Featured Post from Emory University, Goizueta Business School

Expert Insight: Training Innovative AI to Provide Expert Guidance on Prescription Medications

Jul 9, 2024

10 min

Karl Kuhnert



A new wave of medications meant to treat Type II diabetes is grabbing headlines around the world for their ability to help people lose a significant amount of weight. They are called GLP-1 receptor agonists. By mimicking a glucagon-like peptide (GLP) naturally released by the body during digestion, they not only lower blood sugar but also slow digestion and increase the sense of fullness after eating.


The two big names in GLP-1 agonists are Ozempic and Wegovy, and both are a form of semaglutide. Another medication, tirzepatide, is sold as Mounjaro and Zepbound. It is also a glucose-dependent insulinotropic polypeptide (GIP) agonist as well as GLP-1.


Physicians have been prescribing semaglutide and tirzepatide with increasing frequency. However, both medications come with a host of side effects, including nausea and stomach pain, and are not suitable for every patient. Many clinics and physicians do not have immediate access to expert second opinions, as do the physicians at Emory Healthcare.


Creating a Digital Twin



That lack of an expert is one of the reasons Karl Kuhnert, professor in the practice of organization and management at Emory University’s Goizueta Business School, is using artificial intelligence to capture the expertise of physicians like Caroline Collins MD through the Tacit Object Modeler™, or TOM. By using TOM, developed by Merlynn Intelligence Technologies, Kuhnert and Collins can create her “decision-making digital twin.” This allows Collins to reveal her expertise as a primary care physician with Emory Healthcare and an Assistant Professor at Emory School of Medicine, where she has been leading the field in integrating lifestyle medicine into clinical practices and education.


Traditional AI, like ChatGPT, uses massive amount of data points to predict outcomes using what’s known as explicit knowledge. But it isn’t necessarily learning as it goes. According to Kuhnert, TOM has been designed to learn how an expert, like Collins, decides whether or not to prescribe a drug like semaglutide to a patient. Wisdom or tacit knowledge is intuitive and rooted in experience and context. It is hard to communicate, and usually resides only in the expert’s mind. TOM’s ability to “peek into the expert’s mind makes it a compelling technology for accessing wisdom.”


“Objective or explicit knowledge is known and can be shared with others,” says Kuhnert.


"For example, ChatGPT uses explicit knowledge in its answers. It’s not creating something new. It may be new to you as you read it, but somebody, somewhere, before you, has created it. It’s understood as coming from some source."


Karl Kuhnert


“Tacit knowledge is subjective wisdom. Experts offer this, and we use their tacit know-how, their implicit knowledge, to make their decisions. If it were objective, everyone could do it. This is why we hire experts: They see things and know things others don’t; they see around corners.”


Mimicking the Mind of a Medical Expert



Teaching TOM to see around the corners requires Collins to work with the AI over the course of a few days. “Essentially what I do is I sit down with, in this case, a physician, and ask them, ‘What are thinking about when you make this decision?'” says Kuhnert. “The layperson might think that there are hundreds of variables in making a medical decision like this. With the expert’s tacit knowledge and experience, it is usually between seven and twelve variables. They decide based on these critical variables,” he says.


"These experts have so much experience, they can cut away a lot of the noise around a decision and get right to the point and ask, ‘What am I looking at?’"


Karl Kuhnert


As TOM learns, it presents Collins with more and different scenarios for prescribing semaglutide. As she makes decisions, it remembers the variables present during her decision-making process. “Obviously, some variables are going to be more important than other variables. Certain combinations are going to be challenging,” says Collins. “Sometimes there are going to be some variables where I think, yes, this patient needs a GLP-1. Then there may be some variables where I think, no, this person really doesn’t need that. And which ones are going to win out? That’s really where TOM is valuable. It can say, okay, when in these difficult circumstances where there are conflicting variables, which one will ultimately be most important in making that decision?”


