And because I can tell them, oh, you know, there's this, this is a finding, you know,
how's the patient doing?
Are they having pain in this location still or is it improved?
If it's improved.
Welcome to the part two of our very interesting conversation with Dr. Gautam.
Previously in the part one, he gave us brief introduction about himself and so many other
information concerning vision radiology, how it was founded and how he manages to wear
two hearts as a nuclear engineer and a medical professional, especially as a consultant radiologist.
I guess you want to find out so much more about him.
Go back to the part one with the link you have found below, click it and then join the
flow in part two.
With him, Gemma and Bazo as the hosts and Theodora Ijoma as the co-host.
Thanks.
What was the element that contributed to that increased confidence?
Was it your competency or your communication skills or your personal?
It's not me.
That's what I'm saying.
Like when physicians hear something from another physician and there's a back and forth exchange,
you feel it's called a disposition condense.
I know what to do with the patient and I feel confident about doing because I've spoken
to another doctor that, you know, so it's like you're sharing some of the load.
It's like a team based approach, right?
Yeah.
I quite agree with you.
This is really, really important because I remember when I was in my lab, when I, like
my professor gives me some tasks and then I take it back to him.
Like, although I put in my best, like my very best to execute any task he gives me, either
in research or in administrative stuff.
So when I go to give him some report because we normally do some presentation, so he will
say, Jeremiah, I trust what you say.
I'm going to take it like without any editing, you know?
So there is a very strong point of building confidence and I think it's really and rightly
corroborates what you said about the doctors trusting you and not having to order for more
images to verify their maybe curiosity or stuff like that.
So I quite agree with you.
There's an interesting downstream effect of this too because not ordering excessive images,
not ordering excessive consults has actually a great value, right?
One, it saves a lot of cost.
Two, it saves anxiety because you think about a patient waiting for results.
It's nerve-wracking if you're not feeling well and you're waiting.
So this idea of being able to improve the speed and quality simultaneously is very valuable.
And think about a busy ER.
There may be 50,000 admissions a year and half a million patients that they're being
seen in a given year.
If you order 12% less cases and less clinical consults, you're saving millions, if not dozens
of millions of dollars in healthcare at just that one hospital every year.
And so even though it takes me a couple extra minutes to talk, it saves the system huge
amounts of time, money and effort.
I totally agree with that.
I can give one experience I had recently.
We are a doctor sent a patient for an examination and after I had done the radiological examination
and sent the patient back, the doctor called to confirm.
What did you see and how is it?
Because I've seen the report, but I just want to be sure.
This is where they presented.
And by the time we finished talking, he was so sure that, okay, he doesn't need to send
this patient for any further evaluation.
He can work with the results.
And yes, what he has been thinking is actually the correct thing.
Like the report confirmed his suspicion.
And then it saves the patient a lot of extra cost of going around or doing some unnecessary
imaging.
And the doctor too has his confidence backed up by the report.
So what you see is true and the reality.
And if your lawn is shared something that's more clinically tangible, right?
Like I'll just give you an example of something that happened to me, a patient and a clinician,
right?
So I was looking at a CT scan, a CAT scan.
And so the patient was coming in with pain in the right upper quadrant.
So kind of along where the liver is, right?
So the history that I get is just R U Q space P N.
That's the entire history.
Five letters.
That's all I have.
Right.
Exactly.
So I'm looking at this.
It looks normal, right?
It's a middle-aged woman.
She's a little overweight.
And so typically when you hear middle-aged woman overweight with right upper chronic
pain, you automatically think, oh gosh, it could be the gallbladder or the liver, duct
and things like that.
So I'm looking at this.
It looks normal, completely normal.
I didn't see a single thing, the gallbladder is normal.
There's no stones.
There's no dilatation.
There's nothing, nothing that would indicate anything.
So most radiologists, when they see something that's normal, they don't press any further.
They just, they call it normal and move on, right?
That's not how I do things.
So I called the doctor.
I'm like, hey, it's looking pretty normal.
Anything going on with this patient is like, man, the doctor said to me, he's like, man,
this patient is really ill.
Like she is extremely tender in the right upper quadrant.
I'm pretty sure she has a gallbladder attack, meaning colostiitis or something like that.
And so, so I, you know, I told him, I'm like, this is definitely not colostiitis.
There's no finding here that would be consistent with that.
Does she have any fevers?
Does she have any white count, any, you know, liver function tests out of whack?
He's like, no, everything's stone cold normal.
I'm like, this doesn't make any sense.
And like, is there any other histories?
There any other information?
He's like, nothing that was contributory, right?
Nothing that would make sense.
Like, well, what was non-contributory?
You know, like, and so he's like, Oh, well, she fell like five days ago, but she didn't
have any problems when she fell.
Of course now I'm going, how could I have missed a rib fracture?
