It is now my great pleasure to introduce this year's President's Choice State-of-the-Art Lecturer, Dr. Leslie Saxon. Dr. Saxon is a professor of medicine at the University of Southern California. She's a world-renowned interventional cardiologist and the executive director of the USC Center of Body Computing. She's an innovator and a leader in wireless diagnostics, implantable computing devices, and human performance wearables. Dr. Saxon has dedicated herself to using technology in a positive way to revolutionize human performance as well as to guide and help patients through medical diagnostics and treatments. She's moving away from the traditional sick care to life care. Dr. Saxon has been recognized internationally with multiple prestigious awards, including the 2019 California Science Center's Woman of the Year Award. She's regularly quoted in the media, including the Wall Street Journal and New York Times, and she's a highly sought-after speaker. So we are honored to have her join us and deliver this year's President's Choice Lecture, entitled Digitalized Medicine. Dr. Saxon. Hi. Okay, here we go. Good evening. I'm honored to be here. As a cardiologist, I've never, I don't think, ever been to a non-cardiology or internal medicine meeting, so it's an honor. And as a cardiologist, I need to tell you how much I respect what you do. It's very complex, and it's an amazing specialty. So because we're talking about the future of medicine tonight, I plugged in into OpenAI the title of my lecture. And this is the image that I got with one of the image plug-ins, so I thought that was good. I formed the Center for Body Computing 16 years ago, and it was like six months before the iPhone came out. And a little bit of science fiction was involved there, but I'll tell you a little bit of why I was so compelled to start a digital health center before there was a lot of digital. And our mission at USC, at the Center for Body Computing, is to extend the human potential by modernizing health and human performance through technology. So we work in a multidisciplinary way across specialties, across industries. We provide, I think, a lot of really unique educational opportunities that are going to prepare people for this future, and hopefully we develop intellectual property. So my journey here started, I have a pretty traditional academic career doing clinical trials in interventional electrophysiology and heart failure. And when implantable defibrillators, at that time we're about $60,000 a piece, and indications adjust increased for defibrillators for primary prevention reasons. So implants went from, say, $40,000 a year to about $20,000 a month. So one of the things that happened about seven years after that was defibrillators became networked. You could communicate with them daily from a patient's home. I thought that was so amazing in these high event-driven patients, most of whom had heart failure, that you could actually talk to this device daily and understand not only if it was working, but what was going on with these people that had very high incidence of AFib and stroke and all sorts of things. So we did the first trial, and we found looking at just outcomes of people who were connected, their defibrillators were connected, and those who weren't, because some physicians were sort of suspicious of this. They thought they'd get sued, the usual fear of a technology, they'd get sued if they didn't look at the remote data, kind of a nihilistic approach to patient care. We found that we studied 67,000 patients against people who weren't connected, who were connected, and we found that they lived 3.9 times as long. So the defibrillator had already been shown to improve survival, but for a device that cost $60,000, it's pretty amazing to get an additional improvement. And what was so great about that was that was just a one-off, right? That was one therapy for, you know, select patients. But the science fact part happened, and this is the better lucky than good. Worldwide networks, the dominant computing platform of our time, the mobile phone, global access, high-definition video and cloud storage. So that is what is going to enable, I think, this expanded future. The other thing are these really important and powerful cultural shifts we're seeing, right? We're making a handshake with technology at every level across all sectors of our culture, which is both incredibly exciting and incredibly scary in a lot of ways. But we are making this handshake, and with, you know, the advent and the rapid growth of AI, we're basically, as humans, now embracing the world's knowledge and trying to understand how to interact with the world's knowledge. I think that also presents enormous opportunities. As we thought about what healthcare could be like with the patient in the center of care, the customer of healthcare being a patient, not a doctor who implants a Medtronic defibrillator over a Boston Scientific. I'm not the customer. The patient I'm implanting that is. How could we surround that patient with care in a way that would improve outcomes? Asynchronous, leveraging the dominant computing