Toby Cosgrove ’62 – From Vietnam to the Cleveland Clinic

Dr. Toby Cosgrove ’62 reflects on a remarkable life that took him from upstate New York to Williams, through medical school at UVA, into the U.S. Air Force during the Vietnam War, and ultimately to the helm of the Cleveland Clinic. A renowned cardiovascular surgeon who performed more than 22,000 operations and later served as CEO of one of the world’s leading medical centers, Cosgrove shares stories from his military service, his decades in medicine and leadership, and his lifelong experience managing dyslexia. This episode offers an intimate look at the journey behind his extraordinary career.

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Senior Producer: Jon Earle ('09)

Transcript

[00:00:00] GORDON EARLE: I want to start by welcoming all of you to this latest episode of A Williams Life. Yet this is not just any episode, but one that will launch the first podcast featuring all Williams alumni. When we started the podcast in 2022, it only featured graduates from the class of '75, my class. That's because we wanted to profile classmates from that year as a lead-up to our 50th reunion this past June.

But with the reunion behind us and with the full support of the college, we are now opening the podcast to include Williams alumni from all classes. I'm honored today to launch this new, expanded version of A Williams Life with Dr. Toby Cosgrove. Before retiring in 2017, Dr. Cosgrove enjoyed a stellar career as CEO of the Cleveland Clinic, a multi-billion dollar enterprise that is widely regarded as one of the best hospital systems and academic medical centers in the country, if not the world.

He is also a renowned cardiovascular surgeon, having performed more than 22,000 operations during his long career. If that weren't enough, he's also published nearly 450 journal articles, book chapters, and a book entitled "The Cleveland Clinic Way." And if that weren't enough, Dr. Cosgrove is the holder of 30 patents. Where he found the time to do all this—

I haven't a clue, but we'll ask about that. Finally, I would be remiss if I didn't mention that Dr. Cosgrove served as a surgeon in the United States Air Force during the Vietnam War, where he was awarded a Bronze Star. So, welcome, Toby.

[00:01:36] TOBY COSGROVE: It is a pleasure to be here. Thank you for having me.

[00:01:39] GORDON EARLE: We usually start these interviews with a little bit about your background, and I know that you grew up in Watertown, New York, near Lake Ontario. And when I read about the town and its rich history, two things caught my eye: it was a place where the safety pin was invented—I don't know if you know that—and also where the concept of the five-and-dime store was invented. So it seems, from an outsider's point of view, to be pretty idyllic. How would you describe your upbringing?

[00:02:06] TOBY COSGROVE: I had a wonderful upbringing in a very small town. It was less than 30,000 people, and I had two great parents. My dad was an attorney. He'd gone to Williams and to Yale Law School and came back and practiced law, and set the example of what he expected from me. My mother was incredibly supportive. She'd gone to Mount Holyoke and always was supportive of me.

It was interesting. I would come home with a report card and, for example, if I got a 98, my father would tell me, "Room for improvement." My mother would say, "Great job." One had expectations and the other was supportive, but both were incredibly loving. And I had a great sister as well, who's six years younger than I am.

[00:02:53] GORDON EARLE: Was your dad a disciplinarian? I know there was a lot of love you talked about, but he seemed to set very high expectations for you.

[00:03:01] TOBY COSGROVE: He did, and he told me exactly the sort of things that he expected. I remember vividly, as I played basketball, one time I came off the court and I kicked the bench, and he took me aside afterwards and told me if I ever displayed that sort of behavior again, I wouldn't play any more basketball.

[00:03:19] GORDON EARLE: I know that you wanted to become—and became—a surgeon. Your dad was a lawyer. Was there any pressure for you to go into law school as opposed to medical school?

[00:03:29] TOBY COSGROVE: No, actually, my parents told me that I was supposed to contribute to society and they wanted me to have some sort of a profession. He said there are three ways to do it: you can look after somebody's spiritual life by going into the ministry, you can look after their financial life by going into the law, or you can look after their physical life by going into medicine. So those were the choices I got, and I gravitated towards medicine.

[00:04:00] GORDON EARLE: Did you know when you were growing up in Watertown that you wanted to be a doctor? Was there some point where you said, "This is something I might be interested in"?

[00:04:09] TOBY COSGROVE: I didn't want to be a doctor. I wanted to be a surgeon, and the reason I wanted to be a surgeon is that, at about 10 years old, I saw a photograph of an operating room with everybody wearing a mask, and it looked terribly glamorous.

[00:04:22] GORDON EARLE: And you thought you'd look good in a mask.

When did you start thinking about applying to Williams, and why?

[00:04:27] TOBY COSGROVE: My father went to Williams. It seemed like all of his friends went to Williams. There was even a picture of the Purple Mountains hanging over our fireplace. So Williams was a very big thing in our lives.

