WEBVTT 00:00:02.350 --> 00:00:05.429 Hi, Ben. Thanks for joining us today. Yeah, thanks 00:00:05.429 --> 00:00:10.070 for having me. You're currently leaving clinical 00:00:10.070 --> 00:00:12.890 medicine behind and your stethoscope or your 00:00:12.890 --> 00:00:15.550 hammer, as you might call it in the ortho world. 00:00:16.690 --> 00:00:20.550 And you're joining as a leadership at Commons 00:00:20.550 --> 00:00:23.710 Clinic. Tell me about your path and how did you 00:00:23.710 --> 00:00:27.519 get here? Right. So yeah, I've been in practice 00:00:27.519 --> 00:00:31.219 for 17 years with paediatric surgery, joint replacement. 00:00:31.399 --> 00:00:34.479 So a lot of hammering and sawing and malleting 00:00:34.479 --> 00:00:38.200 things into place. Very typical standard career 00:00:38.200 --> 00:00:41.399 for probably the first at least 10, 11 years 00:00:41.399 --> 00:00:45.420 for that career. And then about six, seven years 00:00:45.420 --> 00:00:49.789 ago. got interested in entrepreneurship, healthcare 00:00:49.789 --> 00:00:52.789 technology, got involved in some value -based 00:00:52.789 --> 00:00:55.490 care stuff in my own practice, and just kind 00:00:55.490 --> 00:00:57.630 of got to the point of my career where I started 00:00:57.630 --> 00:00:59.950 to think about, you know, what's next? What's 00:00:59.950 --> 00:01:03.469 my legacy? Am I going to do this forever or is 00:01:03.469 --> 00:01:07.069 there something more to my career? And so I started 00:01:07.069 --> 00:01:09.930 doing some angel investing, some advising with 00:01:09.930 --> 00:01:13.390 some companies, started to build a network by 00:01:13.390 --> 00:01:16.859 posting stuff on LinkedIn just to kind of drive 00:01:16.859 --> 00:01:18.719 conversations, get in front of people I wouldn't 00:01:18.719 --> 00:01:22.780 otherwise get in front of. And that led me to 00:01:22.780 --> 00:01:25.319 a guy called Nick Aubin, who's the CEO and founder 00:01:25.319 --> 00:01:27.700 of Commons Clinic. And what Commons Clinic was 00:01:27.700 --> 00:01:31.260 doing and is still doing was trying to build 00:01:31.260 --> 00:01:34.519 value -based care models, tech forward models. 00:01:35.069 --> 00:01:38.670 of care, like a new care delivery model surfaced 00:01:38.670 --> 00:01:41.750 or revolving around MSK initially, but with the 00:01:41.750 --> 00:01:44.689 goal to do multi -specialty at some point. So 00:01:44.689 --> 00:01:46.189 I had come up with this, what I thought was a 00:01:46.189 --> 00:01:48.769 brilliant idea of arthritis centers of excellence, 00:01:48.890 --> 00:01:51.730 where you get high quality surgeons you try to 00:01:51.730 --> 00:01:54.530 work with instead of against insurance companies, 00:01:55.030 --> 00:01:57.049 you incorporate technology into what you're doing, 00:01:57.170 --> 00:02:00.030 you revolve around outpatient centers and ASCs. 00:02:00.459 --> 00:02:02.780 And so I wrote this white paper. I put together 00:02:02.780 --> 00:02:04.980 this slide deck, but I had no idea at the time, 00:02:05.140 --> 00:02:06.739 like, well, what do I do with this? I didn't 00:02:06.739 --> 00:02:08.360 know how to get in front of investors. I was 00:02:08.360 --> 00:02:10.020 a full -time practice. I didn't really have the 00:02:10.020 --> 00:02:12.840 time to, you know, kind of pursue it. And then 00:02:12.840 --> 00:02:14.979 came across Commons Clinic and it turned out 00:02:14.979 --> 00:02:17.500 that they were already doing or building what 00:02:17.500 --> 00:02:21.030 I had kind of envisioned. And so met Nick. made 00:02:21.030 --> 00:02:23.590 a small angel investment in their seed round. 