How a Brain Surgeon Became an Inventor of Life-Saving Neurosurgery Technologies
(upbeat music) Welcome to "PeopleForce Podcast" by TriNet. I'm your host, Michael Mendenhall. TriNet is a full service HR solutions company committed to empowering small to medium-size businesses by supporting their growth and enabling their people. We work with amazing small to medium-size businesses and I'm so excited to bring their voices to life right here.
You can catch new episodes of "PeopleForce Podcast" every month on Apple, Spotify, YouTube and rise.trinet.com. Today I have the pleasure of introducing Dr. John Adler, CEO and founder of Zap Surgical Systems. Dr. Adler is a pioneer and world-renowned inventor
of the CyberKnife and the related field of image-guided therapeutic radiation. While creating the CyberKnife, Dr. Adler founded Accuray in 1992 to commercialize this invention. Up until 2009, he served in varying roles at Accuray, including CEO, chief medical officer and chairman. To date, Accuray technology has been used to treat more than tens of thousands of patients.
And the most modern radiation equipment now incorporates Dr. Adler's basic idea of image-guided targeting. Since 2015, he has served as the founder and CEO of Zap Surgical Systems.
Dr. Adler's use of technology-based treatment for neurosurgery is paving the way for the future of brain surgery. Dr. Adler has served on the faculty at Stanford University for over 35 years, being appointed the Dorothy and TK Chan Professor of Neurosurgery and Radiation Oncology in 2007. He's the author and or co-author of more than 300 peer-reviewed articles and book chapters. He served or has served on editorial boards of eight different peer reviewed journals.
In 2009, Dr. Adler founded the Cureus Journal of Medicine, which today is one of the largest medical journals in the world. Dr. Adler is also named an inventor on 20 patents. In 2002, Dr. Adler founded the CyberKnife Society
later in 2012 renamed Radiosurgery Society. He also served or has served on the scientific advisory boards of seven different medical device or pharmaceutical companies. Thank you, Dr. John Adler for being with us today.
We're so excited to have you here. So many new developments in this space, so welcome. Thank you, Michael.
You know, so many people want to understand how you wound up getting into a profession. When did that start? Why? And then we'll, we'll sort of progress through. So when did you know you wanted to get into the medical profession? Not too well into college. I hadn't given that much thought about what my life work would be. But it was interesting times in the early '70s and there was a lot of unemployment. And a lot of young people today have no idea what it was like to come outta college and not be able to get a job.
And I don't think I was worried about being employed, but I was mindful that the economy, it was a different time. And having spent a lot of money in an expensive education in Harvard, I wanted to make sure I was employed at the end of it. And I was just kind of a middle-class kid, and I love science. And the right, the small town I grew up in, the most respected guy in the town was the doctor.
So that was the full extent of the world I had lived in up to that point in time. And so, I kinda stumbled into medicine in some ways and that has just been the ladder that's pulled me along for the last 40 years of my life. Well, certainly you're inquisitive and we're gonna get to some of that. Did you specialize right away or as you got into the profession in undergrad? 'Cause you did both, I think undergrad and your medical degree at Harvard.
Did you know you were gonna get into neurosurgery and radiology? Oh no, I had no idea. Again, I said the only doctor I knew in life was a small-town general practice doctor in a, it's literally a town of a couple thousand people. So that was the full extent of what I knew about medicine unlike most people go to medical school, they're pretty sophisticated. A lot of times their parents are physicians. They know what you're getting into. I really had no idea. So again, it was just seemed like, I was a dumb kid.
Seemed like the right thing to do with a kid who liked science, especially biochemistry. Well, talk to me then when you began to specialize. So what part in your career did you decide you were gonna move in this direction where you are today? Well, now almost anybody's a doctor can tell you that in the middle of medical school there's this moment of self reckoning, and everyone has, they, you look in a mirror and you say, "Am I a surgeon or I am not, am I an internist?" And that's kind of the great dividing line of the medical community. And it is clear that my personality, by instinct, I'm a surgeon. Most people think of it's in your hands.
And there's an element of that you, you know. You can't be totally ham-handed. But most of it is, do you have an instinct for action and are you kind of, instinct for masochism because the hours are much longer in surgery. And then can you really handle the stress, and you don't even fully realize that till you're well into your career. And so I knew right, pretty well, midway through my medical school training that I was a surgical temperament, and there wasn't really, wasn't much doubt about it.