[00:04:40] GORDON EARLE: All right, let's turn the attention to Williams now. During my research, I discovered that you have dyslexia, and it wasn't something you discovered until your mid-thirties or so. So I'm wondering, looking back at Williams, how did the condition influence the academic or other parts of your life at Williams?

[00:05:00] TOBY COSGROVE: Well, I was a disaster academically at Williams—well, probably a disaster scholastically, athletically, and socially as well. I had to have a language requirement, and I decided to take French, never having heard anybody speak a foreign language before. They put me in a remedial French meeting five days a week at eight o'clock in the morning, and I got a grand total of three D-minuses and a D, but I got through French. Thank goodness. I didn't come very well prepared. I'd gone to a local high school and I wasn't ready for the academics, and I certainly was not blessed by having dyslexia.

[00:05:43] GORDON EARLE: Given what you've just said, I was surprised when I read that you were a history major, because it requires a lot of reading and writing. I'm wondering why you picked that major.

[00:05:53] TOBY COSGROVE: It was the only one that was left open to me after my grades in my freshman and sophomore years. So I managed C's there, which allowed me to major there.

[00:06:05] GORDON EARLE: And did you enjoy history? Obviously, you must have been pre-med at some point, so you enjoyed both the sciences as well as the liberal arts.

[00:06:15] TOBY COSGROVE: I hated chemistry. I had to take three years of chemistry and I just disliked it intensely and was not very good at it. I enjoyed history much more.

[00:06:25] GORDON EARLE: Did anyone at any point say, "There's something here—a medical condition—which is impacting your academic performance and you should do something about it?" Was it ever raised?

[00:06:37] TOBY COSGROVE: So, interestingly, the first time I ever heard the word "dyslexia," I was 34 and I was dating a teacher. We were going someplace in the car, and I was trying to read the New York Times out loud, and she said, "You're dyslexic." And I said, "What's that?" Subsequently, I met a lady by the name of Sally Shaywitz, who was a professor at Yale, and she was the one who did the first functional MRIs of people with dyslexia and showed that they had a different pattern of going through their brain when they tried to read, and she confirmed, "Absolutely, you're a classic dyslexic."

[00:07:20] GORDON EARLE: So it may explain your academic performance, but then you understood the condition you had and how to cope with your future life as a surgeon, knowing that you had dyslexia.

[00:07:33] TOBY COSGROVE: What happens is, it's interesting that dyslexics have been demonstrated with functional MRIs that the pattern that goes through your brain when you see something goes increasingly towards the area of the brain where it's innovative and creative. I found that I thought about things differently than other people did. I remember sitting around the table with four very prominent surgeons from around the world, and we were throwing out a question and they all answered one way, and I came at it totally differently just because I was thinking about things differently. I see things differently than a lot of people do, and I think that helped me. I frankly think dyslexia is a gift after you get through the difficult academics, and it just gives you a different way of approaching life.

[00:08:27] GORDON EARLE: You've described it as a blessing in disguise. 

[00:08:32] TOBY COSGROVE: I want to talk a little bit more about Williams on another subject, but tell us about any professors or courses you had that had a meaningful impact on you during your time at Williams or afterwards.

Well, interesting. At the time I was at Williams, the art history group was very prominent and loved by all the students, and so I went and sat in the back of the room and audited an art history course, and it has changed and spurred my interest in art and architecture, particularly architecture, over the years. It had an enormous influence on what I was able to do as CEO of the Cleveland Clinic in terms of buildings and in terms of my appreciation for architecture, particularly in art in general.

[00:09:22] GORDON EARLE: Overall, when you look at your Williams experience, what were the most important takeaways that you have from those four years at Williams?

[00:09:30] TOBY COSGROVE: It was a very humbling experience for me, but on the other hand, I was exposed to what I always say was the most diversely talented group of individuals I've ever been associated with. They came in every flavor of capabilities, and I've been able to keep up with a lot of them since that time and value my experience at Williams enormously.

[00:09:54] GORDON EARLE: Let's go on to medical school. I don't recall whether you went directly from Williams to medical school. Did you do that?

[00:10:02] TOBY COSGROVE: I did. I went straight to medical school. I almost didn't get to medical school, to be honest with you. I applied to 13 medical schools at the time. By chance, there was somebody from UVA interviewing and I just happened to run into a friend who suggested that I have an interview. I went and had an interview. Of the 13 medical schools I applied to, UVA was the only one that accepted me. They must have been desperate for people from Williams.

[00:10:29] GORDON EARLE: So I don't want to keep harping on this, but it's interesting to me that you had a rough time academically at Williams. Did things improve at UVA?

[00:10:38] TOBY COSGROVE: Oh my gosh. If you can get through Williams, you can get through medical school, that's for sure. Medical school was not anywhere near as intellectually challenging as Williams was, and when I got to the last two years, it became clinical. I sort of found my footing and it became fun and exciting and challenging instead of drudgery.

