The “Four Cs” of Innovation - Dr. Lloyd Minor, Dean of Stanford University School of Medicine

Shiv Gaglani: Hi, I'm Shiv Gaglani, and today I'm delighted to welcome Dr. Lloyd Minor to Raise the Line. For the past decade, he has been the Carl and Elizabeth Naumann Dean of the Stanford University School of Medicine, where he has focused on precision health, increasing diversity and transforming the future of life sciences, among many other initiatives. Dr. Minor is also a professor of otolaryngology, head and neck surgery, and a professor of Bioengineering and of Neurobiology, by courtesy, at Stanford. 

Prior to joining Stanford, he was a provost and senior vice president for Academic Affairs of Johns Hopkins University, where he had also served as chair of the Department of Otolaryngology. With more than 160 published articles and chapters, Dr. Minor is considered a leading expert in balance and inner ear disorders and is a member of the prestigious National Academy of Medicine. 

So, thanks so much for taking the time to be with us today, Lloyd. 

Dr. Lloyd Minor: Thank you very much, Shiv. It's great to be with you. 

Shiv: So as you know, our audience is comprised of a lot of current and future healthcare professionals, so we always like to ask our guests to, in their own words, explain what got them interested in a career in medicine.

Dr. Minor: I think since childhood, adolescence, I'd always thought that being a physician and contributing to the health and well-being of others, to directly be involved in patient care and also doing science that hopefully advances health and well-being, those always were appealing to me. I was attracted to math and science, and so I think I always had being a physician in my mind. 

Then when I was an undergraduate, I took a course in bioengineering that used the vestibular system, and I'm pleased to see that just off your right shoulder, you have a wonderful image of a labyrinth on your background there. But this course used the vestibular system to show how you could use relatively straightforward mathematical and engineering principles not only to describe the way the system behaved and worked, but also really to drive the structure and testing of hypotheses on the function of the system. I thought then and think today that it's just an incredibly beautiful system.

I read the papers of the person who later became my mentor for my postdoctoral research fellowship, and just decided that this is where I wanted to bring things together as a physician-surgeon focused on the inner ear and related areas of otology and neurotology, and as a neuroscientist studying the physiology of the vestibular system. So, that's how I got started. 

Shiv: Yeah, it's very impressive. I started bioengineering in college, and I remember one of the most interesting classes I took actually went into the mathematics of the vestibular system, so I'm sure a lot of your work was cited in that. 

One aspect of your work and research work that I wanted to be sure to touch upon was that early on in your career, you discovered an inner ear syndrome that was quite debilitating for patients, and then later developed a surgical procedure to treat it, which is pretty unique. Can you tell our audience a bit about that disorder and what it was like to establish your career as a

physician-scientist in that way? 

Dr. Minor: Sure. I like to talk about the “four Cs” of innovation: it's combination, collaboration, chance, and culture. For me, those four Cs really are what enabled me to describe and discover superior canal dehiscence syndrome, and then ultimately develop a surgical therapy for those patients who are severely debilitated by the syndrome. Not everyone who has the syndrome needs to have anything done about it. It really dates back to the spring of 1995 when a couple of patients came to my clinic a few weeks apart from each other, but complaining of very similar symptoms. They complained that when they heard loud noises, they could see things move.

In fact, my very first patient showed me. He said, “Look, if you play a loud noise to my right ear, it'll make my eyes move.”  Sure enough, it did, and I recorded those eye movements. The second patient had similar symptoms, but also had this very debilitating symptom and sign of what we describe in the field as pulsatile oscillopsia. In other words, her vision in visual images of the world moved in time with her venous pulse pressure. There’s a physiologic reason for that, and that was quite debilitating. It was interfering with her ability to read. She basically couldn't drive a car because imagine trying to look at the road signs with a car in front of you when things are bouncing up and down. The point is, though, that the eye movements in these patients were not random. They were very specific, and they were aligned with the orientation or the plane of the top balance canal, the superior semicircular canal.

So, the combination part was being able to relate what I was doing as a basic researcher in the vestibular system to what I was seeing in the patients that had this complaint, and being able to study their eye movements in quantitative detail. Then there was collaboration because we reasoned, you know, what would cause the eyes to move in the plane of the superior semicircular canal? Well, going back over a century to the early days of vestibular physiology when all of the principles were being worked out, one of the experiments that was done was to remove the bone covering the semicircular canals in pigeons and to show that loud noises cause the pigeon's eyes and head to move in the plane of that canal. So, then we inferred that there must be something that is causing a deficit in the bone covering the top balance canal.

