, all of those things right and none of that really happened because there really was enormous pushback for all of this

**[28:26]** And of course over time

**[28:29]** We've done things like have national meetings to show the value of it

**[28:35]** It's hard to show an outcome study

**[28:37]** If I say you have von Willebrand's disease and I give you the diagnosis in a day and you don't have to wait a year

**[28:44]** Do you live an extra five years? Well, I don't know. I have to wait

**[28:47]** 15 20 30 years until you get to that point where I can make that assessment

**[28:53]** But it should be awfully logical that if you identify a disorder which you will treat appropriately

**[29:00]** A faster that's got to make a difference not only in patient care, but also in money, right?

**[29:06]** The more you bleed the more it costs. Yeah, and I suppose we'll get to it in a future discussion

**[29:11]** but by

**[29:13]** 2014

**[29:14]** the National Academy of Medicine

**[29:16]** decided that

**[29:18]** Misdiagnosis including bleeding disorders was such a big problem that they needed to convene a group which I got to sit on and

**[29:26]** 21 of us identified the fact that it's at least 60,000 Americans who die an unnecessary death

**[29:35]** Because nobody said that's what you have

**[29:37]** They underwent surgery when they had a major bleeding problem. Suddenly, they couldn't stop the bleeding

**[29:43]** So that and a million other things

**[29:47]** Became apparent to the general medical community by the 2000 teens. Yeah, you know, I I do wonder I I

**[29:55]** sort of rather like

**[29:59]** Donald Rumsfeld's

**[30:00]** Characterization of the known knowns and unknown unknowns this business. Yes, and it seems to me like

**[30:07]** The DMT is answering the mail for the unknown unknowns in clinical practice. Exactly and I

**[30:16]** wonder if

**[30:18]** There are ways that you've learned about through the DMT process

**[30:23]** To try to disseminate that information in a more effective way to clinicians, you know clinicians

**[30:29]** Traditionally, they're the smartest person in the room for the vast majority of the rooms that they ever go into. They're the smartest person and

**[30:35]** it takes quite a bit of humility to recognize that, you know, Mike and his team know more than they do and

**[30:44]** That can be sometimes a surprise

**[30:48]** What have you learned about that interaction through this process? So that's a good question. It's layer two

**[30:54]** It's layer two what I've learned

**[30:57]** Especially in recent years is that family medicine docs primary care docs?

**[31:03]** They want us to tell them

**[31:07]** What the story is with their patient? They have lots of patients. They're seeing a day maybe 15 patients a day

**[31:14]** Please tell me what a PTT is prolonged right? Otherwise, I'm doing this at 930 at night in my pajamas. Yep

**[31:20]** So that's one group that has really embraced the notion. They just need to have more of us

**[31:27]** To show them here are the cases will always give you answers and there are not enough of us right now

**[31:32]** To show that that's happening and how it should happen

**[31:37]** The other group that loves us our surgeons all the people who are procedurals. They want to know can I

**[31:43]** take this person's tonsils out and the PTT is long and

**[31:49]** If I tell them in a paragraph PTT is long we did factors 8 9 11 and 12

**[31:54]** The only one that's missing is factor 12 and people who have a factor 12 deficiency do not bleed go ahead and do the surgery

**[32:03]** They're not humiliated by that information. They're enabled

**[32:06]** on the other hand people in a in a specialty

**[32:10]** find it very hard because if you're a pulmonary specialist and somebody is chatting on about the

**[32:17]** 2,000 different mutations in the CFTR gene and you just did an internal medicine residency and you did a

**[32:24]** Pulmonary fellowship part of which was seeing CF patients

**[32:29]** You might think you know enough and how could they possibly know more than me, but for that specific topic

**[32:36]** You have to know all about the genetics

**[32:40]** associated with that particular gene

**[32:43]** Now cystic fibrosis is six different disorders. It's got class one through six

**[32:48]** One of those classes just gives you infertility nothing to do with the lungs or the pancreas

**[32:54]** Well, that's an important thing to know and that means you have to know the genetics

**[32:58]** so

**[33:00]** It is difficult for the specialists in

**[33:04]** 2026 to say I don't know everything and that is a current major holdup because

**[33:12]** If you're planning this as you were planning

**[33:15]** The movement of troops doing during a war you would move into the primary care areas and the surgical areas and

