Why the CEO of Cleveland Clinic Embraced Functional Medicine

Welcome to the Doctor's Pharmacy. I'm Dr. Mark Hyman and this is Pharmacy with FARMACY, a place for conversations that matter. And today's conversation really matters to all of us, 'cause my guest today is Dr. Toby Cosgrove, who's my boss, or I guess he was my boss until I retired.

I was.

And who's an extraordinary visionary healthcare leader who is gonna talk to us today about healthcare, because it is one of the seminal issues of our time that determines so much about what's happening in the world today. And it's often something that people really misunderstand. And Toby is the former CEO and president of Cleveland Clinic. He served from 2004 to 2017, led this $8 billion organization, did all sorts of amazing things in terms of leading the organization, building a new medical school and healthcare campus, building extensions in Abu Dhabi and now in London and Florida and Canada and Las Vegas. He's reorganized the entire clinic to be more collaborative. He's really inspired innovation. He's really a quite unusual guy. He went to Williams College, University of Virginia School of Medicine, worked at Mass General. He's in Vietnam as a surgeon and has done some extraordinary things with his life. And now is, I would say retired, but not exactly, 'cause I don't know how he's, I'm not gonna say how old he is, but he's a lot older than he looks. And he's going as hard as ever transforming healthcare and keeping the mission going.

So welcome to Doctors Pharmacy, Toby.

I'm delighted to be here. Thank you very much for the opportunity. so, you know, you're a kind of unusual guy. We met a number of years ago. I was speaking at the World Economic Forum and I think it was maybe your wife, you probably know who I was, invited me to dinner at a small group of people. And I jokingly was very provocative and I went up to you and said, Hey, Toby, what if I could empty out half your hospitals and cut your angioplasties and bypasses in half? And this is the number one heart hospital in the world. And you were like, that would be a good idea. I said, how are you gonna pay the bills? He said, we'll figure it out. And then after that, we began a conversation about how we need to rethink our approach to chronic disease. But, you know, you're a heart surgeon, you've done 22,000 heart operations, you've pioneered 50 patents, you've done extraordinary things with your career, and have led this organization in a way that has made it one of the best in the world, if probably not the best in most categories. So what was it that sort of shifted you from the traditional medical paradigm to actually being visionary and innovative in your thinking about health and healthcare?

Well, really at the end of the day, we want to keep people healthy. And a lot of the problems that we deal with every day are secondary to how people lead their lives. Smoking, obesity, those sorts of problems are first and foremost in our minds. And if we can stop dealing with those problems, we can have people live a lot better and a lot longer. And that's really what we're up to in as far as health care is concerned. Now, most doctors are not focused on.

That end of the stick. They're focused on the other end, which is dealing with the patient when they come to the hospital. You're like, well, wait a minute. We need to do something differently here. What was the aha moment where like, oh, wait a minute. I'm not going to just be operating.

On people's mitral valves.

I need to do something bigger.

Well, you know, what we really need to do is we need to move from sick care organization to a healthcare organization and we need to try and keep people healthy. And that was the whole impetus of trying to think about how we change the organization and our incentives for doing that. And at the end of the day, everybody's headed in the same direction. Eventually everybody's gonna get sick with some sort of a problem or another, but we wanna minimize that, have people live as long as possible and live great healthy lives.

And you've done that here at Cleveland Clinic. I mean, you took risk as a CEO. You got in big trouble for trying to get rid of McDonald's here.

You got rid of all the soda. I mean, this is unheard of in most hospital systems. Yeah, well, we started out by deciding that we would not allow any smoking on our campus. And then we decided not to hire smokers. And I got a lot of pushback on that. But at the end of the day, it really was the right thing to do. And now our incidence of smoking has gone from somewhere around 15 to 20%.

Down to 5% of our employees, and they're healthier. and you've saved huge amounts of money within the organization on healthcare costs for the employees.

Yeah, at the end, what we did is we really began to look first at keeping people well. We didn't hire smokers, we encouraged exercise, we changed the food across the organization, and then we went to disease management with people who were incentive to take care of themselves if they had diabetes, hypertension, hypercholesterolemia, asthma, smoking, or hypertension. And what we've seen is that The inflation rate of health care has gone from going up at 7.5% a year to being flat for the last five years.

Yeah, you actually said something that is very important. You paid people to get well or stay well. You incentivize them with reductions in their health care premiums and other incentives, right?

Exactly.

And you paid for smoking cessation and Weight Watchers and other health programs and for their Cigna membership or whatever it is.

