Are you managing chronic conditions like migraines, diabetes, or obesity?
Discover LilyDirect, your patient care resource designed to support you during those steps when you need it most.
With options to help connect patients to independent telehealth and in -person providers, and obesity and wellness education and information, LilyDirect helps you get the guidance and expertise you need when you need it.
Plus, their online pharmacy solution, powered by licensed pharmacies, delivers your medicines directly to your door if prescribed by a healthcare provider.
Visit LillyDirect .com today and take the first steps towards a healthier, more balanced life.
Hello, hello, Revisionist History listeners.
Happy New Year. 2025 is going to be a great year for this podcast, and I want to give you a little preview of what to expect.
The main event of the year is going to be a multi -part series from Alabama, True Crime, but with a very revisionist history twist.
So keep that in mind.
Then, before we drop that, we're going to do two other smaller things.
If you remember last season, we did a series of interviews with screenwriters on their favorite ideas that never made it to the screen.
We're doing another round of interviews this year, half a dozen or so.
And then we're also going to do a smaller batch of old -school Revisionist History episodes.
Some weird, some funny, some that will break your heart.
Over here at Pushkin, we've been hard at work, all with the goal of bringing you a little bit of audio happiness.
Stay tuned, everyone.
Welcome to Revisionist History.
We have a special treat today.
I had a chance to sit down with a guy named Diogo Rao.
who worked for years at Apple, way up high, and then left to become the chief information and digital officer at Eli Lilly and Company, one of the biggest drug makers in the world.
Diogo, as you will learn, is irreverent and fascinating and sees a good 10 years ahead of the rest of us.
At the end of our conversation, Diogo said to me, you know, we never got to AI, which is true.
Can you imagine a conversation about technology so interesting that you never get to the subject of artificial intelligence that's what you're about to hear we're going to talk about a whole long number of things but i i wanted you to start because you're a very unusual figure you work for eli lily but you are a very unusual figure at eli lily is that a fair statement uh i think i have that reputation of being unusual uh at least i like to try to do things a little bit different like you know I was talking about your background yeah yeah you you you worked in the tech industry for how many years
I worked in the tech industry well really my whole life but I the last 10 years before I came to Lily I was at Apple and before that I was doing other kinds of technology work and McKinsey and before that I was in the startup world so I've really spent my whole life in technology how many people do you think have moved from Apple to a life sciences company?
About five. I know them all.
I recruited most of them.
Oh, I see. And how did, sorry, this is a kind of, I want to start on this little tangent, but how did that work exactly?
So somebody comes to you and says, have you ever thought to work for a pharma company?
Well, yeah. And that's the way a lot of these things start.
It's, you know, there was a recruiter that I worked with who gave me a call and said, hey, I've got this opportunity.
It's life sciences.
And I was like, I've never done anything in life sciences before.
He's like, that's okay.
So I look at the spec and the spec is, you know, it's pretty interesting.
So I'm like, okay, it's worth a phone call.
Um, and then I meet our CEO and our head of HR and like, these people are really nice.
And so that's like the second thing that I noticed is that they're really, really, really nice.
And that's, that's a big difference by the way, coming from versus the tech world.
I had to say a little more about that.
Um, and then I start talking to our head of research and development about some of the problems that we're trying to solve in life sciences.
And I realized, wow, this is like a fascinating space.
I kind of thought that like everything exciting in the world was happening in tech.
And then I, then I came to realize, no, actually there's a lot of exciting stuff that's happening outside of just the tech world.
Yeah. So let's start.
So you make this, when did you, when did you start your job at Lilly?
May 17th, 2021. So go through, just off the top of your head, the most surprising things you learned moving from Silicon Valley to a life sciences company.
Well, the number one thing that I actually saw was actually the nice people parts.
But, you know, the second thing that I noticed was really long timescales, like the size and the duration of things is just, is just beyond belief.
My first executive committee meeting in 2021, we were talking about a revenue forecast that was for 2030.
And that was nine years out.
In tech, looking 18 months out in revenue is ridiculous.
Wait, so when you see that, what's your reaction?
Yes, there's no way we can predict our revenues for nine years from now.
And of course, now I realize that I'm in here that there are a lot of things that you can predict.
And it is actually very predictable.
It's a big bet, and if it works, you'll hit it.
But it's much less volatile.
These timescales are crazy, though, because like at our last executive committee meeting right before the break, we were talking about a product launch.
I'll ask you a question.
Guess when our product launches that we were talking about in December.
Well, now that you've primed to be, it's going to be five, six, seven years.
