Health Tech: Dr James Min On How Cleerly’s Technology Can Make An Important Impact On Our Overall Wellness
An Interview With Dave Philistin
Be earnest. To me, that defines being loyal to the mission, accomplishing goals with humility, and understanding that a team-based effort is what is required to succeed. The race to accomplishing anything meaningful is long — a marathon not a sprint — and the outcome is never known until the end. For startups, you often hear this analogy in the context of Mike Tyson’s words, who said, “Everyone has a plan until they get punched in the mouth.” Anyone attempting to achieve something significant will, at some point, get punched in the face. Don’t let the highs get you too high, or the lows get you too low. Instead, just keep maniacally focused on the mission while ensuring that you enjoy the daily journey of getting there.
In recent years, Big Tech has gotten a bad rep. But of course many tech companies are doing important work making monumental positive changes to society, health, and the environment. To highlight these, we started a new interview series about “Technology Making An Important Positive Social Impact”. We are interviewing leaders of tech companies who are creating or have created a tech product that is helping to make a positive change in people’s lives or the environment. As a part of this series, I had the pleasure of interviewing Dr. James Min, founder and CEO of Cleerly.
James K. Min, MD, is the Founder and CEO of Cleerly. Prior to Cleerly, Min served as a Professor of Radiology and Medicine (Cardiology) at Weill Cornell Medical College and the Director of the Dalio Institute of Cardiovascular Imaging (ICI) at NewYork-Presbyterian Hospital. He is a board-certified cardiologist with a clinical focus on cardiovascular disease prevention and cardiovascular imaging. For Min, the development, validation and dissemination of Cleerly’s AI-powered products and services–that are aimed at creating a new standard of precision heart care–offers him an opportunity to translate the large-scale clinical trial research he has spent conducting for nearly two decades into standard clinical practice through innovative solutions that have not existed in the marketplace to date.
Thank you so much for joining us in this interview series. Before we dive in, our readers would love to learn a bit more about you. Can you tell us a bit about your childhood backstory and how you grew up?
Thanks for taking the time to speak with me, Dave. I had a great, uneventful childhood. I was born in Norman, Oklahoma to my parents who were South Korean immigrants. I have one older brother, and we moved when I was very young to Whitewater, Wisconsin. Beyond a small state college in the town, the industry driving most of the economy was agriculture — dairy and soybean farming. I have fond memories — the people were amazing and it was a fantastic place to grow up. As a small child, however, I do remember wanting to explore more of the world. So, after high school, I leaned toward larger metropolitan areas and since then, have lived in Chicago, New York, Philadelphia and Los Angeles. Currently, I live in Denver, Colorado.
Can you share the most interesting story that happened to you since you began your career?
In 2013, I had the serendipitous opportunity to meet a gentleman in the halls of NewYork-Presbyterian Hospital. We briefly spoke about the clinical research that we were pursuing in our laboratory to improve diagnosis of heart disease. This gentleman was very generous with his time, and I had the opportunity to show him some of our work. It was not a long meeting–perhaps 20 minutes at most, but a very momentous one.
I received a call about 30 minutes after the meeting from my boss who informed me that this gentleman had decided to donate $20 million to our research laboratory. As you might imagine, I was totally flabbergasted. Later, our hospital leadership asked him why he decided to donate so generously on such short notice. He replied that he thought that there was a possibility that I was a “shaper” and might be able to meaningfully advance the field of cardiology. In truth, I’m not certain that he was right, but it was one of the greatest compliments I have ever received.
This gentleman’s donation allowed our lab to think “outside of the box,” and to challenge clinical norms. For me personally, it gave me the opportunity to rethink heart disease. In doing so, we had so much fun pursuing diagnostic, prognostic and therapeutic solutions using clinical trials, machine learning, materials science, electrical engineering, biomedical engineering, and many other fields’ technologies. We looked at the problem as if there was no limit to what we could approach and try to solve for. This was one of those instances that influences your career in a manner that you can’t quite grasp at the time, and the interaction and learning from non-cardiologist engineers, data scientists, and others, was just so much fun.
