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About the Guest:

Steven Charlap, MD, MBA
Founder and CEO at SOAP

Steven Charlap’s healthcare career spans over 30 years and has taken him in several directions.

Trained as a surgeon, and armed with an MBA, he was initially recruited to become Director of Corporate Development for T-Cell Sciences (TCS), a publicly traded biotechnology company, at which he oversaw technology licensing and pharmaceutical partnerships. In 1989, Steven left TCS to co-found, as CEO and Chief Medical Officer, HealthDrive Corporation, the largest U.S. provider of medical and dental services to extended care facilities. Over twenty years, a two-time Inc. 500 company, HealthDrive served more than five million patients in some 1,500 facilities across 13 states. At HealthDrive, he built the first, mobile, productivity-enhancing, multi-specialty electronic medical record system, still in use today. In 2000, he published Making Sense of Nursing Homes — A Guide for Families.

During his HealthDrive tenure, Steven witnessed how the healthcare industry’s non-focus on preventing chronic diseases often results in costly, invasive, and reactive medical treatment for patients. In response, he developed the concept of MDPrevent—a multi-disciplinary, integrated primary care and preventive medicine practice focused on helping patients make lasting lifestyle changes to achieve exceptional lives.

While a Stanford DCI Fellow, Dr. Charlap focused on genetics, genomics, and preventive medicine as well as consumer behavior, problem-solving, and health care and media technology.

He also consulted with dozens of genetics/genomics and computer science experts both at Stanford and across the country, and mentored over two-hundred entrepreneurs. In 2017, he received a Stanford SPADA grant to further develop VALIDATE, Virtual Agent Linked Intelligent Disease Assessment Tool Engine.

He then spent two years as a Visiting Scientist at Harvard before founding SOAP Health, a digital health care startup applying AI-driven Perfect Medical Assistants™ to improve comprehensive health care data collection, risk assessment, diagnosis analysis, and documenting for various applications, e.g. cancer and heart disease predisposition assessment.

Steven Charlap received a BA from Yeshiva University, where he majored and minored in Speech & Drama and Film, respectively, an MD from New York University School of Medicine, trained as a surgeon, and an MBA from Harvard Business School, where he majored in entrepreneurship. He has published a book and in a national magazine and loves to mentor and give talks.

About the Episode:

For this week’s episode of Entrepreneur Rx, I had the pleasure of speaking with Steven Charlap, founder and CEO of SOAP Health. SOAP, which stands for Subjective Objective Assessment Plan, focuses on reducing misdiagnosis and improving early disease detection.

Steven and I start off by discussing how the loss of his older brother to a misdiagnosed cancer diagnosis lead him down a non-traditional path in medicine and his obsession to save a million lives in his brother’s memory. We then shift to how Steven has been able to use SOAP’s AI-powered digital human called Perfect Medical interviewer to eradicate cognitive biases and misdiagnoses in physicians, and then he explains the research and development of the AI tool and how it works with existing EHRs.

Guided by his mission to solve misdiagnoses, Steven has been able to save the lives of millions of people he’ll never meet, through SOAP and its Perfect Medical Interviewer, their AI-powered conversational digital human.

Entrepreneur Rx Episode 53:

Entrepreneur Rx_Steven Charlap: Audio automatically transcribed by Sonix

Entrepreneur Rx_Steven Charlap: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

John Shufeldt:
Hello everybody, and welcome to another edition of Entrepreneur Rx, where we help healthcare professionals own their future.

John Shufeldt:
Hey everybody! Welcome back to Entrepreneur Rx. Today, I'm in the great pleasure of talking with Dr. Steven Charlap, whose whole career spans over 30 years and has taken him, and we're going to go through these, in a variety of directions. Steve is trained as a surgeon. He has an MBA, post-MBA, he did the Director of Corporate Development for T-Cell Sciences, which is a publicly traded biotechnology company where he oversaw technology, licensing, and pharmaceutical partnerships. And then in '89, he left to found his own company and became CEO and chief medical officer of Health Drive, which was the nation's largest provider of medical and dental services to extended care facilities, which is super remarkable. Today, Steve is working on a project called SOAP that we'll get into because I have a real interest in A.I. and it's what, he and I were just talking about before we started. So, Steven, welcome.

Steven Charlap:
Thank you, glad to be here.

John Shufeldt:
You have a super long introduction that I skipped about two-thirds of because I want to go through it all as opposed to me just reading it. So give us a little bit of background about how you ended up even just going to medical school. As I recall, you were a drama undergrad major.