00:02:23.770 --> 00:02:25.930 This was probably three or four years ago and 00:02:25.930 --> 00:02:27.990 just kept in contact with them through the years. 00:02:28.509 --> 00:02:31.229 We would touch base every so often, trade notes, 00:02:31.550 --> 00:02:35.129 just riff on value -based MSK. I started my own 00:02:35.129 --> 00:02:38.689 blog about two years ago, just to kind of share 00:02:38.689 --> 00:02:41.490 more long form thoughts. And a lot of it was 00:02:41.490 --> 00:02:43.909 in line with still what Commons was doing, not 00:02:43.909 --> 00:02:45.650 necessarily intentionally, but just because we're 00:02:45.650 --> 00:02:48.969 pretty aligned on the thought process. So Nick 00:02:48.969 --> 00:02:51.129 reached out to me a year ago, said, hey, would 00:02:51.129 --> 00:02:53.550 you consider bringing your blog under our banner? 00:02:53.689 --> 00:02:56.509 I said, sure. Along with that, started doing 00:02:56.509 --> 00:02:59.939 some ad hoc. clinical consulting with their team 00:02:59.939 --> 00:03:03.479 here and there. And that just kind of grew from 00:03:03.479 --> 00:03:07.020 there became kind of this organic thing of they 00:03:07.020 --> 00:03:09.080 seem to like me, I like them seem to be a good 00:03:09.080 --> 00:03:12.060 fit. And it really kind of became where I saw 00:03:12.060 --> 00:03:15.039 my career evolving to and in terms of what I 00:03:15.039 --> 00:03:17.180 want my impact to be, how can I have impact in 00:03:17.180 --> 00:03:21.020 a higher, broader scale, larger scale? And what 00:03:21.020 --> 00:03:23.740 do I find fulfilling and You know, 17 years is 00:03:23.740 --> 00:03:25.719 a very fulfilling career. I'm proud of what I 00:03:25.719 --> 00:03:28.419 did in orthopedic surgery. I feel like I'm leaving 00:03:28.419 --> 00:03:30.240 at the height of my career. And then I think 00:03:30.240 --> 00:03:33.099 that's important to me to, you know, not be running 00:03:33.099 --> 00:03:35.759 away from my clinical career, but to be running 00:03:35.759 --> 00:03:37.400 towards something that I think could be more 00:03:37.400 --> 00:03:40.639 impactful and as fulfilling, if not more fulfilling, 00:03:40.800 --> 00:03:46.979 depending on how successful we are. What do you 00:03:46.979 --> 00:03:49.240 think you'll miss the most about your clinical 00:03:49.240 --> 00:03:51.159 career and what are some things you won't miss? 00:03:52.169 --> 00:03:54.430 I think I'll miss the most, particularly with 00:03:54.430 --> 00:03:57.150 joint replacements. The big part of the reason 00:03:57.150 --> 00:03:59.650 I decided to go into hip and knee replacements 00:03:59.650 --> 00:04:03.150 was you're solving a problem. You see arthritis 00:04:03.150 --> 00:04:06.069 on an x -ray. Somebody comes in, they're debilitated 00:04:06.069 --> 00:04:09.469 by it. In the span of a whatever hour long operation, 00:04:09.610 --> 00:04:11.569 you cut it out. That said, the arthritis is gone. 00:04:11.750 --> 00:04:13.789 They can never get arthritis again. The recovery 00:04:13.789 --> 00:04:17.000 for some might be longer than others. You're 00:04:17.000 --> 00:04:20.120 really curing arthritis. It may be kind of crude, 00:04:20.180 --> 00:04:21.720 but it's the best we have, and it works pretty 00:04:21.720 --> 00:04:24.180 well. And so I like that concrete part of it. 00:04:24.240 --> 00:04:26.620 I like the fact that