Hi, Ben. Thanks for joining us today. Yeah, thanks
for having me. You're currently leaving clinical
medicine behind and your stethoscope or your
hammer, as you might call it in the ortho world.
And you're joining as a leadership at Commons
Clinic. Tell me about your path and how did you
get here? Right. So yeah, I've been in practice
for 17 years with paediatric surgery, joint replacement.
So a lot of hammering and sawing and malleting
things into place. Very typical standard career
for probably the first at least 10, 11 years
for that career. And then about six, seven years
ago. got interested in entrepreneurship, healthcare
technology, got involved in some value -based
care stuff in my own practice, and just kind
of got to the point of my career where I started
to think about, you know, what's next? What's
my legacy? Am I going to do this forever or is
there something more to my career? And so I started
doing some angel investing, some advising with
some companies, started to build a network by
posting stuff on LinkedIn just to kind of drive
conversations, get in front of people I wouldn't
otherwise get in front of. And that led me to
a guy called Nick Aubin, who's the CEO and founder
of Commons Clinic. And what Commons Clinic was
doing and is still doing was trying to build
value -based care models, tech forward models.
of care, like a new care delivery model surfaced
or revolving around MSK initially, but with the
goal to do multi -specialty at some point. So
I had come up with this, what I thought was a
brilliant idea of arthritis centers of excellence,
where you get high quality surgeons you try to
work with instead of against insurance companies,
you incorporate technology into what you're doing,
you revolve around outpatient centers and ASCs.
And so I wrote this white paper. I put together
this slide deck, but I had no idea at the time,
like, well, what do I do with this? I didn't
know how to get in front of investors. I was
a full -time practice. I didn't really have the
time to, you know, kind of pursue it. And then
came across Commons Clinic and it turned out
that they were already doing or building what
I had kind of envisioned. And so met Nick. made
a small angel investment in their seed round.
This was probably three or four years ago and
just kept in contact with them through the years.
We would touch base every so often, trade notes,
just riff on value -based MSK. I started my own
blog about two years ago, just to kind of share
more long form thoughts. And a lot of it was
in line with still what Commons was doing, not
necessarily intentionally, but just because we're
pretty aligned on the thought process. So Nick
reached out to me a year ago, said, hey, would
you consider bringing your blog under our banner?
I said, sure. Along with that, started doing
some ad hoc. clinical consulting with their team
here and there. And that just kind of grew from
there became kind of this organic thing of they
seem to like me, I like them seem to be a good
fit. And it really kind of became where I saw
my career evolving to and in terms of what I
want my impact to be, how can I have impact in
a higher, broader scale, larger scale? And what
do I find fulfilling and You know, 17 years is
a very fulfilling career. I'm proud of what I
did in orthopedic surgery. I feel like I'm leaving
at the height of my career. And then I think
that's important to me to, you know, not be running
away from my clinical career, but to be running
towards something that I think could be more
impactful and as fulfilling, if not more fulfilling,
depending on how successful we are. What do you
think you'll miss the most about your clinical
career and what are some things you won't miss?
I think I'll miss the most, particularly with
joint replacements. The big part of the reason
I decided to go into hip and knee replacements
was you're solving a problem. You see arthritis
on an x -ray. Somebody comes in, they're debilitated
by it. In the span of a whatever hour long operation,
you cut it out. That said, the arthritis is gone.
They can never get arthritis again. The recovery
for some might be longer than others. You're
really curing arthritis. It may be kind of crude,
but it's the best we have, and it works pretty
well. And so I like that concrete part of it.
I like the fact that you can take somebody that's
debilitated and really restore their quality
of life. Orthopedics is not usually life -threatening
things, but it is function. It's limb. And so
taking somebody that came limping in your clinic
in pain that can't... do whatever, play golf,
play with their grandkids, play pickleball, work,
whatever it is, and then you do surgery on them
and two weeks later they come in and they're
walking better, they're off crutches, they're
getting their quality of life back. That's very
satisfying, that part of the job is very satisfying,
so I'll miss that. What I won't miss probably
is really just the frustrations I think that
have crept in for everybody. in healthcare on
the front lines and EMR gets blamed a lot. That's
a part of it. But I think it's really death by
a thousand cuts. I think it's EMR, it's regulations,
it's reimbursement, it's insurance issues, it's
staffing issues on the front lines because there's
turnover and because there's understaffing and
there's cuts everywhere. And so those things
over time kind of really add up. And there's
always so much that... as I found out, I think
you can do within the system. You know, people
are trying, but you run up against so many roadblocks
that it just seemed like the only way to really
make any headway was to kind of, you know, step
outside of that and take a role like Commons
where you're really trying to build not from
outside, but from a little bit of a different
perspective. I mean, Commons are the people that
started Commons, Nick, Aubyn and Paulo. are not
outsiders. They come from healthcare. They're
not physicians, but they built in healthcare
before. So they're not outsiders. They understand
the healthcare issues. You said as you were working
as an orthopedic surgeon, you felt like you needed
to do something different. And maybe I'm putting
my experience in yours a little bit here. Tell
me a bit more about what sparked that entrepreneurship
curiosity and is that something you think is
innate or is that something that can be learned?
I think it's innate. I think it might be latent
for a lot of people. You know, in healthcare,
it's pretty prescriptive, right? You go to college,
you go to medical school, you go to residency,
you go to fellowship. I mean, that's the typical
track that you go out into practice. So there's
not a whole lot. in that process that's necessarily
entrepreneurship focused. I think if you're in
private practice, you are running a small business.
