A surgeon's path to fixing healthcare - Ben Schwartz (Commons Clinic)

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Hi, Ben. Thanks for joining us today. Yeah, thanks

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for having me. You're currently leaving clinical

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medicine behind and your stethoscope or your

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hammer, as you might call it in the ortho world.

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And you're joining as a leadership at Commons

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Clinic. Tell me about your path and how did you

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get here? Right. So yeah, I've been in practice

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for 17 years with paediatric surgery, joint replacement.

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So a lot of hammering and sawing and malleting

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things into place. Very typical standard career

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for probably the first at least 10, 11 years

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for that career. And then about six, seven years

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ago. got interested in entrepreneurship, healthcare

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technology, got involved in some value -based

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care stuff in my own practice, and just kind

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of got to the point of my career where I started

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to think about, you know, what's next? What's

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my legacy? Am I going to do this forever or is

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there something more to my career? And so I started

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doing some angel investing, some advising with

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some companies, started to build a network by

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posting stuff on LinkedIn just to kind of drive

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conversations, get in front of people I wouldn't

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otherwise get in front of. And that led me to

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a guy called Nick Aubin, who's the CEO and founder

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of Commons Clinic. And what Commons Clinic was

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doing and is still doing was trying to build

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value -based care models, tech forward models.

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of care, like a new care delivery model surfaced

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or revolving around MSK initially, but with the

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goal to do multi -specialty at some point. So

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I had come up with this, what I thought was a

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brilliant idea of arthritis centers of excellence,

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where you get high quality surgeons you try to

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work with instead of against insurance companies,

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you incorporate technology into what you're doing,

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you revolve around outpatient centers and ASCs.

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And so I wrote this white paper. I put together

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this slide deck, but I had no idea at the time,

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like, well, what do I do with this? I didn't

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know how to get in front of investors. I was

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a full -time practice. I didn't really have the

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time to, you know, kind of pursue it. And then

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came across Commons Clinic and it turned out

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that they were already doing or building what

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I had kind of envisioned. And so met Nick. made

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a small angel investment in their seed round.

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This was probably three or four years ago and

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just kept in contact with them through the years.

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We would touch base every so often, trade notes,

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just riff on value -based MSK. I started my own

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blog about two years ago, just to kind of share

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more long form thoughts. And a lot of it was

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in line with still what Commons was doing, not

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necessarily intentionally, but just because we're

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pretty aligned on the thought process. So Nick

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reached out to me a year ago, said, hey, would

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you consider bringing your blog under our banner?

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I said, sure. Along with that, started doing

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some ad hoc. clinical consulting with their team

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here and there. And that just kind of grew from

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there became kind of this organic thing of they

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seem to like me, I like them seem to be a good

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fit. And it really kind of became where I saw

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my career evolving to and in terms of what I

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want my impact to be, how can I have impact in

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a higher, broader scale, larger scale? And what

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do I find fulfilling and You know, 17 years is

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a very fulfilling career. I'm proud of what I

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did in orthopedic surgery. I feel like I'm leaving

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at the height of my career. And then I think

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that's important to me to, you know, not be running

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away from my clinical career, but to be running

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towards something that I think could be more

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impactful and as fulfilling, if not more fulfilling,

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depending on how successful we are. What do you

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think you'll miss the most about your clinical

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career and what are some things you won't miss?

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I think I'll miss the most, particularly with

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joint replacements. The big part of the reason

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I decided to go into hip and knee replacements

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was you're solving a problem. You see arthritis

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on an x -ray. Somebody comes in, they're debilitated

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by it. In the span of a whatever hour long operation,

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you cut it out. That said, the arthritis is gone.

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They can never get arthritis again. The recovery

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for some might be longer than others. You're

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really curing arthritis. It may be kind of crude,

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but it's the best we have, and it works pretty

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well. And so I like that concrete part of it.

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I like the fact that you can take somebody that's

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debilitated and really restore their quality

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of life. Orthopedics is not usually life -threatening

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things, but it is function. It's limb. And so

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taking somebody that came limping in your clinic

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in pain that can't... do whatever, play golf,

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play with their grandkids, play pickleball, work,

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whatever it is, and then you do surgery on them

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and two weeks later they come in and they're

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walking better, they're off crutches, they're

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getting their quality of life back. That's very

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satisfying, that part of the job is very satisfying,

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so I'll miss that. What I won't miss probably

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is really just the frustrations I think that

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have crept in for everybody. in healthcare on

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the front lines and EMR gets blamed a lot. That's

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a part of it. But I think it's really death by

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a thousand cuts. I think it's EMR, it's regulations,

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it's reimbursement, it's insurance issues, it's

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staffing issues on the front lines because there's

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turnover and because there's understaffing and

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there's cuts everywhere. And so those things

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over time kind of really add up. And there's

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always so much that... as I found out, I think

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you can do within the system. You know, people

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are trying, but you run up against so many roadblocks

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that it just seemed like the only way to really

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make any headway was to kind of, you know, step

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outside of that and take a role like Commons

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where you're really trying to build not from

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outside, but from a little bit of a different

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perspective. I mean, Commons are the people that

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started Commons, Nick, Aubyn and Paulo. are not

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outsiders. They come from healthcare. They're

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not physicians, but they built in healthcare

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before. So they're not outsiders. They understand

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the healthcare issues. You said as you were working

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as an orthopedic surgeon, you felt like you needed

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to do something different. And maybe I'm putting

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my experience in yours a little bit here. Tell

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me a bit more about what sparked that entrepreneurship

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curiosity and is that something you think is

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innate or is that something that can be learned?

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I think it's innate. I think it might be latent

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for a lot of people. You know, in healthcare,

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it's pretty prescriptive, right? You go to college,

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you go to medical school, you go to residency,

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you go to fellowship. I mean, that's the typical

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track that you go out into practice. So there's

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not a whole lot. in that process that's necessarily

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entrepreneurship focused. I think if you're in

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private practice, you are running a small business.

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So in a sense, you are an entrepreneur. I think

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even if you're employed, you are managing your

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schedule, you are managing your views, whatever

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it is. So there is some form of entrepreneurship

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involved in that. Um, so I think it's, it's innate

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in us, but it's latent. And I think you just

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have to kind of uncover that for me. It was getting

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to a point in my career where the day -to -day

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became, I don't want to say easy because it's

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never easy. The day -to -day became more predictable

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though. I kind of knew how to prepare for each

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day. I knew what I needed to do to be prepared

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for the OR. I needed, I knew what I needed to

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do to be prepared for clinic. And so that part

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of it kind of slowed down for me and it freed

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up more mental capacity to start thinking about.

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other things. And on top of that, I was experiencing

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things sort of in my own career on the day to

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day that I felt like, you know, this could be

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done better. And let me figure out, are there

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ways to do it? Are there people that are already

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trying to do that? And that kind of brought me

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to the entrepreneur world of where are the people

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that are trying to fix these problems? What are

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the solutions that they're trying to bring? Let's

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talk about arthritis a little bit more. So I'm

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a family physician. I see quite a few patients

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and I do my own joint injections. There's been

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a lot of advancements at the edges that really

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haven't taken hold in the medical community,

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you know, PRP and stem cells and back in the

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day, prolotherapy, which is kind of out of favor

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now. What are your thoughts on you know, what

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is next in terms of arthritis treatment? Is it

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just, and maybe you have a different brand name

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there, here it's Sinvisc or Neuvisc, which is

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hyaluronic acid, cortisone and joint replacement,

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and then Tylenol and Advil, is that kind of the,

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all we need to know about arthritis, and if not,

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what's more and what's the future of arthritis

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care? Yeah, I think that's still the tried and

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true are still a lot of it. We've tried all these

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things. We have how ironic acid here. It's not

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covered by some of the insurance companies because

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the data on it is is mixed at best. Still do

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a lot of cortisone shots, still do NSAIDs, although

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fewer and fewer patients are really candidates

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for NSAIDs for whatever reason. They're on blood

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thinners, they have gastric issues, they have

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liver or kidney issues, and arthroplasty. So

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we've thrown a lot of things at joints and arthritis,

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and not a lot of them had staying power for whatever

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reason. And joint replacements ultimately are,

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I think, the best, most predictable long -term

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cure, I think. Hopefully we can get better preventing

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arthritis. I don't think you can prevent all

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of it, but I think there are certain things that

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we can do to maybe decrease the incidence of

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arthritis. First of all, there's nerve stimulation

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or nerve blocks and things like that that are

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coming along as pain relieving types of procedures.

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There's always companies working on injectables

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or things that try to support cartilage. I don't

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think there's any that have made it past the

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trial phase that have gotten out into mainstream

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usage. I think we're getting better maybe with

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detecting arthritis earlier, whether it's through

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advanced MRI imaging or analyzing synovial fluid

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to see if there are markers of early joint breakdown

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that maybe you can intervene a little bit earlier.

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I think someday. We'll either have gene therapy

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where we'll rearrange your genes and you won't

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get arthritis at all. Or maybe we'll be able

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to 3D print cartilage on a joint or do better

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with cartilage restoration. We've tried those

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things. It's been a mixed success, but somebody

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that's got advanced arthritis is beyond that

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point. So will we someday be able to open somebody's

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knee up and just kind of 3D print a cartilage

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matrix or cartilage on the ends of the bone?

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Possibly. Maybe in my lifetime. maybe in my lifetime,

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we'll have gene therapy to kind of prevent arthritis

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in the first place. But I don't think there's

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anything on the immediate horizon that's going

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to take the place of joint replacement for the

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patient with advanced arthritis. It sounds like

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your transition out of clinical medicine was

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more inspired by finding something to run forward

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to, as you said. A lot of my colleagues and to

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an extent me myself, our transition is running

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away from clinical medicine. Why do you think

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physicians are burning out? And did you burn

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out? And if you did, what protected you from

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burning out? Yeah, I think there was definitely

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times where I had symptoms of burnout. I don't

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know that I ever like, you know, fully. burnt

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out, but there were definitely times where it

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felt like, you know, you would show up and you

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would do your job. You didn't feel like you were,

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you know, making the impact that you intended

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to make when you got into health care. And that

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can be very frustrating, very, very deflating,

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because this is a challenging job. It's a stressful

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job. You know, it's a job that you put a lot

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of your life into. And it's it's more than a

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job. I think it is a career that. isn't just

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a nine to five. So for me, it really was getting

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involved in the entrepreneurship and realizing

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that. I think some of the burnout or a lot of

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the burnout maybe comes from thinking that you're

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hopeless and helpless in a situation, right?

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There's just nothing you can do about it. You

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show up every day and these problems exist and

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you're kind of shouting into the void or bang

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your head up against the wall. And I think that

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more than anything can be extremely frustrating

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for people to feel like, you know, you have no

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agency, you have no ability to change anything

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and getting involved in entrepreneurship and

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being around people that Some are grifting, some

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are in it for the wrong reasons, but a lot of

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them aren't. And being around people that maybe

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don't always 100 % understand what the problems

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are, but have an earnest interest in trying to

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solve them was refreshing. And then taking what

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I had learned from being on the front lines,

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my front line experience and being able to translate

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that to people that were building in healthcare,

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but maybe didn't have a great grip on what was

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going on on the front lines was... was satisfying.

