Preventative Medicine, AI, and the Future of Personalized Care

Rian Gauvreau: [00:00:00] I'm Rian Gauvreau, and this is Healing Healthcare, a podcast where we explore the challenges, innovations, and ideas shaping the future of healthcare Today I'm joined by Ryan Kingen, a primary care physician and an entrepreneur behind Sapere Health, a new service designed to help patients better track and interpret their own biomarkers and health factors.

Rian Gauvreau: We've gotten to know Ryan at Aeon over the last year and have been inspired by his vision for the future of medicine and the insights about how to make primary care more accessible and efficient. In this conversation, we'll explore the challenges facing modern primary care practitioners, the impact AI and other novel technologies are having on the medical landscape, and Ryan's perspective on what excites him about the future opportunities to heal the healthcare industry.

Rian Gauvreau: Here's our conversation. Ryan, thanks so much for being here. My first question for you is, as a practicing primary care doctor, what do you feel is really front of mind for you in terms of the challenges facing healthcare especially in the context that [00:01:00] you see every day? 

Ryan Kingan: Thanks for the big first question.

Ryan Kingan: Keep it easy. Challenges in primary care, it's getting more complex in almost every way possible. 

Rian Gauvreau: Are there particular areas where you're seeing the emergence of a unique level of complexity that, maybe hasn't impacted the industry in the way it is right now? 

Ryan Kingan: That it hasn't impacted the industry?

Rian Gauvreau: Yeah. I think certainly the arrival of AI things like that could... I think it's applying a lot of pressure to all industries right now, and I think that, you're starting to see some emergent behavior around changing consumer expectations, changing practitioner expectations and, I could see that adding a lot of confusion to things.

Rian Gauvreau: But I also assume that you have perspective on a lot of other changes that are afoot in the industry and how they're coming to bear on practice. And yeah, would love to just hear what are the things that are impacting you day to day and holding you back in terms of delivering the kind of care and the health journey that I think you probably imagine you want to be true but are maybe prevented from doing in some cases.

Ryan Kingan: Yeah. So I think there's [00:02:00] multiple forces at play making it really complicated. Basically every industry I think AI is a big one- ... 'cause everyone's still trying to figure out how to use that- 

Rian Gauvreau: Yeah 

Ryan Kingan: ... and sees a lot of potential there. But then there's also a lot of potential for this weird middle ground where you're just creating a lot of slop and ends up creating more work.

Ryan Kingan: So that's definitely a part. But I think the thing that's been going on even longer is just that, that people, patients are living longer with multiple diseases or chronic diseases- ... and treatments are getting better and more sophisticated. So the average GP who used to have just a handful of really complex patients on novel drugs now has a bunch of them, and they're just not trained for that.

Ryan Kingan: They're not used to dealing with four or five different comorbidities and a few different novel drugs that all need to be monitored, and we're not sure how they're interacting, [00:03:00] and you make one little change to try to improve something and you break two other things. 

Rian Gauvreau: Yeah. 

Ryan Kingan: And the medical system was more set up for this episodic care where somebody has a problem. You come in with one problem dealing with that problem. 

Rian Gauvreau: Yeah 

Ryan Kingan: Exactly, and then they're gone.

Ryan Kingan: I'm really lucky that I actually don't work in that model as much anymore and that we get to focus on more of a preventative care model. But that brings a whole host of other problems, trying to work in the medical system with that. 

Rian Gauvreau: That leads naturally to my next question, which is, like, how, given that people are living longer, perhaps living with multiple comorbidities and chronic health conditions what do you think is the solve around that?

Rian Gauvreau: Because if, it sounds to me as though that's going to be a more consistent state of affairs for most doctors, and so how are they going to cope with those changing conditions? And one thing we hear from all the doctors we talk to is capacity and efficiency is a huge problem.

Rian Gauvreau: And if now you're not [00:04:00] even dealing with episodic cases and you're still carrying the same patient load, but the tax of each one of those patients and the conditions that they need management, it feels like potentially the situation's getting worse for doctors instead of better.

Rian Gauvreau: And what might be the unlock there to, helping to alleviate some of the burden on doctors to make sure that these people that do carry these chronic conditions are getting the care that they need? 

Ryan Kingan: Yeah, I don't think there's one specific thing or even just a few. I think it's gonna be multifactorial and multiple solutions and just chipping away at it.