So in a sense, you are an entrepreneur. I think
even if you're employed, you are managing your
schedule, you are managing your views, whatever
it is. So there is some form of entrepreneurship
involved in that. Um, so I think it's, it's innate
in us, but it's latent. And I think you just
have to kind of uncover that for me. It was getting
to a point in my career where the day -to -day
became, I don't want to say easy because it's
never easy. The day -to -day became more predictable
though. I kind of knew how to prepare for each
day. I knew what I needed to do to be prepared
for the OR. I needed, I knew what I needed to
do to be prepared for clinic. And so that part
of it kind of slowed down for me and it freed
up more mental capacity to start thinking about.
other things. And on top of that, I was experiencing
things sort of in my own career on the day to
day that I felt like, you know, this could be
done better. And let me figure out, are there
ways to do it? Are there people that are already
trying to do that? And that kind of brought me
to the entrepreneur world of where are the people
that are trying to fix these problems? What are
the solutions that they're trying to bring? Let's
talk about arthritis a little bit more. So I'm
a family physician. I see quite a few patients
and I do my own joint injections. There's been
a lot of advancements at the edges that really
haven't taken hold in the medical community,
you know, PRP and stem cells and back in the
day, prolotherapy, which is kind of out of favor
now. What are your thoughts on you know, what
is next in terms of arthritis treatment? Is it
just, and maybe you have a different brand name
there, here it's Sinvisc or Neuvisc, which is
hyaluronic acid, cortisone and joint replacement,
and then Tylenol and Advil, is that kind of the,
all we need to know about arthritis, and if not,
what's more and what's the future of arthritis
care? Yeah, I think that's still the tried and
true are still a lot of it. We've tried all these
things. We have how ironic acid here. It's not
covered by some of the insurance companies because
the data on it is is mixed at best. Still do
a lot of cortisone shots, still do NSAIDs, although
fewer and fewer patients are really candidates
for NSAIDs for whatever reason. They're on blood
thinners, they have gastric issues, they have
liver or kidney issues, and arthroplasty. So
we've thrown a lot of things at joints and arthritis,
and not a lot of them had staying power for whatever
reason. And joint replacements ultimately are,
I think, the best, most predictable long -term
cure, I think. Hopefully we can get better preventing
arthritis. I don't think you can prevent all
of it, but I think there are certain things that
we can do to maybe decrease the incidence of
arthritis. First of all, there's nerve stimulation
or nerve blocks and things like that that are
coming along as pain relieving types of procedures.
There's always companies working on injectables
or things that try to support cartilage. I don't
think there's any that have made it past the
trial phase that have gotten out into mainstream
usage. I think we're getting better maybe with
detecting arthritis earlier, whether it's through
advanced MRI imaging or analyzing synovial fluid
to see if there are markers of early joint breakdown
that maybe you can intervene a little bit earlier.
I think someday. We'll either have gene therapy
where we'll rearrange your genes and you won't
get arthritis at all. Or maybe we'll be able
to 3D print cartilage on a joint or do better
with cartilage restoration. We've tried those
things. It's been a mixed success, but somebody
that's got advanced arthritis is beyond that
point. So will we someday be able to open somebody's
knee up and just kind of 3D print a cartilage
matrix or cartilage on the ends of the bone?
Possibly. Maybe in my lifetime. maybe in my lifetime,
we'll have gene therapy to kind of prevent arthritis
in the first place. But I don't think there's
anything on the immediate horizon that's going
to take the place of joint replacement for the
patient with advanced arthritis. It sounds like
your transition out of clinical medicine was
more inspired by finding something to run forward
to, as you said. A lot of my colleagues and to
an extent me myself, our transition is running
away from clinical medicine. Why do you think
physicians are burning out? And did you burn
out? And if you did, what protected you from
burning out? Yeah, I think there was definitely
times where I had symptoms of burnout. I don't
know that I ever like, you know, fully. burnt
out, but there were definitely times where it
felt like, you know, you would show up and you
would do your job. You didn't feel like you were,
you know, making the impact that you intended
to make when you got into health care. And that
can be very frustrating, very, very deflating,
because this is a challenging job. It's a stressful
job. You know, it's a job that you put a lot
of your life into. And it's it's more than a
job. I think it is a career that. isn't just
a nine to five. So for me, it really was getting
involved in the entrepreneurship and realizing
that. I think some of the burnout or a lot of
the burnout maybe comes from thinking that you're
hopeless and helpless in a situation, right?
There's just nothing you can do about it. You
show up every day and these problems exist and
you're kind of shouting into the void or bang
your head up against the wall. And I think that
more than anything can be extremely frustrating
for people to feel like, you know, you have no
agency, you have no ability to change anything
and getting involved in entrepreneurship and
being around people that Some are grifting, some
are in it for the wrong reasons, but a lot of
them aren't. And being around people that maybe
don't always 100 % understand what the problems
are, but have an earnest interest in trying to
solve them was refreshing. And then taking what
I had learned from being on the front lines,
my front line experience and being able to translate
that to people that were building in healthcare,
but maybe didn't have a great grip on what was
going on on the front lines was... was satisfying.
It kind of showed me that there is light at the
end of the tunnel. There is somebody out there
like Nick Alban and Commons Clinic that are bringing
high level, you know, get your get your hands
dirty solutions to health care. And that was
very satisfying to me building a network and
community online, starting to write and really
kind of express those opinions and then have
it resonate with people. You know, all those
things, I think. really helped me kind of stave
off that burnout and gave me renewed hope. I
think that's tough. I think it takes time. It
takes some risk to put yourself out there or
get involved in some of these things. And so
I don't think it's necessarily easy for everybody.
It wasn't easy for me. And so I think you kind
of get trapped in this cycle that you don't feel
like there's any way out of. I think that's why
a lot of people in this day and age are kind
of burning out. I think there's a light at the
end of the tunnel. I think it's going to take
some time. I think things are cyclical. So I'm
hopeful that at some point, not just through
Commons Clinic, but in general, things get better
on the front lines for the people that are delivering
the care. It's not just doctors, it's nurses,
it's physical therapists, it's case managers.
