Bright Ideas with Dr. Nicholas LaRusso

MPR News "Bright Ideas" series welcomes Dr. Nicholas LaRusso, Charles H. Weinman Endowed Professor of Medicine, Director of the Center for Innovation at Mayo and Distinguished Investigator of the Mayo Foundation.

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Stephen Smith: This is Bright Ideas, fresh thoughts on big issues from Minnesota Public Radio News. I'm Stephen Smith. Each month, we invite a guest to the forum here at MPR headquarters to talk about important issues and ideas and to take question from the studio audience.

Our guest this time is Dr. Nicholas LaRusso, a physician and a scientist at the Mayo Clinic in Rochester, where he directs Mayo's Center for Innovation. A native of Brooklyn, New York, Dr. LaRusso has spent much of his medical career at Mayo. He started as a resident and went on to study and treat certain kind of liver ailments. He made breakthroughs in the diagnosis of liver disease, and then went into clinic administration heading up his department and eventually becoming chair of the department of medicine.

More recently, Dr. LaRusso has helped create and lead Mayo's Center for Innovation, an ambitious project to transform healthcare. His mission is to change how patients are treated and to make healthcare more accessible and affordable. Please welcome Dr. Nicholas LaRusso.

[applause]

Dr. Nicholas LaRusso: Thank you.

Smith: So, you came to Minnesota from a working class Italian American family in New York. And I'd like to know how and when you got the idea to be a medical doctor.

Dr. LaRusso: If you grew up in the 50s like I did, in a working Italian American family, the professions that were revered were medicine and the clergy. So, I really had no difficulty in making a choice between those two.

Smith: You had to wear a certain kind of coat in either case.

Dr. LaRusso: Well, yeah. So, the clergy was never an area of interest of mine. I think the first influence was our local family doctor. And he would come to the house whenever I had a sore throat, which was quite frequent. And he just exuded confidence, and compassion, an interest in me. And I could see the anxiety on my mother's face gradually disappear because he had arrived. And so that was sort of my first exposure.

I think the next big influence on me when I was in high school. I went to a Jesuit prep school in Brooklyn which had an enormous influence on my life. That experience helped focus me on the satisfaction that comes from helping other people. So, when I went to college, I choose between majoring in English because I loved English, I loved to read or premed. I figured it was easy to switch from premed to English than to switch from English to premed. And that's kind of the way it happened.

Smith: And if you had stayed in English, you would be in my job and that would be a drag.

Dr. LaRusso: Well, actually, it's interesting that you... I mean, I think that I would make the argument that the best physicians are those who have a broad liberal arts education.

Smith: Because?

Dr. LaRusso: Because they're not trained for anything in a liberal arts education, but they're prepared for everything. They learn how to communicate. They're educated, they've read widely.

I'm a little biased in that regard because my oldest child, my daughter Elisabeth, had expressed an interest in medicine. And I discouraged her from taking premed. I said, "Get a good liberal arts education," which she did at Middlebury. She was a history major. And then she did all of her science courses in one year and went on to get her medical degree at Harvard.

So, I think we in medicine now are beginning to look at the curriculum for medical school. And increasingly, I think attitudes are shifting to the importance of a broad based education. Not so heavily focused on the science that one tends to forget rather quickly.

Smith: So, as a medical student, you did your residency at the Mayo Clinic. And the Vietnam War played an unexpected role in how you decided, essentially, what kind of medicine to specialize in. Can you explain?

Dr. LaRusso: Yeah. Well, I enjoyed all the rotations I had when I was at the Mayo Clinic and I couldn't make my mind up as to what specialty I wanted to go into as a fellow. So, it was like March of my last year. And I was actually thinking of doing a locum tenens in a small town in Minnesota.

Smith: I'm sorry, what's that?

Dr. LaRusso: That's a temporary appointment.

Smith: Only in Latin, so it sounds a lot better.

Dr. LaRusso: Well, it's a common phrase for physicians. To make some money to pay for my college loans, and medical school loans. And then someone got drafted, who turned out to be a college of mine later on. Al Chia, an internationally known liver specialist. I got a call from the program director and he said, "Are you interested in GI?" And I had been interested in GI -- gastroenterology.

And in fact, sitting in the audience is Sid Philips, who was one of my first bosses. He probably remembers that this position opened up. And the next thing I knew, I was in the GI research unit becoming a gastroenterologist. So, that's an example of what often happened in life where things that are unpredictable have a transformational effect on what you wind up doing, and where you wind up.

Smith: You have been, throughout your career, both a research scientist as well as a physician doing clinical work. And that's relatively... Is that unusual? Do most people decide early on that they're going to do lab work primarily, or they're going to be primarily a clinician?

Dr. LaRusso: I think if you look at... There are about 750,000 doctors in the country now, and if you look them, the vast majority of them are practicing physicians. There's a subgroup of those practicing physicians who work in academic medical centers places like the Mayo Clinic, the University of Minnesota. And within that group, there's subgroup that not only does clinical work but also does research.

I didn't intend to become a researcher when I started out, but the position that opened up happened to be in the GI unit at the time. That was my first serious exposure to research. And I had the privilege of working at that time with a brilliant scientist by the name of Allen Hoffman, and in the company of people like Sid Philips and Bill Summerskill marvelous individuals. So, I got very excited about research.