device, access to education in the moment, high-fidelity healthcare. Again, that was science fiction. What I've learned doing a lot of research in this area since then is that virtual care, it's borderless medical care, right? We're liberating patients from bricks and mortar and ourselves. It's not really a science problem. It's an engagement problem. What is the narrative that we need to tell patients? What is the information they need to have to diagnose themselves, to understand in the moment what's happening, to understand their load over time? We've made enormous strides in sick care. You could argue we're the best ever at that, right? We're great at people who have very established disease, and the sicker they are, it's almost the better we are. What we're not so good at understanding because we didn't have the tools is the progression from wellness to disease. This allows us to fill that in, but we can't fill it in unless we engage the user in their own health narrative and make them medically literate. For years I built apps for USC athletes because I love athletics and human performance that tied their health with their finances, with their class schedule, with their athletic performance, and built apps to quit smoking, kids with congenital heart disease, patients with heart pumps, Marines trying to fight 20 years of the last war, kids with diabetes, and patients with implantable devices. Each one of those studies has been positive. Each one of those studies has dispelled the myth that these certain groups will not use technology, including a ride sharing study we did in people over 70 years old who used ride sharing 34 times a month, not just to get to medical appointments, but to other things. But what I learned from that was that it's one thing to build one-off apps. Most of us in health care don't have a programmer. What we realized is that we needed to build an architecture and a software platform that would support multiple studies without a programmer, where you could connect a metabolic device, a continuous glucose sensor, to an app or a consumer device or blood work, anything you wanted to, to spin off a research study to surround an individual with their own data, to go to a secure cloud, undergo advanced analytics, and also provide a report in a de-identified confidential way to others who may be interested in that data. That's what we spent about the last 10 years building. And more and more, I'm recognizing that things like the Apple Watch, particularly the Ultra in some military contexts we're using it in, it's a wellness device, it's a medical-grade health device, and in the military context, it's also a tactical device. Other than the physiology that an Apple Watch brings, which is AFib detection, fast or low heart rates, balance, a new digital biomarker for early Parkinson's or fatigue in an active duty warfighter, O2SAT, we are now able within this app platform to deliver these things right on the phone in many studies taking less than 5 or 10 minutes a day from the participant. So but this virtual future of healthcare, it isn't just the delivery, it isn't just the engagement of the patient, it's the protection of the data. That's the dystopian part. It's the ability to really know that the data will not be weaponized against the patient or anyone else. That's where we've also spent a huge amount of time. We call this new model of care from the virtual care clinic in 2016 and through the studies and the advances in technology life care, because it's wellness, it's human performance, and it's chronic disease. Because if it's facing you, we all go through those stages, right? That's what we're calling life care. What is the narrative of life care? What is the narrative we need to tell patients and how is life care integrated with other aspects of our life? I'd like to show you this video. For storytellers to work with doctors and researchers to literally change the way healthcare is delivered. My name is Ed Saxon. I'm a film producer. Most famously, I produced a movie about a doctor called The Silence of the Lambs. Dr. Lecter, my name is Clarice Starling. May I speak with you? Why am I watching this is a question when you're watching a film. In The Silence of the Lambs, it's can a woman save another woman? In your health narrative, as you're working with a device, it may be, can I lose weight? Can I make my family more healthy? You're looking in each discrete case for a storyline that people can connect to emotionally. This is going to make me stick around longer. Scott put it in a car, basically. Leslie found out about the stuff we were doing with BMW and kind of developing a persona for the car. Figuring out how do you turn the car into a character? And then got excited about, oh, how can we do that around devices? I'm a cardiologist. I love the heart. The heart is the center of the soul and everything else. So we started with heart. We can take any sensor in. Ideally, it should be agnostic, but to start with something like your heartbeat that changes on a minute, like the car, you know, that kind of responsiveness seemed intuitive and the