And I gravitated towards the surgeons that I had worked with and ran as fast as I could away from the world of internal medicine, despite my utter respect for the people in the field, including my own brother, so, and daughter. Oh, wow. So, as you got into this field, you wound up after some time going back to becoming a professor at Stanford, certainly in this field. What led you to move from what was probably real-time surgery, which you probably still may be doing to teaching and professing? Well, you need a job. So, so I you know, there's, you know, the neurosurgical training process is long and arduous and most of your listeners may be horrified to realize is, it's literally 15 years. So from the moment you first step foot in college to the time you're prepared to be a licensed neurosurgeon, it's 15 years.
And even then, there's a couple more years after that before you're, what we call board certified. So it's a very, very long process. And you know, when I get done after 15 years of training, especially a guy that had a couple kids, you know, you need a job and you gotta get paid. And there is a, again, another major decision point in every physician's career.
I mean, what are you gonna do with yourself as a doctor? And, I had options to go to a large community hospital and operate in those large community hospitals, and just be a practicing neurosurgeon, something that I have a lot of respect for. But I had some big dreams around inventing what I hope would become the future of neurosurgery, and I still believe today the future of all surgery. And those dreams were just too big to pass up. And although I would've made a lot more money right out, certainly out of the gate, going to becoming a regular neurosurgeon, regular just a community practicing neurosurgeon.
I chose the, what we call the academic route, and then the academic route, you have to find the right medical school. And I was very fortunate to end up at Stanford because I'd known my life would've probably turned out very differently if not for Stanford University. Well, so well first, you have changed many lives and you certainly have innovated and we're gonna get to that. So it certainly seems like, you know, a wonderful path in that you really have, you know, changed this world and in a very positive way.
And I think what's so interesting is when you think about Stanford University and how they cross-pollinate the different sort of academia within the university. So what I mean by that is you sort of have the medical profession but you have engineering. You have all of these different industries where people are excelling and they cross-fertilize the information.
And I think you started down that path because you worked with the engineering team in developing some of these new technologies. Is that correct? Oh, absolutely right. And that's kind of why I said Stanford was so special in my professional career. I think it would've been hard to do a lot of what I'd done in the past, in almost any other medical school and any university.
And it, but I also have to give a shout out to Silicon Valley as well. Which is of course, you know, the genesis of which was Stanford, but now it's its own little world in addition because there's a lot of technologies and engineering talent and practical talent. You know, I mean universities are very good at thinking big ideas and writing papers about it, but it's a very big step between going from that to a real world invention that impacts patients lives. And there's a lot of that latter capacity here at Silicon Valley.
So I really have relied on both of those throughout my career. And in doing that, like many small businesses, many of who hope will watch or listen to this podcast, you know, are in the same position you are. Where they have big ideas that'll have great social impact, but they can't find funding, or they're told it's too expensive, we're not sure this will scale. So there's a lot of doubt that surrounds some of that.
Talk to us about your process of pitching your first sort of big idea, the CyberKnife, and trying to get people to buy in. Because I think, and I believe historically you had to rely on friends to help you fund the first iteration of this. Is that true? It's very true. And of course I have only my story to report and there are people who have had a much easier path than myself. But um, I faced a lifetime of having most funding sources say no.
And I don't mean just no once, but no hundreds if not thousands of times. And it's so, these are, you know you have to just have kind of a thick skin and yet be really kinda committed to your cause. I sometimes wonder if I need a sanity check to do what I've chosen to do, because you just, it's very discouraging to repeatedly hear no. And I know every now and then I hear some, you know, young startup person talk to me about how they've been rejected a few times, and I almost have to kinda laugh it off.
I mean, it is elemental to the entire life of startup life, especially if you're trying to do something important. Now, you know, there's a big trend right now, maybe now the trend is AI, I'm not gonna speak with confidence in that way. But, you can jump onto that trend and you can then get funding much more readily than if you're trying to, you know, ply waters that have, are not well understood by the venture capital community.
It's, and they're very skeptical. The venture capital community is very herd mentality. You know, a few years ago it was fintech, then there was food delivery services. It's not just one, there's a whole herd of companies that move in that direction.
But if you're doing important work, chances are you're not part of the herd. And that means people don't understand you, you're gonna be rejected a lot, and I was rejected a lot. In fact, I was universally rejected.
It was you know, none of the big name venture capitals here in Silicon Valley, including the Health Care Group which was quite robust at that time, really would give me the time of day. They heard my story and said, thank you, we're not interested. And so I did, you know, one of the good things about neurosurgeons is they're well paid. And so neurosurgeons in the world were my friends, were the foundation by which I put together the initial seed money to start the company. And it was kind of audacious, maybe crazy, could have easily failed, but by luck or by skill or whatever it worked. And you're referencing Accuray, you're referencing Accuray.