[00:11:00] GORDON EARLE: At what point did you decide that you definitely wanted to be a surgeon? You said you wanted to be a surgeon from a young age in high school, but at what point were you locked in and said, "This is what I want to do"?

[00:11:12] TOBY COSGROVE: No, I wanted to be a surgeon all the way along. I never considered being a medical doctor. I always wanted to be a surgeon. And I got intrigued by cardiac surgery at the time because cardiac surgery was in its infancy. They had just developed a heart-lung machine. The valves were being replaced at that time. It was a specialty that was just getting off the ground and, almost immediately, there was something new that came along—the first coronary bypass, the first operations for congenital heart surgery, et cetera, et cetera. So it was a very exciting time.

[00:11:52] GORDON EARLE: You just alluded to your clinical training, and you had that training at several outstanding institutions, but as I understand it, at the end of your training, at the end of your fellowships and all of that, you were unemployed. Right. How did that happen?

[00:12:09] TOBY COSGROVE: Well, the training from the time I left medical school to the time I finished my training was 10 years. I finished up at Boston Children's Hospital, where I was chief resident in cardiac surgery for six months, finishing in January. I thought I had a job lined up in San Francisco, and they called me at the last minute and said, "We've decided not to hire you. We're going to take somebody else." And so I was left high and dry with no job, so it was a little bit embarrassing. About four months into this period, I got a letter from the Cleveland Clinic saying they were looking for someone to be an associate staff, and I couldn't believe that this opportunity was happening to me. I remember falling on my knees and reading the letter over again because, at that time, Cleveland Clinic had just done the first coronary bypass operation in the world. They were the busiest cardiac program in the country and probably the world. I had a chance to go there, so I hot-footed it out to Cleveland as fast as I could, and they gave me a job for a year to see if I was good enough that they'd keep me on.

[00:13:18] GORDON EARLE: Well, we're going to go to the Cleveland Clinic in a bit. I want to dial back a little bit before then, because you found your way to the US Air Force. Tell us how that happened.

[00:13:28] TOBY COSGROVE: Well, it was at the time of the Vietnam War, and when we graduated from medical school, everybody got a commission, and so you were going to go one way or another. I was taken out of my residency. I had a year of surgical internship, a year of surgical residency, and then I went straight to Vietnam in the Air Force.

[00:13:49] GORDON EARLE: Well, you went to Vietnam, but you didn't go to just any place in Vietnam. You went to Da Nang, and that was a city that experienced extensive fighting during the war. Paint us a picture of what a day was like for you being a surgeon in Vietnam in a combat zone.

[00:14:08] TOBY COSGROVE: Well, it was interesting. Two things happened in my first couple of days in Da Nang. The first thing that happened was we were standing on the back porch of the facility watching a firefight, because the hospital was right on the perimeter of the base, and the bullets started to bounce off the hospital and we decided we better go inside. So that got my attention. Then, a couple of days later, I just met two forward air controller pilots and we had a rocket attack in the middle of the night. One of them was killed by being decapitated, and the other one wound up going to the hospital in the middle of the night and putting a chest tube in him. So the rocket attacks on the base at Da Nang were pretty regular, and it was the busiest airfield in the world at the time that I was there. So, very active.

[00:15:05] GORDON EARLE: Now your official title was—this is a bit of a mouthful for me—Chief of US Air Force Casualty Staging Flight. What does that mean?

[00:15:15] TOBY COSGROVE: So it turns out that in Vietnam, when a soldier got hit, they were taken to a sort of tent hospital. The bleeding was stopped, the wounds were splinted, and then they were moved to a hospital in Saigon or Da Nang, where they had the specialists, et cetera. Then, when they were convalescing, they were moved out of the country. So they would send their patients who were ready to be evacuated to the Air Force. Every day we would get a load of patients ready to be evacuated. They would have one or two major aircraft come in—C-141s—we'd load them up and they'd go to Japan, Guam, the Philippines, et cetera. During the time that I ran that facility, we evacuated 22,000 sick and wounded individuals.

[00:16:12] GORDON EARLE: Paint me a picture. Is that a field hospital in the middle of Da Nang? What does it look and feel like?

[00:16:17] TOBY COSGROVE: It's a hundred-bed facility and it's kind of like a bus stop for patients on the way out, and we would have to take care of them. The major thing was we needed to make sure that they were well enough to fly for 12 hours without any medical attention. That was my main job. Then I spent time in hospitals on the front lines. I got experience there. I operated in Vietnamese hospitals. I had two other things that I did. One is, weekly, we would go out into the Vietnamese community and have sick call, where we would see anybody who wanted to come in and be seen.

