Stanford Medicine Dean Lloyd Minor on Apple Heart Study, Biomedical Revolution and Precision Health

Stanford School of Medicine Dean, Dr. Lloyd Minor, on Apple Heart Study,
Biomedical Revolution and Precisi on Health

[Music]

Margaret Flinter: Welcome to Conversations on Health Care with Mark Masselli
and Margaret Flinter, a weekly show where we speak to the top thought leaders
in health innovation, health policy, care delivery, and the great minds who are
shaping th e health care of the future. This week, Mark and Margaret revisit their
conversation with Dr. Lloyd Minor, Dean of Stanford University School of
Medicine, where he's overseeing a culture of transformation in care delivery and
medical training, building a culture of collaboration between the university's many
science and health divisions. He'll talk about Stanford's partnership and the
groundbreaking Apple Heart Study.

Lori Robertson also checks in, the Managing Editor of FactCheck.org, looks at
misstatem ents spoken about health policy in the public domain, separating the
fake from the facts. We end with a bright idea that's improving health and well
being in everyday lives.

If you have comments, please email us at [email protected] , or find us on
Facebook or Twitter. We love hearing from you. Plus, you can find us on
iTunes, or Stitcher, or wherever you listen to podcasts. Please feel free to leave
a review for us there. Now, stay tuned for our interview with Stanford Medicine
Dean, Dr. Lloyd Minor, on Conversations on Health Care.

Mark Masselli: We're speaking today with Dr. Lloyd Minor, the Carl and
Elizabeth Naumann Dean at the Stanford School of Medicine, where he's
established a strategic vision to lead the biomedical revolution in precision
health, a scientist and surgeon. He's also professor of otolaryngology and head
of neck and surgery as well as professor of bioengineering and neurobiology at
Stanford University.

Before coming to Stanford, Dr. Mino r was Provost and Senior Vice President for
Academic Affairs at Johns Hopkins University , where he served as Chair of the
Department of head and neck surgery at Johns Hopkins University School of
Medicine. Dr. Minor earned his bachelor's in medical degree from Brown
University and completed his residenc ies at Duke University's Medical Center
and the University of Chicago Medical Center . Dr. Minor, welcome to
Conversations on Health Care .

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

Mark Masselli: Yeah. As you know , Stanford School of Medicine is one of the
most recognized medical teaching institutions in the world, which is also
supported by some of the best scientists at Stanford University across a number
of disciplines . You' ve launched a very bold strategic vision at Stanford to break
down the barriers between all of these disciplines to accelerate the pace of

Stanford School of Medicine Dean, Dr. Lloyd Minor, on Apple Heart Study,
Biomedical Revolution and Precisi on Health

biomedical discovery to bring us closer to the promise of true precision medicine .
I'm wonder ing if you could share with our listeners more about the 21st century
strategic vision and your goals in this endeavor.

Dr. Lloyd Minor: For years, we've been treating disease after the fact, making
diagnoses far too late to achieve the outcomes that we would really like to
ac hieve. Certainly , when we have a severe acute disease like cancer, we want
precision medicine . We can think of precision health as encompassing precision
medicine, but very importantly focusing on health . There are really three
components to our vision of leading the biomedical revolution in precision health.

First is to predict , and then prevent , and then to cure disease precisely using the
same levers of genomic medicine, big data science, regenerative medicine, but
applying those in a predictive, pre ventive , and proactive way. The way we know
we will have succeeded in precision health is that the inciden ce of those
diseases requiring precision medicine will be far less. Isn't that what we all seek
is to have healthy lives , and when disease does come up , to either diagnose it
much earlier , so we can treat it more effectively or prevent it all together .

Margaret Flinter: Well, Dr. Minor , we had one of your colleagues on with us a
few years ago , Dr. William Newsome, who's Head of the Stanford Neurosci e nces
Institute, and as you know is Co - Chair of President Obama's BRAIN Initiative .
He said to us then that in order to unlock the secrets of the human brain, that
long, siloed scientific disciplines would have to come together and start working
collabora tively , c omputer science, neurology, biomedical engineering, physics,
advanced mathematics.