**[33:24]** Go there first because they want your answer. We give it to them fast. We give it thoroughly. You can ask me a question

**[33:30]** I'll give you an answer as

**[33:32]** Opposed to waiting three days referring the patient. They'll be seen in two weeks

**[33:36]** The person they see may or may not know anything about pulmonary medicine

**[33:41]** Relative to cystic fibrosis and then you go to somebody who does and boy that took a long time

**[33:47]** So the fact is it's gonna change it'll probably affect

**[33:50]** The number of patients that are seen by specialists

**[33:54]** Everybody is most defensive of that the pathologist the interns. I

**[33:59]** Think part of the reason we were successful is we were always focused on the patient. How do we get the answer to the patient first?

**[34:07]** I I have given this this comparison many times

**[34:14]** Here is what I think will happen when diagnostic management teams get in place

**[34:20]** In a lot more places than they are now two women are taking a walk after dinner

**[34:25]** The one woman says to the other I saw my doctor today and my doctor told me I have

**[34:31]** porphyria and

**[34:34]** the other woman says I'm amazed I have porphyria and

**[34:39]** She said to the first woman how long did it take for that doctor to give you an answer and she said well two days

**[34:48]** she said come on mine took five years and

**[34:53]** The first woman said well, I do know this my doctor is

**[34:59]** connected to something called a diagnostic management team and there's some experts somewhere in the country that sees porphyria cases

**[35:06]** Many times a day all night. Yeah, and they just said your patient has porphyria do these four tests to confirm it and

**[35:15]** The other woman said yeah, my doctor referred me to somebody at yeah, his or her hospital

**[35:21]** But they really didn't know much about porphyria and it just lingered on they treated me for anything that was symptomatic

**[35:28]** But I have a lot of symptoms and problems

**[35:31]** Yeah

**[35:32]** Do you think?

**[35:35]** the nature of our

**[35:37]** Medicine the structure

**[35:39]** Made DMTs inevitable or do you think that it was really just a unique circumstance that you came up with the idea

**[35:48]** Hard to predict. Yeah, but I would say this

**[35:53]** Certainly there are inevitabilities, but they took 20 years to occur

**[35:59]** some

**[36:00]** inevitabilities

**[36:02]** Happen to somebody who sees it 20 years earlier

**[36:07]** Tries to do something about it and then can't

**[36:11]** I would say there were people in the 1980s who looked at this and said this is a big problem

**[36:20]** But looking at all the obstacles

**[36:22]** They weren't gonna do it. Yeah, I would say it takes a

**[36:28]** Personal circumstance that somebody like me would be in

**[36:32]** Where you realize, okay, I'm gonna do experiments

**[36:35]** I'm gonna get grants and I'm gonna do this too and these two things are linked. So for much of my career

**[36:42]** People would look at me and say what is he? Well, he's a basic scientist who studies fatty acids

**[36:48]** And then gradually as I did more and more cases, they would say and he's an expert on

**[36:54]** clinical cases involving bleeding and clotting and

**[36:58]** Just staying connected to that. It was clear and more clear with time because the test got

**[37:05]** more in number and more in complexity and everybody said I don't know what that is and

**[37:11]** Then it was more and more clear

**[37:13]** So I knew I was on to something and then of course when the National Academy of Medicine said

**[37:17]** We have a major problem in America where people don't know what the results of the test mean

**[37:23]** What do we do about it?

**[37:24]** interestingly in our committee which met over two years and

**[37:29]** produced a

**[37:31]** significant

**[37:32]** report at the end

**[37:35]** Really had only one recommendation for a potential fix for this problem of

**[37:42]** Doctors need to know more about the lab test results and that was the diagnostic management team

**[37:48]** I was sitting there the the book is pretty much an analysis of how many people die

**[37:54]** because your doctor doesn't know when you're short of breath whether you have a clot in your lung or asthma and