Yeah, we did do that because and you know, the end of the day, what it did was we saw a 20% reduction in sick days. We saw a major reduction in people coming with diabetes and hypertension and coming to the emergency room and being admitted to the hospitals. It just kept people well and it's 100,000 people. And so we learned how to keep people well and keep them out of the hospital.

So you've done that for the employees, but now we have to focus on the patients. And I think part of what's happening, and I want to get a little nerdy in this space, 'cause it's an area where I think you're passionate about, is the whole idea of value-based care. Now for people who don't know what that is, it means Historically in medicine, doctors got paid when they did something. Like if you did a procedure, if you saw a patient in business, it was like basically widgets, you know, volume. The more volume you did, the more money you made. Exactly. Now we're shifting to paying for value, meaning getting people healthy and reducing costs. Exactly. And that's a very big different shift in trend. So how as a healthcare leader do.

You think that's gonna impact practice and what are the kinds of changes you're gonna see? Well, what we're gonna do is now incent people to take care of people, keep them out of the hospital, keep them well, And, you know, that's gonna start with primary care initially. But the whole idea is to try to keep people well and we're gonna be paid, you know, a certain amount per month per individual to take care of people. And if we have to have them have heart surgery, it's gonna be more expensive. So if we can keep them, their cholesterols down and their hypertension under control, we're not gonna have to do so much heart surgery.

So maybe emptying out the hospitals would save you a lot of money.

It will. But at the end of the day, you know, the hospitals are, turning more and more into acute care organizations. And we can't build the intensive care units fast enough because we get really very sick people. But we're seeing more and more people being taken care of out of the hospital and less and less invasive surgical procedures, and that's the way it should be.

So in terms of the economics here, is this something that's going to happen? Because I think people are still stuck in the old model of thinking in the individuals approach healthcare and the way businesses, even policy, hasn't quite moved there. But if it does, it seems like it's going to incentivize payment for the right things instead of necessarily just doing more things.

Exactly. And we've been on this journey now for almost 10 years, but the Medicare has said they're going to be paying for 50% of what they could pay us for on the basis of value by 2020.

So half of all the reimbursements from Medicare are going to be based on whether or not you're creating healthier people and lowering costs.

Exactly. And so I think that's one of the big payers in healthcare and I think that's going to be a spur to having more and more people moving to the value And what is that.

Going to look like in a practical way in a place like Cleveland Clinic where it's traditionally a volume-based place, like everybody in healthcare, and it's an acute care hospital?

How do you begin to shift that? Well, I think the way we're going to shift it is we begin to incent physicians to look after people differently. Right now they're being incented to do more of various things. Happily, we're not as far along on that road as other places because we're all straight salaries, so it doesn't really make any difference. We do more, we do less. on a day-to-day basis as far as our pay is concerned. But over time, we're going to be an incentive to keep people out of the hospital, to manage their diabetes, to keep their weight under control, all of those things instead of just being taken care of them for their acute problem.

Yeah, I met with the former chief of staff here when I asked him, what did he think about healthcare at Cleveland Clinic in five or 10 years, what would it look like? And he said, it's healthcare without walls, meaning we have to rethink delivering healthcare as well as what we're doing, where we do it. And whether it's virtual care, whether it's using other tools we're gonna talk about in a minute, like artificial intelligence and healthcare, whether it's actually community-based models. I know you know a project we're working on, creating a food pharmacy, which would take the idea that if diabetes is caused by food, why don't we give them food instead of drugs and see what happens and give them the support in their community to actually change their behavior. And some groups have done this, guiding are going to reduce their health care costs in these diabetic patients by 80% over a year or so, which is dramatic. I mean, if you think one in three Medicare dollars is on diabetes and you can do that, that's a game changer.

Well, there's no question about it. We need to have more incentive to keep people well and all kinds of ways we can do it. Now, the interesting thing is that so much of what we're talking about is the social determinants of health care.

Yes.

And traditionally, we have not been involved in that as health care providers. And more and more we're being called on to do that. Now, interestingly, the payment model so far has not incentivized us to do that, nor have we had the training nor the expertise to do those sorts of things. So it's a whole paradigm shift. So true.

It's true. You know, the biggest things that drive disease are the social determinants, and that includes the food. Exactly. And if you address those two things, you can dramatically change. And that's part of what we're doing with the food pharmacies, the food insecure diabetics, teaching them, you know, going to their kitchens and cleaning out their cupboards and showing them how to shop and showing them how to cook and what an avocado is and how to do the things that they need to do to actually change that. And it works if you do it, but it's a very different model. But all of a sudden, if Cleveland Clinic is taking care of 3 million diabetics and you have to pay, if you don't take care of these patients well, then the incentives change and the monetary changes. So all of a sudden, Cleveland Clinic may be paying for 10,000 health coaches or maybe paying for food for thousands of people to actually do this at home. It's a very different vision.

