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Q&A: Health data science director, former FDA Commissioner on Duke and transition to Alphabet

Starting in November, Duke Forge Director Robert Califf will become the head of medical policy and strategy at Alphabet, Google’s parent company. The Forge is Duke’s center for health data science. Califf, vice chancellor for health data science and Donald F. Fortin, M.D. professor of cardiology, will step back from his leadership roles at Duke, but will continue to serve as an adjunct professor in the School of Medicine. 

The Chronicle sat down with Califf, Trinity’ 73 and Medical School ‘78, to delve into his diverse career path through medicine, public service and research. He discussed his decades at Duke, his experience serving as the U.S. Food and Drug Administration Commissioner and his new position at Alphabet. This interview has been edited for length and clarity.

The Chronicle: What has been your biggest learning or growth experience at Duke that you’ll carry forward to your new position?

Robert Califf: I grew up here running intensive care units. It’s a very human thing. I think the biggest thing that I bring to Alphabet is helping them figure out how to integrate the human part of the effort with the more technical part of the effort. My career as a clinician was built around working with statisticians and information scientists in a team. A clinician just depending on his or her own memory is not as good as a clinician armed with data. It’s all a team effort.

TC: What are you most looking forward to in your upcoming role at Alphabet (as head of strategy and policy for Verily Life Sciences and Google Health)?

RC: There are very few jobs where you can impact a billion or more people every day. Obviously, that’s a major responsibility. But I’m one of many people working at Alphabet. If we think about the number of people searching to learn more about their health issues, just making that better in a small way and scaled to an entire world could have a very large impact. I think medicine and healthcare are going to change to become deeply information-based enterprises. I want to help make that happen.

TC: What inspired you to found and expand the Duke Clinical Research Institute?

RC: I was exposed, as a medical student, to computers in medicine. In 1976, a computer took up a whole room. You had punch cards and your code would take hours to compile. It’s hard to even imagine now how primitive it was. I had some mentors [at Duke] who were really revolutionary in their thinking. It was amazing. I was sort of always thinking that computers had the power to expand the capabilities of clinicians.

And then, while I was a fellow working on some problems in that regard, the cardiac care unit director quit and went into private practice, and I was asked to step in while finishing my fellowship. 

At the time, smoking was very common. The units were full of young men having heart attacks and sudden deaths. We didn’t know what caused it. It was the year I took over the cardiac care unit that it suddenly became a center to explore the correlations because we had computing capabilities. What was really driving me was that I was dealing with three or four deaths a day. Mostly very young people. It’s especially tragic when a young person dies and there’s no warning. The idea was to figure out what the right treatment was, which required a global effort, so we had to build an institute that could work in multiple countries. At the core, it was about wanting to do something about people that were dying too soon.

TC: What’s your opinion on the future of personalized, particularly cardiovascular, medicine?

RC: I actually think that the term “personalized medicine” has been a little bit overhyped. People tend to think of it as looking at someone’s genes, proteins, and lab values to figure out exactly what treatments that person would need based on their individual characteristics. 

I think where personalized medicine is extremely valuable is taking into account people’s preferences. If you take a treatment for a disease, and if you tell two different people the benefits and risks, each [person] could very rationally make two different decisions.

I’ll give you an example that I’ll never forget. There was a famous politician who had been caught doing something wrong; he was actually going to trial. He had multi-vessel coronary disease. It was clear that his survival chances were greater if he had surgery and then medical treatment over the next decade. However, the best option for his chance of being alive in the next three months while he was trying to clear his name under trial was the medical treatment. Surgery posed a greater situational risk. He ultimately decided to not have surgery until after the trial. That’s an example of personalized medicine.

I think the biggest new thing that’s happening now is the ability to integrate behavioral and social information to help people be healthier and make better decisions. We used to think of medicine as something that happens when someone goes to a clinic and sees a doctor. But your health is really much more based on what you do when you’re at work, home or school. The future of medicine lies in fine-tuning health care, fostering continuous interaction with patients in everyday life as opposed to confining it to the clinic or hospital.

TC: What was the most rewarding aspect of serving as FDA Commissioner under President Barack Obama? What was the most challenging aspect?

RC: The most rewarding aspect was that I got up every day with the well-being of the American people as my mission. At the University, it’s a noble purpose in general, but the mission is not quite so clear. There’s a lot of egos involved at the University, more individualism I would say. Being part of an organization where everyone had a unifying mission was amazing. That made me feel good.

The most challenging aspect was knowing that you’re making decisions that often have major trade offs⁠—a mixture of good and bad. That was often very difficult, particularly when I wasn’t sure what the right decision should be. In some ways, it was like running an intensive care unit. You have to make decisions when you don’t have the best information you’d like to have. No one’s sure what the right thing to do is.

TC: You mentioned you were a Duke Chronicle reporter in your undergraduate years. Is there anything from that experience that inspired or enhanced your passion to pursue medicine?

RC: I didn’t really have a passion for medicine in 1969⁠—the peak of the Vietnam War. The draft was on then. I was lucky to get a very high draft number, so I was not drafted, but a lot of people that I knew were. A lot of days, classes were canceled due to protests. It was a very tumultuous time. The Chronicle office was vibrant. It was a time of very strong emotions. People were upset with authority and student activism was really at a peak. The year before I got here, there was a woman named Brenda Armstrong who occupied the Allen Building. It was very interesting to see the political activism and the standoffs that followed. Brenda actually went on to become the associate dean of admissions at Duke School of Medicine after all that.

TC: What would be your advice for an undergraduate first-year student who is considering pursuing medicine as a career?

RC: My advice would be to not spend too much time thinking about it for the first couple of years. Learn as much as you can and learn how to think. With the way things are evolving, medicine is going to become an intensely information-based thing where understanding how to gather information and deal with it is going to be much more important than the way it used to be.

When I grew up, there was no Internet. So the great doctors were the doctors who could remember things better than other people by applying mental algorithms or heuristics. That’s already different, but it’s going to change even more radically. You’ll be presented with integrated information from artificial intelligence. And now the job is how you take that information and fit it in with a person’s personality and preferences to help them do the right thing.

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