That's kind of an interesting story. One day they bring in a kid who's got a cleft lip, and obviously we're not going to fix a cleft lip out in the field. There were offshore naval hospital ships and they had all the plastic surgeons on board. So I called up the ship and I said, "Can we send the kid out?" They were delighted to have something to do besides just debriding wounds. So we sent this little baby out to the naval ship to get his lip fixed. I didn't think much more about it. Three weeks later, the family comes by and says, "Where's our kid?" and I go, "Oh my gosh." So I called the ship and I said, "What happened to the kid?" "Well, we think we sent him to the Hue Provincial Hospital." So I called up the Hue Provincial Hospital and I said, "Have you got a kid out there with a fresh, recently fixed cleft lip?" "Yeah, we think we do." It was almost like two tin cans and a string between them trying to talk. So I got a helicopter and I fly to Hue. I walk into the hospital, I get the kid, I'm walking out carrying this Vietnamese kid and I thought, "Man, if there was an opportunity to get shot in the back for walking off with a Vietnamese kid, this is it." We get in the helicopter, we fly back to Da Nang, the nurses take care of him, and the next day in comes the family. I hand them the kid and they look at the kid and they look at the kid, and I think, "Oh my God, it's not their kid." And then they go, "Oh, it's our kid." And I go, "Oh, shoot." So it was an interesting experience to try and help the Vietnamese.

[00:18:48] GORDON EARLE: You've gone through some of your experience in Vietnam. What major lessons did you learn from your service in Vietnam that you later applied to the rest of your personal or professional life?

[00:18:59] TOBY COSGROVE: Yeah, I learned a lot. Let me talk about some of the things I learned about the military and I applied them to Cleveland Clinic. The first thing I learned was, while we had two doctors and maybe 15 or 20 nurses, we also had just a squadron of corpsmen. They took x-rays, they drew blood, they started IVs, they did all kinds of stuff for us. We applied that to the Cleveland Clinic and the cardiac surgical approaches. So I never wound up having to take out stitches or pull chest tubes or move patients or do any of that sort of stuff. When I got to the Cleveland Clinic, we just operated and we continued to use the surgical techs to do an enormous number of things.

The second thing I learned is I watched the Air Force, and when you got hit, you got picked up by a helicopter and taken to a tent hospital, and then you got moved from there to another hospital, which was more sophisticated, and then finally out of the country. So I realized that not all hospitals can be all things to all people. The same applies, I think, in the United States. So we set up a transportation system that had helicopters, fixed-wing aircraft, ambulances, et cetera, and moved patients to the right location at the right time for the right kind of care. We moved about 30,000 patients a year into the hospital, out of the hospital, to the right location. We picked up people in South America, we picked up people in Asia, and put medical personnel on board the aircraft. So I learned that in Vietnam and it was a great lesson.

[00:20:48] GORDON EARLE: So you start as a heart surgeon at the Cleveland Clinic, and you're later named chairman of the Department of Cardiovascular Surgery. And I read that the clinic's heart program was ranked number one for 10 years in a row, and I wondered, how did you make that possible? What were the things that made you number one, 10 years in a row?

[00:21:08] TOBY COSGROVE: We were fanatical about our results. We looked at them intensely and we were also innovative. I always thought that there's always somebody, someplace in the world that's doing something better than you are. I would, and other people would, go in, we'd take trips and we'd just stand with a notebook and look over a surgeon's shoulder. We brought things back from all over the world. I probably did 20 of these trips to go see other people doing things that I heard about or learned about. So we were pressing the frontiers of cardiac surgery all the time by piecing together things that other people were doing well and bringing them to our organization.

We were also very transparent about our results. When I became chairman, I thought we needed to report our results to the cardiologists who were reviewing them. We did that, and then they asked for a booklet of the results, and we did that. Then we said, "Gosh, you know, we ought to just publish our results and send them out to cardiologists all over the country," which we did because I believe in transparency, both internal and external, and comparing yourselves. In fact, we were the only hospital that wound up ever doing that in the United States. Eventually, we did it for every specialty.

[00:22:46] GORDON EARLE: Well, you had a great run as chair of that department. Then you were named CEO of the Cleveland Clinic, and one of your first acts was to adopt a policy called "Patients First." So when I saw that term, I said, "Well, that seemed to me a fairly obvious orientation for a hospital," but it resulted in major changes at the Cleveland Clinic initiated by you. This "Patients First" policy—describe some of them.

[00:23:11] TOBY COSGROVE: Well, it was an organization that was very much built around the culture of the doctor, and that was pretty true for most places. In fact, when we did it, people started saying, "Well, what is this? The patient's first, doctor's last?" But, you know, we persisted. So my first speech I gave, I handed out 40,000 buttons that said "Patients First" to everybody, and we painted it on the walls and we began to think about it.