And then Allen, my mentor, said, "If you're serious about research, you need more training." I had done a couple of years of research training. And he said, "You really need to train yourself in the evolving basic sciences of cell and molecular biology."

So, Mayo Clinic has a program that extends back for many decades called the Mayo Foundation Scholar Program where they identify young potential faculty members and they send them off somewhere for a couple of years to get additional training, and to bring something back that's new and different.

So, I had the privilege of going to the Rockefeller University for two years, where I worked with Christian de Duve, who had just shared the Noble Prize in physiology or medicine. And I learned cell biology. So, that's kind of the way it happened.

Smith: So, what's the advantage of being both a researcher and a clinician at the same time?

Dr. LaRusso: Well, first of all, one of the major advantages, it's a very exciting career. It's a lot of fun because you're involved in discovery, on the one hand. But, more to the point, the physician scientist, as opposed to say a basic scientist who is a Ph.D., is constantly in the clinic, exposed to disease. And that exposure generates questions.

So, that stimulates your creativity. Because fundamentally, if you're a physician scientist, in my opinion, you're interested in understanding disease, because that's what you deal with. So, that, I think, explains what a physician scientist brings to the table.

Smith: Early in your career, you essentially, as a physician scientist, as a person who is doing research, you had to essentially figure out what disease you wanted to work on. I'm making it sound a little more simple than I'm sure it is. But, this may be kind of a revelation to some non-scientist, non-physician folks in the audience that when you're doing that work early on, you've got to figure out where you're going to make your mark, where you're going to make your discovery. So, tell us about where you started, and how you decided that particular... As I think you said, it was a bit of an obscure disease.

Dr. LaRusso: Well, let me try to put this in context a little bit. In my opinion, in the opinion of many of the mentors that I had, the most efficient and effective way to make relevant discoveries in areas of disease is to link your research program with the kinds of patients you see in the clinic.

When I came back from the Rockefeller, I had developed an interest in liver disease, because I had worked on it at a very basic level. Because Mayo at that time, and even now, has such expertise in so many areas, many of the obvious areas within liver disease had already had individuals who were making major contributions. So, for example, Al Chia who got drafted and whose position I got, was making major contributions in something called autoimmune hepatitis.

So, I was looking for something that nobody else was working on, and that I might have some interest in. And that's when I came across this obscure condition called primary sclerosing cholangitis. Over a period of a decade or two, in conjunction with wonderful colleagues, we helped define that disease.

It's a disease of the biliary tree, which is the intersecting conduits, the tube system within the live through which bile is generated and flows. It's still a disease that we really don't understand in terms of its etiology. But, the ultimate result is the obliteration of the biliary tree, resulting in sclerosis, uncompensated liver disease, and at least early on, before liver transplantation, essentially death.

Smith: Right. I think you said that at the time that you started getting into this, there really was virtually nothing that could be done for people.

Dr. LaRusso: No. In fact, after the first seven or eight years that I was back at Mayo when I was increasingly seeing patients with this condition, I was becoming very discouraged because there was very little that I could do for patients. Most of the patients with this disease were young men in their 40s with three or four kids. There was very little we could do at the time. And then a monumental occurrence happened, and that was the development of liver transplantation. And that changed everything in herpetology.

Smith: But before that, you had to work on the diagnosis. And if I remember correctly, you sort of had a hunch about what was going on with certain kinds of cells.

Dr. LaRusso: Well, yeah, you're right.

Smith: An educated hunch.

Dr. LaRusso: At the time, I was studying a cell within the liver called the hepatocyte which most people were studying. But, I began to realize that the cells that are involved in this condition and several other chronic liver diseases were the cells that lined the biliary tree. And they were called, we actually coined the term, cholangiocytes.

So, I had an idea file. And what I used do is if I had an idea, put it in the file and look at that several times a year. And the serendipity of the right fellow arriving in the lab at the right time led me to pull out the idea, and start to develop techniques to study cholangiocytes. And so, that's what we spent the last 15 years on.

Smith: And do you remember how you got that idea? Where you were, what you were doing?

Dr. LaRusso: You know, the thing about ideas is that it's often difficult or impossible to remember where they came from. Sometimes it's a casual discussion you have with someone over a beer, and if we get to the Innovation Center, that's exactly how it began. Sometimes you can't even remember where the discussion was.

So, it just seemed to me that these cells had to be important and that at the right time and it was the serendipity of a wonderful Japanese scientist coming to work with me that it was time to pull the idea out and start figuring out how to pursue it.

Smith: Let's go to the work that you're doing now with the Center for Innovation. I'm going to skip over a big part of your career, which was going into the administration, as well as continuing to do the science and the research. Let's talk about innovation. This was an idea, as you say, came up over some beers?

Dr. LaRusso: Well, it evolved actually.

Smith: [laughs]

Dr. LaRusso: When I was Chair of the Department of Medicine, we had a strategic plan. And one of the six objectives of the strategic plan was to promote innovation. At that time, I didn't know very much about innovation.

Smith: Even though you'd been doing it in your own work?