You know, I'm not looking specifically for like, and I go through all the ribs and I'm
looking and there's no rib fracture either that I can see.
And so, and so I'm like, you know, Hey, man, I just don't see anything.
He's like, man, this patient is really tender.
It's, and, and he said something so specific to me.
He said, this is along the lower part of the rib margin, four centimeters from the xiphoid
process, which is the little tip of bone that's at the end of your sternum at the bottom,
just before you get to there.
Right?
Yeah.
So then I move, so I go straight to the, that area on the CT scan and there is a hairline
fracture that's not displaced through the cartilage, which is an exceedingly hard diagnosis
to make you.
And I would never make it was on a single image that I could see it and, and, you know,
an incomplete fracture through this area.
So, so interestingly, the thing that he thought was non contributory was actually quite contributory.
She just didn't realize she had, you know, that level of pain or this and now she's got
a non displaced fracture.
Okay.
So you think, well, taking that extra time, like, did I save the patient's life?
Absolutely not.
They weren't in any imminent threat or harm.
And had I even missed the finding, they probably would have gone on to eventually heal on their
own, no problem.
But what was the impact to the patient?
Right?
Well, had I, had I just said that it was normal in the ER that night, they would have gotten
an ultrasound because the clinician would have thought that there was still a gallbladder
problem, even though the CT was normal.
So they would have had an extra test and they may have had another test later as an outpatient
to do what's called a hepatobiliary scan, which is a type of nuclear medicine test where
they check to see the gallbladder function and the liver function and the, the, the ducts.
Right?
So, so this woman would have had multiple excess tests.
It would have occurred, you know, typically over the next week or two or three, she would
have waited for results and, and none of it would have been relevant because she had a
hairline fracture.
And to give you a sense of like, you know, you may have, let's say 500 images that you're
looking at, this is on one of those 500 images, each image has 500 million, I'm sorry, 500,000
pixels.
So out of, you're talking about reading something like 250 million pixels and finding eight abnormal
pixels in a single image.
No human being can do that, except when you know, like it's like a needle in the haystack,
right?
When you know where the needle is, you know the color and you know the position, it's
easy to find the needle.
Right?
Yeah, yeah, yeah.
It makes me think of rare events and probability in my, right?
So, so it's very hard to find these things, but when you take the time to talk to the
clinician, you can produce a better result.
And I think that's the key.
That's the most crucial thing because at the end of the day, you know, you're really trying
to help this patient and the clinician figure out what's going on.
And I think that's the great privilege of being a radiologist and being, you know, a
physician in general, like, think about how incredibly good you feel when you help somebody
in this way.
Yeah, that's true.
I didn't say the person's life, but I helped them and I helped relieve their pain or suffering.
You know, I helped get them to the right answer to what, you know, to what's causing their
life to be miserable at a given time.
That's a very empowering, amazing feeling, I promise.
Very, very fulfilling too.
Okay, so I quite appreciate this great, in fact, you've dealt so much and then explained
quite a lot of very useful details.
As you try to send these images to the doctors, you transmit these images through some electronic
means.
So I wonder, like, what measures are in place to preserve image quality or how are the image
transmitted to preserve their quality and diagnostic value?
Does it add to the overall cost of your service or patient's care?
It doesn't actually add to the cost.
In fact, we can dramatically decrease the cost because we can aggregate multiple patients
across multiple hospitals so that we can keep, you know, keep the cost low.
The reason being, like, let's say at a given hospital, you have to sit there at night, you
know, let's say there's 10 cases overnight, but you have to be there.
You have to sit there in the hospital reading cases.
For a radiologist, that's very inefficient because at nighttime, you may not have the
same amount of volume or work as daytime.
And so when you think about it from a work or a cost standpoint, to keep a radiologist
up for, you know, the whole night is very expensive, right?
And thousands of dollars per night, and if they're reading 10 cases, you're going to
be losing money.
But what if you could pay a tiny fraction of that only for the cases that come through?
And some nights you may have two, some nights you may have 16, but you're only paying for
what you actually use.
And at a given time, those things are being done read faster and more efficiently than
even if the radiologist was in house.
Because our average reporting times are faster than the local radiologist, despite being
thousands of miles away, our average reporting is faster.
So you can actually reduce the cost.
Now, going back to your initial question a little bit about, like, how do you ensure
the validity of the information because it's acquired in South Carolina now it's coming
all the way to Nevada or something like that.
Well, this is what I had talked about a little bit earlier when I said that, you know, this
stuff had been standardized 25 years earlier.
And this is it has something called the DICOM standard, right?
D-I-C-O-M.
And this is, yeah, this is a standard in medicine and radiology specifically that was developed
for, for this process to standardize it.
And interestingly, we have these like very specialized powered monitors, right?
That it doesn't matter where I am in the world, what the lighting conditions are in the room
that I'm in, the monitor will perform so it'll detect the background lighting.