Ryan Kingan: There's been things proposed like having more multidisciplinary settings so specialists and GPs are working closer together in, in one kind of clinic where they have easy access. Locally, there's been some good success with that too. We've got, in Vancouver, we have a program called the Race Line where family physicians can basically just pick up the phone and call a specialist and ask them questions about any particular problem- 

Rian Gauvreau: That's cool 

Ryan Kingan: ... about a patient right away, whereas before you had to refer them out and it would take six months for them to see and it was just not efficient. [00:05:00] That, that's one example. I was just talking to my colleague the other day about how AI has really changed our referrals.

Ryan Kingan: There's a lot of times when you've got a problem with a patient and one of the problems is we know a tiny bit as family physicians, we know a tiny bit about a lot of things. But then we're out of our depth quite quickly. 

Ryan Oakman: Yes. 

Ryan Kingan: And with AI geared towards medical problems, like there's one called OpenEvidence- 

Rian Gauvreau: yep ... 

Ryan Kingan: we've found that we've really cut down on referrals 'cause a lot of times a referral is essentially a question. You don't really know what the step, next step in managing this patient is or investigating it, or you're not quite sure and you can input a lot of data into something like Open Evidence and it basically researches all the guidelines or clinical knowledge of that area that you're questioning, if it's a endocrinology problem.

Ryan Kingan: We've been able to cut down a lot on referrals, so that's another little thing, and it's easier for us and then it's easier for the ... It's better for the patient. It's better care for them. They get the answer, the treatment, the investigation a lot quicker than they would. 

Rian Gauvreau: Yeah. 

Ryan Kingan: Like you mentioned, I think there's a ton of [00:06:00] places where medicine is incredibly inefficient, probably for some good reasons and some not so good reasons.

Ryan Kingan: A lot of the EMRs are not doctor centric. They're, they were built to be, Like 

Rian Gauvreau: billing centric ... 

Ryan Kingan: optimized around billing. Yeah. Yeah. Optimized around the accountants, the billing and then, and then- charting and the doctoring was an afterthought, just plugged on after. There's probably 10 or 20 other things like that, but those are the, probably the big ones that stand out to me.

Rian Gauvreau: Yeah. 

Rian Gauvreau: And, like you, you mentioned AI, and I think that's of course, front of mind for literally everybody at this moment in time. And curious, beyond open evidence, where are you starting to see or hear from other colleagues? I guess inspiring, kind of stories or opportunities where, AI is maybe starting to have an impact or could potentially have an impact.

Rian Gauvreau: And, maybe more broadly, is there, are there other things in the kind of technology landscape that you feel are you're looking forward to them arriving and having the impact , or have you identified any kind of [00:07:00] gaps in the kind of technology universe that, have yet to be solved?

Rian Gauvreau: And if somebody was able to come in and solve those problems, so that would be an unlock in some way for efficiency and productivity in the medical industry. 

Ryan Kingan: Yeah. I'm still trying to work through that 'cause sometimes when you think an AI has helped- 

Rian Gauvreau: Yeah 

Ryan Kingan: ... it creates a lot more work.

Ryan Kingan: Or it opens up something that you never thought you'd be doing, and then you go down this rabbit hole. Some things I've found it really helpful for is it's a good way to bounce ideas off of or reassure yourself that you haven't missed something, keep yourself open-minded. 

Ryan Kingan: 'Cause we can sometimes fall into these traps of you got somebody with a bad cough, oh, it must be pneumonia, and you just, you fall into this box, and you give them antibiotics and you don't think about anything else. 

Rian Gauvreau: Yeah. 

Ryan Kingan: You don't think about oh, could it be asthma or just something really unusual.

Ryan Kingan: But- I think 

Rian Gauvreau: everybody gets myopia in their own way, right? 

Ryan Kingan: Yeah. Yeah. Yeah. So it keeps you honest like that, it keeps you [00:08:00] open-minded, and then there's all the automation kind of stuff. There's the manual sort of grunt work, data entry, the things we do a million times a day. 

Rian Gauvreau: Yeah. 

Rian Gauvreau: Like- Again, that's something we've heard very consistently is that, like One of the biggest taxes that I think a lot of people don't appreciate that doctors have is this massive data entry burden.

