Things & Thinks Half & Half Ed. 5
I started this dialog series with healthcare innovation leaders from all walks of healthcare lives, to gain an understanding of their journeys, both personal and professional, and get their thoughts on current healthcare challenges and innovation.
In this fifth edition, I am privileged to have Elizabth (Betsy) Garofalo, a physician, scientist and above all one of the most empathetic leaders I have ever worked with. Betsy trained as a pediatric neurologist and started her career taking care of children with epilepsy. That lead to a job in the pharmaceutical industry working on new epilepsy medications. That was about 30 years ago and she never looked back. She feels fortunate to have had such an interesting and varied career working on new medications for the central nervous system. I feel fortunate to have worked under Betsy’s leadership during my Novartis days!
T&T: Hi Betsy, welcome to Things & Thinks! I am so happy to have you as a guest. Let’s begin with your backstory?
BG: I was someone who loves to learn. Basically I loved to read, I loved to learn so, as a child that was always the background situation. My formative experiences that were really imprinted into my personality were related to my parents. I did not have my parents long enough, they both passed away in their early 50s. So life lessons happened very early and actually my dad who was himself an engineer knew I liked science. I like math a lot and so engineering would have been logical but he said to me, don’t go into engineering, it’s not a nice field for women and at that time, probably it was correct!
As an undergraduate, I started in a program where I would do three years of studies and then apply to medical school and they would transfer back the credits after my first year of med school to get the undergrad degree. And after first year of college, my dad died, and of course it impacted me as my mother had passed away 4 years before. I kind of stepped back from the very heavy load of college, for the next year. But then at the end of that year I decided that I still wanted to complete those studies as soon as possible. I was short of two credit hours — one class in ecology not offered in summer school, but I applied to medical school after 3 year of college anyway. So long story short, I never graduated from college- now it’s this funny and confusing situation when people are writing my bio, I have no undergraduate degree!
T&T: That’s definitely fascinating! And how was it at the medical school?
BG: So I liked analytical things. I liked math very much. And medicine is not so math oriented. Right? so you learn when you get into medicine, that it’s really about the huge information and marshalling that information and remembering and understanding. And so it’s a very different kind of study and skill set. The thing about medical school is that it’s not that the concepts are so difficult to understand. It’s the volume of material that you need to get in your mind and retain and use.
T&T: And then what was the reason for choosing to study pediatric neurology?
BG: So there was no one in the family that was in medicine; mine approach was more one of ruling out certain specialities — such as surgery. Obviously the brain to me is the most fascinating organ that exists- it’s the most complex. It’s probably the least well understood. And so, that was appealing. What’s interesting is that there’s this difference in thinking about the brain and the mind, right? So, the psychiatrists are thinking about the mind, the neurologist, are thinking about the brain, it’s an artificial construct. I realized that, assuming I was going to practice medicine, I was drawn to neurology! To be honest, at that time I felt the children make happier patients and was drawn to pediatric neurology. I did not have the full appreciation until later that one must care for the child, the parents and the whole family.
T&T: How did the shift to industry happen?
BG: I had gravitated towards epilepsy and I liked the idea that there were therapeutics. The pharmacology of these therapies was kind of more mathematical- pharmacokinetics, pharmacodynamics, more about data- these things appealed to me. At the University of Michigan, we had a lot of drug trials at that time. There was an adult epileptologist who was doing all the adult trials; I saw him do these studies and he helped me become the principal investigator for the Felbamate in Lennox-Gastaut syndrome and I enrolled 5 or 6 pediatric patients. I was a high enroller! Those kids did really well on Felbamate and so I had a good experience with that and I really enjoyed that experience. Then I was approached by Parke Davis when they had a job opening and that was quite serendipitous.
I worked for Parke-Davis (which became a part of Pfizer) for 14 years. Through this time, two things happened-one was understanding my potential as a leader, so I I enjoyed managing our CNS clinical group, and I really learned a lot about that- we had access to management coaches, we were sent to short courses at the business school and we learned quite a bit about team dynamics and running teams and how much more powerful team is when it’s a high performing team. It all resonated with me and so then I started seeking out those positions because I could get more done than if I was just an individual contributor.