About three years later, I met with this gentleman at a board meeting, and he raised a very logical question, asking, “So when do these advances get to humans?” I recall thinking that the answer was really never, as we were academic physicians who took care of patients and our research goals were to influence societal clinical practice guidelines rather than to directly deliver solutions to humans. But that question was a challenge. I realized that we desperately need to translate science into products that can be used by patients and physicians. I had, at the time, been part of a small startup and we sold that company, so I figured it was time to do it again — but this time on a much larger scale.
The last time I met with this gentleman in person, I told him that he had appreciably altered the direction of my life. I had never planned to leave Cornell and NewYork-Presbyterian Hospital — I loved my job there and those that I worked with and for. I didn’t say that out of a certainty of appreciation — we are in the middle of the Cleerly journey and no one can really forecast our ultimate outcome. I said that because I hoped what it meant was that this change in direction would allow us to deliver our technologies to each and every at-risk patient, and hopefully change the standard of cardiology care.
None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?
Yes, absolutely. As I look back on my life and how I ended up at Cleerly, I see a version of the movie “Sliding Doors,” where the protagonist’s life completely changes based upon whether she makes or misses the subway train. In my case, this ‘sliding door’ dates back nearly 20 years to cardiology fellowship when I saw a CT scan of a heart for the first time. This was early in the development of CT technology, and it was a four-slice CT scanner that required a patient to hold their breath for one minute to get adequate image quality of the heart. While I knew that most patients cannot hold their breath for that long, even then I could see the potential for how this technology could fundamentally change our understanding of coronary heart disease.
I was determined to master this evolving field of cardiology and received permission from my program director to learn this field elsewhere because back then, it wasn’t offered at the University of Chicago. I called around to about 20 different health systems, contacting physicians who had published papers in the scientific literature on cardiac CT. Of those calls, 19 of 20 informed me that while they published papers in the field, their institutions did not yet perform clinical cardiac CT. The one exception was a cardiologist in the suburbs of Nashville, Tennessee who was performing cardiac CT scans on 15–20 patients per day. He was generous enough to invite me to join him for approximately six months to learn the field.
As I drove down for this sabbatical, I started to question whether or not I even wanted to go. The practice was private, and I had been trained only in academic institutions. Further, as a fellow, I couldn’t afford to pay for a place in Tennessee in addition to my rent in Chicago. And to make matters worse, I ended up driving down during the middle of a massive blizzard. I remember thinking that I should turn back and head home to Chicago, but that it would be rude not to even show up. I told myself at the time that I should continue driving for one hour and, if the snow didn’t let up, I would find a hotel room and drive back to Chicago the next day. Fortuitously, the snow relented, and I ended up in Tennessee later that day. That turned out to be one of the most significant decisions of my life.
Over the next six months, I found that this cardiologist who spent countless hours teaching me the field was a true pioneer who just saw the technology’s power earlier than everyone else. He is also a precious and wonderful human being who I am lucky enough to count as a close friend even 20 years later.
At times, I wonder what would have happened had I turned back to Chicago. What I know is that my life would have been totally different, and it emphasizes that we should explore all our possibilities, and not run from them. Had I not had that experience and opportunity, I wouldn’t be sitting here at Cleerly today.
It’s these seemingly little decisions that can have dramatic effects on your life–along with the generous people along the way–that really help to foster where you end up in your career. I’ve been so lucky to have had several people in my life influence it in such a positive way that I cannot imagine what life would look like had I not had the blessing of meeting them.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
There’s an Albert Einstein quote that I often think about — “If I had an hour to solve a problem and my life depended on it, I would use the first 55 minutes determining the proper question to ask.” To me, that is a poignant comment, as I see a lot of companies developing very cool technology and then trying to figure out where to deploy it. I believe that it is better to identify the problem to be solved first, and then create the most perfect solution to that problem. In my career, the question that applies to all patients at risk of heart attacks is: “What question am I trying to answer?” In the past, we would ask: “Are this patient’s symptoms due to blockages in the heart arteries?” That is an important question, but what we have realized as a field is that treating symptoms relieves symptoms but does not reduce heart attacks.
