Originally presented at the ASSFN Virtual Scientific Update on June 28, 2020.
Thoughts on Technology, Times and The Future or our Species: Good, Bad or Other?
Thank you for the introduction, Emad.
And thank you Emad and Sameer and the organizing committee for this first – and hopefully NOT biennial Virtual ASSFN meeting.
For the last year or more, I had planned to be speaking today about the process of innovation and disruptive technology. In the last four months, however, we’ve seen striking disruption of another kind affecting the CONTEXT of this address, not to mention the setting, and I didn’t feel like that could be ignored. I will indeed speak on the topic of innovation and disruption, but it will be in the BROADER context of disruption, not just in technology, but in our lives.
“It was the best of times, it was the worst of times.” That’s how Dickens famously opens “A Tale of Two Cities”. Is that a paradox? These do seem like OUR worst of times: Worldwide pandemic, high unemployment, recession, lives disrupted, educational plans on ice, meetings cancelled – and even some good ones!
Add to that the inequity of the burden on vulnerable segments of the population – in particular Black Americans and others of color, and of people in poverty. Add again the acutely escalating evidence of systemic racial inequality in our local and national institutions and worldwide. More lives lost and disrupted.
Maybe the worst of times…. But in what way could these possibly be the best of times? Dickens, remember, is writing of the past: it WAS the best of times, and it WAS the worst of time. And it is with perspective that we should take OUR measures of the present circumstances, and place our judgments upon the recent events. What is the ‘best’ that will come out of all this disruption? Are we even in a position to judge best and worst, good from bad, without historical perspective? Perhaps this will seem an odd and maybe even insensitive question, but: IS there really a good and a bad when it comes to current events?
The answer, of course, comes from Star Trek. Yes, we are nerds. As some of my students, residents and fellows know, I think most of life can be reduced to an analogy from the original Star Trek series. In the award-winning episode “The City on the Edge of Forever” – McCoy is delirious on some medication, and jumps through a time portal to inadvertently end up in NYC in 1930. And this of course somehow changes the entire course of history. The Enterprise and the Federation no longer exist. So Kirk and Spock jump through the portal to enter a week earlier to figure out what happened and change it back. Spoiler alert: it turns out that because of McCoy’s presence, Sister Edith Keeler – a compassionate young social worker played by Joan Collins – lives to become a pacifist who eventually delays the United States entry into WW2. Nazi Germany gets the bomb first, wins the war and changes history. Spock, with only vacuum tubes to play with, amazingly figures out that she must die for the Allies to win the war, save the world and the galaxy! Tough stuff! Ultimately Kirk, despite of course having fallen in love with her, has to restrain McCoy to prevent him from saving her from being hit by a truck. Of course, the Enterprise reappears and the galaxy returns to normal, but who could watch and say her death is anything but horrible? Kirk is conflicted and distraught. Spock is, well, Spock. And McCoy is incredulous because he doesn’t have the perspective of history. And THAT’s the point. It is only with this perspective, from the passage of decades, that this tragic event can be understood to be, in fact, a ‘good’ thing. The lesson here is that to judge is human hubris. We can’t judge until we know the ‘end game’ which we never know.
Can we, and should we, apply the same reasoning to “disruptive” technology? We definitely value disruptive technology as “Good.” The iPhone and Android and cell communications, GPS, Waze, – I even take it to work 4 miles away, social media. They keep us connected and even oriented in this increasingly centrifugal and disorienting world of mobility. We can stay in touch with parents and children moment to moment, keep long distance friendships warm. Capture crimes in real time. Turns out the revolution IS being televised, and that is the key! This is indubitably “Good.” On the other hand, kids – and grown-ups too – sit in rooms all alone, seeing everyone else’s movie-lives, feeling increasingly isolated. And people are willing to say almost anything to anyone on social media, never confronted by the person sitting across from them, and the resultant empathic activation of their own anterior cingulate cortex. This fuels polarization and the echo chamber. This is indubitably NOT “Good.” “Disruptive technology” – both good AND bad. Yin AND Yang. BOTH…or – lesson 1 – neither.
Spock had to twiddle with vacuum tubes in 1930. But in 1947 Bell Labs gave us the transistor, one of the most disruptive of technologies in the history of mankind. Today’s electronic connectivity is the direct outgrowth of the Bell Labs environment – fostering direct and unregulated collisions between scientists and engineers, yielding the transistor and unleashing Moore’s law, cell communication, and the laser – something near and dear to me. I have tried to emulate in some small way this concept in the Emory Neuromodulation Technology Innovation Center which I had one of the great honors of my career to found with the towering figures of Mahlon DeLong and Helen Mayberg. Here they are, and there in the lower left corner with my predecessor at Emory – the late, great Roy Bakay. (Emory always gives out these OR hats when we are being filmed). Anyone who doesn’t know who Roy Bakay was please look him up. Roy’s departure from Emory in 2000 gave me the opportunity of a lifetime.