00:13:07.519 --> 00:13:09.379
It kind of showed me that there is light at the

00:13:09.379 --> 00:13:10.860
end of the tunnel. There is somebody out there

00:13:10.860 --> 00:13:13.639
like Nick Alban and Commons Clinic that are bringing

00:13:13.639 --> 00:13:16.240
high level, you know, get your get your hands

00:13:16.240 --> 00:13:19.779
dirty solutions to health care. And that was

00:13:19.779 --> 00:13:22.120
very satisfying to me building a network and

00:13:22.120 --> 00:13:24.720
community online, starting to write and really

00:13:24.720 --> 00:13:26.659
kind of express those opinions and then have

00:13:26.659 --> 00:13:29.220
it resonate with people. You know, all those

00:13:29.220 --> 00:13:34.690
things, I think. really helped me kind of stave

00:13:34.690 --> 00:13:39.169
off that burnout and gave me renewed hope. I

00:13:39.169 --> 00:13:41.769
think that's tough. I think it takes time. It

00:13:41.769 --> 00:13:44.450
takes some risk to put yourself out there or

00:13:44.450 --> 00:13:47.169
get involved in some of these things. And so

00:13:47.169 --> 00:13:49.610
I don't think it's necessarily easy for everybody.

00:13:49.610 --> 00:13:51.850
It wasn't easy for me. And so I think you kind

00:13:51.850 --> 00:13:54.389
of get trapped in this cycle that you don't feel

00:13:54.389 --> 00:13:56.789
like there's any way out of. I think that's why

00:13:56.789 --> 00:13:58.889
a lot of people in this day and age are kind

00:13:58.889 --> 00:14:02.419
of burning out. I think there's a light at the

00:14:02.419 --> 00:14:03.519
end of the tunnel. I think it's going to take

00:14:03.519 --> 00:14:07.200
some time. I think things are cyclical. So I'm

00:14:07.200 --> 00:14:10.159
hopeful that at some point, not just through

00:14:10.159 --> 00:14:12.799
Commons Clinic, but in general, things get better

00:14:12.799 --> 00:14:14.919
on the front lines for the people that are delivering

00:14:14.919 --> 00:14:16.559
the care. It's not just doctors, it's nurses,

00:14:16.799 --> 00:14:18.860
it's physical therapists, it's case managers.

00:14:19.539 --> 00:14:22.279
I think just about everybody that touches a patient

00:14:22.279 --> 00:14:26.950
has experienced that. What would 20 year old

00:14:26.950 --> 00:14:29.169
Ben think of where you are today both in terms

00:14:29.169 --> 00:14:31.250
of your personal life and your professional life?

00:14:32.629 --> 00:14:34.990
I Think a personal life he'd be pretty happy.

00:14:34.990 --> 00:14:37.129
I mean, look, I can't complain. I have a great

00:14:37.129 --> 00:14:40.389
family You know, I've had success in my career,

00:14:40.509 --> 00:14:42.129
you know, not just in clinical medicine But some

00:14:42.129 --> 00:14:43.750
of the things I've done, you know outside of

00:14:43.750 --> 00:14:46.929
it side gig wise. So, you know, I live a very

00:14:46.929 --> 00:14:50.429
good life And I've been very fortunate in that

00:14:50.429 --> 00:14:53.429
way. So I think he'd be happy with where he was

00:14:53.789 --> 00:14:57.549
Personally, I think professionally, I think it

00:14:57.549 --> 00:15:00.230
would depend. If he knew the journey it would

00:15:00.230 --> 00:15:02.850
take to get there, I think he'd be like, oh,

00:15:02.970 --> 00:15:05.870
that's going to be a journey, residency, and

00:15:05.870 --> 00:15:09.450
fellowship, and early in your career struggles,

00:15:09.590 --> 00:15:13.090
and then making that pivot towards more leadership,

00:15:13.190 --> 00:15:15.590
entrepreneur type of stuff. I think if you saw.

00:15:16.120 --> 00:15:19.559
the end result. You know, he would be pretty

00:15:19.559 --> 00:15:23.340
happy and hopefully proud of future Ben, because

00:15:23.340 --> 00:15:25.639
because I'm really excited about, you know, where

00:15:25.639 --> 00:15:30.159
I've been, but also where I'm going. I don't

00:15:30.159 --> 00:15:32.480
know if you have kids and if so, how old they

00:15:32.480 --> 00:15:35.899
are. How old are your kids? So I have two daughters,

00:15:36.120 --> 00:15:38.419
14, who will be in high school next year and

00:15:38.419 --> 00:15:41.740
12. Okay, I have two daughters, 12 and five.

00:15:42.879 --> 00:15:46.450
If your daughters came to you, And they said

00:15:46.450 --> 00:15:49.450
they would like to become an orthopedic surgeon.

00:15:49.769 --> 00:15:52.789
What would you what would your response be? Yeah,

00:15:52.830 --> 00:15:54.929
I'm not one of those doctors. I was like, I'm

00:15:54.929 --> 00:15:57.450
crazy. Don't go into, you know, health care or

00:15:57.450 --> 00:16:00.470
whatever. I mean, look at the core of it when

00:16:00.470 --> 00:16:02.549
you strip away all the stuff that that makes

00:16:02.549 --> 00:16:05.399
it less appealing. It's still. a great profession.

00:16:05.639 --> 00:16:07.940
Unfortunately, I think we've lost a lot of what

00:16:07.940 --> 00:16:11.559
makes being a doctor great. But I think at the

00:16:11.559 --> 00:16:12.919
core of it, it's still there and you still have

00:16:12.919 --> 00:16:15.019
those moments. Like I was saying before, when

00:16:15.019 --> 00:16:17.299
you take that person that could barely walk when

00:16:17.299 --> 00:16:20.159
you first met them, some of them are even in

00:16:20.159 --> 00:16:23.659
wheelchairs or on walkers and they come in and

00:16:23.659 --> 00:16:26.330
you've... change their lives and some of them

00:16:26.330 --> 00:16:29.149
will tell you, look you changed my life. That's

00:16:29.149 --> 00:16:31.769
extremely rewarding and I think that's as close

00:16:31.769 --> 00:16:35.529
to a superpower as you can get. It doesn't always

00:16:35.529 --> 00:16:38.370
like that, clearly, but I think when it is it's

00:16:38.370 --> 00:16:40.330
very rewarding. I think I wish those moments

00:16:40.330 --> 00:16:43.590
were more common than they are now. So I would

00:16:43.590 --> 00:16:47.049
never, my approach when it comes to that is do

00:16:47.049 --> 00:16:50.100
what you find fulfilling. I'm here to guide you.

00:16:50.200 --> 00:16:52.120
If you're interested in being orthopedic surgeon,

00:16:52.120 --> 00:16:55.460
they're with you. Every step of the way, I would

00:16:55.460 --> 00:16:59.220
never let my own experience dissuade them from

00:16:59.220 --> 00:17:01.580
doing it. I would guide them and share my experiences,

00:17:01.580 --> 00:17:04.880
but I would never tell them, don't do it because

00:17:04.880 --> 00:17:11.299
X, Y and Z. Yeah, I've been I think if you ask

00:17:11.299 --> 00:17:14.160
physicians within and I'm going to just crossing

00:17:14.160 --> 00:17:18.920
the. the eight -year mark out of post residency.

00:17:19.319 --> 00:17:21.140
If you ask physicians around the five, six -year

00:17:21.140 --> 00:17:24.099
mark post residency, they will all say, we would

00:17:24.099 --> 00:17:26.779
never want our kids to be physicians. And then

00:17:26.779 --> 00:17:28.660
as you get more experience about other fields

00:17:28.660 --> 00:17:31.420
and how things work, you tend to get a better

00:17:31.420 --> 00:17:35.119
appreciation of how strong of a factor that immediate

00:17:35.119 --> 00:17:39.039
reward we get from our patients is, and how rare

00:17:39.039 --> 00:17:42.140
it is in other fields and other jobs. It could

00:17:42.140 --> 00:17:44.579
be congratulated every day and multiple times

00:17:44.579 --> 00:17:47.700
a day. Yeah the grass is always greener and you

00:17:47.700 --> 00:17:49.380
know the highs can be very high and the lows

00:17:49.380 --> 00:17:54.160
can be very low. And yeah I think that that five

00:17:54.160 --> 00:17:56.400
to six year mark you know you kind of you're

00:17:56.400 --> 00:17:58.839
not wide -eyed anymore you're experienced and

00:17:58.839 --> 00:18:00.720
then I think you start to feel the weight of

00:18:00.720 --> 00:18:03.900
some of that but if you can get past that period

00:18:03.900 --> 00:18:06.940
I think you learn to be a little bit easier on

00:18:06.940 --> 00:18:10.539
yourself a little bit less perfectionistic and

00:18:10.539 --> 00:18:13.890
realize that you know, it's not always going

00:18:13.890 --> 00:18:16.150
to be perfect. But at the end of the day, if

00:18:16.150 --> 00:18:19.049
you're doing the best you can, and most patients

00:18:19.049 --> 00:18:23.410
are doing well, you know, then you, I think you

00:18:23.410 --> 00:18:25.390
have to resist the tendency to be too hard on

00:18:25.390 --> 00:18:31.349
yourself. Do you think you live a balanced life?

00:18:31.390 --> 00:18:33.289
And this is coming from someone who has no balance

00:18:33.289 --> 00:18:36.529
in his life. And it's like, it's not a good thing,

00:18:36.529 --> 00:18:40.009
right? Because I work too much and right. Yeah,

00:18:40.009 --> 00:18:43.509
and I'm programmed to just work, work, work.

00:18:44.549 --> 00:18:46.769
And it's hard to undo that programming. Do you

00:18:46.769 --> 00:18:49.369
think you have that kind of inherent drive to

00:18:49.369 --> 00:18:51.150
work all the time? And if so, how do you offset

00:18:51.150 --> 00:18:53.910
that? Yeah, I think I have the drive. I think

00:18:53.910 --> 00:18:58.730
a lot of doctors have that drive. And so I've

00:18:58.730 --> 00:19:01.049
tried to be mindful, like, you know, as a full

00:19:01.049 --> 00:19:03.509
time clinical practice, I basically had almost

00:19:03.509 --> 00:19:07.259
a full time like sidekick job, but my responsibility

00:19:07.259 --> 00:19:10.240
while I was in practice was always to my patients.

00:19:10.299 --> 00:19:13.440
They came first. And then this other stuff was

00:19:13.440 --> 00:19:16.359
after hours on weekends between surgeries at

00:19:16.359 --> 00:19:19.140
lunch, you know, whatever it was. And then you

00:19:19.140 --> 00:19:21.099
have to be careful about stripping away all your

00:19:21.099 --> 00:19:24.220
free time and finding that balance. I mean, I've

00:19:23.920 --> 00:19:27.740
found the side gig work to be fulfilling and

00:19:27.740 --> 00:19:30.299
I found it to be they talk about work -life harmony

00:19:30.299 --> 00:19:32.460
instead of work -life balance and that means

00:19:32.460 --> 00:19:33.799
that you know some of the stuff if you're working

00:19:33.799 --> 00:19:35.539
all the time is always that sort of in harmony

00:19:35.539 --> 00:19:39.519
with your your life and not you know just work

00:19:39.519 --> 00:19:41.119
work work all the time or doesn't feel like work

00:19:41.119 --> 00:19:46.940
work work all the time is less taxing but I definitely

00:19:46.940 --> 00:19:49.440
had to learn how to kind of pull back and say,

00:19:49.539 --> 00:19:52.200
you know, to things or OK, it's time to shut

00:19:52.200 --> 00:19:55.920
it off. It's family time. You know, it's time

00:19:55.920 --> 00:19:58.240
to get away from it, because I think that can

00:19:58.240 --> 00:20:00.400
also obviously lead to burnout if you're not,

00:20:00.400 --> 00:20:02.420
you know, take enough time just to kind of give

00:20:02.420 --> 00:20:07.700
yourself a break. There seems to be a growing

00:20:07.700 --> 00:20:11.400
divide between leadership and health care, especially

00:20:11.400 --> 00:20:15.160
in hospitals and health systems and frontline.