We worked with our colleagues in radiology to be able to image the canals, the semicircular canals. That was the late 1990s. CT imaging was nowhere near as sophisticated as it is today. We actually had to develop the algorithms to specifically look at those canals. So, that was a collaboration. 

The chance element was that these patients came to see me, and they had very specific complaints. I'm confident that in my career, I've learned more from my patients than they've learned from me in terms of what they've taught me about their lives and the problems they are having, which has helped to guide much of the science that we've done. So, that was the chance part. 

In addition to the chance part was the eye movements in that first patient evoked by sound were among the largest eye movements evoked by sound that I've seen in my career in any patient with the disorder and I've now seen hundreds of patients with the disorder. That was fortuitous because if it had been a very, very subtle eye movement, I'm not sure that I would have seen it or appreciated it as clearly as I did in that patient. 

And finally, culture...and this is where being at an academic medical center and a research university matters because a culture of inquiry and a culture of collaboration is so important to making scientific advances that benefit patients. I certainly benefited from the Hopkins culture during the nineteen years that I was at Hopkins, and now very much benefit from the culture here at Stanford. So, that's the story behind what we refer to as superior canal dehiscence syndrome.

Shiv: That's incredible. I never heard that four C's framework. Is that from a book? I'd love to explore that further. 

Dr. Minor: Well, I started out with three C's -- combination, collaboration and chance -- and added the fourth based upon some discussions with others once I came here to Stanford that culture does play such an important role. 

Shiv: Okay. So, it's your framework. That's awesome. Yeah, that's great, and great examples. It reminds me of Louis Pasteur's statement that “chance favors the prepared mind” as well. Clearly, the fact that you knew about this pigeon paper, or found it at least, was very interesting. Very cool. 

So, let's talk about Stanford. We talked a bit before the show started about Hopkins, but you moved over to Stanford just over a decade ago. Can you tell us a bit about the program and what sets it apart? We'd love to hear from you about what makes it such an awesome place. 

Dr. Minor: Well, I became provost at Johns Hopkins in 2009 and that, for me, was the best leadership learning experience I've ever had. I learned a tremendous amount as provost and had the privilege of working with President Ron Daniels at Johns Hopkins and the deans. Hopkins is a huge institution. It's nine schools spread out in the Middle Atlantic region, but also globally. The provost is oftentimes the problem solver, but also has a very important proactive mission in thinking about the academic future of the university and working with others to help make sure that that future is bright and successful.

As a provost, I met other provosts -- including at the time Stanford's provost, John Etchemendy -- through a group called the Ivy Plus Provost Group, which includes the Ivies plus I think it's Stanford, University of Chicago, Duke and Johns Hopkins.  I had just led the search that resulted in the recruitment of Paul Rothman to be the dean and CEO of Johns Hopkins Medicine and John Etchemendy asked me if I would come out, this was in 2012, to meet with the search committee to talk about that process and talk about my thoughts about the future of academic medicine. 

I did make that trip, had a wonderful visit, and that led to a discussion about whether or not I might make a move to Stanford. After further meetings with the search committee and with the president, John Hennessy, I was offered the position of dean of medicine here and have had the good fortune of starting here officially as dean on December 1st of 2012.

I think what attracted me to Stanford was and is Stanford's academic medical center, Stanford Medicine, which is the school of medicine in our two health systems: Stanford Health Care, our adult hospital and delivery system; and Stanford Medicine Children's Health, our children's hospital and associated delivery system, and Lucille Packard Children's Hospital. Those three entities are very much a part of Stanford University. We're physically, geographically on the campus of Stanford University, at least our core facilities are. We're now, of course, spread out throughout the Bay Area region in terms of our outpatient facilities and some other activities. But our core activities are here on the campus. 

I'm a five-minute walk from the dean's office in the engineering school, a three-minute walk from the biology department, the chemistry department. Similarly, for my colleagues on the faculty, there is a level of collaboration here that partly is the ethos of the institution but it's encouraged by everyone being co-located. It's also, I think, promoted because we as a school of medicine are a school within the university and our faculty appointments and promotions processes begin within the school, but ultimately are completed at the level of the university. So, there's a consistency and a cohesiveness here that I think is very, very conducive to and supportive of interdisciplinary and multidisciplinary scholarship. 