The Process: Trusting AI


After working with TOM for several hours, Collins will have reacted to enough scenarios for TOM to learn to make her decision. The Twin will need to demonstrate that it can replicate her decision-making with acceptable accuracy—high 90s to 100 percent. Once there, Collins’ Twin is ready to use.


“I think it’s important to have concordance between what I would say in a situation and then what my digital twin would say in a situation because that’s our ultimate goal is to have an AI algorithm that can duplicate what my recommendation would be given these circumstances for a patient,” Collins says. “So, someone, whether that be an insurance company, or a patient themselves or another provider, would be able to consult TOM, and in essence, me, and say, in this scenario, would you prescribe a GLP-1 or not given this specific patient’s situation?”


The patient’s current health and family history are critical when deciding whether or not to prescribe semaglutide. For example, according to Novo Nordisk, the makers of Ozempic, the drug should not be prescribed to patients with a history of problems with the pancreas or kidneys or with a family history of thyroid cancer. Those are just the start of a list of reasons why a patient may or may not be a good candidate for the medication.


Kuhnert says, “What we’re learning is that there are so many primary care physicians right now that if you come in with a BMI over 25 and are prediabetic, you’re going to get (a prescription). But there’s much more data around this to suggest that there are people who are health marginalized, and they can’t do this. They should not have this (medication). It’s got to be distributed to people who can tolerate it and are safe.”


Accessing the Digital Twin on TOM


Collins’s digital twin could be available via something as easy to access as an iPhone app. “Part of my job is to provide the latest information to primary care physicians. Now, I can do this in a way that is very powerful for primary care physicians to go on their phones and put it in. It’s pretty remarkable, according to Colllins.”


It is also transparent and importantly sourced information.


Any physician using a digital twin created with TOM will know exactly whose expertise they are accessing, so anyone asking for a second opinion from Colllins will know they are using an expert physician from Emory University.


In addition to patient safety, there are a number of ways TOM can be useful to the healthcare industry when prescribing medications like semaglutide. This includes interfacing with insurance companies and the prior approval process, often lengthy and handled by non-physician staff. “Why is a non-expert at an insurance company determining whether a patient needs a medication or not? Would it be better to have an expert?” says Collins. “I’m an expert in internal medicine and lifestyle medicine. So, I help people not only lose weight, but also help people change their behaviors to optimize their health. My take on GLP-1 medications is not that everyone needs them, it’s that they need to be utilized in a meaningful way, so patients will get benefit, given risks and benefits for these medications.”


The Power of a Second Opinion


Getting second, and sometimes third, opinions is a common practice among physicians and patients both. When a patient presents symptoms to their primary care physician, that physician may have studied the possible disease in school but isn’t necessarily an expert. In a community like Emory Healthcare, the experts are readily available, like Collins. She often serves as a second opinion for her colleagues and others around the country.


“What we’re providing folks is more of a second opinion. Because we want this actually to work alongside someone, you can look at this opinion that this expert gave, and now, based on sourced information, you can choose. This person may be one of the best in the country, if not the world, in making this decision. But we’re not replacing people here. We’re not dislocating people with this technology. We need people. We need today’s and tomorrow’s experts as well,” according to Kuhnert.


But also, you now have the ability to take an Emory physician’s diagnosing capabilities to physicians in rural areas and make use of this information, this knowledge, this decision, and how they make this decision. We have people here that could really help these small hospitals across the country.


Caroline Collin MD


Rural Americans have significant health disparities when compared to those living in urban centers. They are more likely to die from heart disease, cancer, injury, chronic respiratory disease, and stroke. Rural areas are finding primary care physicians in short supply, and patients in rural areas are 64 percent less likely to have access to medical specialists for needed referrals.


Smaller communities might not have immediate access to experts like a rheumatologist, for example. In addition, patients in more rural areas might not have the means of transportation to get to a specialist, nor have the financial means to pay for specialized visits for a diagnosis. Collins posits that internal medicine generalists might suspect a diagnosis but want to confirm before prescribing a course of treatment.