Steven Charlap:
Yeah, I was a speech and drama major with basically a film minor, always attracted to the creative sides of industry. Unfortunately, when I was 17 years old, my high school guidance counselor talked me out of going into advertising and architecture by giving me some BS excuses why they weren't a fit for me. When I got to college, I fell in with the wrong crowd, all the guys who wanted to become doctors, and, but I wanted to not go through college as for the purpose of getting into medical school. So I decided to take a different path and keep things interesting. Taking a lot of speech courses and film courses and really made college much more meaningful for me.

John Shufeldt:
So you went to undergrad at Yeshiva University?

Steven Charlap:
Yeah, Yeshiva University in Manhattan.

John Shufeldt:
In Manhattan, and then where? And then you go right into medical school after that?

Steven Charlap:
Yes, then I went to NYU for medical school. Then I did a surgical residency at Beth Israel, and then I went to Harvard for business school. And then I went to work for a publicly traded biotech company. I spent a year and a half there, got a big deal done with SmithKline Beecham, and then I started my own company.

John Shufeldt:
Wow, Did you? Was that so, was that straight through? Residency, MBA, and then biotech company?

Steven Charlap:
Yep, I did work for another company, a publicly traded small company between first and second-year business school, and part of the second year. I was pretty poor. At the time, I had to beg the business school to give me a scholarship because I literally no longer had a penny to my name, and I was married with a very young baby. So I pleaded with them and they eventually gave me a scholarship.

John Shufeldt:
Now, did you finish a surgical residency?

Steven Charlap:
I did two years, which is what I knew I needed in order to get a license in most states in the United States, and I've gotten licenses in multiple states. I'm currently licensed in Florida.

John Shufeldt:
Wow, did you, I mean, when you were doing it, did you think, you know, this surgical gig is cool, but it's probably not where I want to spend my life? Was that the construct that you went through or were you for a while dead set on being a surgeon?

Steven Charlap:
You know, I went into surgery because I thought it would be more exciting, but when I found out, it was essentially, it was like a trade, no different than a building handyman, not a handyman, but I'm saying somebody who does a particular trade and construction. It's more about the hands than it is about the thinking, at least that's how I perceive surgery. But what happened that actually was the defining moment and changing trajectory, because I really didn't want to be a surgeon or a doctor, believe it or not, I like helping people, but I found it very limiting to be one-on-one, although I did have patients write letters to the dean of my medical school saying how good I was one-on-one, but I didn't so much enjoy that, I wanted to do something that was more meaningful and more impactful, but what happened was that I went out to dinner with my wife during my first year of residency, and I met a guy who was ranked right below me in college who ended up going to Harvard Business School. And I remember thinking at the time I was going to medical school, he was going to business school, that there was something wrong with him for going to business school when he was smart enough to go to medical school. And so I bumped, I saw him in a restaurant, I went up to him and I said, How'd you like business school? And he said it was great, and I was like, What? I've never gone to school and ever said it was great. So I went back to my wife, I said This guy said, Business school is great. That's it, I'm leaving medicine, I'm going to business school, and that was the point of no return.

John Shufeldt:
That's classic, you know, it's kind of funny on your LinkedIn page it said, To save the lives of millions of people I will never meet. That may be one of the best missions I've ever seen on anybody's LinkedIn page, which kind of speaks to what you're just talking about. You want to make a difference for more than one person at a time.

Steven Charlap:
Yeah, look, I love mentoring and I've mentored over 400 companies and anybody who contacts me on LinkedIn and wants to be helped with something they're working on. Other than that, they're trying to sell me. Even though they're trying to sell me, I always connect with them, and then I say, No, thank you. I think it's the humanistic thing to do. They're just trying to make a living, but if they need help, they have a question, they want me to help answer it. I'm always willing to help answer something, particularly if it's business related or medically related. But for me, I feel that my time on Earth needs, at this point in my life, to be dedicated to helping as many people as possible. I'm driven by a mission, I lost an older brother who I loved very dearly. I shared a room with him growing up in a three-bedroom in Brooklyn and a walk-up. He was the brother that spend the most time with me. I have an older brother, and older brother as well, but this was the brother that I grew up with, and he passed away from a misdiagnosed cancer. The cancer was diagnosed way too late despite an extensive family history, and my mission is to save a million lives in his memory. And unfortunately, several weeks ago, a very dear friend lost her life to a misdiagnosed cancer. And so I've dedicated now my efforts not only to my brother but to this very dear friend. And I almost lost my life to a misdiagnosed heart condition, and so misdiagnosis is something that's really gotten to the very core of me. So I'm obsessed now with solving this, and people don't understand why I work seven days a week, don't take any compensation, because I'm on a mission. And it is the very essence of why I live now, is to realize success at that mission, even though I've got grandchildren coming all the time and I want to spend time with them, and I love my wife, I love spending time, but anyway, yeah, so that's what I'm all about at the moment.

