June 12, 2020


Josh Clemente [00:00] All right. So are we recording? Yeah, we are recording. Cool. So, welcome to June 12th. Today I am grateful for friendship. I had some, you may know, I had a really good friend in town past few days, who I used to work with and who I used to live with in LA. And we just had like some really awesome conversations over dinner and such. And it’s just great to have really great friends and to reconnect with them when crazy things happen like the past few months. So, I’ve just been really enjoying, yeah, appreciating those friendships, and not taking them for granted, and hopefully seeing these people in my life more often in the next few months. Here we go. So, recent achievements, I just want to, like, high-level just kind of highlight what’s on the screen here visually. I had to down select just a few examples, but the enthusiasm that we’re seeing on social channels is just absolutely amazing. I, week after week, am stunned by it. And this past week, we saw a few beta users in particular who went out of their way to produce, basically advertisements for why Levels is doing what we’re doing, and why it’s so powerful. I highlighted the, in the middle there, David Lee who’s, you know, definitely a rock star user who, you know, showed this habit loop for how specifically Levels features like the metabolic score, effect change and like, trigger reward pathways for people to help them make better choices throughout the day. And he had a whole Twitter thread in there. It’s definitely worth reading if you get a chance. But it’s amazing to see that. It’s amazing to see Derek Morris up there, like putting us on the same list as Aura, Calm, Zero Fasting and Eight Sleep, you know, saying these are the mechanisms that you should use to get control, it’s the bicycle for the mind and your body, basically like a paradigm shift. You went from walking to being able to move quite quickly between, between points. So that’s awesome. And then on the bottom, right, we’ve got, a screenshot from Dave Asprey’s account. He did a podcast episode with Dr. Molly Maloof, who’s amazing. And she’s like functional medicine doctor in this space, and she’s extremely knowledgeable about CGM. She’s worked with it for a long time. And, so that podcast is really good. Definitely check that out. And then she shot a shout at us out in the comments, which is just huge. I mean, it’s great to have people, who are honestly at the forefront of the space recognizing Levels for what we’re doing, what we’re trying to accomplish. So yeah, I just wanted to shout those out. Also a quote down the bottom left saying, you know, I’ve been following Levels for a few weeks now, given the crowd writing about your product, I assume you won’t have any trouble raising, but I still love to invest. But, just, you know, people are following along and they just, it continues to ramp up and ratchet up week after week. I feel like just amazing. So anyways, in terms of both sides of the lists, we’ve got monthly reports are rolling out, or have been launched. Absolutely amazing work to the whole team on all the backend work that has to happen to make the data, you know, sort of sync nicely with a, a structured report. And then just the beautiful design and effort that, you know, David and Jeff and Sam and everyone who’s worked on this all together. It’s really amazing. I saw a few examples of actual reports for customers, and this is key because it documents the way that Levels helps people improve. And so we can see the trend line, in each of these metrics that we track in the report. So this deliverable, I think, is going to be a real closure mechanism. It’s going to show people, this is the summation of everything you did over the past month, and it’s going to tie a bow on the experience and that’s super clutch, yeah. Awesome work, everybody. Weight loss challenge launched this week. We’re on day one or yeah, yesterday was day one of the payout rules. So people are now like controlling their glucose levels in order to unlock payments and in order to, ideally lose weight. So that’s going to be a good thing to follow. The Fitheads podcasts, Alex Spagnola released this week. I thought it was really good, you know. I had a great time talking with them, and it was a nice light-hearted conversation. It didn’t get super complicated, I think in terms of the technical speak. So, pretty approachable. In top right on the screen, you can see we launched version one of our help center. So this is support.levelshealth.com. There’s going to be a resource center, like a self-help opportunity for customers to answer their own questions without having to wait for a synchronous response. And, I think it’s going to be a really nice resource, a way for us to be able to share, you know, reusable notes with people, rather than typing out a response each time. It’ll give us faster turnaround times. And then, some huge progress. Thanks to everybody for working on these big operational efforts. These big projects are going to unlock growth opportunity for us. So the Truepill EHR moving away from G Suite for our consultations, getting integrated with Zendesk, across all of our operational capacity that needs customer interaction, and then getting retool stood up. And then our LevelsHealth.com/Start website, which is going to guide people through getting started. So right now we’re using email. The future is this Getting Started page. You know, we haven’t launched these things yet, but we’re getting very close and, there’s been a lot of work to get to this point. And then there’s been a big push from, you know, the whole team on defining scaling strategy. So we have a ton of appetite for our product. There’s a lot of people that are, that really want to get into the beta. We’re operationally limited right now, but it’s not just operations, you know, when it comes to scaling, we also have to consider how we’re going to grow and maintain our channels. So that has implications for our media outreach, ops and engineering of course. I mean, they’re just make sure that the whole company is structured so that we can grow, and grow sustainably. So we spend a lot of time talking about that. We’ll continue to do so, and this will end up leading to pre-orders and ultimately launch. And I just wanted to highlight June is our biggest month by well, over a hundred percent. So we have, due to the changes we made to the onboarding process and getting public TestFlight links and, you know, some changes to the app, such that we can really move this to an asynchronous process. We were able to onboard over a hundred people in just a week, at the beginning of the month or towards the end of May. So that seems to have gone really, really well. And, it’s a great signal that we can continue to improve these processes so that the customer can have a smooth, elegant experience getting started. Any questions on any of this. We’re also approaching 15,000 waitlist signups, which is really cool. That’s obviously the curve looks like it drops off, but keep in mind, we’re only part way into June. So a lot of this is the same as last week, but the primary goals right now, as I just touched on, in terms of scaling, we have to build market share, mind share. You know, we need to be the dominant force in the space. And we’re seeing signals that we are that, but we have to really lean in and not rest on our laurels. So expanding brand presentation and exposure is the way that we can maintain growth. Rolling out pre-orders will give us an opportunity to grow without necessarily delivering on the products right away. So it will give us an opportunity to get that demand into the pipeline. And then, you know, we can have a much better understanding of the underlying unit economics and the volume that we’re looking at and conversion rates and things like this. So that’s huge. And then getting launch ready. So this means an app feature set and experience design that is ready for a larger, a more mass market. Right. So moving out of beta mode, and getting ourselves thinking like, what is the user demand, if they are not purchasing a beta product. It’s going to be a different mindset and a different expectation set. And then, you know, of course launching this year in securing an extra hardware partnership, we’re going to keep banging this drum. This is something that we definitely need. The current two app product is going to be significantly improved with direct data integration. So we have to get there. We will get there. Any questions there. Cool. So weekly beta trends, we had 47 signups this week, 12 consultation approvals, 18 asynchronous, onboarding invites. And you’ll notice that’s a huge dip from last week, which was about 10 times larger. And the reason for that is that, we front loaded all of our June slots. We fulfilled everyone at, towards the end of May and beginning of June, who was going to go through our program in June. And now we’re kind of in a holding pattern until July. In July, we’re going to work on amortizing people so that we won’t have that huge spike at the beginning and then a taper. We’re going to actually spread people out through July, is how we’re going to try and do it. So, and then 12 onboardings and 19 people finished the program. Yeah. Sam.