**[37:59]** Many of them are going to give you treatment for asthma because it's a nebulizer

**[38:02]** You could just pick up and not do the complex test that you would do to find out if you had a clot in

**[38:07]** your lung so you get the clot it gets bigger and

**[38:11]** Then you're gone. You know, it's as you're talking. I was I was thinking about

**[38:17]** How

**[38:19]** ideas

**[38:20]** come about in

**[38:22]** different areas of our lives

**[38:25]** For example in in business in a business context

**[38:29]** an idea will

**[38:31]** sometimes be

**[38:32]** You know formulate it and then maybe a team will assemble around that idea and then they will

**[38:39]** Begin working on the idea and they may get funding from outside sources and they sort of spin up and they do the thing

**[38:45]** but very often an

**[38:48]** Idea like that will fail the vast majority of startups fail, right and

**[38:54]** Some of the time many of the times those ideas are good ideas all by themselves

**[39:01]** They're just fantastic ideas. They just were at the wrong moment

**[39:05]** Yeah

**[39:05]** So the team will fail and then two years later another team totally different people will pick up basically the exact same idea

**[39:13]** and then it'll be a wildly successful idea and

**[39:17]** It sounds to me like the concept of the DMT

**[39:21]** Has been allowed to survive

**[39:23]** Because of the nature of academic medicine. Yeah, you've been within academic medicine

**[39:28]** There's a good idea whose time had not yet come and you've been able to keep the germ of the idea

**[39:35]** Going and alive for a long period of time and now it feels like with the advent of AI and all these other tools

**[39:43]** It's an idea whose time has come. So that's a very good point

**[39:48]** I've been given the opportunity to speak at at least half the academic medical centers in America

**[39:54]** I've given more than 600 invited talks and most of them are about the diagnostic management team

**[40:03]** Everybody knows this is a good idea. Right? We've had three national meetings that you and I were involved in right created

**[40:10]** Well attended and now I think it probably has enough

**[40:15]** Support because people have heard about it and they know it would be valuable to them that it will carry on

**[40:22]** I will say it's a good thing. I didn't have my heart attack at 41 because this was a longer project than I

**[40:29]** recognized

**[40:30]** You and I were both in a meeting where somebody said

**[40:35]** Every really good idea takes about 20 years from the time you first have it until

**[40:41]** Something is truly happening. So this has taken a little longer than that closer to 30 or 40

**[40:50]** but I

**[40:51]** Think right now we are poised to do it

**[40:56]** Because we have all the pieces. Let me tell you what they are

**[40:59]** We already said AI is making it possible for us to do

**[41:03]** Instead of 10 cases a day 50 a hundred cases a day huge and get them all right

**[41:09]** It's clear from the data. We're collecting right now

**[41:13]** AI is only perfectly right when we put the lab tests in the patient's history. It's about 35% of the time and

**[41:21]** It's pretty close

**[41:23]** About 16% of the time. So if you put those together, that means it's right enough

**[41:28]** So that if we gave it to a doctor seeing a patient

**[41:32]** 50% of the time it would be right

**[41:35]** When you do work in clinical medicine, you're shooting for being right

**[41:41]** 99.9% of the time. I mean, I don't want to have a diagnostic error and

**[41:47]** In what we're doing and diagnostic management teams

**[41:51]** And so I'm looking for 99.9% how do you get to that? So AI alone can't do it

**[41:57]** It still needs us it needs us to create a knowledge base

**[42:00]** That's bigger than chat GPT. That's got all the other things related to coagulation

**[42:06]** And things that we continuously put in there

**[42:10]** And it's got us to look at it and say all those tests are unnecessary

**[42:14]** But this one is necessary and it's not in there. So we have the other half of them need clarification

**[42:21]** Or they're completely wrong. Yeah, so AI helps us write the paragraph

**[42:25]** But the fact is it's still going to take us five minutes to tell the whole story where before that took us 30 minutes or