Another aspect I really enjoyed was the hands-on clinical trial work aspect-I sat with the CRAs, I called the investigators; I understood the moving pieces of data. After I left Parke Davis-Pfizer, I was a consultant and this on-the-ground work helped me during my work there.
T&T: And then you worked at Novartis, right?
BG: While consulting, me and some others from ‘Pfizer Diaspora’ were hired into Astellas. At Astella we had a S1P1 modulator and we had a small team, with whom I learnt a lot and thoroughly enjoyed working with. The funny thing is my then team and I were attending an FDA review meeting and I reconnected with some former Pfizer colleagues who were at Novartis at that time. They were presenting in front of the FDA advisory committee for Gilenya (Fingolimod). That lead to a job at Novartis as the Head of Development in the Neuroscience Franchise. Another anecdote-I was hired while my predecessor was still at the company and it was a bit of an awkward transition!
The experience at Novartis was a whole another level of responsibility and workload compared to my previous jobs -whether it was managing the Neuroscience franchise work or whether it was working with you and other colleagues building the clinical development unit. It was really a fantastic experience!
T&T: Betsy, what are you busy with since Novartis?
BG: So I retired from Novartis and I am back doing some consulting, mostly organically when people approach me. And then recently I was appointed to be a board member for two companies — Exicure Pharma and at Acadia Phrma; this is definitely a new learning phase for me; so far I’m used to being on the ground, a lot of hands-on work and am transitioning into a role where I can give advice but and essentially hands off in the day to day work of the companies. There is still a shortage of female leaders on many boards particularly in the US these days. I am quite proud of the work we are doing at Exicure and Acadia.
T&T: Is there something you learned in college that’s proved almost wrong?
BG:. Well, one of the things that was proven wrong was my advisor at Purdue told me well you will regret not graduating! Another thing is if you’re going into the science stream, STEM education, you still need enough liberal arts work to have an understanding of the world and you need to be able to write- not just technical writing but you need to be able to express your thoughts well and learn how to write and that’s been something that just differentiates people as you go along. Many people don’t think it is important but I have learnt that it can make a difference.
T&T: What new habits did you form through the pandemic? Did you start any new coping mechanisms?
BG: Absolutely! So one thing that we started doing was to ‘zoom call’ with my kids,and honestly my husband and I have spoken more with our kids this year than during normal times! So it’s self-discipline but it’s also just thinking about it new hobbies or areas to focus on — when you think about it then you can actualize it but otherwise you can just go through the day and think here we go, another day I’m stuck inside! So the other thing, my husband I just started Italian class and that’s going quite great for now!
T&T: What’s something new you’ve learnt about yourself in the past 3–6 months?
BG: One thing I learnt about myself-I love change but I also end up overthinking! My sister was explaining to me the concept of self-doubt and I relate with that. Since my work started on the two boards, I have been stressed! I literally had sleepless nights. It’s getting better because it’s been months and many meetings and I understand better what the role is and how to behave and to add to the conversation but I still get stressed.
T&T: So let’s shift gears now to healthcare- what’s the best piece of advice you could give to someone starting their first healthcare job now?
BG: My initial thought is thank you for doing it, you know? Because all of healthcare is a service. The next piece would be to not get confused with all the information being at ones fingertips though because it’s all about the patient. It’s about really learning and listening to the patient and being empathetic. I think for me, it was very much a humbling experience and seeing that I grew up and lived a certain way with certain advantages and opportunities. And there are many people that don’t, you know, and that lots of, there’s lots of great stuff that there’s lots of adversity out there. So remain aware of this through your work, that would be my advice.
T&T: What do you think about our current healthcare ecosystem?
BG: What I’m struck by is what the pandemic is really showing us- that there’s a lot of disparity in healthcare access. There are certain Health Care Systems that are working better than others. There are certain Health Care Systems are public health-oriented. The US and many other countries are not; In the US, we have a very robust system but it tends to focus on caring for patients who are ill and not as much preventative medicine. We have the luxury of the extreme variety, diversity and sophistication in our health care system. There is less focus on primary care; Well we know now you should exercise more, lose weight, we’ve gotten blood pressure under control, so there are less strokes etc. But for major public health issues, like being able to vaccinate, we have kind of fallen down on the job, that it’s not set up for that kind of work.
