Primary Care: Amazon Health • Andrew Schutzbank
Back to Basics
What if innovation isn't just about finding the next breakthrough—but knowing which ideas to stop?
Andrew Schutzbank has built a career doing exactly that: spotting bad assumptions, challenging teams before they waste time, and redirecting innovation toward what can actually work.
We explore the tension between avoiding mistakes and pursuing blue-ocean opportunities; why healthcare needs to streamline its blocking and tackling before chasing moonshots; and why solving seemingly basic problems—like actually getting the medicine into the patient—can be some of the most consequential innovations of all.
Because sometimes the smartest innovation is solving the problem everyone else overlooked.
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Nic (00:00)
Andrew, welcome to UnNatural Selection.
Andrew Schutzbank MD, MPH (00:02)
Thank you, Nick. Great to be here.
Nic (00:05)
looking forward to this. Obviously we're both, you know, we both spent quite a bit of time in the healthcare space and doing innovation there, life sciences and so on. And so I think this is gonna be a a fun little geek geek out session.
Andrew Schutzbank MD, MPH (00:17)
Yes.
That's that's the hope.
Nic (00:20)
That's
the hope.
That's the dream. but before getting too far into it, I always like to start with the same question that kind of gives you a set gives you the ability to level set and give the listeners some context for at a high level, like what drives the work that you do and and gets you up in the morning. So with that, Andrew, could you please let us know what need or impact drives your work?
Andrew Schutzbank MD, MPH (00:43)
Sure.
So I think fundamentally there is a Jewish mystical philosophy that as I've come to understand it called tekuno lum, which is the idea that the world is broken and it's each of our jobs to pick up the pieces and put them back together. And that's really what I've always been doing. I have like an insatiable need to fix things. and all the building that I do is kind of building in service of fixing. where that comes into play kind of in my clinical career, it's what got me into medicine. then I quickly realized that healthcare was a service business that refuses to admit.
admit
it. And we have, as Tool Gawande puts it, space age technology and a stone age delivery system. and so there's this crystallizing moment. I've a you know quite a few in my career where I was at the VA hospital in Boston and Tom Rocco, who's an amazing cardiologist, we walk into a patient's room and there's a series of med cups next to their bed, all with the meds in them. So like six or seven days of medicine. And he just turns back to us with his wry little smile and says, it helps to get the medicine in the patient.
And like, yeah, like that.
That's all I've been trying to do my entire career. It's like it is really hard to get the medicine in the patient. Right. We we there's so many problems there. And so other folks, you know, like yourself are involved in life sciences and making new agents and new technologies. And I've always been a simple services like, yeah, but how do we actually get this in the hands of people? Secretly wishing, by the way, that y everyone will come up with a drug that just it delivers itself. So we don't
Nic (02:06)
Mm-hmm.
Andrew Schutzbank MD, MPH (02:06)
have to worry about all this healthcare stuff and it'll just be kind of automated. So but that's always been my need. It's there's so much opportunity to make the world a better place.
just by getting done what needs to get done.
Nic (02:16)
Yeah, that makes total sense. Yeah, maybe we'll just aerialize drugs and you can just breathe them in as you walk by.
Andrew Schutzbank MD, MPH (02:22)
Ay, ay,
ay.
Nic (02:26)
bad idea, bad idea. We'll scratch that one. and and and you obviously have like an umbrella under Schutz work, where you include Schutz stock and a number of other different products. Can you just kind of give us a little bit of context for people that don't know about it? Like you know, what is it? you know, just a a quick version of what the organization is meant to do.
Andrew Schutzbank MD, MPH (02:47)
Sure. So Schutzworks, the nice part of a a last name like Schutzbank is that it is uncolonized brand real estate. and so I've leaned into it entirely. my entire life I've been referred to by my last name, so I figured might as well just go with it. so Schutzworks is the parent company and that started as an advisory company, which is for years people have been calling me for advice, and at some point along the way people started offering to pay me for that advice and give me a chunk of their company to do so. And so I work with about ten or fifteen companies at any given time.
Almost in like a primary care arrangement, right? Like I will I will help you with any problem you have. The ones that I'm best at are you as CEO helping you recognize all the problems you're causing and how your behavior has to change to fix them. and then organizational design, product development and strategy.
Almost all the companies I work with are in healthcare. They live on either side of fever service or value-based care, but they're generally in healthcare services or adjacent technologies, because that's where I feel most comfortable in being helpful. and then actually the oldest property I have is Schutz Blog, which I started in residency because I needed an outlet for all of my feelings and frustration and things I was seeing that didn't make sense that I wanted to make sense. And so I started writing there. and over time it's kind of been assembled as the best I can do of a wiki style knowledge base of everything.
I've learned and everything I've figured out and every helpful framework. And the the purpose of Schultz blog is to just be as helpful as possible. and the feedback I get is someone texted me the other day, it's an island of sanity in an otherwise insane healthcare world. And so I try to write like, here's what I figured out, 1800 words at a time. And then coming out of that, some point along the way.
I got a piece of feedback that a recent article was a great article. and the the challenge with Schutz blog is that it's on a sub stack and so it's a periodical format, even though it's not really periodical in the way that I write it, it's just what I happen to publish that week or month.
And so I wanted to play around with these newfangled chat bots. And so I made the Schutzbot, which is a librarian, to try and direct you to the right article. And immediately people started abusing it and trying to get advice out of it the way they abuse me and trying to get advice out of me. and so that's where Schutz Duck was born, which was basically a full-fledged advice chatbot based on all of my writing and as well as other kind of proprietary advisory materials that I've created in my voice. And it's my attempt again to just be more useful and scale some of these ideas out.
and allow people to get the advice they need and the help they need to run the companies they're a part of to make the career pivots they need to make just today actually one of my users told me she's using it in her company to onboard new employees and explain to them how crazy healthcare is and how value-based care works. She's like I thought about building a thing I just sent them to the duck and it told them everything they needed to know. so like
Nic (05:29)
That's great.