you can take somebody that's 00:04:26.620 --> 00:04:29.079 debilitated and really restore their quality 00:04:29.079 --> 00:04:32.040 of life. Orthopedics is not usually life -threatening 00:04:32.040 --> 00:04:35.860 things, but it is function. It's limb. And so 00:04:35.860 --> 00:04:38.779 taking somebody that came limping in your clinic 00:04:38.779 --> 00:04:41.430 in pain that can't... do whatever, play golf, 00:04:41.649 --> 00:04:44.790 play with their grandkids, play pickleball, work, 00:04:44.850 --> 00:04:47.430 whatever it is, and then you do surgery on them 00:04:47.430 --> 00:04:50.689 and two weeks later they come in and they're 00:04:50.689 --> 00:04:52.790 walking better, they're off crutches, they're 00:04:52.790 --> 00:04:54.930 getting their quality of life back. That's very 00:04:54.930 --> 00:04:57.110 satisfying, that part of the job is very satisfying, 00:04:57.170 --> 00:05:00.569 so I'll miss that. What I won't miss probably 00:05:00.569 --> 00:05:03.350 is really just the frustrations I think that 00:05:03.350 --> 00:05:06.490 have crept in for everybody. in healthcare on 00:05:06.490 --> 00:05:09.410 the front lines and EMR gets blamed a lot. That's 00:05:09.410 --> 00:05:12.209 a part of it. But I think it's really death by 00:05:12.209 --> 00:05:15.610 a thousand cuts. I think it's EMR, it's regulations, 00:05:16.370 --> 00:05:19.870 it's reimbursement, it's insurance issues, it's 00:05:19.870 --> 00:05:22.189 staffing issues on the front lines because there's 00:05:22.189 --> 00:05:25.550 turnover and because there's understaffing and 00:05:25.550 --> 00:05:28.110 there's cuts everywhere. And so those things 00:05:28.110 --> 00:05:30.810 over time kind of really add up. And there's 00:05:30.810 --> 00:05:32.970 always so much that... as I found out, I think 00:05:32.970 --> 00:05:35.170 you can do within the system. You know, people 00:05:35.170 --> 00:05:37.829 are trying, but you run up against so many roadblocks 00:05:37.829 --> 00:05:40.550 that it just seemed like the only way to really 00:05:40.550 --> 00:05:43.170 make any headway was to kind of, you know, step 00:05:43.170 --> 00:05:45.470 outside of that and take a role like Commons 00:05:45.470 --> 00:05:47.990 where you're really trying to build not from 00:05:47.990 --> 00:05:50.269 outside, but from a little bit of a different 00:05:50.269 --> 00:05:53.329 perspective. I mean, Commons are the people that 00:05:53.329 --> 00:05:58.069 started Commons, Nick, Aubyn and Paulo. are not 00:05:58.069 --> 00:05:59.689 outsiders. They come from healthcare. They're 00:05:59.689 --> 00:06:01.310 not physicians, but they built in healthcare 00:06:01.310 --> 00:06:04.009 before. So they're not outsiders. They understand 00:06:04.009 --> 00:06:09.949 the healthcare issues. You said as you were working 00:06:09.949 --> 00:06:13.470 as an orthopedic surgeon, you felt like you needed 00:06:13.470 --> 00:06:16.189 to do something different. And maybe I'm putting 00:06:16.189 --> 00:06:20.629 my experience in yours a little bit here. Tell 00:06:20.629 --> 00:06:24.439 me a bit more about what sparked that entrepreneurship 00:06:24.439 --> 00:06:27.160 curiosity and is that something you think is 00:06:27.160 --> 00:06:29.540 innate or is that something that can be learned? 