No Priors Ep. 130 | With OpenEvidence Founder Daniel Nadler

0:05 Daniel, thanks for doing this. >> Happy to be here. >> So, uh, give us a sense of this incredibly viral sensation that has been open evidence, uh, in terms of what type of, um, coverage it has of American doctors today. As much as we would like to think that it's going especially well for us, I would sort of say as a qualifying point that um in all of the subindustries of AI, you see an acceleration and compression, right? So the the adoption cycles even outside of open evidence before we get to open evidence in other fields of knowledge work and coding and so on are hyperco compressed, right? It used to take, you know, half a decade or a decade for something to become standard and now it seems to happen in two years or or a year. So the same thing's happened with open evidence. In about 18 months, it's become the operating system for clinical knowledge in the United States. Uh it is used something like 20 times more than the next most used platform of any kind in our specific segment which is high stakes clinical decision support for doctors. So high stakes clinical decision support for doctors is a specific category of medicine. It's distinct from say paperwork or it's distinct from scribing.

1:17 um those things are, you know, part of the workflow of being a doctor. Uh but the stakes and the consequences uh are different. Um if you get it wrong, you can go back and do it again. Uh that's not the case with a patient. Uh you have to get it right. You have one shot to get it right. And so clinical decision-m of which clinical decision support uh is in service of is unquestionably the highest stakes area of medicine. We're probably the only company working at the tip of that spear. Most people have self- selected themselves out of the problem of high stakes clinical decision- making uh certainly through an AI lens um because they view it as ambitious >> and could you explain it or because I think fundamentally it's about picking information and then translating that into specific either recommendations or diagnosis for a patient. Can you tell us more about how that works?

2:04 >> Yes, one way to sort of simplify it down is at its foundation it's a search problem but it's a very semantic search problem. Uh so most search traditionally works with keywords, right? So like you know flights to Barcelona or hotels in Barcelona most of the you know most of the key words there can be captured in like a couple of words and certainly in a sentence and that's sort of traditional Google search. Even if you were to think about clinical decision support as a search problem simply describing your search query if you want to think about it that way usually takes many sentences. So an example I like to give is you have a 44 year old female patient. She has moderate to severe psoriasis. That's the red stuff on your skin. um you know you're a dermatologist that's so far so simple you would just prescribe one of the many creams you see commercials for on television except uh she has um MS uh so now it gets interesting because you want to treat her psoriasis um but you don't want to make the MS worse and you are not a neurologist you're a dermatologist so neurology is not your specialty um but you don't want to go refer her to a neurologist because you want to treat her psoriasis and and if you just keep referring people in circles medicine never happens from the ether. You might have heard as a dermatologist that the new classes of psoriasis treatments um which are biologics they're IL7 inhibitors and I2L23 inhibitors might have some interactivity uh with the neurological dimension of a patient's condition.

3:28 That's about all you know. Um you didn't learn this in medical school because IL23s were FDA approved in 2019, right? And it's one of the great themes of open evidence is that the sort of golden age of biotechnology is sort of the dark ages of physician burnout because it's just impossible to keep up with all the new drugs and all the new mechanisms of action and so on. So you know it was approved in 2019. You might have graduated medical school in 2005, right?

3:51 So you you didn't cover medical school and that's it. That's kind of that's what you know. So your question then is, you know, for a 40-year-old female patient with moderate to severe psoriasis, is an IL7 inhibitor, an IL23 inhibitor more appropriate and more safely tolerated with respect to not aggravating the MS? Now that's that's not a academic question. Um that's a very consequential question. I 17 inhibitors will actually make the MS worse. I 23 inhibitors are safe and well tolerated case of MS. That's an example of where medicine can go wrong because even five or 10 years ago, um either you're referring that person to a neurologist in which case you're just getting referrals in circles and medicine is not happening or unfortunately what would more likely happen is they would just 50/50 and that MS might be aggravated. And you know it's well known and it's been often repeated that medical error is a third leading cause of death in the United States after heart disease and cancer.