Dr. LaRusso: Well, yeah. I think that innovation there are a lot of definitions, but it's fundamentally creating something new. And so, my colleague, Mike Brennan, and I, used to run marathons together. That was a decade or so ago before knee surgery and old age or senior citizenship.

And so, we would talk, because he was my associate chair for the outpatient practice. We would talk a lot when we were running about the practice and how to make it better. And so one night in particular and he's from Dublin and he likes Guinness, and I'm from Brooklyn and I like Guinness, and we ran and we wound up at his house drinking a lot of Guinness.

And the idea came up, "Well, maybe what we should do is try to develop a lab that we could study the interaction of patients and providers," analogous to the way that I study cells and rodents in my lab. And we started thinking about that.

At the same time, I learned about a company called IDEO in Palo Alto, which is probably the premier design company, certainly in this country. And we started some conversations with them, and we began to learn about this evolving discipline called "design thinking." And that helped us implement the outpatient lab that we ultimately developed and we populated that lab, in part, with designers.

And so, that was the first application to my knowledge of design thinking and the use of designers in healthcare.

Smith: We'll get to the design thinking in a moment, but I want to know what the problem was that you were setting up this sort of laboratory for patient care.

Dr. LaRusso: That's a good question. The problem was that the outpatient practice was becoming increasingly challenging. Now, one of the things that Mayo has done that's innovative it's done many things over the years was to develop a practice that's heavily focused on the outpatient setting.

So, most of the patients that we see, we see in the outpatient practice and it was becoming increasingly challenging to our faculty to work in the outpatient practice because of regulatory requirements, complicated kinds of problems that were occurring.

And we felt that if we could study this the way we study things in the lab, observe the interaction of providers and patients, we might be able to get some insight into how to improve, make more efficient, the outpatient practice. That's really what started it.

Smith: But, was it that the providers were, as we've heard, famously unable to spend as much time with patients? Was it that they had to spend a lot of time looking at paperwork or doing paperwork?

Dr. LaRusso: Yes. Increasingly, the time of physicians was being, in my opinion, shifted to clerical work which arose for a whole host of reasons largely regulatory.

Smith: Right.

Dr. LaRusso: And so, the idea was, could we remodel -- and this is an on going challenge right now, quite honestly -- could we figure out ways by applying the scientific method, fused with design thinking to develop new models of outpatient care delivery?

Smith: Well, when you started in the business as a physician, what was your relationship like with your patients and how has it changed over time? How have those burdens you've described changed the way you, personally, have interacted with folks?

Dr. LaRusso: Right. It's changed substantially. First of all, the workload expectations have gone up. The degree of complexity of the patient. So, for example, especially in seniors over the age of 65, it's rare to see an individual with a single problem. Usually they have four or five chronic problems.

The number of medications that people are taking has gone up dramatically. The expectations of what the encounter required have gone up substantially. The introduction of the electronic medical record, which increasingly has made us more efficient, at the time, to adapt to it was a huge challenge and it still is to some degree. We're totally paperless at Mayo. We have a wonderful electronic medical record, but the learning curve of that, for many people, was a bit of a struggle.

Smith: Do you find in that system that you spend when you're actually sitting there talking to a patient and going through their record and interacting with them, that you're doing a lot of clicking?

Dr. LaRusso: Well, I don't look at the computer and talk to the patient at the same time and I don't think that most of my colleagues do. I think the interaction with the patient, a quality interaction with the patient, is diminished if one is distracted by looking at a computer screen. Now, I'll use the computer screen if I'm explaining something to a patient.

Smith: Right.

Dr. LaRusso: So it's a marvelous device if I want to show you your CT scan and explain to you what the problem is, but I rarely deal with the computer and the patient at the same time.

Smith: OK, so let's talk about what design thinking means. And then we'll go on to talk about how you're applying that to this patient interaction.

Dr. LaRusso: So, design thinking is an approach to problem framing and problem solving. It's focused on identifying the explicit and implicit experiences and needs of an individual. In this case, it would be patients. It's an evolving discipline. Probably the best description of it is in a book called "Change By Design" by Tim Brown, who is the CEO of IDEO. It's been increasingly used in non medical industries -- so places like Proctor and Gamble, for example, have used it extensively.

Smith: And you get design I mean, these are designers.

Dr. LaRusso: These are designers. Right now in the Center for Innovation, we have probably 10 full time designers that are embedded in the practice, and a number that we contract that work with us. So, these are marvelously bright individuals, virtually all of whom have come from some of the best design schools in the country.

Virtually all of whom have worked in industry but have gravitated to the Mayo Clinic and to healthcare because increasingly, they recognize that their skills can be devoted to something really, really important like patient care and healthcare.

Smith: I suppose what they bring is the consumer or the user's perspective. I mean, if you're a designer and you're making a product, you're actually thinking about how it's going to be experienced, used, handled by the thing people call the "end user."

Dr. LaRusso: They bring an enormous number of things that didn't exist in the healthcare system in my opinion. One of which you've alluded to, it's this concept of experience. It's the idea that when an individual is ill, there's a global experience that goes along with dealing with their illness that they encounter.

So, for example, a simple observation that they made in one of the projects that we've done is that when a patient comes to the Mayo Clinic, they spend 70 percent of their time elsewhere than actually interacting with the Mayo Clinic.