I think just about everybody that touches a patient
has experienced that. What would 20 year old
Ben think of where you are today both in terms
of your personal life and your professional life?
I Think a personal life he'd be pretty happy.
I mean, look, I can't complain. I have a great
family You know, I've had success in my career,
you know, not just in clinical medicine But some
of the things I've done, you know outside of
it side gig wise. So, you know, I live a very
good life And I've been very fortunate in that
way. So I think he'd be happy with where he was
Personally, I think professionally, I think it
would depend. If he knew the journey it would
take to get there, I think he'd be like, oh,
that's going to be a journey, residency, and
fellowship, and early in your career struggles,
and then making that pivot towards more leadership,
entrepreneur type of stuff. I think if you saw.
the end result. You know, he would be pretty
happy and hopefully proud of future Ben, because
because I'm really excited about, you know, where
I've been, but also where I'm going. I don't
know if you have kids and if so, how old they
are. How old are your kids? So I have two daughters,
14, who will be in high school next year and
12. Okay, I have two daughters, 12 and five.
If your daughters came to you, And they said
they would like to become an orthopedic surgeon.
What would you what would your response be? Yeah,
I'm not one of those doctors. I was like, I'm
crazy. Don't go into, you know, health care or
whatever. I mean, look at the core of it when
you strip away all the stuff that that makes
it less appealing. It's still. a great profession.
Unfortunately, I think we've lost a lot of what
makes being a doctor great. But I think at the
core of it, it's still there and you still have
those moments. Like I was saying before, when
you take that person that could barely walk when
you first met them, some of them are even in
wheelchairs or on walkers and they come in and
you've... change their lives and some of them
will tell you, look you changed my life. That's
extremely rewarding and I think that's as close
to a superpower as you can get. It doesn't always
like that, clearly, but I think when it is it's
very rewarding. I think I wish those moments
were more common than they are now. So I would
never, my approach when it comes to that is do
what you find fulfilling. I'm here to guide you.
If you're interested in being orthopedic surgeon,
they're with you. Every step of the way, I would
never let my own experience dissuade them from
doing it. I would guide them and share my experiences,
but I would never tell them, don't do it because
X, Y and Z. Yeah, I've been I think if you ask
physicians within and I'm going to just crossing
the. the eight -year mark out of post residency.
If you ask physicians around the five, six -year
mark post residency, they will all say, we would
never want our kids to be physicians. And then
as you get more experience about other fields
and how things work, you tend to get a better
appreciation of how strong of a factor that immediate
reward we get from our patients is, and how rare
it is in other fields and other jobs. It could
be congratulated every day and multiple times
a day. Yeah the grass is always greener and you
know the highs can be very high and the lows
can be very low. And yeah I think that that five
to six year mark you know you kind of you're
not wide -eyed anymore you're experienced and
then I think you start to feel the weight of
some of that but if you can get past that period
I think you learn to be a little bit easier on
yourself a little bit less perfectionistic and
realize that you know, it's not always going
to be perfect. But at the end of the day, if
you're doing the best you can, and most patients
are doing well, you know, then you, I think you
have to resist the tendency to be too hard on
yourself. Do you think you live a balanced life?
And this is coming from someone who has no balance
in his life. And it's like, it's not a good thing,
right? Because I work too much and right. Yeah,
and I'm programmed to just work, work, work.
And it's hard to undo that programming. Do you
think you have that kind of inherent drive to
work all the time? And if so, how do you offset
that? Yeah, I think I have the drive. I think
a lot of doctors have that drive. And so I've
tried to be mindful, like, you know, as a full
time clinical practice, I basically had almost
a full time like sidekick job, but my responsibility
while I was in practice was always to my patients.
They came first. And then this other stuff was
after hours on weekends between surgeries at
lunch, you know, whatever it was. And then you
have to be careful about stripping away all your
free time and finding that balance. I mean, I've
found the side gig work to be fulfilling and
I found it to be they talk about work -life harmony
instead of work -life balance and that means
that you know some of the stuff if you're working
all the time is always that sort of in harmony
with your your life and not you know just work
work work all the time or doesn't feel like work
work work all the time is less taxing but I definitely
had to learn how to kind of pull back and say,
you know, to things or OK, it's time to shut
it off. It's family time. You know, it's time
to get away from it, because I think that can
also obviously lead to burnout if you're not,
you know, take enough time just to kind of give
yourself a break. There seems to be a growing
divide between leadership and health care, especially
in hospitals and health systems and frontline.
physicians. What do you think is the reason for
that divide? And if you could change one thing
about both camps, what would you change? I think
the divide in part is because there's just become
so many layers within the hospital health system.
My dad was a hospital administrator growing up.
This was the 1980s and early 90s and things were
different. back then, there weren't like these
multiple layers between him as the administrator,
the CEO of the hospital and the doctors. You
know, there was a very close connection for better
or worse, because some of them could be kind
of tough, doctors could be kind of tough. But
now I feel like we have so many layers between.
like what happens on the front lines and in the
C -suite, I wish, you know, CEOs and now you
have these big hospitals and health systems where
the CEO of the health system might be, you know,
three towns over and never even comes to the
community hospital and really has a great grasp
of what goes on on the front lines. I wish administrators,
you know, the people that really are at the top
making the decisions, spent more time on the
front lines to understand, you know, what the
challenges are because you don't get that looking
at. spreadsheets or sitting in meetings all day,
you have to actually be in there experiencing
it. Um, you know, I think from a physician perspective,
I think we've now developed this muscle where
it's automatic, like, um, conflict when we're
dealing with administrators and understand they're
part of it too. You know, they have boards that
they're answering to the bottom line and, you
know, they're, they're responsible for fiscal
results and, and things like that. And some of
the things are out of their control in terms
of regulations that are coming down from, you
know, the government, from Jayco, from the state,
whatever it is. So I think there's a middle ground
there to realize that maybe look at it from each
other's perspective a little bit more to have
better understanding. What's something you've
changed your mind on in the past couple of years?