technology was there. Here we have one of our prototypes. It's a five-seater steering wheel where we changed the stitching. So we integrated a heart rate sensor in the steering wheel. Are you stressed? Are you relaxed? Things like that we want to monitor. And this is where Leslie came into place with the Center for Body Computing. Having this great experience in the car and then in the background, passively, if you need to access it, you're also learning about your own health and wellness. So imagine I've had a long day. I get into my car. I turn it on. I grab the steering wheel. It immediately goes to the right temperature because I'm warm, I'm tired. It then measures my biometrics without me even being aware of it, and it plays a song that it knows, tends to bring me into a zone that I've identified and it's identified as good for me. People are not going to learn themselves and participate in their health and wellness without having these experiences create habits and follow them everywhere and enhance their relationship with everything they do in their life. Medicine can no longer be segregated in some place you can never access. It has to be entertaining. This car with this product is an unbelievable opportunity. For everybody to love this, it has to be easy and a seamless experience where suddenly I'm getting the mashup of the music I like, the driving experience I like, and my heart rate. A couple of things about that, that movie producer is my brother, so proud sister, who's always said to me, look, you doctors, you make healthcare a horror movie. It's the shot behind the closed door. You need to open it up and get a lightsaber, have people be the hero of their healthcare narrative. I think in this vision I'm talking about, that's very true and very important. The second thing is I'm not a commercial for BMW, and that suddenly now feels very elitist, but it's this idea of being able to take health and legitimate healthcare metrics through every experience we have so that we're gaining our sort of health load over time. I have spent probably 40% of my time over the last eight or nine years in this very difficult area of cybersecurity. We were honored at the White House for our work in this area over the summer, and that's myself with the head of the healthcare system. This is difficult work. It involves policy. I have all these clearances all of a sudden because of it, but we can't do this ethically or responsibly without paying a lot of attention to how we're going to deal with these massive data sets. I don't want to talk a lot about retail care, but I just want to say that it's there and it's working out, at least in the primary care specialties, CVS, Walmart. It's efficient. It's cost effective. People can get a diagnosis and a therapy within the physical space, and recently, I don't know if you saw a couple days ago, Amazon announced they'd made an acquisition of something called One Medical, which was a part virtual, part in-person primary care business with Doc-in-the-Boxes all over the country. They've now just announced that they're going to allow Amazon Prime members to pay $9.99 a month to get health insurance and get treatment at One Medical, either virtual or otherwise. What could be wrong with Bezos taking over healthcare? It's just another example, though, of the kind of disruption, I think, that we're going to see. I talked about life care, and life care, again, there's life care for athletics. This is a study we did in our own USC Trojan football team where I was able to measure the real-time ECG of players in our coliseum in a scrimmage game 24 hours before and 24 hours after. As a cardiac electrophysiologist, I never knew that being a running back as opposed to a lineman or a defensive back is arrhythmogenic. There was more non-sustained VT seen. We saw the same heart rate response when there was a direct contact between players, but very different recoveries. I think this is the kind of data that's going to help us get insights and prevent important things like sudden cardiac death. Another example of a consumer device, I was on a plane coming back from North Carolina pretty recently and this lady passed out like literally right next to me. And they wanted to turn the plane around and I was like exhausted and I wanted to go back to Los Angeles, this is a half an hour in. And like we got her laying down and we got her blood pressure taken and I was able to put my Apple watch on her and get an ECG and see that she was an AFib and that she was okay and we were able to just kind of have her there for the rest of the flight. Again a really big insight. What is life care, and she gave me permission to show that by the way, lovely lady. What does life care mean for war fighters, particularly as I mentioned people who fought these long conflicts for our country? Well we're trying to measure load of service members both on themselves and for their family member because being a service member is about force and family. And this is an example in January of a Marine battalion, this is not a battalion, this is like a company, I mean a squad of Marines who were