(If it ducks like a quack jingle)
- There is so much I could say about
the collision of the worlds of Silicon Valley
and the mindset that drives it,
sometimes referred to as the 'tech bros',
with the world of medicine,
and the strange bedfellows that they make.
And I will explore many of the phenomena
that arise when this happens in future videos,
things like novelty bias,
where you assume that something new must be better.
And while this normally holds true for computing,
and we're all familiar with Moore's law,
it very commonly isn't true in medicine,
with many new and exciting therapies being quietly,
or occasionally loudly,
shelved years later for being useless, or worse, harmful.
Or how Silicon Valley's motto
of "Move fast and break things,"
can be catastrophic for medicine.
So if you want to hear about tech and medicine
then please do consider subscribing – but for this video,
I want to focus on one aspect:
The obsession with data.
The belief that if we just measure more and more,
we can unlock the secrets to the human body,
we can use 100% of our brain
become immortal and transform into supernatural beings
composed of pure energy [wonder intensifies]
If I say to you 'medical grifter'
you probably think of people selling quack remedies
like essential oils
or some sort of herbs.
You might not immediately think
of the enormous industry loosely centered around longevity.
People, mostly men, focused on maximising lifespan,
optimising performance and so on, which sounds fine.
Unlike the Herbalife or Mercola natural shtick,
this is futuristic sexy cool sounding stuff,
sciencey sounding stuff.
And if you're not familiar with this world,
to be honest, they're really not that different
from other promoters of pseudoscience,
but unlike magical thinking –
the magical thinking employed by your common or garden
alternative medicine practitioner,
these guys feel like they're invoking science
because they reference some study,
apparently utterly ignorant to the fact
that it's complete garbage.
And what particularly winds me up
is that so many of them are medical doctors
or scientists in relevant fields,
who either demonstrate what I've said many times,
that you really don't have to be that smart to be a doctor,
or they are just shameless money-grabbing grifters.
Now I see variations on this tweet a lot,
So this is just one example of the phenomenon
but the other day tech entrepreneur Peter Diamandis posted:
"Do an annual "Full-body Health Upload."
Most of us have *no idea*
what is really going on in our bodies.
Every year, I do a full-body MRI,
an AI-driven CT, Genome,
Genome?
Microbiome, and much more.
A key to longevity is proper screening
and preventative medicine."
Well, first of all Peter, the actual word is preventive (I will die on this hill).
But I was stunned.
I mean this man claims to be interested in longevity
but only does these tests once a year?!
I mean, what an amateur.
Every morning I perform a full body MRI, colonoscopy,
bladder flow cytometry,
testicular volume analysis,
lung function, liver percussion
and complete genomic sequencing
in case I have been replaced by a clone in my sleep
who differs from me by one base pair on chromosome 15.
My entire house has been converted into a PET detector
all my food is radiolabelled.
I monitor my heart rate and blood glucose
on a picosecond basis
anything less was TOO IMPRECISE
and I have been in a continual state
of CT scanning since 1996.
It's lucky I've already reproduced
because I now require a 60 metre
radiation exclusion perimeter
and my sperm have been rendered as impotent
as Boris Johnson's influence on Russian foreign policy.
Now I don't want to focus too much on one individual
because publicly talking about how many medical procedures
you submit yourself to
is a staple of many movers and shakers
in the wellness and maximising performance
life-extending space.
But I think Dr Diamandis is a useful case
because he's been very into longevity in recent years,
and he is a really really clever guy.
He's a Harvard graduate medical doctor,
he's also an engineer,
and in a neat linked to my other recent video,
he also founded Zero G,
the parabolic flight company based in the US,
he's had a whole career involved with space,
and medicine he's friends with Elon Musk,
he founded the X Prize,
he's a best selling author.
On paper, this guy should be my hero,
I mean these are all things I love.
Well maybe.
So why do I think that this idea
of getting the most ridiculously detailed
medical check up is completely barmy?
Actually just before we move on,
I only just learnt this incredible alleged fact
about Diamandis,
that after he held a $30,000 a pop party during lockdown,
which was declared a super spreader event
as almost everyone tested positive for COVID,
he tried to sell some guests
inhaled amniotic fluid
and ketamine lozenges as COVID therapy.
Which I mean, fairplay. Anyway.
The urge to measure everything is not limited to tech bros.
It appears to be human nature.
Ancient records of physicians show meticulous studies
of what was administered to patients.
Santorio Santori, a friend of Galileo's, in Padua,
was a doctor, and a genius,
as I imagine you'd have to be to be friends
with Galileo,
and he invented many measuring devices
such as a wind gauge,
a water meter, a device to measure the pulse,
which is amazing,
the precursor to the modern thermometer,
and most famously he weighed himself
and everything he ate and drank,
as well as everything he excreted,
using a massive set of scales
that, you guessed it, he invented.