Rian Gauvreau: I've shared with, a lot of people who have expressed interest in our company, just around there's a data point that I think we collected from the American Medical Association, and they had interviewed some large body of doctors and said, "Hey, where's your time going?"

Rian Gauvreau: And in an eight-hour day, five of eight hours gets spent in software. And I don't know if that maps to your experience, but that seems like it's a literal catastrophe. 

Ryan Kingan: I think a lot of times people think doctors, most of their job is spending time with patients or seeing patients. '

Rian Gauvreau: Cause we got everybody watches "The Pit" and "ER" and like- Yeah

Rian Gauvreau: "Grey's Anatomy," right? And I think that gives you a pretty distorted take on what an actual doctor's day looks like. 

Ryan Kingan: Yeah. Yeah, definitely. And that's what most doctors would prefer to be doing, but the reality is you [00:09:00] probably spend 20 to 50% of your time doing administrative work or data entry or reviewing results or looking for trends and stuff.

Ryan Kingan: And okay, sometimes maybe you'll see the patient for 5 or 10 minutes, but a lot of times you've done 20 or 30 minutes before that, unfortunately. 

Rian Gauvreau: Yeah. 

Ryan Kingan: And then there's some work afterwards. But, so I think a lot of that could be cut down by a good EMR AI, automation all the above. Yeah.

Rian Gauvreau: That's our conviction as well. 

Ryan Oakman: Yeah. 

Ryan Kingan: I think there's some, definitely some low-hanging fruit there. 

Ryan Oakman: It doesn't seem like it's about eliminating administrative work, right? I don't think that if we were to say "Hey we could make 100% of your time seeing patients, no administrative work," like I don't necessarily think that's the answer.

Ryan Oakman: It's just how do we make that administrative work less burdensome? 

Ryan Kingan: Yeah. Yeah, definitely. You're... At the moment I can't really see a time where physicians are gonna completely hand everything over to a software or an [00:10:00] AI and... But there is a lot that could be sped up by that, I think.

Ryan Kingan: Yeah. You are still gonna s- I think at the moment as it's almost like you're gonna have a few resident doctors working for you and you're overseeing them. You're still gonna have to review everything and then have that interaction with the patient 'cause that's what they trust.

Ryan Kingan: They're not gonna trust some software and there needs to be some accountability there, and needs to be a person- Yeah ... I think, for the foreseeable future. So there's always gonna be some admin work. 

Ryan Oakman: Yeah. 

Ryan Kingan: But definitely some of the grunt work, a lo- some of the, even some of the stuff that the MOAs end up doing in assistance, I think a lot of that could, can be a lot more efficient.

Ryan Kingan: And then that would allow more clinics to open leaner- 

Ryan Kingan: And more doctors that wanted to open a clinic but never felt they were able to 'cause they didn't have the resources. But now if it's more efficient, you just don't need the resources. 

Rian Gauvreau: Yeah. And I think one theory that we've had, and I don't know whether you have conviction around this or not is just that, the idea that if [00:11:00] doctors aren't spending so much of their time on the administrative thing, side of things, then they have more time to devote to patients and patient care, which means they can attach more patients, which means that some of the structural problems we see in the system are actually perhaps partially technology problems.

Ryan Kingan: Totally. 

Ryan Kingan: Yeah. Yeah. That was my thought as well. It, all this AI stuff, it's not eliminating work- 

Rian Gauvreau: Yeah 

Ryan Kingan: ... for me at least. It's getting rid of some stuff, but then it, there's plenty of other work to do. 

Rian Gauvreau: Yeah. 

Ryan Kingan: Or you can see more patients or you can spend more time with that patient, or you can spend more time diving deeper into their past medical history and you just end up doing some things better.

Rian Gauvreau: Yeah. 

Ryan Kingan: If anything, I think we're working more- 

Rian Gauvreau: Yeah 

Ryan Kingan: ... with AI. 

Rian Gauvreau: And I think that's actually a really interesting comment at this moment in time because I think that, if you pay attention to the zeitgeist out there, it's like everybody's talking about how AI is coming for everybody's job.

Rian Gauvreau: And I think that, my experience has been that, there's a lot of hype around that, but, you know, is the rubber hitting the road and [00:12:00] is that resulting in job loss at scale? And I think certainly in some industries it probably is true, but I think that, that's a bit of fear and uncertainty and doubt taking root in the medical industry.