Smith: Where are they?

Dr. LaRusso: Well, they're in Rochester. But most of their time is not spent so the question then becomes, "How does this impact their experience?" A consequence of that, or an extension of that is a major project now that Mayo is doing called the Destination Mayo Community, where we're partnering with city leaders to address the 70 percent of time when they're not actually in the Mayo Clinic buildings. And that insight was generated by the designers. And it was generated by the development of the personas, that was the result of their observational research.

Smith: And Rochester may be many things, but a tourist destination is not one that springs immediately to mind. I mean, a destination where you're going to go and spend 70 percent of your time not being at the Mayo Clinic. Great town.

Dr. LaRusso: I have to be very careful there in how I respond to that.

Smith: Great town to live in, you know.

Dr. LaRusso: It actually is, it's a marvelous town to live in. But, that's just one of the examples of one of the insights that relates to experience and another extension of that is that the aspiration now of the Mayo Clinic, in terms of what we aspire to be, is to provide an unparalleled experience for our patients.

Those terms, the words "unparalleled experience," in my opinion, was influenced by the designers' recognition of the importance of identifying the user's needs, the patients' needs, the family needs.

Because for every patient that comes to Rochester, as a patient, they bring 2.3 people with them. And for any of you that have dealt with illness, you know that it's a family affair. And so how do we deal with the mother and father of a child that has an illness? Or, how do we deal with the daughter who brings an elderly parent to Rochester? That's all part of the experience that we're trying to figure out how to make unparalleled.

Smith: Now, in this laboratory, as you've described it, at the Center for Innovation, you have patient consultation rooms that are wired up with video so that... and of course, obviously this is with full consent, and, "there's certain kinds of scenes that won't be on video," blah, blah, blah.

Dr. LaRusso: Absolutely.

Smith: But this is a way for you to do different kinds of what? Time and motion kinds of studies of what goes on in the room to see what the facial interaction is like? What's the point?

Dr. LaRusso: To do that, to also assess whether the space itself is conducive to an interaction. The computer, while essential, could be a distraction. And how is the room organized? We've become very tuned in to the importance of space and how space contributes to the experience.

Smith: Do you have those exam tables with the exam paper that comes out of them? Because I've never found those particularly comfortable to hang out on.

Dr. LaRusso: No, and it turns out that through our observations, if 100 represents the amount of time that a patient and physician interact face to face, the need for an exam table probably represents 20 percent of that time. So, the idea of developing a different kind of space for the portion of the encounter that doesn't require it evolved from our observations.

Dr. LaRusso: One other point that I want to emphasize, the concept of the fusion of the scientific method with design thinking. The whole idea of laboratories to study these is a result of that fusion. The designers happen to be the individuals who work in the laboratory, if you will.

I want to mention another laboratory that we're developing because this is a new initiative. It's the HAIL Laboratory, which is an acronym for Healthy Aging and Independent Living. So, we're developing a laboratory now in our assisted living facility to try to understand the needs of elderly people with the ultimate goal of allowing them to remain longer and longer independent than in their own home.

This is another example of the use of a laboratory approach to learning about how to develop new models of healthcare delivery.

Smith: So you've been at this what, two and a half years roughly at this time?

Dr. LaRusso: Two and a half years, yeah.

Smith: What have you made substantive and sort of system wide changes in any of the patient/doctor interaction so far? What are they?

Dr. LaRusso: Yeah, I think we have. One of the initiatives that we began actually in the department of medicine was based on the observation that there was going to be a significant shortage of doctors in the future. By the year 2020, we'll probably be short about 80,000 physicians, not just primary care docs.

Secondly, that Mayo Clinic had substantial expertise that could never be made available if the model involved a face to face interaction in Rochester, Arizona, or Florida, where we have three locations.

Thirdly, that technology was evolving so fast that there were opportunities to utilize technology in a more efficient way to address this problem. That was sort of the landscape. Then, we started to think about this.

We also recognized that in certain types of practices, like mine for example, where I see a lot of patients with liver and biliary tract cancer, that I can often provide the answer to the referring physician without actually seeing the patient, as long as I have the information. So, that led to the eConsult experiment.

Smith: EConsult? This is telemedicine, 21st century.

Dr. LaRusso: A combination of a number of levels of interactions that did not require initially, a visit to a bricks and mortar location.

We have this philosophy that we try to apply. It's called "Think Big, Start Small, Move Fast." So, the big picture here was how do we make Mayo Clinic's expertise available to people that we can't see within Rochester, Arizona, or Florida?

The experiment was a partnership with Blue Cross Blue Shield of Minnesota in which we provided subspecialty consultations within 36 hours to a primary care clinic in Duluth, Minnesota. We did that using our physician portal and we show that it would work. The patients were happy. Why were they happy? They could get Mayo Clinic expertise without having to drive to Rochester, Minnesota.

Smith: Which is a great town to live in.

Dr. LaRusso: Which is a great town to live in, but you have to take time off from work. You have to stay in a hotel. So, there's all of those added costs. The primary care physicians loved it because they could get expert input quickly and easily. So, it seemed to work.

Now, this is probably a longer answer to your question than you want. But, ultimately, we did the same thing on our campus.