00:06:30.899 --> 00:06:32.879 I think it's innate. I think it might be latent 00:06:32.879 --> 00:06:35.160 for a lot of people. You know, in healthcare, 00:06:36.439 --> 00:06:39.300 it's pretty prescriptive, right? You go to college, 00:06:39.620 --> 00:06:41.139 you go to medical school, you go to residency, 00:06:41.259 --> 00:06:42.740 you go to fellowship. I mean, that's the typical 00:06:42.740 --> 00:06:44.600 track that you go out into practice. So there's 00:06:44.600 --> 00:06:48.620 not a whole lot. in that process that's necessarily 00:06:48.620 --> 00:06:52.139 entrepreneurship focused. I think if you're in 00:06:52.139 --> 00:06:54.060 private practice, you are running a small business. 00:06:54.120 --> 00:06:56.079 So in a sense, you are an entrepreneur. I think 00:06:56.079 --> 00:06:58.959 even if you're employed, you are managing your 00:06:58.959 --> 00:07:01.459 schedule, you are managing your views, whatever 00:07:01.459 --> 00:07:04.959 it is. So there is some form of entrepreneurship 00:07:04.959 --> 00:07:08.800 involved in that. Um, so I think it's, it's innate 00:07:08.800 --> 00:07:11.079 in us, but it's latent. And I think you just 00:07:11.079 --> 00:07:14.139 have to kind of uncover that for me. It was getting 00:07:14.139 --> 00:07:17.459 to a point in my career where the day -to -day 00:07:17.459 --> 00:07:19.519 became, I don't want to say easy because it's 00:07:19.519 --> 00:07:21.660 never easy. The day -to -day became more predictable 00:07:21.660 --> 00:07:23.319 though. I kind of knew how to prepare for each 00:07:23.319 --> 00:07:25.100 day. I knew what I needed to do to be prepared 00:07:25.100 --> 00:07:27.019 for the OR. I needed, I knew what I needed to 00:07:27.019 --> 00:07:30.360 do to be prepared for clinic. And so that part 00:07:30.360 --> 00:07:33.360 of it kind of slowed down for me and it freed 00:07:33.360 --> 00:07:36.279 up more mental capacity to start thinking about. 00:07:36.319 --> 00:07:38.819 other things. And on top of that, I was experiencing 00:07:38.819 --> 00:07:41.620 things sort of in my own career on the day to 00:07:41.620 --> 00:07:43.620 day that I felt like, you know, this could be 00:07:43.620 --> 00:07:46.759 done better. And let me figure out, are there 00:07:46.759 --> 00:07:48.759 ways to do it? Are there people that are already 00:07:48.759 --> 00:07:51.600 trying to do that? And that kind of brought me 00:07:51.600 --> 00:07:54.720 to the entrepreneur world of where are the people 00:07:54.720 --> 00:07:56.620 that are trying to fix these problems? What are 00:07:56.620 --> 00:08:00.759 the solutions that they're trying to bring? Let's 00:08:00.759 --> 00:08:03.079 talk about arthritis a little bit more. So I'm 00:08:03.129 --> 00:08:06.490 a family physician. I see quite a few patients 00:08:06.490 --> 00:08:11.149 and I do my own joint injections. There's been 00:08:11.149 --> 00:08:16.230 a lot of advancements at the edges that really 00:08:16.230 --> 00:08:18.250 haven't taken hold in the medical community, 00:08:18.350 --> 00:08:23.269 you know, PRP and stem cells and back in the 00:08:23.269 --> 00:08:24.970 day, prolotherapy, which is kind of out of favor 00:08:24.970 --> 00:08:29.579 now. What are your thoughts on you know, what 00:08:29.579 --> 00:08:33.019 is next in terms of arthritis treatment? Is it 00:08:33.019 --> 00:08:36.539 just, and maybe you have a different brand name 00:08:36.539 --> 00:08:39.320 there, here it's Sinvisc or Neuvisc, which is 00:08:39.320 --> 00:08:43.059 hyaluronic acid, cortisone and joint replacement, 00:08:43.379 --> 00:08:46.820 and then Tylenol and Advil, is that kind of the, 00:08:47.059 --> 00:08:48.820 all we need to know about arthritis, and if not, 00:08:49.179 --> 