Then I had an interesting thing that happened to me. I got to know Michael Porter at the Harvard Business School and he wrote a bunch of case studies about the Cleveland Clinic. I was invited to go up to the time that he, the first time he presented at the class, and the class got to study, and then I'm up there, never having been in a business school before and very nervous, answering questions. About halfway through it, a girl in the second row on the left-hand side of this amphitheater raises her hand and says, "Dr. Cosgrove, my father had mitral valve prolapse, and we know that you've done more of those operations than anybody else, but Dr. Cosgrove, we decided not to come to see you because we heard you don't have empathy. Dr. Cosgrove, if you teach empathy..." I have no idea what I said after that. This humiliation was reinforced about two weeks later. I'm in Saudi Arabia and we are opening a hospital there in conjunction with a group from Saudi Arabia. The king and the crown prince are both there. The president of the hospital stands up and says, "This hospital is dedicated to the body and the spirit and the soul of the patient." And I'm going, "Yeah, yeah, yeah," and I look over and the king and the crown prince are both weeping. Tears are coming right down their cheeks. And I'm saying, "Oh boy, Toby, you must have missed something here."

I mean, I don't have to be hit on the head too many times before I get it. So I began to think about my career, and I'd become a technician. I would do two to four operations every day, five days a week, and I'd look after the patient in the operating room, in the intensive care unit. I didn't spend a lot of time holding hands or being at their bedside because I felt that, there's a saying in surgery: "Cut well, sew well, do well." The more I did, the better I got, and I thought that was what I should do. But then I realized, okay, there must be something that I'm missing here. So I began to think about, okay, what does a patient want when they come to the hospital? If this is patient first, well, they want three things. They want a great clinical experience, and we'd work like crazy on that. They want a great physical experience and a great emotional experience. So we started with the physical and we cleaned up the corridors so they didn't have file cabinets in them. We decided that we would paint things white because patients wanted to have something that looked scientific and clean. I convinced Diane von Furstenberg to develop a wrap gown so you didn't have one of those things that's open in the back, but it's a little more modest. And I began to think about, okay, what can we do about the emotional experience? So we wound up taking all of the employees—and there were 40,000 of them at this time—offline for half a day and putting them around round tables and talking about the Cleveland Clinic experience. When they came out of it, everybody got a button that said, "I'm a caregiver." That was whether it was the bus drivers or the technicians or the people who cleaned the room or the neurosurgeons—everybody is referred to as a caregiver. Actually, it turns out that the people you see most of are not the nurses or the doctors, but the people who look after your room.

What we saw from that is the patient experience grades that we got took us from about last in the country to first, and the employee engagement went soaring up. So it really started with me being humiliated at the Harvard Business School.

[00:27:44] GORDON EARLE: It seems to me the people in your position, they're sort of locked in and they don't often evolve in terms of their thinking and leadership, but it sounds as though you evolved, and that seems to me fairly unusual for a leader.

[00:28:02] TOBY COSGROVE: Well, I had to grow up. I mean, I had no experience with leadership other than being a surgeon. One of the things that I did was I went around to leaders that I could find who would spend time with me—Michael Porter being one of them, and Jack Welch being another. I decided I needed to educate myself and I read incessantly about leadership. I told everybody at the Cleveland Clinic I wasn't ready for this job. I wasn't prepared for it when I took it, and I want my successors to be better prepared. So we started thinking about, okay, how could we begin to educate doctors about leadership? I wound up getting 250 doctors in some sort of a leadership position.

I thought about, okay, what organization has been at this the longest in thinking about leadership the most, and it turns out to be the military. They've been thinking about it for hundreds of years, and they have a pretty simple method for doing it. Actually, it's not simple—it's very sophisticated. What they do is they give you leadership for a small group, and if you do well at that, you get a bigger group. But you're critiqued all the way along and you get bigger and bigger groups as you go along. In between, they send you off to school. They may send you to the Naval War College, they may send you to Harvard Business School, but they continually educate you along the way. By the time those guys get those stars on their shoulders, they're very impressive. They've been selected and groomed for leadership. So I decided that we needed to do something like that in healthcare.

I started out by putting 250 docs in some sort of leadership position. Some of them did well, some of them did terribly, and then we sent them off to business school, got other degrees, and my successor was a cardiac surgeon. We sent him off to Abu Dhabi, started our hospital there, and he went from chief of staff to president of that hospital over time. In the meantime, he went to Harvard Business School and now he is better trained, smarter, and nicer than I am.

[00:30:18] GORDON EARLE: Just from hearing you, my experience with people in senior positions is they tend to think that they have the answers and it's sort of top-down, and it seems to me what you're saying is, "I didn't have all the answers. I didn't have close to all the answers, so I asked a lot of people to get the right answers," and there's a degree of humbleness in that, which seems to me is unusual.