Talk with us, if you will, about how the academic landscape is being
fundamentally restructured to facilitate this new approach that will help you
realize that gra nd vision ?

Dr. Lloyd Minor: This is the century of biomedicine . We're seeing so many
disciplines from science and technology converge on biomedical problems.
Biology as a discipline has grown up. It's now firmly a quantitatively rooted
discipline . The refore the techniques from the physical sciences, from
engineering, the techniques that have been so successful in other areas can now
be applied in biology and medicine.

At Stanford , we do have the advantage of ev eryone being on the same campus.
Our Aca demic Medical Center with the School of Medicine and Stanford Hospital
and Lucile Packard Children's Hospital , we are on the campus of Stanford
University. My office , it's literally across the street from the chemistry
department, the biology department , and the engineering school . There's a very
fluid interchange of faculty and students between and among the various
different disciplines at the university.

Stanford School of Medicine Dean, Dr. Lloyd Minor, on Apple Heart Study,
Biomedical Revolution and Precisi on Health

Also, I think Stanford and our peer institutions as well are moving towards a more
collaborative i nterdisciplinary culture. We provide incentives like seed grants . In
some of our seed grant programs , we require that faculty from different
disciplines collaborate in preparing the grant proposal. Oftentimes , the catalyst
that brings laboratory groups together is the student , who has expertise in and is
gaining expertise in relatable complimentary [ PH ] field s that really brings the
faculty together. All those are mechanisms that are being used to encourage
and promote interdisciplinary scholarship and research .

Mark Masselli: Dr. Minor , the notion of precision medicine is certainly taking hold
across the health care landscape . We have the National Institute of Health's All
of Us Precision Medicine Initiative . We're also seeing this explosion of targ eted
drug development in the world of pharmaceuticals . For the first time , we're
harnessing personal health data from wearables to gain better understanding of
population health . I'm wondering if you could tell us what are you most excited
about .

Dr. Ll oyd Minor: Several things . There's explosion in terms of basic biological ,
biomedical discovery. Our knowledge of receptors on the surface of cells , our
knowledge of -- that knowledge is increasing at a prodigious pace. In the past , a
scientist makes a discovery . That scientist thinks that might be a druggable
target . Then there's a big gap between that fundamental discovery and
answering the question , whether or not this is a target . If it is a target, then
making the compounds that interact with it as a target.

Classically , what people would do, they would file for the intellectual property ,
then seek to get commercial funding , and work it up from there. That's easy to
say in two or three sentences . It turns out to take a lot of time and effort , and
years. We're trying to shorten that lag time in a number of different ways through
partnerships with industry to bring the benefit of medicinal chemists on campus,
to provide incentive funds that will help a faculty member to cross that first valley
o f death , and really determine if that receptor or ligand is indeed a target .

Another area relates to this rapid development of the field that's known as digital
health. I think of digital health as having two components, a consumer - facing
component, wear ables and other devices , and second , an analytical, artificia l
intelligence machine learning - enabled component, which is extracting information
f rom the treasure troves of data, data that are locked in our electronic medical
record systems, but being able to decipher relationships , and therefore develop
better care delivery pathways based upon this enormous amount of data.
Getting from basic discovery to therapeutics , second , being able to more
meaningfully gather data about health , and then extract inform ation from those
vast quantities of data .

Margaret Flinter: I'm thinking , listening to you, it's changed in the way we train
our next generation of health care professionals to o if we're going to be

Stanford School of Medicine Dean, Dr. Lloyd Minor, on Apple Heart Study,
Biomedical Revolution and Precisi on Health

successful . You're certainly one of the most renowned campuses for training of
health professionals. What are you seeing in the changes in the education and
training of future physicians , and other health care professionals at Stanford?