Over a decade ago,
The Atlantic ran a piece about a computer scientist
named Larry Smarr,
who was at the vanguard of a movement
called the Quantified Self.
which I'm sure you've subsequently heard of.
He was measuring everything.
Weight of food in,
constituents, how many steps he took,
he collected all his feces and urine
had it analysed.
I remember reading how he said
that stool had a capacity of 100TB of data per gram.
I guess that's what you'd call a semi-solid state drive.
Fast forward ten years
and we're all counting our steps,
our oxygen saturations,
our heart rates and diligently entering our food intake
into apps.
What tech guys think today,
often society adopts tomorrow.
So I'm not saying gathering data is bad,
if the urge to do it appears to be very human.
But it is what to do with that data
that is the problem, how to interpret it.
And yes I know what some of you are saying
that "How will we ever figure it out
how to interpret it unless we collect it?"
and I agree but that should be as actual research,
not individuals making decisions
based on half cooked data and huge assumptions.
So let's go through some examples.
So you can understand the kind of thing I mean.
I'll start with why I would advise someone
who is feeling perfectly well
AGAINST having that full body scan.
Diamandis says that he has a yearly CT scan,
which is completely nuts
because each one gives you a fair whack of radiation.
One CT, a few in your lifetime,
okay not such a big deal.
But every year?!
I guess we've just figured out why he checks his genome
so often.
But ok let's say full body MRI scan,
free of ionising radiation.
Some of you might recall
that I actually did my doctoral research in MRI.
So I have reported many thousands of images.
And the main reason it's not a good idea
to get a screening MRI scan is incidentalomas.
There are other reasons as well.
But this is the key one.
Now I go into this in more detail here
but let me break it down super simply.
The human body is complicated.
It's got squishy bits,
hard bits, walls between those bits,
cavities, protuberances and holes.
It's not colour coded like in textbooks
and think about how different we look from the outside,
why assume it's going to be any different on the inside
humans are wonderful and varied and messy.
So sometimes you see something slightly weird.
A spot.
A blob.
A smudge.
If you come to hospital with abdominal pain,
I do a scan on you,
I am paying particular attention to your abdomen.
Well I'm not. I mean a radiologist is, I have
no interest in anything beneath the diaphragm.
If I see a blob in your abdomen,
and you are having abdominal pain,
well I will feel confident and saying something is wrong.
But if you're having a screening scan,
i.e you have no symptoms,
and I see some blob in your abdomen,
or a cyst on your kidney,
or a mass on your uterus,
a shadow on your liver,
plus more blobs and smudges in other body parts,
I have no idea
if some of them, none of them, all of them are significant.
So what do I do?
Is that blob a benign polyp
that's of no consequence?
Or is it early cancer?
So I tell you I can't be sure,
and I suggest repeating the scan in 3 months.
Now you have a potentially serious diagnosis
hanging over your head.
You have to declare this on insurance forms.
You spend 3 months worrying.
You then shell out for another scan.
It kind of looks about the same, maybe slightly bigger?
Hard to know.
scanning isn't some perfect science.
There is a bit of ambiguity.
So I tell you again I can't be sure.
Let's do a biopsy just to make sure.
Now you're having an invasive procedure,
with some risks,
to remove a sample of tissue
from a mass that has caused you no symptoms at any point.
It comes back benign, thank goodness,
but what a stressful few months.
OK Rohin you say,
that's one scenario.
I've got common sense,
I know how to interpret these findings.
What about the scan where it does pick up early cancer
and it's removed and a life is saved?
Well in spite of multiple studies looking at this,
that has never been shown to outweigh the risks.
You can pick out some anecdote
of someone whose life was saved,
by a screening test
but that ignores all those whose lives were made worse.
Screening 'wellman' or 'wellwoman' scans do not improve mortality,
they just increase health anxiety,
they increase the costs to the individual
and often to the health system
as well, if that has to pick up the additional aftercare
and they over medicalise normal life.
Thinking these risks won't apply to you,
and only the benefits
is something called exceptionalism bias.
And talking of exceptionalism,
I saw a news report, from America of course
where they cheer on any money-making scheme
at the expense of someone else's health,
where a fit retired athlete
had a screening heart scan
which showed some coronary artery disease
and he went onto have open chest heart surgery,
a coronary artery bypass, in his 40s.
Having never once had chest pain!
And there was a photo of him grinning with his doctor
who he says saved his life.
But unfortunately not a single study in cardiology
shows that operating on asymptomatic heart disease like that
saves a life,
all it does is expose him to the risks of surgery.
Another asymptomatic case
ended up with a patient suffering a complication
from an angiogram
and invasive tests of the heart,
and they ended up needing a heart transplant,
he started with a normal heart. This was a tragic waste,
that he ended up having a test
that he didn't need.