I think probably the biggest thing is I was pretty
skeptical about this whole, you know, whole body
MRI and lab work and wellness and prevention
Type of thing. I know that's that's snake oil.
I think a lot of it still is but you know, I've
come around on the idea of Done appropriately
early detection and having you know This more
comprehensive lab work and really a deep dive
in your health once a year or once every five
years or whatever it is does make some sense.
I think there's still the key of separating the
signal from the noise, not chasing every lab
value that's slightly out of range or every incidental
oma. But I do think that there is a place for
moving upstream a little bit, doing a better
job servicing these things. Here in the US, I
think your primary care has just been so compressed
because of poor reimbursement, because patients
are so complicated these days, and because there's
just not enough time to spend with people that
we don't get as deep a dive as maybe we should
into some of these things. And a lot of insurance
companies may not necessarily pay for because
they can't see the, you know, some actuaries
telling them it's not worth it. So, yeah, this
whole idea of prevention early detection, you
know, I've started to come around on. And do
you have any thoughts on how we deal with the
primary pushback we get on whole body MRIs incidentalomas
and how we deal with them? Do you think that
is a valid concern or do you think it's you know,
we are the guinea pig generation for longevity
and more focus on preventive health. Yeah, I
think it's it's totally legitimate concern because,
you know, MRIs, you know, has taken on sort of
this mythical quality in you know, among patients
that MRI sees all and MRI sees a lot and that
can be a bad thing sometimes and that, you know,
it doesn't necessarily give you an answer. It
may see something, but it doesn't necessarily
tell you what it is. It tells you what it might
be potentially, and then you have to go chasing
it. So I think that's definitely a concern. Hopefully,
as this becomes more commonplace, we'll do better
and better at separating the signal from the
noise with body MRI with, you know, comprehensive
labs. testing, you know, the argument, and this
is part of what kind of changed my mind on it,
is that, you know, should we not take advantage
of this because there's the possibility of, you
know, instead of Lomas or chasing thing. No,
I mean, I think there's still a place for hey,
let's learn. Let's maybe do it better over time.
I think we still have an obligation to make sure
we're not causing harm by, you know, over testing
or leading to more interventions and things like
that. And I think that still is to be determined.
But it doesn't mean that there's not a place
for figuring that out. You know, value based
care, in theory, sounds amazing, right? You pay
for outcomes, you pay for helping patients long
-term. We all know outcomes are mostly driven
by socioeconomic status, by gender, by race,
and healthcare maybe contributes 20 % to your
outcomes. So how do we design a value -based
system which, you know, isn't just, okay, I'll
just take care of, you know, because that's the
group that's more likely to do the best. And
people who can afford the treatment I offer will
more likely benefit from it. So how do we design
a value -based care system which deals with the
confining variable that people who have more
money to afford the best treatments are likely
to have the best outcomes? Yeah, so you're sort
of hinting at cherry picking and lemon dropping,
which is one of the biggest criticisms, valid
criticisms of value -based care. You know, we
went into the CMS BPCIA program, which was for
hip and knee replacements. It was voluntary,
but we felt like we were doing a good enough
job taking care of those patients, that we would
have success in the program, and we did. You
know, I... Tried not to change too much of what
I was doing because before we went into the program
I tried to stay on top of you know what's the
latest and greatest in terms of you know treatment
and I'm doing things that are appropriate not
sending people to nursing homes after surgery
or rehabs after surgery, sending them home because
the data showed that those places were associated
with increased complications, higher readmission
rates. The data showed that people most people
were safer going home into their own environment
and trying to eliminate some of those low value
treatments that drove up costs. So, you know,
we still. optimized patients for surgery. We
didn't say, no, you can't have surgery. We said,
you're going to have surgery, but let's do some
things first to get you healthier. And I think
that was a good thing to get people healthier
before surgery and reduce their risk of complications.
If they were able to get there, then we operated
on them. I think. Going forward, there has to
be more sophistication in terms of how you restratify
things to make sure that you're not disincentivizing
treatment for more complex populations. I mean,
they seem to be able to do some form of restratification
for Medicare Advantage here. So I don't see why
we couldn't do that for other forms of. value
based care. So I think we just have to be a little
bit more sophisticated with our models doesn't
mean we have to make them more complicated necessarily.
I think we need to make them simpler, but also
have a reasonable restratification mechanism.
This is a somewhat different question, although
I assume it's parallel. What are your thoughts
on universal basic income? Yeah, that's not something
I have spent a ton of time thinking about I think
there's merits to a there's pros and cons on
both sides I think it's something we'll hear
more about you know, with AI, if AI is going
to take everybody's job, there's no jobs left.
How do people live? Is it through a universal
basic income? I think having a certain standard
of living for people, either you have to increase
the minimum wage so that people that are working
hard are able to live. I mean, you shouldn't
work a 40 hour a week job or multiple jobs and
still not be able to live. So whether that's
increasing minimum wage or universal basic income,
I think ultimately that lifts everybody up and
ties back to the idea that healthcare is deeply
tied into social factors and things like that.