00:20:15.470 --> 00:20:19.150
physicians. What do you think is the reason for

00:20:19.150 --> 00:20:22.049
that divide? And if you could change one thing

00:20:22.049 --> 00:20:25.930
about both camps, what would you change? I think

00:20:25.930 --> 00:20:29.589
the divide in part is because there's just become

00:20:29.589 --> 00:20:33.069
so many layers within the hospital health system.

00:20:33.869 --> 00:20:36.470
My dad was a hospital administrator growing up.

00:20:36.470 --> 00:20:39.910
This was the 1980s and early 90s and things were

00:20:39.910 --> 00:20:42.130
different. back then, there weren't like these

00:20:42.130 --> 00:20:45.130
multiple layers between him as the administrator,

00:20:45.289 --> 00:20:48.710
the CEO of the hospital and the doctors. You

00:20:48.710 --> 00:20:50.789
know, there was a very close connection for better

00:20:50.789 --> 00:20:52.849
or worse, because some of them could be kind

00:20:52.849 --> 00:20:56.049
of tough, doctors could be kind of tough. But

00:20:56.049 --> 00:20:59.670
now I feel like we have so many layers between.

00:20:59.920 --> 00:21:02.319
like what happens on the front lines and in the

00:21:02.319 --> 00:21:05.099
C -suite, I wish, you know, CEOs and now you

00:21:05.099 --> 00:21:06.880
have these big hospitals and health systems where

00:21:06.880 --> 00:21:09.740
the CEO of the health system might be, you know,

00:21:09.859 --> 00:21:12.140
three towns over and never even comes to the

00:21:12.140 --> 00:21:14.440
community hospital and really has a great grasp

00:21:14.440 --> 00:21:18.220
of what goes on on the front lines. I wish administrators,

00:21:18.680 --> 00:21:20.200
you know, the people that really are at the top

00:21:20.200 --> 00:21:22.200
making the decisions, spent more time on the

00:21:22.200 --> 00:21:24.799
front lines to understand, you know, what the

00:21:24.799 --> 00:21:27.359
challenges are because you don't get that looking

00:21:27.359 --> 00:21:29.619
at. spreadsheets or sitting in meetings all day,

00:21:29.700 --> 00:21:31.700
you have to actually be in there experiencing

00:21:31.700 --> 00:21:35.839
it. Um, you know, I think from a physician perspective,

00:21:35.839 --> 00:21:39.259
I think we've now developed this muscle where

00:21:39.259 --> 00:21:42.640
it's automatic, like, um, conflict when we're

00:21:42.640 --> 00:21:45.779
dealing with administrators and understand they're

00:21:45.779 --> 00:21:47.420
part of it too. You know, they have boards that

00:21:47.420 --> 00:21:49.880
they're answering to the bottom line and, you

00:21:49.880 --> 00:21:52.079
know, they're, they're responsible for fiscal

00:21:52.079 --> 00:21:54.279
results and, and things like that. And some of

00:21:54.279 --> 00:21:55.500
the things are out of their control in terms

00:21:55.500 --> 00:21:58.299
of regulations that are coming down from, you

00:21:58.299 --> 00:22:00.509
know, the government, from Jayco, from the state,

00:22:00.569 --> 00:22:03.569
whatever it is. So I think there's a middle ground

00:22:03.569 --> 00:22:06.450
there to realize that maybe look at it from each

00:22:06.450 --> 00:22:08.529
other's perspective a little bit more to have

00:22:08.529 --> 00:22:13.049
better understanding. What's something you've

00:22:13.049 --> 00:22:15.509
changed your mind on in the past couple of years?

00:22:16.930 --> 00:22:18.829
I think probably the biggest thing is I was pretty

00:22:18.829 --> 00:22:24.160
skeptical about this whole, you know, whole body

00:22:24.160 --> 00:22:27.839
MRI and lab work and wellness and prevention

00:22:27.839 --> 00:22:31.220
Type of thing. I know that's that's snake oil.

00:22:31.220 --> 00:22:33.900
I think a lot of it still is but you know, I've

00:22:33.900 --> 00:22:38.400
come around on the idea of Done appropriately

00:22:38.400 --> 00:22:41.660
early detection and having you know This more

00:22:41.660 --> 00:22:43.720
comprehensive lab work and really a deep dive

00:22:43.720 --> 00:22:45.980
in your health once a year or once every five

00:22:45.980 --> 00:22:49.240
years or whatever it is does make some sense.

00:22:49.359 --> 00:22:51.900
I think there's still the key of separating the

00:22:51.900 --> 00:22:54.519
signal from the noise, not chasing every lab

00:22:54.519 --> 00:22:56.920
value that's slightly out of range or every incidental

00:22:56.920 --> 00:23:01.150
oma. But I do think that there is a place for

00:23:01.150 --> 00:23:04.309
moving upstream a little bit, doing a better

00:23:04.309 --> 00:23:07.690
job servicing these things. Here in the US, I

00:23:07.690 --> 00:23:09.990
think your primary care has just been so compressed

00:23:09.990 --> 00:23:12.430
because of poor reimbursement, because patients

00:23:12.430 --> 00:23:15.269
are so complicated these days, and because there's

00:23:15.269 --> 00:23:18.650
just not enough time to spend with people that

00:23:18.650 --> 00:23:22.170
we don't get as deep a dive as maybe we should

00:23:22.170 --> 00:23:24.710
into some of these things. And a lot of insurance

00:23:24.710 --> 00:23:27.119
companies may not necessarily pay for because

00:23:27.119 --> 00:23:28.779
they can't see the, you know, some actuaries

00:23:28.779 --> 00:23:31.019
telling them it's not worth it. So, yeah, this

00:23:31.019 --> 00:23:35.180
whole idea of prevention early detection, you

00:23:35.180 --> 00:23:40.480
know, I've started to come around on. And do

00:23:40.480 --> 00:23:43.779
you have any thoughts on how we deal with the

00:23:43.779 --> 00:23:48.559
primary pushback we get on whole body MRIs incidentalomas

00:23:48.559 --> 00:23:52.579
and how we deal with them? Do you think that

00:23:52.579 --> 00:23:55.359
is a valid concern or do you think it's you know,

00:23:55.359 --> 00:23:58.759
we are the guinea pig generation for longevity

00:23:58.759 --> 00:24:03.160
and more focus on preventive health. Yeah, I

00:24:03.160 --> 00:24:06.119
think it's it's totally legitimate concern because,

00:24:06.119 --> 00:24:08.200
you know, MRIs, you know, has taken on sort of

00:24:08.200 --> 00:24:12.960
this mythical quality in you know, among patients

00:24:12.960 --> 00:24:17.059
that MRI sees all and MRI sees a lot and that

00:24:17.059 --> 00:24:19.960
can be a bad thing sometimes and that, you know,

00:24:19.960 --> 00:24:21.660
it doesn't necessarily give you an answer. It

00:24:21.660 --> 00:24:23.200
may see something, but it doesn't necessarily

00:24:23.200 --> 00:24:25.420
tell you what it is. It tells you what it might

00:24:25.420 --> 00:24:27.119
be potentially, and then you have to go chasing

00:24:27.119 --> 00:24:30.559
it. So I think that's definitely a concern. Hopefully,

00:24:30.759 --> 00:24:34.200
as this becomes more commonplace, we'll do better

00:24:34.200 --> 00:24:36.339
and better at separating the signal from the

00:24:36.339 --> 00:24:40.160
noise with body MRI with, you know, comprehensive

00:24:40.160 --> 00:24:43.000
labs. testing, you know, the argument, and this

00:24:43.000 --> 00:24:45.500
is part of what kind of changed my mind on it,

00:24:45.779 --> 00:24:48.200
is that, you know, should we not take advantage

00:24:48.200 --> 00:24:50.980
of this because there's the possibility of, you

00:24:50.980 --> 00:24:53.799
know, instead of Lomas or chasing thing. No,

00:24:53.920 --> 00:24:55.960
I mean, I think there's still a place for hey,

00:24:56.000 --> 00:24:58.900
let's learn. Let's maybe do it better over time.

00:24:58.940 --> 00:25:00.880
I think we still have an obligation to make sure

00:25:00.880 --> 00:25:04.259
we're not causing harm by, you know, over testing

00:25:04.259 --> 00:25:06.400
or leading to more interventions and things like

00:25:06.400 --> 00:25:08.799
that. And I think that still is to be determined.

00:25:08.799 --> 00:25:10.480
But it doesn't mean that there's not a place

00:25:10.480 --> 00:25:16.319
for figuring that out. You know, value based

00:25:16.319 --> 00:25:20.380
care, in theory, sounds amazing, right? You pay

00:25:20.380 --> 00:25:25.779
for outcomes, you pay for helping patients long

00:25:25.779 --> 00:25:30.680
-term. We all know outcomes are mostly driven

00:25:30.680 --> 00:25:34.700
by socioeconomic status, by gender, by race,

00:25:35.460 --> 00:25:40.240
and healthcare maybe contributes 20 % to your

00:25:40.240 --> 00:25:43.960
outcomes. So how do we design a value -based

00:25:43.960 --> 00:25:48.059
system which, you know, isn't just, okay, I'll

00:25:48.059 --> 00:25:54.599
just take care of, you know, because that's the

00:25:54.599 --> 00:25:58.019
group that's more likely to do the best. And

00:25:58.019 --> 00:26:00.940
people who can afford the treatment I offer will

00:26:00.940 --> 00:26:03.859
more likely benefit from it. So how do we design

00:26:03.859 --> 00:26:05.980
a value -based care system which deals with the

00:26:05.980 --> 00:26:08.660
confining variable that people who have more

00:26:08.660 --> 00:26:11.920
money to afford the best treatments are likely

00:26:11.920 --> 00:26:15.970
to have the best outcomes? Yeah, so you're sort

00:26:15.970 --> 00:26:17.890
of hinting at cherry picking and lemon dropping,

00:26:17.970 --> 00:26:20.970
which is one of the biggest criticisms, valid

00:26:20.970 --> 00:26:23.549
criticisms of value -based care. You know, we

00:26:23.549 --> 00:26:30.069
went into the CMS BPCIA program, which was for

00:26:30.069 --> 00:26:32.450
hip and knee replacements. It was voluntary,

00:26:32.589 --> 00:26:34.670
but we felt like we were doing a good enough

00:26:34.670 --> 00:26:37.390
job taking care of those patients, that we would

00:26:37.390 --> 00:26:40.910
have success in the program, and we did. You

00:26:40.910 --> 00:26:43.799
know, I... Tried not to change too much of what

00:26:43.799 --> 00:26:46.119
I was doing because before we went into the program

00:26:46.119 --> 00:26:48.240
I tried to stay on top of you know what's the

00:26:48.240 --> 00:26:51.240
latest and greatest in terms of you know treatment

00:26:51.240 --> 00:26:53.480
and I'm doing things that are appropriate not

00:26:53.480 --> 00:26:56.789
sending people to nursing homes after surgery

00:26:56.789 --> 00:26:59.210
or rehabs after surgery, sending them home because

00:26:59.210 --> 00:27:01.789
the data showed that those places were associated

00:27:01.789 --> 00:27:03.549
with increased complications, higher readmission

00:27:03.549 --> 00:27:05.809
rates. The data showed that people most people

00:27:05.809 --> 00:27:08.670
were safer going home into their own environment

00:27:08.670 --> 00:27:11.470
and trying to eliminate some of those low value

00:27:11.470 --> 00:27:14.569
treatments that drove up costs. So, you know,

00:27:14.609 --> 00:27:17.900
we still. optimized patients for surgery. We

00:27:17.900 --> 00:27:20.259
didn't say, no, you can't have surgery. We said,

00:27:20.539 --> 00:27:22.119
you're going to have surgery, but let's do some

00:27:22.119 --> 00:27:23.839
things first to get you healthier. And I think

00:27:23.839 --> 00:27:26.140
that was a good thing to get people healthier

00:27:26.140 --> 00:27:29.319
before surgery and reduce their risk of complications.