I'm starting by it, very much talking about Accuray, yes. So I wanna do one step back and I want them to understand this idea of the Gamma Knife, why and when you went abroad, and what you learned, and how you wanted to improve healthcare relative to this radiation therapy and the imaging around that. And making it a lot more precise in what it delivers. Can you talk us through that piece of your career? Sure.
Well, again, there was a lot of serendipity here and at one point in my neurosurgery training, I needed to spend a year someplace and I learned something new. And mostly by serendipity, by coincidence, I chose to go to a place called the Karolinska Institute in Stockholm, Sweden. It's where they actually give out the Nobel Prizes so where it's, that's why it's most famous for. But there was a neurosurgery department there that I didn't know that much about. And I had two kids and I wanted to live in a place where my kids could be supported, you know, and thought it might be an interesting place to spend a year. And it wasn't, again, not much thought given to it.
Yeah, there's no surfing there though. No, there was no surfing and it was cold as hell. But I went there expecting to become a better technical surgeon in the operating room, and I quickly fell in love with this idea of radiosurgery.
The founder of, creator of which is a guy named, professor there named Lars Leksell, which I had known nothing about beforehand. And it, the idea of the, his creation, the Gamma Knife was that if you could focus enough tiny little beams of radiation on a target very precisely, you could kill that target and spare all the intervening normal tissue. And I liken this concept of radiosurgery to a magnifying glass. Sunlight is not so powerful by itself, but if you put a magnifying glass and just pass that between the sunlight and a point in space, you can concentrate the energy and you can start fires or do you know, it's a potent energy. And so, he figured out the same way to do that with regular kind of penetrating radiation, like the radiation they use in radiotherapy or the radiation they use to get in your dental X-rays.
And so it was a transformative idea and it has in fact totally changed the practice of neurosurgery over the last 35 years. And when I saw that I wanted in. You know, I'd come from Harvard and I actually specifically, I'd been a resident at Mass General Hospital. And we referred the Mass General hospital as MGH and the euphemism is its "man's greatest hospital." But I bought into the, you know, I drank the Kool-Aid and I thought I knew everything. And then I suddenly went to Sweden and I realized I knew nothing.
The future of medicine was not what I'd been taught, but what I was witnessing at the Karolinska Institute. And patients that would spend sometimes weeks in the hospital, were being treated as regular, almost outpatients in Sweden. And so I bought in, I fell in love, but I was also kind of a restless soul as I always have been, and realized that as great as it was, maybe radiosurgery could be better, because the invention of the Gamma Knife required literally a frame screwed into the patient's skull. And it was a vise, so basically a vise for the cranium. And I wanted to see if we couldn't do this without that vise, what we call image-guided radiation.
And that was kind of my invention to the world, image-guided radiation, tracking very precisely inside human body without frames attached to the skeleton. Wow, but, and you've done amazing work here because you've developed that into the CyberKnife, and tens of thousands of patients have used your technology. - Millions, millions. millions.
Probably millions, millions and lifesaving. And you know, I have to tell you, being here in New York City, they actually promote your product. NYC Langone uses it to promote their hospital.
And so it is that prolific and you've done amazing things, but you haven't stopped there, which I think is fascinating. You're now moving, moving that needle even further. And I want you really to talk about now what you're doing today and the difference that's going to make? Well, CyberKnife proved an important tool in taking this precision radiation beyond what the Gamma Knife did in the brain. And the CyberKnife because of the general nature of its targeting, could actually treat a tumor anywhere in the body. And it seemed like an amazing concept from my humble way of looking at it. But it was, and it has been very impactful in medicine.
It's changed a lot. But I came to realize that nine out of 10 of the patients who would benefit from this type of treatment are not getting it today. It's probably worse than that. It's probably 95 out of 100 patients who would benefit, do not get this procedure. - Wow. Now maybe in America it's only one in three or one in four, not getting, but around the world, most patients are not getting it. And I've kinda given my life and sweat and toil to this field and yet had not had as much a benefit as I dreamed. And so I kind of gave myself a, my life, a checkup, you know, probably about 15 years ago.
And as proud as I was at what I had accomplished, I was dismayed I hadn't done more. And so I had to kind of try to analyze what I had done and why it wasn't it more successful. And it's not because of the technology, per se, the technology's very powerful.
It has more to do with all the things that are visible to many patients, they're visible to even what's the word in many people in the industry is what motivates doctors to treat with a procedure and not treat with it, what motivates a hospital to buy something. And unfortunately, it's not about outcomes. It's not about necessarily saving patients' lives, unfortunately it's too often it's about money, money and control.
