Fighting Cancer and Avoidable Suffering Through GI Innovation with Dr. Austin Chiang, Chief Medical Officer of Endoscopy at Medtronic, and Dr. Nate Merriman, Medical Director of GI and Digestive Health at Intermountain Health

[00:00:10] Hello everyone, and welcome back to Executive Uninterrupted brought to you by Outcomes Rocket. I'm so excited to be hosting another episode today because I have two very special guests. We're going to be looking at the future of GI health innovation from a few vantage points. On the one hand, the clinical and industry side, and on the other hand, the health system side. We're going to get into how digital tools like GI Genius, the Solvable Pill Cam, as well as Reshabilitation, and the Health System side.

[00:00:40] Endoscopy, Food as Medicine, and other ideas and strategy change can lead to effective pathways in this field. But I can't do this discussion without my two amazing guests. First, I want to introduce Dr. Austin Chiang. He's the Chief Medical Officer of Endoscopy at Medtronic. Austin, thank you so much for joining us. Thanks for having me.

[00:01:01] Of course. And joining him, we have Dr. Nate Merriman. He is the Medical Director of GI and Digestive Health for Canyons and Desert Regions at Intermountain Health. Welcome to the podcast, Nate. Thank you, Sol. Great to be here. Yeah, it's such a pleasure to have you guys here. And to kick things off, how did you guys meet? Because I understand you guys have known each other for a while. Nate tells this story better than I can, so I'm going to defer to him.

[00:01:27] Oh, wow. So no pressure. Austin and I are both gastroenterologists. And over the years, actually multiple years, I've seen some of his work online. He really has a powerful presence, to be candid, online that all of us as physicians can learn from, and specifically on Twitter previously.

[00:01:47] And so I reached out to him and I said, Austin, nice to connect with you. I was curious, would you be willing to help teach some of our physician leaders at Christianic Care when I was out in Delaware? That's cool.

[00:02:00] And we lived nearby. So Austin was in Philly. I was in Philly for my training. So it was a relatively easy ride down the road from Philly to Delaware, which brings me to my next point, which is when we were talking about transportation, it was getting a little overly complicated. I said, well, why don't I just drive up and get you? I know Philly. That's awesome. I didn't have to move on. So hard to get to Delaware. That's right.

[00:02:27] And it was incredible. It was an amazing ride for us from Philly down to Delaware. We talked the whole time. It's not like an hour. How long is the drive? Like an hour and a half? Something like that? It was like an hour. Hour? Yeah. With a little traffic. That was perfect. Good connection time. And we got to the other part of things I love hearing is things that aren't on people's CVs or online profiles, right? Is let's get to know each other as people at a deeper level. So it's cool.

[00:02:57] That's the best. And what's what about you, Austin? What was your key memory from that drive? Oh, my gosh. I think I was I in training still then. I was just honored to even be invited and to meet Nate and and then to see where things were headed for him and seeing his transition to Intermountain has been awesome. And I feel like we've both been learning along the way. And so it's been great to just stay in touch and share our experiences over the years.

[00:03:24] I love that. And what I love about that is that, Nate, you reached out, right? And nowadays, people I feel like are afraid of doing that. So you're a great example, Nate, of reach out and make the connection. And next thing you know, you're driving with someone to do something cool. And now you're doing a podcast together. So I love this. What a great story, guys. Thank you so much for sharing it. Let's dig into some of the questions, shall we? Yeah, let's do it. So, Austin, I'd love to start with you. You're several years into your CMO role covering endoscopy.

[00:03:53] How have you seen digital interventions evolve over time? It's been really interesting. I've been in my role for almost five years now. And learning our portfolio, which has always been a collection of pretty disruptive, complex kind of digital tools, digitally empowered tools, I should say. So within the endoscopy portfolio, it's not as much like mechanical forceps and those types of things.

[00:04:20] It's a lot of functional diagnostics. And there's a lot of digital benefit and challenges, I guess, associated with those that I've been able to witness over the years. But I would say you mentioned GI Genius at the outset of this. That was introduced to the market. We were the first kind of FDA cleared device in our space to use artificial intelligence to help detect colorectal polyps during screening.

[00:04:49] And that was a couple of years ago. And to see how the market has initially, I think it wasn't exactly ready for innovation like this, but how it's been received over time with emerging evidence and with competitors and just the conversation evolving just the landscape in general, even outside of healthcare and how AI has changed.