And he lost a perfectly healthy heart.
If you're in any doubt that these are more about money
than medicine,
then here's a company
advertising their $2500 full body MRI
that you can sign up for,
which can detect a bunch of conditions
where early diagnosis really achieves nothing
and also pre-kidney stones.
Now full disclosure,
I have no idea what pre-kidney stones are.
Actually I mean this is genius,
if you don't have kidney stones,
you are healthy
and we can't make any money from healthy people.
We hate them.
So no, no, my friend you have pre-kidney stones,
very serious.
In fact this is a new pandemic,
everyone without kidney stones
actually has pre-kidney stones
and you need annual scans
and Dr Francis's Renal Revelation,
just $200/month to keep your kidneys clean.
I'm afraid we don't accept pre-dollars.
Next example.
I've made a couple of videos about the Apple Watch.
I love my Apple Watch.
But for the vast vast majority of people who buy it,
maybe 98%,
the ability to detect atrial fibrillation,
an irregular heart rhythm,
will be useless.
Not just useless but potentially could lead
to unnecessary involvement with the medical profession,
tests, maybe even treatment.
Because AF is so uncommon in young and middle aged people,
in fact it's rare AF,
that false positives will dwarf true positives,
even if the detection accuracy
was one of the highest on the market.
Which it isn't.
It's extremely low.
And it's designed to be that way.
It's designed to be more sensitive
than specific I.e the engineers
feel that it's better to catch more cases,
even if that means misidentifying normal rhythms
for abnormal ones,
rather than missing an important diagnosis.
So they'll pick up a good amount
of the real problems out there
but also loads of bycatch flapping around on the deck.
Needlessly.
There are gonna be way more false positive
than true positives,
and if you get an alert from your watch
it's almost certain to be incorrect.
Unless you're elderly,
as the only population with potentially useful data
are the oldest.
For under 65s,
the likelihood of a positive AF detection episode
on an Apple Watch
actually being AF are less than 5%.
But let's assume the Apple Watch is 100% accurate
at detecting atrial fibrillation
and it tells you that you had one 20 second episode
in a month.
What do we actually do with that information?
All the literature and medicine up till now
has been about AF recorded
on a heart tracing or maybe over a day or two,
but we've never monitored people
constantly like we can do with wearables.
So what is the cutoff between where normal ends
and abnormal begins?
Does 20 seconds of atrial fibrillation
have any implication for your health?
Should you do anything else?
What about 5 seconds?
What about two hours?
We don't know the answers to these questions.
And these are really genuinely interesting questions.
I asked this one on Twitter,
and I got a dozen different answers
from 100 different cardiologists.
So again, I'm not suggesting that asking these questions
or gathering data is wrong.
I'm just saying that we've still got a lot of knowledge
left to gain
and this leads me on to my next example
about the diabeetus.
Type II diabetes is abnormally high blood glucose.
We measure long term glucose levels,
because obviously a one off test
at at a specific point
will miss the diagnosis a lot of the time
because blood sugar goes up and down all day long
depending on what you eat when stress,
sleep, illness, medication lots of different factors.
Recently continuous glucose monitors
have become easily available.
They're brilliant devices,
and can wirelessly link up with your phone all day long
and record accurate, near continuous body sugar levels.
They're life changing for diabetics
an example of tech and medicine coming together beautifully.
But the longevity/high performance guys
have got their hands on them
and started using them even though they don't have diabetes.
Peter Attia, another very very smart guy
whose opinion I value on many things, he's a doctor,
But he also, I think it would be fair to say
has a tendency to sometimes promote un-evidenced medicine
and of particular interest,
which I didn't know before researching this,
he was a paid consultant for a company
that makes continuous glucose monitors CGMs,
and he's talked about them quite a bit.
Now people can watch their blood sugar respond
to things they eat,
and just kind of goes here on the arm
and connects to your phone.
Awful refined sugar, like a can of Coke
or donut sends it up.
But complex carbohydrates
can also cause an elevation like potatoes, brown rice,
whole grain bread and fruit,
whereas pure fat and protein to a much lesser extent,
which has led a lot of these people to conclude
that this is objective evidence
that carbs are bad for you,
and that you should stick to a purely keto
or carnivore style diet.
which I understand, that seems very logical.
But that's based on the mechanistic assumption
that a physiological variation in your blood glucose
as all of our blood glucoses do vary,
that's assuming that a normal variation
is actually pathological.
And there is no evidence that these gradual,
short-lived rises in blood glucose are harmful.
In fact they're totally normal.
And indeed you're only getting half the story,
by concentrating on CGMs
if there was a continuous triglyceride monitor
which is a kind of fat molecule,
you'd see that high fat meal
cause elevations in this after eating (as shown in studies).