John Shufeldt:
So I want to talk a lot about what you're doing to save a million lives. But let's talk about this intervening the building block years. So you went for the publicly traded companies, you made a deal with SmithKline at the time. And then what was the company that you found that it became CEO of?

Steven Charlap:
Yeah, it was called Health Drive, and we became the largest provider of medical and dental services to extended care facilities in the United States. And while we were there, while I was there, we also developed what we believe to be the world's first mobile multi-specialty electronic health record system. So this was a system using tablets that our doctors took with them into nursing homes, and we were able to document everything electronically and digitally and then transmitted back to our office server, which then transmitted the medical note to the nursing home fax machine. So we were just way ahead of our time. This goes back 19, 20 years ago at this point, building something so sophisticated, which actually resulted in a bidding war when we sold out, and allowed me to make enough money that I never needed to work again, and I actually tried retiring for one year, It was the worst year of my life, so anyway, not going to happen again.

John Shufeldt:
Interesting.

Steven Charlap:
I actually became depressed.

John Shufeldt:
You and I may be cut from the same cloth on that one. Okay, so what year was this when you did the EHR? So that's 2000, 2001?

Steven Charlap:
Yeah, I'd say around that time.

John Shufeldt:
Because I definitely heard of Health Drive. I didn't know it was yours and I didn't know you had sophisticated EHR back then. The urgent cares that I started, we started using next-gen about 2005 I think, and we were early, so you were way early, particularly on the mobile front. That's pretty genius.

Steven Charlap:
Yeah, well, it was a necessity because trying to deliver records to the doctors every day physically became exhausting and very expensive, and unsustainable. And so, you know, the old phrase, Necessity is the mother of invention. We felt the need to build something that could solve that problem, and we had a very good tech team. And we actually used people in Belarus to supplement our in-house tech team, and it worked out very well, and we built something quite amazing. I think they're still using the same product today, 20 years later, because it was so far ahead of its time, but of course, they've made major improvements to it. But it was really pretty ingenious what our tech team put together.

John Shufeldt:
So you had a group of basically hospitalists and dentists that went around to all these long-term care facilities and saw patients. So you were a really early hospitalist company, it sounds like.

Steven Charlap:
Well, actually, we had some primary care, but we were mostly dentists, dental hygienists, optometrists, opticians, podiatrists, podiatrists, audiologists.

John Shufeldt:
Wow, yeah, that's, that was way out of your time. So you sold out, you sold Health Drive, and then what?

Steven Charlap:
So I heard that the Affordable Care Act was coming out and I heard that it was going to change the paradigm in medicine with a greater focus on prevention, and so I decided to open up a primary prevention medical center that was based on insurance. Little did I know that there was more lip service paid to prevention than actual reimbursement, and I spent $2 million dollars of my money and a friend's money putting together this state of the Art Prevention Medical Center that included nutritionist, exercise physiologist, yoga instructor, psychologist, Ph.D. in health education, nurse practitioners, myself teaching kitchen classroom, gymnasium, the whole kit, and caboodle. And it was unbelievable what kind of clinical results we were accomplishing, but there was no meaningful reimbursement to cover our efforts. And then my brother got sick and I spent a lot of time by his bedside till he passed so that business was doomed from two perspectives. In fact, I published an article in The Atlantic in January 2014. All the challenges we faced in putting forth a preventive primary prevention model in the US, including local doctor hurdles and the hospital system hurdles, if you could read it, it published in The Atlantic January 2014, it was, I got a lot of notoriety from that article.

John Shufeldt:
Interesting, so how long was that clinic open for? Was it?

Steven Charlap:
Three years.

John Shufeldt:
Three years? Interesting, and you're able to track some, basically, basic improvements of health of the people you interacted with?

Steven Charlap:
100-pound weight gains, multiple patients lowering insulin, the hypertension medications, statins, people just feeling much better about themselves, we were doing, I literally think, some miracle work, but the long and short of it, for example, Medicare was reimbursing for something called intensive behavioral therapy for obesity for a 15-minute session with a patient, which typically a physician would get about $75, they were reimbursing $25. It was costing me $50 to provide the service, so I was the only idiot in the country that was providing that service at a relatively high level, generated about 35,000 in revenue and I got audited, and initially, they wanted all the money back and I said Why? And they were wrong on multiple fronts, and they eventually they left me alone. But I said one idiot in this country actually accepts 25 dollars for 15 minutes and they actually want to take the money back even though they ended up not. I said this is just a broken system and I'm not going to fix it in this particular effort.

John Shufeldt:
Wow, okay, so when did you go to Stanford?