4:50 But even that kind of that statistic kind of understates it because that's just looking at death, right? In the case of my in my example, um this patient is not going to die as a result of taking an IL7 inhibitor. She's going to have a relapse of MS. And so it's not just that medical error historically was a leading cause of death. It's that uh as many people died from medical error probably a factor of 10 to a hundred as many people had a a co-orbidity or condition that became aggravated and got worse and so on. So coming back to your question that whole string is the search query and so you can't just do search in a traditional way where you sort of say you know isle 17 because that's not really what the question's about. um nor does the physician have the time to go read book chapters on this stuff. What you need is a semantic understanding of the of the query in the way that another human physician would semantically understand that query and then it's actually quite deterministic and simple after that. Um once you semantically understand the query uh you can from the world of published biomedical literature you could find the exact snippets in a phase 3 RCT a randomized control trial in the New England Journal of Medicine that tested each of these things and found that one aggravated MS and the other didn't. Right? So once once you have a semantic understanding of the query the rest is fairly deterministic and it's almost a search problem. Um, but all of the all of the juice is in, you know, connecting the very complex semantic meaning of a medical scenario to the answer where the answer might be in a phase 3 RCT in the New England Journal of Medicine and in a snippet in in not even in the in the abstract but in the methodology section or in the population. I don't deal with that ambiguity actually because I feel like in the context of medical information, there's things that are uh in pre-baked clinical guidelines, you know, yeah, >> certain types of conditions, we're going to do XYZ and that's sort of the recommended path.

6:45 >> There's stuff that's kind of recently published. There's evidence in a certain direction or maybe it's by the label or something else >> and there's a bunch of stuff that's a bit more TBD in terms of those clinical trials that may cont sporadic. How do you how do you deal with that third bucket of ambiguity and how do you think in Dell about capturing that broader knowledge growth over time? >> So the first way to deal with that third bucket of ambiguity is ensure that your users are physicians and not patients and we've made that strategic decision and we keep thinking we're going to change that decision and uh we've been talking about changing that decision since the inception of the company and so far have not changed that decision for all the reasons implicit in your question. There's an enormous luxury that we have as builders um in having doctors as users because the MD is attached to their name, right? So, they need to protect that MD and they're going to use us as a tool in the same way as a Wall Street trader might use a Bloomberg terminal. If a Bloomberg terminal, for example, produced, you know, an inaccurate quote on a bond that was very obviously inaccurate, you know, is off by an order of magnitude and the and the trader, you know, in a hedge fund just sort of, well, I mean, that's odd. do you indicate in the the user NRP that hey there's some ambiguity around this or here's complete evidence and here's the >> absolutely so there are areas of medicine where there's a lot of conflicting evidence and and that's indicated and and it's not presenting answers you know we're used by 40% of doctors in the United States daily on average it's about 20 times as as much usage as the than the the next thing that could be described as a clinical decision support platform it's become the default operating system of clinical knowledge and a lot of the value proposition early on is that we made references and citations is a first class citizen uh before that was in chatbt. So we were actually providing references and citations 6 months or 9 months before chatbt started doing that.

8:29 Um that was a big reason we had adoption because people could interrogate and audit the source. Right? So right there there's a difference because then it's not an answer engine. It was never presented as an answer engine. It was always presented as a search engine. The way we did frame it was um as part of the long continuum of of search and and Google uh you know we're a Google portfolio company and I've always framed this as part of the very long continuum of search engines as opposed to something net new um because I do view technology as a progression and continuum and that created a certain social contract with the users who in addition to being physicians and have that MD that they need to defend um on top of it viewed this as a uh a router to the phase 3 RCT in the New England Journal of Medicine and maybe the conflicting phase 3 RCT in JAMAMO, right? And we'd route them to both. Very useful.

9:17 >> Users do look at source material some of the time. all the time. I would say it's almost the default behavior of a user to start with some complex query that you could not put into Google for the reasons I mentioned because it's a paragraph long and then have it produce within you know from a search space or a surface area of 35 million biomedical publications the exact three to five you know canonical landmark phase 3 RCTs or guidelines lines or other sources of information that um are responsive not answers that that are responsive to their question and then I would say almost the default behaviors then they go out you know I think we're one of the largest sources of referral traffic to the England Journal of Medicine after Google and the rankings I don't number two or three or four but we're we're one of the largest sources of referral traffic to our partner in the New England Journal of Medicine that's a testament to the way people use it historically it was very hard to do two things it was hard to describe a complex patient scenario or case um into a search engine and have it come out with anything useful. And it was hard to find um from the tens of billions of tokens, if you want to think of it as an engineer, uh that constitute the world of peer-reviewed public medical literature, it's very difficult to find, you know, the seven snippets that are directly responsive to a question and to the semantic meaning of the question as opposed to a few keywords. So, we just did those two things. just did those two things extremely extremely well. We framed the right social contract. We picked our audience extremely well, you know, and all of those things start to stack um into something that looks more like a, you know, a Bloomberg terminal for doctors uh where it's just a protool.