So, if a general internist has a patient with abnormal liver tests, historically what they would do, they setup an appointment for the patient to see me a day or two later during their stay in Rochester and they would come to my office. Now, they can do it electronically. They can order an eConsult from me. They can get it within less than 24 hours. So, this saves the patient time. It maintains the relationship of the primary provider with the patient, which we think is essential.

Smith: That's the experience part, really.

Dr. LaRusso: That's the experience part. It's also the expectation that as new models of healthcare develop in this country, primary care teams are going to have to be central to this experience.

Smith: Designers and doctors working together?

Dr. LaRusso: Interesting, interesting.

Smith: The Mayo Clinic famous for everybody wearing a tie and being sort of...

Dr. LaRusso: Well, not all the time.

Smith: Well, you're not now, that's good, because you've been hanging out with designers.

[laughter]

Dr. LaRusso: Actually, that's very interesting.

Smith: For the radio audience, he's dressed in a very nice sort of suit with a very attractive blue T-shirt. Kind of mod looking, kind of San Francisco.

Dr. LaRusso: My designers would be proud of me, actually, in that regard. But, there are challenges when you bring a diverse group of people together. Initially, when we brought -- and our group is about 50 now. So, we have designers, we have project managers, we have physicians, we have IT people.

The challenge was to get everybody to understand what the skill set was that the other people brought to the table. It was to change the model, which is generally hierarchical in an academic/medical center to a more flat one.

For the designers to recognize what the physicians brought to the table; for the project managers to recognize what the designers brought, and we struggled. We had a number of team building retreats. But, I think we're over the hump right now.

Smith: Well, how would you characterize the differences in approach?

Dr. LaRusso: I'll give you a good example. It's the distinction between the what and the how. So, physicians are trained to get to the answer as quickly as possible. It's what I call solution rush. That's what we do.

If we're presented with a problem, we're trying to figure out how to solve it. We're not prepared, naturally, to sit back and reflect on it, to gather information, to look at it from two or three different perspectives. That's what our designers have encouraged us to do. But, that caused a clash initially.

I think we've worked through that now. Because the physicians have seen the enormous value that the designers bring to helping us frame the problem. Helping us clarify the issues. Often times, when you articulate the problem prematurely, you're missing an opportunity to see it more broadly.

Smith: Don't rush to diagnose.

Dr. LaRusso: You do that when you're taking care of a patient, to some degree, but not when you're trying to develop innovative ways to change the way we care for patients.

Smith: So, what have you learned? I mean, if I'm a patient, I'm coming into the consultation room of the future. Maybe you already have it there. Based on what you've done so far, how is my experience, as your patient, going to be different in that room, and interacting with you? How are you going to be different towards me?

Dr. LaRusso: I can't answer that yet, quite honestly. What I will say is that the interactions may not require you to come into my office. They might allow me to confer with you and your primary care doctor remotely.

For example, we're doing that now with a project that we have in Alaska. We're providing expert consultation for women with breast cancer via remote face to face interactions in Alaska, because they're an underserved area, they don't have this expert.

So, the first point is you might not be in my bricks and mortar office. I can't answer exactly what this is going to look like. I can tell you that we've just embarked on a major project called Project MARS, which if this flies...

Smith: Project MARS? That's going to be some serious telemedicine.

Dr. LaRusso: Project MARS, I will explain that in a minute. No, the concept is that if we were going to Mars, and we were going to start from scratch to develop an outpatient system, what would it look like? That's the concept.

That, I think, as we work through this, would allow me to more confidently answer the question that you've asked. If you invite me back sometime in the future, maybe I'll be able to answer. I can't do it right now.

Smith: Once you've been to Mars and back. Why is this necessary? What's the urgency in this? Is it that Mayo has to figure out as a provider of healthcare a way to cut its own costs? Is it really driven by some hard business motivations? Is it some larger you guys got together and realized that you haven't been treating the experience suddenly?

Dr. LaRusso: We have arguably the most efficient, high quality, outpatient model that exists right now, in terms of what we call the integrated group practice. But, our ability to maintain the quality to allow it to be not only trusted, which is what it is now, but affordable, is challenged. That's what this is largely about.

The goal here is to figure out how to provide increasing value, more quality at less cost, how to do it so that we can touch the lives of many more people and do it in an affordable and accessible high quality way.

So, there's an internal imperative, but there's also an external imperative. Because, as I think we were talking about earlier, the healthcare system in this country is totally dysfunctional and needs fundamental change. So, this is part of that bigger necessity, I would say.

Smith: In the healthcare profession, as in some other sectors, if you will, of industry, the amazing breakthroughs and progressions in technology have not lead to and especially in healthcare have not lead to amazing breakthroughs in productivity. So, you have a lot of additional costs in arguably better diagnosis and treatment, but not in more productive and less expensive diagnosis and treatment.

Dr. LaRusso: Completely agree. Another way to address that and maybe expand on it is to acknowledge that if you look at the science of medicine, particularly since the Second World War, it's been enormously innovative. We understand disease better than we ever did. More diseases we can diagnose them more quickly, we can predict them more reliably, we can explore the inner recesses of the body without making an incision.