Andrew Schutzbank MD, MPH (05:30)
new use cases are being invented all the time for it and it's a lot of fun because it's
I get to argue with myself and people will will quote advice that I didn't actually give them that the duck gave them and but it's been a fun experience both technically and and experientially in the way that I'm able to help people.
Nic (05:45)
Yeah, and and and for people also listening, I mean, you you have a long history in healthcare and not only are you a clinician, but you also helped build up Aura Health. You know, so you've spent a lot of time thinking about how to improve primary care. Can you tell us a little bit about that journey and kind of the perspective
Andrew Schutzbank MD, MPH (06:01)
Sure.
Nic (06:01)
that it gave you?
Andrew Schutzbank MD, MPH (06:02)
Sure. So I was lucky in to be here for residency in the Boston area, which especially if you look at the time I was here 2008 to 11 for residency. That's what brought me to town. The number of people that I either went to residency with or worked in the Boston hospital at that time that run all the coolest companies now is staggering. It was like a magic time to be here. I was at a conference once and I sat between the chief clinical officer at Google and the chief medical officer at Walgreens, both of whom I worked with worked for as an intern, right? Clinically. It's just like it's a magic place. So
Fortunate in the right place at the right time. And even amongst that, I was obsessed with services.
Delivering great service and with primary care is kind of the answer to what was going on in healthcare. because everything seemed so backward, right? Specialties and kind of the long tail was wagging the dog. And so I met a gentleman named Rashika Fernando Poole through probably 50 conversations, trying to figure out what to do with my life, and and that conversation changed my life for the better. he brought me on right out of residency. Actually, used to, there's a number 47 bus that goes from Longwood Medical Center to Kendall Square. sorry, the CT2 rather, and I would jump on the
CT2 and like sneak over, meet with them and sneak back to keep residency going, like a real startup story. So I came on as the third person to join with a title of assistant medical director, which he described as do whatever I need you to do, whatever it may be, like that is your job. and my first assignment was we were building our own EHR because we decided if you wanted to practice differently, you need a different technology to support it. And he validated that hypothesis in previous iterations. And so he said, join the tech team.
Get a hoodie, learn to code. They need to trust you. You need to speak their language. I need you with them every single day. and so I became the kind of designer doctor on the technical team right away. And then no sooner did that happen than I got dispatched to Las Vegas to practice in our first practice because our medical director quit on the second day. So I had to get an apartment and every week I'd fly out and fly back and fly out, which was amazing because I'd fly out, use the software, fly back, fix the software and back and forth and back and forth, back and forth.
and that was actually my introduction to concepts like Scrum and Agile and DevOps, which have just defined the way that I've tried to modify care since then. And so that's kind of the early days of my order. Happy to go as deep as you want, just it's it's just tremendous experience.
Nic (08:22)
No, I
I love it. It's and you quoted Dr. Tulgawande earlier on, right? I spent a lot of years working with him as well at Ariadne Labs. And he's got a lot of really great sayings. And when you mention he also talks about pit crews, you know, more pick crews, less cowboys, and you know, th they they resonate because like you said, healthcare it is a services business. we don't necessarily treat it that way. There's a lot of really good intent, but also a lot of
bad dysfunction.
Andrew Schutzbank MD, MPH (08:52)
Yes.
Nic (08:53)
And and often it it boils down to communication and and and data transfer and information processing and so on. i so from your your background, within the healthcare space, would you say like your focus has mostly been on the primary care space?
Andrew Schutzbank MD, MPH (09:08)
Yes. for lack of a better reason that I like to solve the biggest problem. or at least the place where I think it's the maximum lever point. And so primary care seems to be it, right? We're we're missing almost in its entirety kind of a coordinating function. and I don't mean like little C, make sure you meet reach your appointments coordinating. I mean big C, right? So
How should the health system be deployed for individuals? a mentor of mine named Bill Taylor once said the job of the primary care clinician is to help you understand when you should enter the healthcare system and when you should exit it. And those are two very hard decisions to make. And so this is complex decision making. It's a lot like sales and account management and strategy and portfolio management. There's all these other
industries that are hidden within primary care, which is silly 'cause it's like, it's your doctor and they take your weight and blood pressure, but there's so much going on under the scenes or could be. And when it works right, everything else works. and so I've always been drawn to it. And the the other truth of the matter is specialists
fall in love with the diseases and conditions and organ systems and the kind of depth of the field that they're in. As primary care doctors, we we just like helping people that happen to have problems. And in fact the more
Nic (10:19)
Mm-hmm.
Andrew Schutzbank MD, MPH (10:19)
varied the problems they are, the more we like it 'cause, you know, we get bored easily. And so I was taught that generalism is is a disease that can be treated but not cured. and so I've been afflicted with it. And so I've always lived there partially 'cause of my preferences and partially 'cause I think it's a major lever point an underfunded area in order to really change the way we take care of people in this country.
Nic (10:39)
I completely agree. Yeah, and I brought it up for a reason because I spent a lot of my time in the precision medicine world, whether it be you know genomics, newborn sequencing, and so on. And if you're gonna use any of these technologies for prevention, which is an ideal place, as opposed to treatment when you actually go to a specialist for some reason, that that linch point is primary care. I mean, they are really that is the layer.
That should be seeing you more regularly, whether you're sick or whether you're healthy and regular visits, identifying
Andrew Schutzbank MD, MPH (11:09)
Exactly.
Nic (11:10)
potential using wrist stratification and other mechanics to try to identify potential downstream conditions that you might be susceptible to, and working like crazy to try to avoid them, monitor them, prevent them, cure them, whatever it is, right? So that is your front line to health. Once you get past the primary care layer.
You're sick, probably. Right. And so,
Andrew Schutzbank MD, MPH (11:32)
Yes, exactly.
Nic (11:34)
and yet at the same time, we we so woefully underfund that layer. And at the same time as underfunding it, we overburden it with everything
Andrew Schutzbank MD, MPH (11:41)
Yes.
Nic (11:42)
because you are that frontline. So it's like every technology is thrown at you, all the economics are thrown at you, trying to prevent costs and all that kind of stuff. So it's it's a it's a very chaotic and overwhelming space, and yet it's so central to any
Andrew Schutzbank MD, MPH (11:55)
Yeah.