Steven Charlap:
So I went to Stanford in 2015. I was accepted into a program called the Distinguished Careers Institute, started by a guy named Phil Pizzo, who used to be the dean of the medical school. It was a program for people who had had very successful careers. So the number seven guy at Apple was there and a Harvard JD partner from a big firm was there and somebody from the Levi Strauss fortune was there. So a lot of very successful people, 20 people were accepted into the program. And that program allowed me to take any course I wanted at Stanford, which is why I applied. So I took a lot of genomics because it turns out my brother had a genetic mutation that was responsible for his cancers. And so I was really obsessed with trying to understand the genetic predisposition to disease because in my preventative medicine clinic, I started giving lectures all over Florida, and one of the big themes was genetics is secondary to lifestyle. And because of my brother's genetic mutation, I said, you know, maybe I don't know as much about genetics as I should, and my thing now is, genetics loads the gun and lifestyle pulls the trigger, but sometimes genetics loads the gun and pulls the trigger even without the lifestyle. And so I spent a year studying and then I spent the second year at Stanford involved with a research project that looked at whether Stanford doctors know how to do risk assessments, particularly around hereditary issues, and the answer was known we published that. And the third year, Stanford gave me a grant to actually build one of the early prototypes of what we've built at SOAP. And then I left Stanford and spent two years at Harvard as a visiting scientist, continuing to do, I did a small pilot at Harvard of an early prototype, and then I started the company in September 2019.

John Shufeldt:
I love, so I want to get in, I want to talk about SOAP, because it's such, it's the little stuff I love. But let's talk about the year when you tried to retire. What did you do during that year? I mean, did you go out and play golf seven days a week, did you sit on the beach? What occupied your time and your thoughts?

Steven Charlap:
I actually played the stock market and did exceptionally well, made over $700,000 dollars playing the market with my older brother, but honestly, it was the most intellectually dissatisfying, stress-inducing year of my life. I actually had no reason to get out of bed in the morning, just laying in bed with a laptop on my lap and, and played the stock market and was horrible. And yeah, most people would say if you make 700,000 dollars in a year, basically betting on something, that's a pretty good year. For me, it was the worst year in my life.

John Shufeldt:
How quickly, how soon into that year did you know this was going south? In other words, how soon? Joe okay, this is cool, maybe it's not cool at all, but it's not for me.

Steven Charlap:
Very early on and my wife started becoming very concerned that all I do is follow the stock market all day and all night. And, you know, and at the end of the day, what do I really know about the stock market? Nothing. I mean, the reason I made so much money, because the market went up that year. Everything I touched, literally everything I touched, I made money on. And I realized that when it was going down, I had like a little pit of my stomach and when it was going up, I didn't really feel any satisfaction because I knew it was just luck. I always say it's better to be lucky than smart, but at the end of the day, I need both intellectual stimulation, I need social interaction, I need and want to impact other people's lives, not just self-serve.

John Shufeldt:
Okay, so, all right, so you did that for about a year, realized it wasn't for you, then went through the Stanford, then Harvard. So let's talk about.

Steven Charlap:
No, then I opened up that three-year preventive medicine, then I went to Stanford and Harvard.

John Shufeldt:
All right, looking back at it, just for folks who are going to, I mean, hopefully, we're in a better time now than we were in 2017 when you did that. I mean, arguably, I like to think we're a little bit more about prevention now than we used to be. Maybe we're not, so I'm not reimbursed much better. But looking back, what would you have done differently to make that successful? With a cash business? Would that have made it successful?

Steven Charlap:
You know, it might have. A cash business in the right location where there are wealthy people, but that's not what I was going for. I was really going for to create a new model of primary prevention, primary care in the United States. I've been, having made money already, making more money wasn't the ultimate goal. The ultimate goal was to develop a legacy of having built something incredible that truly changed lives, and so, but charging private could have made a big difference. And the other thing that someone asked me early on was creating a digital version of it, as opposed to a brick and mortar, because we spent a lot of money building out a 4000 square foot center and that took several hundred thousand of the 2 million, and then maintaining that center was very expensive. So the brick-and-mortar part of it. Yeah, I just want to add one thing for your listeners. You know, someone might listen to this and say, oh, this guy obviously is a smart guy and, you know, maybe I'm not as smart as him. So let me tell you that applying to Brooklyn College out of high school, I was rejected, the local community college because I was not a good high school student. And in fact, one of the teachers once went around the room asking, telling everybody, what do you think he or she would he would become? And to me, he said artist, because he had no confidence in my intellectual capability. So I did not impress virtually anyone, maybe one teacher in eighth grade, but I know I didn't impress anybody growing up as a smart kid. And in fact, in second grade, I overheard a teacher tell my parents that your child is fundamentally lazy. And so that stuck with me into early adulthood, that I was the hardest working, laziest person in the world because the teacher must be right, I'm lazy. So anyway, I just want people to realize it wasn't smooth sailing for me. Nothing came to me easily, everything was a struggle, but I persevered and persisted and with some tenacity, that's what the key to success was for me.