Our mission at ENTICe is to innovate new technology for the treatment of neurological and psychiatric disorders and our modus operandi is the collision of clinicians, scientists, and engineers, like the environment at Bell Labs that yielded the transistor. And we presume that such innovation is good – who wouldn’t? …All but the most entrenched Luddite would judge the transistor to be “Good.” But do we yet have the appropriate perspective of time, do we know the endgame? The transistor is certainly the basis for the incredible and literally mind-expanding advances in our own field of functional neurosurgery. It is the basis for deep brain stimulation – both the ‘dumb’ kind and its open loop stimulation, and ‘smart devices’ that can analyze an endless stream of data coming from both inside you and from outside, too. The transistor is the enabler of AI, which can diagnose you with depression or coronavirus, and which can figure out if your beta oscillations are too high or too low. All of this is, ostensibly, “Good.” But what happens when, not if, we lose control of this, as asked by Yuval Noah Harari, the Israeli historian and author of “Sapiens.” His 2nd book, “Homo Deus: A Brief History of Tomorrow” is one of the most expansive and mind-expansive books I have ever read – actually 3 times. Another spoiler alert: It’s all about the data: data is lord, he convincingly argues, always has been and always will be. Homo Sapiens’ superior command of the data was responsible for our species’ ascension. It was the underpinning of the triumph of agriculture. And more rapid data transmission within the marketplace was why, he argues, communism capitulated to capitalism. But, he posits, as Homo Sapiens, for the first time, loses the battle of intelligence to the artificial kind, left only with consciousness in our corner, we will have to join em because we can’t beat em. And thereby become Homo Deus, or Man God, when we all have devices implanted in or on our heads, and assimilate with them and the data. We are already altering humans with onboard computers – that’s the holy grail of functional neurosurgeons! And yes, we believe we are doing “Good.” Helen does…I know I do. But when will it cross the line? When will WE cross the line? Is the advent of cognitive augmentation even in doubt? And given that it would be self-paid, will it lead to empowerment of the haves over the have nots? And, Harari wonders, are there cultural, socioeconomic and/or racial factors – call them classifiers – that will decide who has them and who doesn’t? Smart devices are “Good.” But, this is perhaps NOT so “Good.” Disruptive technology – both good AND bad. Both Yin AND Yang.
I was honestly depressed for months after reading Homo Deus – thought I’d need one of these stimulators. Are functional neurosurgeons unknowingly – in our unbridled enthusiasm for shiny new toys – being complicit in the demise of our species? I even invited Professor Harari to our meeting in 2022 to discuss this, but his AI said he was busy…next year. But then my friend and 1st MD/PhD student, John Rolston, now functional neurosurgeon at University of Utah – the site of my own 1st job – put me onto Steven Pinker, the Harvard cognitive psychologist, psycholinguist, stylist, and somewhat controversial popular writer, and in this situation my life-raft. In Enlightenment Now – his most recent book – Pinker in some detail catalogues how “Doomsday Scenarios” – such as Harari’s – have always been with us, and he even cogently counters the Harari thesis. The trajectory of humanity has steadfastly, if not steadily, been upward. The apocalyptic fear of nuclear holocaust has not manifested – at least not yet. Global famine from explosive population growth – the apocalyptic Malthusian theory re-popularized by Paul Ehrlich in 1968 – never manifested because both curves were incorrect – population growth is actually going down and food production up – although that didn’t stop Dan Brown from coming up with his own twisted pandemical solution to our Inferno. Whether it is poverty, violent deaths, life expectancy, and myriad other metrics, the arc is improvement – ups and downs, but always improvement. Perhaps we are now in a downcycle, a correction. But alas, we always come out of it, and it is always in fact technology that comes to the rescue. And when we are despondently looking into the future, we never know the technology around the corner that will be our savior. Maybe it won’t come this time, but it always has in the past. Perhaps Zoom meetings, such as this one, are part of the good technology to come out of this pandemic, and will help mitigate global warming. For certain, Telehealth is; we’d been working on this at Emory for 10 years to no avail, and it literally took 1 week to implement, and our patients love it. Neurosurgical house calls save gas, time, money, and aggravation, and maybe our planet. As reasonable as Professor Harari’s arguments are, I am more inclined towards Pinker’s more so-called ‘possibilist’ if not ‘optimist’ views. Technology will come to the rescue….