[00:30:42] TOBY COSGROVE: Well, cardiac surgeons have never been accused of being terribly humble, but I certainly stepped into an arena that I recognized I was not prepared for.

[00:30:55] GORDON EARLE: Well, I keep on thinking of that Williams experience and maybe the artistic part of your brain kicking in and other things. So you weren't the typical surgeon, trying to work a problem through as the CEO. You were bringing other elements of your personality and your brain to problem solving, trying to—

[00:31:17] TOBY COSGROVE: Yeah, but you know, I had a lot of failures along the line. I thought that I had had this great experience going to other places and learning from other great surgeons, and I thought, "Okay, I'm going to offer this opportunity to all the doctors at the Cleveland Clinic." I said, "Go once a year someplace. I don't care where you go, just go someplace and learn something different." It was a total failure. I couldn't get them to do it. Maybe 50 or 80 of the 2,000 doctors did it, but that was one of my fallacies of attempting to expand our intellectual capabilities.

[00:32:00] GORDON EARLE: You know, you've talked about the patient first and all the stuff you're doing for them, but I just want to talk a little bit about the employees because you were interested in their welfare as well as your patients. One of the things that I noticed that you did is you implemented a policy at the Cleveland Clinic where you wouldn't hire smokers. That seems to me a very dramatic policy. Now, you were interested in their health, but also the health of the Cleveland Clinic. How did that go over when you said, "We won't hire smokers"?

[00:32:34] TOBY COSGROVE: Well, the first thing that I did is, having been a chest surgeon, I'd seen the ravages of smoking up close and personal for a long time. I decided that we needed to try and do something not only for the health and welfare of the Cleveland Clinic, but for the community, and we needed to model what appropriate healthcare for yourself was like. So I thought if we're going to be a healthcare organization, we can't have doctors with a cigarette dangling from their lips tell a patient they shouldn't smoke. So we said, "Okay, we're not going to have any smoking on our campus, and then we're not going to hire smokers." Happily, I could do that legally in Ohio. It was not legal to do it in several states, but we did it here, and the incidence of smoking in the city of Cleveland dropped dramatically subsequently.

[00:33:40] GORDON EARLE: Now, there was another little—what I would call sort of a smaller story, but it interested me in the same way that the smoking story did. When you assumed the role at the Cleveland Clinic, you had a contract with McDonald's of all places—it was McDonald's—and you wanted the health of your employees and nutrition and not smoking. How did you work that through?

[00:34:03] TOBY COSGROVE: Well, I couldn't stand the fact that the smell of french fries was wafting up into the cardiac surgical intensive care unit, which was right above it. So I said, "We want to serve you good food, even if that means the end of McDonald's." Well, it turns out that McDonald's had a 10-year contract and they decided to take the fight to the public. I thought that was a bad idea. So I called up a Williams friend of mine and said, "Could you introduce me to the CEO of McDonald's?" So I called him up and I said, "I'd like to come and talk to you guys." I went out to Hamburger University in Chicago. I walked in and there's a long table and it's got the chairman of the board, the CEO, the head chef with his chef's hat on, their head of marketing, et cetera, and me. We exchanged pleasantries and they said, "Well, Dr. Cosgrove, what can we do for you?" I said, "Well, you seem like very nice people, and I'd love to have you stay if you just took the french fries and the Big Mac out of the menu at the Cleveland Clinic." They looked like I just told them their oldest daughter was ugly.

So we had a long discussion. It turns out that the french fries at the time were being cooked in something that turned out to be a carcinogen. The long and short of it was, after having a long discussion with them, they took out the triple cheeseburger and they brought in salads and apple slices, et cetera, and rather than trying to pay them $10 million to get them out of the Cleveland Clinic, after 10 years the contract was up and they left.

You found your solution. Actually, during the time of this fairly public fight, there was an article that appeared on the front page of the Washington Post where I was referred to as the "Big Mac Attacker," and you can imagine the amount of grief I took from my friends about that.

[00:36:11] GORDON EARLE: I think you should print that and put it up on your wall or something. That sounds like a badge of honor. I don't want to get too far into the weeds in terms of the administration of the Cleveland Clinic, but you made a policy that the physicians and the medical staff were salaried, not tenured, and everyone was under a one-year contract, which was extended only if they did their jobs well. For physicians, I think you were looking at patient outcomes, and another thing is that one-year contract applied to you, the head of the organization. So when you implemented that, how did it go over?

[00:36:48] TOBY COSGROVE: Well, I didn't implement it. That was the ethos of the Cleveland Clinic. The Cleveland Clinic is physician-led, not-for-profit. We are all straight salaried and it's adjusted annually. There were no bonuses and we all had one-year contracts and annual reviews. I had 44 one-year contracts.