So one of the things we've done is we started putting kitchens in a lot of the places that we've built recently that will have the ability to teach people how to cook. And by the way, our new health education facility is going to have that same sort of capability to begin to teach medical students and nurses, et cetera, how to prepare meals.

Yeah, imagine if everybody after they got discharged from the cardiac unit had to go to a cooking class for a few days as part of their discharge. You know, it's amazing. So you've been around a long time. I don't want to say how long.

I have been around a long time.

And you've seen a lot of changes in healthcare. In terms of the biggest trends that are happening now, you have a unique view because I know you really well and I see you go to all sorts of non-medical meetings where there's technology and innovation and business and science and things that are out of the normal domain of healthcare, but it informs your thinking and informs your way of seeing the world. It gives you ideas about where these worlds intersect. And it's led to, I think, some really, probably very interesting insights about where we're going, what are the biggest things that we need to be thinking about going forward? Because we're in an unsustainable nosedive as far as I'm concerned in terms of chronic disease, which is counting, I mean, just obesity and type 2 diabetes, according to the Milken Institute, accounts for $3.4 trillion in direct and indirect healthcare costs. That's 20% of our GDP.

So where are we going? What are the trends and what should we be thinking about? Well, clearly we've got to do two things. We've got to begin to make the healthcare delivery system for people who are sick, more efficient. And we've got to keep people well. We've talked a little bit about keeping well about food and smoking and preventing diabetes and all the things that are associated with that and the obesity that is associated with everything from heart disease to cancer. So let's talk a little bit about the efficiency of the health care delivery system for people. One of the things that's really fascinated me has been the explosion in data. Yeah. And in fact, if you look at it just for doctors, there are 5,800 journals putting out 800,000 articles a year.

Now, I read a few of them.

Yeah, I read a few of them. I doubt it. You got through 800,000?

Maybe 10.

Yeah. But that's just an overwhelming amount of data. The second thing is that we're just being inundated with data. Just think about the human genome. It's got three billion base pairs, and that's going to be part of looking after people who are sick. So how are we going to keep track of all this? So the total amount of knowledge in healthcare is now doubling every 73 days.

And it used to be what? Every 150 years.

Yeah, it used to be 150 years. But now we just have this explosion of data. Now that's a problem and that's also a blessing and an opportunity. The problem is we've got to be able to store it and we've got to be able to retrieve it and we've got to be and that is an issue that I think is probably ultimately going to get solved with putting that information, storing it in the cloud. And I think you're seeing more and more healthcare organizations realize that they've got to have that sort of capacity to keep track of that information. Now, the opportunity with that is we've got this huge amount of data. Now we can analyze it. And we've got AI and machine learning that are gonna come in and bring us realizations about people that we had no idea about, predictions about where people's health are gonna go, how you can prevent these, sorts of problems. And as we begin to analyze this data, we're coming to all kinds of conclusions we had no idea existed. So I think it's both a curse because we got so much and it's a blessing because we have so much and now we have the opportunity to begin to learn. And that's why I've been interested in working with companies like Google.

Yeah. But you now are on the-- yeah, I'm on the Google Health and Life Sciences team.

I'm a consultant for them. and it's a fascinating capability that they have. And I think if we can direct that towards managing this healthcare, it's gonna improve our efficiency and keep a lot of people healthier than they have been in the past.

Yeah, it's important. I remember once I had a guy come in from Merrill Lynch who was a financial advisor, and I said, How many of your decisions you make every day are guided by your computer technology and the data you have? He said, what do you mean, everything? I said, you, know how many we have in medicine that are driven by that? zero. Exactly. It's you got the doctor, you hope he learned what he's supposed to learn and he's going to do what he's supposed to do. And it's overwhelming because you can't connect all the dots. And so this whole machine learning AI is actually going to make sense, hopefully, of this. And, you know, I think functional medicine, I believe, is a way of thinking about how to filter the data because you have to make sense of it through some kind of algorithm and you need to have a way of learning based on principles. So I think it's a very powerful thing. Watson, I know you're very involved with, which I think is the computer that beat the guy in Jeopardy, which is awesome, but he only knows what information you put in. So if you're putting in the world as flat information, it's very different than our understanding of systems biology and the future of healthcare based on this model.