Rian Gauvreau: And I, in my observations haven't seen, any kind of meaningful shift in terms of AI having this massive impact in terms of joblessness in the medical industry. But by the same token, it feels like there's also a bit of a narrative around AI's gonna solve everything, and I think your experience is obviously not that in that, yes, it has provided some benefit, but is at least the state of AI today the master solve that everybody thinks it is, and is it coming for everybody's job?

Rian Gauvreau: I think I'm hearing that your conviction is no. But I think it's there aren't enough people talking about the counterpoint, like where AI is maybe not having the impact and where AI doesn't worry and where AI is maybe creating more work. And kinda curious around your perspective on that.

Ryan Kingan: Yeah I think the human factors it's not gonna replace that anytime soon. Obviously, I'm a bit biased. 

Rian Gauvreau: Yeah. 

Ryan Kingan: Personally, I can't imagine just going to a, [00:13:00] some sort of virtual doctor's office where you're just interacting with an AI. People-- I think it's gonna be a long time before people trust that.

Rian Gauvreau: Yeah. 

Ryan Kingan: And then there's the accountability problem. I think you're right that people are-- physicians are gonna be a lot more efficient. So whereas maybe before you could handle a panel of 1,000 patients or 1,500 patients, maybe that doubles. 

Rian Gauvreau: Yep. 

Ryan Kingan: Because all that admin work, all that, all those Screening through results and following up with the patient on them, that can easily be automated.

Ryan Kingan: Looking, like looking for trends in results and figuring out which of your patients have had their cancer screening tests and when they're due and scheduling that, it's a lot of manual kind of grueling work. 

Rian Gauvreau: Yeah, 

Rian Gauvreau: and 

Rian Gauvreau: that's the kind of work that humans aren't good at, right? 

Ryan Kingan: Exactly, yeah. 

Rian Gauvreau: That's what a computer's really good at.

Rian Gauvreau: Yeah. And, but humans are really good at, the interpersonal interaction and that's where, in my imagination I can't imagine myself going and getting interviewed by a, an AI [00:14:00] robot. I'd far rather talk to a human being that, has that emotional connection and, can, bring a human level of care.

Rian Gauvreau: And so I think I agree with you, but I, that, that doesn't change the narrative out there being like AI's coming for everything. And so I think it's nice to hear that, from s- somebody who's living through it, that there are some positives to be gained from it. But, y- this hasn't been a universally positive shift and it's not necessarily gonna have a transformative impact on the industry from an employability standpoint.

Ryan Kingan: I, I have no idea if I'm right. 

Rian Gauvreau: Yeah. 

Ryan Kingan: That's just my gut feeling. But,

Rian Gauvreau: And I think everybody, I think everybody's got their own personal opinion about where AI is gonna take the world. And I think, everybody is probably right that it's gonna have a transformative impact, but what that's gonna look like- 

Ryan Kingan: Yeah

Rian Gauvreau: I think we're all gonna be surprised. 

Ryan Kingan: I know. And there's some really smart people that are really deep in this stuff that have opposing views on that and-

Rian Gauvreau: yeah ... 

Ryan Kingan: like I remember may- it was almost like two years ago, right? I met this guy that worked in Microsoft Azure, like a fairly high executive and it [00:15:00] was just like by luck we ended up going for lunch and in the entire conversation- He was telling me about AI, and this is two years ago, and i- I wasn't paying much attention to it back then.

Ryan Kingan: And he was scared out of his mind- 

Rian Gauvreau: Yeah 

Ryan Kingan: ... 'cause he was telling me some of the stuff that, that Microsoft has that's not released to the public and the experiments essentially they've been doing with it. And he has two daughters, like one of them is just finishing a residency in radiology and one of them is going into medical school, and he's "I don't know what to tell them 'cause I don't think they're gonna have a job in a year or two.

Ryan Kingan: The AI is moving so fast and it's so good already." He's like, "Radiologists are done." And this is a guy that was like deep in this stuff, knows a lot about it. Yeah, there is that doomerism out there- 

Ryan Kingan: But, y eah, I haven't seen any real indication of that. Like even in radiology, it seems to just be helping radiologists do more work.