I realized our field was asking the wrong question and that all the tools and approaches that we have used in cardiology leverage indirect markers of heart disease rather than direct measurement of the disease itself, which is atherosclerosis. The general question that we ask ourselves is: “How can we prevent heart attacks?” Everything we have learned over the last two decades points to direct measurement of heart disease as the answer. In hindsight, that seems obvious but those tools weren’t available to us and so it was difficult to imagine a world where they were available. I’m proud to be part of the team at Cleerly that has taken that improved understanding of heart disease, developing tools for its evaluation, and figuring out how best to treat patients to prevent heart attacks.
You are a successful business leader. Which three character traits do you think were most instrumental to your success? Can you please share a story or example for each?
If I had to pick three character traits that have served me well, I think they would be the following: (1) Mission-Driven, (2) Intellectual Curiosity and (3) Value Creation.
For the first, I have been interested clinically and academically in coronary heart disease since 2002, when I began my cardiology fellowship. It struck me even then that the world’s number one public health epidemic was heart attacks and death due to heart attacks. In recent years, the rate of decline of heart attacks that we have observed over 20 years has stagnated. Given that someone will die of cardiovascular disease every 1.6 seconds across this world, it is this sense of urgency that fuels me and my colleagues at Cleerly. It’s why I have devoted my life to understanding how different types of heart disease affect a patient’s outcome, and how we can influence the natural history of that outcome to prevent heart attacks.
Intellectual curiosity is something that I admire in others, and I hope that I have some measure of it myself. At Cornell and NewYork-Presbyterian Hospital, we were privileged to be the recipient of a very large grant from a wonderful, gifted and generous philanthropist who supported our program. I got to know him and beyond being brilliant, what I most respected about him was that he was the most incredibly and innately curious person I have ever met in my life. While his background was in finance, he was intellectually curious about everything he encountered — whether it was healthcare, systems engineering, or any other field. I have tried to adopt some of that in my own life, as I believe it leads to a much richer existence. At Cleerly, we try to harness our collective intellectual curiosity to ask the right questions so that we can develop the right answers through our technologies.
The third trait is more of a question that I ask myself daily: “Am I creating value?” It is a high-level question with many different answers. Whether it is value creation for patients, for our partners, for our shareholders or for society, the question can be asked and answered to help promote our mission and our company. At Cleerly — similar to many other startups, I believe — we were very focused on product development early on, and this was very appropriate for our company’s stage. However, as we started to evolve and mature, we needed to transition to other goals to continually create value. I think a healthy respect for where you are as an individual or company, what the present goals are (which often change), and the constituents you serve can help us ensure that what we are doing truly creates value.
Ok super. Let’s now shift to the main part of our discussion about the tech tools that you are helping to create that can make a positive impact on our wellness. To begin, which particular problems are you aiming to solve?
Our goals at Cleerly are to disseminate AI-enabled leading-edge technologies through a comprehensive end-to-end digital care pathway that directly addresses the limitations in current cardiovascular care. Historically, we have evaluated symptomatic patients with suspected heart disease with stress tests whose findings represent indirect surrogate markers of heart disease rather than heart disease itself. In this paradigm, we are trying to identify a narrowing in the artery that may benefit from a stent or surgery — procedures that are effective at relieving symptoms but less effective at reducing heart attack. Further, in real world practice, the non-invasive tests that we have used to identify narrowings have been shown to be ineffective and inaccurate, with nearly two-thirds of patients sent for an invasive procedure found not to have any actionable narrowing at all.
