Every person grapples with the same question multiple times a year: What do I do when I’m not well?
Dr. Shantanu Nundy said realizing how big that question was and how many people that touched inspired the Human Diagnosis Project (Human Dx) – an online, open medical resource that leverages the collective insights of physicians around the country to improve accuracy of diagnoses and ultimately improve care.
Physicians are often alone in the moment with a patient when making important care decisions, Dr. Nundy said. Human Dx means they don’t have to be.
When Dr. Nundy uses the resource in his safety-net clinic, it can serve as an electronic consultation with specialists to help patients who may not otherwise have access to specialty care. He envisions that the resource can support many physicians and underserved patients.
This proposed solution of a critical problem was one reason why Human Dx was selected as a semi-finalist for 100&Change, a global competition for a $100 million grant from The John D. and Catherine T. MacArthur Foundation.
ABIM Vice President of Medical Research Dr. Lorna Lynn recently spoke with Dr. Nundy about the Human Diagnosis project and its potential to inspire learning and collaboration across internal medicine and the broader medical community.
Dr. Lynn: Hi. I'm Lorna Lynn. I'm an Internist and the Vice President of Medical Education Research at the American Board of Internal Medicine. You might know us as ABIM. I'm here with Dr. Shantanu Nundy, an internal medicine physician who's trying to solve some big problems in healthcare with the Human Diagnosis Project. Welcome, Shantanu.
Dr. Nundy: Thank for having me here, Lorna. I look forward to sharing more about the work we're doing.
Dr. Lynn: So, let's start by talking about the genesis of the Human Diagnosis Project. When did you first realize that we need a better way to diagnose patients' conditions?
Dr. Nundy: Actually, it was in medical school at Johns Hopkins, you know, when you're a pre-clinical student, they always make us meet the nicest patient in the hospital to practice our history and physical. And so, there I was, a second-year medical student with this 30-year-old woman, who was stationed in the Marines, when she started having these recurrent nightly fevers. And by the time I met her, she'd been suffering from these debilitating fevers for well over a year and had seen over 100 physicians, starting from Southeast Asia to Manila to Germany to Walter Reed and finally to Hopkins and was actually about to be discharged, yet again, without a diagnosis. And so, she was you know, a very sweet woman, but definitely feeling pretty down, when in bound this retired infectious disease doctor. And he didn't see the chart, he did'’t talk to the team, he came right in and started asking her some questions and, you know, right in front of my eyes diagnosed her. And said, “you're going to get better,” and she did.
Dr. Lynn: That's amazing.
Dr. Nundy: Yeah. And so, being, I think and that formative stage of my career, yeah, I had thought a lot about what I saw there and realized that you know, there should be a better way that, you know, somewhere somebody knew what to do for this woman, yet she had suffered for well over a year, seen hundreds of doctors, you know, racked up, you know, large healthcare bills. And in many respects, she was one of the lucky ones. And so, I'm starting to think, well there's got to be a way that we can work together. There's got to be a way that doctors can collaborate, so we can bring our cumulative experiences and insights to bear for every single patient.
Dr. Lynn: So, I guess you didn't want to have people depend on the luck of the draw and having some very experienced, very wise, senior clinician happen to walk into the room. How did you start to lay the groundwork then, for the Human Diagnosis Project?
Dr. Nundy: Really the beginning was realizing that this patient, this problem is actually nearly universal. So, I started meeting people. You know, the project's founder is someone who was born with a congenital heart condition and had to get open-heart surgery when he was a young man. The co-founder, who's our lead engineer, his mom suffered from pretty debilitating rheumatoid arthritis most of her life and they were relatively low-income folks living in California. And so, I think as the team sort of started to come together, we realized that we each have these stories. Every person on earth, multiple times a year, grapples with this question of, what do I do when I'm not well? And I think that's really – realizing how big that question was and how many people that touched, was really what motivated us to start the Human Diagnosis Project.
Dr. Lynn: So, I think anyone who is a physician knows that making a correct diagnosis is at the core of what we do. Right now, that happens when an individual physician recognizes something that he or she has seen in the past or maybe consulted a few colleagues or maybe looked something up on their favorite internet resource. It sounds to me like your tour could shift how we diagnose patients into something completely different. How do you think this would work for physicians?