Right. Stop and think about it. I mean, healthcare is way more difficult than Jeopardy. There's a lot more information.

It's true.

And it's much more complicated than the game of Go, for example. We have got to see that that capability increases. And not just about the actual dealing with people's health, actually dealing with how we manage patients coming through the health care delivery system. Just think, for example, about how hard it is to make an appointment to see a physician. It's nearly impossible. We have 500 people working in our call center. and doing five million calls a year to try and get people into the system. We ought to be able to put together an algorithm that'll handle that quick as a wink.

Yeah, and also billing and other, all the inefficiencies, it's pretty frightening. But I think the biggest thing is how do you get medical decision support? How far away are we from having medical decision support for doctors where patients can fill out questionnaires, or labs go in, all their biometrics, their microbiome, their genetics and come up with, okay, here's what you should think about, doctor.

Well, I think we're coming to that. It's not going to be tomorrow for everybody all over the country, all over the world to do that, but we're starting to see the capabilities of doing that and we're starting to see more and more information coming from the human genome.

Yeah, interesting. I went to a lecture recently at this conference and there was a cancer doctor giving a talk about immunotherapy and about food as medicine. and he said, we found that there's a particular bacteria in the gut called Akkermansia, which doesn't matter, it's a fancy name, but that if people don't have this bacteria in their gut, which is a beneficial bacteria, they don't respond to immunotherapy, but those who actually have this bacteria respond to immunotherapy. Now, that's just one little tiny data point, but think about the implications of that, you know, where he actually ran through all these different foods and how they compare to drugs. these fancy diagnostic throughput technologies allow us to see what drugs or foods work. The foods were as good or better than a lot of the drugs for the same condition.

Well, think about the ramifications of not thousands, but millions of permutations and combinations. There are food, drugs, individuals, sex, weight, microbiome, genetics. It's huge.

Yeah, it is huge. So any other trends you're seeing in terms of health care? value-based care, we've got AI and big data.

Well, the other trend that we have to see is the fact that we are dealing and just basically in the economy, we are seeing the cost of health care go up. We're going to see it continue to be pressure on it for two reasons. One is more older people and two, more things we can do for people. So those are the reasons that we have to be able to figure out how we make delivery and prevention much more efficient.

So you've been involved a lot with Washington. I know you know the head of Medicare. You were asked by three different presidents to help them thinking about healthcare. Cleveland Clinic's been held up by presidents as the bastion of what we should all be going for in healthcare. What's your sense of the ability to actually change policy? Because we have so many disparate policies that are all at odds with each other that are actually promoting the exact opposite of what we want. And I think it's not about cutting entitlements or keeping entitlements. It's about figuring out how to change the the values would get people better.

It's really hard to change policy in Washington. There's no question about it.

Which is why we didn't take the jobs that they offered.

But I mean, just think about it for a second. One of the things that makes me really crazy is the fact that we are subsidizing the growing of sugar. And sugar is in everything. And so we pay for it to help them grow it, and then we pay for it to help get people well from the results of giving them sugar. It makes very little sense.

We pay for this commodities to be grown with subsidies. We pay for food stamps, which is almost a trillion dollars every 10 years in food stamps, 75% of which is junk and sugar and soda. And then we pay for Medicare and Medicaid on the back end, triple taxing the consumer.

Exactly.

And it's kind of a whole screwy thing. I don't know if you know, but with Tim Ryan and another Congresswoman and Darius Mazur is the dean of Tufts School of Nutrition Health Policy. We got them to get the GAO, the General Accountability Office, to do an analysis of all the different agencies, policies that relate to food, how they're often odds with each other, and how they're helping or subverting our health in the economy, which hopefully will come out and.

Shed some light on all the nonsense that's going on. Well, it's very difficult, and it is actually wound up being very detrimental to the health of the country. I think another area that you could begin to think about as far as policy is smoking. And cigarettes are clearly the most reversible or preventable cause of cancer. And I don't think anybody questions that. Happily we're seeing our incidence of smoking going down across the country. It's still 13% other people in the United States smoke. It's a major cause of emphysema, it's a major cause of cancer of all types. And, you know, it would be very nice to just tax cigarettes right out of existence. And, you know, you could.

Aren't they like $10 a pack now?

Well, you know, make them $20 a pack. And then, because, you know, we are in fact causing that to cause the cost of health care to go up. Yeah.

I had Larry Summers on the podcast. We talked about his new initiative with Michael Bloomberg around fiscal policies, working with fiscal leaders and fiscal secretaries, ministers, finance ministers, treasury ministers all around the country, all around the world to tax junk food and soda as a way of creating these disincentives for consuming the wrong thing.