John Shufeldt:
It's funny, there's a theme in a lot of these discussions, and resilience seems to be one of the themes. I come from the same era of, you know, my getting C's and D's in report cards all through high school and grade school, and my parents thinking, you know, this guy will never even get in the college, let alone make anything of themselves, so I can totally identify with that. Let's talk about SOAP. So you did the product, you did validate while you're at Stanford, and validate was, I understand, the early version of SOAP. What is SOAP?

Steven Charlap:
So SOAP stands for a Subjective Objective Assessment Plan, it's one of the formats that physicians document a patient encounter. And the basic idea behind it is that we all know that doctors, particularly internal medicine, primary care, subspecialists, are having a really tough time these days. The pandemic was really just another whack on the side, but between administrative burdens, and time constraints, and insufficient reimbursement, coupled with decision fatigue, and cognitive bias, and knowledge deficits, it's really tough to be a physician. And in fact, according to the American Medical Association, physicians get sued at a rate that's 65% of them are sued by age 55. Now, why are they getting sued? Because they're making diagnostic errors. And if you ask a physician, are you the one making diagnostic errors, they always say no, but it's estimated that up to 15% of medical encounters results in a diagnostic error, costing over 250,000 lives a year and nearly a trillion dollars. And the two most common reasons these diagnostic errors are made is because physicians with cognitive bias often have the wrong context when the patient comes in and they cut short the exploration too soon. In fact, the two most common diagnostic errors are missing early cancers, as in the case of my brother, and missing early heart disease, as in my case. And so the challenge is we're not going to suddenly find more time for physicians to spend with patients. In fact, adjusted for inflation, internal medicine doctors are paid less than they were in the 1970s, before diagnostic related groups in 1982 were implemented. So they're not paid enough, they don't have enough time. They're trying to get by with a certain volume of patients a day to sustain their livelihoods, and therefore, unfortunately, mistakes are being made. And so we had SOAP have built what we believe to be the new gold standard of the perfect medical assistant, and it's comprised of several parts. One of them is called the Perfect Medical Interviewer, and we have a patent now on the use of the Perfect Medical Interviewer, which is a conversational AI-powered digital human. So this is an animated character, a young woman with a white coat sitting in a chair that's talking to you like you're talking to a person, and she's doing a far more comprehensive medical interview than most doctors have the time and inclination to do these days. And she uses branching logic and she uses natural language processing, and she uses a whole bunch of different tools, including intuitive imagery, to really get the most accurate responses, including giving you time to pause and do some research. And studies have shown that when human beings interact with the digital human, they tend to disclose both more about themselves and more honestly about themselves. So we had a situation with a young Hispanic woman who was going to be sent to the wrong doctor because she failed to disclose to the doctors and nurses that she had been sexually abused. And because she disclosed it to the digital human, which then disclosed it to the doctor, they were able to make the right referral and diagnosis. So having truthful, more truthful responses is very important because as the study showed a couple of years ago, more than half of Americans lied to their doctors about things potentially embarrassing, and up to 30% of mental health patients don't disclose their symptoms to their doctors. So with a digital human that can get a more truthful, accurate and comprehensive response, right away, we're starting out with better data. And also the fact that it's always accessible, infinitely patient, sometimes funny, surrounded by intuitive imagery, reflecting answers back to the user, it is truly the perfect medical interview, but doctors told us they don't want more information on their patients. I did a survey sponsored by the National Science Foundation. Why? Because more information is more work and they don't have time to do more work. And more information might include something important, if they miss it, they have fear of liability. So I took 12 sets of medical association guidelines, and with the help of experts at Harvard and Stanford, we created hundreds of algorithms focused on early disease risk based on hereditary factors, lifestyle factors, social determinants of health, mental health, environmental exposures, and finally, preventive measure utilization. And these algorithms then take all the data we collect and do risk assessments everywhere from who should get a sexually transmitted test to who should get a bone density cemetery, to who should get a chest CT scan, to who should get genetic testing because of a cancer syndrome or genetic testing for cardiology syndrome. It does all that.

John Shufeldt:
So the patient comes in or they do it virtually. They do it online, they go through this.

Steven Charlap:
Any web-enabled device, it's cloud-based, the application.

John Shufeldt:
So then by the time, so it's me, so by the time I come in to see you as a provider, you have this really comprehensive, redacted in some respects, because it gets to the point, history, not physical, but history of why I'm actually there. Does it suggest diagnoses based upon my history?

