David Klonoff: 0:14

Hello, I'm Dr David Klonoff. I'm an endocrinologist at Sutter Health in UC San Francisco. Welcome to Diabetes Technology Report. Today we have a very special guest. I've been trying to get him on our show for a long time and he's here today. I'm going to introduce our co-host, dr David Kerr, who will start the interview.

David Kerr: 0:34

Thanks, david, and welcome everyone. This is David Kerr. I'm speaking to you from, as usual, santa Barbara, california, and you're quite right, we have a superstar of technology on the program today, dr Daniel Kraft. Daniel, welcome, it's an honor to have you on board. Actually, we like to begin these conversations with kind of finding out what makes you tick. I mean, you were trained as a physician, I think internal medicine, oncology, that sort of thing but you've ended up being this superstar looking at the future and technology. How did this transformation come about?

Daniel Kraft: 1:10

Well, I would say I don't call myself a futurist, I'm more of a nowist and I just sort of always just follow my passion for well often lots of things. In medical school I went to Stanford. I liked everything. I had to pick a specialty. I liked ER. I was almost a surgeon. I ended up I loved kids and I loved medicine. So I ended up doing med peds and then, at Boston Children's and Mass General, came back and did hematology, oncology and bone marrow transplant.

Daniel Kraft: 1:35

But I think I was lucky, especially while at Stanford, I had the flexibility to follow my interests in aviation and space. I helped design missions to Mars with a bunch of AeroAstro folks and went to International Space University. I started learning digital health and built an early digital health startup. I kept abreast of other fields while I was doing stem cell biology etc. So I think my passions for cross-connecting and looking at different fields kept me sort of interested in sometimes, you know, outside the traditional physician scientist box. That's the path I took.

Daniel Kraft: 2:09

And then, back in 2009, I was asked to help, you know, the founding summer of something called Singularity University, which was framed around understanding where technology is heading, often on the exponential, and so I sort of came into this role of what's the future of health and medicine as driven by the accelerations of AI and wearables and digital health, to low cost genomics, to 3D printing, to chatbots, to drones, and that sort of took me on this sort of unexpected journey of how do we think about getting out of our usual silos as clinicians we often get you know, I'm an oncologist, you're an endocrinologist. How do we cross, fertilize and look at our fields and health and medicine writ large and see where technology is today and where it might be going, and how do we do things, maybe a bit differently and more collaboratively?

David Kerr: 2:51

So let's start with today. I mean, we are diabetes, we live and breathe diabetes. If you put your technology guru hat on and said, what do you see as being the hot topics, the things that excite you in the age of diabetes and metabolic health at the moment, will come to the future, in the future well, this is the moment.

Daniel Kraft: 3:13

The future is coming faster than we think. I mean even and it's not evenly distributed a famous quote. But obviously, as you guys know, we're we're entering this era of proactive, predictive, preventative care. Who's going to get diabetes, especially type one? Maybe optimizing their early, super early diagnosis of stage zero, preventing it from happening. The ability to start seeing, the ability to over the counter consumer cgms and all the implications on the artificial pancreas. The ability to maybe even leverage emerging stem cell biology and ips cells to cure diabetes in some cases. So that's already the art of the possible today and, I think, big picture.

Daniel Kraft: 3:49

You know we're so much in a sick care mode and get paid to treat disease, especially all the downstream implications of diabetes. I think the exciting elements today is to start to be a little more personalized and proactive, and these new tools are enabling us to often get lots of data. The challenge is connecting the dots between all this data to turn it to insights and information that you, as an endocrinologist, can use, that your patients and communities can get more engaged with. I love the whole. We are not waiting movement. The engaged community you're often involved with have helped push the field faster to meet many of the unmet needs of the patients and the researchers that can make a difference sooner.

David Klonoff: 4:23

Daniel, what do you think of the concept of precision medicine?

Daniel Kraft: 4:28

I mean more broadly. I mean we all know that most of our research is based on the average patient and no patient is average. And so we're now in this new era where, you know, through wearables and digital health, we can have much more precise data. The old model is, you know, intermittent reactive data. We collect the data in the clinic and the four walls. I think diabetes is probably the first area where you start.

Daniel Kraft: 4:48

We started to get continuous or intermittent seed, you know, blood sugars et cetera, eventually shared off and on paper or faxed in to you as a, as a clinician.

Daniel Kraft: 4:59

And I think big picture I mean especially with type two diabetes and never forms the type one.

