These Afrinuk podcasts will be in two parts.
The downside risks, like if I'm a software engineer, right?
Like if I mess something up, usually it doesn't have catastrophic outcomes.
You know, usually people don't die or get hurt, but you know, in medicine when you make mistakes
or you do things incorrectly, you know, you can really damage somebody.
I mean, I guess as a nuclear engineer, you got to be careful because you don't want your reactor to blow up.
Welcome to part one of this episode with Dr. Gautam from Vision Radiology.
Today I'm joined with Dr. Gautam Agrawal.
Dr. Gautam is a nuclear engineer, also a consultant radiologist in the US.
He is the founder and the CEO of Vision Radiology.
Today, we are going to have a very deep and intense conversation with him.
He's going to take us through his journey from being a nuclear engineer to becoming a consultant radiologist.
This is like having two great safety conscious professions subsumed in one practice.
So listen up and have a very good time with us today.
And today I'm joined with a very seasoned radiographer.
My name is Teodora.
Hello and welcome to today's podcast. We hope you enjoy the session.
Thank you very much. So without much ado, we want to dive right in.
Dr, can you tell us about you and Vision Radiology just as a way of brief introduction?
Sure, absolutely. So, you know, my name is Gautam Agrawal.
I'm a practicing radiologist. My subspecialty area of interest is musculoskeletal and mirine.
But I got my start, you know, kind of in nuclear engineering.
I was at the University of Michigan many moons ago, just 30 years ago.
And I learned quite a bit from that background and it has served me incredibly well in medicine.
So we eventually then, you know, as I moved into medicine, kind of realized some of the power of
telemedicine and how we could make and improve patient care.
So we kind of formed this tele radiology company and, you know, 20 years later, things are still going.
So that's the short introduction.
Okay, that's quite interesting because I was like, okay, this is vision radiology and you have two hearts, I would say, on you.
And I think safety, we will not have any root of escape because you will be very, very keen to details and also very careful.
Both as a nuclear engineer and also a radiologist, you have keen attention to details.
And I hope that your patients will be very grateful for this because it's a very rescue that you have brought it for.
So this brings me to Rayleigh Ting because I kind of went through your website and
I saw that you kind of do kind of online or do I say it's like it looks like an Uber kind of model business model.
Can you like, I don't know, is it like an Uber kind of radiology or tele radiology or telemedicine?
I'm used to telemedicine, but I've not heard of tele radiology.
So what's the right 20 word for your personal model, please, doctor?
Sure. So in fact, it is tele radiology and tele radiology essentially predates telemedicine.
It was the first kind of area of telemedicine.
And part of the reason is that it became highly standardized in a sense.
The way images are acquired, how they're transmitted, that was standardized 25 years ago.
And so because everything got standardized, it allowed for rapid kind of dissemination of information in very uniform ways across the entire world.
As the internet started to kind of grow as our ability to move this information from point A to point B expanded.
It really dramatically changed our reach, our scale to the point where you should really mostly not be thinking about radiology in time and space.
It can be very much made independent of time and space.
And that's part of what we do within our company.
So to think about, you know, when we say like, is this the, let's say the Uber of radiology?
Yeah.
The model, I think, is wholly different.
You know, patient care and it's a very different, very real person to person type of interaction.
Now, as a physician, you know, you frequently have interactions with your patients, right?
You go to see your doctor, they talk.
And it's a very human element. There's a lot of kind of things that you need to know about the patient.
You talk, you examine them, you do this.
As a radiologist, I don't see the patient.
I see inside of the patient.
Right.
And so my role is actually one that partially exists in the background.
So my goal is to help your doctor figure out what's going on inside of you in a way that they can help you.
So I don't, I'm actually more a physician's physician, right?
So my interaction is with the doctors.
More so than the patient themselves.
So in that sense, it doesn't have that very sort of direct to consumer approach,
at least the way we practice tele-radiology.
That's awesome.
And it's kind of very unique.
And I get to see that you get to interact with the doctors more than the patient from what you've explained.