Dr. Nundy: Yeah. Well, I can tell you in a minute, how I use it in my practice, but I think conceptually you’re exactly right. I think physicians, we're alone when we're making these really important decisions for our patients. Right, we're just in the room, just us and the patient. You know, we have a whole team of folks that help us, but not at that moment. And that computer that's sitting there in the room, it's just for us to record what we're doing after the fact. It's not helping us in that moment do the best we can to make that really major decision around diagnosis. And so, I think conceptually, the idea is how do we access the collective insights and experiences of physicians everywhere and bring that to bear with that individual physician, right? So if you think about how we all trained and you think about rounding as an example, right? What was that, right? That's several of us hunkering around the room you know, looking at the patient scratching our heads, stepping outside and saying, “Hey, what do we think's the answer here?” And of course, there's a senior physician, there's a junior physician, but we each have different perspectives and insights to bear on the problem. And so, that's really what we’re enabling, but just through technology. So, the way it works today is, in my safety net clinic, I'll see a patient&mdah;most of my patients are uninsured&mdah;and I will often find myself with a question. I step out of the room, I post the basic information on my question to using the Human Diagnosis Project software tool. And over the course of the next day, multiple physicians around the country, around the world, weigh in on that case and then we combine their insights together into a single collective prospective using things like natural language understanding and other sort of computer science tools to synthesize all of those different insights into a single collective answer that can help me answer that question for my patient.
Dr. Lynn: So this sounds like something that could be used by someone at an academic medical center here in the United States, but also it sounds like there's potential to help anyone anywhere. Can you share some of the ideas for how the Human Diagnosis Project could help even the most vulnerable patients?
Dr. Nundy: Yeah absolutely. I think before I do, I think it's important to kind of frame the challenge, right? So, just thinking about the United States today, there's over 50 million Americans who are underserved. That's nearly one in six. Worldwide that's one billion people. And what's remarkable here in the United States at least, as well as 50-odd million people, we do have the safety net. The safety net is the largest health system in the country actually. Most people don’t realize that. And it's a patchwork set of public hospitals, free clinics and community centers that take care of these folks. And actually, they do a remarkable job at providing primary care at an affordable price, you know, at low cost or free, like most of my patients, to the underserved. But really where the rubber hits the road is when those patients need a specialist, which is not uncommon. You know, the way medicine's gotten more complex with client diseases, this is not an uncommon condition, but it's not something that when we designed the safety net we really built for. So, there's a large body of research showing that actually by bringing the specialist into primary care using technologies, so using electronic consultation, we can actually solve that patient's specialty care problem 25 to 40 percent of the time, right. So, by bringing the specialist kind of digitally into the primary care clinic, we can do that. And what that does is, obviously solve that patient's problem, but more broadly, it actually reduces wait times for all the other patients who do need to actually have a visit or have a procedure or something that requires a specialist. The problem is that solution only exists in various pockets around the country, and there are generally large academic teaching hospitals in urban centers, but what about the rest of the 50 million people who are underserved? And so, our idea is really simple. It's how do we create a national system for electronic consultations, so that any underserved person in the country can have access to the same level of specialty care expertise that those of us who are so fortunate to have healthcare have.
Dr. Lynn: So, how do you get these specialists involved in the Human Diagnosis Project? I can see you know, as a general internist, I would want to sign on and ask my questions. But what's the incentive for the specialist to join?
Dr. Nundy: Yeah, that's a great question, and I think it really harkens back to what it means to be a physician, right. If you ask most people of my generation and prior generations, “why did you become a doctor, what keeps it going?“ It's helping patients.
Dr. Lynn: Right.
Dr. Nundy: It really is. And the next thing they'll say, is actually helping colleagues. It's the collegiality of being in the room and hunkering down thinking about a patient problem. And the last one, is actually mastery. The idea that I want to continue to get better. I want to be like those master clinicians that helped train us. Someone once synthesized that for me really nicely, they said, “It's the three M's. It's meaningful, it's mastery, and it's membership.” That's what really is the intrinsic motivator. And I think we kind of accidentally and sometimes not accidentally, tapped into that really core set of values that every person has and that's what's helped us grow into the largest open medical project in the world.
Dr. Lynn: Wow. I know you're working with several different institutions and organizations, including ABIM, and you're exploring potential opportunities for the tool. Can you tell us a little about how you connected with ABIM?
Dr. Nundy: Yeah, absolutely. I mean, when we started you know, the project, when we started to focus on diagnosis, you know, I think as internists we often think of ourselves as the doctor's doctor, right? Or the diagnosticians in medicine. So, it was very natural for us and, of course, for me as a board certified internist, to want to bring my community to the project first. And so, as we began to grow and as we began to build ourselves kind of organically, bottom-up in terms of a group of interns who really cared deeply about this problem, you know, I think the first opportunity we had to sit down with the ABIM, you know, the organization that's really the largest medical board and represents our specialty, you know, we're really excited to do so and we're fortunate to have their ear very early on in our development.
Dr. Lynn: Well, like you've said, I think all physicians should have the goal of providing good patient care and improving that care in our daily work. It's clearly a transformative time here at ABIM. We are trying to engage 200,000 internists and specialists to ensure that we recognize the important work that they do every day and to see how they are continuing their own learning and providing high quality care. Do you see the Human Diagnosis Project as a learning tool that we could link with?
