Podcast Transcript: Operating Room Innovation: the ExplORer Surgical Story

[Dr. Alex Langerman]
Yes. Well, I appreciate your summing it up at the beginning. I am a practicing surgeon. It's perhaps how I define myself. When you think about your self image, it's just something that I've totally fell in love with from before medical school. The reason I went to medical school is because I wanted to be a surgeon and I got to do it. It's such a dream come true. I love taking care of patients and it just keeps me going. It's one of the big motivators in my life.

I moved down to Nashville in 2015. I'd done some training here in 2010 for a little while, saw a little bit of the old Nashville before coming back to see it rapidly changing and continuing to change in amazing ways, which you can appreciate too. I'm a dad and have two wonderful little kids and an amazing wife. Now a little puppy just joined us too.

[Dr. Brian Hartley]
Nice. What kind of puppy did you get?

[Dr. Alex Langerman]
It's a Swiss Doodle.

[Dr. Brian Hartley]
Oh, nice.

[Dr. Alex Langerman]
It's some kind of combo, Bernedoodle, Aussiedoodle combo. It's just an awesome dog.

[Dr. Brian Hartley]
Ball of fluff probably.

[Dr. Alex Langerman]
Yes, just a ball of fluff and it likes mountains, likes running around. It's cool.

[Dr. Brian Hartley]
Awesome. Fun fact, you and I actually met at the Food and Wine Festival in Nashville for the first time if you remember that. I think you had--

[Dr. Alex Langerman]
It was the first Food and Wine Festival.

[Dr. Brian Hartley]
Yes, that's right.

[Dr. Alex Langerman]
It was the inaugural one where they were just giving away all the swag.

[Dr. Brian Hartley]
Which was incredible. I remember just bumping into you and then finding out you were a surgeon, you were starting at Vandy and you were an entrepreneur too. I was like, "Oh my God, this is crazy."

[Dr. Alex Langerman]
We had so many overlaps. It was perfect.

[Dr. Brian Hartley]
I know. That's right. Cool. Awesome. How did you get into ENT? It sounds like you loved surgery early on, but ENT is very unique and specifically head and neck, which from my opinion, going through med school, seeing residency, doing radiology, those are some big cases. That was always the big cases, the head and neck surgeon. How'd you get into that?

[Dr. Alex Langerman]
Initially when I came to medical school, you're influenced by your surroundings, right? I had looked to do some research and ended up in an immunology lab and spent five years in that lab, including one year as a Howard Hughes fellow-

[Dr. Brian Hartley]
Oh, cool.

[Dr. Alex Langerman]
-studying T-cell immunotherapy. Yes, it was great. I learned a ton about science from there and I had a wonderful mentor, Mike Nishimura, who just taught me to be a good thinker and careful with my data and have extreme integrity. He was an important person in my life. Because of the immunology transplant overlap, I was like, "I'm going to be a transplant surgeon. This is amazing stuff." Right? You get to take a body part for one person and put it in another person and save their lives.

[Dr. Brian Hartley]
It's magic.

[Dr. Alex Langerman]
It is magic. I was certain I was going to do that. My girlfriend at the time was anti the lifestyle that a transplant surgeon leads, which--

[Dr. Brian Hartley]
Can't imagine why.

[Dr. Alex Langerman]
Yes, I know. Admittedly, I think it's gotten better for that specialty, but it's a tough lifestyle because in the moment you need to head somewhere and go do something huge. There was that. Then I had a transplant surgeon who was a mentor of mine and I affiliated with the lab and I told him, I was like, "I think I want to be a transplant surgeon." He got right up, like an inch from my face and said, "Are you sure?" I was like, "Maybe. Yes, I'm not sure."

[Dr. Brian Hartley]
I guess I'm not. Clearly, I'm not sure. Clearly, you are sure that I should not be sure.

[Dr. Alex Langerman]
Yes. The girlfriend and this interaction opened my mind a little bit to say, "Well, what else is out there?" Then, again, a little bit of a serendipity, I suppose, is the New England Journal of Medicine article came out that was about laryngeal transplantation, transplanting the larynx, and it was performed by otolaryngologists, head and neck surgeons. I was sort of like, "Who are these people?" I had started interacting, I said, "Well, I'm going to go check out their clinic." I went to the clinic and I just found the otolaryngologists at University of Chicago, where I ended up doing my training. I was a medical student there too, while I was a medical student.