So, which means, I don't know, perhaps it's easier job, more, maybe makes you more specialized.
I wouldn't know.
In some ways, it's easier in some ways, it's harder.
Right. Frequently, the patient tells you the answer.
And if you don't necessarily, you know, because they have these symptoms,
and if you can take the time to talk to the patient to examine them,
frequently you can figure out the answer without going to any sort of imaging or other testing and stuff.
But I think frequently in medicine, especially in much of the world,
we're so pressed for time that we don't stop to take the time to listen to the patient carefully,
because they've got the answers frequently, and you just have to tease it out.
So in that way, I think that's a disadvantage not being able to talk to the patient.
The advantage is that you can talk to the clinician, and frequently, you know,
it's a much quicker interaction because you're both speaking the same language.
You're speaking medicine, and so you don't have to translate from, let's say, a lay person to a
trained medical professional. So there are some advantages there, but overall, it's just a fabulous
career. It's been absolutely spectacular, you know, kind of growing within the field and seeing
how things have evolved. Oh, that's great. And then thanks for the insights you've given us
as regards to your work. Do you think there's any edge being a nuclear engineer has given you
over others in the field? Kind of like any benefits, additional benefits? Absolutely. So I think
there's, so when you think about a background, an engineering background, but in particular,
for me, a nuclear engineering background, you know, the things that were most important or the
thing that I've most learned in my training and college and school and stuff like that was, well,
how do I learn? Right? And I think that's the take home message from college. How do you learn
the best most effectively? Because if you can teach yourself that the rest of your career is set up
nicely because, you know, when you're done with college, I mean, most of your professional career
is going to be when you know how to learn or how you learn best. I think it provides an incredible
advantage to you. Nuclear engineering and engineering in general, I think, just as a problem
solving thing, it focuses you in a very different way. And so I loved that about nuclear engineering.
In addition, many times it's extremely precise. You know, I remember doing, you know, radiation
measurements, right? And you do these experiments and you're like, well, like, you know, my best,
you know, my best fit plot has an R squared correlation coefficient of 0.9999997, right?
And you're like, wow, that's, you know, and you're sometimes you're wondering, well, where do the
points here, there's two go, you know, in medicine, you get a 0.7, you're like, whoa, this is amazing,
right? Biologic systems don't quite behave the way that these, you know, kind of physical systems.
So in sort of a, you know, the advantage is it's rigorous, it's exact, it's precise, it's linear.
The flip side of that same coin is that biologic systems are not that precise. And that was one
of the hardest things I had to learn, right? Because I came from, you know, hard science,
and now I'm going into a soft science, medicine, the body, biology is a very soft, almost a pseudo
science, right? And so understanding that biologic systems don't behave the same way as physical
systems like we think of, because there's way more variables than you don't even know about.
And in case in point, right, like a person can be, you know, you can give a person a medication
and they do great with it. And the next time you give them a medication, they have allergic reaction.
And then the next time you give them that same medication, they don't have an allergic reaction.
Now think about that, that's the same system in your mind, but in reality it isn't. And so you
have to be able to understand that biologic systems don't behave as consistently as physical
systems. So that was one disadvantage of being an engineer, right? Because I'm used to like,
you know, with these inputs, I get this output. And it's just not like that, you know, frequently
the output comes out unexpected and you then have to adapt. And that was that was a bit of a learning
lesson for me. So in essence, you're trying to say that it wasn't right, easy for you to adapt
from being a nuclear engineer to being a medical consultant, radiologist.
It's not, I don't think it was necessarily easy to adapt. But it was a, it was a perfect fit for
me. I mean, I love, you know, kind of essentially all of science. I mean, there's very few areas
where I don't, you know, just completely nerd out and geek out, right? I mean, I love quantum,
I love, you know, coding, I love biology, I love materials. I mean, it goes on and on.
Anything scientific or curious or interesting. So I think when you, when you have that interest
or love, right, the transitions become kind of a pretty easy, right? Because it's just, you just
follow where your passion goes. And that's, I think that's where I've been very lucky.