[00:37:07] GORDON EARLE: Well, another thing that you emphasize in your book repeatedly is innovation—over and over again, including impediments to innovation. Give us an example of an innovative policy that you put in place at the Cleveland Clinic that changed things for the better. Give me an example of innovation.

[00:37:27] TOBY COSGROVE: A couple of the things we did, which kind of harks back to Williams and my experience: When we added new buildings, I went and figured out how we could get the really outstanding architects, and I got Frank Gehry to do one of our buildings. I had Norman Foster do buildings. I hired the same landscape architect who did the 9/11 memorial, where the waterfalls are in New York, to do our landscaping. He did a fascinating thing. He had a design for a fountain in front of our main entrance, and it looked a little bit like the Bellagio—water squirting all over the place. I said to him, "You know, everybody who comes to the hospital is anxious when they're walking in, and the calmest thing that I know is calm water." So he made a pool out in front that is nothing but a pool of water with plexiglass walls that hold it in, and it changes as the steam comes off it in the winter. It is a very quiet entrance to the institution. It was really a great opportunity to change the culture of the physical surroundings.

[00:38:59] GORDON EARLE: Toby, let's go to some major health issues now, which are part of the public conversation and in newspapers and media every day. I want to start with artificial intelligence. Can you explain how AI is shaping the future of healthcare for systems like the Cleveland Clinic and just how profound this new technology is?

[00:39:25] TOBY COSGROVE: Artificial intelligence is going to radically change healthcare in a way that we can barely imagine at this time. For example, there are 1.8 million medical articles in the literature annually. The total amount of knowledge in healthcare is doubling every 73 days. Nobody can possibly keep up with all that. I have in my pocket, on my cell phone, something called Open Evidence, which is available free for all doctors. I can go and ask it a complicated problem, and it doesn't hallucinate. It takes the data from the literature—the best literature that there is: the New England Journal, Lancet, et cetera—and makes it available for doctors. Forty percent of the doctors at the Cleveland Clinic are using it now. Forty percent of the doctors at Stanford are using it. It begins to deal with that explosion in knowledge that nobody can keep up with. So just from that standpoint, I think that you're going to see enormous opportunities, and a lot of that's in the business side.

Then you begin to look at AI and how it's going to affect the pharmaceuticals and improve the speed at which you can develop new drugs and decrease the cost of delivering new drugs. Let's take just an example: diabetes, for example. A diabetic is supposed to get his eyes examined by ophthalmologists once a year, and there aren't enough ophthalmologists in the world to do that. So there's now capabilities that can totally automate that and get your eyes checked for diabetic retinopathy. These are just some of the technologies that are coming along that are going to vastly improve the economics, the efficiency, and the spread of knowledge.

[00:41:23] GORDON EARLE: But as a diagnostic tool, it's not foolproof, right? You can ask advice of AI, you could have the physician's own knowledge. It's a combination of AI and the physician to really nail down a difficult diagnosis.

[00:41:38] TOBY COSGROVE: Well, it's not just that. It's being able to see more people, it's being able to be more efficient in seeing people. This will stretch your imagination. Think about AI. Right now you have something that's called ambient listening. That is where, you know, you go to see your primary care physician and he spends most of his time typing, not looking at you. I've experienced that many times, right? Now there is what's called ambient listening, and essentially that records and synthesizes and outlines and fills in the blanks in your conversation with your physician.

Now think about the greater scheme of what this might be for a primary care physician. Primary care may become very much like Uber. You call up, you talk to the bot, if you will, you tell them what your symptoms are, it asks you questions, it then suggests that you need to go to X, Y, and Z. The primary care physician may have one or two things happen to him. He may be taken and replaced by a nurse or an empathetic social worker who asks the questions, it's recorded, and the open evidence will eventually be plugged right into the ambient listening. So the primary care physician is not doing that, or it may be that the primary care physician uses that and then expands into a lot of things that are going on by a cardiologist or a gastroenterologist, an endocrinologist, and makes them not do the sort of standard things that they do, but instead is done by a primary care physician with greater breadth of capabilities.

[00:43:32] GORDON EARLE: You know, it is a little scary for me because I'm an old school guy, right? So I like to see my doctor and talk to my doctor. My internist, by the way, is an MD PhD, so, you know, highly skilled. I get what you're saying. It'll be a transition for someone like me to get AI to give me that basic consult, but it's something I'll have to get used to, I think.

[00:43:57] TOBY COSGROVE: You think you can get into a robotaxi?

[00:43:59] GORDON EARLE: Yes. So there you go. Right. Let me move the discussion along a little bit. There was a New York Times piece recently from nine former CDC directors—I know that you're aware of it—that criticized recent administration decisions. It was really across the board, having to do with healthcare issues. They cited specifically the billions of dollars of cuts in research funding. And as a former associate dean of a medical school, I know how important that is. And skepticism about vaccines. So they gave their review. Give us your assessment of the impact of these kinds of changes on the health of Americans.