No, 2036. Oh, my God.
And I can guarantee you there are zero tech companies right now talking about what they're going to launch in 2036.
Yeah, yeah. So there is certainty that this product will be approved, but just the, you can be 10 years away and be certain it'll be approved, but know that you still have 10 years worth of work to do?
Yes. You can't be certain, of course, that anything is going to be approved.
And so we apply a probability of technical success.
This phrase I'd never heard of before I got here, but every step along the way has probability of technical success.
And so you factor it in and you take all that into account.
But you know when you have a good medicine and you know what it's going to take.
But it just takes 10 years to bring a medicine to life.
And I don't think that was one of the things that I realized before I came into this, just how long it takes and how much money it takes.
So it is possible that you will work on things that you will never see come to fruition?
In fact, most of our scientists that work here will never see their medicines that they're working on come to life, which is kind of crazy to think of.
Does that affect the culture of an organization?
It gives it a really long term perspective, like a crazy long term perspective.
When we're talking about things, making decisions, we're really not thinking, you know, like at an executive committee level, Well, there are some things that we're doing on a this year basis, but there are a lot of things that we're doing that we're really talking about like the 2030s.
Like just a much different time scale from anything else.
And so we're not going to do anything stupid, I think, is one of the good things.
We're not going to trade off some of the long term to give a little bit of benefit in the short term.
So I think it makes us much more rational that way.
I guess I would say we play the long game.
But I want to go back to, so you come to Lilly.
And I'm curious. So what did they want from you?
My boss, our CEO, gave me a mandate to really change, to bring in technology into everything that we did.
So it was not a caretaker role, sort of a mandate.
We want you to just keep running the things.
We want you to really figure out what can you do to shake things up.
And so that was really the goal.
And I think a big part of it was bringing a consumer orientation as well.
And I think this is an industry that has largely worked the same since the 1950s.
I mean, if you look at it, the way you get medicines today as a patient is basically unchanged.
You go to your doctor, they write a form.
Maybe now they submit your prescription electronically.
You still have to make sure you can pay for it.
You still have to go to a retail pharmacy in most cases.
None of that's really changed since the 1950s, even though we have so much more.
So a big part of what we're trying to do is actually, a big part of my mandate is to really bring this into the 21st century, or at least the late 20th century.
But is there, within the portfolio of things that Lilly does, do you touch on everything?
Or just are you focused on the consumer side of the business?
I mean, what's the kind of what you remit?
The great thing is that I get to focus on all of that stuff.
So everything that's technology -related.
I do cover everything from the discovery side through the consumer side.
And actually, those are probably some of my favorite parts, because of course, I shouldn't be saying favorites.
But I love the discovery side and discovering new molecules and what we can do there.
A lot of cool stuff, especially with AI, we could talk for hours about.
And the consumer side is also the place where I see, where I have a passion coming from my prior life at Apple and just seeing the potential we have to change everything there.
I think this whole industry hasn't really focused on how do we make it an amazing experience and work backwards.
I think the kinds of things that you see at Apple and a lot of other consumer -oriented companies just haven't arrived here yet.
And how does putting the customer first in that chain of interest groups change the way you do business or change the way you think about what you're doing?
That was the most fundamental thing that I learned from my time at Apple.
And I think most companies will say, oh, we care about the customer.
But whenever you start a project, people will have, I don't know, they'll have five pillars or five things they need to go after.
Well, maybe there's the business case, the product, the customer, you'll have like five or six different things.
And the way you'd always do things at Apple was different.
You would always start by, like, what's the customer, the consumer experience that you want to create?
And then work backwards and then figure out, can you make it a financial case around it?
Well, maybe you can't.
OK, so we need to, maybe we can see how we can change things back and forth.
But it really was, everything was centered on the customer experience.
It wasn't like a pillar of one thing of five.
It was like the thing that was guiding everything.
And I think that's, we're not there yet, but that's like, that's the kind of thing we need to do.
Like every single time we need to go, we need to go back and see what's the customer experience like.
We need to actually focus on like making a customer experience better.
Yeah, yeah. This episode is brought to you by LilyDirect, using innovation to help simplify managing your chronic conditions.
From independent in -person care or telehealth consultations to direct deliveries of select Lily medications if prescribed by a healthcare provider, LilyDirect is committed to making your health journey more seamless.
And don't forget, LilyDirect's platform also offers well -being content tailored to help you navigate your day -to -day life as you manage your condition.
Visit LilyDirect .com and discover how they can support your overall wellness.
Now, back to the program.
You have a whole table full of goodies over there.