going out to an intense training environment in the desert outside of Los Angeles. You can see their weaponry and their other weapon is their Apple watch because that's how they're going to make sure that they're healthy, that they're balanced, that they don't need sleep, that they don't make mistakes, that they're resilient. We were able to study them over a pretty intense six weeks of continuous combat, water and in air and on land. This is the type of data that we're showing them. How are they sleeping? How is their reaction time? How does that compare to others? What is their anxiety level? Obviously a pretty stressful thing and if they're feeling any of those things, how do they click on a video, TikTok style, Instagram style, a video library that we make that is secure that addresses all the issues that could happen for them within two minutes of them getting that measurement that teaches them in the moment what's going on and why it's important to mitigate that. This is a thing that we're pretty proud of that has really advanced adherence into these digital solutions for us is creating these videos that teach people in the moment what's going on. We can do this for any medical scenario or for a military scenario. Here I'm talking to someone about why metabolic sensing with a continuous glucose sensor matters. Can we play that video? Go back please, Shane. Thank you. Sorry. Go back. Can you... Do I need to click? What we've provided you with is a patch that can stay on your body for up to two weeks and it measures your glucose every minute and stores it every 15 minutes. This patch was developed for diabetics to help them manage their insulin. Why do we want you to have this patch if you're not diabetic? 80% of Americans who aren't diabetic could benefit from better metabolic health. We're trying to help you get insights to manage your loads and your performance over time, both mentally and physically. A key component of that is some insight into metabolism. Glucose metabolism in particular is critically important to what you eat, how active and energetic you feel, and how stress impacts your body. People have different glucotypes. We're going to help... Is there such a thing as a perfect protein? Absolutely. The egg is a perfect protein. The egg has all of the amino acids needed to create a whole chicken. The perfect protein actually includes all of the amino acids you need and in the right ratios. If you find yourself at the salad bar and you're looking to add extra protein to your salad because you want to try to stay a little bit healthier, rather than adding something like bacon bits, pick hard-boiled eggs. At least one whole egg a day has been shown to give us the right amount of the right types of protein. The other thing that you hear a lot about, and I'm sure you think a lot about, you may be impacted by, is sleep, sleep hygiene, sleep... You can see that this is the way that a generation of people digest news. My 20-year-old son gets his news, his entertainment, and everything from two-minute videos or Instagram or TikTok. How do you teach people in the moment in a way that they're used to learning? You can see what we built into these apps. You can get a very sensitive piece of information on your TBI or your depression or learning how to eat well if you're a young Marine from a trainer that you know and you're in your mess hall. These are the types of things that we're creating that are getting this adherence and adoption that I'm talking about, because we all want to get to this place where we can quantify what this means. In the military context, it's readiness and resilience, but that's what it is for all of us. As a subspecialist working 30 years in cardiac electrophysiology and heart failure, I didn't think a whole lot about that. My incentives were on how many procedures I could do, or other academic advancements that have very little to do with holistic outcomes of my patients. We focus generally in healthcare on a very narrow aspect of the physical. If we're really good, maybe we get to the cognitive, psychological, social, and spiritual, the real things that actually determine outcomes for our patients. I think this is a fascinating area to work in, to be able to manage people holistically, because we're measuring them holistically, we're educating them holistically. They're coming to us so much more literate and smart, which then allows us to quantify actually what this is. Very high fidelity, individual, and then over a group. In chronic healthcare, I think of this, and the areas that we spend most of our time, is this kind of focus now on precision health. How do we get the feeds that we need to understand earlier and earlier how to predict disease and mitigate, and provide the right treatments? We now understand health and disease as something much broader, behavioral, genomics, social, metabolomics, environmental, all these other things that we're now understanding, we can learn and understand. Why? Why are we doing this? This is because of the digitization of society, providers, patients, everyone wants the seamless digital experience