Yeah, I think that taxing soda is one thing, but the base problem is not just soda. It's the sugar and everything. And soda is just one of those. And so I would think about getting down to the root cause, which is sugar rather than the actual delivery. And it's also starch. Starch and sugar, a friend of mine.

Who'S a professor at Harvard says, below the neck, your body can't tell the difference between a bowl of cornflakes and a bowl of sugar. Because the way it works metabolically is almost the same. Exactly. It's such a huge issue. So changing subjects for a minute, why in the world would you bring somebody crazy like me into Cleveland Clinic to do functional medicine?

Especially. Well, I've been asking myself that for a long time now. No, I think that we understand that functional medicine is really built around the things that influence you, which are your genes and the things in your environment. And one of the things that is in the environment is food, and that's a lot of what causes chronic disease. And you have addressed this very directly. with functional medicine and I think this is a capabilities that we at the Cleveland Clinic need to bring into our repertoire and begin to learn from and to begin to understand the data and put it out there so other people can follow the lead.

That's amazing, Toby, because most healthcare leaders would not take a risk. So what is it about you that allows you to take these risks and put up these bold initiatives that everybody's going to sort of criticize? And by the way, you got a lot of pushback from a lot of doctors here when you brought us in.

Yeah, no, I've gotten a lot of pushback on a lot of things, but at the end of the day, you have to go with what you think is an appropriate sort of thing, and you can't be afraid of failing. I mean, I've failed so much along the way that it doesn't bother me anymore. And I think you always learn from your failures, but you're not afraid to begin to push in a direction you think might work. I think this is one of those opportunities.

Yeah, it's true. I mean, we've been really blessed to be here. We've grown from just six people, and we have over 50. beautiful center space you created for us. We have 3,000 people on the waiting list. We're doing innovative programs in the community and shared medical appointments. We're trying to do the value-based equation in our research, which we're going to be publishing this year. It's very exciting to see this change. And we see just without our pharma data, we're seeing 20% cost reduction over 18 months. We're seeing improvement in clinical outcomes better than most other practices. So I think it's really a risky you took, but I hope you don't regret it. And I think it's been a real, both a flash point, but also an inspiration for a lot of people in healthcare and other healthcare institutions. If Toby's doing it, why aren't we doing it?

Well, feed it to Toby and see if Toby likes it.

So good. One of the things that is really important is this work with Google that you're doing. And I think it's really something people don't understand. I think, I don't know how much you can share given the constraints of what Google is doing, but it would be great for people to hear about how are technology companies creating innovation where healthcare isn't? Because a lot of innovation doesn't come from the center, right? Kodak didn't create a digital camera, maybe they did, but they didn't figure it out, right? You've got a whole different world of disruption in business that's happening, but now it looks like it's happening in healthcare. I think Obama went to meet with a bunch of leaders on healthcare, and he didn't go to the healthcare institutions. He went to the Silicon Valley to meet with them and everybody's doing it. What is happening out there with the tech world and how are they getting involved in healthcare and what are the implications for that?

Well, I think one of the interesting things we've seen over time is all of a sudden people have realized that healthcare is the biggest industry in the United States and everybody's interested in it. The tech companies are interested in it, the financial world is interested in it and I'm delighted to see that because it brings new thinking, new impetus into healthcare, which has been a very slow moving industry. And you stop and think that the model that we have across the United States as far as hospitals concerned was built in the Hill-Burton legislation, which happened in 1950, with every hospital, every community having its own community hospital. Well, that model is gradually being unwound, but it's very slow and essentially Actually, people don't want to take risks with their care, and so they have been reluctant to move into different areas. Doctors have not been trained to be particularly risk-taking individuals, so they don't want to veer very far from the tried and true. So healthcare has moved incredibly slowly relative to other industries.

So you're one of the most revered healthcare leaders we have today, and if you're going to be advising leaders in healthcare, whether it's insurance or other healthcare institutions or government policy. What are the things that you would say to them given everything you've learned.

In the last bazillion years? You know, I think the thing that we have to understand and sometimes we lose track of is the only reason that we are in medicine, the only reason we have salaries, the only reason we have hospitals, clinics, whatever it is, is because of the patient. And if you keep the patient at the center in your North Star and ask yourself every day, what's the right thing to do for the patient? that'll take us faster and in the right direction. And so I think that that should be the North Star, the guiding principle of which we drive healthcare going forward. And it'll be an amazing change in how we look after people.