I want you to pick a goodie and let's use this as a specific, Walk me through the kind of thinking behind the product, the specific challenges, how it represents this process that you've been talking about.
You pick. Okay, great.
Just so people know this, but a couple of feet from Diego is there.
There's about, it looks like eight to ten mysterious boxes that are.
so I have to I have to I have to share with everybody that like Malcolm and I had a little prep call before you know a couple weeks ago and it was only about 10 minutes because he just said okay you know if you got any toys any goodies like bring them along and so like my team gave me a box of goodies here which is all splayed out on the table and then and then I think you said okay I don't want to talk too much more let's not do any more prep let's get going well the thing if you have small children as I do you think exclusively in terms of yeah of shiny little gifts.
I almost said, can you bring snacks?
That would be something that was top of mind.
Awesome. All right.
So let me grab a box.
All right. I'm going to show you something that is...
No, let me grab that one.
Yep. And I'm going to hide it here for just a second and tell you what the problem is that we're going after.
One of the big challenges in the world right now is medicine and medicine safety.
When I was at Apple, I saw counterfeit iPhones and I couldn't believe it.
You wouldn't know that they were counterfeit until you actually picked them up and played with them for like half an hour.
And sometimes you would have to send them in and have them get x -rayed to know that they're fake.
Well, those were on products.
That was like a $1 ,000 product.
The electronics, very hard to make a counterfeit, but the economics were there.
Medicines are a lot easier to fake, or at least make them look fake.
All you need to do is copy the box, and if it's in a vial, put a label on it, something like that.
And with some of the medicines that are out there right now, there's a huge financial incentive for people to have to make, to say that they're making medicines that they really are not, and they're faking them.
What would be, this is fascinating, is there a particular kind of medicine for which the counterfeiter's motivation is greatest?
Well, right now, in chronic weight management, we have the GLP -1 medicines.
And so both for us and the other leading maker of GLP -1 medicines, counterfeiting is a real, real threat.
And back to formularies and things like that, a lot of insurance plans do not cover chronic weight loss management.
And so there's a huge financial incentive on the black market to say, hey, we're going to go...
And some uncertainty about outcomes.
So it would take you a while to figure out you're taking a fake.
Correct. And I mean, it's not only, I mean, it's not only fake, it's actually, many of these cases are risky because once you see like the sterile environments that these medicines go through to be made, you know, that it could, in the best case, it's harmless, right?
I mean, the best case is you don't get any effect.
And so what I've got here is a product.
this can be any product and don't pay attention to what product this actually is and I've got the product right here and I can tap my phone against it and I will put it in an NFC tag and that NFC tag is just like when you do a contactless payment and it will bring up a page to show you that can actually verify that the packaging matches something that we've produced unlike a qr code it can't be copied it's cryptographically secure and this is where the technology part gets interesting uh because they can copy the box they could do all kinds of things like that but they can't copy that tag there's
one and only one uh tag that you can that you can tap and then we can verify it yeah so how how how long did it take to develop that particular technology so it took uh this is something we did within my first few months of coming here.
And we haven't launched it yet.
So designing it is very easy.
The developing it is very hard.
So what you're saying is what you have is a technology that could be a platform for building an interaction between the consumer of the pill, the patient, and the manufacturer.
That's absolutely right.
And we actually don't even care about it necessarily being just for us.
This is the kind of thing where we'd say, this is a great thing if adherence can improve for patients across all medicines, all manufacturers, that would be fantastic.
Yeah. But you've put that RFID tag on the box.
Correct. But now there's still a thing inside the box.
There's still a thing inside the box.
So this is version one, which is on the box, and then version two, which we'll come to later, will be on the individual medicine itself.
What about protecting against an unauthorized use of the medicine?
What if the wrong person taps their phone against?
Absolutely. Then you could actually make sure that you're taking the right medicine.
I also think making sure that you haven't taken your medicine more than once in a day is also an important thing because, you know what, it's actually very easy to do.
I also think that in a hospital environment, it also is, you know, you could tie it into systems and make sure that you're actually administering the correct medicine, not something that you can imagine a alert flashing up on the health care provider's device if it's the wrong medicine.