Dr. Nundy: Absolutely. I mean, if I just go back to the simple question of how do we all train, right? If we look back, where did we learn the most, right? What were those formative experiences? I think most of us would say, it was rounding. It was the case conference, right. It was in the service of a patient in front of us. We not only provided that care, but we actually took the moment to reflect on that and we also brought to bear different perspectives on how we could serve that patient and future similar patients better, right? To me, that's the core experience that made us who we are today and that's really the experience that the Human Diagnosis Project enables, but just through technology. So sometimes I joke of it, as the tumor board for every doctor. Yeah, my wife's an oncologist and they don't get to choose who they present, and who they don't. Every week, Tuesday night, she sits down and she sits in a room with her colleagues, and discusses every patient. And sometimes it makes that patient's care better, but often it makes the next patient's care better, to get those different perspectives and to reflect on the decisions she's making and to learn from each other and from the evidence base around. How do we do that better?
Dr. Lynn: You know, I bet everybody listening to this is thinking right now about one or two master clinicians that they work to in their training. I know that I am. And I'm remembering some of the lessons that they learned and what you’re talking about is getting me really very excited and interested in the potential here. I know that many others have also recognized the potential for your project. I want to congratulate you and the Human Diagnosis Project Team. I know you've been named as semi-finalist for the MacArthur Foundation's 100 & Change Competition. Could you talk a little bit about this opportunity?
Dr. Nundy: Absolutely. And I think first of all, I'd like to say you know, we were named, you know, we are, I think the medical community at large. You know, we think of ourselves in an open project, we're lucky to have over 5,000 physicians in 60 countries and this is really a tremendous success for all of us and for all of our partners, which includes the ABIM. The MacArthur Foundation 100 & Change Competition is really unique. So, it's the largest open sort of call-for-proposals ever. It's a single award for $100 million.
Dr. Lynn: A hundred million?
Dr. Nundy: A million dollars to solve a critical problem of our time. And if you look at prior competitions, the largest to date was something in the $10 to 2 million range. So, it is something in the philanthropic world that, I think, is being followed and tracked. And this is the first time they've done it. And it's not around health care only. It was open to solve any critical problems, so environment, education, social justice, and so we really feel honored. They had over 7,000 registrants. They had over a couple thousand applications and having had a chance to see the top 200 organizations, I think these are all really compelling ideas for how we solve a wide range of challenges that we face today, both here in the United States and abroad. And so, first of all, we feel incredibly honored and we're the only medical project in the semi-finalists. There's eight semi-finalists right now and we're the only project that actually is for a solution here in the United States, the rest are in largely developing countries. And the process from here is we're going to go from eight to later this summer get to three to five finalists and then in December they'll make a final decision. So, yeah we feel really honored and I think for us, the way we think about our work in relation to those, is I think number one, is we think that this is a problem that impacts every single person on Earth, right? If you look at most projects, they only serve a specific population of people, but I think every person — rich, poor, this disease, that disease, this socioeconomic set, this border, that border — this question of what are you doing when you're not well affects every single person. I think, number two, I think it's some of them we're already doing. Today physicians through the Human Diagnosis Project are helping me with my patients and my safety net clinic and many other places around the country and around the world, and so, this is something that's already happening and this is just a way to accelerate it. And finally, it's not just something that's short term. I think it's an enduring solution in our minds, because as physicians are collaborating on these cases, the system is learning so that it can continue to help more patients in the future. And so, we think it's a solution for everyone, for something that's really important and that can, you know, hopefully outlive me and be there for my daughters and so on. So, yeah, really honored to be a part of it.
Dr. Lynn: Well, it sounds like you have a very exciting several months ahead of you and we look forward to hearing more about it. Is there a web address or some point in fact, you'd like to share, so that our listeners can find out more?
Dr. Nundy: Absolutely. I mean, this is a project for us, so the website is www.humandx.org and we’d love for more ABIM diplomates to join and start contributing their insights and it’s also an app on the App Store, so for those of us who are iPhone, iPad users, you can just go to the App Store and download Human Dx and jump right in.
Dr. Lynn: That's terrific. Well, I really appreciate you taking the time to speak with me today, Shantanu. It's been terrific to have learned about the Human Diagnosis Project and to think about the latest ways that we can work together to better serve our patients.
Dr. Nundy: Thank you.
Dr. Nundy is a board certified internist and Director of Medicine for the Human Diagnosis Project. In addition to working on behalf of the Project, he practices primary care at Mary's Center, a safety net clinic for low-income and uninsured individuals in Washington D.C.
Dr. Lynn, a board certified internist, is Vice President of Medical Education Research at the American Board of Internal Medicine. She has leadership responsibility in providing clinical oversight for ABIM’s evolving approaches to assessment. Dr. Lynn has served on committees of the National Quality Forum and the National Academy of Medicine addressing care coordination, interprofessional education, conflicts of interest, and clinician well-being and resilience. She is a member of the Board of Directors for the American Board of Family Medicine.