“If I have a patient for whom I am trying to answer a specific question, ‘Does this patient have lupus?’, for instance. I’m not going to be able to diagnose this person with lupus. I can suspect it, but I’m going to ask a rheumatologist. Let’s say I’m in a community where unfortunately, we don’t have a rheumatologist. The patient can’t see a rheumatologist. That’s a real scenario that’s happening in the United States right now. But now I can ask the digital twin acting as a rheumatologist, given these variables, ‘Does this patient have lupus?’ And the digital twin could give me a second opinion.”


Sometimes, those experts are incredibly busy and might not have the physical availability for a full consult. In this case, someone could use TOM to create the digital twin of that expert. This allows them to give advice and second opinions to a wider range of fellow physicians.


As Kuhnert says, TOM is not designed or intended to be a substitute for a physician. It should only work alongside one. Collins agreed, saying, “This doesn’t take the place of a provider in actual clinical decision-making. That’s where I think someone could use it inappropriately and could get patients into trouble. You still have to have a person there with clinical decision-making capacity to take on additional variables that TOM can’t yet do. And so that’s why it’s a second opinion.”


“We’re not there yet in AI says Collins. We have to be really careful about having AI make actual medical decisions for people without someone there to say, ‘Wait a minute, does this make sense?’”


AI Implications in the Classroom and Beyond


Because organizations use TOM to create digital twins of their experts, the public cannot use the twins to shop for willing doctors. “We don’t want gaming the system,” says Collins. “We don’t want doctor shopping. What we want is a person there who can utilize AI in a meaningful way – not in a dangerous way. I think we’ll eventually get there where we can have AI making clinical decisions. But I don’t think I’d feel comfortable with that yet.”


The implications of using decision-making digital twins in healthcare reach far beyond a second opinion for prescription drugs. Kuhnert sees it as an integral part of the future of medical school classrooms at Emory. In the past, teaching case studies have come from books, journals, and papers. Now, they could come alive in the classroom with AI simulation programs like TOM.


"I think this would be great for teaching residents. Imagine that we could create a simulation and put this in a classroom, have (the students) do the simulation, and then have the physician come in and talk about how she makes her decisions."


Karl Kuhnert
“And then these residents could take this decision, and now it’s theirs. They can keep it with them. It would be awesome to have a library of critical health decisions made in Emory hospitals,” Kuhnert says.


Collins agreed. “We do a lot of case teaching in the medical school. I teach both residents and medical students at Emory School of Medicine. This would be a really great tool to say, okay, given these set of circumstances, what decision would you make for this patient? Then, you could see what the expert’s decision would have been. That could be a great way to see if you are actually in lockstep with the decision-making process that you’re supposed to be learning.”


Kuhnert sees decision-making twins moving beyond the healthcare system and into other arenas like the courtroom, public safety, and financial industries and has been working with other experts to digitize their knowledge in those fields.


"The way to think about this is: say there is a subjective decision that gets made that has significant ramifications for that company and maybe for the community. What would it mean if I could digitize experts and make it available to other people who need an expert or an expert’s decision-making?"


Karl Kuhnert

“You think about how many people aren’t available. Maybe you have a physician who’s not available. You have executives who are not available. Often expertise resides in the minds of just a few people in an organization,” says Kuhnert.


“Pursuing the use of technologies like TOM takes the concept of the digital human expert from simple task automation to subjective human decision-making support and will expand the idea of a digital expert into something beyond our current capabilities,” Kuhnert says. “I wanted to show that we could digitize very subjective decisions in such areas as ethical and clinical decision-making. In the near future, we will all learn from the wisdom codified in decision-making digital twins. Why not learn from the best? There is a lot of good work to do.”


Karl Kuhnert is a Professor in the Practice of Organization & Management and Associate Professor of Psychiatry, School of Medicine and Senior Faculty Fellow of the Emory Ethics Center.


If you're looking to connect with Karl to know more - simply click on his icon now to arrange a time to talk today.