11:04 They're using this because it has, you know, the right data that goes in because AI is gold in, gold out, garbage in, garbage out. So, they know this is not training on tweets. They know this is trained on New England Journal of Medicine and JAMAMA and the rest. They know that we have these partnerships, these strategic partnerships with the um you know gold standards of medical knowledge. They know that they're not going to get an answer from open evidence. They're going to get a routing to a source that answers the question.

11:33 And so I think all these things sort of stack into something that feels just like a a pro tool. >> I want to remind for a minute, you were already a successful entrepreneur before you started Open Evidence. um you wanted to build an impact driven company like you wanted to work in health. What was the moment of decision to serve physicians versus consumers because you also think a lot like a consumer entrepreneur in terms of growth?

11:56 >> Well, that I served both. So, this was a hack. I wanted to build a consumer internet company for knowledge workers and I don't think that ever been done before. So, I didn't want to build a healthcare company uh at all. Uh I love uh Sequoia's quote that um open evidence is a consumer internet company masquerading as a healthcare company. Uh I had zero interest in building a healthcare company. Open evidence is not a healthcare company. I wanted to build a consumer in a company but I wanted to do something that no one had ever done before which is treat knowledge workers like consumers. So my whole career had been you know prior to this dealing with knowledge workers right and and people have a reductive view of consumers. they think of, you know, they think of like 14-year-olds on TikTok and that tends to be like their archetype of what a consumer is. And that's one type of consumer. Um, but, you know, traders on Wall Street are consumers and people.

12:48 Lawyers are consumers and people, and doctors are consumers and people. And what I realized is no one had ever treated doctors that way before. Doctors were just kind of treated as these appendages of health systems. I was like, hm, it's an interesting way to organize the medical system and the health system. And you know, you start to investigate and pull the thread a little bit and you start to understand why, you know, there there very few things that people can agree about in America. They can agree Congress is dysfunctional and they agree that American healthcare is dysfunctional.

13:19 It's like bipartisan universal consensus. But you start to really investigate and you know, you come across two or three things and you're like maybe that begins to explain the dysfunctionality, right? And to me in particular, the idea that doctors who were the fighter pilots, who were the knowledge workers, who were the people who have that MD on the line and have to make that high stakes decision, weren't even their own gatekeepers as far as the technology they use. That was that was a pretty profound realization. And so we did something that had never been done before, ever, which is we treated them as consumers and as people that uh could go on to the app store and download a free app and start using it. And it sounds so stupidly simple, but it was it was really profound and it was really effective because no one had ever done that before. It's kind of almost analogous to in relationships, whether friendships or romantic relationships.

14:12 People can get caught in these sort of culde-sacs where there's a rigidity to their dynamic and to their relationship. And then there's a breakthrough where one person says something that they've it they've just never said it before or they've just never said it in that way before and then there's like a breakthrough. It hits different, right? And in in in uh in psychiatry or psychology and therapy, a lot of that field is encouraging this behavior in others is to just sort of break free of culde-sacs um of of dialectics of relationship dynamics and just say something in a way that's never been said before. Do something that you know that hits different. And um long story short, you know, we we we did that with doctors and and it was it wasn't the complexity of the idea. it was just no one who had ever addressed them as consumers before. And um you know we had this realization which is pretty obvious that while this wouldn't have been possible 20 years ago today every virtually every doctor in America is walking around with a computer in their pocket that they own called an you know an iPhone or an Android phone usually and they own that computer right >> now it's really cool yeah I mean the the velocity of it and usefulness and value is reflective in that velocity >> the scale and the speed of it and more common cases are cases in which the leadership of the hospital system are very avid users. So the entire, you know, this whole senior leadership of UCSF, of MGH, of Mayo Clinic, of Cleveland Clinic, of New York Presbyterian, um, Mount Sinai, Cedar Sinai, you know, right up to the the chief medical officers, the chief physicians, and the CEOs in many cases are personally avid users.