They were incredibly warm, welcoming, fun. They enjoyed these awesome cases. It seemed like people were just happy doing their job. I was like, "Well, this is refreshing." I had always thought it was tubes and tonsils. In fact, head and neck surgeons do huge procedures and we get to use a lot of cool equipment. This is sort of the wannabe pathologist nerd in me, but we operate on every tissue type in the body, which is its own sort of interesting thing because you see all sorts of different pathology. My career has waxed and waned as to what I do a lot of. Depending on where I've practiced and just over time growing my practice, some things grow more than others, but it continues to be challenging and interesting. I love it. I like taking care of the people. It's very rewarding.

[Dr. Brian Hartley]
Yes. Like I said, those are big cases. I didn't really have a full understanding until you're in med school and you're rounding on some of those patients and you're like, "Holy cow, that's a big surgery," and follow-up can be really tough, especially a lot of those patients that get radiation and have mucositis. That's tough.

[Dr. Alex Langerman]
The changes to their basic functions, right, swallowing, speaking.

[Dr. Brian Hartley]
Yes, eating.

[Dr. Brian Hartley]
That kind of thing.

(2) From the Operating Room to the Innovation Lab: Dr. Langerman’s Entrepreneurial Journey

[Dr. Brian Hartley]
Yes. It takes a compassionate person to do that. There's no doubt about it. That's awesome. How did you get involved in entrepreneurship in general? Did you always want to be an entrepreneur or is this something-- How did that little spark start inside of you to be like, "I like improving things," or solving problems?

[Dr. Alex Langerman]
Yes, accidental. It's funny. I didn't actually realize this until well into my road down entrepreneurship. I was talking to a mentor who was an experienced venture capitalist and he had asked me what my parents did. My dad had died many years ago. I said my dad had started out as a drug salesman for Bayer Aspirin. He was sales manager for-

[Dr. Brian Hartley]
Oh, wow.

[Dr. Alex Langerman]
-Bayer, of all things.

[Dr. Brian Hartley]
He's a salesman for Bayer Aspirin.

[Dr. Alex Langerman]
Right. He was born in 1924. He was older when he had me and then he moved up to another drug company and then ultimately started his own company, Windmill Vitamins. This mentor of mine comments, "Oh, he was an entrepreneur." I was like, "Oh, yes, I guess he was." Admittedly, there was ups and downs with his job and there were times when he was a really good salesman and a really nice, honest dude, loved, beloved by everybody. He had some business partners that I think were a little bit more cutthroat. I saw that interaction. I think I had a very negative impression of the business world as a result of that.

In fact, it was sort of like, "I don't think I could do that," be in that world. It was very intimidating to me. I've since grown a lot as a human being and then seen a lot of different examples of how people can be in business and it's a part of the ecosystem that keeps this world going, and part of what delivers huge value to patients. I say, I learned differently, but I think when I was younger, that world seemed very scary to me, a place you could get taken advantage of, a place you could lose a lot of money, and unsafe, that kind of thing.

[Dr. Brian Hartley]
They're not wrong.

[Dr. Alex Langerman]
No, no, they're not.

[Dr. Brian Hartley]
Those things are not wrong.

[Dr. Alex Langerman]
Important because just like in medicine, you can kill somebody if you screw up. You can make huge devastating things to other people and things that will weigh on your conscience forever if you're not careful. There's risks to every endeavor. Anyways, that's me going into this where I didn't really think about that as a viable pathway. I left my fellowship here at Vanderbilt. I left my fellowship with this plan of studying how patients perceived treatment options vis-a-vis things that they value. Wearing my ethics hat, I had thought a lot about, well, what are the things that are important to patients? At the time, there was a paradigm shift happening in the treatment of oropharyngeal cancer.

We had recently discovered the connection between human papillomavirus and tonsil throat cancer. These are patients who actually could be cured more readily. The options were really, do you do surgery and then maybe radiation, or do you do chemo radiation upfront? That pathway seemed to be driven by who the patient saw first more than anything. I thought maybe there's a different way to do it. I recruited a mentor, an oncologist at University of Chicago, and just went after it with writing a K award. Nine months I had written a K application, which got scored on the first-- It didn't get scored high enough for the pay line, but it got scored. I was like, "This is my path. I'm going to get the K. Then I'm going to get the R. Then I'm going to be this funded researcher."

[Dr. Brian Hartley]
You're the research path, what you're saying, yes.

[Dr. Alex Langerman]
Research path, right. Then in the time between getting the feedback on my first application and the resubmission, my mentor left the institution for this project. One of the national trial organizations proposed a clinical trial. It was very similar to what I was proposing on more of a local level. It's because it was an obvious trial. It just worked out that way.

[Dr. Brian Hartley]
Yes, it was coming.