00:27:29.400 --> 00:27:31.619
If they were able to get there, then we operated

00:27:31.619 --> 00:27:34.859
on them. I think. Going forward, there has to

00:27:34.859 --> 00:27:38.019
be more sophistication in terms of how you restratify

00:27:38.019 --> 00:27:42.380
things to make sure that you're not disincentivizing

00:27:42.380 --> 00:27:45.519
treatment for more complex populations. I mean,

00:27:45.559 --> 00:27:48.180
they seem to be able to do some form of restratification

00:27:48.180 --> 00:27:51.440
for Medicare Advantage here. So I don't see why

00:27:51.440 --> 00:27:55.250
we couldn't do that for other forms of. value

00:27:55.250 --> 00:27:57.509
based care. So I think we just have to be a little

00:27:57.509 --> 00:27:59.809
bit more sophisticated with our models doesn't

00:27:59.809 --> 00:28:02.190
mean we have to make them more complicated necessarily.

00:28:02.190 --> 00:28:05.269
I think we need to make them simpler, but also

00:28:05.269 --> 00:28:07.910
have a reasonable restratification mechanism.

00:28:09.789 --> 00:28:12.890
This is a somewhat different question, although

00:28:12.890 --> 00:28:15.549
I assume it's parallel. What are your thoughts

00:28:15.549 --> 00:28:20.940
on universal basic income? Yeah, that's not something

00:28:20.940 --> 00:28:23.940
I have spent a ton of time thinking about I think

00:28:23.940 --> 00:28:27.160
there's merits to a there's pros and cons on

00:28:27.160 --> 00:28:28.980
both sides I think it's something we'll hear

00:28:28.980 --> 00:28:32.740
more about you know, with AI, if AI is going

00:28:32.740 --> 00:28:35.019
to take everybody's job, there's no jobs left.

00:28:35.140 --> 00:28:38.240
How do people live? Is it through a universal

00:28:38.240 --> 00:28:42.539
basic income? I think having a certain standard

00:28:42.539 --> 00:28:44.839
of living for people, either you have to increase

00:28:44.839 --> 00:28:47.299
the minimum wage so that people that are working

00:28:47.299 --> 00:28:49.720
hard are able to live. I mean, you shouldn't

00:28:49.720 --> 00:28:52.799
work a 40 hour a week job or multiple jobs and

00:28:52.799 --> 00:28:55.039
still not be able to live. So whether that's

00:28:55.039 --> 00:28:57.740
increasing minimum wage or universal basic income,

00:28:57.799 --> 00:29:02.119
I think ultimately that lifts everybody up and

00:29:02.119 --> 00:29:06.019
ties back to the idea that healthcare is deeply

00:29:06.019 --> 00:29:09.480
tied into social factors and things like that.

00:29:09.559 --> 00:29:13.079
So if we can get people living better, that's

00:29:13.079 --> 00:29:14.759
the solution I don't think is talked about enough

00:29:14.759 --> 00:29:17.880
in terms of solving healthcare because we always

00:29:17.880 --> 00:29:20.779
talk about how America has this terrible healthcare

00:29:20.779 --> 00:29:23.759
system and the outcomes. It's not that the outcomes

00:29:23.759 --> 00:29:26.630
are bad, it's that there's so many social factors,

00:29:26.690 --> 00:29:31.109
your access to care, access to mental health

00:29:31.109 --> 00:29:35.069
resources, you know, access to income. So we

00:29:35.069 --> 00:29:37.250
don't have violent deaths, we don't have people

00:29:37.250 --> 00:29:41.049
that are kind of forced to make poor health choices,

00:29:41.049 --> 00:29:46.450
because that's really all they can do. Why did

00:29:46.450 --> 00:29:49.309
you do an MBA? And is it something you'd recommend

00:29:49.309 --> 00:29:53.380
to physicians? I did it because as I got more

00:29:53.380 --> 00:29:56.660
involved in the entrepreneurship, investing,

00:29:57.180 --> 00:29:59.279
and even in my practice, I became a part owner

00:29:59.279 --> 00:30:03.599
in a surgery center. We ended up pursuing a private

00:30:03.599 --> 00:30:06.579
equity sale of our practice. I wanted to understand

00:30:06.579 --> 00:30:10.259
the language of business better. I didn't expect

00:30:10.259 --> 00:30:13.140
to walk into a Fortune 500 company and take over,

00:30:13.180 --> 00:30:16.210
but it was more... What does that mean? What's

00:30:16.210 --> 00:30:19.069
a P and L statement? What are leadership types?

00:30:19.289 --> 00:30:21.309
What is marketing? What are market for you? All

00:30:21.309 --> 00:30:25.089
these things just to try to understand them better.

00:30:26.470 --> 00:30:29.390
I did an online MBA. It was self -paced. It was

00:30:29.390 --> 00:30:31.809
very reasonably priced. I wasn't going to spend

00:30:31.809 --> 00:30:35.480
six figures and take. six months to a year out

00:30:35.480 --> 00:30:38.500
of my practice to go do it. I worked it into

00:30:38.500 --> 00:30:40.599
my practice because it was self -paced and it

00:30:40.599 --> 00:30:43.240
was very recently priced and I got out of it

00:30:43.240 --> 00:30:45.400
what I wanted to get out of it. I think if you

00:30:45.400 --> 00:30:48.059
go into an MBA thinking that getting that degree

00:30:48.059 --> 00:30:50.460
is going to magically just open doors for you,

00:30:50.480 --> 00:30:55.589
I think that's a mistaken notion. I don't think

00:30:55.589 --> 00:30:58.150
it's necessarily going to pry open a bunch of

00:30:58.150 --> 00:31:00.670
doors. And I worry a little bit that, as you

00:31:00.670 --> 00:31:02.509
talked about, if you have doctors that are sort

00:31:02.509 --> 00:31:05.289
of running away, that they feel like an MBA is

00:31:05.289 --> 00:31:08.109
going to be a thing that gives them that landing

00:31:08.109 --> 00:31:09.930
spot. I don't think that that's necessarily the

00:31:09.930 --> 00:31:12.250
case. Now, if you go to a Harvard Business School,

00:31:12.369 --> 00:31:17.089
or you go to Stanford GSB, or at MIT, and you

00:31:17.089 --> 00:31:19.730
go to those programs. probably at least you can

00:31:19.730 --> 00:31:22.089
network. You'll have good networking opportunities.

00:31:22.150 --> 00:31:23.970
It might open some doors for you, but you're

00:31:23.970 --> 00:31:26.049
going to spend a lot of money, a lot of time

00:31:26.049 --> 00:31:30.150
doing that. How have your startup investments

00:31:30.150 --> 00:31:33.869
gone and what was your diligence thesis or criteria?

00:31:35.309 --> 00:31:40.309
So far, let's see, maybe four or five years into

00:31:40.309 --> 00:31:45.890
it, it's been a mixed bag. So I think I've had

00:31:45.890 --> 00:31:50.069
my first Official exit as an angel investor the

00:31:50.069 --> 00:31:53.650
company got acquired. I got nothing Because I

00:31:53.650 --> 00:31:57.690
was an early angel investor. They raised money

00:31:57.690 --> 00:32:00.470
Quite a bit of money and then had a significant

00:32:00.470 --> 00:32:04.789
down round I my shares I didn't put in more money

00:32:04.789 --> 00:32:06.829
So my preferred shares got converted to common

00:32:06.829 --> 00:32:09.890
stock and then once they sold because they were

00:32:09.890 --> 00:32:12.390
you know underwater with the waterfalls I ended

00:32:12.390 --> 00:32:15.730
up with nothing So it was an interesting experience,

00:32:15.730 --> 00:32:18.359
but that didn't do so well. I've had a couple

00:32:18.359 --> 00:32:22.799
of others that flamed out. So I think I've made

00:32:22.799 --> 00:32:26.619
10 investments so far. So one exit where I got

00:32:26.619 --> 00:32:29.259
nothing, two that folded, the rest are still

00:32:29.259 --> 00:32:32.359
going. And the ones that are still going seem

00:32:32.359 --> 00:32:34.359
to be doing fairly well. I have another company

00:32:34.359 --> 00:32:38.200
that looks like it's on the verge of being acquired.

00:32:38.279 --> 00:32:41.329
And I probably will see. uh some return on investment

00:32:41.329 --> 00:32:44.269
and that was that'll be my first win i also so

00:32:44.269 --> 00:32:47.509
i got some stock options i wrote articles for

00:32:47.509 --> 00:32:50.980
doximity so doximity um has the op -med fellows

00:32:50.980 --> 00:32:53.119
program and i wrote a series of articles for

00:32:53.119 --> 00:32:55.339
them and they paid you in stock options and i

00:32:55.339 --> 00:32:57.859
was fortunate enough to get my stock options

00:32:57.859 --> 00:33:00.440
right before doximity went public and they were

00:33:00.440 --> 00:33:02.880
kind enough to double the stock options for us

00:33:02.880 --> 00:33:05.160
right before it went public so yeah it wasn't

00:33:05.160 --> 00:33:07.559
a huge amount of money but it was um it was a

00:33:07.559 --> 00:33:11.940
decent win and then i did some advising for uh

00:33:11.940 --> 00:33:15.480
another company that's well known in the digital

00:33:15.480 --> 00:33:19.000
health MSK space that will probably go public,

00:33:19.000 --> 00:33:21.519
I would guess, in the next year or two. I got

00:33:21.519 --> 00:33:24.579
some stock options or some options for doing

00:33:24.579 --> 00:33:26.720
that consulting work, and I exercise those options.

00:33:26.740 --> 00:33:31.599
And they've had a couple of buybacks, so to speak.