00:08:51.360 what's more and what's the future of arthritis 00:08:51.360 --> 00:08:54.539 care? Yeah, I think that's still the tried and 00:08:54.539 --> 00:08:57.460 true are still a lot of it. We've tried all these 00:08:57.460 --> 00:09:00.419 things. We have how ironic acid here. It's not 00:09:00.419 --> 00:09:02.379 covered by some of the insurance companies because 00:09:02.379 --> 00:09:07.009 the data on it is is mixed at best. Still do 00:09:07.009 --> 00:09:10.250 a lot of cortisone shots, still do NSAIDs, although 00:09:10.250 --> 00:09:12.470 fewer and fewer patients are really candidates 00:09:12.470 --> 00:09:14.690 for NSAIDs for whatever reason. They're on blood 00:09:14.690 --> 00:09:16.509 thinners, they have gastric issues, they have 00:09:16.509 --> 00:09:20.830 liver or kidney issues, and arthroplasty. So 00:09:20.830 --> 00:09:24.450 we've thrown a lot of things at joints and arthritis, 00:09:24.769 --> 00:09:27.509 and not a lot of them had staying power for whatever 00:09:27.509 --> 00:09:30.289 reason. And joint replacements ultimately are, 00:09:30.289 --> 00:09:32.690 I think, the best, most predictable long -term 00:09:32.690 --> 00:09:36.029 cure, I think. Hopefully we can get better preventing 00:09:36.029 --> 00:09:37.549 arthritis. I don't think you can prevent all 00:09:37.549 --> 00:09:38.970 of it, but I think there are certain things that 00:09:38.970 --> 00:09:41.870 we can do to maybe decrease the incidence of 00:09:41.870 --> 00:09:45.210 arthritis. First of all, there's nerve stimulation 00:09:45.210 --> 00:09:47.269 or nerve blocks and things like that that are 00:09:47.269 --> 00:09:50.590 coming along as pain relieving types of procedures. 00:09:51.490 --> 00:09:55.610 There's always companies working on injectables 00:09:55.610 --> 00:09:58.720 or things that try to support cartilage. I don't 00:09:58.720 --> 00:10:00.340 think there's any that have made it past the 00:10:00.340 --> 00:10:04.000 trial phase that have gotten out into mainstream 00:10:04.000 --> 00:10:06.779 usage. I think we're getting better maybe with 00:10:06.779 --> 00:10:08.600 detecting arthritis earlier, whether it's through 00:10:08.600 --> 00:10:13.759 advanced MRI imaging or analyzing synovial fluid 00:10:13.759 --> 00:10:17.059 to see if there are markers of early joint breakdown 00:10:17.059 --> 00:10:18.820 that maybe you can intervene a little bit earlier. 00:10:19.559 --> 00:10:23.139 I think someday. We'll either have gene therapy 00:10:23.139 --> 00:10:25.259 where we'll rearrange your genes and you won't 00:10:25.259 --> 00:10:27.820 get arthritis at all. Or maybe we'll be able 00:10:27.820 --> 00:10:31.419 to 3D print cartilage on a joint or do better 00:10:31.419 --> 00:10:33.279 with cartilage restoration. We've tried those 00:10:33.279 --> 00:10:35.960 things. It's been a mixed success, but somebody 00:10:35.960 --> 00:10:38.200 that's got advanced arthritis is beyond that 00:10:38.200 --> 00:10:41.200 point. So will we someday be able to open somebody's 00:10:41.200 --> 00:10:43.419 knee up and just kind of 3D print a cartilage 00:10:43.419 --> 00:10:45.720 matrix or cartilage on the ends of the bone? 00:10:46.580 --> 00:10:51.100 Possibly. Maybe in my lifetime. maybe in my lifetime, 00:10:51.139 --> 00:10:53.320 we'll have gene therapy to kind of prevent arthritis 00:10:53.320 --> 00:10:56.000 in the first place. But I don't think there's 00:10:56.000 --> 00:10:58.399 anything on the immediate horizon that's going 00:10:58.399 --> 