Daniel Kraft: 5:03

It's multiple different diseases at its omics level which mean they might be mediated differently with exercise, diet, medications et cetera.

Daniel Kraft: 5:14

And now the ability to collect that data in real time and optimize and have a feedback loop can make the care not just always more precise but more tuned and shorten the cycles of optimization. So, and I think it's healthcare writ large, is getting much more multimodal. I mean we train as clinicians, we get our chem 20 and 40 in our basic vitals. Now we can have your digitome and look at your food intake with ai, and use your voice as a biomarker, even to predict blood sugar, uh and. And look at our multiple signals, from you know, from your microbiome, which certainly infects, impacts you know, metabolic health, to your base genome, to your digitome, and start to synthesize that this idea of the digital twin interfacing with agentic health and precision will hopefully give layers and interfaces, the user interface that's not just the same one size fits all app to really engage each of us as consumers, as patients, as clinicians, to make sense of all this massive data, to be more precise and proactive.

David Klonoff: 6:09

Well as we make sense of all this. Data treatment will be entered into the mix as well. What do you see as the role for physicians in the future?

Daniel Kraft: 6:18

That's a great question. I mean now with. I mean it's only two years this month, essentially, that GPT was launched to the world and I'm sure we've all been playing with it and patients are going to doctor GPT and you could probably feed in your CGM data and that would help program your CNGOS pumps, et cetera. I think the role of the clinician is going to be emerging and shifting. That begs the question of how do we choose medical students? How do we train them? How do we train our fellows? How do we engage the patient and the clinician in new ways, particularly when a lot of healthcare and some of diabetes care is arguably somewhat algorithmic can be much more continuous and optimized and AI-enabled. So I think we're going to see not just obviously physical care shifting to virtual, but more digital. We'll still need those relationships.

Daniel Kraft: 7:11

What the clinician is going to do will hopefully be maybe more synthesis and more optimizing for the individual, but using these new tools, the challenges. There's lots of tools out there. I have a platform called digitalhealth. If you search there under endocrinology or diabetes, there's lots of solutions. The challenge for, I'm sure, many of your clinicians and colleagues is how do you plug that into your workflow? How do you align the incentives to do that remote patient monitoring, to build that sort of digital empathy and feedback loops and cross connections, and how do you fit that into the payment models, the regulatory, the reimbursement and the sort of workflow of the clinician and the patient?

David Kerr: 7:51

and their families. Daniel, I mean, you clearly have all of this information and are enthusiastic and, as you said, clinicians the challenge is closing the gap between what is out there and what they know about and what they can implement. Just looking back, have you come across something that you thought at the time was probably a good idea, but it never got anywhere? Maybe it needs an opportunity to be resurrected. I'm just thinking if you've come across an area which could be potentially hugely valuable in the metabolic health but it's underexploited at the moment.

Daniel Kraft: 8:30

Well, we all know sort of Moore's law, the power of technology, which is why we have a supercomputer on our wrist or in our aura ring or whoop, you know.

Daniel Kraft: 8:41

Another area that's maybe beginning more appreciated is and it's becoming cheaper and more available is augmented and virtual and extended reality. Right, there's still CluG the Apple Vision Pro, expensive, heavy Oculus Quest as an example getting consumerized. Great for video games, but also with lots of applications for metabolic health, where you can look at an avatar of yourself and interact with others in a virtual clinical environment or show yourself future you if you're managing your weight and your medication and your diet in new ways. Great for interacting and doing medical education, simulating things. So that's an area maybe that's starting to come into the zeitgeist of both medical education and even therapy. I've been doing workouts during the pandemic, when the gyms were closed and something called Supernatural put on the headset, do amazing workouts in fabulous environments, interact with coaches, and that kept you engaged, gamifying health. So I think it's not being resurrected, but we're seeing some of these consumer type tools, whether it's virtual reality or even wearables, that are becoming consumer and shifting into the true health and medical angle as well.

David Kerr: 9:44

And just going back to the medical education, because we have the diabetes technology interns here today, and if you had advice for young people who were thinking about a career in health care, thinking about getting into medicine, are there certain skill sets that are now must-have, compared to perhaps when David Klonoff and I went to medical school, which was when dinosaurs still ruled the earth?