15:53 >> The reality too is that people are basically using Google for some of these use cases, or are they using a new tool to just work? I I have a sort of slightly separate question which is maybe back to the consumer versus medical or physician side of this because you know I started a digital health company maybe a decade or 15 years ago and one of the thing and we were basically initially providing uh really key genetic information. We had a physician in the loop at all times. But one of the things we ran into was um what I kept as almost journalistic viewpoint in the medical community towards what information their patients should and should not get. And I think part of that was real concern about what the patients could do in terms of exacting information, but I think a lot of it was just wanting to be a gatekeeper or part of it was just not wanting to deal with the questions of the patient. How do you think about that philosophically in terms of what what type of information should patients have access to versus not? How much should patients be able to advocate for themselves? So I' I've experienced both sides of this. So I've I've been on the patient side and I'm very sympathetic to that. Um because the reality is medicine is not perfect. Uh if it were, you know, everyone would be living to 80 or 90 years old. So clearly medicine is not perfect and uh in a world where it's not perfect, patients should definitely have some some role in agency in that. Um what we what we have done is encourage physicians to use open evidence to generate patient handouts. And that's actually a very um widely used secondary. It's mainly clinical report, but we have all these secondary use cases like prior authorization letters and insurance appeal letters. And one of the most common of those sort of secondary use cases is generating these patient handouts. The other side of this that I can appreciate is it it took me personally taking my first graduate level statistics course at Harvard to really understand these clinical trials, >> right? And so I'm sympathetic to the idea that a patient simply finding some clinical trial published in the New England Journal of Medicine because it was mentioned on CNN or Fox News and then going and trying to read it, especially through the lens of fear or hope >> is not necessarily going to result in a in the most sort of constructive decision-making process. I mean there's no good answer. The reality is is very tough, right? You want to give pat you want to enable patients with all the answers that are clear and consensus >> and certainly you want to give them the tools to make sure that their physician is not missing anything. At the same time, you you you know, you don't want you can imagine all the failed cases where that could go wrong, where they're coming and saying, "Well, why aren't you putting my mother, you know, on this drug with this with their own handouts?"

18:34 And the answer might be a very technical answer, right? The answer might be that um because your mother also has this other coorbidity and if you look at the p value, the p value of the efficacy of this drug is not statistically robust in the presence of this other coorbidity. And the patient is like what's a p value? But they're not going to just stop at what's a p- value. They're going to get really upset. it says in this case that this other treatment is effective and then then you're just in this endless circle where where the physician who has by definition taken at least one graduate level statistics course is trying to explain to a civilian what a p value is and and I think that's a that's probably not a constructive outcome. So it's a balance.

19:20 We we encourage physicians to use open evidence to use p patient handouts especially where guideline based medicine is concerned. >> So I think you mentioned something really interesting earlier which is the velocity at which your product got adopted was incredibly fast and I think part of that was just it's incredibly valuable as you have a lot of these new different tools. Uh and I think that's one of the almost underappreciated aspects of this wave of AI is not only is there a fundamental technology shift that's enabling all sorts of new products but also there's this massive shift in terms of the openness of adoption but people and organizations to new technologies and that's in terms of what you've been doing with evidence it's to your point of the medical scribing thing it's companies like a bridge or others um if you think ahead 10 or 20 years and this may be impossible to extrapolate how do you think the change of medicine or the state of medicine changes in general like Are we are you still going to the doctor's office for visits? Are you interacting with some online tool and it's backed stopped by a doctor?

20:15 Are drugs developed differently? I'm just sort of wondering at a high level how you think about the whole industry evolving or changing given both suddenly markets are open in ways that they weren't before but also there's new technology ways that are going to impinge on markets. >> It's getting difficult. The the definition of a of a singular event horizon is you cannot even project you know into the near future let alone the far future. And I think we're you know we're probably in the midst of something like that. with respect to doctors in the loop. Planes have been able to land themselves for a very long time. It's a peak into an in a way a future by analogy because that's a that's a that's a domain or an industry where there's no debate really uh as to whether the technology is there and yet you don't see this sort of mass movement um of airline passengers to get the pilots uh out of cockpits. There just isn't. I I'm not aware of one mass movement to get pilots out of cockpits.

21:06 Then the question is why? And and of course uh that is a uh attribute of of human psychology that we are anthropologically tribal and uh we don't abstract trust well. Um we we we personify trust and we trust things that we personify and anthropomorphize. Um and there's a whole history >> already doing a lot with the chatbots, right? In other words, there are people who >> effectively view themselves as being in relationships with >> Yeah. They don't have bodies yet. I mean, you could start to reason by analogy. Would there be any more of a mass public movement to have computers land planes if in if you still had a cockpit? If you just remove the two seats, no one wants that. Okay. What if you keep the two seats, but they're empty? I still think no one wants that.

