An App for Gut Health Using “Whole Self Science” - Jeff Glueck, CEO and Co-Founder at Salvo Health

MICHAEL CARRESE: Hi everybody, I'm Michael Carrese. Each year, 60 to 70 million Americans are diagnosed with a digestive disorder, and many more than that go undiagnosed. To help meet the need for care our guest today Jeff Glueck co-founded Salvo, described as a medical clinic in an app, to provide specialty care for people suffering from chronic GI conditions such as IBS, GERD, and celiac. But there's a larger mission at hand as well, and that is to improve access to specialty care for many other chronic conditions and to develop a new model for healthcare delivery. Jeff is a longtime tech executive with more than 20 years of experience in startups and growth companies, including a couple that you just might have heard of, called Travelocity and Foursquare. Jeff, thanks very much for being with us today.

JEFF GLUECK: Thanks, Michael. Glad to be here.

CARRESE: We always like to start first with learning more about our guests. In your case, what first got you interested in tech and being a tech entrepreneur?

GLUECK: I've been a tech entrepreneur, or executive, for over twenty years now. I started my first e-commerce company back in 1999. It was a last-minute travel company inspired by a problem my friends and I had organizing a trip for ten to go see Jazz Fest in New Orleans. We thought there should be an easier way to buy a last-minute trip to someplace fun. We created Site59 and grew it to $100 million in sales. Travelocity acquired it, and that's how I ran marketing for Travelocity for seven years and launched the Roaming Gnome and all that, but that was my start.

CARRESE: That's a pretty good start.

GLUECK: Yes, I love entrepreneurship and solving problems. We can talk about how I came to Salvo, but I think entrepreneurship is best when you have a deep passion and mission for the cause and you bring together experts from different disciplines, and in my case, a knack for working with scientists and technologists and consumer designers to try to solve things that make people's lives easier.

CARRESE: So, do you see your role as kind of a bridge? Some people talk about it as being a translator between different sorts of people, different sorts of brains.

GLUECK: Absolutely. As a founder or CEO, I sometimes describe my role as an integrator, but that's very much about translating between finance types, technologists, marketers, customer service people, and everyone else. Most importantly, it's about listening to the stakeholders, particularly the users, the customers, and that's the journey that led to Salvo.

CARRESE: Yes, well, let's get into that. Obviously, getting into healthcare is a departure from the spaces you were in before. How did you guys all come together to create Salvo, and what problem were you trying to solve?

GLUECK: My personal journey influenced coming together with my two partners. I'll give you one minute of background. The thing that probably inspired it the most started about fifteen years ago. My wife and I were expecting our first child, and we lost what would have been our first son at twenty-three weeks into a pregnancy and it was just the worst, most traumatic experience losing a child before they're born. As we went through it, we heard all kinds of things that just stuck with you through this emotional experience. I remember asking the physicians—it was a clotting disorder that had caused the problems with the child—why didn't they catch that in genetic testing more often, and the doctor said, "Well, we don't even bother because the insurance companies won't pay for genetic testing for the parents until you've had three miscarriages."

CARRESE:  Oh my goodness.

GLUECK: I thought, “Wow, that doesn't seem cost effective, let alone, cruel,” but I also remember asking our physician, "Please tell me,”—at the time I was CEO of Foursquare; we used machine learning all the time to try to solve problems. We had years of longitudinal data, machine learned, anonymous aggregated data, privacy-safe data, and we were constantly using data scientists to mine to look for trends—I said, "Please tell me that my wife's experience, and mine, and thousands of other parents' goes into some really well-structured research database, and doctors and data scientists are constantly helping each set of patients get better care because of the patients three months ago, and six months ago and nine months ago and a year ago." And the doctors just shook their head and said, "That's not how healthcare works." I said, "Wow, well, that sounds like something we should fix, because healthcare is the most important industry in the world.”

I was thinking about that. I grew up the son of a doctor; my dad was trained at Mass General, Harvard Medical School, very outstanding doctor, his patients loved him, but very conventional. My mom, growing up in the 70s, was interested before a lot of people in what you now think of as lifestyle and preventative medicine, things like getting sugars and processed foods out of your diet, or herbal supplements, or exercise and mental wellness and how that could affect your health. For my dad and a lot of the physicians I grew up around, it didn't matter what you ate, and exercise wasn't that important, you could just take a pill. They were great doctors, but they were very conventional. 