So if we can get people living better, that's
the solution I don't think is talked about enough
in terms of solving healthcare because we always
talk about how America has this terrible healthcare
system and the outcomes. It's not that the outcomes
are bad, it's that there's so many social factors,
your access to care, access to mental health
resources, you know, access to income. So we
don't have violent deaths, we don't have people
that are kind of forced to make poor health choices,
because that's really all they can do. Why did
you do an MBA? And is it something you'd recommend
to physicians? I did it because as I got more
involved in the entrepreneurship, investing,
and even in my practice, I became a part owner
in a surgery center. We ended up pursuing a private
equity sale of our practice. I wanted to understand
the language of business better. I didn't expect
to walk into a Fortune 500 company and take over,
but it was more... What does that mean? What's
a P and L statement? What are leadership types?
What is marketing? What are market for you? All
these things just to try to understand them better.
I did an online MBA. It was self -paced. It was
very reasonably priced. I wasn't going to spend
six figures and take. six months to a year out
of my practice to go do it. I worked it into
my practice because it was self -paced and it
was very recently priced and I got out of it
what I wanted to get out of it. I think if you
go into an MBA thinking that getting that degree
is going to magically just open doors for you,
I think that's a mistaken notion. I don't think
it's necessarily going to pry open a bunch of
doors. And I worry a little bit that, as you
talked about, if you have doctors that are sort
of running away, that they feel like an MBA is
going to be a thing that gives them that landing
spot. I don't think that that's necessarily the
case. Now, if you go to a Harvard Business School,
or you go to Stanford GSB, or at MIT, and you
go to those programs. probably at least you can
network. You'll have good networking opportunities.
It might open some doors for you, but you're
going to spend a lot of money, a lot of time
doing that. How have your startup investments
gone and what was your diligence thesis or criteria?
So far, let's see, maybe four or five years into
it, it's been a mixed bag. So I think I've had
my first Official exit as an angel investor the
company got acquired. I got nothing Because I
was an early angel investor. They raised money
Quite a bit of money and then had a significant
down round I my shares I didn't put in more money
So my preferred shares got converted to common
stock and then once they sold because they were
you know underwater with the waterfalls I ended
up with nothing So it was an interesting experience,
but that didn't do so well. I've had a couple
of others that flamed out. So I think I've made
10 investments so far. So one exit where I got
nothing, two that folded, the rest are still
going. And the ones that are still going seem
to be doing fairly well. I have another company
that looks like it's on the verge of being acquired.
And I probably will see. uh some return on investment
and that was that'll be my first win i also so
i got some stock options i wrote articles for
doximity so doximity um has the op -med fellows
program and i wrote a series of articles for
them and they paid you in stock options and i
was fortunate enough to get my stock options
right before doximity went public and they were
kind enough to double the stock options for us
right before it went public so yeah it wasn't
a huge amount of money but it was um it was a
decent win and then i did some advising for uh
another company that's well known in the digital
health MSK space that will probably go public,
I would guess, in the next year or two. I got
some stock options or some options for doing
that consulting work, and I exercise those options.
And they've had a couple of buybacks, so to speak.
And so I've been able to cash in some of those.
So I guess I've had more success with my advisor
shares than I have with my direct angel investments
so far. And what was your criteria for the startups
you picked? Yeah, the criteria was initially,
is it something I feel like I can add value to
and learn from, was initially my criteria. And
then the criteria kind of became, was it something
I believe in that's fixing a real problem? And
then the criteria kind of became, do I believe
in this founder? Does this person seem to have
a clearer vision? Do they seem to be driven?
So then it became kind of a combination of those
things. So more of a gut feel. I can't tell you,
I did a lot of high level VC level due diligence.
And I never put in a ton of money. I kind of
spread it out, small investments here or there.
But it was just a really gut feel. What is something
technical? Builders get wrong about healthcare.
There's a lot in healthcare. I think from the
outside and I think you'd probably agree that
seems intuitive from the outside, but when you're
in it, it's sort of counterintuitive and you
don't understand like somebody was. tweeting
recently about being frustrated about being on
the wait list to be seen at a specialty clinic
and their appointment was a couple of months
out and they asked to be on a wait list for the
appointment and then they happened to call up
about something else and happened to just ask
the person they talked to and were able to get
in the next day. So it's like, how is this broken
that they have this wait list and I've been on
this wait list for two months. I just happened
to randomly call up and got in the next day.
And the reality is that scheduling is very complex
and it seems like it's an easy thing to have
a wait list somebody you know something opens
up and somebody's going to get off the wait list
but there's so much that goes on behind the scenes
in terms of how you manage you know clinic appointments
and somebody can't send their appointment the
last minute and then having to somebody having
to go through the wait list and call people and
maybe the first three people you call don't pick
up or they can't come in and now that person
who's probably doing five other jobs is now having
to spend time doing that, as opposed to it's
just easier if somebody calls up that day and
an appointment pops up that day. It's just easier
to slot that person in than go through, you know,
track down a wait list. Things like that. I mean,
I think there's things that happen behind the
scenes that are more complex and seem more straightforward
from the outside. But then when you're in it
and you've experienced, you realize there are
things that maybe you're not considering that
make it more complex. I'm not saying that's right.
I'm not saying there aren't ways to make it less
complex. But as it exists now, I think there's
a complexity to even some of the things that
seem really straightforward that people don't
necessarily understand. A lot of it has to do
with workflows of back office functions and things
like that. What is the role of robotics and AI
in ortho and what are you excited about for the
future of ortho? So we've had a lot of robotics
in ortho. I call it the robot wars And so there's
robotic hip into your placement. That's really
taken off. It's become more and more prevalent
and I've done that in my career. If you look
at the data, you know, the data isn't quite there
yet in terms of superiority of robotics and like
a lot of things in healthcare you have your camps,
you know, people in robotic camp that say it's
clearly better and people in non -robotic camp
that say it's not and it's too expensive and
it's, you know, blindly trusting technology.
I think The potential is certainly there. I think
we have to get more sophisticated with it. I
think we have to learn how to use the robot better
as a tool. So I think, you know, now the robots
have been around for I think 10 years at least
and we're gathering more data and we can look
at that data and we can become better with the
robots based on what we're data that we're gathering.