But will disparities in the adoption of new technology, such as AI and smart devices, inevitably lead to Harari’s mythical Homo Deus. I argue that it won’t, not because we, Homo Sapiens, and functional neurosurgeons in particular, have the will to stop it – I don’t think we do. It’s because, as he says, ‘data is lord.’ Data has to be transmitted, and that happens through connectivity; connectivity between neurons… and people… and communities. And connectivity between people and communities is ever increasing – again due to the transistor. Increasing connectivity links components in ever enlarging systems or networks. And systems have principles governing their behavior.
How do these systems behave? Systems theory applied to business was developed into The Deming Philosophy, which was arguably the major driver of The Toyota Production System. This may seem trite and obvious, but it’s not: as he said: “It would be better if everyone worked together as a system with the aim for everybody to win.” The individual must appreciate their role in the system and their interactions with others. Many of us are experiencing the Lean system in healthcare these days. These principles include, amongst many others, the following:
- In an optimized system, every part of the system benefits, for example…customers, stockholders and the community; and
- You can’t just optimize one part of the system because it may deoptimize the whole system.
- The problem is to achieve a balance, a tolerable level for all parts of the system.
- And – this is my addition – To optimize the system, there must be cooperation between all the components, which requires connection and communication.
An example of considering the whole system is our adoption of laser ablation. Many patients – i.e. the customers – are willing to sacrifice, that is, deoptimize, a degree of seizure freedom for what matters most to them, not having an open surgery. We as surgeons can argue with them, but we have to consider what matters to each individual patient, even if it is not what matters most to us.
All optimal system behavior – or team behavior – requires effective connection between the parts or people, and effective communication – or data flow – between them. These principles are timeless, and were most effectively presented by Stephen Covey in the famous book “7 Habits of Highly Effective People”, which applies to all organizations from families to businesses, that is, all systems. These are habits that underlie effective team behavior, and I recommend it for anyone having team difficulties; these principles – my favorite is Habit 5: ‘seek first to understand, then be understood’ – help us move from independent thinking to interdependent thinking, which is particularly important for functional neurosurgeons that have to work with many other teams including neurologists, psychiatrists, neuropsychologists, physiologists, engineers, industry and on and on. Some functional neurosurgeons may function more inter-dependently than others. Success in team behavior characterizes our most famous and successful modern functional neurosurgeons, including both my mentors… and distinguishes them from some of our more infamous ones.
An optimal system, any system, requires cooperation between the components, which requires connection – or what we now call ‘connectivity’ – and ‘communication’ or data flow, to achieve a usually delicate balance. That is, the system equilibrates. From aequi meaning ‘equally’ + libra meaning ‘balance’. Equally balance. Connection and communication allow equilibration, just like both sides of a seesaw are connected, and communicating.
And connectivity and communication are what technology is giving us evermore in quantity. So, Harari’s argument that one segment of our species will successfully speciate goes counter to the equilibration through connectivity and communication that technology has afforded the world, to bring every part into the same system. We see this every day. It is the underpinning of globalization, which allows the optimization of the whole Earth system, although it also is the underpinning for massive disruptions in ways of life, including setting up the conditions for the rapid spread of pandemic. Connectivity and communication – and globalization: both Good and bad.
Connectivity and communication on a cellular and systems level have been the basis for the ascension of the brain, and in particular the brain of Homo Sapiens, and the technology to analyze it has allowed functional neurosurgeons and neuroscientists to increasingly understand how this system works, if it can truly understand itself. The advent of closed-loop technologies allows the system to equilibrate much more rapidly, as compared to the physician-in-the-loop model, enhancing the function of the system as a whole, which now literally incorporates technological devices into the brain’s system. So, within the brain, connectivity, communication, technology and equilibration – all go hand in hand.
We are all part of many systems and thus need to consider equilibration – equally balancing – in the broader context of our society – both our Society for Stereotactic and Functional Neurosurgery, and the society at large. Echoing Dr. Deming, Whole Foods cofounder John Mackey argues in Conscious Capitalism that the only successful form of business is one that respects and addresses the needs of ALL stakeholders, from customer to employee to supplier to the community and the environment. This was the basis for the innovation of the Whole Foods Diet, a plant-based whole food eating style, also advanced by others like Joel Fuhrman – which I follow and DO want to take this opportunity to promote – that optimizes health of customers, employees, and also the Earth Ecosystem in which we all live. In this approach, all stakeholders within an organization’s system are equilibrated so as to optimize the system as a whole, while no single stakeholder within the system is necessarily optimized.