Rian Gauvreau: That's a really positive impact, right? Is if radiologists can get to more volume, I think that's a net positive. But I think by the same token are we creating [00:16:00] so much like fear and uncertainty around the arrival of AI that we're actually preventing people who should become doctors from going into medical school?

Rian Gauvreau: Like that seems like perhaps too far. 

Ryan Oakman: Yeah. Yeah. Ryan, I know we talked about this a couple of days ago, but just that idea of the theory of constraints and I wonder too how that kind of plays out in a clinic. And so like the theory of constraints is that like people just generally don't know what the problem is that they're fixing, so they try and fix the easy things, low-hanging fruit.

Ryan Oakman: And so like when I think about AI in a doctor's office, I wonder if part of the problem too when you are talking about not not always finding that it's making you more productive but creating more work is that it's just like an there's still so much of an unknown around like how do I best apply this.

Ryan Kingan: Oh, yeah. Yeah. Totally. I, I-- and I think- Most people are not even thinking about applying AI to their medical practice. I think. Yeah. Most people are just so busy they're like in survival mode. Yeah. They're not really thinking about "Oh what's the next AI product I can use [00:17:00] to make my practice a bit more efficient?"

Ryan Kingan: From like informal surveys with doctors, it seems like 

Rian Gauvreau: everybody's just treading water. 

Ryan Kingan: Yeah. Yeah. And like 10% of people are regularly using AI in their workplace. Maybe if you count scribes it- it's a bit higher than that, but even with scribes it seems to be like 40%.

Ryan Oakman: And we see that talking to doctors too, where it's like you see there's a problem and it's like we're trying to show you a solution, but the gap is that they're like, "We have no..."

Ryan Oakman: "Yeah, we're just treading water so much that we have no time." 

Ryan Kingan: No bandwidth. We have... 

Ryan Oakman: There's no bandwidth to fix the problem. 

Ryan Kingan: Yeah. 

Ryan Oakman: We're just like, "We just have to survive." 

Ryan Kingan: I feel like in all industries, some... if you don't adopt this stuff or pay attention to it, you're kinda gonna be left behind.

Rian Gauvreau: Yeah. Yeah, it's almost like you need to invest in it just so that you're sufficiently familiar with it that like you can kinda see the trends and, attach yourself to those trends so you don't get left behind. 

Ryan Kingan: Yeah. 

Rian Gauvreau: Yeah, it feels like even if you're anti-AI you should probably [00:18:00] still have a toe in that water.

Ryan Kingan: Yeah. 

Rian Gauvreau: I know you have recently launched your own business, Sapire Health, and I imagine in launching that business you had a unique kind of take about like what you wanted to be true i- in, as a function of, how you're performing medical care in that business. And so would love to just hear about, more about why did you start Sapire Health what are you planning on doing a- as a function of that business and how are you building a business that ultimately will do a best job of serving your patients and hopefully delivering healthcare efficiently?

Ryan Kingan: Yeah, so the problem I was trying to solve is getting people in BC better access to preventative and elective tests. Doesn't need to be more complicated than that. 

Rian Gauvreau: Yeah. 

Ryan Kingan: The problem in BC is there's a lot of gatekeeping. 

Rian Gauvreau: Yep. 

Ryan Kingan: The public medical system is very reactionary. You can't go see your GP just because you want a checkup.

Ryan Kingan: You, you have to have a problem. And the reason for that is they can't bill MSP or the government for [00:19:00] that. So if you go and see your GP and say, "I just wanna check my cholesterol," "I just wanna know, I'm 25 years old, I just wanna know if I have high cholesterol," you might get some strange looks.

Ryan Kingan: And then you kinda gotta argue with your doctor. Or another classic one is hormones. A lot of people just wanna ... whether or not just curiosity or they just ... A lot of it's curiosity. 

Ryan Kingan: Or maybe they're looking to improve things. They wanna get a baseline and they just want the knowledge.

Ryan Kingan: Can't do that. So I'm just trying to give easier access to people to do that. Also, give easier access to preventative medicine so that people don't have to pay thousands of dollars a year-

Ryan Kingan: To get some pretty basic preventative medicine and know their- Their relative risks of developing some of the big diseases.

Rian Gauvreau: Yeah. 

Ryan Kingan: Because most of this stuff is way easier to treat if you catch it early. 

Rian Gauvreau: Yep. 