00:33:32.000 --> 00:33:33.380
And so I've been able to cash in some of those.

00:33:34.160 --> 00:33:37.099
So I guess I've had more success with my advisor

00:33:37.099 --> 00:33:39.380
shares than I have with my direct angel investments

00:33:39.380 --> 00:33:44.910
so far. And what was your criteria for the startups

00:33:44.910 --> 00:33:48.349
you picked? Yeah, the criteria was initially,

00:33:48.849 --> 00:33:51.970
is it something I feel like I can add value to

00:33:51.970 --> 00:33:55.950
and learn from, was initially my criteria. And

00:33:55.950 --> 00:33:58.289
then the criteria kind of became, was it something

00:33:58.289 --> 00:34:02.289
I believe in that's fixing a real problem? And

00:34:02.289 --> 00:34:05.609
then the criteria kind of became, do I believe

00:34:05.609 --> 00:34:09.530
in this founder? Does this person seem to have

00:34:09.530 --> 00:34:12.070
a clearer vision? Do they seem to be driven?

00:34:13.110 --> 00:34:15.070
So then it became kind of a combination of those

00:34:15.070 --> 00:34:17.449
things. So more of a gut feel. I can't tell you,

00:34:17.449 --> 00:34:21.630
I did a lot of high level VC level due diligence.

00:34:22.150 --> 00:34:25.130
And I never put in a ton of money. I kind of

00:34:25.130 --> 00:34:27.449
spread it out, small investments here or there.

00:34:27.489 --> 00:34:34.550
But it was just a really gut feel. What is something

00:34:34.550 --> 00:34:38.110
technical? Builders get wrong about healthcare.

00:34:40.030 --> 00:34:42.170
There's a lot in healthcare. I think from the

00:34:42.170 --> 00:34:45.550
outside and I think you'd probably agree that

00:34:45.550 --> 00:34:48.769
seems intuitive from the outside, but when you're

00:34:48.769 --> 00:34:50.610
in it, it's sort of counterintuitive and you

00:34:50.610 --> 00:34:54.489
don't understand like somebody was. tweeting

00:34:54.489 --> 00:34:58.210
recently about being frustrated about being on

00:34:58.210 --> 00:35:00.170
the wait list to be seen at a specialty clinic

00:35:00.170 --> 00:35:02.030
and their appointment was a couple of months

00:35:02.030 --> 00:35:04.849
out and they asked to be on a wait list for the

00:35:04.849 --> 00:35:06.610
appointment and then they happened to call up

00:35:06.610 --> 00:35:09.030
about something else and happened to just ask

00:35:09.030 --> 00:35:12.150
the person they talked to and were able to get

00:35:12.150 --> 00:35:14.429
in the next day. So it's like, how is this broken

00:35:14.429 --> 00:35:16.230
that they have this wait list and I've been on

00:35:16.230 --> 00:35:17.769
this wait list for two months. I just happened

00:35:17.769 --> 00:35:20.210
to randomly call up and got in the next day.

00:35:21.389 --> 00:35:25.010
And the reality is that scheduling is very complex

00:35:25.010 --> 00:35:26.510
and it seems like it's an easy thing to have

00:35:26.510 --> 00:35:28.110
a wait list somebody you know something opens

00:35:28.110 --> 00:35:29.449
up and somebody's going to get off the wait list

00:35:29.449 --> 00:35:32.030
but there's so much that goes on behind the scenes

00:35:32.030 --> 00:35:34.730
in terms of how you manage you know clinic appointments

00:35:34.730 --> 00:35:36.309
and somebody can't send their appointment the

00:35:36.309 --> 00:35:38.230
last minute and then having to somebody having

00:35:38.230 --> 00:35:39.949
to go through the wait list and call people and

00:35:39.949 --> 00:35:41.570
maybe the first three people you call don't pick

00:35:41.570 --> 00:35:43.909
up or they can't come in and now that person

00:35:43.909 --> 00:35:46.829
who's probably doing five other jobs is now having

00:35:46.829 --> 00:35:49.909
to spend time doing that, as opposed to it's

00:35:49.909 --> 00:35:51.989
just easier if somebody calls up that day and

00:35:51.989 --> 00:35:54.030
an appointment pops up that day. It's just easier

00:35:54.030 --> 00:35:56.510
to slot that person in than go through, you know,

00:35:56.670 --> 00:35:59.329
track down a wait list. Things like that. I mean,

00:35:59.329 --> 00:36:01.030
I think there's things that happen behind the

00:36:01.030 --> 00:36:04.710
scenes that are more complex and seem more straightforward

00:36:04.710 --> 00:36:06.610
from the outside. But then when you're in it

00:36:06.610 --> 00:36:08.289
and you've experienced, you realize there are

00:36:08.289 --> 00:36:09.909
things that maybe you're not considering that

00:36:09.909 --> 00:36:12.329
make it more complex. I'm not saying that's right.

00:36:12.449 --> 00:36:14.210
I'm not saying there aren't ways to make it less

00:36:14.210 --> 00:36:16.969
complex. But as it exists now, I think there's

00:36:16.969 --> 00:36:19.010
a complexity to even some of the things that

00:36:19.010 --> 00:36:22.269
seem really straightforward that people don't

00:36:22.269 --> 00:36:24.010
necessarily understand. A lot of it has to do

00:36:24.010 --> 00:36:27.130
with workflows of back office functions and things

00:36:27.130 --> 00:36:33.840
like that. What is the role of robotics and AI

00:36:33.840 --> 00:36:36.380
in ortho and what are you excited about for the

00:36:36.380 --> 00:36:40.059
future of ortho? So we've had a lot of robotics

00:36:40.059 --> 00:36:44.059
in ortho. I call it the robot wars And so there's

00:36:44.059 --> 00:36:46.019
robotic hip into your placement. That's really

00:36:46.019 --> 00:36:49.030
taken off. It's become more and more prevalent

00:36:49.030 --> 00:36:51.829
and I've done that in my career. If you look

00:36:51.829 --> 00:36:54.210
at the data, you know, the data isn't quite there

00:36:54.210 --> 00:36:56.809
yet in terms of superiority of robotics and like

00:36:56.809 --> 00:36:58.570
a lot of things in healthcare you have your camps,

00:36:58.869 --> 00:37:00.690
you know, people in robotic camp that say it's

00:37:00.690 --> 00:37:02.369
clearly better and people in non -robotic camp

00:37:02.369 --> 00:37:04.349
that say it's not and it's too expensive and

00:37:04.349 --> 00:37:07.210
it's, you know, blindly trusting technology.

00:37:07.869 --> 00:37:10.849
I think The potential is certainly there. I think

00:37:10.849 --> 00:37:12.610
we have to get more sophisticated with it. I

00:37:12.610 --> 00:37:14.889
think we have to learn how to use the robot better

00:37:14.889 --> 00:37:17.690
as a tool. So I think, you know, now the robots

00:37:17.690 --> 00:37:20.110
have been around for I think 10 years at least

00:37:20.110 --> 00:37:21.809
and we're gathering more data and we can look

00:37:21.809 --> 00:37:24.269
at that data and we can become better with the

00:37:24.269 --> 00:37:28.110
robots based on what we're data that we're gathering.

00:37:28.409 --> 00:37:30.769
And I think robotics will continue to. become

00:37:30.769 --> 00:37:32.570
higher and higher yield and eventually be proven

00:37:32.570 --> 00:37:36.690
to be superior probably to non -robotics. So

00:37:36.690 --> 00:37:39.269
I think AI will help us get there by taking in

00:37:39.269 --> 00:37:41.550
large amounts of data, unstructured data, structured

00:37:41.550 --> 00:37:44.190
data, you know, parsing through it and helping

00:37:44.190 --> 00:37:47.590
us figure out how best to use the robots and

00:37:47.590 --> 00:37:50.519
really personalize care. I think that's part

00:37:50.519 --> 00:37:53.099
of the challenge that we have particularly in

00:37:53.099 --> 00:37:55.820
hip and knee replacements is classically you're

00:37:55.820 --> 00:37:57.960
taught to kind of do it the same for everybody.

00:37:58.099 --> 00:38:00.139
But in reality, people's anatomy is different.

00:38:00.440 --> 00:38:02.300
We just don't know how it's different from one

00:38:02.300 --> 00:38:04.559
person to the next and how you tailor it from

00:38:04.559 --> 00:38:06.000
one person to the next. So you kind of treat

00:38:06.000 --> 00:38:08.059
everybody the same way. And you're going to capture

00:38:08.059 --> 00:38:12.800
80%, 90%, 75 % of people doing it the same for

00:38:12.800 --> 00:38:14.860
everybody. But you're going to have that 10 %

00:38:14.860 --> 00:38:18.800
to 20 % who don't need the standard hip or knee

00:38:18.800 --> 00:38:20.780
replacement needs something a little bit different.

00:38:20.820 --> 00:38:22.920
And we just don't have great tools to identify

00:38:22.920 --> 00:38:24.500
who those people are. And then even if we do

00:38:24.500 --> 00:38:26.659
identify them, what they do need. So I think

00:38:26.659 --> 00:38:29.820
robotics and AI are going to help us there. I

00:38:29.820 --> 00:38:32.500
think the other big thing with AI is being able

00:38:32.500 --> 00:38:35.940
to tailor non -surgical treatment or figure out

00:38:35.940 --> 00:38:39.260
what the best treatment is for that particular

00:38:39.260 --> 00:38:41.860
individual and be a little bit more personalized

00:38:41.860 --> 00:38:48.820
in terms of our treatments. Do you think AI will

00:38:48.820 --> 00:38:51.699
replace the family physician? And then do you

00:38:51.699 --> 00:38:54.019
think AI will replace the orthopedic surgeon?

00:38:54.500 --> 00:38:56.559
And if it does, which one will happen first?

00:38:57.739 --> 00:39:02.139
That's the hot button topic. I think the AI models

00:39:02.139 --> 00:39:04.260
will get better and better. It's very hard right

00:39:04.260 --> 00:39:08.380
now to, I think, parse through what's real and

00:39:08.380 --> 00:39:11.519
what's hype in terms of you pass USMLE or you

00:39:11.519 --> 00:39:14.300
pass this test, you pass that test. Well, I think

00:39:14.300 --> 00:39:17.840
people overestimate how much the sort of the

00:39:17.840 --> 00:39:20.699
diagnosis issue plays into things in health care.

00:39:20.820 --> 00:39:23.559
At least for orthopedics, the diagnosis isn't

00:39:23.559 --> 00:39:28.539
usually all that confusing or the diagnosis part

00:39:28.539 --> 00:39:30.820
of it isn't necessarily the hard part of it.

00:39:31.039 --> 00:39:34.199
The hard part of it is talking through the patient

00:39:34.199 --> 00:39:36.619
what the problem is, what the solutions are,

00:39:36.980 --> 00:39:39.980
choosing the right solution. what to do if the

00:39:39.980 --> 00:39:42.099
patient chooses a low value solution, what to

00:39:42.099 --> 00:39:44.440
do if the patient doesn't, you know, agree with

00:39:44.440 --> 00:39:46.380
the treatment recommendation. And I'm not sure

00:39:46.380 --> 00:39:48.940
that that's, you know, is that something AI is

00:39:48.940 --> 00:39:51.139
going to resolve? Is it something AI can't resolve?