This year we began to apply these same principles to our own society, by launching our first ever Strategic Planning process. We asked what is the purpose of our business, who are the stakeholders in our society and the broader community in which we exist, including our physicians, scientists, patients, allied societies, industry partners, etc., and how can we most effectively serve their needs given our resources? We will roll out the draft plan in the coming months for all members in our society to weigh in on. Again, the most effective plan is one that optimizes the whole society and its system of stakeholders, rather than any one single component. What good would we do if our reimbursement was optimized, but at the expense of not helping the broadest number of patients possible? Another critical underlying principle of strategic planning is the longer-term view, over 5 years, to smooth out the ups and downs of both events and the idiosyncratic priorities of individuals.
And here, our ongoing planning process collided head-on with Covid-19. In person meetings we had thought to be essential to the process were replaced with less costly and less resource-laden Zoom meetings, that turned out to be equally and perhaps more effective. But most recently the process also intersected with the other major societal “disruption” – the scab, if ever it existed, being torn off of systemic racism omnipresent in our society for the last 400 years. Given the pervasiveness of systemic racism, we could not shy away from reckoning with the role our own society plays in it. Diversity is good because it equilibrates opportunity across all parts of our system, and leads to a stronger system based on the principles I’ve discussed. And remembering that our most important stakeholder is our patient population, the best way for us to serve our patients’ needs most effectively and most widely is if we as doctors, and as functional neurosurgeons, mirror the diversity of that population. We have, in recent years, focused on gender diversity, although we have a long way to go, with 8.7% of female AANS members, woefully below the percentage of female doctors. However, women are represented equally in ASSFN as in AANS, at 9.5%, and indeed we have 3 female board members, comprising 19% of leadership. But we have, honestly, simply not paid sufficient attention to racial diversity in our own society or on our board. Although 13% of the US population characterize themselves as Black, they comprise only 5% of active physicians, 2.8% of AANS members, and only 1.1% of ASSFN members. That is, there are only 3, yes 3, black functional neurosurgeons in our society, all men, and there has never been a black American or Canadian on our board. The numbers are essentially the same for self-characterized Hispanic neurosurgeons – 5 self-characterized Hispanics in our society, and none on the board. Our strategic plan will incorporate goals and strategies to rectify this systemic inequity. We can only improve access to the best care for our Black patients and others of color by doing better at equilibrating – equally balancing – our own society, and giving diverse members of our community an equal opportunity to be functional neurosurgeons, the best job in medicine.
I have talked about the paradox of times being both the best and the worst – they are both, and neither, when we judge events from an historical perspective, or better yet, avoid the hubris of judgement altogether. These are the events: how we respond to them is the most effective and important question.
I have talked about disruption: we cherish it in ‘disruptive technologies’, and bemoan it when it disrupts the flow and pace of our habitual lives. But the increased pace of disruption is part and parcel of the rapid connectivity and communication that have been afforded by nature’s advances in our Homo Sapiens technology, and the technology that we have spawned. We have to take the good with the bad, or rather, accept disruption and always use it to advance the equilibration of the system that is disrupted. Our day to day lives have been disrupted because underlying and neglected inequities have been enlightened and we need to work tirelessly to equilibrate – equally balance – the system to the enhancement of the quality of life for everyone within.
And I have talked about technology. It is good, and bad, and neither. We need to, we cannot possibly avoid, embracing it. But we need to also work to make sure it equilibrates, is equally balanced, across all of society. Let’s use this moment, and the likely increasingly frequent moments to come, to identify disparities and opportunities, and use disruptive technology and connectivity for the optimization of the system and systems in which we spend our daily lives.
It has been a wonderful 2 years serving you as President of ASSFN, and indeed 6 total years in leadership and 8 years on the board, for a total of 14 years. I have tried to accomplish some things, like the launching of our first strategic plan, and have both succeeded and failed. But it has been the realization of my ambition to have an impact on this field, and it has been enjoyable every moment, made all the more so by the frankly frightening brilliance and dedication of all of the board members with which I have had the honor to work these several years. Your society, which is on firmer financial and intellectual footing than ever, will be in great hands both these next two years under the leadership of Joe Neimat, and for years to come, based on the dedication of the other executive council members Andre Machado and Secretary-Treasurer elect Julie Pilitsis and the rest of the board.
Thank you for your kindness and your attention.