Ryan Kingan: Which is not the philosophy of the medical system in BC at the moment. 

Rian Gauvreau: And are you seeing a bigger uptick in that kind of [00:20:00] behavior where I have, a unique curiosity about my health and, or I have a particular health objective in mind, and so I'm just gonna take agency for myself and try and drive this home without necessarily needing to go through the the medical system as, most of us have been trained to consume it?

Rian Gauvreau: And yeah I'm certainly having a lot of conversations with people that are almost consuming healthcare a bit more a la carte than I've ever seen it done before. And I think that's really great because I think a lot of people have, a very unique perspective in terms of what they're trying to achieve.

Rian Gauvreau: But, I also know that it's sometimes hard because some of those things are tightly regulated, or you need to be able to put the right context around the results so that people can understand it, and I assume that's a dimension that you're offering as well. 

Ryan Kingan: Yeah. Yeah. I kinda have this argument more data's better.

Ryan Kingan: Yeah. That's generally how I always feel. There's definitely downsides to it. You can cause yourself some anxiety. There can be a lot of noise. There can be false positives, false negatives. But I guess I have the more libertarian view that if you wanna do something, you wanna check some biomarker, I think you should be able to do [00:21:00] that.

Ryan Kingan: Yeah. I don't think, I don't think you should have to go through a gatekeeper and take half your day off work to go sit in a walk-in clinic to get the appointment, and then schedule an appointment at a lab two days later, and take another half day off work, and then you go back to the clinic to get the results.

Ryan Kingan: That's just absurd in- 

Rian Gauvreau: Yeah ... 

Ryan Kingan: in today's in today, yeah, it's absurd. I think it's part of moving the culture towards preventative medicine and taking ownership of your health and trying to be healthier. 

Ryan Kingan: People are interested in this data, like all these wearables. The amount of people that are using CGM continuous glucose monitors, which are meant for people with diabetes.

Rian Gauvreau: Yeah. 

Ryan Kingan: They're these patches that you stick on your shoulder and you can check your blood glucose any time of the day for two weeks straight. And it seems initially it seems silly. It's like you're not diabetic why would you wanna do that? And but there's some amazing behavior modification that comes out of it.

Ryan Kingan: Like people learn that if they eat a bowl of [00:22:00] pasta, they see their blood sugar spike up right after. 

Rian Gauvreau: Yeah. 

Ryan Kingan: And then they'll notice if they go for a walk after that it really evens out and it doesn't stay high the whole night. Or they'll eat some foods that are lower glycemic index or whole foods or vegetables, some cooked vegetables, and they're like, "Oh, I didn't see that huge blood sugar spike.

Ryan Kingan: Turns out what my grandma said was true." 

Rian Gauvreau: Yeah. 

Ryan Kingan: You should eat more vegetables- ... and exercise a bit. And like a lot of it is very common sense, but this little, these little- 

Rian Gauvreau: It's like database reinforcement. 

Ryan Kingan: Totally. Yeah. Yeah. Yeah. Yeah. And you can get in, you can fall into these really academic traps with medicine.

Ryan Kingan: The academic trap would be like, "Why do you need a continuous glucose monitor? You don't have diabetes. You never need to worry about your blood sugar." But actually getting that data can reinforce good behavior, can change bad behavior. So I think medicine is moving a lot more towards that area and doctors are becoming more open-minded and people are just more interested in this stuff.

Rian Gauvreau: Yeah. We definitely hear a lot about this idea of N of one medicine, right? And, having, custom supplements and [00:23:00] custom drugs and all of these kinds of things, and it certainly seems like that's the direction that things are moving. I was just at Web Summit and was kinda co-panelist on the stage with another biotechnology company, and they're custom-designing molecules for people so that, that can, treat a disease that truly is an N of one, which, kinda seemed like that would never be a reality, and it's really cool to see that coming to fruition.

Rian Gauvreau: But not sure whether you're seeing any kind of other drivers that, around that whole N of one. It seems like everybody's so data-fied now that, it must almost be the case that you're coming, getting people coming to you with "Hey- Yeah ... I got all this data. Help me make sense of it." W- what's your take on the, the future of medicine as it pertains to truly individualized medicine?

Ryan Kingan: Yeah. There, there's a lot coming in there. Some of the genomic stuff is- ... is pretty wild. Most of, most doctors are used to the monogenic mutations, so like single gene mutations. Big ones would be like BRCA. If you have a BRCA mutation, you're at much higher risk of breast cancer.