As an integrator, and as an evidence-based, data-based kind of entrepreneur, I kept thinking, "Well, why can't you use science to reconcile and integrate the best of these two approaches, rather than just dismiss them?" Especially because we live in a country where, if you look at healthcare spending compared to the other 30 richest OECD countries, we spend about 19% of GDP on healthcare. The average is around 9%, so we're spending about double, but we don't live longer; we don't have healthier stats than the other wealthy thirty countries. So, something's broken, and how do we get at it?

The third thing that was personally moving for me is that when we finally had our twins, we brought the twins home and we discovered they would break out in rashes. We discovered that they were having reactions to some of the chemicals, like formaldehyde, in the diaper creams, and in the breastfeeding pillow that the hospital gave us as we left as new parents. It started my wife on a journey to research and meet some of the leading scientists and physicians, and understanding how chemical and toxic exposures and diet and things can affect health. She launched a nonprofit called MADESAFE.org that helps people find products that are free of known carcinogens, endocrine-disrupting chemicals, and other neurotoxins. It's harder than you think, to find products like that, that are free of those dangerous chemicals in the United States. 

So, in that process, I got to know a lot about functional medicine and meet some of the leading physicians in the country.  Particularly, one of our inspirations is the co-founder of the Cleveland Clinic Center for Functional Medicine, Dr. Mark Hyman, who agreed to help us launch Salvo with a number of other renowned physicians: Dr. Mark Pimentel, who leads the Pimentel Center at Cedars-Sinai in LA; Dr. Megan Oser, who led cognitive behavioral therapy at Brigham and Women's and taught it at Harvard Medical School; Professor Emeran Mayer, who's one of the world's microbiome and brain gut experts. They helped us launch this. We said, today, to get to one of these super doctors, it's a two-year waiting list and thousands of dollars—that doesn't help the average person. How do we make better medical care at lower cost available to lots of people? 

Gut health is kind of where functional physicians start. It's the root cause -- not just of GI disorders like IBS, or GERD, which Salvo Health focuses on initially -- but a lot of other conditions are related and so it seemed like the natural place to start. My co-founder Avi Dorfman, who helped found a real estate company called Compass, is a GERD sufferer, and he also was passionate about how difficult it was to find a specialist. There are only 15,400 board-certified gastroenterologists in the entire United States. Estimates say there are 60 million sufferers, chronically—that's probably too low a number—and the reality is that most of those GI physicians are highly trained surgeons, and their business is focused around healthy people who need a colonoscopy, which is a really valuable, important service, but it leaves very little time left over for chronic gut sufferers. This is a huge and underserved population, and there's no telehealth, leading virtual center of excellence or digital health clinic, and so we decided to found it. That's Salvo Health.

CARRESE: How did you design it from a user perspective? How does all this work?

GLUECK: From the user experience, it's very important to be mindful, and your audience of physicians and healthcare experts and healthcare practitioners will be aware of this: telehealth can do a lot, but telehealth is only appropriate in certain circumstances. The first part of the user experience is a long intake where we determine if your symptoms and your medical history are appropriate for telehealth care. We triage out any signs that someone needs to go immediately to an in-person GI physician for, say, a colonoscopy—classically, blood in the stool, unexpected weight loss, those kinds of contraindications will cause us to say, “We need to get you to a local GI immediately; we are not the appropriate treatment until you've ruled out more serious things,” and that's appropriate. But well over 70%, almost 80% of people are perfect candidates for telehealth. 

Our belief is that these chronic conditions like IBS -- where you have millions and millions of people who suffer for years from diarrhea, constipation, abdominal pain, nausea, vomiting, bloating, inflammation -- all these problems…they don't have an on-off switch. You can't just give someone an antibiotic. These require what we think of as continuous intervention rather than a doctor's visit. “Here's a pamphlet; see you in six months.” That just doesn't work. 