Nic (11:55)
form of.
prevention and and true health care that we can imagine.
Andrew Schutzbank MD, MPH (12:01)
That's absolutely right. I appreciate as a nonprima care doctor how you understand our plight and our value. So thank you. Thank you for your your advocacy there. It is really
One of the things that you learn is the the problem of presentation bias. Right? When you're a specialist, and I let's say I'm a pulmonary specialist, I specialize in the lungs. I see the world through sick lungs. And so my first assumption if the system's working right is almost everyone who sees me is already sick. As a private care doctor, almost everyone I see is fine. Right. And so the hard part of our job is finding the people that are not fine out of those who look like those who are. And it's a totally different game. And so you end up doing all these weird things. Like there's a concept from the house of God, which is a great book.
which took place at Beth Israel, which says that the mod practice of modern medicine is doing the most nothing possible.
Nic (12:51)
I like that. I live by that.
Andrew Schutzbank MD, MPH (12:52)
Yeah. Yes.
Everything's got downside risk and so you just gotta be really judicious. And so, yeah, no, it is it's it's a special place. And I think the reason for the underfunding is I like to live in a world where there are no or very few villains as my first assumption, 'cause I think once you make someone a villain, it's really hard to work with them and you're gonna have to work with them.
Nic (13:12)
Mm.
Andrew Schutzbank MD, MPH (13:13)
we just decided for better or worse to pay based on
pay output costs based on input costs, right? So we impute value and fee for service based on how much it costs to run the thing. So complicated surgery is hard to do, therefore it's worth a lot, which
Nic (13:26)
Mm-hmm.
Andrew Schutzbank MD, MPH (13:27)
they're valuable, but it's sort of silly to to base how much input costs. And I like to joke at primary care, it's like, I mean, all we did was sit there and listen. We were gonna go to work that day anyway. Would you think a little bit? Like you were going to think anyway. What do we have to pay for? Right. And so there's because our work isn't as visible or obvious or easily expensive,
It's not it's hard to pay for in the system that we have.
Nic (13:50)
Mm-hmm. Yeah, and you know, it's a obviously it, you know, with such a complicated space, there's also no lack of innovation trying to enter into that space, whether you're thinking about the diagnostics or therapeutics or any number of different things, even implementation level innovation. How do you define innovation? What where with so much going on and and honestly?
So much innovation being thrown at PCPs. Like everybody thinks
Andrew Schutzbank MD, MPH (14:19)
Mm-hmm.
Nic (14:19)
they're built the next mousetrap. And so they're going to come to the PCP layer and say, like, here, try this. What they don't think about is the fact that like for every single try this, there's like another 2,000 that same day that came at you saying like try this, right? You can only absorb so much. So it what what what's the level of innovation you think really drives the needle that you you try to focus on?
Andrew Schutzbank MD, MPH (14:40)
Sure.
So the rarest innovation is if two doctors did the same thing for two patients twice. Like I've never seen that before. And so if we could just get that kind of consistency and care, I think we would blow the world out. The type of innovations, honestly, that excite me the most are what I'll call productizing innovations. Right. And so if you think of in especially in in medical care.
all our products are our medicines, right? Like you y we've taken all this stuff and put it in a pill and and the pill is supposed to be the same every time and you put it in your mouth and that's the best we've got. And so early in my career,
We had to learn how to manage a medicine called warfarin, which is rat poison invented in Wisconsin, which thins your blood and helps prevents clotting, which can be lethal, right? And so, you know, too much and you bleed, too little and you you clot. And it involves taking labs regularly, adjusting doses, people have to take different pill amounts every day. You know, you'd get dosing regimens like two milligrams on Mondays and Fridays, and one milligram every other day. It's just fraught with peril, right? It's just, it's a risky intervention.
And then at some point, direct oral anticoagulants came out. You could take one pill once a day and have pretty much the same effect. They weren't perfect, right? Because you couldn't always reverse them and people could have bleeding trouble and in trauma. But all these cumidin clinics and cumidin nurses or warfarin nurses and all this infrastructure around managing these crazy doses of medicine could get wiped away. Right? And so I love innovations like that where you can simplify the service by productizing something. And so
You know, one could argue that not to put too much stock in GLP ones, although they are kind of magic. my own personal
Nic (16:15)
Mm-hmm.
Andrew Schutzbank MD, MPH (16:15)
story, I'm I'm down 75 pounds the easiest way in my entire life.
Nic (16:19)
Wow.
Andrew Schutzbank MD, MPH (16:20)
so and like I've never felt better before, and so these are wonderful medicines. They are addressing most of what primary care's clinical domain is, right?
Nic (16:28)
Mm-hmm.
Andrew Schutzbank MD, MPH (16:29)
Weight, obesity, mood, blood pressure, sleep, all these things that we had various mediocre or behavioral interventions for which were effective but hard to pull off. all of a sudden, like, wow, this one thing seems to be linked to all of them. And so I'm not a fan of wonder drugs or or panaceas, but innovations like these where whole elements of service can get simplified and more easily distributed, those are the ones that excite me the most. that's where I see the potential versus the reality being so different.
Nic (16:57)
yeah,
no, especially if you're when you're dealing at population levels, like you know you want to try to drive consistency. Where do you think AI fits into that space, right? I mean, that's the the beauty about that is that it understands it can bring context and intent and start connecting the dots in ways that before we just expected the human mind to do, which is not that good at doing it, or we had semi-useful tools to try to help and enhance the human mind to do that. Now it's like, hey, I can just do it for you.
and and build that level of consistency and and connectivity for us, right?
Andrew Schutzbank MD, MPH (17:32)
Yes. I so I'm thrilled about these new fancy word machines that we have because medicine's a lot of words.
Even our lab values are qualitative, right? It's like, okay, so that the your AST was 110, but it's also high, right? And so like what's more important, the 110 or the high? Well, high is qualitative, right? So the the job of being a doctor, and as a joke, surgeons are known to consult infectious disease doctors at the ends of long hospitalizations because the infectious disease doctors will sit down, read through the chart, and write the discharge summary for them. Right? It's one of those secrets inside the hospital. And so we use very well trained humans.