Daniel Kraft: 10:11

Well, I grew up in partly that era. I mean we had to study for the MCATs and do well in organic chemistry and physics, and is a good MCAT score and being good at organic chemistry going to make you a good clinician of the future? What? Who do we select and what skills should be? Sort of maybe part of the pre-med requirements, maybe it's a little bit of coding. Sort of maybe part of the pre-med requirements. Maybe it's a little bit of coding. Maybe it's selecting folks on better EQ, emotional intelligence and can you know, because those skills would be more important If you're going to be an interventionalist, are you good at hand-eye coordination, video games?

Daniel Kraft: 10:38

But I would encourage folks getting into medicine today, and even those folks who are well past our residencies and trainings, to have that beginner's mindset. You see a problem in the clinic or in the research space and go how might I solve that? Not with just the tools and technologies of today, but where are we going to be in two and five years? We're already at $100 genome. Soon we'll be at a $10 genome. How might you leverage that into proactive, early diabetes-related management?

Daniel Kraft: 11:04

The next generation wearables there's rumors out that the Apple Watch, let's say, in a year or two will have relative real-time blood pressure and real-time blood sugar. What is that going to mean? Maybe not for the full-on type 1 diabetic, but for metabolic health. Writ large all the impacts of GLP-1s, et cetera massive things. But I would challenge clinicians and medical students today have that beginner's mind. See a problem out there, keep a little note especially when you're as a medical student or intern or resident and see a problem and say how could I solve that in new ways? Maybe it's an app, maybe it's convergence of digital health and wearables, maybe it's leveraging AI and agents and then start building them and prototyping them or trying some of these emerging solutions you can find on digitalhealth or at my NextMed health conference, and start plugging them in early, before they're always approved and paid for.

David Klonoff: 11:49

Daniel, you organized a meeting called NextMed. Could you talk about that? Tell us what it is?

Daniel Kraft: 11:59

Yeah, back in 2011, I was at Singular University putting together some executive programs looking at the future on AI and robotics, reprinting, nanotech, et cetera. But everyone and most of them were not healthcare folks were interested in health and medicine, personally or otherwise, and thought most medical meetings I'll go to Ash and Asko, you go to American Diabetes Association meetings et cetera are very siloed around fields or sometimes technologies, medical device, pharma, et cetera. And I thought what happens if we bring together physicians, pharma payers, inventors, technologists, investors? And that became this platform called NextMedHealth, which we've been running at the Hotel Del Coronado every year. The next one will be March 30th to April 2nd.

Daniel Kraft: 12:34

Nextmedhealth has all the information and what's exciting is you get people sparked and they have sometimes no idea what's already here, right, what a wearable can do that your camera can pick up your vital signs. That voice is a biomarker for blood sugar. That, in a chat bot of today, can already do this, and what might it be doing next and how that might inform your clinical practice, your research program, what field you choose to go into, how you build the next generation startup or academic program. So the magic there has been connecting the dots between different fields again letting people see the cutting edge, like we had moderna there in 2015. We had AliveCore there in 2011. And that can inform your mindset and what you do in your own clinical space and your research space and personally for your own health and medicine. So that's NextMedHealth and I think it's a pretty unique not just gathering but community to sort of catalyze the future.

David Klonoff: 13:26

Daniel, I'm a principal investigator on many clinical trials. With the new technologies that are emerging, including remote visits and real-world evidence, what do you think is the future of clinical trials for new drugs and new devices? I think there's.

Daniel Kraft: 13:43

I mean huge implications. Number one picking the right, let's say new drug. Ai is enabling new forms of drug development. The Nobel Prize just went for new ways to discover proteins and folding, so hopefully find new drugs with AI to targets and sometimes multimodal targets and multimodal therapies. Patients for your trials through mobile apps, through social media, and they don't need to travel to the ivory tower as it used to be, and so you get a much more hopefully representative population.

Daniel Kraft: 14:13

Three we can use these new digitally enabled tools. You know your wearable devices can give you digital biomarkers, not just for your blood sugar but your activity, your food, your diet, so we can pull in new forms of information and pick new primary endpoints and secondary ones, and then the ability to crowdsource that information. I love the. You know the students on the call won't remember driving without Google Maps or Waze, but we can imagine driving out without Google Maps or Waze.