That's true. Okay. So can you give us some insight why you found vision radiology and
what were the circumstances when you did? Yeah. So if you'll allow me, because this story goes back
a little bit before even founding vision radiology, and it's related to the nuclear engineering. So
there's a fellow that you probably all know, his name is Glenn Noel. He wrote a pretty important
book in radiation protection and measurements, right? It seems to be sitting on the, you know,
desk of almost every reactor operator I've ever seen. So, you know, so Professor Noel, incredible
teacher, incredible teacher and an absolute wonderful gentleman and human being. So in the, in the summer
between my junior and senior year, you know, I was wandering around in the hallway. This was at
the University of Michigan and the kind of in the department. And he's like, Hey, what are you doing
for your summer project? And like, what summer project? He's like, Oh, this is unacceptable.
So, so you wrote down on a piece of paper a gentleman's name, telephone number, he said,
I want you to call this guy. And we'll come up with something for you. This fellow happened to be,
his name is Jim Carrey, and not of course, the famous actor Jim Carrey, but James Carrey, he's
he's the kind of director of the non physician director of the nuclear medicine department at
University of Michigan hospital. So, you know, I met with him and we had a project on Isaac,
I done 131 and spectral artifacts and things and how to minimize that better predict dose and
you know, thyroid ablation and blah, blah, blah, fine. So the basic thing was I got into this nuclear
medicine department. And you know, I was trying to apply the things that I learned from, from
previous, you know, nuclear engineering, and it was great project with that. And then like a weekend,
he's like, Hey, look, you know, I want you to go sit with the radiologists and just see what they
do. And, and so I went in the reading room, which is where the radiologists, they kind of sit together
typically, and they sometimes were collaboratively, but they'll be on their workstation. So I just sat
with them and watched and watched and watched and I was like, God, this is the greatest thing in the
world. This is like what I want to do with my life. It's like, I apply the technical parts of,
you know, engineering science, I apply some of the puzzle solving of medicine, the biology, and it
was like such a perfect fit for me. I'm like, this is what I'm going to do. As you can imagine, now
I'm, you know, just about ready to start my senior year, finishing a degree program and changing,
you know, career paths was kind of a weird thing. And so, you know, but I knew that I wanted to do
it. And so I basically said, Okay, if I'm going to go into medicine, I've got to make some, some,
you know, I've got to take these classes that are fine. So I did that. And it turned out that I needed
to actually take an extra year to complete all the prerequisites. And in that year, I ended up working
with another mentor, Kim Kierfot, also at the University of Michigan, I did my master's degree in
radiation, like protection and radiation safety, and, you know, basically as a medical physicist,
right? And that was a great, it was a great transition between the nuclear engineering,
kind of the hard science, and starting to move towards the biological or soft science.
And so then I applied to medical school. And this is the part that was kind of interesting,
because as I was working in radiology, I really found that the way radiology was being done in my
mind, it wasn't, it wasn't that efficient. I was like, well, and so that this is in the early 90s,
right? And so it's like, you know, I think we would be better served by pooling all these radiologists
into a central area of reading from there, and then sending out information so you can pool an
aggregate expertise. And the reason why, and so I ended up writing my entire med school application
personal statement on this concept. And it wasn't called tele-radiology at the time, but I'd written
out the, essentially the, you know, the diagram, the floor plan for how to build a tele-radiology
practice, right? Not knowing that that's what it was. And back then we had things like ISDN lines,
right? So I was like, well, you got to put it in Nebraska, in the center of the country, maybe Iowa,
so that, you know, all the distance gets mitigated, and all this stuff. And written this detailed
thing, as you can imagine, I got very few medical school interviews, because they were like, this
guy's crazy. He's completely nuts, right? Like he's like off in his own little, you know, Jetsons
Future Land. And so, but I did eventually, you know, get into medical school. And this stayed
with me, but I kind of had to shut this off because now I'm training as a general, you know,
medical school kind of thing. And radiology was still, you know, in excess of like five years
away before I would even become a resident. And then another five years after that, before I'd
finished, there's still 10 years out. Okay. This story I'll try to get it up, but it's a long story