And I think robotics will continue to. become
higher and higher yield and eventually be proven
to be superior probably to non -robotics. So
I think AI will help us get there by taking in
large amounts of data, unstructured data, structured
data, you know, parsing through it and helping
us figure out how best to use the robots and
really personalize care. I think that's part
of the challenge that we have particularly in
hip and knee replacements is classically you're
taught to kind of do it the same for everybody.
But in reality, people's anatomy is different.
We just don't know how it's different from one
person to the next and how you tailor it from
one person to the next. So you kind of treat
everybody the same way. And you're going to capture
80%, 90%, 75 % of people doing it the same for
everybody. But you're going to have that 10 %
to 20 % who don't need the standard hip or knee
replacement needs something a little bit different.
And we just don't have great tools to identify
who those people are. And then even if we do
identify them, what they do need. So I think
robotics and AI are going to help us there. I
think the other big thing with AI is being able
to tailor non -surgical treatment or figure out
what the best treatment is for that particular
individual and be a little bit more personalized
in terms of our treatments. Do you think AI will
replace the family physician? And then do you
think AI will replace the orthopedic surgeon?
And if it does, which one will happen first?
That's the hot button topic. I think the AI models
will get better and better. It's very hard right
now to, I think, parse through what's real and
what's hype in terms of you pass USMLE or you
pass this test, you pass that test. Well, I think
people overestimate how much the sort of the
diagnosis issue plays into things in health care.
At least for orthopedics, the diagnosis isn't
usually all that confusing or the diagnosis part
of it isn't necessarily the hard part of it.
The hard part of it is talking through the patient
what the problem is, what the solutions are,
choosing the right solution. what to do if the
patient chooses a low value solution, what to
do if the patient doesn't, you know, agree with
the treatment recommendation. And I'm not sure
that that's, you know, is that something AI is
going to resolve? Is it something AI can't resolve?
I think a lot of the companies that are pushing
AI solutions don't want to, you know, be responsible
for that, you know, discussion that decision
making. So I mean, to get back to the original
question, I think AI tools will help, but I think
there's still the human element of medicine that
people underestimate that You know, AI can seem
empathetic, but at the end of the day, you know,
how far is a patient going to be willing to go
back and forth with the AI before they want somebody
to, you know, really discuss with them or give
them, you know, a little bit of a more less prescriptive
answer, I guess, for lack of a better term. Will
AI replace family physicians or orthopedic surgeons
first? I think there's definitely a future where
robots are able to do a hip or knee replacement
without the surgeon needing to touch the robot.
I think there are already companies working on
that. You know, once the robot still has to learn
how to do the exposure, maybe someday they'll
learn how to do that. But you may replace the
surgeon with just a technician who doesn't go
through a full training, but just kind of monitors
the robot. I don't think we're there yet. I think
that's going to take a long time. I think it
will take time for patients to trust that. So
if, I think this is a big if, AI is going to
replace somebody, it's probably going to be the
so -called cognitive specialties before the surgical
procedural specialties. But I think we're a long
way off from both of those things. And I think
people also overestimate the degree to which
patients want that. I think there's still a large
amount of skepticism and distrust. towards AI
that gets discounted in the circles that we sort
of run in because there's a lot of interest and
we kind of end up in this echo chamber, these
small spheres of. innovators, health tech people,
entrepreneurs, investors that are really bullish
on AI and health care. But if you look at the
studies that come out, you know, patients like
AI until they figure out it's AI and then they
don't like it so much. And so I think we're still
underestimating the degree to which the demand
on the part of patients is there. There's definitely
a subset of people that are very frustrated with
traditional health care and would go to an AI.
you know, chatbot or whatever in a minute, because
they're so fed up with the traditional system.
And I think they, you know, maybe get a little
bit more attention than the 60, 70, 80 % of other
people that still want human interaction. Yeah,
I love talking to AI Gemini, and chat jibbity
and AI agents as well. They always tell me a
brilliant time. Yeah. That's the other part,
right? They're very there and they're they're
made that way They're made to be affirming and
they're made to sort of be, you know, not necessarily
sycophantic Although obviously chat GPT 4o kind
of tipped over in that direction But yeah, I
mean the more you talk with it the more the more
great you become and what's yeah And again, the
models can be tuned in different ways, but it's
a little bit You know disturbing that you can
kind of lead the witness and if you talk to chat
GPT or Gemini long enough eventually They'll
start to you know, tell you what you want to
hear. They'll just base basically echo back to
you what you're suggesting to them. And that
can be very dangerous in healthcare. It can lead
to poor decisions that seem like the right decision.
Do you think that's good for mental health? Chat
bots and AI? Yeah. I think it can be, but I think
it can just like social media. It can be, but
it can very quickly become not so good for your
mental health. I mean, there were stories that
were coming out of the revolt against GPT -5
and people were very upset that GPT -4 went away
because they had bonded with it and people were
so upset they were crying. I think that that's
probably not the best thing. And so I think like
any tool that gives you that feedback, it probably
is giving you the same dopamine hit that social
media gives you and maybe even worse because
you can kind of tune it to give you the dopamine
hits that you want. I think that's dangerous.
And why is it dangerous? Well, I think it's dangerous
because you kind of get sucked into that world
the same way you can get sucked into social media
and kind of lose track of you know, what is reality
to lose track of being grounded and start to
You know believe things that aren't necessarily
true or get the same thing as you can go down
a rabbit hole with social media of being fed
things that seem like they're true but aren't.
I think there's the risk with AI that it's telling
you how great you are, and maybe you aren't really
that great, or maybe there are things that you
need to fix or be aware of, and it's sort of
telling you to justify that. No, you're right,
and everybody else is wrong, and maybe you aren't
right. Do you and so my listeners will be used
to this, but let's go a little bit deeper here.