Sorting through effectively pages of information one page at a time, whether they were screens or pages is kind of happenstance, and connecting all the dots as you described and summarizing them. And until LLMs got released, we had no real tool to help us. And most of the tools made things worse. Having designed software for docs in multiple organizations now for years, the design principle goes like this. Hey, so only show me what I need to know. What do you need to know? Well, that depends.
Well depends on what. Well, I don't know. So I guess just show me everything. You're showing me too much. Only show me what I need to know. And around and around and around we would go forever. And now all of a sudden we have the ability to deploy these technologies to give us context, to pluck significant things from noise, to do my favorite thing, which is listen in on our our
interactions and capture it's one thing to capture the narrative information for kind of note writing. The much more value aspect is what promises did I make? What plans did I make? What contingencies did I speak out? And making sure that that's now visualized so we can get it done. so much of work goes to die because it lives in the bottom of a note and no one ever sees that note again and nothing ever happens. And so I'm ecstatic at the ability for these tools.
And having used them to advise people, to develop software, a little bit clinically through some of my companies, if you treat them like a pretty good employee instead of like software, it's the right level of expectation. Right? It's like if well like, you know, it messes up sometimes. Yes, so do we. Right? Like don't think of it like software. Think of it like another person on the team that you gotta coach and manage and and double check sometimes. And it's incredibly empowering. So I'm really ecstatic for these tools and and and all the possibilities.
Nic (19:54)
absolutely. absolutely.
And and and to think that, you know, when you were helping to build up Iora, you didn't even have that technology. Imagine you know, when you look back at your career, and at some point, you know, people just think about AI as like sucking nature because it we already do, but future generations will just but they won't be able to imagine it not being in their lives any less than you and I can imagine not having the internet, right?
Andrew Schutzbank MD, MPH (20:18)
That's right.
Nic (20:19)
And
so, but you know, you look back and you think, wow, man, if I had LLM-based technology just five years ago, right? Like how differently things would have been. And and you have a very unique perspective because as you mentioned a second, you know, a few minutes ago, you're you're both a clinician, but you also have this like product development experience, you know, a true technical product development from understanding Scrum
Andrew Schutzbank MD, MPH (20:42)
Yes.
Nic (20:42)
and Agile development. And and you play that function at Aurora, which is obviously focusing on improving.
primary care, which is a very complex space. And so and and in that process, you've obviously learned a lot and there are in different product development methodologies. There are different ways of thinking about creating stimulating innovation and creating products. and and in that process you've talked about things like you know, who I think you said that the the most valuable person in the room is is being is the person who tells you you're about to make a mistake, right?
Andrew Schutzbank MD, MPH (21:17)
Yes.
Nic (21:18)
and so I'd love to unpack that a little bit because I think you're right. I mean, I think having somebody that can kind of cut through the noise and and really be able to not only see where the trajectory is going and all of the variables there, but also have the fortitude to be able to look at you and be like, hey, you're making a mistake. Not a lot of people even do that, right? Some people just play along because they don't want to be rude. I think there is tremendous value there, but then somehow you have to balance that with also kind of
the the ideation phase, which usually starts with a very imperfect idea that you have to nurture into something bigger. Sometimes you gotta kill it early because you're like, well, this is going nowhere. But when do you know this is going nowhere enough to be able to say like, no, that's a bad idea?
Andrew Schutzbank MD, MPH (22:03)
Sure. So there's a lot in there and I wanna I wanna tease a few out if that's all right. So the first thing I would say is after having spent a few days working with LLMs, it occurred to me that everything we were trying to do at IORA was actually not possible, the technology available at the time. We just didn't know it.
Like we were trying to do primary care deterministically and build rules and consensus and approaches. And I wrote spent hours of my life writing examples and details and plans and everything. And it was never gonna work. but I didn't know that until I saw the lens and I like, yeah, no, this is what we needed. So it was a it was cool to see in some ways, like we if we were earlier. whereas I like to tell my 14 year old son, we used to have to read all the words.
All of them. Like there was nothing to read the words for us. We'd read every single word and figure out what to do with it. on that idea though of of, you know, someone who's telling you you're about to make a mistake, I've played this role many times. I've had others play this role for me as well. And I think the nuance is really you know, you it's it's a clinical role as much as a product development role. and I too I see the two very similarly. It's people get excited about what could be true.
And I often find that the less you know about a topic, the more excited you can get about what would be true. And like the people who know a lot are kind of glum because they know where where all the the dark corners are. And so the role I try and play is first
When people are innovating and trying to change things, are they aware and saying out loud the assumptions they're making? Doesn't matter if they're right or not, but are they at least aware of what what they what would need to be true, what they believe to be true, in order for their solution or hypothesis. And so a lot of it is just like, hey, let's just state all your underlying assumptions and first principles first, which is sometimes gets frustrating, but it's never showstopping, right? You always get more clarity after that. And then it's like, all right, well, now that you've you've seen them out loud,
which ones are r are are verifiably wrong versus or verifiably right versus need to be tested and let's go find out. and so what I find it's kinda like my role in a lot of these organizations ends up being like, don't go down that hallway because of this reason.
Aim down that hallway instead. And you still have to do all the iteration and all the user testing and product discovery. And you still have to bounce around in blind alleys and get lucky and all the same things. It's more like, yeah, don't go walking off that cliff. I I promise you there's nothing you want at the bottom of that cliff. I've I've looked over, it's not there. And so it really it's more about redirecting early energies toward a disciplined iteration process instead of kind of sometimes exuberant time wasting iterations.
But you're right, it's absolutely a balance. and also enthusiasm is worth a lot. And so you never want to dull enthusiasm, you just kinda want to challenge it the right direction. and then I'm a big fan of at the same time, you better go test your solution as fast as you can before you fall in love with it. Because there's nothing more dangerous than falling in love with your idea, because then you start rejecting all the evidence you can that conflicts with it. and one of my beliefs is that everyone's wrong when they get started, but that
it's the only way to be right is to figure out why you're wrong when you start. And so the sooner you accept that your idea is good but not great, I think to quote Paul Graham, the 'cause great ideas live near good ones, then you then you can get going. but it does take courage. It's never a long lived position to be the guy who tells the CEO, No
Nic (25:27)
Yeah.