At the same time, our infant mortality is still among the worst in the world. Our longevity is, I think, 19 or 20 in the world. The costs for what we do are jeopardizing the future of the country. So, the delivery system, the incentives for providing quality, or the lack of incentives, the fee for service model are all up for grabs right now and have to be addressed seriously. Some of that is what Mayo has been thinking about.

Smith: Do you view the work you're doing at the Center for Innovation is work that is primarily for Mayo, or are you hoping to transform medicine at large?

Dr. LaRusso: I think that what we're doing will have its initial major impact at Mayo. It'll depend on the project though, as I said. So for example, the Project MARS will largely be, the result of that will be largely beneficial, I think, to Mayo and secondarily to patients. But, when you see a project like the Alaska project that we're talking about, I see that as being enormously beneficial to society and I think that if we can make Mayo's expertise...

Let me step back. Last year, we saw about a million patients at all of our sites including the Mayo health system. We touched probably... If you look at some of the other products and services that we have we've estimated we touched 20 million lives.

Well, why can't we touch 200 million lives, and if we could do that, wouldn't that be beneficial to society. Make the expertise that's available there available to a much larger number of people, to a much larger number of physicians and providers. So, to that extent, I think, what we're aspiring to do has enormous societal benefit.

Smith: And to be clear, the Mayo experience is really one where most people have already been to their primary care doctor and they're coming to Mayo in one form or other for greater expertise with a problem.

Dr. LaRusso: Absolutely.

Smith: So, when you talk about telemedicine or eConsult, on the one hand it makes me think, "I don't want to talk to a doctor on a screen. But, I will have a doctor who is in the room with me," I may up in Mayo physically.

Dr. LaRusso: In our model, the relationship between the primary care provider, which will ultimately become in my opinion the primary care provider team, and the patient is maintained, that's critical. So, the focus now of most of our efforts is to provide our expertise to the patient through the primary care provider. And that's historically what we've done when patients come to visit us because we would be getting back to the referring physicians with our recommendations, our diagnosis, etc.

Smith: I want to shift gears and come back to your principal specialty which is treating diseases of the liver, and as you mentioned one of the great see changes in your work over the course of your career over the last 40 years has been the emergence of the transplant. In fact you were involved in creating the transplant program at the Mayo Clinic. Could you characterize the current state of, especially the liver transplant system and how you think that's going to change moving forward?

Dr. LaRusso: Well, like most things, there's good news and there's not so good news. The good news is that people who would die are no longer dying because of this miraculous advance. Just as an aside, two weeks ago, I saw one of my patients 22 years after a liver transplantation. She wouldn't have been alive quite honestly with the condition that she had if she hadn't had a liver transplant. So, it's a life saving procedure, it's becoming incredibly reliable. It's becoming standardized. We're getting patients out of the hospital in less than a week. The survival is spectacular.

On the other hand, we don't have enough livers. And there have many efforts to increase the donor pool including the use of living donors which has had an impact, a modest one.

Smith: Because you can use part of a healthy liver and it's a very regenerative organ?

Dr. LaRusso: Exactly. There are patients who are dying that shouldn't be dying because of the lack of livers. So, many people believe that the ultimate solution to that will be what the general term is regenerative medicine, figuring out how to give people their own selves from a different part of their body that have been transformed in a petri dish into the cells of interest and injecting them back. There was a lot of interest at one point in the use of animal organs. That sort of slowed down a bit right now.

Smith: It didn't work as well?

Dr. LaRusso: I don't think there were enough people studying it quite honestly, and I don't think it was given a chance to evolve, my personal opinion. There were concerns about the transmission of diseases that exist in animals that don't exist in humans which could ultimately manifest themselves in humans. So, xenotransplantation hasn't really advanced, in my opinion, to the extent it could have.

We were envisioning at one time having animals and you walk in and you pull an animal off the shelf and you have a liver for someone. It hasn't advanced to that.

So, the regenerative medicine based on the understanding of stem cell biology is the latest area of attention for organ transplantations in general. Solid organ transplantation.

Smith: Is the liver one of the easier things... I mean nothing's easy, but relative to other organs, is it easier to replace?

Dr. LaRusso: You mean from a technical point of view?

Smith: Yeah. From a success sort of point of view. Not availability, but are some organs trickier?

Dr. LaRusso: The technology required, the surgical technique is more complicated than say a kidney transplant, for example. The applicability of regenerative medicine to the liver may be, for example, less easily done than say for the heart. We are already doing experiments now where people that are in institutions, other institutions, are injecting cells into the heart that could restore cardiac function to patients who might have otherwise needed a cardiac transplant.

Smith: I want to shift to one other part of your career that's been really big for you and that is training mentoring physicians. Obviously you're a teacher, you're a mentor. Has the advice that you give young physicians changed substantially over the course of your 40-year career?

Dr. LaRusso: No. No. Actually it hasn't. When I talk to people who are potentially interested in the career that I know the most about, which is a physician scientist career, I talk with them about having fun. I talk to them about getting adequately trained. I talk to them about identifying a scientific niche. I talk to them about associating with the smartest people that you can.

It's no accident that if you look at data on Nobel Laureates, a significant proportion, maybe a majority, have previously trained with Nobel Laureates. Unfortunately that's not going to be the case in my situation.

Smith: Well, you never know, the call could come next year.