Here at the clinic, once you come in, you're assigned a physician that you work with over the months it takes to heal one of these chronic conditions. You're also assigned a care navigator and a health coach, and they are your team and you can write them any time and they will respond, usually within a few hours or a day. People are pretty reasonable; they don't expect instant answers, but they are extremely grateful not to have to make an appointment three months from now because they're in pain today, or the care plan is not working and they need to adjust something. We respond quickly. 

So, you come through, you do an intake, we will order labs -- whether it's stool tests at home or blood tests at Quest, or anything that a local doctor's office would do -- we'll look at those labs. We'll also begin a lengthy intake and start you on one of 15 pieces of our program that takes at least 90 days to complete. We might get you started on an elimination diet with support from a program designed by a registered dietician, with help from a health coach and your doctor, to figure out which foods are triggering you. We might start you on daily diaphragmatic breathing or other brain-gut exercises. We might get you on a gut-friendly, microbiome-friendly diet, including lots of medical grade supplements like fiber supplements, or we might get you on a peppermint oil supplement. We might have to escalate to something like Rifaximin, in the case of SIBO diagnosis, which is a more advanced prescription medication. 

It's a complete program: diet, mind, mental health, stress, sleep, nutrition, movement, blood labs, all of those are part of what you work with the doctor on. People aren't used to that kind of comprehensive program, but it's really effective. We're getting rave reviews from members. We ask our members daily, through a gut check on their smartphone, because all of this is through our app, how they're doing today. Did they have any one of these five symptoms for their diagnosis today? What level? Did they do the four things the doctor had asked them to do today? Maybe avoid dairy, or take a supplement or a medication, and do a breathing exercise or something. 

Almost 80% of them are answering these questions daily, so we're really starting to build that data set to understand what kinds of interventions work for different kinds of patients. We don't have to wait for an appointment three months from now. If we see someone worsening, the team proactively will reach out and say "Let's adjust your care plan.” I think it's in many ways the future of medicine. It's doctor driven, it's human, but because there's an app and technology and a lower-cost team around the highly trained physician, we can bring down the cost tremendously.

CARRESE: How much of the communication between the members and your team is text versus, video versus other modalities?

GLUECK: The communication now in the app is primarily through messaging, as well as video programs from our doctors that are tailored daily, over time, that the members can access on their time through the app. So, it's asynchronous, as they would say, today. We are shortly rolling out synchronous visits, and classic video doctor appointments as well, especially to kick off the process of meeting your team. But it's really nice to have both. What our members say is, it's nice that even two weeks later, they can have a question or concern and they can just pick up from the thread. They don't have to re-describe to a new physician their whole medical history. They just can start from where they left off with a question about a treatment or a concern. We think that the combination of a sync visit with mostly asynchronous content, communication, and messaging will enable us to stretch each physician to serve more patients and actually higher quality continuous intervention style.

CARRESE: You've also trademarked an approach called "Whole Self Science." Tell us what that's all about.

GLUECK: Whole Self Science is an approach that we designed in conjunction with leading physicians and psychologists and researchers. It's really about a comprehensive approach, getting to the root cause with your diagnostics and using a wider set of treatments than simply a prescription medication alone or simply a surgery alone. Thinking about our food system, that it's not just the food you eat, but how it's made and how that could affect your gut microbiome, chemical exposures, and the mind-gut connection. One of the things that people don't know outside of the medical field is that 90% of the serotonin, the brain's happiness and calm chemical, is produced in the gut. So, if your gut is disordered, you're not going to have enough serotonin to be happy or calm, no matter how much talk therapy you do. It's just a neurochemical reality. 

Half the patients that walk in our door with GI disorders are already on SSRIs. They're depressed. There's a very tight link between mental health and the gut and it's not just depression and anxiety causing gut issues, but it's a two-way interaction. We brought on amazing experts like Emeran Mayer at UCLA and Mark Hyman and others who are guiding our protocols there. It's essentially the belief that it's all connected. Your health is all connected, and our modern lives -- how they interfere with healthy diets, or lack of sleep, or lack of movement -- affect our health as much as biochemical markers. So, I think it's just a comprehensive, more holistic approach. We really have a sick care system, not a healthcare system right now, and we'd like to get back to having a healthcare system.