[00:44:41] TOBY COSGROVE: I'm very concerned about the questioning of vaccines. Vaccines have been probably one of the great things that's happened in healthcare in the last hundred years. Let's take polio, for example. When I grew up, I had a friend who spent two years in an iron lung and is still wearing braces on his legs to this day. Polio was virtually wiped out. Smallpox the same way, and they're probably one of the great lifesavers. What's happened with mRNA, with the recent COVID epidemic, it was incredible that they came across that as fast. And then children's vaccinations—we're now seeing a resurgence in measles. I have to remind people that mumps is associated with sterility in males. So to cast doubts about vaccines in general is very scary for me. I worry about resurgence of many of these diseases which have been virtually eliminated, and it has been done with very little scientific support.

So as far as the vaccine is concerned, I think they've been unfortunately maligned, and I think that it's going to cause a lot of people to not have their children vaccinated. I'm sure we're going to see more reticence to have your kids vaccinated, and I think we're going to see more infectious disease as a result of that. I worry about it a lot.

[00:46:16] GORDON EARLE: Let me turn on a more hopeful note. In the medical profession, there's much talk about medical breakthroughs and what will happen in the next five to ten years which will improve the health of all Americans. Can you give us an insight into what some of those breakthroughs might be?

[00:46:35] TOBY COSGROVE: Oh, there are going to be enormous breakthroughs in lots and lots of areas. One of the ones that's fascinated me, though, recently has been the potential for neurologic diseases. Let's give you sort of an example. We now understand what areas of the brain where epilepsy starts. The first sort of foray into this was surgical removal of that particular aspect. Now it turns out that you can destroy that portion of the brain simply by various focal therapies without ever opening the brain, and it relieves people's epilepsy. That's the kind of breakthrough that we're beginning to see. I think our understanding about Alzheimer's disease—which, you know, turns out to be the sixth leading cause of death in the United States, which is a horrifying disease—I think we're learning increasingly about that. We've been down the road for hundreds of therapies that did not work. We're now looking at different etiologies that cause Alzheimer's, and so the first drug has just gotten approved which looks like it slows the onset of Alzheimer's disease. So I'm optimistic about neurologic diseases. I think there's going to be great, exciting things happening there.

I see increasing use of GLP-1s, which are an amazing new therapy. Not only do they reduce weight, but it turns out that they've had salutary effects on cardiac disease. Now we're seeing GI disease. They're helping people with addiction. Every time you turn around, they seem to have a salutary effect on another organ system. So I think it's an amazing breakthrough.

[00:48:37] GORDON EARLE: We now go to a part of the podcast as we wind up, which is sort of final reflections. Toby, I don't want you to think that I'm picking on you, but there was one final comment that I read that caught my eye and it said—this came from you—you are not, quote, "the sharpest tool in the drawer," but your career has been by any measure a tremendous success. How do you explain it?

[00:49:04] TOBY COSGROVE: I thank you for the flattering comment. I was lucky, but I also think that I attribute a lot to the dyslexia, which taught grit. Angela Duckworth wrote extensively about grit. While it took me twice as long to do my homework as most people, I learned that in high school and expected to do it all the way along. I think that's an important aspect of things. Recently, I had an opportunity to talk and read a book by a friend of mine who talked about courage. Courage comes in all kinds of forms. It's not necessarily the hero that steps into the line of fire, but there's ethical courage and courage to do small acts. I think great leaders—and I don't put myself in that category—but I think great leaders have the courage of their convictions and don't necessarily always worry about the consequences if they think that something's right. I just thought not hiring smokers was the right thing to do. I didn't worry about it. Those are small, ethical things. So I think leaders have both the courage of their convictions and grit.

[00:50:32] GORDON EARLE: Finally, Toby, what are you doing with your life now? I know you're biking. I know you've been to Morocco biking recently. What else are you doing to fill your days?

[00:50:43] TOBY COSGROVE: I have a portfolio of things that I'm doing. I am on a couple of public boards. I work for a private equity group in New York that does devices. I work for a company called Iconic, which is Mark Zuckerberg's family office, advising them about investing in healthcare, and I am trying to help a number of startups enter into the healthcare arena, particularly around AI.

[00:51:10] GORDON EARLE: Toby, on that note, I want to thank you for joining us today. It was an honor and a privilege to talk with you. I also want to thank the college for supporting this new expanded edition of A Williams Life, as well as my classmate Peter Kiernan, who is supporting the podcast through the Peter and Eaddo Kiernan Foundation. Without their support, I wouldn't be talking with you today and neither would Toby. You can visit the Williams website to view photos of our guests and read more about their life stories. Until next time, producer Jon Earle and I hope you have enjoyed this podcast and others to follow during the academic year.