Do you have any things that you wish you had accomplished or had done in your tenure as CEO that you didn't get to do?

Well, there's a whole lot of things. You know, I just wish I'd done things faster. You always look back and say, gosh, I wish I'd done this faster.

In the world of technology, one of the things that's kind of exciting that you brought in here was through a friend of yours who's a technology officer at Microsoft, and you created a really revolutionary healthcare campus. It's still going up, so it's not quite done yet. It's beautiful, and it's designed by the guy who, Mr. Foster, Norman Foster. Who did Apple's headquarters, and you got the most amazing architect. and you're bringing in all these different modalities and disciplines into this one center. But you're also changing not only the structure, but you're also changing how people are learning.

Well, you know, one of the things that we realize is healthcare is really team sport. And it's so big and so complicated that no longer you can count on just the doctor. But it has to have doctors, nurses, physicians, and of all types. You need to have the pharmacist, you need to have the PAs, you need to have the dentist, everybody pulling in the same direction. So this is the first time that they've all been educated in the same location. So we're going to have the medical school, the nursing school, the dental school, and the PA school all in one building, learning together, and we're going to try to bring together new technology like Microsoft's HoloLens. Interestingly, we're going to be teaching anatomy now using virtual reality. Yeah. And you may have heard me when.

I much less formaldehyde exposure is better for the doctors.

Oh, yeah. And that, and it's going to be good for their social lives, too, because they're not going to smell like formaldehyde. But, but the other day, I'm walking around with a headset on. I'm walking around a heart that's out in space.

Yeah.

And you can walk all the way around it. And they say, Toby, stick your head in. And so I go like this. My head's in the left ventricle.

And I'm looking at the outflow track.

A view that I've never had is a cardiac surgeon after 22, 000 operations. You never saw happily I never did. But it gives you a much better understanding of what the anatomy is than some shriveled up cadaver does. So we're not going to have cadavers anymore. And I think that this begins to apply to a whole lot of things about education. So thinking about educating as a team event and educating using the new technology. I'm excited about it.

That's so great. So you also are Good friends with a guy named Leroy Hood, who you I think were in Vietnam with maybe or no? No, but I- Know him at least back then. Yes. And he's a brilliant scientist who's led the way in systems biology. Yes, he is. And you were part of this program called the Pioneer 100, which- Yes, I was. -He set out your biology and create a predictive model. He calls it the P4 model, predictive, preventive, personalized, and participatory. About how do we rethink the way we do healthcare based on systems thinking and systems biology. That's really what functional medicine tries to do. How is that gonna change what we do and also education? Because a lot of our medical education system has been set up based on the Flexner Report, which was in the 20s, it's a 100-year-old as an organization. And now we're breaking down the walls. You've got people at Cleveland Clinic here like Dr. Stan Hazen who'll be on the podcast and Kara Saunders who are looking at the microbiome and its role on cancer or heart disease. Well, what you go to cardiologists, not talking about poop, well, maybe that's important, right? So how do we then take this emerging science of systems biology and take that and put it into medical education, medical practice? How do you see that going and unfolding?

Well, that's interesting, you know. So I tried to get the healthcare medical school here to begin to talk about teaching genomics. And there was a long, hard pull before we got them to do that. And the same with nutrition. You know, we go into, I never had a single course in nutrition. as a medical student, nor anything about genetics or genomics. And this is all new information that is going to have to be shared with medical students, so they are not thinking so much about anatomy and physiology, but thinking increasingly about the metabolic aspects of healthcare, which is tremendously exciting in brand new areas.

It is huge, and it's such a paradigm shift, because all the, not just this not just the collaboration between people as teams, but even how we think about disease and autoimmune disease and diabetes. And these are all complex diseases that have a requirement for a new way of thinking. And yet, it's very hard for anybody in science to actually change the paradigm. There was that book called the Structure of Scientific Revolutions by Thomas Kuhn talking about the idea of a paradigm shift and how we have this normal science where everything is the way it is. I mean, you've been around long enough, you know that ulcers are caused by stress, that autism is caused by refrigerator mothers, things that we just now are no longer ridiculous, but these were the beliefs at the time and it took a long time to overturn these. So how do we do that? Because if I were a healthcare leader, I would want to know, well, I guess I am a little bit, but not like you. But I want to know how do we change the educational system to bring up a new generation of doctors? How do we change the reimbursement to pay for people to do these things? How do we get the technology to actually be able to think about using all this big data information, systems thinking, biology, put it all together and actually make sense of it all.