Dr. Lloyd Minor: One of my friends in the venture capital world would usually turn
to me on the panel and say, you know, we're going to put you out of business
and your medical school out of business in the next decade. There will be a
need for physicians . E verything will be handled by data scientists. No w, I worry
about a lot of things in life , right? That's not one thing that I tend to worry about .
The need for physicians and other health professionals to understand what can
be accomplished through data science , that need is increasing prodigiously .
During the first t wo years of medical school, we basically follow the same
calendar as the rest of the university . We have first and second year medical
students tak ing courses in computer science and engineering , as well as in the
humanities and social sciences. Medical students get combined degrees in law
or in business as well as in more traditional scientific disciplines.

Today, more than ever , the need to train physicians to be valuable members of
teams , we also want to have physicians graduating from our medical sch ool that
have competencies in other areas as well. I like to think of what we're moving
into in health care is being high tech enabling high touch. I don't believe that
health care professionals are going to be put out of business by high tech.

When we ask people in our health care delivery system, do you want to receive
all of your care virtually , or do you want to have a primary care health provider ,
and be able to access others virtually ? No one elects to eliminate a primary care
provider . T hey also want the immediacy that virtual interactions an d digital
health provide today. Those of us who a re responsible for training the health
care workforce of the future , that's what I think we want to focus on.

Mark Masselli: We are speaking today with Dr. Lloyd Minor, Dean of the
Stanford School of Medicine , where he has established a strategic vision to lead
the biomedical revolution in precision health. Dr. Minor , I think that probably the
area where we need the most is in sort of managing all of this bi g data. We had
Apple ' s Chief Operating Officer, Jeff Williams , on the show , who talked about
their plans for entering the health care space . Now , Stanford is partnering with
Apple and the telemedicine company, American Well , on the Apple Heart Study
to a ccelerate research in population health . I'm wondering if you could talk to our
listeners about this collaboration . How might it inform the future of population
health research?

Dr. Lloyd Minor: One of the things that excites me the most about the Appl e
Heart Study is it's starting to put information about health into the hands of each
of us as a health care consumer . Technology has transformed every other
aspect of our lives and our economy , except for health care . You and I can use
our ATM card pret ty much at any ATM on the planet. Like w ise , the way we order

Stanford School of Medicine Dean, Dr. Lloyd Minor, on Apple Heart Study,
Biomedical Revolution and Precisi on Health

essential goods and services has changed dramatically . The way we access
information about our health has undergone very little change.

We still walk into doctors ' offices and we see fax machi nes that in other sectors
have gone out of business a long time ago . One essential next step is to make
information about our health more accessible to us . That's exactly what the
Apple Heart Study is intended to do. It's looking for the arrhythmia o f a trial
fibrillation. We know it's the most common arrhythmia . We really don't know
today the true incidence and prevalence of atrial fibrillation . We have designed a
study to look for indicators of atrial fibrillation . T hen as you described working
with American Well to , when the watch picks up that there may be an ar rhythmia
for the consumer to contact American Well and get information about next steps
to screen further for the possibility of atrial fibrillation.

This will , first of all , give us a trea sure trove of data about the true incidence and
prevalence of atrial fibrillation . It's an essential first step towards ultimately
designing a monitoring system that will enable people to know if they have the
arrhythmia and enable physicians to make a mu ch more informed judgment
about when it needs to be treated , or when it can simply be observed.

Margaret Flinter: Dr. Minor, maybe focus for a minute on prevention. Do y ou talk
about the next big thing in health being precision health , and you believe i t will be
a game changer to population health in the future ? Talk about this precision
health system that you have at Stanford and what would you like our listeners to
know about it?

Dr. Lloyd Minor: There are several components addressing the social,
e nvironmental , and behavioral determinants of health. We look at health and
health care as a pie. Our traditional health care delivery system only addresses
maybe a quarter of that pie . Social, environmental, and behavioral determinants
account for 75 % o f the pie. We also know that those are the most difficult
components to address.

One project we're doing here, o besity among Latino American c hildren is very
high in the United States. Prevalence is about 39 %. We know that children who
have obesity, ma ny of them morbid obesity, go on to develop a very high
incidence of diabetes, heart disease, kidney failure, a host of complications
triggered by obesity . We have a group of our faculty , who receive funding for a
project , called SPHERE , Stanford Precisio n Health for Ethnic and Racial Equity.
One component of that project looks at obesity among Latino American c hildren
in Santa Clara County .