Andrew Schutzbank MD, MPH (25:28)
But I've been told I don't have good career defense instincts, for better or worse.
Nic (25:33)
Well, you're honest. And you know, it and like you said, the balance is important too because any number of really successful startups started because the people didn't know any better that it wouldn't work. Right. And
Andrew Schutzbank MD, MPH (25:43)
Yes. Yes.
Nic (25:44)
and I can think about myself. I mean, looking back at some of the startups that I helped start or founded, I was blessed by the ability of being ignorant that I jumped into it and did it because if I knew more, I would have like, there's at least a dozen reasons why this won't work.
Andrew Schutzbank MD, MPH (25:59)
Yes. Th there's an ice
cream shop nearby, in Union Square in Somerville called Gracie's. And there's a flag when you walk in and it says in bright red background, white letters, We did this not because it would be easy, but because we thought it would be easy. And I think that is the most important sentiment for all startups. It's okay. You like you better believe you can pull it off even if you don't know how. At the same time, there are a lot of
silly mistakes you can avoid, right? If you just pay attention or you can choose to make them, right? Like even with open eyes. Like, hey, you know what? You know, that sounds reasonable, but maybe there's something wrong in your body. Let's try it anyway. Even that is a much better position than just kind of stumbling around blindly.
Nic (26:39)
I totally agree. When you know, when I've done group-wise innovation projects before, and and we we implemented this when I started the innovation lab at Perkinama years back. I I love this book, the The Six Thinking Hats by De Bono. And conceptually speaking, you know, the way that we applied it was there are these six hats, you know, starting from the white hat to the black hat and a bunch of different colors in between.
And they each stand for something different. What the white one is there are only yeses and ands, there are no bad ideas. And and the black hat is there are only no's and buts, there are no good ideas. And in between, you've got yellow and green and different colors that stand for different things. Some could be like checking for technical feasibility, some could check for economics. But the the core premise here is that when you're ideating and innovating.
You want to have everybody on the same page because if you have, say, four people that are coming up with raw, you truly unique ideas, that takes a lot of energy. It takes a lot of mental capacity to be able to do that over and over again. It's a lot easier to be No, it won't work. You know, let me tell you all the reasons. So, if you have three people coming up with good ideas and one wearing the black hat, you're gonna stifle those ideas very quickly. So
Andrew Schutzbank MD, MPH (27:53)
Yeah.
Nic (27:53)
the best thing is to say, okay, let's all wear the white hat. We're gonna go through a progression, and at the very end,
If your inclination is to say no, you're gonna get your chance, but only in due course. And at that point we're all gonna be wearing that hat. And if this idea makes it through all the hats and comes out the other end and it's still viable, then maybe we have something worthwhile investing our time into.
Andrew Schutzbank MD, MPH (28:13)
Absolutely right. It is it's important to read and match the energy in the room. One of the I don't know if you're familiar with the dark forest hypothesis, which is like why we haven't found other other other lifeforms on other planets yet. It's because they're killing them all. So
Nic (28:24)
Yes.
Andrew Schutzbank MD, MPH (28:26)
or they're hiding. there's a little bit of that in healthcare. And th this is one that I this always feels like a I'm pulling out a black hat too soon, but I've just seen too many companies
that have not squared the value capture problem and they end up having to make a choice of doing the right thing and going out of business.
Or basically doing some version of acceding to the current platform and maximizing coding revenue, maximizing risk adjustment revenue, some other kind of like either anti-patient or patient neutral game in order to get paid. And so I'm always listening for anyone who's found new ways to capture value in healthcare that better match with value creation. Because I've just seen the movie end so many times. And it's so it's so depressing, right? Especially because I'm always on the side of do the right thing and go out of business.
Like explicitly. I like if given a choice every time I will do the right thing and go out of business if forced to make it. That's just the way I was raised and the company I like to keep. But it's I'd like to live in a world where you don't have to make that choice. Where doing the right thing gets you the rewards that you you know rewards you with some of the value that you're creating.
Nic (29:36)
Yeah, that makes sense. And so from your experience, it sounds like maybe one of the leading indicators of whether something's gonna succeed or not is our economic drivers, especially in healthcare, right? Who's gonna who's gonna pay for this? who's the customer, right? Is the customer the the patient? Is it the healthcare system? Is it insurance? Is it the doctor? There it it's so conflated and confusing to understand where the economic value really is.
Andrew Schutzbank MD, MPH (30:01)
Yes.
Nic (30:01)
as opposed
to the technical and product value, like who's actually benefiting from this versus who's paying for this. and that
Andrew Schutzbank MD, MPH (30:05)
Mm-hmm. That's right.
Nic (30:07)
level of indirection is just it has is this massive moat that startups.
Andrew Schutzbank MD, MPH (30:11)
Yes.
Yes. It's I mean there's two strategies, right? There's basically find a way to attach to the current payment system but still do the right thing for patients. Or or I guess don't, but that's I don't sort of don't consider those companies in in my world. Or
and this is a little what we did at Iora, start doing the right thing, set expectations that you don't have the business model worked out yet, raise a lot of money and find your way to figure it out. And and our work and I were involved the creation of new government programs. I mean, there's amazing work that Rashika led to try and solve that value capture problem without compromising care. and he was dynamite and still is at coming up with new novel ways to solve this problem. I don't think we've all totally nailed it yet, or you know, I'd be out of I'd be out of work and we'd all just be seeing paid.
and everything would be great again. but it really is you at least have to be aware of it or if you're if you're aware that you don't have the answer, recognize you need a lot of money to burn to kind of make up the shortfall and the difference. Which is it's valid. I mean there's not a clear, easy answer here.
Nic (31:13)
And you know, when we think about kind of like being a, you know, taking a little bit of a contrarian view, I mean, that's a a a bit of like you like we were talking before, the the premise behind Schutzduck, right? It's it's providing this wealth of knowledge, but also bringing in that edge that takes away some of the psychophantic nature of LLMs.