So this is beta with the box.
how long how many years before you think you'll be actually in the pill itself the pill itself i don't know if we'll ever get past the consumer uh acceptance of rfid like if it like actually being in the pill itself but if we could get there um that's that's not super far out that's probably you know um probably five years out uh yeah yeah but uh it's not the technology is the even better version is that you point your phone you've got and you find out all the stuff that's in there you're like oh my goodness what what do they have for dinner yeah exactly might not be good to find that out pick
another wearable because now i'm interested first of all has lily ever done a wearable before uh no uh we've not produced a wearable of our own um and it ends up being a little bit challenging as a manufacturer be a lot easier if we didn't make drugs uh to to actually launch a wearable, but because you make drugs, then the question is, well, are you using this to, does it have to be, is it required for somebody taking the medicine?
So there's a whole host of things that makes it really complicated for us to do it.
So for the most part, where we use these things are in clinical trials.
So how many wearables, take me 10 years into the future, how many wearables am I wearing if I want to be completely, you know, if you're going to nerd out on all of this.
You know, I think it's probably on the scale of two to three, I think.
I think there are only so many places that you're willing to put a wearable.
You know, you can imagine there's your ring, there's a watch, you know, that you might be able to, if you've ever had like a Xio patch or anything like that, a heart patch, those are not terribly uncomfortable.
Insoles, you know you could uh you could imagine but after that um you don't have that many more places i think that you would that you'd be willing to wear something so i'll go i'll go with the three tops i was going to say eyes i was reading eyes yeah that's a really uh i was reading a really fascinating study that was looking trying to figure out what the difference is between a novice police officer and an expert police officer and they use eye tracking gave them scenarios and figured out they're looking at different things right so you have a scenario of like a bad guy here and this happening
here and someone throwing this here and we see the experts like looking doot doot doot doot doot doot doot doot and the novice is looking whoo right yeah one spot versus but i'm just curious about like you know my sense is this is kind of once you start going down this road yeah there's lots and lots and lots and lots of things no i thought you were going to go down a different path which is like the uh what you might uh like enhancing your eyes or your hearing or things like that which is also like that's just another fascinating space uh of science and yeah yeah why one of the things you said
earlier piqued my interest when you said that if you're making drugs and the question one of the questions that comes up is are you using the something like this a wearable to market the drug but i'm wondering whether that's there's another way to frame that That is, surely one logical step here is that you start to, you're not just giving someone a drug or giving someone a drug in combination with a set of wearables that allow us to maximize the value of the therapeutic, right?
Are you going to be getting from your pharmacist or your doctor a package of things to take home along with your medication?
We do that with some of our clinical trials.
You'll get like, here are the devices to take with you.
But if you look at weight loss medications, we're already all doing that right now, like because we all have scales in our house, right?
And so I think that is a great example of like, if you give feedback to the person taking the medicine, they're going to be more likely to stay on it.
At least that's one of my hypotheses.
I think that if you took away scales and you took away mirrors, I think a lot more people would drop off the chronic weight management medicines early on.
Yeah. But the fact is when you get on the scale and you can see, hey, I lost, you know, I lost some weight, you want to stay on it.
We don't have anything like that for statins or anything else.
Right. And that's again, like why people drop off.
Just imagine if you could just see, oh, hey, actually, you know, or I'm taking cholesterol medication and you know what, hey, my cholesterol went down versus yesterday, not versus three months ago.
Yeah. Who controls this data?
So interesting, you began this conversation in talking about the multitude of steps that exist between the manufacturer of some of these medicines and the user.
That's right. Now you're talking about a system where presumably the manufacturer can speak directly to the patient.
Correct. Does this mean you cut out some of the middlemen?
That's my hope. But the data, ultimately, the first part of your question, the data really should be with the patient.
And I think there's a tendency to say, Even still today in this industry That the data is really for the healthcare provider And I think that's A mistake I think ultimately the data is for the patient And the patient can choose to share it with the healthcare provider And the healthcare provider can look at it But it really is My mom Is in a nursing home Has arthritis Which acts up And so she moves around a lot This is a perfect Tool for her So somebody, so does she, is the model here that she checks her movement scores and that's a way of, and she can choose, she can see, oh, this is time to
share that, my data with a practitioner?
Isn't it more efficient for her to have someone who is, or say AI or something, it's continuously monitoring her?
I think the continuous measurement part is, you're absolutely correct about it.
But I think it needs to be, I think she always needs to be able to see the data herself.
Yes, you can see that.
And by the way, that's one of those things that sounds obvious if you're coming from outside the industry to inside.
But inside the industry, it's like, wait, why would you share the data with the patient themselves?
That's something that the healthcare provider should see first.
I mean, what happens if your mom misinterprets the data without the advice of a healthcare provider?
That's kind of the big caution that would keep the industry from saying your mom should be able to see that data herself.
But I take a very different view on that.