Today, the future of the life sciences in biomedicine is so much defined by that interdisciplinary approach. So many fundamental advances -- both in curiosity-driven discovery science and early and advanced stage translation -- so many advances are at the intersection of fields and the interstices between fields. The organizational structure here at Stanford really helps to further and nurture those sorts of interactions and that feeling of really being a part of an enterprise that has excellence in all of its areas and that's so beneficial in life sciences and biomedicine today. 

Plus, the other thing that attracted me here was that at the time I was having the discussions about moving here in 2012, Stanford Medicine made the commitment to build two new hospitals and therefore, there was this very tangible commitment to growing the clinical enterprise and to making sure that our excellence in the clinical enterprise equaled our excellence in discovery-driven science and in our teaching programs.

One of the true silver linings is we opened our new adult hospital in November of 2019, just before the world changed in March. So, we'd had a chance to get moved in and get any sort of kinks worked out in the system. I can't imagine how we would have dealt with COVID had we not had that wonderful facility. We'd opened our new children's hospital a couple of years before that, so we had the facilities that we needed. 

Now we've been able to build up, I think, some truly remarkable excellence in clinical programs that make it very exciting to now see this continuum from fundamental discovery-driven, curiosity-driven science, all the way up through advances in clinical trials.

Shiv: Absolutely. We've had some previous guests on the Raise the Line podcast who have deep Stanford affiliations, people likeBJ Fogg, a professor there in behavioral sciences, and also Matt Wilsey from Grace Science who I think was on the board of fellows for Stanford Medicine. They say the same exact thing. 

Obviously, you have the best 360-degree view of the entire enterprise and, you know, it's always good to know, in the leader's own words, what makes a place special. I mentioned precision health as one of the main initiatives you've been driving in the course of your time at Stanford. You even have this book that you wrote called Discovering Precision Health. Can you tell us a bit about how you define precision health, and what our audience should know about that field because many of them are going to be clinicians of the future, and we want to make sure they're prepared for a future that includes precision health.

Dr. Minor: Yes. As I mentioned, I officially became dean on December 1, 2012. I'd never been on the Stanford faculty before. I'd given talks here, and certainly had colleagues and friends here. But the first responsibility of any leader is to learn the organization, learn the people, and build trust and establish constructive patterns of communication. So, as I was meeting with people in my early days here to talk about where the big opportunities are, there were many opportunities that came up. 

Then in the spring of 2013, I think it was, Susan Desmond Hellmann -- who was at the time the chancellor at UCSF -- hosted really the first conference, to my knowledge, on precision medicine. The conference had a truly amazing, distinguished group of panelists and participants, including Francis Collins from the NIH and other leaders in biomedicine. Most of the topics dealt with what you would expect in 2013, and that is applying genomics and the advances in genomic medicine to individualizing the treatment of severe acute diseases like, for example, cancer. 

Certainly, we've seen enormous benefit to human health from precision medicine. Today, a patient with breast cancer is not treated with a one size fits all, off-the-shelf type treatment approach. That treatment approach is tailored to the receptor status of the tumor. It's tailored to the status of any metastatic disease and a variety of other factors that have helped to individualize the treatment in an evidence-based way that has led to a significant improvement in outcomes over when we just had one garden variety approach that was used for anyone. 

We certainly did precision medicine at Stanford then, but what we then discussed after I participated in that precision medicine conference at UCSF, was that we should actually strive for something a bit different. We should be striving to take those enablers of data science and genomic medicine and apply those in a predictive and preventative and proactive way. I still remember a breakfast meeting that I had several months after the UCSF meeting with Steve Quake and Peter Kim. In my notebook that morning from that meeting, I have the two words precision health written down and that was really the birth of the concept. It sort of goes by several different descriptors. 

We think about precision medicine being about sick care and, for sure, if we have a severe acute disease such as a cancer or cardiac disease, then we want to have the very best precision medicine driven by data and specifics that individualize our therapy. But if we're better at predicting and preventing disease, first of all, we'll reduce its incidence and also we'll ultimately be better at curing disease because we will have detected it earlier when we're not able to predict it and prevent it in the first place. 