Andrew Schutzbank MD, MPH (31:32)
Yes.
Nic (31:33)
And and LMs have started becoming better. I remember, you know, just three
Andrew Schutzbank MD, MPH (31:35)
Yes.
Nic (31:36)
months ago you'd say something, and every idea that came up with was
Brilliant and I was amazing. And don't get me wrong, I love that level of like fluffing up my ego, right?
Andrew Schutzbank MD, MPH (31:42)
I do. It feels great.
Nic (31:44)
It feels amazing. It's going away a little bit. I'm kind of depressed by it, but it's making me more effect more efficient and effective at what I do. but a a big part of that is also saying, okay, let's take away that psychophantic nature of LLMs and start really giving you truth based on evidence that's been that's that can back up certain decision making.
Andrew Schutzbank MD, MPH (32:03)
Yes, it it's been a fun experiment. In some ways, it was the sycophantic nature that got me to release Schutzduck in the first place. So I decided to release Schutzduck to the wild based on a conversation with Schutztuck. That was like, no, no, no, just release me, it'll be fine. So, you know, there's it's it's important we had a little we have a little bit of that encouragement. But yeah, I designed a tool to mirror mirror my advice as much as possible, which is
If things make sense, great. And if they don't, start asking a lot of questions about first principles, about underlying assumptions. the other, you know, my my philosophy of change is basically create enough cognitive dissonance between where you are and where you want to be that will get people to do the things that they know they should but won't.
Right, like to do the hard thing, it's you really gotta feel the pain of I wanna be here and I'm here. And am I if I want to bet enough, I'll do what I have to do to get across the chasm. And so sort of reflecting and amplifying kind of that distance from where you wanna be is really important.
And also recognizing to quote, you know, the if you ever watch the show House, which we watch in med school a lot, everyone lies, right? They lie to themselves all the time. And so a lot of what the duck can do is it kind of pushes back on you and tells you to like, hey, is that really what's going on? That like that doesn't s like you're the choice you're offering me doesn't sound like a real choice, right? Or you're conflating things. And it's incredibly good, you know, based on what Claude can do and then based on all the materials that I've given it as well, at really kind of
threading the needle with people and understanding what's really going on. My other favorite part about it is it's time aware. So every turn includes the system time. And so it will send you to bed. Like I do. Like I'll tell you like it's 11 o'clock, go to sleep. And so I tell people that all the time, like stop texting me, you're tired, go to bed. and so I like that the duck does that as well. It will send you to bed if it thinks you're tired and needs to stop working.
Nic (33:51)
That's super cool. So so you know, obviously we've touched upon AI and healthcare. where where do you see the biggest gap in opportunities right now with where their technology is going? Like you said, right? I mean, it's like I I wish I had LLMs just five years ago. I would have
Andrew Schutzbank MD, MPH (34:05)
Mm-hmm.
Nic (34:05)
done things very differently. And Iora, like like you said again, you would have done things very differently with LM technology. So it's creating an enormous amount of opportunity. And yet sifting through all that opportunity and finding real signal from the noise and what really drives
better
quality health care and better outcomes at the at the public health level, at the primary care level. you know, that's really where some of the magic is gonna is happening and and where we can see this going in the future. So from your perspective perspective, from what technology is capable of doing today, where do you see the biggest opportunities and in and at the same time, where do you still see the biggest gaps to getting to that next level?
Andrew Schutzbank MD, MPH (34:44)
Sure.
So they're fun I mean, they're fundamentally word machines, and so I like using them
To help sort through all the words of medicine to help get to help me visualize the present. So we spend a lot a lot of time in the last 10, 15 years. A lot of companies have been pitched and lived and died on predictive, prediction and predictive analytics. And my pushback was always the same, which is, do you know what's happening with your patients today? Like, do you know what happened yesterday? Do you know what's going on right now in the present? Because I bet you the future is way more dependent on the present than you want. And there's this fantasy that like the future is somehow perfect and we can predict it, but the present
is messy so let's ignore it. And I love these tools' ability to help us make sense of claims data and patient chat information and new clinical information and new studies to help us figure out and visualize the present. What is going on right now and then layer on top of that what what's intended to happen or what's supposed to happen. So like forgave even if if forget even if the medicine I prescribed to you was the exact right one.
Did you get any, did you get the medicine I prescribed at all? Right? Did you even get the wrong one? And then we can iterate from the wrong one if we needed to. So I think that is the greatest opportunity. We've started with what I would consider very safe and logical use cases, with back office, with billing, with reducing a lot of the administrative crush, and then it's the exact right place to begin. It's lower risk than clinical care. It's also a faster path to revenue, which is a great start. And it's taking away a lot of the pain of medicine. I I learned at my time at Iora the best thing to do with software
software was find things people were already struggling to do and just make it easier. And anytime I try to get them to do something new using software, I would get, you know, drawn and quartered. And that was probably appropriate, right? And so so once again, like using the tools to do that. But if we can push
Nic (36:25)
No.
Andrew Schutzbank MD, MPH (36:31)
New ways of practicing, new ways of being aware and cognizant of what works, simplifying things for patients, simplifying things for care teams. I think that's the real opportunity. the gaps and limitations still seem to be around numbers. They're they're just I mean, they're better than they used to be, but
interpreting lab information, interpreting these quantitative, qualitative divides, it it seems to not really be great at that yet. and so I I assume it will be, right? Like and the technology is gonna get faster because we have it to help us make it. so there's still a lot to go there. And then there's also always an equity gap.
Right, so these devices still require a certain amount of hardware to interface with them, and so you gotta get that in the hands of people. Again, I think it's another solvable problem, but one we shouldn't forget that the sickest and most vulnerable in our population usually have the least access to tools. something I learned in my work in California with with my with Scan Group, there was a plan to start a black focus medical group. And scan is a Medicare provider primarily, and when you looked at the numbers,
A significant number of black Americans died before they got on Medicare. They just didn't make it to 65. And so nothing we would have done, not I it would have helped maybe, but a lot of the work needed to be done at earlier ages. And so there's problems like that all over
Nic (37:43)
Well So your retainer so your retainer is one year with the goal
Andrew Schutzbank MD, MPH (37:51)
healthcare where you have answers, but they arrive too late or too expensively. And so I do think these tools, by lowering labor costs, will also allow us to distribute care to a much wider population.
at a higher quality. So I mean I just
Nic (38:05)
yeah.