21:52 What if you keep the two seats and there are mannequins essentially? >> Mhm. that act as visual surrogates for the computer system and what it's doing. I think if you were to pull people, that'd be the first time you see this little uptick in willingness. I think it would still be the minority. >> Can I ask a question? If we're talking about the near future, um uh you've you've mentioned before like we are in an era of um you know uh in an amazingly optimistic way like an explosion of biomedical knowledge and it should accelerate. You've mentioned before that the half-life of the knowledge you learn in med school as a physician is decreasing rapidly.

22:34 >> Do you think that's going to change like how you were educated as a doctor? >> I think medical education is going to radically change. I I I I think doctors are are going to be in the loop for a very long time. They have been a loop since you know the ancient Greeks if not you know the ancient Egyptians. I think you're going to be in the loop for very very very long time and for for the rest of our lifetimes if not longer. medical education is going to change radically um because um it's just you know the the statistic I I cite and all of this is in peer-reviewed public uh publicly available medical literature the rate of doubling of medical knowledge as measured by citations uh in 1950 was every 50 years so every 50 years the number of total citations of peer-reviewed medical literature doubled uh today it's every 73 days uh by an estimate in the British medical journal and one in nature I think that methodology was a little bit aggressive uh because they were looking at the totality of all publications. Not all publications are equal. But, you know, we came up internally with a more conservative one cuz we didn't want to, you know, we didn't want to drink the Kool-Aid. So we said, okay, let's just look at the top quartortile of peer-reviewed medical literature and let's let's pretend that physicians never need to read the bottom three/arters of medical literature, which is not really true, but let's just let's let's let's do this with one hand tied behind our back. And if you do it that way, it's every 5 years. So um if you if you use the more conservative methodology it's not every 73 days but every 5 years uh the the the the total sum of the top cortile of peer-reviewed medical literature by citations uh doubles. Now you could say well look for for humans medicine has become specialized so your dermatologist doesn't you know need to read everything in neurology. That was my initial example and now they have open evidence so they can bridge some of this stuff.

24:27 Um, so why don't we go even more conservative still and say if a physician just needed to read the top 10% of peer-reviewed medical literature in their own specialty. So now this is very conservative. There's no cross functional interdisciplinary medicine at all. Everybody's hyper specialized. It's not a great outcome, but let's just pretend that's the case. Um, what would that mean? Well, now you're in the realm of doable. Obviously, every 73 days and every 5 years is not doable. But now you're in the realm of doable. But you but that physician would need to spend on average nine hours a day just reading the top 10% of peer-reviewed medical literature just in their own discipline.

25:06 Of course, they would never see patients, see, spend time with their family and so on. Now, you can sort of keep going more and more conservative with these methodologies. And realistically, not everything even within pediatric cardiology is relevant to every pediatric cardiologist. And so maybe it's not 9 hours, maybe it's 4 hours, maybe it's 3 hours a day, but you there's some point at which it's going to be like you'd want them to know all this stuff even the, you know, narrowed down all the way and it still is kind of uh impractical. At minimum, I think that this framework of medical school being a very defined period in time and then having continuing medical education, which is kind of historically been this sort of like uh-huh okay sort of, you know, wink wink kind of thing that is going to more or less invert where the continuing medical education is going to be the majority of your medical education. Um, and that's already happening. That's not a future projection, right? If if you speak to really phenomenal, you know, world-class physicians, they will tell you very openly that 90 95% of what they practice, they learned postgraduating medical school and and in most cases post their fellowships, they had fellowships and residencies for their residencies. And some of the greatest physicians that I've ever met and spoken with tell me, you know, extreme things like the majority of what they practice today, they learned in the last two years. And I've had I've had a 70-year-old physician tell me that. Now, these are worldclass people. But what that shows for everybody is that um you you're going to need to invert the construct of >> Does that change the nature of a residency or the the way that physicians are trained? It's very structured today >> in a very specific sequence of steps that was based in some part on how you should train somebody 50 years ago.

26:55 >> Yeah. No, it's going to it's going to change. It is it is changing. there there are these very um avanguard >> approaches to residency at some of the top places like Mayo, Cleveland, UCSF which are trying to deconstruct the 50-year-old model. And >> what do they do differently? >> They encourage evidence-based med medicine, not just guideline based medicine. Um they uh encourage the curbside consult. Um they basically try to solve the problem of information overload through uh you know distributed hive mind. So >> what does a curbside consult mean? So, a curbside consult uh sounds fancy, but it just means, you know, go ask some other physicians who might know something about this. I mean, all of these things sound obvious. Who wouldn't want evidence-based medicine? Who wouldn't want physicians asking a panel of other physicians who might also know something about it, you know, about the thing? The demands on a knowledge worker are highly correlated to the number and complexity of the tools available, right? Like in 1917, you know, at the end of World War I, your tools were basically nothing.