So, this notion of precision health is about keeping us healthy, and yes, when we do get sick, we need precision medicine. That's what we're doing on a day-to-day basis here in our tertiary/quaternary academic medical center. But in parallel, we're looking at ways that we can improve overall health and well-being through advanced diagnostics, through tailoring preventative therapies to risk factors in individuals, and how we can do a much better job at predicting when we're going to have a problem with our health and, hopefully, either forestalling it or preventing it altogether. 

Shiv: Now, that's a really good differentiation between precision medicine of reactive sick care versus precision health. I'm glad you share that with our audience. 

Now is actually a good time for me to ask you about a topic that's been top of mind for everyone over the past several months, ever since ChatGPT was released, and what your views are of artificial intelligence. I know it's obviously been applied at Stanford and other health systems for many years in other contexts -- radiology, dermatology, etc. But maybe you can talk about the future of life sciences work that you do as well as precision health and then any thoughts on AI that may have changed especially over the last six months since it's taken the world by storm.

Dr. Minor: I think that Large Language Models and Generative Pre-trained Transformers, the GPTs, are going to be, already are and will even be more so a true inflection point in human history, standing right up there at the top with other inflection points in human history. I mean, I've been a user of ChatGPT. I've also used a beta version of BARD, which is Google's large language model product that's undergoing evolution and development. It's incredible the way it brings information together and assimilates that information in a way that oftentimes is extraordinarily revealing and accurate. 

Now, what's been written about is there are issues related to hallucinations. I've noticed just in the time that I've been using it since the initial rollout of ChatGPT in November, that there are already improvements in that regard and one can only expect that they'll continue to improve with additional updates and training. 

Then it raises a number of questions. How is that going to impact discovery-based science? We've already seen, for example, AlphaFold being able to predict the protein structure of any protein which is incredible, and it’s having a profound effect on accelerating and increasing the shots on goal in drug discovery processes. 

I think there’s opportunity to improve the delivery of care. It's extremely frustrating for physicians and for patients that when you go to see any doctor today, the first thing they oftentimes do after saying hello to you is sit down behind the computer screen and start typing a note from the encounter. That's not the way it should be. Being able to capture that through AI-based approaches and accurately record the encounter -- at least what's important about the encounter -- and allowing the physician and patient really to connect with each other in the way that they should...I think that's going to be transformative. Being able to have interfaces to the public that are informed by these Large Language Models is going to be important to make sure that things aren't missed. 

So, there's no question in my mind that there will be lots of changes. The stakes are high, of course, in healthcare in particular. Whereas a hallucination or spurious association in some areas is annoying and can be misleading, it rarely endangers someone. But in healthcare and health, of course, it could do that very quickly and devastatingly. So, getting it right is going to be really important. 

Also, it was announced last week that Apple is requiring that any of its employees that use these Large Language Models declare and get permission and have it monitored by Apple because of this phenomenon that I guess in AI circles is known as jailbreak. It means that as we are typing in information to ChatGPT or whatever Large Language Model, it's looking at that and comparing it to its existing database. One can imagine a perfectly innocent inquiry of a physician who says, “I have a sixty-five-year-old patient with congestive heart failure” and fills in a bunch of other details that then based upon information already in the database might lead to an identification, even though the physician has not put anything that would resemble a unique patient identifier. That's not an inconceivable possibility. So, there are going to be a lot of things that have to be put in place both to protect privacy and also to make sure that misleading information is not being generated by the models.

Shiv: Yeah, totally. It's a very nuanced answer and an important answer because obviously, there's that double-edged sword of a lot of excitement around the benefits of LLMs -- especially for healthcare for the reasons you discussed -- but then also these Achilles’ heels, potentially, of the models like hallucination and privacy risk. So, it'll be really interesting to see how the next couple of weeks and months evolve, frankly, let alone years. 

Moving back to your role as the dean, I know leadership is a key interest of yours and you actually have your own podcast dedicated to the topic. I wanted to give you the opportunity to talk a bit about that and maybe some lessons on leadership that you'd be willing to share with our audience.

Dr. Minor: Well, thank you. During COVID, I did a fair amount of media just to try to communicate what we knew about the virus and what we knew about vaccines and some of the other public health measures that were being announced in our region and around the country. I enjoyed doing that and I got some good feedback. I also met a lot of people whom I really respect and learned a lot from in that process. I decided to have a podcast on leadership so that I can continue that learning process from others and also hopefully share what I learned from others in these interviews with a broader audience. 