00:39:51.340 --> 00:39:52.800
I think a lot of the companies that are pushing

00:39:52.800 --> 00:39:54.980
AI solutions don't want to, you know, be responsible

00:39:54.980 --> 00:39:57.739
for that, you know, discussion that decision

00:39:57.739 --> 00:40:00.400
making. So I mean, to get back to the original

00:40:00.400 --> 00:40:04.300
question, I think AI tools will help, but I think

00:40:04.300 --> 00:40:06.880
there's still the human element of medicine that

00:40:06.880 --> 00:40:11.699
people underestimate that You know, AI can seem

00:40:11.699 --> 00:40:14.360
empathetic, but at the end of the day, you know,

00:40:14.500 --> 00:40:16.679
how far is a patient going to be willing to go

00:40:16.679 --> 00:40:19.199
back and forth with the AI before they want somebody

00:40:19.199 --> 00:40:22.500
to, you know, really discuss with them or give

00:40:22.500 --> 00:40:25.860
them, you know, a little bit of a more less prescriptive

00:40:25.860 --> 00:40:28.940
answer, I guess, for lack of a better term. Will

00:40:28.940 --> 00:40:32.320
AI replace family physicians or orthopedic surgeons

00:40:32.320 --> 00:40:36.110
first? I think there's definitely a future where

00:40:36.110 --> 00:40:39.150
robots are able to do a hip or knee replacement

00:40:39.150 --> 00:40:43.110
without the surgeon needing to touch the robot.

00:40:43.230 --> 00:40:45.010
I think there are already companies working on

00:40:45.010 --> 00:40:48.429
that. You know, once the robot still has to learn

00:40:48.429 --> 00:40:50.170
how to do the exposure, maybe someday they'll

00:40:50.170 --> 00:40:52.389
learn how to do that. But you may replace the

00:40:52.389 --> 00:40:54.730
surgeon with just a technician who doesn't go

00:40:54.730 --> 00:40:57.130
through a full training, but just kind of monitors

00:40:57.130 --> 00:41:00.780
the robot. I don't think we're there yet. I think

00:41:00.780 --> 00:41:02.800
that's going to take a long time. I think it

00:41:02.800 --> 00:41:04.880
will take time for patients to trust that. So

00:41:04.880 --> 00:41:08.340
if, I think this is a big if, AI is going to

00:41:08.340 --> 00:41:11.320
replace somebody, it's probably going to be the

00:41:11.320 --> 00:41:14.659
so -called cognitive specialties before the surgical

00:41:14.659 --> 00:41:17.199
procedural specialties. But I think we're a long

00:41:17.199 --> 00:41:19.599
way off from both of those things. And I think

00:41:19.599 --> 00:41:23.019
people also overestimate the degree to which

00:41:23.019 --> 00:41:25.619
patients want that. I think there's still a large

00:41:25.619 --> 00:41:29.059
amount of skepticism and distrust. towards AI

00:41:29.059 --> 00:41:31.659
that gets discounted in the circles that we sort

00:41:31.659 --> 00:41:34.280
of run in because there's a lot of interest and

00:41:34.280 --> 00:41:36.059
we kind of end up in this echo chamber, these

00:41:36.059 --> 00:41:39.360
small spheres of. innovators, health tech people,

00:41:39.860 --> 00:41:41.820
entrepreneurs, investors that are really bullish

00:41:41.820 --> 00:41:44.739
on AI and health care. But if you look at the

00:41:44.739 --> 00:41:47.139
studies that come out, you know, patients like

00:41:47.139 --> 00:41:49.219
AI until they figure out it's AI and then they

00:41:49.219 --> 00:41:53.039
don't like it so much. And so I think we're still

00:41:53.039 --> 00:41:56.000
underestimating the degree to which the demand

00:41:56.000 --> 00:41:59.699
on the part of patients is there. There's definitely

00:41:59.699 --> 00:42:01.820
a subset of people that are very frustrated with

00:42:01.820 --> 00:42:04.380
traditional health care and would go to an AI.

00:42:04.840 --> 00:42:06.900
you know, chatbot or whatever in a minute, because

00:42:06.900 --> 00:42:08.639
they're so fed up with the traditional system.

00:42:08.820 --> 00:42:10.679
And I think they, you know, maybe get a little

00:42:10.679 --> 00:42:14.780
bit more attention than the 60, 70, 80 % of other

00:42:14.780 --> 00:42:18.480
people that still want human interaction. Yeah,

00:42:18.480 --> 00:42:22.340
I love talking to AI Gemini, and chat jibbity

00:42:22.340 --> 00:42:25.219
and AI agents as well. They always tell me a

00:42:25.219 --> 00:42:29.380
brilliant time. Yeah. That's the other part,

00:42:29.400 --> 00:42:31.320
right? They're very there and they're they're

00:42:31.320 --> 00:42:33.679
made that way They're made to be affirming and

00:42:33.679 --> 00:42:36.599
they're made to sort of be, you know, not necessarily

00:42:36.599 --> 00:42:39.480
sycophantic Although obviously chat GPT 4o kind

00:42:39.480 --> 00:42:42.219
of tipped over in that direction But yeah, I

00:42:42.219 --> 00:42:44.000
mean the more you talk with it the more the more

00:42:44.000 --> 00:42:47.159
great you become and what's yeah And again, the

00:42:47.159 --> 00:42:48.739
models can be tuned in different ways, but it's

00:42:48.739 --> 00:42:50.920
a little bit You know disturbing that you can

00:42:50.920 --> 00:42:53.059
kind of lead the witness and if you talk to chat

00:42:53.059 --> 00:42:55.219
GPT or Gemini long enough eventually They'll

00:42:55.219 --> 00:42:56.900
start to you know, tell you what you want to

00:42:56.900 --> 00:42:58.489
hear. They'll just base basically echo back to

00:42:58.489 --> 00:43:00.849
you what you're suggesting to them. And that

00:43:00.849 --> 00:43:03.110
can be very dangerous in healthcare. It can lead

00:43:03.110 --> 00:43:05.829
to poor decisions that seem like the right decision.

00:43:06.929 --> 00:43:11.110
Do you think that's good for mental health? Chat

00:43:11.110 --> 00:43:16.710
bots and AI? Yeah. I think it can be, but I think

00:43:16.710 --> 00:43:19.610
it can just like social media. It can be, but

00:43:19.610 --> 00:43:22.550
it can very quickly become not so good for your

00:43:22.550 --> 00:43:24.809
mental health. I mean, there were stories that

00:43:24.809 --> 00:43:27.619
were coming out of the revolt against GPT -5

00:43:27.619 --> 00:43:30.480
and people were very upset that GPT -4 went away

00:43:30.480 --> 00:43:32.960
because they had bonded with it and people were

00:43:32.960 --> 00:43:35.500
so upset they were crying. I think that that's

00:43:35.500 --> 00:43:39.179
probably not the best thing. And so I think like

00:43:39.179 --> 00:43:41.559
any tool that gives you that feedback, it probably

00:43:41.559 --> 00:43:43.780
is giving you the same dopamine hit that social

00:43:43.780 --> 00:43:46.340
media gives you and maybe even worse because

00:43:46.340 --> 00:43:49.019
you can kind of tune it to give you the dopamine

00:43:49.019 --> 00:43:51.579
hits that you want. I think that's dangerous.

00:43:52.820 --> 00:43:56.650
And why is it dangerous? Well, I think it's dangerous

00:43:56.650 --> 00:43:58.429
because you kind of get sucked into that world

00:43:58.429 --> 00:44:00.150
the same way you can get sucked into social media

00:44:00.150 --> 00:44:04.130
and kind of lose track of you know, what is reality

00:44:04.130 --> 00:44:07.570
to lose track of being grounded and start to

00:44:07.570 --> 00:44:10.170
You know believe things that aren't necessarily

00:44:10.170 --> 00:44:13.489
true or get the same thing as you can go down

00:44:13.489 --> 00:44:17.530
a rabbit hole with social media of being fed

00:44:17.530 --> 00:44:19.769
things that seem like they're true but aren't.

00:44:19.949 --> 00:44:23.349
I think there's the risk with AI that it's telling

00:44:23.349 --> 00:44:25.389
you how great you are, and maybe you aren't really

00:44:25.389 --> 00:44:27.869
that great, or maybe there are things that you

00:44:27.869 --> 00:44:31.469
need to fix or be aware of, and it's sort of

00:44:31.469 --> 00:44:33.590
telling you to justify that. No, you're right,

00:44:33.670 --> 00:44:36.630
and everybody else is wrong, and maybe you aren't

00:44:36.630 --> 00:44:41.440
right. Do you and so my listeners will be used

00:44:41.440 --> 00:44:44.159
to this, but let's go a little bit deeper here.

00:44:44.719 --> 00:44:50.179
Do you think ignorance is bliss? And if so, if

00:44:50.179 --> 00:44:52.059
someone tells you you're right, even if you're

00:44:52.059 --> 00:44:54.179
not and gives you constant validation and you

00:44:54.179 --> 00:44:57.980
fall in love with a robot like her, should we

00:44:57.980 --> 00:45:01.099
deny that for you? If that will lead to happiness

00:45:01.099 --> 00:45:05.059
as happiness, the objective. or is objective

00:45:05.059 --> 00:45:07.860
reaching the truth? And if it's the latter, why

00:45:07.860 --> 00:45:12.900
is that? Why isn't happiness? Yeah, I think we

00:45:12.900 --> 00:45:16.199
would love for ignorance to be blessed because

00:45:16.199 --> 00:45:19.780
facing the truth is painful. But I think there

00:45:19.780 --> 00:45:23.539
is, you know, danger in the ignorance is bliss

00:45:23.539 --> 00:45:26.880
because how long can that continue? You know,

00:45:26.880 --> 00:45:29.599
at some point you may have to face the truth

00:45:29.599 --> 00:45:32.539
whether you want to or not. And I think that

00:45:32.539 --> 00:45:36.219
that can be very painful. I think there's very

00:45:36.219 --> 00:45:38.460
much a parallel in medicine. And I think that's

00:45:38.460 --> 00:45:42.320
why it's going to be hard to have AI replace

00:45:42.320 --> 00:45:45.940
humans in health care. Because if the AI, let's

00:45:45.940 --> 00:45:48.900
say somebody comes in. They have knee arthritis.

00:45:49.960 --> 00:45:51.719
And they get an MRI. They have a meniscus tear.

00:45:51.800 --> 00:45:53.599
And their neighbor had a knee scope. And they

00:45:53.599 --> 00:45:55.440
really want a knee scope. And I sit there and

00:45:55.440 --> 00:45:58.440
tell them, look, you're past the point of a knee

00:45:58.440 --> 00:46:02.500
scope. you know, the really it's either knee

00:46:02.500 --> 00:46:05.340
replacement or, you know, not awkward treatment,

00:46:05.380 --> 00:46:06.940
but that patient's adamant that they want a knee

00:46:06.940 --> 00:46:09.639
scope. And I know that that is, you know, low

00:46:09.639 --> 00:46:14.159
value treatment. You know, at what point does

00:46:14.159 --> 00:46:17.139
ignorance, you know, it's not my job to hide

00:46:17.139 --> 00:46:18.980
the truth from them and just say, you know what,

00:46:19.239 --> 00:46:21.590
this person wants that knee scope. I know it's

00:46:21.590 --> 00:46:23.530
not the best option for them. I know they're

00:46:23.530 --> 00:46:25.530
probably going to do worse with that. But ignorance

00:46:25.530 --> 00:46:27.730
is bliss for that patient. If they don't know

00:46:27.730 --> 00:46:30.889
that going into it, no harm, no foul. But eventually,

00:46:30.909 --> 00:46:33.650
they're going to find out afterwards that ignorance

00:46:33.650 --> 00:46:36.949
is not bliss. So yes, it would be a lot easier

00:46:36.949 --> 00:46:39.750
to just go along with it and say, have that surgery.