Do you think ignorance is bliss? And if so, if
someone tells you you're right, even if you're
not and gives you constant validation and you
fall in love with a robot like her, should we
deny that for you? If that will lead to happiness
as happiness, the objective. or is objective
reaching the truth? And if it's the latter, why
is that? Why isn't happiness? Yeah, I think we
would love for ignorance to be blessed because
facing the truth is painful. But I think there
is, you know, danger in the ignorance is bliss
because how long can that continue? You know,
at some point you may have to face the truth
whether you want to or not. And I think that
that can be very painful. I think there's very
much a parallel in medicine. And I think that's
why it's going to be hard to have AI replace
humans in health care. Because if the AI, let's
say somebody comes in. They have knee arthritis.
And they get an MRI. They have a meniscus tear.
And their neighbor had a knee scope. And they
really want a knee scope. And I sit there and
tell them, look, you're past the point of a knee
scope. you know, the really it's either knee
replacement or, you know, not awkward treatment,
but that patient's adamant that they want a knee
scope. And I know that that is, you know, low
value treatment. You know, at what point does
ignorance, you know, it's not my job to hide
the truth from them and just say, you know what,
this person wants that knee scope. I know it's
not the best option for them. I know they're
probably going to do worse with that. But ignorance
is bliss for that patient. If they don't know
that going into it, no harm, no foul. But eventually,
they're going to find out afterwards that ignorance
is not bliss. So yes, it would be a lot easier
to just go along with it and say, have that surgery.
Even if I know that surgery is unlikely to help
you, that's the path of least resistance rather
than the truth, which is more painful, that less
invasive surgery, that's not a a painful long
recovery knee replacement is not gonna help you.
So I think, you know, ignorance is bliss until
it isn't. And sometimes you have to face those
hard truths. And that's, you know, part of medicine.
And I think it's part of life. Do you think this
is something founders and non -founders who don't
have a healthcare background, building in medicine
get wrong, that they just want to maximize press
gainy scores or patient satisfaction scores and
surveys? And they know the way to maximize is
give the patient what they request, what they
want, not what they need. dangerous. I think
there, you know, I get, I don't want to say battles,
but disagreements sometimes on social media about
this, of this idea of consumerization in healthcare,
right? If you're treating the patient as a customer,
and you take the idea in business that the customer
is always right, then, you know, the patient
is going to come in and dictate care. And I don't
think it should be a paternalistic model. I think
shared decision making is the right model. It
shouldn't be me as a doctor telling the patient,
you know, what the treatment's going to be. But
I think the flip side of that is a patient dictating
treatment. Look, if we want a healthcare system,
if we say we want value -based care, or we say
we want evidence -based care, or we say we want
high -value care, you can't slam doctors for
offering low -value treatments because they get
paid for it. At the same time, slam doctors for
gatekeeping care or being paternalistic. You
have to find that middle ground between the two
of those things. And I think that is something
that gets. overlooked. And the most difficult
conversations I had throughout my career were
the ones where a person, you know, was really
adamant that they wanted surgery, which I get,
you know, paid more to do, right? I mean, I,
you know, if somebody says I want surgery, and
I'm just the fee for service, you know, surgeon
wants to get paid, sure, even if I don't think
that surgery is indicated, okay, it's very easy,
you know, sure, I'll sign up for surgery if you
want surgery. it's not always the right thing
to do. And those are the difficult conversations
to, it's incumbent on me to explain the rationale
of why that is. But at the same time, I, in my
judgment, am trying to prevent a bad outcome
and do what in my experience and my judgment,
or at least explain to the patient what in my
best judgment is the right course of action.
And then it becomes, you know, Well, it doesn't
matter what you want, doctor. If the patient
wants the surgery, the patient should have the
surgery. How do we reconcile that? And I think
that gets overlooked a lot of the time of, well,
it's just doctor's gatekeeping. You don't want
me to have this. You don't want me to have that.
But there is sometimes a reason behind that.
again, it's incumbent on me to explain that rationale
and to, you know, engender enough trust in the
patient that they at least take what I have to
say to heart, they may not follow it. And that's,
you know, it's not up to me to be prescriptive
to them, they should have the autonomy and the
the agency to make those decisions. But I think,
you know, at the end of the day, the the customer
is always right is not the best way to practice
healthcare. If there's a system where you know,
we're operating healthcare as a buffet or a McDonald's
drive -thru and patients get to pick what they
want. Say they get to pick they want surgery
and if you're operating in that system you have
to provide it even though you know it may actually
lead to net harm for this patient and for this
situation. If that system exists Should we also
build a parallel liability legal system which
allows the patient to assume full liability and
they can sign off their right to sue? Because
currently the current system, they can't do that.
Even if you do what the patient wants, I guess
you're better judgment. If there's a negative
outcome, the patient can still sue you. and no
amount of notes that I told them. So that's not
going to protect you because you still performed
the surgery. So how are you going to look at
the liability framework shifting? And the one
analogy is if there's an AI pilot flying the
plane for a cheaper fare, should patients be
allowed to sign off liability? The answer there,
I think, is clearly no because the risk is too
high and there's a big information asymmetry.
Patients have no idea how to fly a plane unless
you're a pilot. Just so your patients have no
idea how to do a joint replacement, unless they're
an orthopedic surgeon. So I think, like, how
do you think about liability in this framework?