Sam Corcos [08:41] Yeah, we have. 591,000 in cash, which is actually more than we had last week. We’ve had a couple of our angels come in and put in some more money, some new ones. Delly, who’s a basketball player for the Cleveland Cavaliers and a couple of other founder friends of mine putting some cash. So we’re still in a really good shape. We have plenty to get us through the end of the year, and certainly enough to the larger raise we’re planning to do the summer. Also on the financial side, we’ve actually already hit our revenue targets for June. So we’re having a discussion later today on how we might scale it faster, and whether or not that’s something that we want to do. So we’re, these are all good problems to have, but it’s certainly looking up.

Josh Clemente [09:33] It is. Questions on finance and biz dev. Cool, Casey.

Casey Means [09:43] Awesome. I don’t know if I need to reload, but it may be helpful for some of the later sides. So, I’ll start with SEO stuff. So on the left, just continual slow progress on kind of getting to the top search, to top tier search rankings. Every single one went up, I think, except for, we went down like, just like one point in one of our terms. But otherwise we’re just like continuing to rise and in the top 10, for a lot of the terms we care about. We need to work on getting Levels in the top 10, but some of these other terms like Levels Health, Levels CGM, unlock Levels where we’re right at the top. So that’s great. The top, right. We’re looking at basically our trends over the last week, our average position continues to go up to, we’re 19 now, moving up from 20. It’s just been a slow progression up and up in terms of our average search position. So that’s great. Next slide. This is just, I think fun to kind of see every week of like, what are the most people clicking on each week? So weight loss continues to always lead by a long shot. And this has been pretty consistent over the last month. So weight loss, the ultimate guide to glucose levels and fueling peak athletic performance are our top performers. And people are still spending about an average of four and a half minutes on those top two posts, which is great.

Sam Corcos [11:16] Yeah, this is really interesting to me because the normal glucose levels post right now, the number five on there, it’s the most scientific and the least consumer-friendly of all of the posts that we have. It’s really written for researchers, it’s written for somebody like Molly Maloof, and yet it seems to be, people are really spending time reading it. It’s pretty interesting.

Casey Means [11:40] Yeah. I was happy to see her email to you, Sam, that she said she copied and pasted from it and said, this is exactly the range that I try and shoot for. So I think we hit, yeah. We’re we kind of hit close the nail on the head. So happy about that. okay. Next slide. Yeah, just the brief overview of the different cylinders were firing on in terms of content thought leadership. We’re doing high-level thought leadership, guest posts, podcasts, Instagram, influencer relationships, content, marketing, research, product partnerships, and press. And so all of those are firing. And then eventually, email newsletter and marketing. Next slide. In terms of the blog, we’ve had some really good posts this last week, so, can controlling my glucose levels give me more energy. A lot of people ask about energy and how to optimize their energy. So that’s up. We had the Alison Crook interview, go live this week, which I think is a really fantastic article that basically anyone interested in optimizing their diet or personalizing their diet. This one is just gold. Yeah, she just, she’s just an amazing advocate for Levels and super grateful for her support. There’s some really wonderful app feature, shout outs in there of how she used the various app features to basically really accelerate her progress. So really exciting stuff. Meal comparison, especially, and then our testimonial from Tony Castillo. So really starting to open the doors, that testimonial interview front. And we’ve got two interviews that are completely done and staged, and just waiting for approval from Alex Herzlin and Samyak. They are also just like funny, and I’m really excited. I think they’re going to really like illustrate the power of the product for people coming to our blog. Next slide. We also had some interesting feedback on Twitter about our PCOS blog posts. I was really happy about, we posted that article, the PCOS and CGM, and got these sort of like organic shout outs from PCOSresearch.org. And then we were featured on the PCOS sister daily newsletter, today. And so yeah, people are finding it, seeing it. It’s great. We also now have a little. There’s this blog, Healthy Body Blog, which has also a Twitter account with 20,000 followers. And, I had chatted with their head of content, and they now have a section for Levels stuff on their site. And basically are just going to be posting canonical links to our site, kind of like once a week, just sort of putting a lot of our blog stuff out there. And every time he does that, he’s going to be doing a tweet about it. So, yeah. So that’s up this week. Next slide. A little bit of good press this week. So, we were featured in another top 10 lists. We were in the top 15 list last week. This is a top 10 list for 150 tech. So top 10 female tech leaders to watch with a link to Levels. We also, I did a short guest post for Entrepreneur Magazine this week, which should come out next week, which was about what it means to be a purpose-driven company. So that was an exciting opportunity. Next slide. Yeah. And then in the pipeline, we’ve just got a lot of great stuff coming down the road pretty soon. So like I said, we’ve got two interviews coming up, which should be live probably this weekend. If we can get approval from Samyak and Alex. We’ve got a thought leadership piece on optimizing mental performance during sports, by Colleen Gulick that’s going to be coming out. Lot of content marketing pieces, you can kind of see the pipeline on the right of all the sort of content marketing stuff we’re going to be getting out. Big podcast outreach push, thanks so much to Nick for helping us really organize that effort. And then our, what is metabolic fitness post version two, really appreciate the feedback on that this week, and that’ll hopefully be live in the next week or so. So that’s it for me.