Further, while our field has been historically focused on symptom-driven care, the majority of people who will suffer heart attacks will feel no symptoms before their event, and more than two-thirds of heart attack victims are considered “low risk” by risk factors such as cholesterol. What is critically needed is a new care paradigm that addresses this “forgotten majority.” At Cleerly, we have a rhetorical question that we often ask ourselves: “Why do we use advanced non-invasive imaging to prevent the most common causes of cancer, but not the most common cause of death?” Whether it’s 3D mammograms to prevent breast cancer mortality, or colonoscopy to prevent colon cancer mortality, or high-resolution CT scans to prevent lung cancer mortality, we have never leveraged advanced imaging to reduce heart attack deaths.
With proper tools and proper large-scale clinical trials, we at Cleerly believe that we can develop an unassailable evidence base to replicate the monumental success stories of mammography, colonoscopy and lung CT scans in reducing cancer, and apply these lessons to prevent heart attacks.
How do you think your technology can address this?
At Cleerly, we believe that every patient — whether symptomatic or asymptomatic — is at a point where heart attacks can be prevented. To support this, Cleerly has developed a comprehensive end-to-end digital care pathway where whole-heart atherosclerosis imaging is simply the first step of pathologic disease assessment. We do so by quantifying and characterizing the type of plaque in an individual’s arteries, with the latter found to be the strongest marker of heart attack risk. Next, we offer tools that translate this advanced imaging science into actionable clinical insights so that treating clinicians and patients can enjoy and understand the information provided by this advanced analysis. Cleerly has also joined forces with the American College of Cardiology to emphasize effective treatment based upon this disease burden and type, and Cleerly’s technology enables quantitative disease tracking over time in a manner that proves therapeutic success or, in the case of therapeutic failure, guides intensification of medical therapy to halt the progression of disease. The beauty of this paradigm is that it is personalized medicine, rather than population-based.
It sounds strange to say, but heart doctors have never actually measured heart disease. We’re great at evaluating surrogates of disease (such as cholesterol levels), signs of disease (such as symptoms of chest pain), and sequelae of disease (such as narrowings in the arteries). But we’ve never actually evaluated the disease itself, which is the atherosclerotic plaque that builds up silently in the walls of a person’s heart arteries. We believe that there will soon be a day when we look back on 2022 with wonder that we focused on indirect measures of disease rather than primary disease process itself.
If we can accomplish what we aim to do, we will disseminate our solutions globally and influence policies so that we can get the right patient the right treatment at the right time. To do so, Cleerly is committed to advancing the clinical implementation and trials to guide decision making by policy makers. If we are successful, we will be witness to a “silent revolution.” By this, I mean that, very quietly, we will simply start to hear less of people suffering heart attacks.
Can you tell us the backstory about what inspired you to originally feel passionate about this cause?
In hindsight, I realize that my journey to this point was driven by the questions patients asked me and that I couldn’t answer. I recall a patient in his mid-30s with no cardiovascular risk factors who presented with a massive heart attack, and another woman in her 90s with carotid atherosclerosis causing her multiple strokes who we found not to have any heart disease at all. It is these outliers that humbled me. We have somehow convinced ourselves that we can identify patients who will have heart attacks with our traditional tools, but that is simply untrue. We continue to miss most individuals who will suffer a heart attack–who are considered “low risk” or who feel no premonitory symptoms before their event–and I believe that the fundamental advance that Cleerly can provide is to provide personalized care so that we don’t miss any at-risk patient before we can properly treat them.
In my career, I’ve had the good fortune to be able to balance patient care with large-scale clinical outcomes research. Part of that patient care included performing and interpreting advanced cardiovascular imaging, whether it be ultrasound, MRI or CT scans. Our research leveraged CT scans of the heart because we felt that that non-invasive tool would most significantly improve our understanding of vascular biology. And it did. From our own research and others as well, we have demonstrated the utility of CT to diagnose and improve outcomes of individuals with suspected heart disease in a manner superior to historical methods. These studies were, in part, largely contributory to the changes we observed in the new and updated American Heart Association and American College of Cardiology clinical practice guidelines where the use of CT was elevated to Level IA recommendation over any other method for coronary artery disease evaluation.