that's on demand. We know that we need value-based sort of outcomes and cost reductions, right? We have to do this in order to continue to practice as we are, and to expand medicine and make it more borderless. We need very strong regulatory input into this, not only on the ethics and data protection, but payment. And we are moving toward a much more patient-centric approach. As I mentioned, I think that's the biggest thing that even the most traditional healthcare provider knows. And that's going to require a completely different payer model, right? For many of these. Another area that I think Nora spoke to, and you seem very aware of, and I'm just kind of coming to age on, is this important aspect of the social determinants of health. How much education, economic stability, access, and social and community support really impact both expression of disease, and then access, and then healthcare outcomes. I think most of us have thought a lot more. I never thought about this until I was like 25 years old, and I was a resident. This is the house I grew up in, in the suburbs of St. Louis, where I enjoyed very good health, and I could pretty much do whatever we wanted. There was a very low crime rate. It was a great place. And then I did my residency, part of my residency, 10 miles down the road at St. Louis City Hospital, where the highest murder rate in the country, and healthcare outcomes were very, very different. And I really got a crash course in that. And I think that the fact that we have ignored that, and not been able to measure and integrate that into medicine, most of us have always been in environments like that. We thought, well, this is a social problem, or this is a political problem that there's no way that we can solve, so I've got to wait for the policy makers to figure it out. And I think we're finally at the place where we don't have to wait for the policy makers to figure it out. We can democratize this, and we can dive into this a little more to improve outcomes for people like that. One of the main places we can do that is in this epidemic of obesity and diabetes, which is definitely impacted, and the incidence is impacted by these factors that I just mentioned. Almost twice as much of pre-diabetes and diabetes seen in under-resourced populations, particularly in the 96 million people who are impacted by pre-diabetes and steatotic-associated liver disease. I think there's an enormous opportunity here, and this is just an example of myself. This is my metabolic profile, like, maybe nine months ago, where I looked pretty good up top by the traditional numbers, but I started using the glucose CGMs we were putting on everybody, and I realized, look at my spikes, and, you know, not good. And what was so profound, and what we're finding in our studies about this, for me, was those things that I craved needed to lose the abdominal fat, and visceral fat, and all that stuff. You know, you can go on a diet, and you can lose weight, but you still crave those things, and you go back to them. Knowing how they impacted my health is really what caused me to pretty much normalize my glucose profile, because guess what? I don't need or want those things anymore. That was the switch that flipped, and I think that's a really, you know, impactful thing, and we're seeing great adoption of the glucose sensor in use in our studies, particularly in military individuals, many of whom have, don't fall in that profile of insulin resistance. They're using it, and this is a de-identified sample of about 100 that we have on a glucose sensor over a two-week period. And what's so fascinating about it is you can see that we have many of these elite, this isn't special operations war fighters, many of them who are getting pretty hypoglycemic during activities, but a fair percentage of them, not maybe the 20, 25 percent of America that has insulin resistance, but a fair amount of them have some insulin resistance, and they're not overweight. So, you know, what do we do about that? I think what's fascinating is even without a lot of education around this, people kind of hack themselves. So, do you need diet trackers? Do you need those things? Well, you know what you ate, and if you know what your glucose is, we're adding ketones now. You know, it can get pretty interesting. So, the tools are there to start to look at not just physiology, but cognition, behavior, personality, to achieve these goals, and I think the integration opportunities between medically regulated, wearable, or implantable sensors, as well as using these tools. The reason I keep showing so much of the Apple stuff is because it has a really, really fantastic security protocol and profile that we can leverage where things are encrypted. You know, you don't have to worry about as much about it. They do a lot of the work. So, where you're kind of encompassing mood at the moment to cognition, to executive functioning, and you're tracking yourself over time. What we found, which I think is fascinating, is things that we thought were fixed, in terms of personality, or profile, or even other things, are actually pretty