Josh Clemente [15:38] Awesome. Yeah, a couple of the articles that came out in particular, the Alison Crook one, highly recommended if you haven’t read them. I think these sorts of examples of real people who have different, you know, different philosophies for maybe what you have, but you can understand immediately as you start to read their experiences, you start to understand specifically why this is a useful tool, as opposed to some of the more abstract concepts I think that are out there. So I’m looking forward to more or less testimonials. David. Product.

David Flinner [16:08] We launched the monthly report. Woohoh, it’s been a long time coming and this is one of the best things about the early beta. And as Josh said, it’s going to be the bow at the end, and it’s going to really help us anchor all of our conversations, and hopefully be a really valuable asset for customers. Yeah. Yeah. With the initial cohort, I generated 16 reports for customers yesterday. We saw a lot of improvement, some people who had no improvement, mixed results. I think we’re going to see a lot of different types of these reports. So I’ll have to pay attention to what people like, what’s useful and keep changing about, to provide more value. Next slide. Okay, so looking forward, just a couple other concepts, we’ve largely been focused on simplifying the signup process and providing the tangible deliverables with the weekly report, monthly report. I just wanted to give a quick sneak peek at a couple of concepts that are coming up and no determinant amount of time. But, as you know, the activity catalog is sort of like your in-app version of the monthly report. And right now you can sort it by, good to bad or bad to good. And, in talking to Casey and some of our team brainstorms, from the last quarter, we thought, what else could we do here? So, I put together some mocks, you can check out a link. I’ll add it to the slides afterwards, around how we might augment it to do searching and filtering and comparing. As you put more and more data into your catalog, it becomes harder to find exactly what you want. If you’re talking to someone who want to quickly find that special day you had, you might want to come in and search for it if you knew what you ate. So here you can come in and search for rice, narrow it down to everything you had and quickly tap it. Or you could, if you wanted to see how you do for rice across all different things, you could search for rice, filter down to scores containing only good scores, and then see your personal meal menu for options for dinner. Next slide. And something else we could do here in the future is provide a bit more interactive concepts. So if you come in, maybe we show you a card that, if you search for rice, shows you rice compared, like all the different times you’ve tried rice, or rice compared to something else. Because we know it’s an interesting comparison to like a big versus low spike. Or maybe you could tap to explore things related to that term. This is all very early, but just some stuff that I was conceptualizing, based on requests we’ve had so far with users, a lot of overlaps with the insight cards that’ll also be coming up. Next slide. And then probably our single most requested feature has been healthcare, Google Fit integration and within that exercise workout import. We’re still a ways off from that, but we had some progress the last week, mapping out what the different fields look like for Google Fit and Apple Health. What is the realm of things that we could be importing? It’s pretty broad. And so we had some thinking around, What data are we interested in and over time, what will be useful for us, both from like a research perspective, but more importantly, driving powerful life-changing insights that we can feed back to our users. So, we did a broad landscape overview, and then we’ll likely be starting sometime in the not too distant future on creating an exercise and important feature. But that’s just, where we’re at with that. Okay. Next slide. Yeah, that’s it.

Josh Clemente [19:48] These features are amazing. The activity catalog like version two is going to be one of my favorite. I’m sure. Andrew.

Andrew Connor [19:56] Cool. So, yeah, I think most of this is, as usual covered. I don’t know how much we dipped into the Wearables Challenge is live. That’s super exciting and, yeah, we’ll get a lot more interest. I think it’s a cool, this is a tangent of engineering stuff. It’s a cool opportunity for us to see how community involves or like interacts with Levels. And like how we might think like in the future about building communities that care about a certain thing. So, it’s really neat. So yeah, they’re kind of doing their own thing. They have their own little, like daily email that’s going to go out today, I guess soon, and stuff like that. One thing I’ll call out with Evan is he ran a ton of these complexity numbers. And just so you can see. So one of the goals of all of this is that this is a feature we can use, like a machine learning style feature, that we can use to very clearly convey like overall metabolic health and stuff to customers. And certain things need to be true. Like we need to like, our populations that needs to be a lot healthier than like type 1 diabetics. And so he’s been running a lot of these, almost like validation checks that like, is it structured the way we expect it to be? And you actually see this really nice distribution where, basically, you know, our entire population set almost is better than type one diabetics. And so, yeah, I continue to look inside of there, the biggest complexity with all of this, no pun intended, the biggest difficulty is that, gaps affect things quite a bit. And so we’re trying to come up with a way to handle gaps effectively. So that’s a neat thing that continues to be worked on. Besides that, I did have a good meeting with Truepill for the EMR. There is movement. And, there’s an update in Slack if you are interested. So that’s most of our stuff.