Steven Charlap:
It does, it provides a score diagnosis for a tool developed by somebody else that we incorporated, but we feed it with so much information that we significantly enhance its diagnostic capabilities. And I just give you a quick example. The genie, the digital human will say, so what concerns do you want to share with your doctor? And you'll say, Well, I need to renew a prescription. She'll say, which prescription? You'll say metformin. And she'll say, Great, I'll let the doctor know you need to renew metformin. Anything else you want to share with the doctor? And you'll say, Yeah, I'm very depressed. I think I might kill myself. She'll say, Whoa, I'm concerned about what I just heard. Here's the number for the National Suicide Hotline. Please take advantage of it. While you say I have a tummy ache and she'll say, Well, have you had that before? And you'll say Yes. And she'll say, Well, what was the diagnosis? If you say no, she'll say, Okay, well, when did you first become aware of it? And then she'll go through a series of questions about if it's pain, how severe is it? Where exactly is it located? What makes it better? What makes it worse? How has it changed since you first became aware of it? If it's a cough, she'll ask questions about, Is it a productive cough? Are you coughing up anything? What color is it? So she'll go into detail, specific questions, and that's what we use for the diagnosis. And then we put it into a SOAP note. But on top of the SOAP note, we have a special color-coded summary section of the most important findings. Because another thing that doctors told me is that they miss up to 40% of what patients write on their health history forms. And in fact, patients told me, because I did 25 patients as well, that they suspect that doctors don't read their health history forms all that carefully. So we basically created something to make it impossible for the doctor to miss anything important. And we're working now on two more modules, which I won't reveal publicly. The first one has to do about labs, and the second one has to do with confirming diagnoses after the visit. Because one of the big problems in America is that you don't always see the same doctor from visit to visit, and so you walk out with the wrong diagnosis. You never come back, and that doctor has no clue that he or she got the wrong diagnosis.

John Shufeldt:
And oftentimes it's just compounded because the next physician looks at the first ... as, oh, you have a history of X. It turns out to be wrong, but we all kind of bias-base our belief system on that misdiagnosis. That is really quite amazing.

Steven Charlap:
Look, seven plus years of uncompensated effort, working essentially seven days a week, and it allows you, if you surround yourself with some highly capable people, to do amazing things. In fact, I'll tell you, John, I like to use this analogy to something that's ascribed to Henry Ford, but it's dubious he ever said it. Henry Ford supposedly was once asked, once said that if he asked his customers what they wanted, they would have said, faster horses. I believe that most digital health companies are looking at fundamentally flawed medical workflow processes and saying, let's try to incrementally improve it by digitizing it. So let's create automated horses, digital horses. We, on the other hand itself are thinking about cause. But we also understand that cause can't operate in a vacuum. A car has no value if there's no road for the car, if there's no gas station to fill up on, if there's no repair shop when things break, if there's no traffic signs and people to police, those traffic signs, cars would be crashing into each other. Tires, radios, lights, you know, the early car, I was, I asked my kids, my son-in-law and daughter, I say, how did the early cars drive at night? So they say with lights. I said, But what lights? What did they do before they had lights? And they said they didn't drive. I said, no, they put kerosene lamps at the front of the bicycle frames. The point of the matter is there were steps until the car of today, right? Multiple steps that had to be taken of fixing problems. And similarly, if you're going to build a car, you have to be thinking about its role within the greater ecosystem. And that's what we're doing, and so that's why I have so many discussions with other companies about collaborating because no one can do it alone in healthcare today.

John Shufeldt:
Yeah, so true. So is your, is SOAP embedded or will it be embedded in different current EHRs like the EPICS and the Cerners and the Athena's of the world?

Steven Charlap:
Yes, absolutely, Because physicians don't like to use two separate systems. They want to use one system and they want to use it as a tab within the system. So our goal is to have a tab within major EHRs where people click on it, open up our browser, edit on note, finish the note, upload it to a discrete field within the EHR. And we've practiced on the EPIC and Cerner databases, and we have somebody joining us from Cerner who's been there for 20 years, and we're meeting with Epic next week through the Mayo Clinic program that we're in right now. Also working with American Heart Association right now, also working with a major life insurance company right now. We just went through a big accelerator called Mass Challenge. We're working with a large medical group in rural Alabama. We're going to do a pilot there in a next few weeks.

John Shufeldt:
That's exciting and that will be, it'll certainly change the world as far as data acquisition goes, because you're right. ... I can't even tell you how many times I've, you know, you have a medical student and a resident go in, they come back, they tell you the whole story to go in there. You ask two questions, you're like, Like, dude, you are, I mean, again, what you're saying, but you kind of definitely missed the elephant in the room, This is why they're here. And then I always think of how many times that happened to me where I go down this path thinking I'm fat, dumb, and happy, and all of a sudden I'm like, Holy crap, I totally missed the real reason why they're here, because either they said it and I missed it, or they were too embarrassed to say it. So, very cool.

