IT’S TIME FOR KING GEORGE TO EXIT THE HEALTHCARE STAGE
Bullies are nothing new, and King George of England was a bully of historic proportions. Like so many bullies, he abused his power to oppress others and maintain his power — no matter how much he was failing.
Bullies lack empathy and are focused on their personal interests. They aggressively intimidate others to maintain an imbalance of physical or social power.1 In the case of King George, he used his power to unfairly accumulate wealth from the colonies and retaliated when the colonists resisted his tyranny.
I love how Lin Manuel Miranda captured the pathology of the patriarchal King George in his musical Hamilton, by putting lines such as these to a jaunty tune:
…I will send a fully armed battalion to remind you of my love…
…My sweet, submissive subject
My loyal, royal subject….
…I will fight the fight and win the war
For your love
For your praise
And I’ll love you till my dying days…
…So don’t throw away this thing we had
’Cause when push comes to shove
I will kill your friends and family to remind you of my love…
Da dada da da
Da dadada dayada
Dada da da dayada
― King George in Hamilton
But, it’s the rise of Alexander Hamilton against the backdrop of King George that most resonates with me. It’s a tale of two personas: Alexander Hamilton, an orphan and immigrant who rose to success, and King George, a tyrannical king who sought to maintain his power and oppression over the American colonies. I think these personas resonate with all of us as an important part of our history and national identities, but also because we have experienced the “King Georges” and the “Hamiltons” in our own lives.
As a female physician, clinical radiologist, cancer researcher and innovator, and start-up founder, I have experienced the behaviors of King George characters on many occasions and understand their impact at a very personal level. I see the same King George persona reflected in many leaders and networks within our healthcare ecosystem. I see this persona in academic departments, healthcare systems, large industry vendors, and venture capital groups.
I also see the Hamilton persona in many start-up founders, non-profit leaders, healthcare professionals, and others who work tirelessly against a broken system. My experiences over many years “on the stage” of our US healthcare ecosystem have given me insight into the pathology of our system and why we are so off track.
A STATUS QUO THAT HURTS US ALL
People in the US are dying from treatable and preventable diseases at rates higher than other high-income nations. 2 3 Life expectancy in many areas of the US is lower than in many third-world countries. System costs and administrative costs continue to escalate at an exponential pace, and vital professional interactions with patients have been dramatically diminished. 4 5 6 7 Physicians have been pushed to do more and more in a failing system which has negative impact on clinical outcomes. 8 Healthcare CEOs have acknowledged that physician burnout is a public health crisis. 9 The system is facing related increasing rates of professional staffing shortages despite having one of the best training systems in the world. 10
The burden of all these failures rests mainly on the shoulders of patients, who must deal with poor quality of personal health and inflated, unfair costs. Medical bills are the number one reason for bankruptcy in the US. 11
In a recent presentation, Gartner outlined how US Healthcare is locked in a vicious cycle of legacy technologies, legacy culture, and legacy thinking. 12 I could not agree more. We have a dysfunctional patchwork of high-end and legacy technologies that are not leading to improved overall outcomes.
Our system is full of cruel inequalities, and many in our country do not have reasonable access to even the most basic medical care. Indeed, we may have created the most expensive and least effective system in the modern world, with poor metrics on quality, costs, access, and care of the disadvantaged. 13
In any other industry, innovation investment in free markets leads to increasing quality at lower costs. Why not in healthcare in the US? Why are our record-breaking investments not translating into improved care and population health? 14 15 Why are we seeing vast and growing inequities?
SOCIAL IMBALANCES
The healthcare ecosystem, medicine, and venture capital are marked by enormous social imbalances. (see Chart 1) Despite the fact that over 50% of medical school students are women, women are greatly under-represented in leadership roles in healthcare. Women represent 80% of the healthcare workforce, and 80% of healthcare decision-makers are women, yet we represent only 20% of its leaders. Only 4% of CEO’s of healthcare companies are women. 16 17 18
In my field, radiology, women are underrepresented among radiology vice chairs, section chiefs, and department chairs. Major journal mastheads have fewer women in editorial roles than would be expected given their representation in academic radiology. 19 20
In the VC world, only 12% of decision-makers at US-based VC firms are women, and 71% of VC firms have no female partners. 21 This imbalanced leadership and representation have translated into a range of experiences for women and underrepresented minorities, from unconscious bias to flagrant bullying. 22
Specifically, I have experienced aggressive “gatekeeper” bullying, both inside academic medicine and as a start-up founder. “Gatekeeper” bullies seek to limit access to resources needed for success, then use diminished output to label the victim as inferior.
For example, as a female scientist, I have had former mentors limit my access to seed funding for my research. Later, these same mentors plagiarized my patented (and published) methods without providing me any credit. Not just once.
These patterns also extend to the world of venture capital. I was told by a local VC in Wisconsin that he believed I would not be able to raise funds locally because my company is a competitor to a “local favorite.” This local favorite was a virtually all-white male start-up, funded by virtually all-white male local VC’s, with far inferior technology and intellectual property.
I was told by another local VC — in a key leadership role controlling innovation funds in the state — that if he invested money into my company, he would immediately take control and remove me as CEO. When I offered to explain the potential enormous social impact of our company, he said he did “not care” and only cared about “my return, my return, my return.”
But perhaps most alarming are the expressed attitudes about healthcare innovation. I’ve had multiple VCs tell me that they only invest in fragmented technology that integrates with existing legacy systems because it’s the most reliable avenue they have found to get a financial return for themselves. By only investing in ways to patch old systems, they are not addressing core major problems. They are stifling critical-need medical technology — such as for cancer — that could bring sea changes for patient outcomes.
Who has almost complete control over our nation’s critical healthcare innovation dollars? Let’s just summarize by saying it’s…King George.
Statistics show that only 2.6% of VC funding went to all-female teams between 2014–2019. Female-only led start-ups in “non-female” sectors raise less than 1.9% of VC dollars. Female-only led teams represent 2.8% of all AI companies, but get only 1.5% of all capital. Only 1% of venture-backed founders are Black, and Latino founders receive only 1.8% of funding. 23 24
In university-based academics, women have diminished access to resources and support for success. Most concerning, many academic leaders within our university systems and private venture capital are tightly networked. This unilateral power over innovation capital stagnates both private and public funds for diverse resource allocation across a wider demographic and for a more diverse array of ideas and approaches.
“Give all the power to the many, they will oppress the few. Give all the power to the few, they will oppress the many.” ―Alexander Hamilton
The patterns continue, yet we know that diversity is critical to innovation. As stated by a recent Scientific American article, “Decades of research by organizational scientists, psychologists, sociologists, economists and demographers show that socially diverse groups (that is, those with a diversity of race, ethnicity, gender and sexual orientation) are more innovative than homogeneous groups.” 25
KING GEORGE’S IMPACT ON QUALITY AND SAFETY
What’s the impact of this imbalanced power and investment on quality of care and safety? I can use the example I know best — radiology. In my opinion, conflicts of interest in radiology academic departments are driving a horrible decline in quality of care and safety, despite massive investments in technology.
On the one hand, academic university partnerships — including academic industry “influencer” advisor deals — have driven high-margin sales for medical imaging machine manufacturers. Similar relationships have simultaneously driven “lock in” of legacy PACS technology that hasn’t delivered any fundamental interface design change since the 1980’s.
The net result is poorly orchestrated innovation, leading to cognitive overload for radiologists, who are now forced to read an image every 3–4 seconds using antiquated technology. 26 This is driving a substantial decline in quality, with an estimated 30% errors rates and 15% misdiagnosis rates. 27 In additional to the horrible impact on patients’ lives, misdiagnosis rates cost the US an estimated $375B annually. 28
In the age of AI, we have seen virtual unilateral and fanatical investment in “black box” Automation AI for medical imaging, to the tune of over $1.2 billion invested in these start-ups in between 2014–2018. 29 Of course, these are virtually all-male groups funded by virtually all-male VC’s. Smarter and safer diverse pathways for adopting new deep learning technologies have been underfunded.
What’s the result? Failure, wasted investment, and unsafe technologies being deployed today in clinical practice. In a recent letter to the FDA, the American College of Radiology (ACR) recently stated that 93% of Radiologists using these new AI Automation “black-box” tools in a clinical environment felt the tools were unreliable, and the ACR called for tighter FDA control in order to protect patients. 30
These patterns increase costs for healthcare systems and patients while decreasing quality and safety, all while these “influencers” generate large personal profits. 31 32 33 34
KING GEORGE’S IMPACT ON POPULATION HEALTH AND HEALTH EQUITY
The impact of these social imbalances on population health and health equity is a topic of extensive research. 35
One of the more dramatic examples is women’s health. This field is severely underfunded in academic research and faces constant roadblocks to innovation dollars. 36 37 For example, Kate Ryder — founder of the women’s health app Maven — spent years being told by male-dominated VCs that women’s health was “not a big enough market.” 38
These stories are shocking given that it’s a market encompassing 50% of the world’s population. Maven’s success despite these boundaries proves the fallacy of the male-dominated VC decision-making. Maven is now a “unicorn” start-up that has raised over $88 million. 39
Another extraordinary example is access to breast cancer screening for minorities. Breast cancer mortality is roughly 40% higher for Black women. This demographic is often diagnosed with late-stage breast cancer when treatment options are limited, costly, and when the prognosis is poor. 40 Despite the known patterns, calls to address health equity remain grossly underfunded. We also know that increased representation within medicine can help, yet the numbers are not shifting — currently, Black women represent only 3% of US doctors. 41
Public health experts reject assertions that there is an inherent tradeoff between innovation and health equity. We should certainly be able to create a highly innovative healthcare system that is simultaneously fair, empathetic, and equitable. 42
But how can we create this outcome if we don’t provide the needed research and innovation resources to diverse academic researchers and founders?
THE HAMILTONS VERSUS THE KING GEORGES
In the musical Hamilton, we learn about Alexander Hamilton, an amazing character in history who was an orphan and rose from a disadvantaged background to become one of the most influential founding fathers.
…The ten-dollar founding father without a father
Got a lot farther by working a lot harder
By being a lot smarter
By being a self-starter……I’m a diamond in the rough, a shiny piece of coal…
…Hey yo, I’m just like my country
I’m young, scrappy, and hungry
And I’m not throwing away my shot…— Alexander Hamilton in Hamilton
In today’s healthcare environment, when we work to solve genuine problems with disruptive innovations, we’re going against the grain of the status quo of legacy culture and thinking, as well as the legacy technologies that have established economies of scale. True entrepreneurship is based on a genuine commitment to solving real problems and proving out new business models, not simply finding fast and easy ways to generate a return. To win, we have to be smarter and more tenacious. It takes genuine commitment to deal with harder conditions to realize a vision that really matters.
Today’s ecosystem is complex, and it can be hard to tell who’s a King George and who’s a Hamilton. Propaganda by healthcare systems and universities around diversity and inclusion is fierce. Even the King Georges I know today tweet “#HeforShe,” while statistics prove that they are handing the real power and resources disproportionately to men — and mostly white men.
Conversely, many empowered women in medicine and industry serve the interests and politics of the patriarchy that promotes them, at the expense of genuine progress. The equation of who’s “good” and who’s “bad” is complex, yet the problem is clear: the needle has not meaningfully moved on statistics for true empowerment of women and minorities in medicine or venture capital whatsoever.
King George has not yet left the stage of US healthcare and venture capital. He is in full control of innovation resources, both public and private. The Hamiltons are hampered in delivering the transformation our US healthcare system so desperately needs, while King George still sits in his throne, abusing his power and position to accumulate increasing wealth and power.
Does history point the way?
As the real Hamilton understood, “infant industries” are vulnerable to existing industries that have established economies of scale. The Hamiltonian economic program implemented by the US Congress allowed the US to establish growth of its new businesses and protect them from larger industries from abroad. The result was a flourishing economy. In less than 100 years, the United States grew into the largest economy in the world, with the highest standard of living, surpassing the British Empire itself by the 1880s. 43
CAN WE SUCCESSFULLY TRANSFORM OUR HEALTHCARE SYSTEM?
We can’t tolerate this status quo that hurts us all, and there is enormous investment, talent, and activity focused on transformation.
“We are finally on the field, we’ve had quite a run. Immigrants: We get the job done.”
- the Hamilton Musical
But, to be successful, we must assure that King George exits the stage and that Hamilton gets his (or her) shot.
Dominance and bullying manifest in many ways across our healthcare system. The outdated hierarchical and patriarchal culture. Innumerable episodes of gender and race bias, discrimination, and harassment. The “leaky pipeline” of advancement. Patterns of large vendor legacy technology “lock in.” Attempts by large industry to diminish patients’ rights over personal health data and patient data “lock in” for profits. Data-blocking by large EHR vendors. Extended tenures of academic chairs (for up to 45 years in Radiology!) and medical school Deans. Escalating drug prices. Surprise billing. Insurance company denials. And improper academic-industry relationships.
Just to name a few.
Although it’s a complex dynamic, the endpoints are clear: they are winning and we are not. Our healthcare system no longer protects the interests and well-being of physicians and patients, nor the vital patient-doctor relationship. We have a system that turns a blind eye to vast inequities.
How do we fight it?
In my view, patterns of systemic dominance in our healthcare ecosystem need to be addressed at many levels. Here are a few ideas that aren’t being talked about enough:
· Term limits for academic chairs and Deans
· Stricter organizational policies to address bullying
· Stricter conflicts of interest policies at Universities and within professional organizations
· Further education on innovation strategies for healthcare professionals
· New laws to protect patients’ digital rights
· Larger penalties for companies engaged in data blocking
· Dedicated federal funding for start-ups led by women and under-represented minorities
· New laws to address the anti-competitive tactics by large vendors.
I am confident we will see many ideas by experts in a variety of fields as the topic of healthcare is brought forth on a national stage, once again.
But, as the saying goes, “culture eats strategy for breakfast.” It is incumbent on all us to reject the “King George” culture and replace it with a new culture of “Hamiltonian” continual innovation. Only then can we deliver good, disruptive innovation and transform our US healthcare system into the best system in the world.
Perhaps we are finally ready to fight for a revolution in democratic and representative systems in our healthcare ecosystem and venture capital.
It may not be the American Revolution. But it’s worth a revolution nonetheless.
“I know that we can win, I know that greatness lies in you. But remember from here on in, history has its eyes on you.”
— George Washington in Hamilton