And, yeah it's a sad. - Well, I was gonna in... - Go ahead. - Yeah, I was gonna interject there because I was gonna say, do the carriers, you know, the healthcare carriers that carry the insurance, do they push back on this type of technology due to cost? Do they say, no, it's not necessary, we're not gonna approve this procedure? Oh, I could go on for days about off this issue and I don't wanna bore you or get sidetracked, but yes, they do. - Yeah, sorry. They do, but ironically, this particular procedure is relatively inexpensive among all the different procedures in medicine.
This procedure does not take a lot, in fact, that's the biggest problem. The biggest problem is it doesn't pay the hospital as much money as other procedures, and the hospitals and doctors often wanna maximize their revenue by building more expensive procedures. As you know, some of these cancer drugs can be literally over $100,000, $200,000 a year.
And this procedure is $10,000, $15,000. So it's really in the noise. And that's one of the reason developing countries love it. - So it's scalable. So it's scalable for sure. - Oh, utterly scalable
but there's an impediment upfront. It costs millions of dollars to get started. And so, what I try to do with my newest companies is try to break down that barrier to the initial development of a facility so that you could treat patients in the first place. So here you are developing new science and new technology around the practice in medical, and yet you're running companies. I mean, your company, your first company is now public, it's doing quite well. You have another company that's a startup that you're involved with where you're the actual CEO, you're actually managing the company, managing the innovation.
Talk to me about how you balance all of that and one, where do you find people that buy into the idea, 'cause you have to buy into the mission of your company and what it's doing, and is it difficult to find those people? Yes, for the record, I was CEO of Accuray for three years as well, so I did manage the business there for a while. But, you know, companies go through this evolution and at the most embryonic phase, the first half dozen employees, it's a very different type of employee than what you hire six years or eight years later. It has enormous risk upfront. And it takes a specifically intrepid individual who often get very bored inside big organizations, who are willing to take the risk. I mean, very few employees are willing to take the risk at that earliest stage. And I think the good thing about Silicon Valley is we have a few more of those people to kinda get the business jump started.
But that same sort of employee who's very good at getting things started, generally they're, they like a minimum of process and they just wanna go fast, and God bless 'em, I love that. But after a few years, you've gotta have, and you're starting to build a scalable business, you need a little bit more process. And of course, I'm in a heavily regulated industry, you know, medical devices for good reasons are carefully watched over by the FDA and others.
So you have to pivot from employees who are just all risk, let's go fast, to employees who hopefully are still imaginative, still innovate, still passionate, but are are more process, more tolerant of process. And then that's kind of what's happened to Zap. You know, the business has grown.
It's, those crazy entrepreneurial intrepid spirits have often moved on to other companies where they can be crazy entrepreneurial spirits, and a new group of more solid, grounded, deliberate employees have taken over. Hopefully everybody's bright, but just with a, a different kind of focus in their work. Have you had to pivot, so have you had to pivot in how you manage and how you lead through that transition? Well, I have and I'm just, you know, I'm still learning and I think you've always gotta learn in life. And it's very painful to lose. I always take it personally when I lose an employee, you know, whether, even if I'm the one who's initiating the change.
But I've matured to the point now that this is a necessary cycle in the evolution of a business. And as much as I may miss or not miss an employee, I too have to adapt. And in fact, I have to embrace processes myself that the disciplines that I need, know are needed to grow a scalable business. Yeah, we see so many of these small to medium-size businesses look at sort of the benefit structures that you offer becoming more and more important.
What's interesting is we're we're now seeing that with the younger generations, the millennials and even some of the Gen Xers, are now paying closer attention to the benefits you offer. We're seeing people make decisions based on that. Have you seen that and how important is that in your industry? Oh, it's all important. I mean, your job pays you a salary and you can't live without it, but you also can't live without the benefits. And I mean, of course healthcare is the single most important element of where our employees look at benefits. But retirement benefits and the even the smaller transportation benefits, just, there's a whole range of things that, that influence employee decision-making, and especially in our, you know, ultimately competitive environment like Silicon Valley.
And I don't want, and I need real talent, I need people who can think on their feet, not afraid to show initiative. I need the people who are most coveted by any company, and yet I can't always necessarily pay them Google or Apple salaries. But the combination of paying 'em a competitive salary and a stellar lineup of benefits does the trick given the fact that we do, we are innovating and changing the world, which is of course key to most of my engineer's decision-making.
Well, that, that's what I was gonna say, the mission and the culture you build is what becomes addictive for some of these employees, because you are changing the world, you are saving lives. You know, your mission is critical and it's great to see at least the CyberKnife scaling. And I wanna ask you, you know, what are we gonna see coming from Zap? Like what are we going to witness, you know, in the next five years? Well, nothing less than world domination, Michael.