[Dr. Alex Langerman]
Yes, it was coming, right. They were going to be able to do it better because it was a national trial. Suddenly this K award became this thing I had to do. It was just this terrible burden on me. I was losing sleep over it, worrying about it. How am I going to find a path? How am I going to salvage this? It started getting so far afield that one of my surgical mentors, who is a clinical trialist, was kind enough to sit down for a couple hours with me on the phone and talk me through the whole project. At the end of it, he goes, "I don't know why a surgeon would be doing this project. This is so far outside--" because it was a lot about chemo and radiation.

It was a lot about things that were not related to the surgical care of patients. Not that surgeons can't be involved in that, but it was like the whole thing was about that, and there was no surgery involved. He said, "You know, it seems like you're trying to stretch yourself beyond what is your domain of experience." That was influential, of course. The other part of it was at the same time, I had had this wonderful medical student named Emily Stocker, who had an MBA, and she had come to me as a medical student to say, "Hey, I heard you're a interesting attending to do research with. I'm trying to come up with a research project that would leverage my MBA. What projects do you have?"

I said, "Well, I don't know yet, but let's tour the operating room and let's think about ways to make it better." I was primed for that because when I had finished my fellowship and started as an attending, I kept feeling like, "Gosh, my OR is so inefficient." The things that I need aren't there. It seems like I'm constantly working uphill to get the patient care done. It's taking longer than I think. Everything's setting up slowly, all the things. This was nothing to knock the team that I was working with. I was like, "I'm doing something wrong." That was my perception.

I had a very special opportunity granted to me by the university of Chicago to tour the country and spend time with luminaries in my field to see how they handle their operating room. What I discovered was, although I learned all sorts of amazing things about how people do operations differently or different tricks and techniques they use or strategies for thinking about how to improve the operation, I was also noticing that a lot of the problems I was experiencing in University of Chicago were common to the hospitals I was visiting.

Even the famous people had trouble and reflecting back, Vanderbilt had similar challenges. I think during my fellowship, I was so focused on the surgical side of things, rather than running the OR that I didn't pay attention to it. This is going around in my head. I'm taking Emily through the ORs and we walk into one of my colleagues operating rooms and he's doing a thyroidectomy. She's asking me questions about everything she's seeing and she says, "Wow, they use all those instruments for this operation." There's four trays of instruments, couple hundred stainless steel items sitting out there on the table. I was like, "[chuckles] Silly medical student. What do you know? No, we'd probably use 10 or 12 of them for this operation."

She said, "Wow, that seems really wasteful." I was like, "Oh my goodness, it does." I'm convinced that when you're trying to become a surgeon, and maybe it's just me because I was so like, I want to be a surgeon, but I think there's something about being in the operating room that to get to do the thing-- The big show in the operating room is that person who's operating. Right? To get to do that thing, you have to follow all of these rules and do it like they do. It breeds out a little bit of a questioning mind and more of a hierarchical following mind, I think, if you're constantly trying to follow what everyone else does rather than go against whatever the norm is.

It was Emily's fresh eyes that opened my eyes to the inefficiencies of the operating room. I owe her such a debt of gratitude. She knows that because it really changed my thinking. Ultimately throughout my career, I've spent a lot of time bringing outsiders into the OR and have worked on methods for making that happen, even in a virtual digital manner, because that improves the sterility worries. That improves the logistics of it if you can just sort of drop in and see and help, but it also brings all of these brains in that know about things that we don't know about as surgeons and nurses and anesthesiologists that can make the operating room better and patient care better.

That's been a theme through my-- honestly, including patients too. I think patients could have a lot to say about what we do in the operating room that because they're asleep, we don't really get their opinion. That's just really been something that motivates me.

[Dr. Brian Hartley]
That's huge. Yes. I think that's a really great point. I love the fact that she saw something. I think when you said the questioning mind versus the hierarchical mind, and I think we're all trained in medicine in mainly the hierarchical way of thinking, right? We're trained that this is the way you do it. It's been done this way for a long time and don't question it. You need to hit all these steps right. There's too many things you need to keep in your mind to question anything. It really can narrow your possibilities for improvement. There's benefits, right? There's huge benefits. You don't stray off track when that happens. That is like a pre-flight checklist, right?

No one questions a pre-flight checklist. "Should we be doing that?" "Why?" "Because it is designed that way." It's designed to be self-enclosed and you don't want to deviate from that, but bringing in people who do not think that way can have huge impact. I love that you were just like, "That's crazy. Yes. This is how we do it. Obviously little med student, you didn't understand," but good on you to be like, "Wait a minute. Is she actually right?"

[Dr. Alex Langerman]
No, she's right.

[Dr. Brian Hartley]
I think a lot of people would have just been like, "No, no, no, no, of course we don't use all those, but we need them just in case something comes up."

[Dr. Alex Langerman]
Oh, yes.