Steven Charlap:
Here's a very important statistic. Most early heart disease is missed in patients with clear risk factors for heart disease. And the three most major problems with missing early heart disease is failing to do an additional test, failing to refer to a cardiologist, and failing to generate an extensive enough differential diagnosis. These are actual statistics out of studies.

John Shufeldt:
Oh yeah, I know. I see it all the time. I do quite a bit of extra work and I see it all the time where it's like if you don't write it down, you didn't think about it. So the physicians, I mean, we ought to say, well, of course I thought about that. I'm like, That's great, but you didn't do anything to prove or disprove it, nor did you write down that you were concerned about it. So in the plaintiff attorney's mind, you didn't even think about it, and so.

Steven Charlap:
You know, as I said to somebody yesterday, one of our medical advisors, I said, human beings are only willing to go so far to accomplish something. And that also includes physicians who have basically told me, look, I'll give a patient a fair amount of time as needed, but up to a limit, A.I. Will have no limits. A.I. Will never get tired, which is why when, even in the early days of A.I. beating chess masters, by the second game, the A.I. was unaffected. By the first game, the chess master was mentally exhausted. And so A.I. within the relatively near future is going to be smarter than the average doctor, and not too long from there, is going to be smarter than the smartest doctor.

John Shufeldt:
Now it's all ..., and when you combine A.I. with a physician, which is kind of what you're doing because the physician still does the physical exam and synthesizes the data, it's, I think that showed that with big blue in chess when they combine it with Kasparov, it was much smarter than A.I. Alone or Kasparov alone, very cool. What do you see? Do you see this becoming the standard of care at some point in the near future? Like if you don't have an A.I. derived, subjective, and objective, I guess subjective, you'll fail, the ... be below standard care?

Steven Charlap:
Well, look, A.I. has to be more than the hype that's associated with it right now, which is why I get a lot of criticism, why I haven't started selling my product yet, because the first rule of being a physician is first, do no harm. And this idea when it comes to software development that you throw an MVP out there and you see how well it operates doesn't sit well with me as a physician. To me, this thing has to be exceptional when the first patient uses it, and it's pretty close to that. We just rebuilt it over the last six months to come out with a mobile-first design and for it to work well in all cloud-based products, and we now drilling it clinically, just going over it and over it and over it just to make sure that it doesn't miss a question, that it's thinking about everything. Because when we put it in front of a patient, you know, perfection at this point may not be possible, but it's got to be better than the human. So that's how it's going to help the human doctor be the best version of themselves.

John Shufeldt:
Yeah, I mean, so it does not have to be FDA-approved, right? Because it's not actually making a diagnosis, it's making suggestions.

Steven Charlap:
Right, well, look, I mean, the FDA is coming out with some new guidelines in the short and the not too distant future. I heard the head of interoperability, Mickey Tripathi speak at the Mayo Clinic platform conference. So there's going to be some new rules coming out, so I can't speak to the new rules. Right now, I don't believe that we require any type of FDA approval. But you know what? I welcome FDA approval because at the end of the day, the product should work appropriately. You know, interesting enough, we had a meeting the other day with some A.I. experts at Google, and all they could talk about was the ethics of A.I. and transparency. And I said to them, Let me ask you something. I think this transparency stuff is overblown. We don't have transparency in most drug trials. We don't exactly know the exact mechanism by which drugs operate and how they help, and in fact, some of the biggest breakthroughs have been drugs, who we thought worked in one way, and we applied it to something else, and it worked even better. My first cousin had a child with a major epileptic seizure disorder that nothing would help until they gave him ADHD medication, and suddenly out of nowhere, the seizures were completely controlled. So we don't have transparency, and when you go to a doctor, how much transparency do you have into the doctor's thinking, okay? Which doctor sits there and explains to you exactly why he or she is reaching the diagnosis and treatment plan? So, look, you know, this stuff is overblown, it's the same like with autonomous vehicles. You know, if an autonomous vehicle kills one person instead of three people because it makes the right choice on the road, we're going to crucify the manufacturer of that autonomous vehicle, but it still did the right thing. And similarly, the A.I. shouldn't be held to a higher standard than human beings. It should be held to at least as high as standard as the best human being, but it shouldn't be held to a standard of perfection, because if we hold, if we put out those standards, we'll never going to be able to benefit from this stuff.

John Shufeldt:
Yeah, I'm not, I couldn't agree more, but I do see a very near-term future. It will become the standard of care for physicians and for medical providers to have an AI-driven, that diagnosis engine, but diagnosis suggestion based upon the subject of questions that it goes to the patient with. So you're yet again ahead of the game, that's very cool.