Andrew Schutzbank MD, MPH (38:05)
it's hard to it's it's hard to temper my enthusiasm and excitement. I mean I you know, we'll all be disappointed and it'll be great in a different way than we think, but man, does it look like we can crack a lot of problems all at once.
Nic (38:17)
I totally agree. And and like you said, the blocking and tackling layer, you know, there's a lot of low-hanging fruit that can just make the whole system better if you get rid of that stuff. You mentioned before, just taking down notes, transcribing, and then summarizing for you what the to-dos are and and then keeping some of the important bits for reference later on.
Andrew Schutzbank MD, MPH (38:37)
Yes.
Nic (38:37)
you know, if that saves you per patient five minutes.
In the during the course of a day that saves you an hour. And during the course of a week, even more and more. And then in that time you can do other things, right? So it's like people go for like the sexiest, coolest thing off the bat. First of all, if you go for that stuff, first of all, it's gonna be riskier, gonna be a little bit tougher to get reimbursement for and get paid for it. Whereas like what you're looking at is like just help cleak get the floors clean and and try how do you convince
Andrew Schutzbank MD, MPH (39:03)
Yes.
Nic (39:04)
people to take their medicines, right? It's it doesn't have to be rocket science, just basic
Andrew Schutzbank MD, MPH (39:06)
Yes. Yes.
Nic (39:08)
human behavior and in
understand the workflows in the hospital system and where the friction lies, right? And if you can tackle those things, then I think you you at the very least create a much more fluid clinical experience that makes doctors more efficient. And then you start ch you know, chipping away at the higher level things. But there's a lot of stuff, a lot of businesses to be built just on that blocking and tackling layer.
Andrew Schutzbank MD, MPH (39:32)
That's right.
That's right. I mean, the reward for succeeding at that layer is we will have many bigger, scarier problems to handle. Right. My favorite example is before kind of the 1980s, if you had a heart attack, you'd just kind of die. And then we invented new medicines and interventional technologies and stents and bypass surgery got better. And all of a sudden, this field of heart failure was born because people were surviving their heart attacks and now their hearts didn't work well. And heart failure dwarves the morbidity and the cost and the misery.
of heart attacks. So like, hooray, we won. We saved people from heart attacks and created this much bigger problem, which we will again get past. And so I like to joke that your your reward for success is way worse problems.
Nic (40:17)
It's
true. And you mentioned before GLPs, right? I mean, that's also gonna start tackling some of the metabolic issues and diabetes
Andrew Schutzbank MD, MPH (40:22)
Yes.
Nic (40:23)
and other things. And and then you, you know, this takes you to longevity as well, which is you know, there is a lot of there are a lot of things that are extending human lifespan and and hopefully health span as well. We're not just
Andrew Schutzbank MD, MPH (40:34)
Yes.
Nic (40:34)
living longer but sicker, we're just living longer and maybe healthier, but then other things will start becoming much more prevalent.
Right. So in theory, I guess when we were living on average 30 years, you know, thousands of years ago, millions of years ago, I'm sorry, you know, maybe things like cancer and Alzheimer weren't as prevalent. Then all of a sudden now we're living to like 76, 77, 80 or beyond. And now we start encountering these things and we keep pushing that boundary. and so, you know, how do you see that from a PCP standpoint? And I know you've done some work on the longevity side as well.
what's your perspective on kind of where we're going as as a species as we're innovating new therapeutics, technologies and treatments making us live longer? How do we see that unfolding over time?
Andrew Schutzbank MD, MPH (41:19)
Yes. So there's a lot of science fiction on the problem of what happens when people don't die anymore. altered carbon is one, it's a great one. and if you know, there's a joke I guess in the science community that sciences advance one funeral at a time. And so we have we have tons of s of societal issues with age and transition and what happens when people in power stay alive in power and like we're we're we're living that now. On the clinical side.
I th what's most interesting to me is if you think about patient problems, I think there are only four types, right? There's I have a a clear symptom or complaint that I want resolved. There's something I want better. I want to run faster, jump higher. That's where I think where longevity fits. You're not going from negative to zero, you're going from zero to a positive. There's some administrative hurdle, like I need a letter to get my power turned back on, or I need a med refilled or something where it's it's sort of clinical administrative and and the doctor is required to do it because of the rules. And then the last type
is not symptom driven, not an enhancement, but it's something that's either preventive or based on chronic disease management. And those are important because they're kind of externally imposed, right? Because you have these organs, we have to stick this tube up year behind. Now, you know, younger and younger, as we're seeing colon cancer in younger people, like that's a sales challenge. People aren't motivated to do it because it doesn't solve a problem for them. But I think starts to emerge
When you combine the analytic capabilities of LLMs and what we're seeing in the imaging space as well, you could imagine, and maybe we've been imagining this our whole our whole medical career, the ability to find earlier and more pre-symptomatic yet significant findings that let you intervene meaningfully to alter the course of people's lives. And so it's still fundamentally kind of symptom-driven in its nature, but but earlier on.
You know, there's bad examples of this. There's a concept called lead time bias that I'm sure you're familiar with, where, you know, we used to to x-ray people for stomach cancer. We would find their stomach cancer or sapphyo cancer and stomach cancer six months earlier. They'd all die at the same time once you can control for earlier detection. So they just had six months of more medicine and worse life than they otherwise would, and so it wasn't a useful intervention. But I do think with combining all the new information we're gonna get, we are gonna be able to find significant things in the population sooner. It's not gonna be fast. There's gonna be a lot of blind alleys to it.
But I think it'll be really helpful. On the longevity side, what I always worry about with prevention is if you don't have a clear goal, if your goal is something not happening, how do you know it didn't happen and how do you know when to stop?