The first half of my career was to take care of patients and to help perform research in a manner that improved our understanding of heart disease and influence societal guidelines, but the lessons learned from research cannot be easily replicated in a daily clinical setting when the tasks of measuring and characterizing atherosclerosis is so manual and time-intensive. I left my academic and clinical positions two years ago to join Cleerly full-time, with the intent to dedicate the second half of my career to delivering standardized, accurate and non-invasive tools that improve cardiovascular care and to add to the scientific evidence base necessary to change healthcare policy such that all at-risk individuals can have access to these solutions.
At the end of my career, I hope to look back and see that we transitioned from using rudimentary tools that measure indirect markers of heart disease to novel technologies that examine actual heart disease itself, and that policies have evolved to enable early identification of all individuals at risk of suffering heart attacks.
How do you think this might change the world?
At Cleerly, our technologies have been developed as a comprehensive solution to evaluating patients presenting with symptoms suggestive of heart disease, such as chest pain or shortness of breath. In this regard, our commercial efforts have been targeted toward health systems where these patients present and can benefit from our solutions. The clinical trials that have evaluated Cleerly have demonstrated them to be the most accurate, and we want to deliver this type of diagnostic certainty to physicians and patients.
However, as most heart attack victims do not actually feel any symptoms before their event, waiting for patients to present with chest pain is a less-than-ideal approach for reaching every at-risk patient. Further, waiting for patients to present with late-stage symptomatic disease is akin to evaluating oncology patients only when their cancer has metastasized. It’s too little too late, and we need to pinpoint at-risk individuals at their earliest stage.
We’re committed to performing the requisite science that influences clinical practice guidelines, but I believe strongly that our technology at Cleerly carries with it the potential to offer universal worldwide screening of heart disease in a manner that can improve millions upon millions of people’s lives.
Keeping “Black Mirror” and the “Law of Unintended Consequences” in mind, can you see any potential drawbacks about this technology that people should think more deeply about?
Yes, that is a great question. We at Cleerly believe strongly that artificial intelligence (AI) can fundamentally revolutionize healthcare and allow for the development of technology solutions to standardize best-in-class care in a manner that democratizes medicine. Despite this, one potential drawback of AI, if not done carefully, is that the developed AI can possess unintended biases if these algorithms are trained and validated on constrained cohorts that do not reflect the general population at large. We have seen this in the clinical tools that we use today, and that were developed in the pre-AI era. As an example, our prediction tools to identify patients at risk of suffering future heart attacks are largely based upon observational cohort studies and randomized trials that are inordinately represented by specific patient demographics. Thus, these tools perform poorly when applied to underrepresented populations by age, gender, race and ethnicity.
At Cleerly, we believe that the easiest and most effective way to democratize care is to practice precision heart care, i.e, personalized cardiology targeted to an individual’s actual disease. In our prior research, we have identified the factors that predict adverse patient outcomes are overwhelmingly represented by an individual’s disease burden and type rather than their age, gender, race and ethnicity. This personalized approach to cardiovascular care ensures that we don’t miss a single at-risk individual because of bias or omission.
At Cleerly, we also believe in delivering personalized heart care founded on the best available science. We’re currently running the largest heart disease outcome study ever. This is a global study called CONFIRM2, and we plan to enroll up to 200,000 patients with four-year clinical outcomes. We have designed the study to ensure that we collect not only the largest corpus of data, but also the most diverse. In this regard, what we are aiming to create is the world’s most heterogeneous data set that encompasses all populations.
We should remember that AI is just a tool in medicine. For many indications, the AI happens to be a significantly better tool than what we had available to us in the past. AI–like any other tool–will output exactly what you design it to. In isolation, for certain commodity tasks, this may be enough, but for the complex management of patients, it’s the integration of that output into daily clinical care that requires a multifaceted approach to improving the life of a patient. For the near-term future, we should think of AI as a tool to augment the role of medical practitioners as opposed to obsolescing them.