because that's what really, this is how it starts. So during, so, you know, I finished medical school
and I got into residency program and as a second year radiology resident. So in my third year post
medical school, my chief resident, Ray, said to me, Hey, you know, I would love to be able to work
with you, you know, and I want to be able to work with like-minded people, you know, really
conscientious, hardworking, dedicated folks. And so he's like, look, I'm going to be going, you know,
to Stanford for a year. And then from there, I'm probably going to move to Hawaii and you're going
to be maybe finishing up residency. And then, you know, maybe going to Michigan. How do we work
together? I'm like, well, kind of, you know, it's like, I've been working on this thing in the back
of my mind for, you know, 50, 10, 12, 15 years. I wrote this up. This is something that we could
potentially do this tele radiology. And little did I know that lots of things were going to change,
right? Like the ubiquity of widespread fast internet started becoming real. And so it didn't,
it didn't actually, you didn't have to put a facility in the center of the country. You could
put, you could essentially put a server somewhere and everybody could read from remotely. And that
was now a real thing that we could do. And so, you know, I, it took me about a year to figure
out not only how to get the server in place, but how to create a redundant architecture so that we
had, you know, immediate failover, because when you're dealing with these emergency patients,
you know, time is of the essence, a few minutes can lead to negative outcomes for them. So I figured
out, you know, how to do this in a way that we put, you know, one server on one coast, one server
on the other coast. And I created at the time, this is like now, actually, two days from now will be our 17 year anniversary of reading our first case in 18 years that we started.
But, but I put together what is now known as a cloud architecture, right? So I had the server synchronizing across a huge distance,
keeping everything kind of redundant and want to, and so that's how it started. And we, you know, we had no idea what we were doing.
We just went out and started telling people, Hey, we're, we're here, we can do this. And we're going to approach it in a very academic way.
We're not going to do, you know, we're going to really take care of these patients with a white glove level of service.
And the message took off. And, and, you know, that the company has just grown since then. It's been really extraordinary.
It's been really fun. So that's a long answer to kind of a simple question. But it really.
But very interesting. I open it too.
Yeah. And it starts 30 years, you know, 30 years ago. And to me, the interesting thing about the whole experience was this idea of serendipity, right?
Just by chance, a professor that, you know, I admired came to me and said, you need to do something here. And that led to an entirely new pathway.
And so for, for people that might be listening, that may be students, right? I mean, these opportunities are all around you.
And I would just encourage you as a student to kind of be very open and receptive to the ideas.
Because these professors that you run into really have your best interest in heart and they will help shape your career in ways that you could never possibly imagine.
So just beyond the lookout for these, these, you know, hugely, hugely helpful mentors in your life.
Thank you so much. I sincerely appreciate this great expose. And, you know, you're giving so much information to us that we cannot really digest in one, in one go.
So I was wondering, since you've given us a very detailed story of how your journey was and your interaction with your professor and how greatly favoured you are to get some asking from him.
And we're like wondering, like, have you had this in mind what you are doing currently, like getting into the field, like this field of tele radiology?
Is this something like you have had in mind? At what points did you consider diving into this field, if I may ask?
Oh, so really the point at which I kind of said, I'm going to do this, right? We are going to do this was when my, my chief resident and co-founder, Ray, came to me and said, look, I want to work with you.
And I felt very blessed that somebody who I respect and admire, he's an incredible radiologist, incredible human being, you know, and so these are the people that you want to be around, people that teach you, that you can learn from, that you can be inspired by.
Yeah, you said, you actually said that.
And so that was the point, like, it's a very specific point in time when he said that he wanted to do this.
And I'm like, boy, it was the, it was the culmination of lots of different steps. And I just, you know, in many ways, I was at the right place, right time.
And even a tiny difference somewhere in my professional career could have made this whole thing not, not materialized.
So I feel very blessed that all these, all the stars came into alignment for this.