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Karl Kuhnert

Karl Kuhnert

Professor in the Practice of Organization & Management and Associate Professor of Psychiatry, School of Medicine. Senior Faculty Fellow of the Emory Ethics Center
Leadership Development and AssessmentDecision Making Artificial IntelligenceOrganizational Change and DevelopmentSurvey Design and Evaluation

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#Expert Research: Incentives Speed Up Operating Room Turnover Procedures

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As a rule, well-established or stable teams work fastest and best, their efficiency fueled by familiarity and well-oiled interpersonal dynamics. But in hospital settings, staff work in shifts and according to different schedules, which creates a certain fluidity in the way turnover teams amalgamate. These team members may not know each other or have any prior experience working together. For hospital administrators this represents a quandary. How do you cut OR turnover time without compromising patient care or hiring in more staff to build more stable teams? To put that another way: how do you motivate OR workers to maintain standards and drive efficiency—irrespective of the team they work with at any given time? One novel approach instituted by Georgia’s Phoebe Putney Health System is the focus of new research by Asa Griggs Candler Professor of Accounting, Karen Sedatole PhD. Under the stewardship of perioperative medical director and anesthesiologist, Jason Williams MD 02MR 20MBA, and with support from Sedatole and co-authors, Ewelina Forker 23PhD of the University of Wisconsin and Harvard Business School’s Susanna Gallini PhD, staff at Phoebe ran a field experiment incentivizing individual OR workers to ramp up their own performance in turnover processes. What they have found is a simple and cost-effective intervention that reduces the lag between procedures by an average of 6.4 percent. Homing in on the Individual Williams and his team at Phoebe kicked off efforts to reduce OR turnover times by first establishing a benchmark to calculate how long it should take to prepare for different types of procedure or surgery. 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Typically, turnover tasks will include removing instruments and equipment from the previous surgery and setting up for the next: restocking supplies and restoring the sterile environment. Turnover tasks and activities will vary according to the type of procedure coming next, but these tasks are always performed by the same three roles: nurse, scrub tech, and anesthetist, working within their own area of expertise and specialty. OR turnover teams are assembled based on staff schedules and availability, making them highly fluid. Different nurses will work with different scrub techs and different anesthetists depending on who is free and available at any given time. With dashboards on display across the hospital’s surgery department, Williams decided to trial a second motivational mechanism; this time something more tangible. “We decided to offer a simple $40 Dollar Store gift card to each week’s top performing anesthetist, nurse, or scrub technician to see if it would incentivize people even more. And to keep things interesting, and sustain motivation, we made sure that anyone who’d won the contest two weeks in a row would be ineligible to win the gift card the following week,” says Williams. “It was a bit of a shot in the dark, and we didn’t know if it would work.” Altogether, the dashboards remained in situ over a period of about 33 months while the gift card promotion ran for 73 weeks. It was important to stress the foundational importance of safety and then allow individuals to come up with their own ways to tighten procedures. 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These are key findings for healthcare systems and for administrators and decision-makers in any setting or sector where fluid teams are the norm, says Sedatole: from consultancy to software development to airline ground crews. Wherever diverse professionals come together briefly or sporadically to perform tasks and then disperse, individual motivation can be optimized by simple mechanisms—cost-effective tangible rewards—that give team members a fresh opportunity to earn the incentive in different settings on different occasions—a recurring chance to succeed that keeps the incentive systems engaging and effective over time. For healthcare in particular, this is a win-win-win, says Williams. “In the United States we are faced with lower reimbursements and higher costs, so we have to look for areas where we can gain efficiencies and minimize costs. In the healthcare value model, time and costs are denominators, and quality and service are numerators. 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5 min