Ryan Kingan: But then there's all this epigenetic stuff- 

Rian Gauvreau: Yeah ... 

Ryan Kingan: where- 

Rian Gauvreau: Yeah, the epigenome is pretty cool ... 

Ryan Kingan: is wild. Yeah. Yeah, [00:24:00] like how, how- 

Rian Gauvreau: Switching on and off factors and, yeah. 

Ryan Kingan: Yeah, how your environment can turn on and off genes and we can actually measure this now. So again, like instilling good behaviors or promoting good behaviors, you can actually see how lifestyle changes affect- Yeah, 

Rian Gauvreau: it just makes me wonder what breakers are thrown on my epigenome that I need to turn back on, right?

Ryan Kingan: Yeah. And then there's other genetic stuff like polygenic risk scores. 

Rian Gauvreau: That I haven't heard about. 

Ryan Kingan: It's a fairly new thing. It's been in the sort of research world for a while, but it's just kinda coming mainstream, there's some diseases out there that it's not a single gene that, that's gonna cause it or there could be a combination of 50 little genes that, that- Small variations

Ryan Kingan: certain combinations of those 50 genes can make you at a higher risk for disease X or cardiovascular disease. These polygenic risk scores, th- there's companies out there now from like Harvard, Boston, doing these tests where they can give you your monogenic risk, so they look for these big mutations that there's no [00:25:00] question they are gonna have an effect, and then they give you a polygenic risk score, which is like an added risk stratification, and say for coronary artery disease.

Ryan Kingan: He can use that plus the traditional stuff like their cholesterol, their LDL, LPA these newer, more dangerous cholesterols like LPA and really risk stratify people- 

Ryan Kingan: Instead of just looking at one biomarker, like just cholesterol. 

Rian Gauvreau: Yeah, in the world, I grew up in and went to university in, it was kinda like one mutation, one problem, right?

Rian Gauvreau: But I, I can see that it's now these combinations of mutations can result in these combinations of problems. And if... And so it's almost it would need to be almost like a, like you'd have to the, I imagine these companies would have to have, like, all these statistical analysis.

Rian Gauvreau: If you sum together these, different types of mutations, then it's gonna result in these increases in downstream risk factors. But that's really cool to learn about. I'm, I or it just seems like every time I turn around medicine has gotten more complex, but also y- more surprising just in [00:26:00] terms of, like, how they're able to better predict, what kind of things are gonna impact you in the long run.

Rian Gauvreau: And yeah, I don't know. I'm just always fascinated at just, like, how quickly things are evolving, and it seems like AI is really just gonna accelerate that. You read about things like AlphaFold, and, they're able to now come up with novel therapeutics in, weeks or months, what they used to take years or decades.

Rian Gauvreau: And and so yeah, I think it's gonna be really interesting to see how it all evolves. 

Ryan Kingan: Yeah. I think this idea of precision medicine personalized for you is gonna become more common. 

Rian Gauvreau: Yeah. 

Ryan Kingan: A- and there were hints of this even 10, 20 years ago with like pharmacokinetics to how people metabolize certain medications.

Rian Gauvreau: Yeah. 

Ryan Kingan: There's a few, there's a few medicines out there where i- if you give it to the wrong person, you couldn't, you could never predict. Sometimes it, it had some correlation with eth- ethnicity, but there are some medications out there if somebody didn't have a certain enzyme- ... or they just don't have the gene for it or they have a mutation there, if they take this certain medication, it can cause some horrendous side effects, or it just doesn't work.[00:27:00] 

Ryan Oakman: Wow. 

Ryan Kingan: And anyway, so those genes were known, and so sometimes we would test people for that gene if you suspected they might be in a high-risk group for that before giving them the medication. When you work as a doctor for a little bit, you ... I ... personally, I got humbled extremely quickly when you're prescribing a lot of medications to people because the textbooks will say it's gonna work this way, and these are the potential side effects.

Ryan Kingan: But when you talk to patients and you see them, nobody's body reads a textbook. Everyone reacts differently to different medications, and they seem to metabolize them differently. And sometimes people will get a side effect that you've never seen from that medication before. So there's a lot out there that we definitely don't understand, and y- I think it's heading more towards that direction of understanding what's going on in each person or personalizing things a bit more to them.