[00:05:13] It's been interesting to see that evolution. And I think that the next phase is really seeing where we take this in terms of developing a platform. And that's really the vision where we're going with all this is it's not just one AI tool or algorithm. It's having a host, having the hardware to be able to host a wide variety of different AI algorithms for different purposes, for different indications along the entire GI tract and different points along the care continuum.

[00:05:43] And so it'll be really interesting to see how that plays out. And over the years, we've seen more evidence about how it improves clinical outcomes, how it can potentially help with efficiency and quality across practices or standardizing quality amongst a group of clinicians. And so it's not just about clinical outcomes, but also standardization of care and maybe even improving access to care if we can improve our efficiency too.

[00:06:10] So just to say that there's been a good deal of transformation just even within that one product alone. And of course, we're looking to apply AI and to other areas within the portfolio and further advanced digital transformation in other products as well. So thanks. Like you said, tip of the spear on the platform, there's the pill cam and all the other things that you guys are working on. Nate, I'd love to hear your side on this.

[00:06:39] There's a lot of innovation, but how do you navigate integrating all this GI innovation, like the ones that Austin's come up with and shared with us, into a large system like Intermountain Health? That is an outstanding question, and I'm sure one that pretty much every health system in the country is struggling with in terms of the balance. I think two things I'll share.

[00:07:02] One is one of my favorite stories of working with Austin and the Medtronic team was what they did in a creative partnership with Amazon Web Services, our ASG society and Medtronic working together to bring GI genius to underserved communities. And to smaller teams who wanted access to it, couldn't afford it. And so we applied for those grants and we were able to get them in four of our small hospitals, rural hospitals in Utah.

[00:07:33] And it was a brilliant idea. I don't remember all the details that Gio shared, Austin, but it was pretty amazing how it happens. And so that was a very smart way for an innovative company to work with others, including a nationally recognized GI society, ASGE, to bring a new product into communities that really often come later in the line or don't get access to that kind of technology.

[00:07:59] So to be candid, I would love for more companies to do things like that. We care for a lot of rural communities at Intermountain across multiple states. So I think that was a great idea. So that was one. Make it free. And it's always easier to say yes.

[00:08:14] The second one I would say is I really have leaned into a mental model that I have of start small, learn fast, analyze the impact, iterate, make those adjustments, and then decide to stop or scale. And I've tweaked that a little bit over time because I was in private practice before and then came out to Intermountain about five and a half years ago. And often my partners were looking at me like, well, what's the ROI? What's going to if we're spending, what are we getting?

[00:08:43] And so I came up with just simple experiments that I ran as a private practice partner that then I tried to improve in a health system on a much bigger scale. And I think that is, I know that sometimes it's stressful to run pilots, but from a health system perspective, it's almost essential to see, okay, let's test this out, see how it works, see what the potential positive and human impact as well as potential cost savings would be.

[00:09:10] And then talk about the data across the partners, meaning the industry vendor partner, as well as us together and think about the patient perspective and then stop it or scale it. And that's really helped me quite a bit working at Intermountain over the last five years. I like that model. It's simple, right? And like to make things work, they got to be simple. And one thing that came to mind that I wanted to ask both of you, I'm actually at the Ask Samba meeting, ASCs.

[00:09:38] So in my brain, I'm seeing all these procedures go to the ASC. Does the ASC then become a place where things can be tried, adopted? Like what are your thoughts there on that? We'll love to hear from you. It depends. I think it depends on the technology and innovation. I mean, some procedures aren't well suited for the ASC. And from a device standpoint, like sometimes it's just unaffordable to do some of these procedures in the ASC as well.

[00:10:07] I mean, that's constantly on our minds with regards to obviously site of service and where a certain technology should live and how large the opportunity is whether or not to include ASCs in our projections. So yeah, it's certainly something we think about. But at the end of the day, it's really about what's safest for the patient, where can this actually be done, and what makes the most sense clinically. I like that, Austin. What about you, Nate? I love everything Austin said. I'm not surprised.

[00:10:34] And as an example, and I think he'll appreciate this because he also loves third space endoscopy and also bariatric endoscopy. So I saw a poem case this morning, and I was thinking to myself, huh, I don't see poem moving into the ASC space anytime soon. And per oral endoscopic myotomy for patients with acalasia, where essentially... I was going to ask you.

[00:11:01] Yeah, and I realized after I said it, I thought, oh man, I got to explain this. I appreciate that. Yes, thank you. So the muscle is just way too tight, hypercontracted in acalasia. And then the esophagus above it is just not functioning and working. So either you can, you have multiple modalities. You can try to break it up carefully with a super balloon. You can go in surgically and cut the muscle with a heller myotomy.