T&T: So how is the way clinical work has changed?
BG: I see both good things happening and some things going in the wrong direction. A lot of good people are coming to the field and are doing fantastic research in biopharma, in the clinics and so on. However, easy access to information has a downside — if you believe you can look things up, you may be less inclined to learn and develop your skills in terms of elucidating a differential diagnosis!
T&T: Out of all these different things, what will be the biggest challenge for healthcare in the next decade?
BG: Well I think it is going to be the sophistication that just keeps growing, in the scientific discovery and so on. It moves at an incredible pace. So how much of GDP is a country going to put towards such innovation?
It’s going to be all managing the cost and the access to these things and every country does it a bit differently.
We knew this from Novartis, I remember, thinking about Gilenya-for instance; in some European countries, Gilenya is given to only a certain number of patients. So once you’re that far in the year and the full allotment of Gilenya has been used, nobody else gets started on it at that time. It’s just a concept that’s foreign to somebody in the US. And yet, that’s how they keep down the cost. So it is a question of how do we balance access vs costs? Where and how do we spend the money? what do we focus on? Obviously that’s why Biopharma comes into this because now we’ve got Gene therapies, things that are tremendously expensive. However, yeah, you’re talking about spending a million dollars on a baby, who’s going to have a whole life? Yet, we’re spending lots of money on end of life care. Why do we do that?
T&T: You are absolutely right; and so far it has been gene therapies for rare diseases but what happens when we get a gene therapy, that lets say cures babies of ever getting diabetes? How do we price that, right?
BG: Exactly! How do we even grapple with that? So now it’s rare diseases, and therefore, the insurers know, it’s a small number of patients and overall will not greatly impact their budgets. The impact to the patient is likely transformative which then justifies a high price. Now, what a company gets reimbursed is also a different topic. What if the CRISPR technology really pays off some way and you can and treat very common diseases. How do we determine the value to society and how do we pay for it and how do we provide widespread access across many countries?
T&T: If you are asked to bet on something about healthcare in future, what will that be?
BG: I would bet that we’re going to have more of this technology that we’re going to be able to impact people’s DNA and RNA in some way that we’ve never been able to, I am not sure about the time horizon but that will surely happen.
T&T: and conversely, is there something that you would bet against?
BG: This other thing that you brought up in your questions that I know will impact healthcare is artificial intelligence. I just am not sure of the timeframe and ultimate impact. I don’t ever see AI being used completely independently — the programming comes from humans and there will always need to be some kind of quality check. So you’re never going to get rid of all of those roles. I mean my husband and I have an Amazon Echo . We talk to Alexa on a regular basis. Alexa is really good at some basic responses. I know it will get better and better and it’s amazing how good it is already frankly, but you still are going to have to have folks that give input into the prgrams and systems. That is always the worry in Pharma that computers will be able to review data — certainly there will be more use of AI — but we won’t replace the workforce in clinical anytime soon!
T&T: Do you have a favorite grudge in healthcare?
BG: This is related to our earlier discussion about disparities in healthcare. There are other practitioners — such as chiropractors — not to pick on them specifically who also provide medical care. I had a patient with epilepsy whose mother was also treated by a practitioner. The evaluation consisted of taking the child’s temperature on the front and back of the head — and then offering therapy based on the findings. I found this a bit concerning that the mother was drawn to that kind of care but she obviously got something from that caretaker that western medicine and me as a doctor could not provide. What I really take away from this, apart from the obvious lack of literature and evidence for such practices, is how much important empathetic listening can help in such scenarios and how if you have a difficult medical problem the healthcare system in the US is not structured to give you all of the attention, time and emotional support that you might need.
T&T: Betsy, it has been wonderful catching up with you! Thank you so much for your time and sharing your thoughts, I have learnt so much from this discussion!