Dr. LaRusso: I'll go to Stockholm but it'll only be to see the city. But, the point is that I don't think the formula has changed dramatically. Maybe what's happened is a greater recognition of the importance of teams. When I was growing up the independence was a critical factor.

You had to show that what you were doing was different from the people you trained with. Increasingly now science has become a team activity. So, I think the ability of someone to work in a team without necessarily having to be the leader of the team I think has become an additional factor.

Smith: A little more collaborative, collegial rather than lone...

Dr. LaRusso: I think the other thing that's changed is the recognition by many scientists that their discoveries are potentially patentable and that that can benefit their institution and themselves from a financial point of view and there are a lot of rules and regulations around this but. So, I think maybe those are two things I would say that we never talk about... we didn't talk about as much when I was starting out.

Smith: But you talk about it now?

Dr. LaRusso: But we talk about it now.

Smith: OK. Questions from the audience.

Sarah Nell: My name is Sarah Nell and I work at Olsen, an advertising agency in town. My question for you is you talked a lot about design thinking which I'm conveniently reading a book about right now, and then talking about the diagnostic process for physicians. Do you think there's anything that young physicians could learn today from design thinking? Anything that would change how you would potentially train future physicians?

Dr. LaRusso: Absolutely. I think that in fact one of responsibilities as a center for innovation is to educate the people at Mayo about the discipline of innovation and the discipline of design thinking. We put together a curriculum. We tested it out last year; we're going to do it again this year. We hope that increasingly our physicians and many of them did last year will participate in the curriculum.

The future of Mayo is heavily dependent upon its ability to continue to innovate and we believe that design thinking can contribute and understanding of design thinking can contribute to our ability to be innovative. In fact this gets to, if I might digress slightly to a question you asked about whether it's Mayo centric or societal.

I think we feel like we're in a position to make the same kinds of contributions at the beginning of this century that our founders made at the beginning of the 20th century in terms of introducing the integrated group practice. So, I think that understanding innovation and design thinking could be significantly helpful in that regard.

Smith: The integrated group practice is a practice where you have people with different specialties in one place?

Dr. LaRusso: Right. It's actually quite more than that but that's essentially what it is.

Smith: That what was certainly different about it 100 years ago.

Dr. LaRusso: Yeah. And what's different about it now is that you can arrive with a diagnostic problem on a Monday and have it solved in three days and everything can take place. You can get six different experts to address the problem in a short period of time because of our ability to have all of these experts working together which exists almost nowhere else in the country.

Smith: One-stop shopping? To put it really glibly.

Dr. LaRusso: One-stop shopping for expertise.

Jody Rome: My name is Jody Rome, I work at Regents Hospital here just in downtown Saint Paul, and my question about the diagnostic versus design was that you talked about the physicians wanting to move quickly on things. In my experience in working with physicians and making changes is that they want to randomly control double live study with thousands of patients over 10 years before making a decision about implementing a practice change. So, I was surprised by your comment that physicians want to move more quickly than the designers.

Dr. LaRusso: I think it's a nuanced issue. I think if you look generally, physicians are a conservative lot that often resist change my personal opinion. On the other hand, when they're faced with a problem -- how do we make the outpatient practice more efficient -- they're anxious to move ahead to figure out how to do it, rather than being willing to sit back and reflect on it and clarify and frame the issue.

So, that's kind of what I was talking about. I don't know if that addresses or clarifies what I intended to communicate.

Smith: Well, when we invited you up here, you weren't going to come unless we did a double-blind study first.

[laughter]

Dr. LaRusso: Absolutely, yeah.

Glennis Butler: Hi, I'm Glennis Butler from Apple Valley. I'm a retired healthcare professional. Thank you for being here. I really admire what you have done. I can make some guesses or assumptions, but I wanted you to elaborate a little bit more about why you cared about what patients were doing with the other 70 percent of their time and what the exam room was like and so on -- if you would elaborate on that.

Dr. LaRusso: Well, let me elaborate on the first point. We didn't care, because we didn't know. We assumed that our responsibility was restricted to the limited time that we had with our patients. When our designers began to examine the entire experience, we realized that what happens outside of the Mayo building was a significant factor in the quality of their global experience.

That happened pari passu with the city understanding that they needed to make Rochester more conducive for people who came for medical problems. So, if the ultimate goal, if our aspiration, is to make the experience an unparalleled experience, it has to take into account not just when they're in the building. Does that answer your question at all?

Smith: What about the exam room? Why did you decide that that needed looking at?

Dr. LaRusso: It was not so much focused on the exam room. It was using the exam room as an opportunity to observe the interactions. And then that became coupled to our growing recognition of the importance of space in influencing the experience.

So when, for example, we observed that if I wanted to talk to a patient and their family about a CT scan, it was very cumbersome because of where the computer monitor was placed. And if we did something like simple as put it on an arm, like this with a lever, we could make the interaction much more effective.

Jay Youmans: I'm Jay Youmans from Rochester. It's evident that you want physicians who come to Mayo to buy into your mindset and this new way of doing business. Where does the selection process begin? Do you start looking at medical students who are coming in, screening medical students to see if you're going to see if they have the wherewithal or the I don't know what to say the attitude that that's something they want to do? Where do you start inculcating this way of doing business?