Josh Clemente [22:05] Awesome. All right. Individual contribution section. All right, Evan. Wanna kick us off?

Evan [22:14] Wow, I get to go first again. That’s great. So one of the things I’m really excited about is I’ve been using this note taking tool called Roam Research, and then the founder of Roam Research signed up to try Levels, a bunch of other people in their own research community. It’s kind of like a cult, Roam Cult, have signed up, to use Levels. And it’s just really exciting to see like the separate community I’m in, merging it with the Levels community. And it’s just like, you know, it’s as beautiful as watching two stars collide in the middle of the light. So I think it’s going to be really great, because these are people who spend a lot of time thinking about like how to best take notes, how to best think about things, and then to expand that focus and to how to be metabolically fit. It is just going to be some really good synergy. And I’m really looking forward to seeing what comes out of it.

Josh Clemente [23:06] Nice. I spent some time digging into what Roam Research is last night. And I like what I read. I also like the hate they trigger with their lack of onboarding, and that they’re standing strong on it.

Evan [23:20] Oh it’s great. Like, you figure it out as you go. My early notes are like ‘pet a dog today,’ and stuff like that as I just tried to figure out what to do. So I’ve like all the days I pet a dog or like tagged with dog.

Josh Clemente [23:37] Mike.

Mike [23:38] Yeah. I’m excited. I think a lot of it’s been said. For sure, the engagement on Twitter. it’s really, for lack of better words, just awesome to see. And, you know, the other thing that I’m really excited are the reports. Excited to get them sent out to our users. And, I think it’s a big thing that’s been missing. And then finally, excited about like the more public push, specifically with Casey and Josh, making a hard effort to get in and on podcasts. You know, I think we saw like a lot of great feedback and results, especially from the Go Work For Change podcast. It’s been really helpful for me when I’m communicating with users or even leads to send that, it’s really powerful. So excited about everything. And then personally, had a lot of fun in California. And I was in Malibu last weekend, and I definitely had some feelings about not wanting to leave, but I’m excited to get home. And who knows, maybe I’ll come back soon.

Josh Clemente [24:55] Nice. Yeah. I’ve been spending a huge portion of my time on ops things, operational things for the last few months. And, now, you know, with the increasing, well, just with the massive movement we’ve had with product and, you know, the successes, I think from everyone on the teams, pushing this thing into a position where people are already deriving amazing value from it, and we’re getting great net promoter scores. And, you know, it’s sort of, the signals are there that we can start to expand, right now, or move in that direction. And so pushing a little bit away from ops over the next few weeks and months, and into more of a yeah, exposure role, and trying to build awareness of Levels and get on podcasts, and have conversations with people. Thought leadership in the space already is really exciting. It’s not something that comes super naturally to me, but I do enjoy it when doing so. I really like talking about what we’re doing. I’m obviously super excited to bring more attention to what we’re doing. So that’ll be a big challenge over the coming weeks, months, and I’m looking forward to it. And also I’m just personally excited to have all the support, you know, in particular on the operation stuff, you know, having a team that, you know, I feel confident on hand, you know, like Nick and Mike and Lori who are pulling all the weight on the operational stuff, and can take over, and yeah, get us ready for the big launch when the time is right. So, yeah, it’s so cool to be talking about these things and to have these opportunities to go out there and have conversations with the brightest minds in the space, and be part of it. So I’m very excited for it. And personally, I’m just spending a lot of time thinking about what to do for the next, you know, sort of physical fitness challenge. Like the iron man, half iron man I was going to compete in was canceled from COVID. And I think there’s like signals that they’re going to start launching races again. And so anyway, I’ve sort of tapered off in my discipline last few weeks and it’s time to get back onto a new personal challenge too. So Mike, I’m going to need you to push me on that. Sam.

Sam Corcos [27:11] Yeah, I have too many things, but, the one that I check regularly. Actually jump quickly to the next slide. This is the one that  I keep paying attention to. In the last month, our organic search is up by more than 100%. Building out a functional SEO strategy is insanely hard. And Casey’s just been doing such an incredible job. Our domain authority keeps increasing, our blog posts keep getting referenced in places even without us knowing it. So I’m really excited about that. It seems to just definitely be working, and every person who reads them continues to give us incredibly positive feedback. We can go back to that last slide. I think also, I’m excited that there was a non-zero chance that when we onboarded a hundred people in a day, that everything would explode. I’m very excited that it didn’t. The new onboarding flow went super well. Mike and Josh really did a heavy lift, and made everything pretty smooth, which is pretty exciting to see. It really shows that our processes are getting a lot better. The last thing is, I started really digging into some of the research projects that Evan has been working on. And, the deeper I get into them, the more potential I see there as real value adds. I shared, like an overview document in Slack earlier today, in the I think general channel. And, there’s a lot of just fundamental value that we can bring, pushing the science forward in metabolic health that nobody else is doing. So, yeah, too many things to count, but those are the top three.

Josh Clemente [28:58] Awesome. Jhon.