functional, in that you'll think somebody, you'll measure a standardized study on grit, or on narcissism, and it's much more fluid if you measure it more commonly, and think about yourself. Maybe at eight in the morning, you, me, I want to run for Senate. At two, I want to jump out the window, and at four, I'm normal again. We are finding that across these populations. So, that's very important for people to know, so they can start to understand and predict where they're going to be, either cognitively, or physically, or against any of these other realms. And then, we can use a lot of things, like this is just an Apple Fitness Plus thing we're using in high BMI people, to just help them take walks, and understand the importance of how walking impacts their glucose. So, you can tell people to walk forever, but if they see that when they do a 15-minute walk, their glucose goes from 190 to 140, that's like super powerful. Again, they know what they ate, and they're motivated by this thing, and they're educated in the moment, in the same time. This is a guy I work with, who's also a patient of mine, but again, we're so ignorant by what we don't see. So, he had rapid AFib. I put him on amiodarone, because he kept having rapid AFib, and he'd be on airplanes, and all these places, and he'd be freaking out, and not feeling well. When the AFib went away, and I saw him, and his EKG looked great, and I'm like, I cured you, you're great. He goes, yeah, but I really can't do anything else. And I couldn't figure it out. And I would have normally just kind of blown him off, and gone, oh, you're okay, you know, you're not chronotropically incompetent, like you have decent heart rates. And then, I interrogated his iPhone from his Apple Watch, and I saw that, yeah, his heart rate range over six months has come down a little bit, but again, I still would have sent him home. And then, I looked at his Apple Watch VO2, which is pretty well validated, and went from like 28 to 18, so now he's getting it to like almost the heart transplant evaluation point, in terms of his cardiometabolic performance. Huge insight for me, off the amiodarone, AFib ablation, chronotropic response needs to come back. I would have, you know, it's like fascinating to me that this kind of stuff can be revealed. So there are a bunch of technologies in the future that are coming out. This is an Israeli company that, with a photograph of your face, cannot just do heart rate, but they, you know, they're claiming they can do glucose pretty accurately, breathing rate, O2 sat, CBC from an eye photo. This is something I've evaluated a little bit from a Canadian company, a startup, where they have a COVID test based on your eye colloid, and it's pretty accurate, and then they can do vital signs, again, from taking a picture of your face. This is all AI enabled. So pretty interesting future. Another piece of software that was developed at USCICT, and a lot of the precursors for the Oculus is VR, which I think we're all interested in, and trying to understand how to use therapeutically. I don't know how many of you have had any clinical experience with it, but it's pretty good for pain, because it's immersive, and it can help distract people from pain. For instance, burn debridements in children, put them in a VR experience of winter, reduced by half the narcotics they require during painful debridements, but using immersive technology to try to help patients either understand a condition, a surgery, or their response after a surgery, or a medical condition over time, or as a distractor, or as a restorative. We're looking at VR scenarios for Navy SEALs who are under a lot of physical and emotional stress during training and operations in order to help restore them quickly on a submarine, because it needs to have the right form factor, because people don't get restored with things like this. They do other things, like drink and don't sleep, and so it's very interesting to think about VR, but the problem with VR is nobody knows the dose, and it's pretty immersive, and it does mess with your brain, right, a little bit, your brain chemistry, so I think this is another really interesting area for research for us, particularly on the medical education side. So I've tried, there's another chat GPT illustration, so I've tried to give you just a briefly canvas where I think we're going with all this, and hopefully food for thought for further research and development. Thank you. So I just want to thank dr. Saxon for a phenomenal lecture very inspiring. I I hope that we leave here with more ideas around our our Life Life health live health life care life care. Oh, there we go. Thank you metabolic associated steatonic. Yeah There we go So that concludes the the welcome tonight. I want to thank you again Thank you all for attending and I want to encourage you to go to the exhibition hall Which is opening and we have a reception there this evening. So please join me there You

Dr. Leslie Saxon

interventional cardiologist

digitalized medicine

technology in healthcare

human performance wearables

precision health

emerging healthcare technologies