Steven Charlap:
Yeah, I'll tell you, I just saw, you know, you mentioned earlier about a doctor sees another doctor's wrong diagnosis. There was a study that came out last week about dermatoathologists. If a dermatopathologist gets information on the patient before he or she looks at their slide, it is known to influence what they see on that slide and it can result in them mislabeling a pathology slide because of the wrong information.

John Shufeldt:
So they're worse with more information.

Steven Charlap:
With the wrong more information.

John Shufeldt:
Right, right, interesting. I have not seen that, but it's not surprising because it's so easy to be, I mean, I'm you know, I'm biased every time I work in the ..., you walk into an exam room and you see the entire patient and maybe their family, and instantly you have some bias out of the gate. You know, if they're, yeah.

Steven Charlap:
Cognitive bias, look, first of all, let's acknowledge that physicians are human beings and they're biased in general, just like everybody else. Just because you go to medical school doesn't eliminate your bias. And then there's cognitive bias, you see something over and over again, right? The teachers in medical school, when you hear hoof beats, think of horses, not zebras, and so if you keep seeing horse after horse after horse in a day, when the zebra walks in, you're going to think it's a horse. Because why? The zebra is present, like cancer and heart disease, presents with the most benign symptoms early on. So you're taught to think of horses, not zebras, and that's why we miss the zebras. And when you find late cancer and late heart disease, you've doomed people. But you know, can you really blame human beings that are paid, you know, I mean, they paid better than the average population physicians, but again, they're not paid for the stress level that they're exposed to on a daily basis of having people's lives in their hand.

John Shufeldt:
Yeah, no, it's true, and, you know, now we're, I don't even want to say we're post COVID, but now with COVID, I have plenty of colleagues who are my age and younger, are kind of going, you know, I'm not sure I want to be doing this anymore because it's a tough gig. I mean, as everybody listening to this knows, it's, I mean, we're pretty well paid. It's distressing to hear that internists make less on a, adjusted for inflation they did in the seventies, so my internal medicine friends out there, I'm sorry, that seems ridiculous, but I suspect it's the same for pediatricians and most of them, you know, most the other ones of us as well.

Steven Charlap:
Yeah, you know, I gave a lecture a few months ago, I was paid to give. Turned out the audience was mostly retired doctors and the title of the lecture was The Rise and Fall of American Medicine What Comes Next? And I asked a question at the end of the lecture and was shocked by the response, given that it was mostly retired physicians. I said, if you had a choice between an always accessible, AI-powered digital doctor that was always accessible, very relatively inexpensive, and clinically validated, versus a human who needed to be scheduled and paid considerably more, what would you choose? And 80% of the audience chose the A.I. doctor, and I ran that same survey on LinkedIn, and again, 80% chose the A.I. doctor. So I think we as a society already for these A.I. doctors, it's just the A.I. doctors have to get to a certain level before they're ready for us.

John Shufeldt:
Yeah, well, thanks to you, it sounds like it's, maybe they're sooner than the majority of us realize.

Steven Charlap:
I'm hoping, I'm giving it everything I got. I tell people I'm going to succeed or die trying.

John Shufeldt:
Amen. So, Steven, where can be able to find out more about you and what you're doing? Because this is incredibly interesting.

Steven Charlap:
So we have a website, https://soap.health or just soap.health, S O A P . H E A L T H. If somebody wants to contact me personally, it's my first initial last name @soap.health. So S C H A R L A P @ S O A P .health. We just basically closed a seed round. I've put in about a third of the total money, so I'm putting my money where my mouth is yet again. And two senior executives just joined, also invested, a small VC just invested, a fund of Harvard MBAs just invested, Jumpstart Foundry invested, The Mayo Clinic is on our cap table. So we've got some good partnerships and we're very excited about the future, but we will not sell this product until it is life-saving.

John Shufeldt:
Very good, well, Steven, thank you so much. We'll contain a lot, we'll have a lot of this information in the show notes. I want to thank everybody for listening. Steven, thank you so much, it's been great chatting with you.

Steven Charlap:
Thank you for having me here and happy to help you in any way that I can be of help.

John Shufeldt:
Pleasure.

John Shufeldt:
Thanks for listening to another great edition of Entrepreneur Rx. To find out how to start a business and help secure your future, go to JohnShufeldtMD.com. Thanks for listening.

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Key Take-Aways:

  • You don’t have to take a traditional path to be able to undertake to create a solution to a problem you feel passionate about.
  • Necessity is the mother of invention.
  • Evaluate your business model in terms of how you will charge and how you will operate before investing in it to prevent big losses.
  • AI has no limits and will never get tired.

Resources: