Scalable Education for Cancer Patients and Their Loved Ones: Dr. David Grew, Founder and CEO of PRIMR

Michael Carrese: Hi, everybody. I'm Michael Carrese, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare. 

Today's guest, Dr. David Grew, is right up our alley here at Osmosis because he believes, as we do, in the power of using video as a learning tool, in the case of Dr. Grew and his company, PRIMR, custom animated videos are created and distributed to spread awareness of clinical trials and to educate patients about cancer. 

Dr. Grew is a board-certified radiation oncologist based in Connecticut and the founder and CEO of Primer, and we're looking forward to tapping his blend of medical expertise and patient-centered insights on today's episode. Thanks so much for joining us. 

Dr. David Grew: Thanks for having me, Michael.

Michael: We love to know more about our guests and kind of what drove them to the path that they're on. So, what's your story about getting interested in medicine and then particularly oncology? 

Dr. Grew: Sure. So, I actually had initially planned to go to college to study business, but as sort of a last-ditch effort, my mom encouraged me to instead enroll in the liberal arts college at the undergrad school I went to, which was Fordham University in the Bronx. That ended up being a good choice because once there, I had always loved science, so I decided to go pre-med and I said, “Well, let's just ride this wave as long as I can. If I fail at it, whatever.” I didn't feel like I had much to lose, to be honest, but I really enjoyed it. 

Along the way there as an undergrad was when like the early seeds of having some ideas about creating a digital product to help people learn with images came to me. Almost always when I was studying biochemistry or physics, I was creating these drawings for myself as my own study aids. I'd be holed up in the library all by myself, just creating reams and reams of paper with these visual maps to understand how biochemical pathways flow or physics problems can get solved. 

I had the beginning of some ideas about how you could turn this into an animated product to help other pre-meds who would come behind me have an easier time studying, but never really went anywhere. I didn't have any time and I didn't have any money and so it just kind of fluttered away. I ended up going to medical school down at Tulane in New Orleans and for some extra money during med school, I got a job teaching undergrads how to take the MCAT at a whiteboard. 

It was kind of like the standard, you know, stand in front of the classroom and solving problems at a whiteboard using different colors and I really loved that. I continued to do it as I studied through med school, and then really just carried that practice of using simple visual aids into my own practice of medicine, where I just ended up doing it just standardly. When I see a new patient who has cancer, I'll get the paper out or draw on the exam table paper or just flip the consent form around and just draw right there: here's your lungs; here's your heart; here's where the tumor is; these are the kinds of treatment options we have. 

I just noticed that patients, when they saw that, it would really allow them to intuit what kinds of treatments they would need and also what kinds of side effects. So, all of these things swirling around, came to a head at the beginning of COVID because there was a real need to create scalable digital products so that you could include family members in the conversation and that's really when the business kind of took off. 

Michael: Yeah, that's a good point because everybody was remote and needing to find a way to be educated and help make decisions for their loved ones and so forth. Before we pursue more about that, why did you choose radiation oncology as a path? 

Dr. Grew: When I was a third-year med student, I was doing my rotation on internal medicine and we had admitted a woman to the hospital who had massive ascites. It was unclear what was going on, but we were pretty sure she had a new cancer diagnosis and ultimately, we did diagnose her with ovarian cancer. I had thought I was going to go into internal medicine. I just remember the team kind of high-fiving each other like, ‘we got it,’ you know? And I was sort of scratching my head like, “Well, this journey is just starting for this patient.”

I ended up following her once she got discharged into the oncology clinic and I started going to the tumor boards, which for those who don't know, it's a really cool thing that's pretty standard across the country. It's a multidisciplinary standing meeting -- usually once a week for a certain disease site, like in her case, gynecologic oncology -- and all the docs are there. The radiologist is there to present the images. Pathologist is there to show slides from the biopsy. Medical oncology, surgical oncology, radiation oncology are all there and I just was totally hooked. I was like, this is so cool. All these docs in the same room talking about one patient all at once. It was just a phenomenal way to collaborate and practice medicine as a team. 

So, after we kind of established care for her case, I just kept going to these meetings every week. I would kind of sneak away from rounds and go and attend these conferences and I started to develop a sense of what each of those team members was really responsible for. Just like a multiple choice test, one by one I was eliminating each of the other roles. Radiologist, he doesn't seem to really ever see patients and the pathologist is certainly not and I liked talking to patients. The surgery seemed cool, but I didn't want to spend that much time in the OR. I never really knew where to put my hands. And medical oncology was just too much medicine for me, to be honest.

So, radiation oncology seemed like the nice blend of anatomy, patient care and multidisciplinary care so I started doing some shadowing in that department and I just loved it. It was a lot of physics, it's a lot of geometry, but there's also a lot of like very practical bedside conversations that happen, and so I kind of took off from there. I went and did some rotations at other institutions. I went to rotate up at Yale and NYU and really just solidified my interest. 

Michael: Well, that all makes sense. And it's really one of the cool things about medicine is, you know, there's so many paths you can take and different ways to kind of scratch your itches. 

So, let's get back to the story of developing tools for people to help understand their situation and their care. Talk about how COVID kind of kicked that off in a way. 

Dr. Grew: Sure. As you recall, there were these no visitor policies, so patients, even though they had a new diagnosis of cancer, had to come alone, which is a big deal and which in retrospect is kind of nuts. I mean, it's almost torturous. This patient is face to face with their mortality for the first time and they are going to meet with an oncologist. They're going to have to trust to put their lives in their hands, and they're alone. It's not an optimal environment for knowledge transfer or knowledge retention. 

So, it was pretty clear to me that at a baseline, oncologists can see the deer in headlights look. They recognize that on patients’ faces, but COVID just really exacerbated that and it was obvious that patients were not retaining much. So, these little hand drawn images that I was making became that much more important. I noticed that patients began to start asking me if they could keep them. I'm looking at it and it’s just this scribbled mess. Usually the value of it is the act of doing it, right? In the end, it just looks like a bunch of pen scribbles on paper. 

So, I was wondering why they wanted to keep it. And a few patients said to me, “Well, I'm going to have to go home and explain all this to my family. There's no way I'm going to be able to do it so I'm going bring this piece of paper and that will hopefully help me.” Then the light bulb went off. I need to digitize these so that we can have this more bespoke custom educational moment between a doctor and a patient and do it at scale so that patients can be involved, they can understand what I'm saying to them. 

So, I started converting the most common explanations I would give my patients across a variety of malignancies -- prostate cancer, breast, lung, CNS malignancies -- and created a library of about fifty, two to three minute long videos that patients could consume either ahead of their appointment with me or in the clinic while they're waiting or at home and share with their family across the country. The response was great. They loved it. I was getting calls from patients. I was getting calls family members who were in California saying, you know, “I didn't understand what was going on, but this was really helpful. Now I can support my family members.”

So, I knew that the spark of creating some value or solving a problem for somebody was there. But around the same time, the principal investigators who were in my network for clinical trials saw what I was doing just from what I was posting on social media and they came to me and said, “We have this complex oncology trial. It is very hard to explain to patients and not only that, we need to standardize a good explanation and distribute it at scale across these forty or fifty sites that will be enrolling patients. So, we want you to create a video for it.” And that was how this just sort of project that I was doing became a business. 

Michael: So, two things I'm interested in. One is that how did you operationalize this? You're not a trained animator or artist. What program were you using to create these in the first place? And secondly, obviously, this is, in the end, about educating people. What skill set were you drawing on to know how to do this and educate in a way that it would have an impact and would stick with people?

Dr. Drew: Sure. I just bought an iPad and started noodling around to find out what are the available simple software programs and iPad applications, that I could use to basically narrate and then draw with an Apple pen. They are very simple drawings. If you've seen them, especially the stuff that I was creating at the beginning, it's not polished. It's pretty rudimentary and that’s intentional. To be honest, it's meant to replicate the authenticity and quality of a physician led explanation. And so it was just a simple iPad app that's called Explain Everything. I've worked with them the whole time, I still do all of my storyboarding with that application. I got to know the CEO, and they're just a phenomenal company. And so that's the tool that I use. I got this Blue Yeti mic and an Apple pen and an iPad, and it was all in maybe $1,500 or something.

Michael: Yeah. 

Dr. Drew: So, you don't need much if you really have experience or knowledge that you want to share with somebody else. It doesn't matter if you're a construction site manager or an oncologist or a school teacher. If you have the drive to create an educational piece of content, you don't need very sophisticated tools to do that and distribute it these days, which is phenomenal. What was your second question? 

Michael: So, just the educational piece of it. I mean, how did you know how to communicate in a way that was going to reach people and know that it would be effective? 

Dr. Drew: Yeah. So, for sure, the answer to that is through thousands of conversations with patients where over the years, you develop a sense of what part of an explanation trips people up or what part of an explanation you can see you've lost someone. You develop a sense of what the follow-up questions are over time to kind of iterate and tighten up what are the elements of a good quality explanation for cancer.

I couldn't tell you that there was any sort of formulaic way of doing it at the beginning. It was really just based on the feedback from my own patients, just from practicing and paying attention to what landed with them and what confused them. 

Michael: So, as the years have gone on and you've gotten more experience doing this sort of thing, have you stayed with that pretty simple approach?

Dr. Drew: It is pretty basic. That's a core principle of what we're trying to build, which is to keep it as simple as possible. The headline on the landing page for our website is “Simple Cancer Explanations.” I believe that complex explanations are probably masking some level of misunderstanding or some lack of knowledge on the side of the explainer. If you can't explain it to a fifth grader, then you probably don't understand it that well yourself. So, we really just are trying to keep the images themselves and the script as simple as possible so that any person who walks in off the street will be able to understand even the most complex clinical trial. 

Over time, have kind of developed a formula for how you can achieve that goal, but at its core, it's really based on simplicity and based on the years of feedback from actual patients.

Michael: Well, speaking of feedback, what kind of feedback do you get from the folks who are running the trials and from patients? What is it that seems to really resonate with them? 

Dr. Drew: Well, I think it does get back to the simplicity. It becomes something that works for the person who has a fifth-grade education level, who comes in off the street and has gone through a few lines of treatment and now only has clinical trial options. They're able to understand these trials where the prior alternative was a forty-page informed consent document written in legalese, which is obviously a terrible alternative and a really suboptimal way to recruit patients’ participation in trials. 

And that's so important, not just for their benefit, but for the benefit of future patients. It needs to be a group of participants who represent a broad swath of the population, because if we just test a drug or a device on one small segment of society that's super selected for the highest education level, the means, the ability, and the social support to travel to enroll in trials, then we've only verified that that drug or device is safe and effective for that tiny group of people. We haven't really established that it works at scale across an entire population. 

We need to be able to recruit patients on trials who have a variety of backgrounds and that is the feedback that we're getting from sites and from real patients who are watching the videos is that, you know, I finally understand this and it establishes a level of trust and credibility that's so important at the beginning stages of a conversation about enrolling on a clinical trial.

Michael: I'm curious to what extent your audience is other providers, and I bring that up because burnout has been a big topic on this program and we've heard from other providers that part of the burnout can stem from doing patient education in a really inefficient way and having to go over the same information with patient after patient after patient. 

Dr. Drew: Yeah. 

Michael: You know, they've asked for resources like this from Osmosis or we've talked about other ways that this can be approached. So, I'm just wondering if you see this as helping in some way or fitting into part of the answer to the question. 

Dr. Drew: Exactly. I mean, burnout is real. It's happening left and right. I think the latest statistics are something like 40 or 50% of current physicians are thinking about exiting the field in the next three to five years. It's a horrible, horrible state of affairs as far as burnout goes, so anything that we can do that is able to still deliver high quality patient care but reduce some of the burden on providers is worth pursuing aggressively and pouring resources into. 

One site that we've worked with quite a bit is New York Presbyterian and Cornell. We've done I think at this point about six trials with them that they have open at that site and a variety of investigator-initiated trials, some NCI-funded large cooperative group studies and then also industry-sponsored trials. So, kind of from each category of clinical trials. They basically have established a workflow where patients are identified earlier in the process of their journey to meet with all of the different subspecialists in the cancer center and they're presented with the content to explain the clinical trial options earlier in the process so that when they get to the conversation with the specialist, they're very well versed in what the options are, they understand the trial, and in many cases, it seems they've already kind of done that. They're kind of self-selected to participate on that trial. 

So what does that do for the provider? It makes it so that the provider doesn't have to then --when they've got five other people waiting for them in other clinic rooms -- spend the fifteen minutes to give that good explanation that any patient needs and deserves to establish the trust and credibility that's necessary to move to the next step towards enrolling on the trial. 

We basically have built a tool for them that has zero cost of replication and that scales infinitely across all of the trial sites and across their clinics, that is still delivering an excellent patient experience and is really just accelerating the time to treatment, the time to enrollment. 

Michael: You’ve mentioned scaling a few times. I'm curious about how the company is doing and what your vision is. How many different kinds of subject areas are you trying to get into and how many physicians and trials you're trying to reach? What's the ambition?

Dr. Drew: It's a big ambition. I think every clinical trial should have short form video that's very simple lay language with simple images and animation like what we build at PRIMR. I'm not saying I want to take over the world. I'm just saying I think patients deserve that. I think that should be just absolutely a standard and like I said earlier, the alternative right now is the forty page legalese informed consent form which is just a lousy way to do it. 

So, I'm kind of on a mission to correct that and make sure that patients have an easy way to understand these trials. We're starting with oncology. That's our beachhead. That's my specialty, but that's where about forty percent of the work of clinical trials is taking place, which makes sense, right? I mean, this is a huge problem. It's one of the leading killers internationally, and so it makes sense to do a lot of the clinical trial work in that disease so that's where that's where we're starting. 

Right now we're a very nimble and international team. We have a combination of some full-time workers and some contract workers across a variety of roles in the business. I still practice medicine, too. I'm in a practice in Connecticut. So we have, you know, graphics designers, we have folks who help us with sales and outbound and revenue generation, business development type things. We have people who help with foreign language narration and translation services, and then we have general administrative workers in the business, too. So it's becoming a growing and more robust business and we're excited to continue to scale. It's super fun and we think we're solving a big problem. So, we're going for it. 

Michael: So, as you know, Osmosis is also in the business of making educational videos and we always like to ask our guests to provide us with some direction. You know, here we have this audience of millions of medical students and other learners at our fingertips, if you will. What would you have us educate them about? What's something that's missing in medical education right now? What's something that you really think is interesting that more folks in their position should know more about? 

Dr. Drew: That's a great question. I think clinical trials are really the great frontier and I think that as medical students, we're really responsible for understanding the rock solid foundation and so that's definitely where you guys probably should be building. But I think having some early exposure to some the broader categories that have really exciting clinical trial work being done would probably be a fun area to build because fundamentally those things are grounded on basics of, you know, medical school level education. 

One area that I'm learning a lot about right now that's really fun is radiopharmaceuticals. I think for medical students, it would be really interesting to learn a little bit of basic information about radiopharmaceuticals, not only because it's combining sort of molecular targeting with antibodies -- which is obviously core to any sort of targeted therapy -- but it's also bringing that in with radioactive materials, which have been a huge field of medicine for diagnostic purposes. And so what radiopharmaceuticals are doing now is they're tagging these one sticky end to a certain molecule in the body that will help them tag like a prostate cancer cell, for instance, and then it will light up with a radioactive glow for a PSMA PET scan. That's a diagnostic application. 

But then there's also therapeutic applications where you can swap out the low dose radioactive compound that will help you for diagnostic purposes and stick in a very high energy radioactive compound that will actually destroy prostate cancer, and so it's just a really interesting and exciting field. There's a lot of biotech companies building not just for prostate cancer, but they've really built sort of a platform technology across which you can easily swap out the sticky end and then put in different payloads of different kinds of radioactive materials that a lot of people think, myself included, could have major implications for the way we approach metastatic cancer in the future. 

Michael: Unbelievable. Listening to you it  just sounds like science fiction, you know? 

Dr. Drew: I know. I know. It's pretty wild stuff. Theranostics, they call it. So, it's therapy and diagnostics. And you can have the same sticky end, but switch out the payload. It's pretty neat. 

Michael: Incredible. 

Dr. Drew: And you can see how explaining that to a patient without visuals is almost impossible. And it sounds terrifying, right? I'm like, wait a minute. You're injecting what liquid radioactive material in my body? I'm not sure about that. But when you can show it and you can show an image of metastatic cancer and then a sticky end that's going to go and attach to that and then while it's there, it's releasing radioactive material…that's very compelling. Oh, yeah. That's something you might want to do. 

Michael: Yeah. I want that, doc. 

Dr. Drew: Yeah, exactly. So, education can go a long way for recruitment. 

Michael: Right. We're running out of time here. I do want to give you a chance to answer one of our favorite questions, which is that, as I mentioned, we have kind of a younger audience, a learning audience. What's your advice generally to them about approaching their careers? And I'm thinking people are listening to your story and saying, man, how did this guy figure out how to create this entirely different part of his medical life? This other mission of education. So, what would you say?

Dr. Drew: The most important thing for me has been to just discard the fear of public failure in front of all of your colleagues and your peers. That is something that is really drilled into us from premed through med school, internship, residency and then in your career, right? Failing publicly is something that we feel could, or would, ruin us. I think you can ruin your reputation if you start doing things that show that you lack integrity, but I think the downside risk for doing things like trying to build something big is way less than people think. Taking a risk and discarding your fear of failure and just getting started is the first step for everybody who is trying to build something.

You can't build something big or small if you're afraid of what people will think of it, because you're going to be wrong a thousand times before you get something right and you just need to not care about that. So, I would encourage anyone who's thinking about doing something a little different, doing something unique, going down a slightly maybe parallel but slightly different path than the one that's carved out for them historically, is just go ahead and let go of that fear and do it for yourself. You only live once. You don't have much time here, so just go for it. 

Michael: That's terrific advice and a great way to end. I really want to thank you for your time today, Dr. Grew. It's been fascinating conversation and we wish you the best of luck. 

Dr. Drew: Yeah, thanks. And I'd encourage any of your listeners to reach out if you have any questions. I'm happy to help. 

Michael: What's the best way for them to do that? 

Dr. Drew: So I'm on LinkedIn. Pretty active there. A little bit less active on Twitter. It's Dr. Grew on Twitter and LinkedIn. It's just my name. And I'll just give my email too. It's [email protected]. 

Michael: All right. We’ll be sure to put all that in the show notes and I'm sure you'll be hearing from some folks. At least I hope you will. With that, I'm Michael Carrese. Thanks for checking out today's show and remember to do your part to raise the line and strengthen the health care system. We're all in this together.