[Dr. Brian Hartley]
That could have been the right answer right then. I don't think anybody would have faulted you for saying that. In fact, I think probably 8 out of 10 people would have been like, "Well, you never know what tools you're going to need."

[Dr. Alex Langerman]
That's right. That is, in fact, the strategy, over-provisioning in the operating room.

[Dr. Brian Hartley]
Yet at the same time, is it really right? It may be right on one level, but is it right on a higher level?

[Dr. Alex Langerman]
Then the number of things that you need at hand in two seconds is limited. Yes. Certainly, there needs to be, and this is part of a larger ecosystem change in the operating room, but there needs to be a way to efficiently get the things that you might need available to you while not-

[Dr. Brian Hartley]
-wasting them or bringing them in, opening them or--

[Dr. Alex Langerman]
Exactly. You open a disposable, it gets thrown out. You open a reusable, it has to get re-sterilized. That all comes with a cost. In fact, that was the project that Emily and I worked on. It's been a paper that's been cited quite a bit in the business world. I've had people pitching the ideas who quote the paper to me, not realizing I wrote the paper. [chuckles] They're like, "Well, the study out of the university of Chicago such and such said that--" I was like, "Yes, I wrote that paper."

[Dr. Brian Hartley]
Mic drop. I love that. Yes. At that point, you said there is waste here. What happens after that? You went and toured. First off, I love that you went and actually-- The way I see this is you went looking for clinical needs in the OR. You found one with the help of a very smart medical student. You didn't stop there and say, "Hey, this must be the problem." You said, "Well, we better validate this. We better make sure this is actually happening in other places," because a lot of surgeons probably would have just been like, "This must be it." That's where you can fall into a lot of problems is not validating your clinical need. It sounds like you went and did that. What made you say, you know what? We should probably make sure this is an issue.

[Dr. Alex Langerman]
I credit some really important mentors. David Song, John Alverdy, and Jeff Matthews, who were leaders in the Department of Surgery at University of Chicago, I guess saw something in me. They basically proposed to me, "Maybe you should make a lab that studies the operating room. You should work on these kind of issues." I think they'd seen some success I had with my interests, that the papers I'd started to write. Frankly, it was something where jumping back to that K award, unlike the K award, this was something I was doing in my spare time and was enjoying. When I finally decided to abandon the K award and this huge feeling of relief, I was still pursuing this other idea, how do we make the ORs better? How do we make them more efficient and cost less and safer? How do we perform with surgeons better?

They let me found this lab and I got some seed funding for it, and more importantly, a space in our brand new-- It was perfect timing. It was a brand new giant inpatient and operating building at the University of Chicago, the Center for Care and Discovery. While the idea was being hatched, the building layout was being finalized, where they were going to assign certain rooms to the building had been built. They gave me this space right next to the operating rooms for a lab where there could actually be through traffic of the lab of anybody from the operating room. We could go right to the operating room. We could also have people from the operating room, nurses, anesthesiologists, surgeons, coming through the lab to interface with ideas that we were working on.

[Dr. Brian Hartley]
Proximity was helpful there.

[Dr. Alex Langerman]
Huge. When you read all the stories about Bell labs or Pixar and you learn about how the way that these ideas--

[Dr. Brian Hartley]
Bill Gates, I guess, living in Silicon Valley.

[Dr. Alex Langerman]
Right. It's these chance interactions and co-localization made the difference. When we founded this lab, and this is something that I don't even know how I came up with this idea or probably some mentor suggested in some way, or I read something, but this is the thing that I think if I could suggest to anyone to try, and this almost comes out of Steve Blank's playbook, although I didn't know about Steve Blank back then.

I was like, "All right, well, I want to make this lab that serves the operating room," so I scheduled a meeting with every department, like a grand rounds type meeting, their Wednesday morning grand rounds. I got up there and I said, "Hi. My name's Alex Langerman. I'm the ENTs, and I've got this new lab where we're studying the operating room. What don't you like about the operating room?" It was stunned silence because everyone is expecting a talk, like a PowerPoint something. I just listened to people. It would take a moment and then someone would speak up and then a bunch of hands would go up and everyone's just talking.

People love to complain, all the things they hate, right? I just kept notes on all the things. That became our roadmap of things we need to tackle, things that we need to make better to start to find the needs that overlapped with not only the clinicians but strategic sourcing, the people who are purchasing all this stuff for the hospital, and hospital administration, and the nurses, and the anesthesiologists, and finding out where the overlapping pain points were. That ultimately was what drove the work that we did in the lab that ultimately led to the app that we commercialized.

(3) Surgical Innovation Through the Biodesign Lens: How an OR App Became a Startup