Rian Gauvreau: Yeah, and I think that really does, kinda reinforce just the core complexity that, you know, to being a doctor. I think, it's very easy for those of us that are exclusively patients [00:28:00] to think that a human is a human, and it's gonna just be kinda rinse and repeat.

Rian Gauvreau: But, I think a lot of people probably underappreciate just how challenging it is to read in a textbook that, this therapeutic will, will r- yield this result, and then actually see that totally break down in the real world. And every two, any two patients could be wildly different in terms of their result.

Ryan Kingan: Yeah. 

Rian Gauvreau: That would give me a lot of anxiety. 

Ryan Kingan: Yeah. Yeah, d- it can give a bit of anxiety to patients, too. 

Rian Gauvreau: Yeah. 

Ryan Kingan: Yeah, I try to be fairly honest with people and ... But sometimes when you tell them "We're gonna try this medication, but it could also kill you" Yeah. There's that. Yeah. But also it's like this is a bit of a trial and error.

Rian Gauvreau: Yeah. 

Ryan Kingan: Sometimes this medication works in some people. Psychiatric medications are a classic one. I usually tell people "It seems to work in 50% of people. I can't predict if it's gonna work with you, but if it doesn't, there's 10 other ones we can try, and usually we find one that works."

Rian Gauvreau: Yeah. 

Ryan Kingan: And, I don't think people find that very comforting . Yeah. No. It's not very precise. 

Rian Gauvreau: Th- that- that's an element I've actually [00:29:00] wondered about and not to drag the conversation on too long here, but I, I think that's something that I've detected is that, there is this default expectation with patients that when I walk in, I'm talking to the authority, and they're gonna have the answer for everything.

Rian Gauvreau: But, I think w- what must, be challenging for doctors is, very often you probably have to say "I don't know, and I don't know what the answer is, and you're gonna have to come on this journey with me." I- is- is that really challenging for you as a doctor? Do you get confronted by that all the time?

Rian Gauvreau: And what do you wish the patients knew that they maybe don't? 

Ryan Kingan: Yeah. It's, it is definitely a big challenge, and there's different styles of dealing with that. I know of some colleagues that are very big on never telling people that, about much uncertainty or trying to be very confident.

Rian Gauvreau: Yeah, project confidence. 

Ryan Kingan: Yeah, and I guess there's an argument there. It's not my style. Yeah. I try to convey the uncertainty, but in a reassuring way. Li- like with the medications. Yeah. I'll tell them "Yeah this works most of the time, but some people it doesn't. If it doesn't work, you let me [00:30:00] know in a week or two and we change it."

Ryan Kingan: And the rest of the uncertainty I try to s- I try to speak to people in terms of probabilities and not definitive statements. I hate definitive statements- ... in medicine, and l- like almost across the board. So I try not to say, "You have this disease," or, "This is the exact problem."

Ryan Kingan: "This is the treatment." Y- 'cause a lot of diseases are just a constellation of symptoms, and- you're not making an educated guess, but you're narrowing things down. 

Ryan Kingan: And it's hard to be 100% sure. So I try to be like, "Yeah it looks like it's most likely this thing."

Ryan Kingan: But then you back it up. If it's not, this is what we're gonna do. This is what I would expect to happen over the next two weeks, and if you notice that, you let me know and we go down that path." Yeah. But I think as long as you keep people informed and let them know what you're doing, it, it seems to work all right for me.

Rian Gauvreau: Yeah. 

Ryan Oakman: Yeah, you wanna be a little bit more specific than Dr. Google, where it's like, "It might just be a sprain, or it could be cancer."

Ryan Kingan: Yeah, 

Ryan Oakman: exactly. 

Rian Gauvreau: Yeah, there's no [00:31:00] middle ground with Dr. Google. Ryan, I think that's our time for today, but I wanted to say, a huge thanks on behalf of myself and the other Ryan, or it's all three Ryans here today.

Rian Gauvreau: But it's been lovely having you, and we would love to have you back for a future episode. 

Ryan Kingan: Thanks for having me. It was a blast. 

Rian Gauvreau: Thank you for listening to Healing Healthcare. I'm Ryan Gauvreau. Be sure to subscribe wherever you listen to your podcasts