But we're moving, what's interesting, you know, a lot of these things, the implication of what you're talking about is we are moving the primary point of contact from the hospital or the doctor's office to the home.
Correct. Right? Yeah.
This is, that's, if you don't mind me going on a tangent on that, too, that's one of the reasons why I'm really, really excited about, like, how we can change things, too, because if you look at it today, it's, there are so many barriers to getting medicine.
You know, like first you have to get a doctor's appointment, which we've all suffered through.
Like it can take months to get one.
Then even after you have one, then you also have to be able to actually get access to the medicine, which is a big problem because I don't know if you've heard these stats before, but 45 million Americans live in pharmacy deserts.
46 % of counties in the country are in pharmacy deserts where there's no pharmacy within 15 minutes of your house.
And so I think, and so if you add all that together, it can take months from like the moment you say, you know what, I'm not feeling well, or there's something I want to change in my life to like the day that you get the medicine.
I want to bring that like down to like the same day.
You should be able to say, you know what, today's the day that I want to do something and you should be able to go in, you know, get a telehealth appointment.
And if a medicine is appropriate get it shipped and get it arrived delivered you know this the exact same day well one last question for you um define what success looks like for you so you're how old are you uh i just turned 50 but you're a young man uh i get to hear that very often so you let's assume you retire from lily at 65 okay and i so take me 15 years into the future And tell me what would have to happen for you to feel like your time at Lilly has been a success.
The biggest thing for me is going to be the consumer side and actually making really cracking this and being able to like get that vision of people saying, I want to take a medicine and I'm going to get it the same day.
And then I've got the tools to stay engaged with it forever.
Like that would be – that's millions and millions of lives touched by just getting medicine and staying on medicine.
That's one side. The other side where I would love to make a mark is on the discovery side.
Discovering new medicines, particularly with AI.
We could talk for hours on that.
But I think we're going to see medicines no human could have ever imagined coming out over the next decade.
And because it takes 10 years or more to develop a medicine, it would take about 15 years for that to come to life.
Yeah. I was thinking, you know, when you were talking, and this is maybe a little bit far -fetched, but in the world of deterrence, so the question is, if I have a law that punishes you for a certain crime, the deterrent value of that law is a function of three things.
the certainty of punishment the swiftness of punishment and the severity of punishment.
And of the three we spend the most time thinking about severity.
Secondly thinking about certainty and the one that we neglect is swiftness.
Right? It takes years and years and years.
And the argument that many people make is that swiftness is actually the most potent of the three if you know you're getting punished the next day then you're...
It's funny Because if you map that onto what you're talking about, you were talking about the idea of getting medicine the same day.
What you're saying is the swiftness variable is the neglected one here.
And what if, if we improve swiftness, do you think we would change the psychological circumstances around which people use drugs?
In other words, would the adherence problem be solved if we address the swiftness problem?
I think so, actually.
I think if we got swiftness and you could actually see an effect and know that something was happening, that would change things.
And by the way, I love that model that you just mentioned.
In the technology world, we have things break all the time.
And what everybody focuses on is like, what's the root cause?
And what's the severity?
And how likely is it?
The thing that nobody ever focuses on, which is where I was trying to get teams to focus on, is swiftness, the mitigation, time to mitigate.
how long did it take you to mitigate that human process of like how quickly did you take the feedback and adapt that's really you can you can have all kinds of risks as long as you've got as long as it's reversible and you can switch that's great so when it comes to medicines if you could try it and get feedback that it's not working or not turning in the right direction and change it that would be that that would be amazing and i think you would find that people would people would say hey now i know that you know this medicine i tried wasn't working i'm I'm going to try a new one today.
I can see progress.
I'm going to stay on it because I know it's doing something.
Well, this has been really fascinating.
Best of luck with all the work you're doing.
I hope next time I see you, I will have at least three wearables.
Excellent. Thank you, Malcolm.
Revisionist History is produced by Lucy Sullivan with Nina Bird -Lawrence and Ben Nadav -Haffrey.
Our editor is Karen Shikurji, mastering by Jake Korsky.
Our executive producer is Jacob Smith.
special thanks to Matt Romano, Eric Sandler, and Kira Posey.
I'm Malcolm Gladwell.
Thank you for tuning in.
Before we go, a quick reminder about Lily Direct, your online healthcare resource.
Lily as a medicine company is rooted in a mission to create medicines that make life better.
Trust Lily Direct to help provide support for managing chronic conditions like migraines, diabetes, or obesity.
Explore their services at lilydirect .com and discover how they can support your overall wellness.
Until next time, stay healthy and well.