[00:11:27] Or you can go in endoscopically into the third space and work either, and this is the interesting part, I think, on the surgeon side or the gastroenterologist side work together, to then essentially cut that muscle, open it up, and help the patient to swallow. It's incredible technology innovation for the patient and our patients with acalasia and some of the other indications for POEM,

[00:11:53] GPOEM as well for the muscle, the gastric side, the muscle out of the stomach. But that's not something that could move in the ASC space given the amount of time and cost that it takes. Generally, I would love to see some of these more complex procedures. I mean, I would love to see more procedures in general, go to the ASC just because for patients, right? The experience of going to an ASC, generally speaking, is probably more pleasant than going to a hospital and having a deal.

[00:12:22] I just working at an academic center downtown in Philadelphia, patients really don't want to go to go downtown and deal with parking. And like just the kind of relative chaos of it all being in a hospital. But yeah, at the same time, the reality is that sometimes it's challenging to introduce these procedures into the ASC, given lower reimbursement for ASC, even for the same procedure. The factor too. Yeah.

[00:12:50] Risk if we want to make sure that we have appropriate surgical backup and whatnot with our colleagues in the hospital, that you don't get at the ASC. So yeah, a lot of things to think about when actually considering what belongs in an ASC. Totally. No, great discussion. And I know it's on everybody's mind. So glad we're touching it. Austin, let's shift the conversation here to food as medicine. And there's potential FDA changes around food quality.

[00:13:19] Talk to us about the impact that those things are having in your work with GI health. I think this kind of touches on a broader topic of just general patient understanding and literacy around their own gut health. And it's complicated. I think food in some ways obviously impacts our health. It can impact people with underlying GI conditions. But at the same time, I think it needs to be very clear to a lot of patients that food doesn't always substitute medicine.

[00:13:48] So we have to be very careful that there are certain conditions that just won't get better no matter how you optimize your diet. But that said, I think the greater attention and understanding of how food interacts with the gut and what changes are being made, hopefully positive changes around how food is being regulated, can potentially prevent certain chronic conditions from developing.

[00:14:12] And we're seeing, for instance, this spike in colorectal cancer incidence in younger people. We don't quite know exactly what's causing it. But, you know, our best educated guess would be that it's probably something from the environment or the foods that we're ingesting, maybe especially ultra-processed foods. And any regulations around that, hopefully we can demonstrate through evidence, will actually lead to some positive clinical changes. But it's hard to say.

[00:14:42] I think right now it's too early. And sometimes we don't see the downstream benefits of these changes for decades, right? And especially for something slow-growing like a colorectal cancer. But yeah, just to get back to patient empowerment, I think generally speaking, food, unlike a lot of the gastrointestinal conditions that we talk about and treat food and our understanding of food, it's a little more close to home for people.

[00:15:07] And maybe it'll help people also just pay more attention to digestive health in general. So for that, I'm hopeful. Austin, thank you so much for that. Yeah. So Nate, talk to us about how Intermountain connects behavioral change, food is medicine, as we've been talking about, and technology to help with patient literacy for some of these challenges in GI. I think, to be open, this is something I learned from Austin.

[00:15:34] And again, he and I have talked about it previously, but I am very grateful to him that, and I actually know a lot of other GI physicians who are grateful to him, and he may not know that, is he helped us to think differently about how we're communicating. Because I think human connection is essential for listening, for clarity of messaging, and also for action and behavior change.

[00:16:03] And to be honest with you, we're all in competition with a lot of other distractions and priorities and companies vying for our patients' attention. And in some ways, some of the information that they're receiving is just wrong, is inaccurate information, not vetted information, or highly biased. And so full disclosure, I learned much more about this from Austin than I have from anyone else.

[00:16:31] Because then I just started to learn and pay attention in a more fine-tuned way about what's going on around us. Who is actually competing for our attention? And then what's their ask? What do they want out of it? And Austin has a very good heart. And the way he communicates is with the intent to connect and to share information to empower patients and people to make the best decisions for themselves. Is that fair, Austin? Wow. I mean, that is high praise.

[00:17:00] So I appreciate that. It truly was the kind of impetus of me being on social media was understanding how patients receive their medical knowledge. And I always wondered before my medical training, who gets to decide what ends up on the evening news? That like there's a breaking news around a study or a medical story. Who's actually deciding what gets shown and who is vetting that information?