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Together with Panos Markou of the University of Virginia’s Darden School of Business, Chan scrutinized 17 years’ worth of information, including detailed transcripts from more than 500 FDA advisory committee meetings, to understand the mechanisms and protocols used in FDA decision-making: whether committee members vote to approve products sequentially, with everyone in the room having a say one after another; or if voting happens simultaneously via the push of a button, say, or a show of hands. Chan and Markou also looked at the impact of sequential versus simultaneous voting to see if there were differences in the quality of the decisions each mechanism produced. Their findings are singular. It turns out that when stakeholders vote simultaneously, they make better decisions. Drugs or products approved this way are far less likely to be issued post-market boxed warnings (warnings issued by FDA that call attention to potentially serious health risks associated with the product, that must be displayed on the prescription box itself), and more than two times less likely to be recalled. The FDA changed its voting protocols in 2007, when they switched from sequentially voting around the room, one person after another, to simultaneous voting procedures. And the results are stunning. Tian Heong Chan, Associate Professor of Information Systems & Operation Management “Decisions made by simultaneous voting are more than twice as effective,” says Chan. “After 2007, you see that just 3.4% of all drugs and products approved this way end up being discontinued or recalled. This compares with an 8.6% failure rate for drugs approved by the FDA using more sequential processes—the round robin where individuals had been voting one by one around the room.” Imagine you are told beforehand that you are going to vote on something important by simply raising your hand or pressing a button. In this scenario, you are probably going to want to expend more time and effort in debating all the issues and informing yourself before you decide. Tian Heong Chan “On the other hand, if you know the vote will go around the room, and you will have a chance to hear how others’ speak and explain their decisions, you’re going to be less motivated to exchange and defend your point of view beforehand,” says Chan. In other words, simultaneous decision-making is two times less likely to generate a wrong decision as the sequential approach. Why is this? Chan and Markou believe that these voting mechanisms impact the quality of discussion and debate that undergird decision-making; that the quality of decisions is significantly impacted by how those decisions are made. Quality Discussion Leads to Quality Decisions Parsing the FDA transcripts for content, language, and tonality in both settings, Chan and Markou find evidence to support this. Simultaneous voting or decision-making drives discussions that are characterized by language that is more positive, more authentic, and more even in terms of expressions of authority and hierarchy, says Chan. What’s more, these deliberations and exchanges are deeper and more far-ranging in quality. We find marked differences in the tone of speech and the topics discussed when stakeholders know they will be voting simultaneously. There is less hierarchy in these exchanges, and individuals exhibit greater confidence in sharing their points of view more freely. 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Tian Heong Chan “So it’s not that individuals are being influenced by what other people say when it comes to voting on the issue—which would be tempting to infer—rather, it’s that sequential voting mechanisms seem to take a bit more effort out of the process.” When decision-makers are told that they will have a chance to vote and to explain their vote, one after another, their incentives to make a prior effort to interrogate each other vigorously, and to work that little bit harder to surface any shortcomings in their own understanding or point of view, or in the data, are relatively weaker, say Chan and Markou. The Takeaway for Organizations Making High-Stakes Decisions Decision-making in different contexts has long been the subject of scholarly scrutiny. Chan and Markou’s research sheds new light on the important role that different mechanisms have in shaping the outcomes of decision-making—and the quality of the decisions that are jointly taken. And this should be on the radar of organizations and institutions charged with making choices that impact swathes of the community, they say. “The FDA has a solid tradition of inviting diversity into its decision-making. But the data shows that harnessing the benefits of diversity is contingent on using the right mechanisms to surface the different expertise you need to be able to see all the dimensions of the issue, and make better informed decisions about it,” says Chan. A good place to start? By a concurrent show of hands. Tian Heong Chan is an associate professor of information systems and operation management. he is available to speak about this topic - click on his con now to arrange an interview today.