00:11:00.639 to take the place of joint replacement for the 00:11:00.639 --> 00:11:05.879 patient with advanced arthritis. It sounds like 00:11:05.879 --> 00:11:08.379 your transition out of clinical medicine was 00:11:08.379 --> 00:11:12.179 more inspired by finding something to run forward 00:11:12.179 --> 00:11:16.299 to, as you said. A lot of my colleagues and to 00:11:16.299 --> 00:11:19.519 an extent me myself, our transition is running 00:11:19.519 --> 00:11:23.460 away from clinical medicine. Why do you think 00:11:23.460 --> 00:11:27.899 physicians are burning out? And did you burn 00:11:27.899 --> 00:11:29.860 out? And if you did, what protected you from 00:11:29.860 --> 00:11:32.799 burning out? Yeah, I think there was definitely 00:11:32.799 --> 00:11:36.299 times where I had symptoms of burnout. I don't 00:11:36.299 --> 00:11:38.889 know that I ever like, you know, fully. burnt 00:11:38.889 --> 00:11:41.070 out, but there were definitely times where it 00:11:41.070 --> 00:11:43.129 felt like, you know, you would show up and you 00:11:43.129 --> 00:11:45.309 would do your job. You didn't feel like you were, 00:11:45.330 --> 00:11:47.909 you know, making the impact that you intended 00:11:47.909 --> 00:11:49.850 to make when you got into health care. And that 00:11:49.850 --> 00:11:52.710 can be very frustrating, very, very deflating, 00:11:53.070 --> 00:11:54.950 because this is a challenging job. It's a stressful 00:11:54.950 --> 00:11:57.149 job. You know, it's a job that you put a lot 00:11:57.149 --> 00:12:00.289 of your life into. And it's it's more than a 00:12:00.289 --> 00:12:04.220 job. I think it is a career that. isn't just 00:12:04.220 --> 00:12:07.960 a nine to five. So for me, it really was getting 00:12:07.960 --> 00:12:11.639 involved in the entrepreneurship and realizing 00:12:11.639 --> 00:12:14.960 that. I think some of the burnout or a lot of 00:12:14.960 --> 00:12:17.080 the burnout maybe comes from thinking that you're 00:12:17.080 --> 00:12:19.039 hopeless and helpless in a situation, right? 00:12:19.159 --> 00:12:20.759 There's just nothing you can do about it. You 00:12:20.759 --> 00:12:22.799 show up every day and these problems exist and 00:12:22.799 --> 00:12:24.460 you're kind of shouting into the void or bang 00:12:24.460 --> 00:12:26.919 your head up against the wall. And I think that 00:12:26.919 --> 00:12:29.059 more than anything can be extremely frustrating 00:12:29.059 --> 00:12:31.360 for people to feel like, you know, you have no 00:12:31.360 --> 00:12:33.840 agency, you have no ability to change anything 00:12:33.840 --> 00:12:37.159 and getting involved in entrepreneurship and 00:12:37.159 --> 00:12:40.769 being around people that Some are grifting, some 00:12:40.769 --> 00:12:42.509 are in it for the wrong reasons, but a lot of 00:12:42.509 --> 00:12:45.110 them aren't. And being around people that maybe 00:12:45.110 --> 00:12:47.309 don't always 100 % understand what the problems 00:12:47.309 --> 00:12:49.570 are, but have an earnest interest in trying to 00:12:49.570 --> 00:12:52.970 solve them was refreshing. And then taking what 00:12:52.970 --> 00:12:55.450 I had learned from being on the front lines, 00:12:55.610 --> 00:12:58.629 my front line experience and being able to translate 00:12:58.629 --> 00:13:00.210 that to people that were building in healthcare, 00:13:00.289 --> 00:13:03.950 but maybe didn't have a great grip on what was 00:13:03.950 --> 00:13:07.259 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.