Jhon [29:03] Yeah, if you remember the dog we rescued in January, a family from Bogota adopted her, just today. And we’re really happy about that. That opens up a spot for a new dog to be rescued in the next few weeks. I’m also excited about this book I got yesterday, it’s called, A Parent’s Guide To Intuitive Eating, How To Raise Kids Who Love To Eat Healthy from Dr. Yami Cazorla-Lancaster. So Casey posted it on Instagram and I went straight to Amazon and buy it. So let’s see if it responds to some questions about the way we are raising our kid regarding food.

Josh Clemente [30:02] Nice. Congrats on the adoption too. Casey.

Casey Means [30:10] Yeah, that’s awesome about that book, John. It’s really good. And, yeah, we talk a little bit about that stuff on the podcast, which will be coming out in a couple of weeks that I did with her. And she’s awesome. So I’m curious to hear how it goes with you and your son. So yeah, for me, man, super excited. I’m honestly so jazzed about these testimonials and interviews that we’re getting up on the blog. I spent some time this week, basically working through the Alison, the Samyak and the Alex Herzon one. And after reading all three of them, if you just read them together, plus Tony Castillo’s, it’s just like, oh my God, we’re making such an impact. Like it really made me feel like so warm and fuzzy about our work, because this is truly changing lives. Like all four of them, their lives are changed. And I don’t know. It’s so it’s so incredible. And so yeah, if you’re ever having a low day, I would just like go read through the testimonials because like it’s really positive. I also really was blown away by reading through that report, the example that I think David or someone sent out that was like the really, really good report of the improvement over time. Like also just seeing those numbers. This is the friend of Mike’s sister that. I forgot his name, but, like that’s better results than probably any doctor has ever achieved in terms of a patient’s improvement in glycaemic function. I can’t even imagine what a doctor would say about looking at that average glucose change in a month. And so I don’t know, just really, really bad ass. And then, yeah, personally, not too much going on this week. I do, I did take part in this thing on Wednesday night called Puzzled Pint, which is this like, I don’t know if anyone’s heard of it, but it’s just like international puzzling group, and they usually do it in person and you have to like figure out a puzzle to even find a location. But now it’s all on Zoom. And I have a friend who’s like in the leadership of this, and I joined this time. And it was so much fun to do puzzles. I never thought it was, I mean, these are like word puzzles, really complex sort of like code word stuff. And by the end of it, I was just like, oh, I’m a puzzling, like convert. And so I felt like a total nerd, but like, it was really fun, and I had judged it for years and now I like it. So, yeah, that’s it for me.

Josh Clemente [32:35] Awesome. Yeah. Plus one of the monthly report, like I, in fact seeing it with real data was way more inspiring than seeing the mock-ups that David put together. Just because like I kept checking, like, is this real data, or did David just make a theoretical one for improvement? Because each metric, all of which are different, you know, it is different. It’s possible to have a good average and yet still have like very crazy variability. So I’m seeing that each metric has improved, and like the metabolic fitness score tracks that shows that in a month report, and the quality of the meals is so obvious. Like you look at the low scoring meals and the high score meals, it’s like fast food on the low scoring meals. And the high quality, like whole foods meals are on the high side. And so just like seeing that the report demonstrating exactly how these features are each reinforcing the same positive behaviors, is amazing. And I was like, just grinning, like an idiot while I was reading it. So super exciting. Awesome. All right. So it’s Casey’s week for her personal share. Do you need me to pull anything up for you?

Casey Means [33:40] No, I have some slides, so I’ll try sharing my screen, although I’m probably going to, I might. Do you want me to just send you a link or what do you think is the best option?

Josh Clemente [33:50] Give it a shot. See if you can share your screen. I think it should work, otherwise you can send me a link.

Casey Means [33:57] Share screen. Let’s try desktop. Okay. Let’s see. I’m going to present. Can you guys see my screen now? Does it say otolaryngology?

Josh Clemente [34:21] Yep.

Casey Means [34:24] Cool. Okay. I thought I would just talk about a little bit about my time in ENT surgery and what otolaryngology is. It was five years of my life, actually more than that, because I was really involved in medical school. But, yeah, I don’t know if anyone has had a neck condition like sinusitis or your problems or ear infections or stuff like that, vocal cord things, hoarseness, chronic cough, anything like that. But, yeah, I just I’ll just go through, just let her like high levels and things from that time in my life, which led me to Levels. So, this is a picture of me, doing one of my first sort of like independent thyroid surgeries. I’m holding up basically a fat flap from the neck. Also. There’s a little bit of surgery photos in here. And so if you’re super squeamish, I might.

David Flinner [35:15] Too late for a trigger warning.

Casey Means [35:17] I’m sorry. I’m sorry. Next slide does have a little bit of like a surgical thing. But there’s no like huge amount of blood, so it’s very clean, but yeah, you might want to like close the screen if you’re super squeamish. So, I became totally enamored with the anatomy of the head and neck when I was a medical student, here’s some anatomic pictures. It is seriously, some of those beautiful anatomy in the body. There are 12 cranial nerves that arise from the brain through the brain stem. And basically they’re in yellow on this picture here. And like, they basically feed like all the functions of the face and the neck. Every muscle that moves, the way the carotid artery contracts, the way you blink and smile and all these things are controlled by these beautiful nerves that are just like under your skin, forming this crazy web. And something can go wrong with all of them. And there’s incredible vasculature about the carotid artery. The jugular vein, you’ve got all the nerves that control life functions, like breathing and heart rate that are running through the neck. So it’s just like this super high density area, of importance. And I just fell in love with it. Also the head and neck is like, the way that you interact with the world in a meaningful way. It’s all, it’s like most all your senses. It’s taste, smell, it’s sight, it’s hearing. And so I found as a medical student that, you know, with head and neck conditions, like you just become so intimate with your patients so fast, because like, you’re just talking about such important things like these really personal things. And you are just like up in their face, like within five minutes of meeting them, looking in their mouth and their ears, and you’re seeing parts of their body that they’ve never seen before, you know, visualizing their vocal chords, their ear drum or, you know, their sinuses. And all this can play, take place in the clinic without sedation. So it just was like, I just found it to be totally, I just got totally enamored in medical school, with kind of the magic of head and neck. And, yeah, I ended up doing my residency in that. So let’s see.