Yeah, great, great. From what you've said now, it shows the importance of mentorship, you know, having those above you,
coming to your life to help stay in the right direction where you may not even have thought about.
But at the time when you began this, when you had this concept, were there any strong competitors?
Were there any difficulties you encountered?
No, you said the, you had to go to the clinicians to tell them, I'm here and I do this kind of thing.
So what were the difficulties you encountered at that point?
Sure. So the first difficulties are always kind of getting people to understand what it is you're doing
and why, and is it better than what is existing, right? Because in medicine, we have to be incredibly careful.
You know, you're dealing with real human life and their consequences.
And so when I have an existing process, right, if I'm going to introduce a new process,
it's got to work and it's got to work better in multiple ways for the patient.
So this testing validation, you know, early on in tele radiology, I think people were very hesitant to do this.
And so we were early enough that we weren't, we certainly weren't the first people to do this,
but we were early enough that the marketplace was fairly wide open.
No, not very many people were doing it. And so that helped us a lot.
I think if I had to start today, you know, with a, let's say, a developed, mature market, it would be quite a bit harder to do it.
But I would also say that the way we do medicine, our company in particular, it's very different.
It's very, very white glove communication oriented.
And what I mean by that is most tele radiology, you know, you get the images, you look at the case, you,
you know, dictate it, and then you send off the images, you send off the results.
You know, somebody gets a fax or an electronic communication email or, you know, with that,
we don't do that. I mean, we do that. But before doing any of that, I pick up the phone and talk to the doctor.
Okay. And that's nearly unheard of. I believe we're the only company in the country that will routinely call on every case or nearly every case,
negatives, positives. Right. So, so one of the things in medicine that is very difficult is over these large distances,
I don't have access to all the information, you know, you're reading it a little bit of a disadvantage.
And so we call and we talk to the doctors. And, and it's amazing what you learn because, you know,
sometimes the history or the information that you get is so limited that the moment I talk to the doctor,
and that doctor's seeing the patient, I can produce very specific and very accurate results,
and sometimes very sensitive results, meaning I can pick up things that I otherwise would have missed
when I know, you know, more specifically what's going on with the patient. So I think this,
this value, even though it's slower, right, to pick up the phone to call, it's very anachronistic in these days,
right, like, you know, because we're all about emails and texts and this and that, and this asynchronous communication.
But medicine, again, I'll reemphasize is a very human thing. It's a very human to human thing.
And the way this practice works, it's, it, there's a lot of direct physician or clinician communication.
And that has a net benefit. And we, in fact, studied this. And I'm happy to go over some of the data
that we found when we looked at, well, what's the net benefit? Because it was stunning to me when we,
when we talk, like, I did a survey of every one of our ER directors, right? And it took like two hours
to do this survey for those ER directors. And we had a 93.5% completion rate on a survey
uncompensated. We didn't pay them to do this to take up two hours of their own time, right? And they
finished the survey and I was like, wow, this is unbelievable. Because if you do a survey and you
get 10 or 15% participation, you feel happy, right? This was almost every ER director, these are directors
of emergency departments at hospitals, right, took the time to do this survey and they give us data.
And there are two fascinating things we found. One is that when we started coming on to do work,
the sites would order 12.5% less cases, less cases than when either the local radiology group or
another teleregular group that was there before us was there. In addition, they ordered less clinical
consults, which means they ordered less other physicians to come in to see the patient, 1.4
less of those per 100 patients. What's actually contributed to this? Yeah. Yeah. Yeah. So that
was a head scratcher for me. So I was like, well, why does this happen? And so I started talking to
these guys and say, well, what's going on? Why would you order less? And at first I thought,
oh, well, you know, we're working sometimes late at night and they don't have access to the MRs and
need this and that and the other scanners, that had nothing to do with it because we could control
for that. And we saw that that wasn't the case. And they said, simply, I just feel way more confident
after I've talked to you as a physician and we've had that exchange. And it just reemphasizes this
idea that medicine is still a very human process.
Let's continue to part two.