00:46:39.829 --> 00:46:41.889
Even if I know that surgery is unlikely to help

00:46:41.889 --> 00:46:44.369
you, that's the path of least resistance rather

00:46:44.369 --> 00:46:48.070
than the truth, which is more painful, that less

00:46:48.070 --> 00:46:50.889
invasive surgery, that's not a a painful long

00:46:50.889 --> 00:46:54.050
recovery knee replacement is not gonna help you.

00:46:54.289 --> 00:46:56.949
So I think, you know, ignorance is bliss until

00:46:56.949 --> 00:46:59.590
it isn't. And sometimes you have to face those

00:46:59.590 --> 00:47:02.429
hard truths. And that's, you know, part of medicine.

00:47:02.449 --> 00:47:06.010
And I think it's part of life. Do you think this

00:47:06.010 --> 00:47:10.210
is something founders and non -founders who don't

00:47:10.210 --> 00:47:11.929
have a healthcare background, building in medicine

00:47:11.929 --> 00:47:16.650
get wrong, that they just want to maximize press

00:47:16.650 --> 00:47:19.309
gainy scores or patient satisfaction scores and

00:47:19.309 --> 00:47:22.469
surveys? And they know the way to maximize is

00:47:22.469 --> 00:47:24.690
give the patient what they request, what they

00:47:24.690 --> 00:47:29.269
want, not what they need. dangerous. I think

00:47:29.269 --> 00:47:31.530
there, you know, I get, I don't want to say battles,

00:47:31.690 --> 00:47:34.090
but disagreements sometimes on social media about

00:47:34.090 --> 00:47:37.130
this, of this idea of consumerization in healthcare,

00:47:37.389 --> 00:47:39.889
right? If you're treating the patient as a customer,

00:47:39.889 --> 00:47:43.670
and you take the idea in business that the customer

00:47:43.670 --> 00:47:46.170
is always right, then, you know, the patient

00:47:46.170 --> 00:47:48.670
is going to come in and dictate care. And I don't

00:47:48.670 --> 00:47:50.809
think it should be a paternalistic model. I think

00:47:50.809 --> 00:47:54.590
shared decision making is the right model. It

00:47:54.590 --> 00:47:56.789
shouldn't be me as a doctor telling the patient,

00:47:56.949 --> 00:48:00.059
you know, what the treatment's going to be. But

00:48:00.059 --> 00:48:01.940
I think the flip side of that is a patient dictating

00:48:01.940 --> 00:48:03.659
treatment. Look, if we want a healthcare system,

00:48:03.900 --> 00:48:06.179
if we say we want value -based care, or we say

00:48:06.179 --> 00:48:08.840
we want evidence -based care, or we say we want

00:48:08.840 --> 00:48:11.780
high -value care, you can't slam doctors for

00:48:11.780 --> 00:48:14.079
offering low -value treatments because they get

00:48:14.079 --> 00:48:16.760
paid for it. At the same time, slam doctors for

00:48:16.760 --> 00:48:18.659
gatekeeping care or being paternalistic. You

00:48:18.659 --> 00:48:21.659
have to find that middle ground between the two

00:48:21.659 --> 00:48:23.320
of those things. And I think that is something

00:48:23.320 --> 00:48:25.949
that gets. overlooked. And the most difficult

00:48:25.949 --> 00:48:28.210
conversations I had throughout my career were

00:48:28.210 --> 00:48:30.829
the ones where a person, you know, was really

00:48:30.829 --> 00:48:32.849
adamant that they wanted surgery, which I get,

00:48:32.849 --> 00:48:35.130
you know, paid more to do, right? I mean, I,

00:48:35.269 --> 00:48:37.590
you know, if somebody says I want surgery, and

00:48:37.590 --> 00:48:39.269
I'm just the fee for service, you know, surgeon

00:48:39.269 --> 00:48:41.010
wants to get paid, sure, even if I don't think

00:48:41.010 --> 00:48:43.030
that surgery is indicated, okay, it's very easy,

00:48:43.130 --> 00:48:45.030
you know, sure, I'll sign up for surgery if you

00:48:45.030 --> 00:48:47.340
want surgery. it's not always the right thing

00:48:47.340 --> 00:48:49.300
to do. And those are the difficult conversations

00:48:49.300 --> 00:48:51.860
to, it's incumbent on me to explain the rationale

00:48:51.860 --> 00:48:56.980
of why that is. But at the same time, I, in my

00:48:56.980 --> 00:49:00.619
judgment, am trying to prevent a bad outcome

00:49:00.619 --> 00:49:04.639
and do what in my experience and my judgment,

00:49:05.219 --> 00:49:08.260
or at least explain to the patient what in my

00:49:08.260 --> 00:49:10.800
best judgment is the right course of action.

00:49:10.820 --> 00:49:13.650
And then it becomes, you know, Well, it doesn't

00:49:13.650 --> 00:49:15.389
matter what you want, doctor. If the patient

00:49:15.389 --> 00:49:16.949
wants the surgery, the patient should have the

00:49:16.949 --> 00:49:18.550
surgery. How do we reconcile that? And I think

00:49:18.550 --> 00:49:21.650
that gets overlooked a lot of the time of, well,

00:49:21.670 --> 00:49:23.010
it's just doctor's gatekeeping. You don't want

00:49:23.010 --> 00:49:24.610
me to have this. You don't want me to have that.

00:49:25.429 --> 00:49:28.829
But there is sometimes a reason behind that.

00:49:29.400 --> 00:49:32.219
again, it's incumbent on me to explain that rationale

00:49:32.219 --> 00:49:35.039
and to, you know, engender enough trust in the

00:49:35.039 --> 00:49:37.079
patient that they at least take what I have to

00:49:37.079 --> 00:49:39.579
say to heart, they may not follow it. And that's,

00:49:39.579 --> 00:49:42.139
you know, it's not up to me to be prescriptive

00:49:42.139 --> 00:49:45.320
to them, they should have the autonomy and the

00:49:45.320 --> 00:49:49.159
the agency to make those decisions. But I think,

00:49:49.159 --> 00:49:51.260
you know, at the end of the day, the the customer

00:49:51.260 --> 00:49:54.199
is always right is not the best way to practice

00:49:54.199 --> 00:49:58.559
healthcare. If there's a system where you know,

00:49:58.980 --> 00:50:02.260
we're operating healthcare as a buffet or a McDonald's

00:50:02.260 --> 00:50:05.719
drive -thru and patients get to pick what they

00:50:05.719 --> 00:50:07.940
want. Say they get to pick they want surgery

00:50:07.940 --> 00:50:10.079
and if you're operating in that system you have

00:50:10.079 --> 00:50:13.559
to provide it even though you know it may actually

00:50:13.559 --> 00:50:16.960
lead to net harm for this patient and for this

00:50:16.960 --> 00:50:22.210
situation. If that system exists Should we also

00:50:22.210 --> 00:50:25.610
build a parallel liability legal system which

00:50:25.610 --> 00:50:30.329
allows the patient to assume full liability and

00:50:30.329 --> 00:50:35.630
they can sign off their right to sue? Because

00:50:35.630 --> 00:50:37.550
currently the current system, they can't do that.

00:50:37.789 --> 00:50:41.329
Even if you do what the patient wants, I guess

00:50:41.329 --> 00:50:43.710
you're better judgment. If there's a negative

00:50:43.710 --> 00:50:46.460
outcome, the patient can still sue you. and no

00:50:46.460 --> 00:50:49.159
amount of notes that I told them. So that's not

00:50:49.159 --> 00:50:50.940
going to protect you because you still performed

00:50:50.940 --> 00:50:53.900
the surgery. So how are you going to look at

00:50:53.900 --> 00:50:57.780
the liability framework shifting? And the one

00:50:57.780 --> 00:51:00.679
analogy is if there's an AI pilot flying the

00:51:00.679 --> 00:51:03.099
plane for a cheaper fare, should patients be

00:51:03.099 --> 00:51:05.239
allowed to sign off liability? The answer there,

00:51:05.440 --> 00:51:08.139
I think, is clearly no because the risk is too

00:51:08.139 --> 00:51:11.099
high and there's a big information asymmetry.

00:51:11.599 --> 00:51:13.940
Patients have no idea how to fly a plane unless

00:51:13.940 --> 00:51:17.349
you're a pilot. Just so your patients have no

00:51:17.349 --> 00:51:19.610
idea how to do a joint replacement, unless they're

00:51:19.610 --> 00:51:23.050
an orthopedic surgeon. So I think, like, how

00:51:23.050 --> 00:51:24.949
do you think about liability in this framework?

00:51:27.750 --> 00:51:30.510
Yeah, I mean, I think even in that situation,

00:51:30.630 --> 00:51:34.050
you could probably still argue that the patient

00:51:34.050 --> 00:51:36.050
can inform themselves, and many patients do,

00:51:36.090 --> 00:51:38.289
are very informed. They have more tools now than

00:51:38.289 --> 00:51:41.489
they've ever had to inform themselves. I'd like

00:51:41.489 --> 00:51:46.570
to think that the Whatever 14 years I spent getting

00:51:46.570 --> 00:51:50.050
through training and then the 17 years I spent

00:51:50.050 --> 00:51:53.389
in my career taught me enough experience that

00:51:53.389 --> 00:51:55.710
even all the reading in the world, all the educating

00:51:55.710 --> 00:51:59.369
yourself in the world isn't a substitute for

00:51:59.369 --> 00:52:01.969
having experienced it multiple patients over

00:52:01.969 --> 00:52:08.659
many years. So can a patient ever fully understand

00:52:08.659 --> 00:52:10.639
the risks. I think a lot of them would argue

00:52:10.639 --> 00:52:13.860
yes. And I can see a lot of them rolling their

00:52:13.860 --> 00:52:15.780
eyes at me right now and saying, you know, doctor,

00:52:15.940 --> 00:52:17.900
it's my decision. I can educate myself. You know

00:52:17.900 --> 00:52:20.139
what you're talking about? I don't know. I mean,

00:52:20.179 --> 00:52:22.679
I think if you looked at other, you know, pilots

00:52:22.679 --> 00:52:26.920
flying a plane, you know, any other type of profession

00:52:26.920 --> 00:52:28.760
where it's, you know, you go through a training

00:52:28.760 --> 00:52:32.260
process that's rigorous. I don't think that I

00:52:32.260 --> 00:52:35.739
would never walk onto a plane after researching

00:52:35.739 --> 00:52:37.280
how to fly a plane and think that I could fly

00:52:37.280 --> 00:52:40.840
a plane. I would never go to a fancy restaurant.