David Flinner [37:19] Can I ask a question on that real quick? How often when you open someone up, are they different from the diagram? Like, is it sometimes like, oh, this person doesn’t have that thing. That’s missing.

Casey Means [37:30] Yeah. That is such a good question. Oh my God. Yeah. Sometimes we call it spelunking because like, you have no idea what you’re going to get when you’re in there. People have really, sort of unusual anatomy sometimes. And a big part of surgery is that you do everything you can to lay out the landscape of the neck or the face before you get in there. You have a plan A, a plan B and a plan C. And that’s based on Imaging. So CT scans and MRIs, which like almost everyone gets before surgery, the physical exam, which any ENT is pretty invasive. We’re sticking cameras in the ear, cameras in the nose, cameras in the throat, all before surgery. So you have like a multi three-dimensional picture of where things are going to be. But then you don’t know what the tissue quality is going to be. So someone who is unhealthy, you know, like with metabolic syndrome, like their vasculature is going to be constricted and clogged. And so these tissues in their head and neck are going to have not gotten great blood flow potentially for decades. And the tissue is almost like scarred, and feels like it’s like scarred and thin and not healthy and robust. And so as you’re moving to the tissue, there could be a really important nerve. And if the tissue is just like not healthy, it makes it a lot more dangerous because you just, yeah, there’s a lot of tactile feedback that goes into it. But there’s definitely like a very anatomic game plan before going into surgery to try and have the best landscape possible. And at every step of the way, you’re basically talking with your co surgeons about like, what are we expecting to see right now? Like if we move this muscle, what do we expect based on the imaging to see behind there. So there’s a lot of that, but. You know, you don’t always get it right. And that’s when hemorrhage and bleeding and stuff like that happens. Or when you cut through a nerve and you have to reattach it and stuff like that. And it happens all the time. So head and neck surgery is, has three names. It’s head and neck surgery or ear, nose, and throat or otolaryngology. They all mean the exact same thing. It’s the specialty, that’s medical and surgical treatment of the head and neck. Excluding the eyes, which is ophthalmology, the spine, which is orthopedic surgery, and the brain, which is neurosurgery. So it’s everything from the clavicle up that doesn’t include those things, which kind of seems probably a little limited, but there’s a lot there. Within the field, there’s a bunch of sub specialties. So as a resident, you get trained at all of these things. You’re equipped to manage all these things, but you can do an extra year of fellowship to be a subspecialist in them. So there’s pediatrics, there’s otology, which is specifically your surgeons, allergy, facial plastic and reconstructive surgery, which is basically like car crash, someone smashes their entire face. You have to put all the bones back together. That’s reconstructive or there’s facial plastics was actually just like facelifts and brow lifts and things like that. There’s head and neck surgery, which is a subspecialty within head and neck surgery. And which makes no sense, but basically head and neck surgery is the term for cancer surgery of the head and neck. So laryngeal cancer, tongue cancer, sinus cancer, all sorts of skin cancers. There’s rhinology, which is specifically nose and sinus doctors within the ENT. And then there’s sleep medicine, which is basically doing all these surgeries that rearrange the jaw and the tongue so that you can breathe better at night. So one kind of cool surgery that we do is you actually take a bone saw, and you cut through the jaw on both sides and you just move it forward and plate it. And that brings the tongue forward. So at night it doesn’t collapse into the back of the throat and cause obstruction for sleep apnea. So it’s a very, very, very broad field. These are some common conditions that are treated. Some of, you may have had some of these in your lifetime things like, asthma, ranging from asthma to gastric reflux, to like full-blown gigantic tongue cancers, things from ear ringing, which is called tinnitus to deafness. We do cochlear implants. Trauma, like I mentioned, ton of nosebleeds, a lot of congenital malformations, like birth defects of the throat, kids coming out and not being able to breathe and having to reconstruct their airways. People have trouble nasal breathing, having to do deviated septum surgeries. So like the cartilage and the role of the nose, straightening it. A lot of cosmetic surgery lifting up, people’s eyebrows to look younger, you know, neck lifts, things like that. So, and then a ton of ear infections. People who have chronic ear infections get little ear tubes put in their ear drums, and that helps drain the pus and did about 500 of those in residency. Here’s just some photos of me doing some surgeries. On the left, there’s a, the nerve that controls voice got severed in this patient. So we’re doing some microsurgery to basically put that back together, doing a thyroid surgery on the right. Some common surgeries that we do this. So these are the top surgeries that I