**[42:32]** 45. So that's why we can do it faster. So we have AI the second thing is

**[42:39]** There's an idea that we can share get experts all over the country

**[42:45]** So let's say there's no thyroid expert here, but clearly people are tested for thyroid disease a lot

**[42:51]** So maybe the thyroid

**[42:53]** Expert is in Cleveland and maybe there's another one in New York. So what happens is they're on service

**[43:00]** They have cases for those days. They will be paid for doing them and

**[43:07]** We can all have a huddle in the morning to say what do you got? What do you got?

**[43:11]** What do you got so we could all be connected and that notion is what I've called the diagnostic center

**[43:18]** And the diagnostic center doesn't have to be in one place with experts

**[43:22]** It may be in one place to as say have the huddle

**[43:26]** But you can just come in by zoom and tell us what you got will feed you the cases and we'll keep the records

**[43:32]** That's a new thing the diagnostic center concept. I used to think we'd have to have all the experts in one place

**[43:39]** So that would be hard because there's too much too many areas. And the third thing is

**[43:46]** We need people who are partners in this

**[43:48]** So who's gonna bring the case forward who is gonna organize it into this category for this expert?

**[43:56]** help organize the report out of AI so that

**[44:01]** AI gets the lab data and it gets the

**[44:06]** the clinical context and

**[44:10]** Those are residents if you have them and that's great

**[44:14]** But we needed somebody who would be a steady player and that's where the idea came in about

**[44:21]** 2001

**[44:23]** On a street in Chicago

**[44:26]** Where people from what was called medical technology at that time said there's no doctoral degree for our people

**[44:33]** they said to me will you

**[44:36]** Be a pathologist who supports that and they said a lot of people will say you're stealing cases from the pathologist

**[44:44]** That would pay them. Yep. I said, that's okay. We're focused on patient care. So that allowed the creation of a doctoral

**[44:51]** program in clinical laboratory sciences and right now our university has the

**[44:57]** Largest number of graduates were pushing a hundred I think

**[45:02]** And so they're in the DMT so that when I show up

**[45:06]** Everything is sitting there. And now my job is to make sure that the DMT is right

**[45:11]** Yeah, so we needed the doctorate in clinical lab sciences. We have it. We needed AI we needed the

**[45:20]** Diagnostic Center concept. I think we've actually surmounted all the barriers. Yeah, so this would be the worst time to quit

**[45:28]** Yeah, because after getting the barriers

**[45:32]** overcome

**[45:33]** That's taken almost 40 years. We now have the ability to do it. You're right on the edge

**[45:38]** Well, this has been fantastic sir. I I wanted to leave with one sort of overarching question

**[45:47]** What do you want

**[45:49]** People to understand about the origins of the diagnostic management team concept. That's a good question

**[46:02]** I

**[46:02]** Suppose it's a lesson in how medicine evolves

**[46:06]** And maybe that's the biggest reason I

**[46:09]** Remember we used to have lots of gastric ulcers and then the drug simetidine appeared

**[46:16]** And we had a doctor who did lots of ulcer surgeries every day in the stomach all gone

**[46:23]** medicine changed and

**[46:27]** So much of what we did before that imagine it was seemed crude

**[46:33]** We used to think that

**[46:36]** that in every

**[46:37]** Sperm cell there was a little creature sitting inside all hunched over a homunculus

**[46:43]** Yeah, that's how the birth started. I mean, so we've had so many concepts that

**[46:50]** Let our our

**[46:51]** folks to practice

**[46:53]** Based upon that science and now now we have so many technical things that we're gonna change again

**[47:00]** And I guess I would like everybody to say how do we help the most patients?

**[47:07]** The most we can and if everybody understands that this was an exercise in making that happen

**[47:13]** Maybe others will say hey in my area we could do this and that's the way I hope things will evolve

**[47:20]** That's wonderful. That's a great place to leave it. Well, thank you very much, sir. I appreciate it and looking forward to our next episode

**[47:27]** Thanks, Chris. Yes, sir