00:52:40.960 --> 00:52:43.920
I think I could go in the kitchen and make meals

00:52:43.920 --> 00:52:46.760
for everybody. Not to trivialize it, but I think

00:52:46.760 --> 00:52:51.519
that can you ever really make a fully informed

00:52:51.519 --> 00:52:54.519
enough decision to take on that liability? Is

00:52:54.519 --> 00:52:57.440
that the right thing to do? And I don't think

00:52:57.440 --> 00:53:03.480
it's necessarily the right thing to do. What

00:53:03.480 --> 00:53:06.639
is a common misconception about ortho? You know,

00:53:06.639 --> 00:53:09.500
there's a lot of ortho jokes, right? Like what

00:53:09.500 --> 00:53:12.679
is a stethoscope? And I don't hear the bone and

00:53:12.679 --> 00:53:16.719
things like that. But what's a more serious common

00:53:16.719 --> 00:53:19.260
misconception? And what advice do you have for

00:53:19.260 --> 00:53:22.119
medical students who are thinking about orthopedic

00:53:22.119 --> 00:53:25.760
surgery as a residency? Yeah, I think there's

00:53:25.760 --> 00:53:28.079
a couple misconceptions that I'll go, you know

00:53:28.079 --> 00:53:32.119
more high high level and low level so I think

00:53:32.119 --> 00:53:34.940
the high level misconception You know is that

00:53:34.940 --> 00:53:38.300
sort of Neanderthal orthopedic surgeon? I'm not

00:53:38.300 --> 00:53:40.599
sure I could get an orthopedic surgery his residency

00:53:40.599 --> 00:53:43.139
spot in this day and age because they're so competitive

00:53:43.139 --> 00:53:46.849
and Even back in my day, you kind of had to be

00:53:46.849 --> 00:53:48.869
at the top of your class and do well on the standardized

00:53:48.869 --> 00:53:52.510
testing to get a spot. Now, I think the average

00:53:52.510 --> 00:53:56.230
number of publications for an orthopedic resident

00:53:56.230 --> 00:53:58.510
or somebody, a medical student applying to orthopedics

00:53:58.510 --> 00:54:00.769
is like 10 publications or something ridiculous

00:54:00.769 --> 00:54:04.789
like that. doing research wasn't even on my radar

00:54:04.789 --> 00:54:06.610
screen in medical school. Now you can't get a

00:54:06.610 --> 00:54:08.469
spot unless you've done a lot of research. I

00:54:08.469 --> 00:54:10.389
think there's good things and bad things about

00:54:10.389 --> 00:54:13.010
that. I think it sort of leads to maybe low quality

00:54:13.010 --> 00:54:15.590
research and there's pressure to publish papers.

00:54:15.989 --> 00:54:19.610
But I guess the misconception would be that orthopedic

00:54:19.610 --> 00:54:22.449
surgeons are just kind of Neanderthals that carry

00:54:22.449 --> 00:54:25.869
hammers around. The lower level misconception,

00:54:26.170 --> 00:54:32.460
we get or the misconception of the orthopedics

00:54:32.460 --> 00:54:35.079
is just all about the money. It's all about how

00:54:35.079 --> 00:54:37.920
many procedures can I do? It's all about the

00:54:37.920 --> 00:54:40.360
financial part of it. We are well paid. We are

00:54:40.360 --> 00:54:42.739
typically at the top of the reimbursement list

00:54:42.739 --> 00:54:48.869
here in the US. I would argue it's in part. because

00:54:48.869 --> 00:54:52.070
we are entrepreneurial. We tend to be more fiercely

00:54:52.070 --> 00:54:55.570
independent than some other specialties. We do

00:54:55.570 --> 00:54:57.670
have the ability to take advantage of ancillary

00:54:57.670 --> 00:55:00.789
services like PT and MRI and owning ASCs that

00:55:00.789 --> 00:55:03.610
sort of are complementary to what we do in our

00:55:03.610 --> 00:55:06.429
day to day. I think that we have gotten more

00:55:06.429 --> 00:55:10.530
efficient and changed with the times. The average

00:55:10.530 --> 00:55:13.250
Medicare reimbursement for a total joint now

00:55:13.250 --> 00:55:17.050
is... I think by 2026 is going to be less than

00:55:17.050 --> 00:55:20.090
$1 ,200 to the surgeon for a hip or knee replacement

00:55:20.090 --> 00:55:23.190
from Medicare. And that's when you adjust for

00:55:23.190 --> 00:55:26.670
inflation down over 80 % compared to it was 20

00:55:26.670 --> 00:55:28.650
years ago. And you say, oh, well, you've just

00:55:28.650 --> 00:55:30.409
done more unnecessary surgeries. Well, at the

00:55:30.409 --> 00:55:33.210
same time, we have this. population that's aging,

00:55:33.429 --> 00:55:35.530
we have this demand for joint replacements that's

00:55:35.530 --> 00:55:37.869
going up. As a baby boomers age, we also have

00:55:37.869 --> 00:55:39.670
the second population of younger people that

00:55:39.670 --> 00:55:42.570
are getting arthritis at an earlier age. So there

00:55:42.570 --> 00:55:45.170
really is no need to do unnecessary joint replacements

00:55:45.170 --> 00:55:47.429
at this point. We've just become extremely efficient

00:55:47.429 --> 00:55:50.769
at it. Patients are getting more complex, but

00:55:50.769 --> 00:55:53.309
our outcomes are the same, if not better than

00:55:53.309 --> 00:55:56.570
they were when patients were healthier. So, you

00:55:56.570 --> 00:55:59.539
know. I think people underestimate you say oh

00:55:59.539 --> 00:56:01.599
you just you just do more do more surgeries well

00:56:01.599 --> 00:56:03.239
the surgeries have to be done you don't just

00:56:03.239 --> 00:56:05.179
you know wave your hand it's still you know work

00:56:05.179 --> 00:56:08.820
to get it done um you know so I think that we

00:56:08.820 --> 00:56:12.280
get ding sometimes for you know sort of being

00:56:12.280 --> 00:56:14.559
just you know money focused and doing unnecessary

00:56:14.559 --> 00:56:16.900
surgeries you know that happens for sure I mean

00:56:16.900 --> 00:56:19.159
I'm not here to say that doesn't happen in some

00:56:19.159 --> 00:56:22.219
cases but I don't think it's as as frequent as

00:56:22.219 --> 00:56:29.269
people make it out to be. Last question, what

00:56:29.269 --> 00:56:32.730
advice do you have for 35 year old Ben if you

00:56:32.730 --> 00:56:36.389
can go back in time and talk to him? So let's

00:56:36.389 --> 00:56:39.010
see 35 year old Ben. So, you know, 13 years ago,

00:56:39.110 --> 00:56:43.429
where was I 13 years ago? I was still early on

00:56:43.429 --> 00:56:47.849
in my career. I would say, you know, just give

00:56:47.849 --> 00:56:50.510
yourself more grace. You know, don't be so hard

00:56:50.510 --> 00:56:53.809
on yourself. Don't be. I think perfection should

00:56:53.809 --> 00:56:57.739
always be the goal. I think back then, I didn't

00:56:57.739 --> 00:57:01.079
understand that perfection is a fool's errand

00:57:01.079 --> 00:57:04.820
in health care and as a surgeon to give yourself

00:57:04.820 --> 00:57:08.119
a little bit of grace when you don't reach perfection.

00:57:08.880 --> 00:57:10.699
And, you know, it's always going to eat at you,

00:57:10.719 --> 00:57:13.440
but you can't let it consume you. You have to

00:57:13.440 --> 00:57:15.219
learn from it. You have to learn from your mistakes.

00:57:15.260 --> 00:57:17.599
You have to get better. But you also have to,

00:57:17.599 --> 00:57:20.679
you know, not overlook your your wins and focus

00:57:20.679 --> 00:57:23.780
too much on on the losses. I think there's a

00:57:23.780 --> 00:57:26.639
tendency. particularly in high achieving people

00:57:26.639 --> 00:57:28.900
to over index on the losses and not give yourself

00:57:28.900 --> 00:57:32.760
enough credit for the wins. I'll ask one more

00:57:32.760 --> 00:57:36.179
question. So I'm 39, entering 40 fairly soon

00:57:36.179 --> 00:57:41.659
in January. My 30s have been more or less a blur.

00:57:42.639 --> 00:57:47.559
It feels like I was 29 yesterday, mentally, physically

00:57:47.559 --> 00:57:53.960
less so. What advice do you have for someone?

00:57:55.000 --> 00:57:57.099
And you know, I'm doing four or five different

00:57:57.099 --> 00:57:59.619
things with my career, partly because I don't

00:57:59.619 --> 00:58:03.260
know what to do still. And partly because some

00:58:03.260 --> 00:58:06.280
things bring in money and some things I do for

00:58:06.280 --> 00:58:09.900
enjoyment. What advice do you have for someone

00:58:09.900 --> 00:58:14.699
who's just entering their 40s? I think take time

00:58:14.699 --> 00:58:19.780
to... Slow down and enjoy the journey Because

00:58:19.780 --> 00:58:22.920
you know when you're really young you feel physically,

00:58:22.920 --> 00:58:26.679
you know invulnerable and Then you're also just

00:58:26.679 --> 00:58:30.559
sort of you know Learning your way Through things,

00:58:30.840 --> 00:58:33.099
you know when you're 30s you still feel physically,

00:58:33.099 --> 00:58:35.460
you know, pretty good. You're starting to establish

00:58:35.460 --> 00:58:38.699
yourself You know, but things are still pretty

00:58:38.699 --> 00:58:40.340
fresh and you're not necessarily thinking about

00:58:40.340 --> 00:58:42.360
the long term at that point I think as you get

00:58:42.360 --> 00:58:45.500
into your you know 40s particularly towards later

00:58:45.500 --> 00:58:48.480
on in your 40s, I think you start to think more

00:58:48.480 --> 00:58:53.300
about work -life balance and not go, go, go all

00:58:53.300 --> 00:58:55.679
the time, but appreciate the journey, appreciate

00:58:55.679 --> 00:58:59.320
the... the people around you, your family, you

00:58:59.320 --> 00:59:02.840
know, appreciate the small moments that you can't

00:59:02.840 --> 00:59:05.420
go, go, go all the time because, you know, you

00:59:05.420 --> 00:59:08.519
start to realize that, you know, you're not going

00:59:08.519 --> 00:59:10.260
to be here forever. And then you don't want to

00:59:10.260 --> 00:59:13.320
look back on it and, you know, regret not spending

00:59:13.320 --> 00:59:15.619
more time doing these things. I mean, I'm sure

00:59:15.619 --> 00:59:17.579
you do it for your family the same way that I

00:59:17.579 --> 00:59:20.500
do it for my family. But at the same time, they

00:59:20.500 --> 00:59:22.860
want you there. They appreciate the work that

00:59:22.860 --> 00:59:26.900
you do, but they also want you present. And so

00:59:26.900 --> 00:59:29.199
it's about finding that right balance and then

00:59:29.199 --> 00:59:34.739
realizing that you only have so much time. Awesome.

00:59:35.019 --> 00:59:37.780
Thanks so much for joining us today, Ben. Yeah,

00:59:37.900 --> 00:59:39.280
no problem. Yeah, appreciate it.