did as a resident. So the first is a tracheostomy tube. And it’s funny, like, I think of ENT is like being a plumber basically, because really it’s like, there’s blockages in the head and neck tubes, and you have to get around them. And so tracheotomy tube is like the biggest example of that. Like, it’s basically this plastic tube. If anyone has any reason they can’t breathe above this level, like swelling or a tumor or congenital issue. You basically just put a tube below it, into the trachea, and then they breathe through that. So did hundreds of those surgeries during residency, and you may see walk around town and see people with like a scarf or something around their neck, or see these little tubes and, and that’s what they are. So a lot of tracheotomy tubes for various airway issues, which were really fun surgeries. They take two seconds, and they changed people’s lives. Intubation, which is putting a breathing tube in, thyroid surgery for thyroid cancer and Hashimoto’s, which is an inflammatory condition of the thyroid. Lot of sinus surgery. Laryngeal cancer surgery, which is when the vocal cords get cancer. Tracheal dilations. So that’s when the airway scars, for some reason, like auto-immune disease and you can’t breathe, so you have to put a balloon in there and basically blow it up and like expand it. Tons of tonsillectomies, ear tubes. A lot of cochlear implants, which is for sensorineural deafness. And you basically put a little sensor here on the back of the skull, and then actually you’re stimulating the nerve, that is the cochlear nerve, which is in the inner ear, which goes straight to the brain. So it’s kind of a little bit of like minor brain surgery, and you’re directly putting an electrode to stimulate that nerve. And then a ton of facial trauma surgery and plating. I was on trauma call like every other week. And so any car accident in Portland where they injured their face, they come to us. This is a cochlear implant surgery. Spent a lot of time doing surgery under a microscope because of either such small spaces. Like we’re looking at millimeters here. So the way that microsurgery works is your patient is draped sterile. And then this whole microscope is sterile, with a bag over it basically. And then you’re just using really tiny, fine instruments to do the surgery under the microscope. And this here in the middle is a cochlear implant. And then this little thing that’s coming off, the cochlear implant is actually going to stick through the inner ear to stimulate the brain, to basically, it will pick up sound signals and then tell the brain, like stimulate the nerve directly. And then the person over time learns how to interpret that as sound. This is one, a pretty famous otologist and we actually got to put the first implant in for, a new generation of basically this type of implant. So this was a photo that we took to send to the company of the first one getting placed. One of the things that drew me to ENT is the fun toys. We had so many fun toys. Basically anything you could possibly put a camera in, we’d put it in. We did thyroid surgery with cameras. You can stick a camera in the nose, you can pull the eye to the side and put a camera in the eye socket. You can put cameras in the ear. Like you can put cameras anywhere down the throat. And so my whole life was just like, figure out a way to get a camera in a place where I need to see something. So this is a sinus endoscope. This is like sticking a small camera, actually under the skin and the forehead to lift the eyebrows up. Using a camera to do a surgery of the thyroid. This is a flexible endoscope, which I actually carried around with me all day, every day for all the times of residency. We all had one. So anytime there was an emergency in the hospital where there was like an airway problem, someone couldn’t breathe, you just whip out your flexible endoscope, run to the ER, and then basically you can use this tool up here to see what’s going on in the throat? Like, is there swelling? Is there an obstruction? Is there a mass? Is there a foreign body? Is there a bead that someone’s swallowed? And so that was on me at all times. And actually of the things I miss about ENT, I missed this the most because it was just like such an empowering tool. Like I could just go around, like scope anyone in a moment’s notice. It had a local sleeve to sterilize it, that you would put over this before putting it in someone obviously. And then this is really cool. I got to use the DaVinci robot a bunch, which is this robotic surgery, where basically the patient is separate from you. They can even be in a different room. And you’re at a console with a 3D stereoscopic view of the patient. And you’re controlling with these really cool sort of joysticks. And then the robot is actually the one doing the surgery. And the benefit of that is. We used it mostly for surgeries that were deep in the back, on the back of the tongue. And you can’t get your tools back there. They can’t bend, but the risks of these robots can articulate like this. And so previously you’d have to open up the, to get to the back of the tongue, you’d have to use a bone saw, open the whole jaw, pull the tongue out and get there. And this way you can just basically stick this robot in the back of the mouth, and it will be able to get around and see. So it saves a huge amount of morbidity for patients.