[00:17:27] So yeah, that really is how I decided to get more involved on social media. And now it's almost a given how we link medical knowledge and social media and its impact on public opinion and public health, partly because of the pandemic and how we were all online and influenced in real time by everything that was being delivered to us via social media. But that wasn't always very clear. That relationship, that intersection wasn't really well accepted before the pandemic, honestly.

[00:17:57] And so, yeah, I would say I've tried to kind of raise awareness and hopefully now it's just a given. Everyone just understands that, yes, there is that linkage. Yeah, I was going to follow. I did not have any more email. I was going to say thank you on this. But sincerely, because if you think about attention as being so important today, especially with just so many channels, so many messages, and to be honest, so much bias about how the stories are shared,

[00:18:24] it's really scary for our patients as our teammates. Because my mental model is patients are teammates in health and care, and we can't do anything without them. Or put another way in colonoscopy speak, I've never done a colonoscopy without a patient's help, right? No prep, no procedure, at least not in a safe way. So if that's true, then how do we connect more with patients as teammates in their care? And that's where I think the focus on food as medicine

[00:18:54] and helping to share accurate information with patients about nutritional therapy and about which foods are potentially helping them, which are hurting them, is something that we've started more of at Intermountain. And we had our national GI meeting, DDW, Digest Disease Week last week. Unbelievable. Cool. All of it go well? It was phenomenal. A lot of focus on nutritional therapy and dieticians as our teammates.

[00:19:23] And that is 100% true. And I think in ongoing digestive health care, dieticians are essential. And that's for eosinophilic esophagitis, celiac, irritable bowel syndrome, inflammatory bowel disease. We need, and for our esophageal clinic, we have a dietician now embedded in the team-based care where each patient sees me. It makes so much sense. Right? Yeah.

[00:19:51] Each patient sees me and then my thoracic surgery partner, Dave Griffin, and then one of our dietician teammates in a combined visit. And so we're testing this theory. Patients love it. It's been a really great way to combine food as medicine, dietician teamwork, and the total experience of care for patients. If I can just add, I think metabolic disease is also an area that GIs are involved with now.

[00:20:18] Areas, even from a procedural standpoint with bariatric endoscopy, that food as medicine piece is, you know, a part of that entire care plan. Totally. We could do a whole episode on this, guys. That's a tease for everybody. So for all you guys listening, watch out. There's a part two here coming soon. I love it. This is such a great discussion. And look, we've talked technology. We've talked innovation and integration. Food is medicine. Let's get to strategy, right?

[00:20:47] At the end of the day is how do we make rubber hit the road and get these ideas to happen? Austin, how do you see Medtronic pulling patient insights into its innovation engine to create a better experience and more connected technology for patients and providers? Well, I think first and foremost, it's built into the mission statement of Medtronic, which I think is just really key to the culture of the entire company.

[00:21:14] But putting patients first is there's actually an initiative called Put Patients First. And what that initiative is focused on is making sure that patient voice is incorporated into every aspect of the development process of new innovation. And it's still currently a work in progress. But I think that patient feedback is so crucial because no matter, even if ultimately the device customer isn't necessarily the patient directly, ultimately it's the patient that we're serving.

[00:21:42] And some of that feedback is just so critical, especially the more that some of our technologies are directly involving patients and where patients have a greater understanding and greater choice around that. One of our innovations, you mentioned the capsule endoscopy product we have, PillCam. So our latest iteration of that is called the PillCam Genius Kit. And how this differs from what was previously on the market is that rather than having the

[00:22:10] patient wear this big bulky belt where they can't really go in public, they can have this adhesive patch where the pill, after they swallow it, it transmits the data to that adhesive patch and they can wear it under their club that. And it just improves the patient experience. And at the same time, it frees up all this bulky hardware. And the doctors aren't limited by that hardware either. They have more capacity, which then improves patient access to be able to get diagnosed more faster.

[00:22:39] Just even focusing on that element of the patient feedback could potentially then lead to other downstream benefits too. Yeah, it's just, it's part of the product development process. And I think that we're still developing other ways to be able to solicit that feedback from patients and get their insights. That's fantastic. Thanks, Austin. Yeah. And I keep hearing the undertone of what both you and Nate keep going to is patient experience.