Here is the main question for our discussion. Based on your experience and success, can you please share “Five things you need to know to successfully create technology that can make a positive social impact”? (Please share a story or an example, for each.)
To successfully create technology that can make a positive social impact, I believe you need to do the following that I’ve outlined below.
Invest in your passion. The journey toward positively impacting our world is long, and there are no shortcuts. I see many technology “solutions” out there that aim after the lowest hanging fruit. Complex problems aren’t solved by tackling the lowest hanging fruit, but by addressing the problem in its entirety. In Cleerly’s case, we are aiming to define a new standard of care for prevention of heart attacks. This is something that has fueled me for more than 15 years, and I have devoted my career and life to it. At Cleerly, I’ve been so fortunate to be surrounded by other hyper-talented folks who are motivated similarly; and would encourage others to invest the necessary time and energy into their passion. Someone once told me that I should be very careful in what type of company I choose to build because it is just as hard to build a company with products that don’t address a meaningful problem as it is to build a company with products that can change the world. I agree wholeheartedly with that statement, and it very much speaks to finding something that fuels your own fire and investing your time and energy into it.
Be earnest. To me, that defines being loyal to the mission, accomplishing goals with humility, and understanding that a team-based effort is what is required to succeed. The race to accomplishing anything meaningful is long — a marathon not a sprint — and the outcome is never known until the end. For startups, you often hear this analogy in the context of Mike Tyson’s words, who said, “Everyone has a plan until they get punched in the mouth.” Anyone attempting to achieve something significant will, at some point, get punched in the face. Don’t let the highs get you too high, or the lows get you too low. Instead, just keep maniacally focused on the mission while ensuring that you enjoy the daily journey of getting there.
If you could tell other young people one thing about why they should consider making a positive impact on our environment or society, like you, what would you tell them?
Challenge dogma. I think often about the progress that we have made in the world in the last several decades across all industries. Across time, with exponentially increasing data, we continually learn new things that challenge our old way of doing things or thinking about things. That is certainly the case in my own specialty, where much of what I was taught as a cardiology fellow has been proven over the last two decades to be fundamentally untrue. These realizations are natural and occur in every industry, but they also represent opportunity. For Cleerly, it’s to introduce a fundamentally new paradigm of cardiovascular care that directly addresses the limitations of our historical approaches. I believe that it is in the imperfections that we find opportunity and a necessity for disruption of the status quo.
Is there a person in the world, or in the US with whom you would like to have a private breakfast or lunch, and why? He or she might just see this, especially if we tag them. :-)
Thomas Edison. Beyond his obvious brilliance as an inventor for the creations that many are aware of — the light bulb, the record player, the motion picture camera — he also invented fluoroscopy, which we use in cardiology and medicine even to this date. Further, he had this insatiable curiosity for how the world worked, and contributed substantially not only as an engineer, but as a chemist and a botanist as well.
And Edison did it his own way–in his own labs in Menlo Park lab in New Jersey and his other lab in Fort Myers, Florida–and not under the rubric of a university or other academic institutions. In many respects, I think that that Edison’s paradigm of linking independent investigation with the development of commercial products that can help our human race is returning to us today. Where traditional academic institutions were well-suited for basic science innovations, I think that they are less suited for the development and dissemination of translational technologies, such as AI, which will likely be more effectively pursued in the private sector.
Finally, what I love most about Edison are the stories of him teaching children about botany in the elementary school close to his home in Florida. A renaissance man who took the time to give back by paying it forward to the next generation. It’s a great lesson and one that should be admired and emulated.
How can our readers further follow your work online?
Readers can follow Cleerly on our social channels — LinkedIn and Twitter — to stay up to date on our latest activities and research. Our website also shares lots of great information about the problems we’re trying to solve and how we’re going to do just that.
Thank you so much for joining us. This was very inspirational, and we wish you continued success in your important work.