4 min

Expert Perspective: The Hidden Costs of Cultural Appropriation

In our interconnected world, cultural borrowing is everywhere. But why do some instances earn applause while others provoke outrage? This question is becoming increasingly crucial for business leaders who must carefully navigate cultural boundaries. Take the backlash the Kardashian-Jenner family faced for adopting styles from minority cultures or the controversy over non-Indigenous designers using Native American patterns in fashion. These examples highlight the issue of cultural appropriation, where borrowing elements from another culture without genuine understanding or respect can lead to accusations of exploitation. Abraham Oshotse, an assistant professor of organization and management at Goizueta Business School, along with Assistant Professor of Sociology and Anthropology at Hebrew University Yael Berda and Associate Professor of Organizational Behavior at the Stanford Graduate School of Business Amir Goldberg, explores this in their research on “cultural tariffing.” They shed light on why high-status individuals, such as celebrities or industry leaders, often come under fire when crossing cultural boundaries. The Concept of Cultural Tariffing Oshotse and coauthors define cultural tariffing as “the act of imposing a social cost on cultural boundary crossing. It is levied on high-status actors crossing into low-status culture, in order to mitigate the reproduction of the status inequality.” This notion suggests that the acceptance or rejection of cultural boundary-crossing is influenced by the perceived costs and benefits. Cultural appropriation involves taking elements from a culture that one does not belong to, without permission or authority. For example, when Elvis Presley brought African-American music into the mainstream, it was initially seen as elevating the genre. However, in today’s context, such acts might be criticized as appropriation rather than celebration. This research seeks to analyze people’s modern reactions to different examples of cultural boundary-crossing and which conditions induce cultural tariffing. The Hypotheses The researchers make four hypotheses about participants’ reactions to cultural appropriation: People will disapprove of cultural borrowing if there’s a clear power imbalance, with the borrowing group having more status or privilege than the group they are borrowing from. Cultural borrowing is more likely to be criticized if the person doing it has a higher socioeconomic status within their social group. Cultural borrowing is more likely to be criticized if the person doing it has only a shallow connection to the culture they’re borrowing from. Cultural borrowing is more likely to be criticized if the person doing it benefits more from it than the people from the culture they are borrowing from. Put to the Test Oshotse et al exposed respondents to four scenarios per hypothesis (16 total) with a permissible and a transgressive condition. In the permissible condition, subjects exhibit lower status or socioeconomic standing or a stronger connection to the target culture. Subjects in the transgressive condition exhibit a higher status or socioeconomic standing and less of an authentic connection to the target culture. Insights from the Study Oshotse’s study offers four key insights: Status Matters: Cultural boundary-crossing is more likely to generate disapproval if there’s a clear status difference favoring the adopter. Superficial Connections: The less authentic the adopter’s connection to the target culture, the more likely they are to face backlash. Socioeconomic Influence: Higher socioeconomic status within the adopter’s social group increases the likelihood of disapproval. Value Extraction: The more value the adopter gains relative to the culture they’re borrowing from, the higher the disapproval. These insights are crucial for leaders who want to navigate cultural boundaries successfully, ensuring their actions are seen as respectful and inclusive rather than exploitative. Real-World Implications for Business Leaders Why does this matter for business leaders? Understanding cultural tariffing is crucial when expanding into new markets, launching multicultural campaigns, or even managing diverse teams. The research suggests that crossing cultural boundaries without deep understanding or respect can backfire. That’s especially true when the adopter holds a higher socioeconomic status. Consider the example of a luxury brand adopting traditional African patterns without engaging with the communities behind them. In this case, it risks being seen as exploitative rather than innovative. The consequences aren’t just reputational; they can also impact the brand’s bottom line. This research isn’t just about isolated incidents; it mirrors sweeping societal shifts. Over the past 50 years, Western views have evolved to embrace ethnic diversity and multicultural exchange. But with this newfound appreciation comes a fresh set of challenges. Today’s leaders must navigate cultural interactions with greater care, fully aware of the historical and social contexts that shape perceptions of appropriation. In today’s global and interconnected business landscape, mastering the subtleties of cultural appropriation and tariffing is crucial. Leaders who tread thoughtfully can boost their reputation and success, while those who falter may face serious backlash. By understanding the hidden costs of crossing cultural boundaries, business leaders can cultivate authentic exchanges and steer clear of the pitfalls of appropriation. Abraham Oshotse is an assistant professor of organization & management. He is available speak to media regarding  this important topic - simply click on his icon now to arrange an interview today.

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