Discovery Scaled. Delivery Didn’t. Yet.
Welcome to the Clinical Decade. Why the future of healthcare isn't about finding molecules or building apps, but designing systems.
Executive Summary (TL;DR):
The Paradox: Clinical technology has failed to increase productivity. For every hour with a patient, doctors now spend nearly two hours feeding a screen.
The Trap: We optimized for “Approval” and “Big Problems” on paper—and ignored the “Last Mile” reality of care delivery.
The Shift: 2015–2025 was the Era of Blind, Linear Development. 2026–2036 will be the Era of Clinical Design.
The Proof: PRAIM (Nature Medicine, 2025) shows that **workflow design—not just the algorithm—**drove a +17.6%increase in cancer detection.
The Promise: We cracked the code of biology. Now we must crack the code of implementation.
In medicine, cutting-edge technology has often decreased productivity instead of increasing it.
The metrics are brutal. Studies (like the Sinsky et al. report) show that for every hour a doctor spends with a patient, they spend nearly two hours interacting with the EHR and other desk work.1
Meanwhile, the world is drowning in data. In 2025, we generated roughly 175 zettabytes globally—about 175 trillion gigabytes.2 But the bottleneck isn’t volume. It’s interoperability, meaning, and governance. Healthcare is a rounding error in the datasphere… until you try to move a single imaging study across institutions.
And in this industry, we keep pretending data is “liquid currency.”
It isn’t.
It’s dirty ore: hard to find, hard to share, full of legal and regulatory hazards, and often unusable.
The result is a tragic paradox: we can cure diseases that were fatal twenty years ago—yet in many cases, a patient’s location and access to top-tier care can rival the impact of their genetic code on outcomes.
We have built the science of the future on the infrastructure of the past.
Discovery scaled. Clinical delivery didn’t. Yet.
Welcome to The Clinical Decade.
2. The Diagnosis: The Incentive Trap
Why does a sector that attracts the world’s brightest minds feel so broken at the point of care?
The answer is uncomfortable: we spent two decades optimizing for Funding and Approval, not for Reality.
We assumed that if the science was sound, the system would absorb it.
We were wrong.
Today we’re stuck in a trap defined by three disconnects:
Regulation ≠ Adoption
“Clearance tells you it’s safe; it doesn’t tell you it fits Tuesday at 11am in the clinic.”
We built an ecosystem designed to jump through regulatory hoops (FDA, CE, GDPR). But clearance is permission to market—not a guarantee of utility. We confused safe to use with easy to use.
Procurement & IT Constraints
“If it’s not in the viewer/EHR where the decision happens, it’s not real.”
We gave clinicians AI tools—and trapped them inside closed systems or endless “pilot purgatories.” Innovation dies at the hands of legacy IT lock-ins and procurement cycles that reward lowest cost over interoperability.
The Payment Disconnect
“Budgets are siloed; benefits are systemic.”
We built million-dollar gene therapies and tried to shoehorn them into reimbursement models designed for aspirin. Value accrues to the patient and society; costs land on a department line item. The incentives don’t meet.
We have mastered the science of discovery.
We are failing the science of delivery.
3. The Shift: From Discovery to Design
History will likely remember 2015–2025 as the end of the Era of Blind, Linear Development—the golden age of the “What.”
Biologics. mRNA. CRISPR. Multimodal diagnostics. Biomarker-driven therapies.
The biological hardware was built.
But 2026–2036 will be different.
This will be the Era of Clinical Design.
And let’s be precise about what “design” means here.
Clinical Design is not about a prettier UX or a sleek app.
It’s the discipline of designing the socio-technical system: the interplay between clinicians, workflows, incentives, evidence, data, and accountability.
Real innovation fails in the Last Mile because we treat implementation as an afterthought—as a logistics problem—when it’s actually an engineering problem.
To move from aspiration to reality, we need a new architecture.
A framework that bridges state-of-the-art science with world-class outcomes.
I call this Clinical Design.
Not the product. The ecosystem around the product. The missing discipline that turns biomedical innovation into adoption, evidence, and ROI.
(Next week, Part II: I’ll publish the 5-layer Clinical Design framework—and how to apply it.)
4. The Proof is in the Design: The Vara Case Study
We don’t need to imagine this future. We’re already seeing glimpses of it.
Consider PRAIM (Nature Medicine, 2025)3: a massive real-world implementation of AI in breast cancer screening across 12 centers in Germany.
They didn’t drop a high-AUC model into a hospital and hope for magic.
They designed the workflow.
The AI (Vara) was integrated as a viewer with two explicit design functions:
Normal Triage: flagging “very normal” studies to reduce workload.
Safety Net: alerting only after a radiologist dismissed a case the AI found suspicious.
The result: across 463,094 women, the AI-workflow group saw a +17.6% increase in cancer detection (6.7 vs 5.7 per 1,000) without increasing recall. The safety net triggered 3,959 times; radiologists accepted the second opinion 1,077times—leading to 204 cancers that would likely have been missed.
Post-hoc analysis suggested that if “very normal” cases were autonomously filtered, reading workload could drop by about 56.7%.
That’s the point.
The productivity didn’t come from deep learning alone.
It came from circuit design: triage + safety nets + integration into the real decision pathway. And when the viewer didn’t fit consensus workflow (e.g., missing synced zoom), adoption dropped.
All of this is Clinical Design in action.
Friction beats accuracy.
The real bottleneck is integration, not inference.
5. The Roadmap: What to expect from The Clinical Decade
This newsletter is my attempt to map this transition. I’m not here to hype press releases. I’m here to dissect the machinery of healthcare.
As a geneticist turned strategist, I look for signal in the noise. In The Clinical Decade, we will explore:
The Unit Economics of Innovation: how do we make precision medicine solvent for public systems?
Delivery is a Science: adoption as a discipline—change management, implementation science, operating models.
Infrastructure Debt: legacy EHRs and data silos as the technical debt of the clinic.
Adoption Metrics: Time-to-Value, Clicks Saved, Pajama Time, % Eligible Patients Reached.
Europe vs. USA: why startups fail differently—payer fragmentation vs public procurement and multi-country scaling.
6. The Call to Action
The era of linear innovation in healthcare is over.
The era of system design has begun.
If you are a builder, a translator, or simply someone who believes the future of health should be evenly distributed—not just evenly discovered—you’re in the right place.
We have the science. Now let’s build the system.
Next Monday: I’ll unveil the Clinical Design Framework—the five pillars required to cross the Last Mile of innovation.
Don’t miss it.
Welcome to THE CLINICAL DECADE
Why I’m doing this: I believe the next 10 years won’t be defined by who discovers the next molecule, but by who figures out how to deliver it.
Whatever your role (clinician, founder, investor, or policy maker) we are all architects of this new system.
Let’s build.
— Marcos
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