So. - It's awesome. (laughs) That's what, if any entrepreneur doesn't believe that they should probably step aside and let the next guy take over. So, you know, we're growing business and we've got 13 of our machines installed around the world, and we got another 30 plus, you know, just waiting to be shipped and more orders coming in all the time and the technology's improving and getting faster and we're ever more precise.
So we're doing what a medical technology company should be doing and growing revenues, and this two or three years we expect to be profitable and you know, ultimately have some sort of liquidity event. So all the good things from a business side, but there is in the background an emerging mission that's coming out of what we're doing. And that's the growing understanding, much of it coming out of the research that our company is driving, that shows that radiation can be used not just to kill tumors but it can be used to alter the activity of pathological circuits in the brain. What do you mean by a pathological circuit? I mean, the pathological circuits that cause like brain drug addiction, pathological circuits that cause you know, depression, obsessive compulsive disease and even something like obesity. So the biggest problems in the world today, biggest medical problems are not cancer and heart disease, they are the behavioral diseases that just plague us, plague humanity. And if you don't believe that, just wander the streets of many of these big urban centers and just see how many people are destitute because of living sad, sad lives because of their psychiatric disorders.
So we think that there's this precision radiation can change like a long-acting drug in a very specific area of the brain, the activity of the entire brain and reverse many of these disorders. And this could be an auto revolution in the way we treat psychiatric disease. Well that's, that's fantastic. Is that something that you're researching now? We have been researching in animal models for the last five, six years, and we are gonna start a clinical trial in this coming year. Oh, that's fantastic.
Again, just amazing work coming from your company. I want to pivot a little bit because, you know, in your genes, I think through your family members, they have this same inquisitive sort of knowledge base, big idea, bold ideas. And your has son started a company Scribd. And it really had to do with the fact that you've co-authored and authored over 300 different types of journals, articles, and it was difficult to get them all published in a timely manner. And he then came up with this idea.
Can you talk to us about that because it's become a very successful, you know, entrepreneurial startup? Yeah, my son Trip has done well. So when he was finishing up college also at Harvard, he need to figure out what to do in life. And I can tell you that working for big other big companies, he did not enjoy or thrive in. And so he wanted to do a startup and he and his co-founder were looking around for some problem to solve. And I asked him, I invited him to try to solve what I was a problem for me was the medical journals challenge, how to make it easier to, and less costly, more efficient. And he was then just finishing college and he looked at the medical journal world and realized it was just much too complex, and too much of a grownup problem at the time.
But he quickly pivoted to just letting anyone publish anything on a website that became Scribd and grew very quickly. And then of course it became even more sophisticated and that is now more like a, he would describe as a Netflix for books. So, you know, almost all the books of the world can now be read on his site for a low monthly fee of, I think it's $10. I don't wanna sell for him. But the point is it's, yeah, he's had this (indistinct). - (laughs) This is so awesome. I sound like a TV infomercial, but so, yeah.
No, no, well, I had to bring that up because it runs in the family. Hey, I have no piece of his business, so it's all good and I'm glad to see it be so successful. And not only that, but my son-in-law, who's in, who's a medical oncologist at Johns Hopkins, he's just started a new pharma company here a couple months ago. So yeah, startups are in the blood.
No, that, that's fantastic. But the work you're doing is so important. I really look forward to hearing about what happens with your clinical trial relative to the behavioral, addressing the behavioral issues relative to the brain. I think that's, you know, very important certainly as you said, as you walk around even here in New York City, you see the issues.
But everything you've done is really saving lives. You're making such a massive difference to society. We see so much sort of negative news and, you know, depressing news. And it's so important, I think for us to share your story and the story of your company that really truly is positive, is making a difference. Small businesses do this. They are under-recognized and hopefully, you know, through what we're doing here at TriNet, we're gonna bring some life to that and share the stories that are positive and that are important.
And you know, John, it's so important to hear your story and your company's stories, so I wanna thank you for joining us. Thank you, and thank you for TriNet for all you do for small business, we need your help. I want to remind everybody that our podcast the "PeopleForce Podcast" by TriNet is committed to helping small to medium-size businesses and their leaders with timely and relevant business content. The "PeopleForce Podcast" drops new episodes every month, and we hope you continue catching our new episodes on Apple, Spotify, YouTube and on rise.trinet.com. To get relevant SMB news and info, make sure you subscribe to our podcast and to our newsletter at trinet.com/insights. Again, TriNet, T-R-I-N-E-T.com/insights.