[00:23:07] It's this obsession around the experience overall. It's so important. So I love that so much. Nate, I'd love to hear from you on this one. Where does GI Health Innovation and Strategic Partnership live inside, specifically Intermountain Strategy, where focused on care of the communities you serve? Talk to us about that and more of kind of what you're seeing. The wonderful and challenging part of being in a big health system is we are in a big health

[00:23:34] system with a diversity of care locations, communities we serve, to your point, especially with different rural communities across multiple states. A lot of different perspectives to include. I think the base model I've tried to build for myself, going back to my own process of mental model development is core design with thoughtful adaptation, is thinking about this is a great

[00:23:59] positive impact, whether it's a new technology or, by the way, a process or workflow innovation. What's the base model? And then how could we adapt that thoughtfully to each of the teams or communities we serve to have the most collective benefit? Rather than thinking, we've got one thing. Let's just push it out to everyone. And so I think that's made a big difference in terms of strategic expansion and scale is

[00:24:27] thinking about, yes, there needs to be a core design and we need to include each community to Austin's point, the patient voices in the community, as well as the clinician voices, which Austin didn't mention. And yet I know for a fact he is very inclusive of physician and clinician voice in the design as well of what Medtronic is doing and how he approaches things. So, yeah, I hope that helps a little core design with thoughtful adaptation and thinking

[00:24:56] through gradual scale of positive impact rather than an assumption of, hey, one thing will work for everyone. I like it, Nate. I like it. We got to get a little handbook of all your models, right? I love that. You want that one? I think a lot of people would. You could get your book out. I know, Austin, you've got your book out, Gut and Owner's Guide. So, Nate, you could do yours there too. The Handbook of Models. This is fantastic, gents.

[00:25:24] I have really thoroughly enjoyed this discussion. For everybody with us today, I want to thank you for tuning in. We're going to do some closing thoughts here, but I want to remind you that in the show notes, you'll find all the ways to get in touch with Dr. Austin Chang as well as Dr. Nate Merriman. So, make sure you get in touch with them and find out more about their work. So, as we get to the end here, I would love to hear closing thoughts from both of you.

[00:25:50] Just to conclude, I think that I have, both of us actually, Nate and I both have a unique perspective of being at the intersection of clinical practice plus kind of med tech and introducing health innovation into health systems plus the digital aspect and patient connection through digital communication. And I think with all that, I'd say for any clinicians who are listening to keep your mind

[00:26:18] open to the entire ecosystem of how healthcare comes together, I think we're very often trained just to focus on the science and the medicine. And there's just so much more that we need to think about to really advance care and take it to the next level. And really in that process, not losing sight of patients. And I was actually told that specifically by a mentor when I joined Medtronic that through this journey, just don't lose sight of the patient. And that's really stuck with me. Great message there, Austin. Thank you for that.

[00:26:48] Nate, take us home. I think two things I'll share. One is thinking about working together to bring diverse perspectives to a shared problem. And I've known Austin for, I don't know, like eight or nine years at this point. I love learning from him. He really, he is a remarkable person and physician and thought leader. And so, and yet we wear different jerseys, right?

[00:27:16] And it's so interesting to me is how important identity is to each of us and how little we talk about it. It's just, I find that fascinating. So Austin and I have a lot in common and we connected early in our careers and, and I love continuing to stay connected and learn from each other. So working together to learn faster and innovate better, I think is one message. And then the other thing is something I started to bring up recently because I am very competitive

[00:27:45] and I don't want to, I don't know if I'm guessing you each are also very competitive. It's somewhat of a human trait. It's definitely a physician trait too, is, but at the end of the day, and I don't know where the switch flipped, but I started to ask who are we competing against or what? And I really believe it's cancer. It's avoidable suffering. That is who we're competing against.

[00:28:09] And I think that mindset can really help overcome a lot of historic challenges or struggles with different companies working together on shared challenges. And so, yeah, who or what is our competition? And in gastroenterology, I think it really is cancer. Gastrointestinal cancers, as Austin said, unfortunately are rising in our young patients. So how can we work together to fight against colorectal cancer as a great example, or pancreatic

[00:28:37] cancer or esophageal cancer, and how can we work together to prevent avoidable suffering? That's great, Nate. I love nothing like a good common enemy to align and get motivated by. That's so great. What a great close there. Folks, thank you so much for tuning in to our podcast again. Just want to thank you all for spending time with us today. Such a privilege to be here with Austin Chang and Nate Merriman.

[00:29:02] Just an incredible opportunity to learn what's at the horizon of GI innovation. Gentlemen, thank you so much for joining us today. Thanks so much, Saul. Thank you, Saul.