27:54 you know, you had gauze and some scissors, right? So, this is all very very new that getting into my early example like IL is 17 inhibitors, resile 23 inhibitors and biologics and the treatment of psoriasis where someone has a neurological coorbidity like that's all the last like 5 seconds from a historical perspective. So, of course, the profession has to change and it's going to change evidence-based medicine, curbside consults, um, distributed decisionmaking. You know, that's a big part of it. Like, a lot of what's so incredible about all these famous places that are rightly famous, Mayo, Cleveland, UCSF, MGH, um, others, um, is they really are sort of at the at the vanguard of thinking about distributed decision making. Like >> if there's a patient with a complex fact pattern, let's bring in sort of interdisciplinary let's bring a group of doctors, you know, across disciplines and look at this in an interdisciplinary way. Let's have a cardiologist and a neurologist and an oncologist look. Now, the issue is that's very expensive. As I'm describing this, I'm just thinking real time like this really expensive to do. So then there's this um equity issue where it's pretty clear what the right way to practice medicine is in 2025 in light of this explosion of treatments in the golden age of biotechnology. It's not clear how to pay for that because now it's not just one extremely expensive specialist. Now it's three or four >> ability. We don't have that many specialist.

29:22 >> We're not making more oncologists at any faster rate than we >> all just translates into sort of AIdriven tooling or things like that that help augment that. The hope and this is kind of where we're in the midst of this is that um in underresourced areas as an example um you know we have uh we we we have physicians using open evidence in in every state electoral county and zip code in the United States including rural Alaska and southwestern Georgia. And you know we we get letters from doctors because when you when you make something awesome that's free when you make something awesome that has a subscription I think people like it but they don't send you fan mail. when you make something awesome that's free, they send you fan mail. So, we get fan mail from, you know, southwestern rural Georgia from an oncologist who's like, I'm one of two oncologists in a 50-mi radius serving a 75% African-American population with a median household income of $43,000 a year. And I use open evidence as my curbside consult, which by which he means, you know, as my panel of other so that starts to bridge it uh and and I think increasingly certainly in rural areas and healthcare deserts at the fringes and edges of healthcare in the United States. That's absolutely how certainly open evidence is being used and how AI I think broadly is going to be used at least to sort of bridge bridge that gap. Um and and I think that's a that's a real clear silver lining or positive side of of AI right now.

30:40 >> What do you think um consumers might do productively in the future in terms of like preventative health? Like you you know you're treating doctors and knowledge workers as consumers. Yeah. Um there's not enough of them. hopefully you will multiply their productivity dramatically. >> Um, do you imagine consumers will be responsible some for some piece of their own health differently? >> This is not going to be a uh a popular answer or or a politic answer, but um if you go spend 5 seconds in Japan, I'm obsessed with Japan. I named my first company Kencho. I was in Japan two months ago. I've been in Japan like a dozen times. I'm obsessed with Japanese culture. Um, the difference in why there's so many differences, some of which are genetic, but a big difference in why they're so healthy in Japan is they just do all the things that everyone know and I'm not generalizing to all Japanese and there's now Western food and Western culinary traditions that have entered Japan and it's all complex. We live a globalized world, but >> disclaimer, disclaimer, disclaimer, >> disclaimer, disclaimer, disclaimer. But there isn't some net new list, right?

31:46 So, I was in Japan a couple months ago and it is striking. It is shocking the extent to which um especially if you go outside the big cities and go to places like uh Kyoto or smaller city cities like Hakone or so on just they're all walking. They're all just the average Japanese and at all ages. You have 70 80 year olds are walking 10,000 15,000 steps a day. It's a walking culture. And and it's not just my sort of romanticized illusion as a white western looking at it. Like I've gone pretty deep on this.

32:14 I've I've been there again like a dozen times. I've had long conversations with people that are there, not just academics and scholars, but just ordinary people on the street, taxi c taxi cap drivers and so on. You know, they like walking and also the older they get, the more they like walking. The younger kids actually, you know, the the ones that are 65 and 70, they'll just go walk four miles um to work. They don't retire. They don't fetishize retirement. um uh they have concepts in their culture of um you know what what what Plato called you know a good life but in in in in Japanese culture a good life is inextricable uh from a life with purpose you know an idol life cannot in Japanese culture be a good life like those are those are um incompatible notions you know idleness and uh and fulfillment and so uh there's no concept of fetishizing like I'm just going to work really hard make a lot of money and at 65 you know, I'm going to hang out on the beach. That's just not a concept really in at least the traditional culture absent the western recent western influences. So people work past 65 into their 70s into their 80s. You know, that's when it really matters, right?