Well, we have got, I mean, think how great it would be if you had a pharmacist and a nutritionist person and a social worker is rounding with you every day on seeing your patients. It would change the way you thought about what their problems were and what you could do for them. So we have got to be more inclusive than the team is, it's a team. It's no longer the Dr. God. It is, he's a member of the team and he brings a specialty and technology to it, but it is going to be a huge group of people who have diverse knowledge and that's when innovation really happens. It happens at the borders of different knowledge. I mean, think about the surgeons, back to your ulcers. Think about surgeons year after year after year, year after year in the middle of the night operating on people with bleeding ulcers, thinking it was stress and treating them with ice water and milk and Maalox. And in fact, it took a pathologist and a microbiologist to finally figure out it was bacteria that was causing the problem. It's true.

He's talking about these ulcers which have this bacteria called Helicobacter pylori or H. Pylori. Actually, that bacteria was seen there for years when people had biopsied, but they just ignored it. It was just incidental. It wasn't relevant. One guy goes, well, maybe it is. And let me take beaker of it. I'm gonna swallow it, give myself an ulcer, then treat the antibiotic and see if I get better. And then he won the Nobel Prize. They all laughed at him, right?

No, that's the sort of thinking that we need to change. We have to question and we have to bring in different specialties and different knowledge and different expertise to begin to change the paradigm.

But it's tough because, you know, the educational system doesn't generate the system's thinking, right?

Well, think about it. Think about how we've been selected. You were selected to get to medical school because you got through organic chemistry.

Yeah, but I studied Buddhism. I don't know why they let me in.

I'm not sure you actually got through, but I barely got through myself. But I mean, think about how you select them. You select people who can memorize, then you memorize for four years, then you do what you're told through your entire early residency and early on into your practice of medicine. So you merge at age 45 without being encouraged to have any original thoughts.

Yeah.

Yeah. Sad.

It is true. Yeah, it's interesting. I did not do pre-med. I majored at Cornell in Asian Studies.

I was a history major.

Yeah. And I always taught to think and to analyze and to be critical. And that was my training was. And when I got to medical school, you know, a lot People were just science driven and they didn't know how to sort through the massive amounts of information. So they were overwhelmed, they were having panic attacks, seeing up all night. I'm like, oh no, I see. This is the story and the narrative. This is basically what's important. This stuff I don't need to learn. And I just did really, really well because I was able to sort of.

Think and be critical about what I was learning.

And that's a very different skill. Yeah, no question it's a different skill. But the systems part is tricky because our definitions are blowing apart about disease. You're seeing these, these themes of mitochondria and inflammation and the microbiome and all these things that are across diseases, across specialties, and nobody's been talking to each other. So I think that's what's going to shift. It's very exciting. It's very exciting. I want to come back to the patients first, because everywhere in Cleveland Clinic we work here, you see this patients first logo. It's prominent everywhere. It's really in front of people's minds. But you're, I think, also not only the first to create a Chief Wellness Officer in a wellness institute, but actually to create the chief experience officer.

Right.

And I think a lot of that maybe came from an experience you had at Harvard Medical School or Harvard Business School. Harvard Business School. Were you embarrassed?

Embarrassed by the king of-- no, I was embarrassed by a student who asked the question. Dr. Cosgrove said, Dr. Cosgrove, my father had mitral valve prolapse and we know you've done more of these than anybody else in the country. But we decided not to to you, Dr. Kosgrove, because we heard you don't have empathy. And I haven't any idea what I said after that. I was totally flummoxed. And then the King of Saudi Arabia burst into tears at an opening of a hospital over there because they were talking about this hospital being dedicated to the body and the spirit and the soul of the patient. And so I decided that, you know, I better sort of examine my career. And I realized I'd spent my whole life trying to to make the cardiac surgicals safer and with lower morbidity and lower mortality. And I'd spent all my time doing that and not paying attention to the person as a person.

The person with the mitral valve. Right.

They were, they were, I was a technician. And so we really needed to change it. And so that's when we made it a C-level commitment with a chief experience officer. And we've changed the whole culture, I think, of the organization around the fact that the patient is the reason we're here.

And what were the biggest things that came out of that in terms of the Chief Experience Officer?

What were the things that shifted when you implemented? Well, you know, we really saw and said, okay, what's quality in healthcare? Well, clearly quality in healthcare is outcomes. And it's also about the physical experience and it's about the emotional experience. And the physical experience, we did all kinds of things. We changed the architecture. We looked at more light in the facilities. We changed the sort of a gown that you had. so you didn't walk around with your cheeks flapping in the wind.