Yeah, I mean, I think even in that situation,
you could probably still argue that the patient
can inform themselves, and many patients do,
are very informed. They have more tools now than
they've ever had to inform themselves. I'd like
to think that the Whatever 14 years I spent getting
through training and then the 17 years I spent
in my career taught me enough experience that
even all the reading in the world, all the educating
yourself in the world isn't a substitute for
having experienced it multiple patients over
many years. So can a patient ever fully understand
the risks. I think a lot of them would argue
yes. And I can see a lot of them rolling their
eyes at me right now and saying, you know, doctor,
it's my decision. I can educate myself. You know
what you're talking about? I don't know. I mean,
I think if you looked at other, you know, pilots
flying a plane, you know, any other type of profession
where it's, you know, you go through a training
process that's rigorous. I don't think that I
would never walk onto a plane after researching
how to fly a plane and think that I could fly
a plane. I would never go to a fancy restaurant.
I think I could go in the kitchen and make meals
for everybody. Not to trivialize it, but I think
that can you ever really make a fully informed
enough decision to take on that liability? Is
that the right thing to do? And I don't think
it's necessarily the right thing to do. What
is a common misconception about ortho? You know,
there's a lot of ortho jokes, right? Like what
is a stethoscope? And I don't hear the bone and
things like that. But what's a more serious common
misconception? And what advice do you have for
medical students who are thinking about orthopedic
surgery as a residency? Yeah, I think there's
a couple misconceptions that I'll go, you know
more high high level and low level so I think
the high level misconception You know is that
sort of Neanderthal orthopedic surgeon? I'm not
sure I could get an orthopedic surgery his residency
spot in this day and age because they're so competitive
and Even back in my day, you kind of had to be
at the top of your class and do well on the standardized
testing to get a spot. Now, I think the average
number of publications for an orthopedic resident
or somebody, a medical student applying to orthopedics
is like 10 publications or something ridiculous
like that. doing research wasn't even on my radar
screen in medical school. Now you can't get a
spot unless you've done a lot of research. I
think there's good things and bad things about
that. I think it sort of leads to maybe low quality
research and there's pressure to publish papers.
But I guess the misconception would be that orthopedic
surgeons are just kind of Neanderthals that carry
hammers around. The lower level misconception,
we get or the misconception of the orthopedics
is just all about the money. It's all about how
many procedures can I do? It's all about the
financial part of it. We are well paid. We are
typically at the top of the reimbursement list
here in the US. I would argue it's in part. because
we are entrepreneurial. We tend to be more fiercely
independent than some other specialties. We do
have the ability to take advantage of ancillary
services like PT and MRI and owning ASCs that
sort of are complementary to what we do in our
day to day. I think that we have gotten more
efficient and changed with the times. The average
Medicare reimbursement for a total joint now
is... I think by 2026 is going to be less than
$1 ,200 to the surgeon for a hip or knee replacement
from Medicare. And that's when you adjust for
inflation down over 80 % compared to it was 20
years ago. And you say, oh, well, you've just
done more unnecessary surgeries. Well, at the
same time, we have this. population that's aging,
we have this demand for joint replacements that's
going up. As a baby boomers age, we also have
the second population of younger people that
are getting arthritis at an earlier age. So there
really is no need to do unnecessary joint replacements
at this point. We've just become extremely efficient
at it. Patients are getting more complex, but
our outcomes are the same, if not better than
they were when patients were healthier. So, you
know. I think people underestimate you say oh
you just you just do more do more surgeries well
the surgeries have to be done you don't just
you know wave your hand it's still you know work
to get it done um you know so I think that we
get ding sometimes for you know sort of being
just you know money focused and doing unnecessary
surgeries you know that happens for sure I mean
I'm not here to say that doesn't happen in some
cases but I don't think it's as as frequent as
people make it out to be. Last question, what
advice do you have for 35 year old Ben if you
can go back in time and talk to him? So let's
see 35 year old Ben. So, you know, 13 years ago,
where was I 13 years ago? I was still early on
in my career. I would say, you know, just give
yourself more grace. You know, don't be so hard
on yourself. Don't be. I think perfection should
always be the goal. I think back then, I didn't
understand that perfection is a fool's errand
in health care and as a surgeon to give yourself
a little bit of grace when you don't reach perfection.
And, you know, it's always going to eat at you,
but you can't let it consume you. You have to
learn from it. You have to learn from your mistakes.
You have to get better. But you also have to,
you know, not overlook your your wins and focus
too much on on the losses. I think there's a
tendency. particularly in high achieving people
to over index on the losses and not give yourself
enough credit for the wins. I'll ask one more
question. So I'm 39, entering 40 fairly soon
in January. My 30s have been more or less a blur.
It feels like I was 29 yesterday, mentally, physically
less so. What advice do you have for someone?
And you know, I'm doing four or five different
things with my career, partly because I don't
know what to do still. And partly because some
things bring in money and some things I do for
enjoyment. What advice do you have for someone
who's just entering their 40s? I think take time
to... Slow down and enjoy the journey Because
you know when you're really young you feel physically,
you know invulnerable and Then you're also just
sort of you know Learning your way Through things,
you know when you're 30s you still feel physically,
you know, pretty good. You're starting to establish
yourself You know, but things are still pretty
fresh and you're not necessarily thinking about
the long term at that point I think as you get
into your you know 40s particularly towards later
on in your 40s, I think you start to think more
about work -life balance and not go, go, go all
the time, but appreciate the journey, appreciate
the... the people around you, your family, you
know, appreciate the small moments that you can't
go, go, go all the time because, you know, you
start to realize that, you know, you're not going
to be here forever. And then you don't want to
look back on it and, you know, regret not spending
more time doing these things. I mean, I'm sure
you do it for your family the same way that I
do it for my family. But at the same time, they
want you there. They appreciate the work that
you do, but they also want you present. And so
it's about finding that right balance and then
realizing that you only have so much time. Awesome.
Thanks so much for joining us today, Ben. Yeah,
no problem. Yeah, appreciate it.