33:23 Like that, you know, that's when that's when risk of mortality starts to go to go up a lot. And then of course famously the diet sort of it's not just you know a sort of a pescatarian scoop diet but it's also the fact that um you know you can you can almost eat anything if it's in the right uh portions. Um you know they they don't they don't gouge themselves on food. They they eat until 70 80% full. All these things that are famously known and I think at least we're having a conversation about it now in the United States. For the longest time, you had things that every doctor believed. No one would there's no I have never met a doctor who disagrees that, you know, as you you get past a certain point in body weight, your risk of all sorts of things goes up. But but 10 15 years ago, no one wanted no doctor would have wanted to say that out loud cuz it sounded like >> Well, how do we break that culturally?

34:13 Because I think ultimately to your point, you know, physicians are viewed as people who have extra knowledge. >> Yeah. who are supposed to be helping patients and obviously they're very focused on that. My sister's a doctor, you know, like I think it's it's that you know >> for many people I know it's really core to why they became a physician. >> Yeah. >> But at the same time political culture took over and prevented them from speaking their minds on things that were really clear on evidence that had a huge impact for the patient population. Yet nobody would stand up and say actually it's really bad that we're glorifying the fact that you know being dramatically overweight is healthy.

34:46 >> I think the pendulum swings back and forth. I think all these issues are are deeply entwined. I think that um we're now for the first time in a long time having a more open conversation that is not just reduced through the lens of identity politics around um health uh life choices. And it's not just obesity versus or or it's not just overweight versus um not overweight. You know, let's use something that has nothing to do with weight. um uh neurogenerative.

35:18 Now there's a there's a strong genetic component to neurogenerative and there are definitely people who have never used their brain in their entire life and never get Alzheimer's. That's obviously true. But no serious neurologist will dispute the fact that a mitigant to neurogenerative disease is to continue to use your brain over the course of your life. It just feels like you know now at least you can have this sort of more open conversation around like you know if you want to at least mitigate the risk of neurogenerative disease you know continue to do all the things Sanjay Gupta do you know if you're if you're left-handed right with your right hand once in a while if you're right-handed right with your left hand once in a while like just silly things like that that will form you know new neural pathways >> this is a different type of AI application um and you are getting adoption with a type of knowledge worker where people are surprised by the pace generally considered conservative industry has gatekeepers everything you described earlier. Um does it what do you believe about what would happen what can happen in other fields or like are there lessons for lots of entrepreneurs that listen to this podcast? While medicine is obviously very specific, the human psychology is not. And everything that was true and that we've seen through the sort of hyperpace consumer internet growth curve adoption by the most traditionally skeptical knowledge workers shows that in any um industry or sub fields that tech might want to touch um the same basic rules of the game psychologically apply which is if you address people um as people and as consumers and if you speak to them in a way they've never really spoken to before and if you sort of hit them different, you know, in a way that no one's ever kind of come at them in that way before. Um that end minimum will be very refreshing and and different and will lead to them uh considering the thing with an open mind and in all likelihood um will break the mold that has typically been the rate limit of the adoption curve of whatever had defined that industry. I think for a long time like if you build it they will come has been just like laughed at as an idea um amongst much of the tech community. Why why do you think there's such skepticism when like there are the cases of you know consumer internet companies or things like open evidence?