Daniel Kraft: 14:38

Today the future of clinical trials is hopefully much more available than anyone can become and often be a data donor in small ways or large ways, and then we build those better health maps, whether it's for you know, as we've seen with type one diabetes folks collating their data and sharing that and helping tune the algorithms. Platforms like MySugar, I think, did that. It was bought by Roche, I believe. So I think lots of opportunities there. A lot of it means we need to re-educate the clinicians, the clinical trialists, and align incentives to make that happen, including some of the privacy laws and technologies to enable people to better share their data.

David Kerr: 15:13

Daniel, just a kind of philosophical question. This is all I mean. So exciting, but if you're the person with diabetes and you're listening to this and you're looking at the future, should you be apprehensive, saying, my God, I have a lot to learn. Learn this is going to consume a lot of time and effort and dollars on my part. Or is the future going to be automate, automate, automate and reduce the burden? How do you see this panning out?

Daniel Kraft: 15:38

Well, healthcare and medicine is often still super confusing.

Daniel Kraft: 15:42

The interfaces are terrible.

Daniel Kraft: 15:43

We're still using fax machines and DVDs to transmit information, for God's sakes.

Daniel Kraft: 15:47

But I think what's exciting about this new AI and sort of avatar-enabled era is that we're quickly moving into the era of agentic health, where it's not generative AI, it's generative health and it will know me and the user interface will be stuck, you know, will match my age, culture, language, education level, incentives, and so if I'm a new diabetic or a parent of one, or a clinician writ large, I can hopefully have these agents help collect that information and present it to me in a way that's super useful and can unfragment things and simplify elements and then again tune the right selection of a digital tool or a wearable or the drug that matches and maybe again let you opt into a clinical trial. So it can be super confusing. But I think we have some new tools to simplify the user interfaces and make them much more highly personalized and then effective, because engagement the engaged, empowered consumer and patient and clinician is much more likely to have an impact across prevention, diagnostics and therapy and patient and clinician is much more likely to have an impact across prevention, diagnostics and therapy.

David Klonoff: 16:49

Daniel, as we get into digital twins and agentic health, will there be such a thing as a doctor visit.

Daniel Kraft: 16:51

What will it be like? Well, sure, we'll still need some laying on to the hands. I think the sort of digital, not just physical or virtual. But the future of a physical or virtual exam might not just be us on a Zoom right, we may be putting our augmented reality glasses, the meta glasses. Over the next couple of years are going to blend augmented and virtual and extended reality. It'll feel like we're in the same room. We could all, instead of being on the flat screen, sort of be in our virtual environment doing this podcast recording. So we'll still need in-person Hospitals will probably be much more higher acuity.

Daniel Kraft: 17:19

We're moving this hospital to home movement, where a lot of folks will be admitted to home for their maybe not DKA, but maybe for their pneumonia and antibiotics. Remote patient monitoring tools are again still quite fragmented. The challenge often isn't the new technology but connecting the dots so we don't just create more data but we have new insights and knowledge that translate to the bedside or, increasingly, the website much more quickly, which back to medical education. How do we train physicians and clinicians of all sorts to not just have good bedside manner but good website manner, and how do their agents start to intervene and have representations that everyone would like to interface with.

David Klonoff: 17:57

Well, you've provided several new terms. I'm going to steal some of these, but I will give you credit. This is great. Daniel, I want to thank you for being a guest today on Diabetes Technology Report. I feel like we're looking 10 years into the future here and we will invite you back. I hope people listening will attend NextMed if they want to hear more of this type of topic. So Diabetes Technology Report is available on Apple, spotify and the Diabetes Technology Society website. Daniel, is there anything else you want to say before we end the interview?

Daniel Kraft: 18:33

Yeah, Thanks so much for having me. I love the endocrinology and diabetes space because it has pushed a lot of technologies and innovation that cross over to many fields and I would say for all of us, let's not wait for this 10-year future. A lot of what I talked about is essentially already here. If you go to digitalhealth that platform I've been building and search for diabetes or endocrinology or metabolic health, you'll find a lot of things that are already out there. You could start plugging them into your own practice or meet your unmet need. It could be a tools that might help your practice or your own clinical and health pathways. So I think we're all needing not to be futurists but to sort of bring it a bit faster and not wait for folks to deliver it fully packaged, because it won't work that way. So let's all collaborate to build that future.

David Klonoff: 19:16

You called yourself a nowist at the beginning, and this is in line with us looking into nowism. So, daniel, thank you. Uh, on behalf of myself and dr david kerr, thank you, have a good day and, uh, we'll see you at our next diabetes technology report. Bye-bye, thank you.