It's been wonderfully enlightening and we've had a diverse group of guests and have even more coming up, and each one of them has contributed so much from describing their life stories, from giving their description of the key lessons in leadership for them during their lives and what they're excited about in terms of the future and what gives them hope for the future. So, that was the reason for the podcast and it's been nice to get feedback that people are learning from it and enjoying it, which is our intention. 

In terms of leadership philosophy, there are several things. One is that -- and this has been written about a lot and maybe what I'm doing is just reinforcing what others have written about very extensively -- there's never been a more important time for empathy in leadership. There's never been a more important time for us as leaders to be great listeners and engaged listeners. All of us, but in particular those of us involved in healthcare, have gone through a truly incredible three-plus years. Nothing like it in our lives or our careers. 

One of our faculty is a good friend of General James Mattis, who is at the Hoover Institution here at Stanford, and General Mattis reached out to this faculty member early in the pandemic and said, “How are you doing? Let me know if there's anything I can do to help you. I'm thinking about you. I'm supporting you.” The last line of the message was, “and remember, this is what you trained for.” I think that for General Mattis to say that, as I'm sure he must have when he was speaking with his troops before he was leading them into conflicts, that is absolutely the case. 

The thing is, for those of us in medicine, none of us trained for what we just went through. We should have, for sure, and hopefully, we're better prepared for the future because of what

we've been through. But none of us was prepared. People in healthcare positions -- nurses, advanced practice providers, the healthcare-related community -- really does a great job of pulling together for crises such as a plane crash or seasonal flu. We can pull together and muster up enormous amounts of energy and focus. 

The challenge with COVID is it was wave after wave, and it was so unpredictable and still is, by the way. And to keep that focus going and to have the unpredictability magnified over the course of months has made it particularly challenging in healthcare. Yes, in terms of workforce issues and in terms of the science and care-related aspects -- which fortunately we're much better at doing today and we have much more in our armamentarium, including some very effective vaccines -- but also just the human factors, the effects of the unpredictability and not knowing what's around the corner. So, empathy and being a great listener, I think, are the cornerstones of being an effective leader today. 

Shiv: That's excellent advice for anyone in our audience who's interested in taking on a leadership role. And frankly, anyone who winds up becoming a clinician is a leader of their care team, of their patient population, et cetera. 

I want to be respectful of your time, so my last kind of question and a half is to build upon that by sharing any advice you want to leave our audience with about approaching their careers in healthcare and then anything else you want to share about yourself, about Stanford or healthcare in general, as a parting word. 

Dr. Minor: I think, Shiv, the important thing for listeners to know that are contemplating or are embarking upon a career in healthcare is there's never been a better time to do what we collectively are doing. That is to provide care to patients at times of need and to engage with people in the unique ways that healthcare providers have of engaging. The future of life sciences is so incredibly bright. We have the convergence today of biology and biomedicine with information science and with technology, which is dramatically increasing the pace of discovery-driven science and the pace of translation. There's never been a better time to do what we do in our fields. 

There's also never been a more important time. Certainly, looking at the success of RNA-based vaccines going from the publishing of the sequence of the SARS-CoV-2 virus to the first FDA EUA for an entirely new class of mRNA-based vaccines in about eleven months...I mean, that's truly, truly remarkable. Now, it was eleven months or less because of the decades of discovery-driven research that had preceded it and because of a lot of very effective partnerships between government, academia, and industry. But let's learn from that to decide how we can use that amplifier effect in other ways that are beneficial for human health. 

But just as there's never been a better time, there's also never been the challenges we've faced... challenges associated, again, with burnout or fatigue in the workforce, challenges associated with funding the level of discovery-driven research that we know we need and want to fund. We have to keep those in perspective. 

But my hope for people would be, don't lose your optimism and maintain that optimism. Provide enough diversity in your life in terms of activities, in terms of your colleagues that you interact with, that you always stay engaged, and that you're always learning and growing in your lives professionally and personally. So, that would be my advice. 

Shiv: I think that's a wonderful and optimistic sentiment to end upon. So, Lloyd, I want to thank you so much for not only taking the time to be with us on the Raise the Line podcast, but more importantly for the work that you've been doing to, as we say, raise the line and strengthen our collective healthcare system.

Dr. Minor: Thank you very much, Shiv. It's been great being with you. Thank you.

Shiv: And with that, I'm Shiv Gaglani. Thanks for checking out today's show and remember to do your part to raise the line and strengthen our healthcare system. We're all in this together. Take care.