37:45 >> I don't think if you build it they will come is true. I and nor would I say that you know Apple or Steve Jobs is a story if that if you build it they will come. To me, you know, Apple or Steve Jobs is a story that um if you have extraordinary will to power and you see reality as malleable and uh you believe as Nichze says that you know ideas and rational thought are are are second order you know uh after projections of the will you know then you'll succeed but that's not a you know that's not a that's not a fairy tale that you can you know tell to why cominator kids or to or to MBAs, right? And there's this tension um and this has been discussed by many people at length, but there's this tension in the history of western thought between, you know, rationalism and will, right? Reason and will or the intellect uh and will. And the enlightenment was this sort of um Cambrian moment and the explosion of uh rationalism and ideas and this sort of uh faith. And it really is a faith because the irony of of the enlightenment is that the notion that reason is supreme was not arrived at through reason but through faith. And there was this faith that reason would ultimately govern and that humans are in their first order uh rational and kito eros and dickart and so much of everything that waterfalls down today to like what MBAs or why cominator kids believe which is just like you know so tell me Daniel when you had the idea for open evidence were you in a coffee shop what kind of coffee shop what coffee were you drinking like what what was the circumstantial thing that gave rise is to the idea, right? And all of that is actually just, you know, a a derivative idea of cartisian thought. And I think a more useful question for people than, you know, what coffee shop, what was the person drinking when they had the idea for something they admire is where can I find um a level of motivation that is almost um compulsive, right? And that's different for different people. There's no one answer, right? There there are a lot of people that find that um from uh proving somebody wrong. Somebody said something to them when they were a kid that really just hit them in the right way when they were really psychologically vulnerable and they've spent the rest of their life trying to prove that person wrong or that person is a parent or a friend or a teacher. I mean, how many famous examples are there, you know, people trying to prove a teacher wrong that, you know, that is literally dead, you know, and that this person's I've met these people, they're they're 75 years old and they're trying to prove a teacher wrong that it's been dead for 30 years. But it turns out that those things work. Um, and those ingredients work. Um, and it doesn't need to be proving someone wrong.

40:34 Uh, you know, it it could be um people that have are born with an enormous amount of aggression and found a constructive way to channel that aggression out. You know, in my case, I was born with an just an unbelievable amount of aggression and through a combination of training my intellect and just luck um I found a more useful channel for that aggression. But you you need to find this sort of perfect storm of things and it has very little to do with ideas. You know, the idea for open evidence is the most obvious idea in the world. It's it's the same as it's no more creative than uh let's go to the moon. Let's do something really hard.

41:12 What are the hard things? >> Do you actively seek to find more motivation for yourself? >> No. Uh I I I and and actually the opposite. One of the things I think is unhelpful about the contemporary cult of psychoanalysis and in psychology and psychiatry that sort of traces its origins to early 20th century and Freud and these guys is um it doesn't appreciate that in the analysis and description of something you kill it. So I've actually resisted exploring trauma.

41:45 I've resisted going back to the origins of my motivation. and I've resisted going back to the origins of my aggression. I have kind of like a partially developed map from childhood and other experiences. But the second I feel myself going close to analyzing it, I I I resist the urge to analyze it because in in the in the analysis of something um is is the deletion of it in a way. >> And you already have the well and the well is deep so it doesn't you don't need it.

42:13 >> I I I don't need more of it. And quite the opposite. Um I I I resist trying to discover uh what the propulsion system is. You know, most propulsion systems originate from from trauma. This, you know, the the the the what's now become the sort of famous like Sequoia methodology of, you know, Doug and these guys of like talking about your early childhood and all this stuff. I I I think there's a lot of truth to it except um you don't want to go too close to that stuff because because you'll actually kill the propulsion system in analyzing it. What of this lens of motivation do you take to recruiting for your own team?

42:48 >> I quickly learned in my first company even that um there is a there's only a moderate correlate. There's like a 65 correlation between frequently smart and output. I think you have to find people that are obviously exceptionally intelligent but um to all the things I've been saying have some propulsion system. They don't need to know where it comes from. But we've all met people that are extremely aggressive, are extremely driven. They might have very little understanding of why they are. That's better, not worse.

43:21 Better. And um and and those are the people that end up, you know, that I try to recruit and that I seek out in recruiting. um because because then all the other stuff that is I you know I actually don't like management um and I don't want to practice the art of management and so much of management needs to come into play in the absence of those things right like a lot of this stuff you know I'm not an MBA by background I've never had never gone to business school I've never had I've never gone to one business school class you know but I have friends that have and I there are people I respect that that have done those things and and you know a lot of that world is like how to motivate people, how to inspire people, like how to give people constructive feedback and constructive criticism and all of this stuff. And I think there's there's definitely a body of knowledge there, like it you can definitely do better or worse at doing those things.

44:14 But what I seek out in recruiting are the people for whom all of that is just entirely redundant because there's just no like they're they're just they're driven on their own war path and the best you can do is sort of get out of their way. >> Awesome. Thanks for doing this, Daniel. Thank you. Happy [Music] Find us on Twitter at no prior pod. Subscribe to our YouTube channel if you want to see our faces. Follow the show on Apple Podcasts, Spotify, or wherever you listen. That way you get a new episode every week. And sign up for emails or find transcripts for every episode at no-briers.com.