Dr. LaRusso: Well, I think that's a good question. There is a cultural tradition and legacy that exists at Mayo that is almost cult ish in a positive way. So, for example, anyone you approach that works at Mayo, and you say, "What's the main value, the major value, of the institution?" they'll all say it as if they were reading it, "The needs of the patients come first." OK? So it's important to maintain that culture, even though most of the... a lot of the other things that we do, the mechanics of what we do are open to change.

Now we have a medical school, and the medical students that enter there begin to be exposed to this culture. So, they know right from the get go that the focus is on what's best for the patient. We have the largest graduate medical education program in the country where we train residents and fellows. They understand that... And the majority of our staff is recruited from people that we train.

So, it begins very, very early. We have a new program that my colleague, Michael Brennan, started in the Department of Medicine, and is now institution wide called the "Program on Professionalism." And we expect all new physicians and increasingly all new Allied Health personnel to go through a didactic program about professionalism.

So, we start as early as we possibly can. And I wouldn't say that we have a unique recruitment approach that would allow us to pick out the people who are going to be most amenable to this, but that occurs over time.

Smith: Is there much serious grumbling or opposition, or would you even hear it, to the idea of transforming healthcare so that it's more patient centered?

Dr. LaRusso: No, I don't... I think... I've been at Mayo many years. I've never seen the leadership of the institution, the employees across all levels, from faculty down, more prepared for change. And the vision that's been set out under our new leadership I think articulates that.

But, it emphasizes that we have a legacy, a culture, that we have to maintain. And the challenge is to accomplish that. I think most people are optimistic. In fact, one of the workshops we just ran, we did a poll of the people that were there on the Project MARS. We talked about this monumental change in the outpatient practice, how many people thought we could... it was feasible, and the majority of people thought that it was... not only that it was accomplishable, but that they would participate in helping to implement and orchestrate it.

So, I've never been more excited about the future than I am now in spite of everything that's happening nationally, because things have to change. And we would like to influence that change in a very positive way, both locally and more broadly.

Smith: We'll take one or two more. Before I ask for questions, though, what else have you got in your idea file, or are you going to tell me?

Dr. LaRusso: Actually, I have more ideas in my idea file in the lab than I have in the innovation center. And that's good in some ways, because the people I have in the innovation center are much smarter and more creative than I am.

Smith: They're a human idea file.

Dr. LaRusso: And they're going to come up with the ideas. But, no, my ideas in my idea file, it's how to come up with a better understanding and ultimately a treatment for the disease we talked about which is still untreatable except for liver transplantation.

Annette: My name is Annette, and I'm here from the Twin Cities. I've read some statistics that the U.S. medical costs are about 16 percent of GNP while in Europe it's closer to 8 to 10 percent. And then I've also personally seen our family healthcare insurance go up 50 percent over the last two years. So, I'm just wondering, these cost savings ideas, what percent of GNP are we going to look for in the future, and can we expect as consumers our healthcare costs to be under control?

Dr. LaRusso: I'm going to have to punt on that. I'm not an expert in the area of medical economics. I think everybody acknowledges that we're spending too much money on healthcare. There are attempts now to deal with that, multiple different attempts. It has to change in the future. I don't have any particular solution to that.

Mayo's position has been, in terms of health policy, has been focused on the importance of making everyone in the country have access to health insurance -- because 40 million people are without health insurance right now of changing the payment model so we're paying for value rather than for volume. Those are some of the key elements, that indigent people might require some subsidies for their health insurance. But, what's going to happen with the percentage of healthcare that's devoted to the GDP, I don't know, except it's unsustainable, and I think everybody acknowledges that.

Cheryl: Hi, I'm Cheryl from Roseville, and my question is really about going back to the model that you have at Mayo where if I have a referral, I come there and you solve my problem in three days. At the same time, I...

Dr. LaRusso: Most of the time. I want to Some problems require even at Mayo more than three days, but...

Cheryl: My question is that I also see Mayo expanding their reach into other communities by partnering with local hospitals and organizations that are already providing healthcare, in places like Owatonna or Eau Claire. My question is, is this intent to take... to use these as standard feeder programs into either Rochester or other facilities, or is there some idea of the hub driving some of these quality and innovation issues out into these other communities and facilities?

Dr. LaRusso: That's a good question. You might get different answers from different people. My opinion is that Mayo has something unique and special to offer in healthcare, that we currently do not have and will never have the capacity to provide that expertise if the model is one that requires you to visit Rochester, Minnesota, that with the shortage of providers that we're anticipating with the underserved areas, including small town communities, that Mayo has a societal obligation to try to make its expertise more widely... I'm having... can I... more widely available.

One of the ultimate goals now for us is to be able to always say yes to anyone that wants access to our expertise. That saying yes may not be, "Come to Mayo, Rochester, Arizona, or Florida." It may be, "Let us connect with you in different ways. Let us provide you the expertise we have in different ways."

The technology, as you pointed, out is there. The connectivity that exists now on the globe is unique. The question is how do we put the infrastructure together to take advantage of the connectivity?

Smith: Nick LaRusso, thanks so much for being here.

Dr. LaRusso: Thank you. Thank you. [applause]

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