Yeah, you got Diane von Furstenberg to create a new. We did.

We did. A wrap gown.

Yeah.

And then we began to look at the emotional aspect of it. And we went and brought everybody in the organization, some 40,000 people at that time, into groups. And we talked about the Cleveland Clinic experience. And as they came out of it, they got that little badge that said, I'm a caregiver. So we refer to everybody now as a caregiver, whether you drive the bus or you're a neurosurgeon, you're all addressed as a caregiver. So it makes a team out of everybody. And that really has begun to change both the engagement of the caregivers and also the experience of the patient.

Yeah, it's really broken down some of the hierarchy.

Yes.

And you were great to support us in our new center where we took that a step further and created the first well-being certified facility in the Cleveland Clinic, which basically has filtered the air differently. The water's the best in Cleveland. The lights are not causing fatigue and stress. All the materials, the carpets are all non-off gassing, non-toxic and it's created a very amazing work environment. And Cleveland Clinic is like that. The spaces here are beautiful. It doesn't feel like a traditional hospital.

I know you've had a huge influence on that.

Everybody talks about it. Some people complain about it, but it's really... That's right. 50 Shades of White is my 50 Shades of White, yeah, that's great. Toby White, they call it. So this has really been a great conversation. I wanted to end with one last question. You have the perspective of years. You have tremendous experience. You've been around in all sorts of different sectors and understand the problems of healthcare and chronic disease and many problems in the world, more than most. And you're very quiet and humble about it, but if you were king for a day or a week or whatever, however long it took, What would be the things you'd want to implement, either from a policy change or a culture change or some things that would actually impact the world in a way that creates more healing and benefit?

Well, first of all, I think we clearly have to move to value instead of paying for volume, pay for value. And that would be across the board. Secondly, there's a lot of things that the government can do in terms of cigarettes. We talked about that. We talked about the sugar tax. to begin to decrease the amount of sugar that are in people's diets. And, you know, we need to think about going back to why we're all in health care and what should it be? And really, I think if increasingly people were incentive to look after the fact that they had anything to do with health care, whether it's manufacturing products or whether and pharmaceuticals or whether it isn't taking care of people. If the idea was the reason that you're there is for people, that's going to be a changer.

And by the way-- People first, not just patients first.

Exactly. That's really what we've got to be about. Because as we move more and more towards wellness and taking care of people and keeping them out of the hospital, it's going to be about people, not just patients.

And you've done that here at Cleveland Clinic, and you've also done it in- We've done it. Yeah, and okay, we've done it. And you also not only just address the patient experience, but you've also addressed, for example, the food in the environment. And it's tough, and you battle against food companies and food service companies and vendors, and it's not been an easy easy path, but you took, I mean, courage. And it's amazing, one of your key leaders is CEO of Abu Dhabi, Cleveland Clinic Abu Dhabi, and he's gone even a step further because there's more ability to do that with less pressures from food service companies. He got rid of all things white, white flour, white sugar, processed anything, and created a whole organic hospital food system, which would be amazing.

So I think I'm delighted that people are moving further. I think we take the first few steps and it's going to be leaders in the future are going to do even better. And the job of a leader is really to take an organization to places they're not sure they need to go. You have to lead people.

So what's the most important thing you feel like you're focused on and working on?

Well, I'd like to see that I'm helping the organization, particularly around bringing the new technologies and I see new technologies and all kinds of locations. I talked about the little things I'm seeing in cloud and the technologies coming there. I've seen some incredible technologies, voice recognition that can tell whether or not you're on drugs. I've seen the ability to do a scan of your retina that can make 60 diagnosis from that. I think virtual care is going to help take the care to the patient from having to come to the hospital. And I think one of the leaders in that has been Kaiser Permanente, which now sees more than 50% of their patients virtually. And just think about the potential of managing people's diabetes without having to come to the hospital to get their blood drawn or their hypertension the same way, or their dermatologic lesion. We had an orthopedic surgeon here recently see a whole clinic of 23 people. from home because he had an injury.

Really?

I think the potential for this sort of virtual care is going to help with rural populations where the hospitals are not big enough to be sustaining. I'm very excited about a lot of the opportunities that are coming through the technology that I see and I want to see them get incorporated.

Amazing, Toby. Thank you so much for being part of the Doctors Pharmacy. you've been listening to conversations that matter, the doctor's Pharmacy with former CEO of Cleveland Clinic, Toby Cosgrove. If you like this podcast, please share with your friends and family on social media. Please leave a comment review. We'd love to hear from you, and we hope to hear see you next time on the doctor's Pharmacy.