CARRESE: I'm just curious about whether this is all unrolling the way you envisioned. I mean, you've got a lot going on here. Are you getting the kind of feedback from your patients that you were hoping for? What kind of challenges are you facing?

GLUECK: The good news is that in the few months we've been in beta with our first sets of patients, we're getting incredible engagement and feedback. Patients love it, and they report at huge numbers that after years of struggling to find solutions, that they're feeling better, and most days, normal, for the first time in years. That's exciting for us. They really love just even emotionally, the access of knowing they have a dedicated team that's looking out for them that is there when they need them.  People say, “My shoulders go down when I can get an answer, that there is a solution. I don't have to live like this forever.” People can't go on dates; they spend hours in the bathroom; they can't go on a business trip; they can't go to their kid's recital—their lives are full of anxiety and limitations that shouldn't have to be there most of the time.

We're really excited about the outcomes. As I said, almost 80% of people are taking their daily symptom tracker, so we'll be able to develop a nuanced view of interventions, adherence, and outcomes with these datasets. I think the challenge is, we're brand new, and it's getting the word out to more people.  I think also it's a kind of medicine that I believe is the future—not for acute conditions, but for these sort of lower-acuity or medium-acuity chronic conditions. A lot of people have to be educated that these are not a quick fixes, one-pill-and-you're-done kinds of conditions to treat; you have to actually invest in your own health, be health forward and partner with scientists and doctors and nurses and dietitians and the like to find the right answer for you. 

So, educating people in what this process looks like, it's been challenging getting more people to know about it, but once people sign up, they're getting outcomes, they're loving it and telling us this is what it should be like to work with a doctor and team. It's kind of a specialist doctor in your pocket.

CARRESE: Yes, a big improvement over what they've been dealing with, as you've pointed out. So as you may know, Osmosis is a teaching company, and most of the audience for this podcast are med students, nursing students, allied health professions students, and early career practitioners. I'm just wondering if there's a gap in knowledge, something you really wish that population knew about and you would say to Osmosis, "Make a video about that." What would it be?

GLUECK: Well, I think what we're hearing from a lot of the physicians and nurse practitioners and LPNs and others is that, in medical school, they're not necessarily trained in areas like microbiome science. They're not necessarily trained in behavioral health and...

CARRESE: Nutrition.

GLUECK: And nutrition. I mean, they might have a couple of hours course on it, but these are really critical things. So as you go out and set up your practice, or have a chance to have a voice in your hospital or your clinic, more places should have a team. If you aren't a nutrition expert, then the doctor should be able to work with a dietician or work with a health coach and work with a gut-directed psychologist in these areas, because it really takes a comprehensive approach. If you take a probiotic, but there's no prebiotic fiber for the probiotic to thrive on, and then you go have a Big Mac and a Coke, the antibiotics in the meat and the pesticides are just going to ruin whatever probiotic pill you just took. You need a comprehensive approach, so I think more clinicians need to be trained in that. 

But I also think they should think about -- and it's hard -- but just thinking about where they want to work, in what kinds of practices they want to work, how they want to work. One of our advisors is a renowned health coach named Chris Kresser, and he wrote a book called Unconventional Medicine, which is interesting. It's all about, as a practitioner, what kind of practice do you want to be part of? Do you want to be locked into a hospital or clinic at your desk for forty hours a week and doing very short appointments with a lot of pressures to order prescriptions or surgeries? Or do you want to be in a more patient-centric kind of setting, and one that has more work-life balance, frankly, and flexibility to maybe take a trip and still be responding to your patients during work hours, working remotely? I think that those are things that your students might want to think about as they develop their careers.

CARRESE: Yes, and really, that's one of the reasons we like doing this podcast, because so much is changing in healthcare, and digital health is a huge part of that. We're hoping the audience is listening to folks like you and trying to figure out, "Where am I going to fit in, in this future?" It's not just necessarily about being in a practice or on the floor of a hospital. We appreciate folks like you painting that other picture for them. It's been a real pleasure to talk to you today; thanks very much for being on with us.

GLUECK: Thanks, Michael.

CARRESE: I'm Michael Carrese. Thanks for checking out today's show and remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.