Sam Corcos [47:24] That tool on the top. I’ve had that go through my nose before, and that is a very weird sensation.

David Flinner [47:38] It’s also weird looking at the doctor who’s doing it to you.

Casey Means [47:41] It’s so weird. Yeah, I’ve got a fun video of my vocal chords that I took of myself, basically. So the camera’s in my nose and I’m like, I think I was singing happy birthday to someone and recording it. Oh, there’s a really cool device that basically you can hook your iPhone up to this camera and take a video while it’s happening. But I couldn’t find it when I was putting this together, so I’ll send it out on Slack, but it’s really fun. Last slide, basically, just some takeaways from my time in ENT. So, yeah, I think the biggest, sorry, I’m trying to present this. Hmm. I don’t know if this is still working. What are you seeing on my screen?

Josh Clemente [48:26] Seeing your desktop. You might be sharing the whole desktop and not the window, let’s see.

Sam Corcos [48:38] You can cancel the presentation. We can still see you.

Casey Means [48:40] Okay, cool. yeah, so I guess some takeaways, like one which like kind of leads me to Levels is that like inflammation literally underlies everything. Like every single thing that I was seeing basically day in and day out was that like these people, these patients, like something in their body was causing chronic inflammation, and ENT conditions are just a manifestation of that. You know, sinusitis is a manifestation of systemic inflammation in the nose. Chronic ear disease and the pus that builds up because of that is because of chronic inflammation that’s showing up in the ears. And, you know, cancers, many talk about it as a metabolic or a chronic inflammatory disorder. Vocal cord polyps are inflammatory masses on the vocal chords. Like it’s just, it’s kind of amazing. And so that, yeah, that sort of like led me on my sort of personal journey to thinking, to really examining, like, why is everyone so inflamed? Like, why are people, and of course, like all these, so many of these patients were, you know, obese or you know, had other medical issues, diabetes, hypertension, et cetera. And so it’s like, there’s something going on here. Like this is this. And the funny thing about ENT is I think, because it’s, so it’s your head. It’s so localized, people don’t really make the connection between like how could this stuff be related to these chronic underlying lifestyle conditions. But like, to me studying the physiology of it and looking at how all these inflammatory cytokines that are upregulated in ENT issues are the exact same ones that are upregulated in obesity, diabetes, you know, interleukin six, TNF alpha, CRP. And it’s like, this is the same thing. Like this is. And so that, that was sort of like a journey for me. And yeah, and I fundamentally think that that changes in underlying inflammation, metabolic health, diet, et cetera, can really save a lot of people from these recurrent ENT surgeries. You know, there’s an interesting, you know, I think there’s a huge place for surgery out there, but the saying in surgery is you eat what you kill. And basically what that means is like, you don’t get paid unless you do surgery. And that mindset, it’s just kind of interesting. Like, you know how I think, I don’t think it drives people to make the wrong decisions in terms of clinical practice, but that culture, like it’s going to have you seeing every patient as a surgical patient, and not a patient necessarily that you want to like coach on diet. So, that’s one. Inflammation is so key. I think the second thing is creativity and problem solving. The urgency of ENT issues. So, you know, the ABCs of emergency medical services, the first one is airway. And we’re the airway team. And so our specialty was the thing that kills you fastest, airway issues. If someone’s swallowed a potato and choked on it, if someone swallowed a piece of meat and choked on it, a kid swallowed a bunch of beads or Legos, like they could die or have brain damage in minutes. And so it was so urgent and there was a lot of running involved, but that created a really fun environment because it was like, it was non-negotiable that you had to figure out a solution. So there was so much problem solving, and on your feet. And I don’t know, it got, I think it got me really confident and just saying like, there’s not, there’s no way that this isn’t going to work, so we have to make it work. How are we going to make it work? Sometimes that meant just like doing it myself, like running down to the basement of the hospital, getting the tools I needed, running back up to the emergency room, you know, and doing a slash tracheotomy  or something or, you know, just shoving whatever I could, if a patient was hemorrhaging out of their mouth, post-op just like finding any gauze I could, putting pressure on it and like just thinking really kind of fast. And then triaging problems. So that was, it was exciting and it was fun, but I think it just created an overall ethos of like, there’s a problem. There is a way to solve it. Like let’s figure it out. And the teamwork element of that was really beautiful. I think nosebleeds were another thing we got called that ER constantly for patients who were on blood thinners who were having nosebleeds. They’d be home. They’d be on their blood thinners for some other issue, and they would wake up in the middle of the night and blood would be just hemorrhaging out of their nose. The nose is one of most vascular areas of the body, beause its purpose is to heat and warm air as you breathe it in. So it’s filled with blood vessels that do that. So people on blood thinners could just bump their nose and have just like hemorrhage. So figuring out. We basically had a tackle box of things that you could do to stuff in a nose. And so I would get to the patient’s bedside, they’re pouring blood on their mouth, they’re choking, and you just have to figure out what are you going to put in that nose to like stop the bleeding. And it was really an art project. It was really creative. And I really enjoyed that. And then I guess the last thing I would say the takeaway was that sleep is so important. Sleep is you know, for surgeons like you’re sleeping sometimes only three or four nights a week. And I just saw so acutely what it did to my brain when I was sleep deprived versus not. Like I could, there were some times that I couldn’t remember like basic facts about life. Like, it was just, I felt like I had dementia, post-call and stuff like that. And everyone feels that way. And there’s so much research to support it, but feeling it in my own life, I was just like, Oh, like, I’m no good to anyone if I don’t have a little bit, like a normal amount of sleep. And so, yeah, I think that the medical education is reforming in that sense, trying to hopefully get residents more consistent sleep, but it’s not a good holdover from the old culture of medicine. It’s not really necessary anymore, but it was definitely a profound sort of on-off switch in terms of health. So, yeah, that’s just sort of like a broad overview. Yeah. Any questions?

Evan [54:14] Can I ask a quick question, like a personal one. So I had my tonsils and adenoids out when I was in college. And it was like a pretty brutal experience. And then I contrast that like my niece, my oldest niece is seven. She had her tonsils out last year. She was able to eat and talk the same day while I couldn’t eat for like two weeks. And I heard that it’s just better when you’re younger. I’m just curious if there’s an actual reason for that.

Casey Means [54:42] Yeah, it’s way better when you’re younger. So the reason is because when you’re younger, your tissue planes are beautiful. So what you do is you basically pull the tonsil, and then you take this heat instrument, and there’s this like fluffy, white capsule around the tonsil. And you just like burn it out, and it’s like two seconds, you know, beautiful. When you’re old, presumably you’ve had chronic tonsillitis, like 20 times, the tonsil is scarred, like flat against the muscle layer, the muscles where all the nerves are. You can’t even grab it. I mean, it’s like ripping through your instruments because it’s just scar. And then you have to basically like burn into the muscle to get this tissue out and it’s terrible. So it’s the scarring, and it’s the recurrent infections, and it’s the lack of tissue planes. And so you’re just like basically injuring muscle. And then you’re having to deal with an entire muscle as opposed to with a kid just like nothing. You haven’t even touched the muscle. So.

Sam Corcos [55:40] Yeah. That’s such a succinct and good explanation. Thanks, Casey. Yeah.

Josh Clemente [55:47] Well, that was awesome. Thank you for presenting on that.