What we're doing in that study, yes, we're doing the traditional scientific medical
analysis of genomic s and other biological indicators , and markers, but we're also
looking at how we can encourage and enable activity, very practical types of
interventions like offering to replace all of the cooking and serving utensils in a

Stanford School of Medicine Dean, Dr. Lloyd Minor, on Apple Heart Study,
Biomedical Revolution and Precisi on Health

household with smaller utensils, hopefully leading to smaller portions . We're
studying all of these interventions to see what's effective in specific patients
according to their social, environmental , and behavioral determinants.

I think being rigorous about the way we study the interventions is the way that
we're ultimately going to understand how to address these determinant s . I also
think this revolution in di gital health, both the consumer - facing component and
the machine learning AI - enabled component , this revolution will help as well
becaus e each of us is going to have a lot more information about our healt h than
we've been able to garner in the past. All of those things make me optimistic
about being able to achieve this vision of precision health.

Mark Masselli: Dr. Minor, we have te ns of millions of Americans who don't have
access to health insurance . Yet on the other hand, we're talking today about
these 21 st century innovations, genomics, proteomics, AI . We're facing this
much larger concern about how do we bend the cost curve . The n we have these
announcements , most recently a collaboration between Amazon, Berkshire
Hathaway , and JP Morgan vowing to reduce the health care cost burden.

There seems to be lots of skepticism in th ese quest s to transform health care . In
your vision of t he future , where is the opportunity to bring these disparate groups
together to form a sort of a more perfect union for the health care delivery
system?

Dr. Lloyd Minor: I , like you , am just now learning about the collaboration
between Amazon, JP Morgan , Berkshire Hathaway. Let me offer a few thoughts.
To the extent that we can simplify and make more efficient the supply chain in
health care delivery , that will increase value , that will lower cost , and conceivably
improve outcomes by making what is today a rather fragmented supply chain,
more cohesive and coherent . Also making information available , o ne can
imagine that 10 years from now, the way we will access health care de livery
services or other health - related services can similarly be dramatically d ifferent ,
and different in a way that adds value, lowers cost, improves outcomes, and
makes the entire system more efficient for us to engage in healthy behaviors.

For example, if we're able to get healthier sour c es of food in an accessible and
affordable way, that will promote health . If people don't have barriers to shopping
for foods that are healthy, that is going to translate into better health . You can
imagine it across the board with multiple aspects o f the economy related to
health, m aking those more accessible, more affordable will help us to achieve a
healthier society. That is my understanding of the overall intent . How it
translates into specific programs and opportunities , I th ink we'll have to wait and
see.

Margaret Flinter: We've been s peaking today with Dr. Lloyd Minor, Dean of the
Stanford School of Medicine. You can learn more about his work by going to

Stanford School of Medicine Dean, Dr. Lloyd Minor, on Apple Heart Study,
Biomedical Revolution and Precisi on Health

medicine.stanford.edu , or follow on Twitter @StanfordM ed . Dr. Minor, thank you
so much for the pioneering work that you are doing a nd for joining us on
Con versations on Health Care today.

Dr. Lloyd Minor: Thank you , Margaret . It's been a pleasure talking to you and to
Mark .

[Music]

Mark Masselli: At Conversations o n Health Care, we want our audience to be
truly in the know when it comes to the facts about health care reform and policy.
Lori Robertson is an award - winning journalist and Managing Editor of
FactCheck.org, a nonpartisan , nonprofit consumer advocate for voters that aim to
reduce the level of deception in U . S . politics . Lori , what have you got for us this
week?