It's almost as if...
you should have a varied diet.
Do you know what else causes blood glucose
to rise in a similar manner,
to the same kind of level
and with the same return to baseline?
Exercise.
Blood glucose can really shoot up
as can your blood pressure.
But is anyone going to suggest that exercise
gives people diabetes or hypertension?
Of course not.
And patients now say that they've stopped eating fruit,
because they saw their blood glucose shoot up
after eating an apple or orange.
That's really sad and kind of crazy.
Please don't believe all the claptrap about fruits
being bad for you.
I certainly wouldn't advise a fruitarian
all fruit diet,
nor would I advise drinking juice,
but an apple a day may not keep the doctor away
you know if you're accompanying it
with crystal meth and a Whopper,
but with the little transient blood glucose
elevation from the Apple is not bad for you.
Think about it like a duck's legs under water,
the up and down perturbations are normal
but the overall function is ideal.
Maybe you're not convinced.
A high sugar is a high sugar you say!
I don't want my blood glucose going up!
Well you've heard of the concept of anti-fragility?
Nasim Nicholas Taleb's term
about systems that are designed to be tested.
And some things are fragile breakable,
other things are tough and robust.
If you knock them around,
they don't break
but neither improve when they are stressed.
However, biology is somewhat different.
Exercise stresses you but makes you stronger.
The immune system develops by being exposed to pathogens.
If you replace glucose with a blood test called a CRP,
an inflammation marker,
you'll see CRP go up with pathogens.
But if you employ the same rationale
that a raised level is bad,
and you should try to avoid any raised CRP
and you meticulously avoid anything
that might provoke an immune response,
what happens?
well you end up with the rate of severe allergy
shooting upwards as it has done in recent decades.
Obviously the immune system
and the endocrine system are very different,
so this is not a perfect analogy
but we all understand that moderate exercise
and moderate immune stressors,
and moderate temperature variation,
are better than attempting to rigorously limit challenges
to the body,
so why assume that we can't handle moderate challenges
to the endocrine and digestive systems?
My point is
that we're gathering more data about this
than we have ever done before,
and we're drawing conclusions and making assumptions
which might well be wrong.
And the bottom line
is, we're not computers.
We're biological and susceptible to chaotic
and stochastic processes.
A bit of abnormality is normal.
The more intensely we look at ourselves,
the more we learn that human biology
has an enormous signal to noise ratio.
and one day I've got no doubt AI and Machine Learning
will be able to see through all of that,
but right now,
it is way too early
to be using this raw unvalidated data
to make big decisions about your health.
By all means buy these gizmos,
I never want to tell anybody who what to do,
but do it for curiosity
and fascination at watching the human body
doing its thang,
not to inform you and instruct you
what to eat in an attempt to let you grow as old as Yoda.
Just believing you can throw AI
at something and expect an improvement is automation bias.
So please,
many of you are adept at pointing out financial conflicts
of interest in medicine,
you'll accuse doctors of being on the payroll of Big Pharma
for prescribing a drug.
And yet you hand over wads of cash
to quack doctors peddling unproven therapies
or you'll shell out for expensive tests
even when you're feeling absolutely well.
And you are right to point out
the problems in modern medicine,
I often do the same thing,
particularly the financial conflict,
but please see these full body scans
and longevity or wellness influencer plans
for what they are, money making schemes.
I don't want to see you.
And it's not me, it's you.
And I don't want you seeing
other doctors behind my back either.
If you are healthy, then enjoy your life,
eat your apple a day
keep away from the medical profession.
Every time I hear about some new app
or screening programme
I think of the 80+, 90+ year old patients
that I know and look after
who are still going out dancing,
hiking, sailing, golfing
and they are mentally just as sharp as ever.
And they didn't do any of this nonsense.
But they all emphasise the importance
of staying fit,
staying active,
eating healthy food
and enjoying life
and the same messages emerge from studies
of the oldest populations on the planet.
So do those things,
and let's keep you out of my clinic room
and off my operating table.
If you enjoyed this video,
I have a few more that you might like
such as a quickie about why you shouldn't send off
every medical test
even if you could,
the one I mentioned earlier
about over-investigation
and failure of screening,
and two on the Apple Watch.
Actually that fake disease one
really blew up over the pandemic
because I think everybody thought
the title was about COVID.
But, you know, view's a view homie.
People, you might've noticed
a bit of a gap between videos lately.
I'm really busy these days
and struggling to find time and energy for videos.
So I've taken a step I should've years ago
hired an editor.
And I hope to instigate some more changes
so that I can keep making videos
alongside full time fatherhood and doctor hood.
I don't think I've directly asked for help before,
and feel a bit weird and parasocial for doing it,
but if you do find the stuff I make useful in any way,
the best way you can support this channel
is not by giving me money,
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