Right. So like my goal for a long time has been to bench my weight. First my bench press got up. Now my weight is coming down and I'm within fifteen pounds. So I'm very like, I'm gonna get there in the next few months unless I hurt my shoulder again. So that's a clear enhancement goal, right? I know when
Nic (43:59)
Yeah.
Andrew Schutzbank MD, MPH (44:02)
to stop. But if your goal is like I don't want to get cancer, well, until you get cancer, you don't know. You you aren't gonna get it. And so it's hard to know when to stop the investment or when you're the harms of the investment are worthwhile. And I think that's still unsolved. you know, obviously with large populations and large studies, you can get more information there.
But that's what I always worry about on the prev on the prevention end of longevity or on the life extension end, which is you you can't ever know you're successful. You can only sort of guess. And so when do you stop and pivot and look at something else? And that's a real tricky problem that I don't hear enough people talking about 'cause you're just so excited about the potential and the upside, which I understand.
Nic (44:38)
Yeah, yeah. And then a lot to think about there from a societal standpoint too. I mean, there, you know, you touch upon the economics there and who's going to pay for that kind of prevention and monitoring for something that you don't know if it's going to happen or when it's going to happen, or maybe you're past the point that it could have happened. and and then you take that per person times however many millions and millions and millions of people that it would be applied to, and then you get into the the the you know the minds of the economics and
policy people and public health and start thinking to yourself, well, what's actually feasible within the constraints of our healthcare system that is already a huge percentage of the GDP?
Andrew Schutzbank MD, MPH (45:16)
Yes.
That's right. That's right.
Nic (45:18)
which is interesting in healthcare because we we talk about equity in healthcare as if it's separate from equity in other places. But in in other places, you know, when the latest iPhone comes out, and you could obviously argue iPhone doesn't mean, you know, life or death or anything like that, but in any other area where there are technology innovations or innovations of any sort.
They usually start disseminating with a core few that can actually get access to it. And then eventually, once enough people do it, the economics go down, supply goes up, and then everybody gets it. And it's like that everywhere. But in in
Andrew Schutzbank MD, MPH (45:52)
Mm-hmm.
Nic (45:52)
healthcare, we seem to think that it shouldn't operate that way. But economics are still economics, and that's just the way that things flow through society. And there's going to be a process of adoption of innovations in healthcare, which usually runs like 17, 18 years or something like that when it diffuses naturally.
and and there are gonna be inequities acr along the process. You just can't take these new innovations that normally are very expensive and somehow magically get them in the hands of everybody that needs them.
Andrew Schutzbank MD, MPH (46:19)
That's right. It is an unfortunate truth. And I think the key is keeping equity as a goal instead of a gate. So the idea being, let's figure out how to get these helpful things in the hands of as many people as we can, not
One one one opinion might be like, who cares? Which I think is wrong. And the other one is you shouldn't do anything unless you can benefit everyone, which is also wrong. I think that each of those is limiting in its own way. And so it's more about the value of equity and the goal and the continuing progress toward it. But you're absolutely right. You know, for for all of the complaining, the best way to get housing supply up is to build high end housing and diffuse through the market. There's no more reliable way that it's been done. So great. So let's just go do that then and stop fighting about it. Right? It's it's it's it's either extreme.
I think concerns me on this one.
Nic (47:09)
I totally agree. Yeah, it's I get frustrated when I hear the purists out there talking about
Andrew Schutzbank MD, MPH (47:13)
Yes.
Nic (47:13)
well, it's gotta be perfect to begin with, otherwise we shouldn't start and it's like, Well, nothing works that way. Then in that case I if that's what you think, then you clearly have never innovated or created a product.
Andrew Schutzbank MD, MPH (47:22)
Exactly. Exactly.
You clearly have never built anything from scratch. If you've yeah. You d you just have to not quit and not run out of money and and hopefully you know and not hurt people along the way as best you can or not make but no, everything that exists exists imperfectly and messily and and has to be propelled forward. It is the it's the sad truth of of progress in reality, but it's also the fun part.
Nic (47:42)
You've been very generous with your time. So I want to finish off with a a signature question that gives you a a chance to kind of like look back in your career and you're nowhere done. You know, you're still doing things and you've got many, you know, many, many years ahead of you. But if you could somehow imagine yourself fast forward into the future.
looking
back and your body of work again, up to
Andrew Schutzbank MD, MPH (48:02)
Yeah.
Nic (48:02)
to date or anything in the future that you want to aspire to, what do you think would give you the biggest sense of s fulfillment? What's that best case scenario? looking at your accomplishments that would give you that sense of fulfillment, whether it be a product level, technology, societal level, that you could look back upon and say, like, yeah, that was all worth it for this one accomplishment or victory.
Andrew Schutzbank MD, MPH (48:28)
So, my core philosophy in how you should do your work and take care of people is that you should make the right promises and then keep them. And if I can get just as many people to believe that as possible, and that's what the writing is for and the advising is for, and the the duck as a persistent digitization of my soul, is to get everyone really to believe that. That like think about the promises you make, be judicious, and then actually figure out how to keep them and keep them well. The world that we would live in if that was, you know, everyone's driving philosophy.
I think we'd be amazing. And so that's really what I'm fundamentally trying to disseminate. It's just a way of interacting with the world and a way of being that helps us support one another and and just make the world a better place.
Nic (49:07)
Well, I love it. I mean, I think that's obviously it cuts across industries, lifestyles, cultures, technologies. it's just it's a good way to live by. And especially in this world where like, you know, we talked about all the benefits of AI, but it also leads to a lot of misinformation and a an erosion of trust in
Andrew Schutzbank MD, MPH (49:26)
Right. That's right.
Nic (49:28)
society generally, right? And so I think having that level of that philosophy of just kind of like delivering on your promises and
And and being truthful and having high integrity, I think goes a long way. So with that, Andrew, thank you very much. This has been true super enjoyable. I look forward to staying in touch and best of luck with Schutz work and and obviously Schutz duck.
Andrew Schutzbank MD, MPH (49:48)
Thank you, Nick. It's my pleasure and I really thank you for having me.