Lori Robertson: With the con troversy over family separations at the border,
much of the political rhetoric in recent weeks has focused on illegal immigration.
We thought it would be helpful to take a step bac k and look at some measures of
illegal immigration in a larger context. First, there were 12.1 million immigrants
living in the country illegally as of January 2014 a ccording to the most recent
estimate from the Department of Homeland Security . The Cente r for Migration
Studies estimates the number at 11 million people in 2015 , and says that 44 %
were visa overstays. That's people who had entered the country illegally on
visas, but overstayed the limits on those visas. As for those trying to cross the
bor der, apprehensions on the s outhwest border peaked in 2000 at 1.64 million
and have generally declined since , totaling 303,916 in 2017.

In recent years, the number of families trying to cross the border has increased,
both in number and proportion of those apprehended. In fiscal year 2013 ,
a ccording to Customs and Border Protection data , there were 14,855 people
apprehended on the s outhwest border who were part of a family unit. Those are
individuals , including children under 18 , parents or legal guardian s apprehended
with the family member. That was 3.6% of all those apprehended on the border
that year . In 2017 , 24 .9% of apprehensions , or 75,622 people were in a family
unit. As for unaccompanied children, the number of children under age 18
apprehended crossing the border without a parent or legal guardian was 18, 411
in fiscal year 2010 . The figure was about 40,000 by fiscal 2013 and it was about
the same in 2017 . It fluctuated in the years in between , spiking in fiscal 2014.
Unaccompanied children a re referred to the Department of Health and Human
Services , Office of Refugee Resettlement .

HHS said in late June that there were 11,800 children in its shelters , with 2047 of
those being children who had been separated from their parents . About 80% or
m ore of all unaccompanied children referred to HHS over the last several years

Stanford School of Medicine Dean, Dr. Lloyd Minor, on Apple Heart Study,
Biomedical Revolution and Precisi on Health

have been age d 13 and older . About 90 % or more have been from Honduras,
Guatemala, and El Salvador.

That's my fact check for this week. I'm Lori Robertson, Managing Editor of
Fact C heck.org .

Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country's major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania . If you have a fact that you'd like
check ed, email us at chcradio.com . We'll have FactCheck.org's Lori Robertson
check it out for you here on Conversations on Health Care.

[Music]

Mark Masselli: Each week Conversations highlights a bright idea about ho w to
make wellness a part of our communities and everyday lives. Tinnitus is a
vaccine condition that afflicts millions of Americans, a condition for which there is
really no viable treatment to date, but a University of Michigan researcher may
have found a solution.

Dr. Susan Shore says tinnitus, marked by a constant ringing in the ears , is really
the results of misfiring brain signals. Her team has developed a device aimed at
getting to the root cause of tinnitus , neurons in the region of the brain ste m.
When those cells become hyperactive, they create a signal that is transmitted to
the part of the brain where hearing perception occurs and the constant ringing
can wreak havoc on sufferer s' lives.

The device is called a targeted bimodal auditory - somat osensory stimulation and
works on two fronts. It uses both weak electrical impulses target ed to the brain
stem region responsible for the problem, and also sends time sound to interrupt
the auditory sensation caused by the tinnitus .

Dr. Susan Shore: We developed this treatment for a particular class of tinnitus in
which the person who has the tinnitus is able to modulate either the pitch or the
loudness of their tinnitus by pushing on their face , or pushing on their forehead ,
or clenching their jaw.

Mar k Masselli: The study group has been relatively small so far, but the results
have been quite promising. Dr. Shore says that the severity of the tinnitus was
greatly reduced in most of the participants and some got to the point where it no
longer interfe red with thei r daily lives.

Dr. Susan Shore: We need a good solution for tinnitus as it's affecting millions of
people .

Stanford School of Medicine Dean, Dr. Lloyd Minor, on Apple Heart Study,
Biomedical Revolution and Precisi on Health

Mark Masselli: A relatively simple targeted device that could potentially help
millions of tinnitus suffer ers from the worst effects of their condition. Now, that's
a bright ide a.

[Music]

Mark Masselli: You've been listening to Conversations on Health Care . I'm Mark
Masselli.

Margaret Flinter: I'm Margaret Flinter.

Mark Masselli: Peace and health.

Female: Conversations on He alth Care is recorded at WESU at Wesleyan
University, streaming live at chcradio.com , iTunes, or wherever you listen to
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