It'll make it so that the image looks the same whether I'm in Timbuktu or, you know,
New York City, doesn't matter.
And so that in that way, I'm getting the exact same thing that somebody would be getting
there sitting right there next to the, you know, console reading the case in the reading
room.
So those monitors must have cost you a lot to purchase.
They do.
They're very expensive.
They're not like your standard home monitor because they've got tons of light sensors
in them that detect, you know, light reflection, temperature, color and a grayscale temperatures,
you know, for how, how luminant the monitors, the receiver operating characteristics, you
know, from a radiologist from my eyes, it has to be the same, right?
So the monitor has to be able to produce that or mimic that across a wide range of parameters.
And so that's another part of that standardization, that dichom standardization.
Don't you have any concern for cyber security threats, maybe any breach in the process of
image transmission in this?
Not so much in the process of image transmission, but let's go back to a more general question.
Are you, you know, is anybody dealing with patient data concerned about cyber threats?
The short answer is, of course, I mean, that is centrally important to, you know, kind of
what we do from the security standpoint.
Yeah.
So, you know, we use, for example, when we connect to a site, we do a point to point
VPN, right?
And that's a fairly secure method of moving data from point A to point B over the internet.
None of it, none of our traffic can be unencrypted.
All of it is encrypted, typically with very strong encryption protocols.
Right.
And in addition, you know, you have, you go through certain types of security certifications
and those are ones that we've, you know, gone through as part of this process.
So we've done it to the point where external third parties look at our workflow and say,
this is definitely secure.
We're giving you kind of our signed off stamp of approval.
So, and we take a lot of time, money and effort to maintain that.
Of course, it sure has to cost a lot.
Of course, it's going to cost a lot.
It does.
It's not inexpensive, but it's manageable.
Okay.
Do you have like any archival system for images you have worked on or do you discard
them rightly after your work?
No, we keep everything in accordance with the law.
So for example, in the United States, there's certain laws on medical image retention.
One thing that I'll state is that we're technically not the final repository.
The local hospital is going to keep that study in that image permanently, right?
Or according to that state law or other law.
But in addition to that, we keep that data essentially permanently.
We haven't had to delete any of the data at this point.
So we keep and maintain it.
And part of the reason is what happens if the patient, you know, let's say they bonk
their head or they did, you know, had belly pain.
What happens if you come back two months later, right?
Well, I'd love to have their old study and what I said about it.
And so we keep and record all that information just because it'll.
Yeah.
Because it will improve the results, the future results too.
So that's why it's hard to kind of delete or let go of that information.
Okay.
I mean, it's not hard on a technical level.
It's just, it's hard on a medical professional level.
Like I would want that information because, you know, in the end, you know, as a patient,
you would want your doctor to have access to all your information, right?
So they can make the right decision.
Same thing.
Has it been used for any litigation?
Like, can you also say that's one of the reasons why you keep some of those images?
You do have to keep them legally and that it does delve into this idea of, you know,
litigation, because if you did get into a lawsuit, you would have to be able to produce
the records, right?
So you do have to maintain it from that standpoint.
And I'll tell you, one really interesting thing, and this is not, you know, we don't
necessarily talk about this much, but, you know, we practice at fairly large scale.
We cover about 4% of the hospitals of the United States.
So one in 25 patients in the United States is coming through our portals, right?
And so despite that, and you know, I've done this for, you know, 18 years or 17 years
now, we have never had a malpractice judgment or settlement to date, which means, and there's
no practice in the country that's operating at scale that can make that claim, not one,
right?
And so again, the story hopefully comes full circle.
Take care of the patient, do the right thing, take the time with the doctor, and you'll
get the best results and answers.
And when you do, liability is less of a concern.
Yeah.
Following best practices actually pays, pays off.
It does.
But you have to have a long term view.
If you have a short term view of it, you know, money, money, money, money, money, money,
then you're going to have a very different type of practice.
That doesn't ever drive us.
Our driving ethical principles are very different than, you know, what you traditionally find
in, let's say, companies and businesses.
Don Silver, you've given us a lot of insights into the model of your work.
Would you like to know, are there any major modalities you don't cover or report?
Yes, in one sense.
So we cover everything that makes sense to cover via tele radiology, right?
So there are things in radiology that you can't cover.
For example, like interventional procedures.
I can't do that from 2,000 miles away very easily.
Now, that's not to say, you know, 20 years from now that we won't be able to do that.
Maybe robotics and remote type things, you know, can develop and I would be, right?
Like, that could be amazing.
But there are things where you actually need to be present, particularly procedure driven.
There's certain breast imaging where you want to be there because in real time you're adjusting
the imaging based on what you see and you'll take another shot.
You'll reposition the breast.
You'll put pressure here just to make sure that, and so that stuff has to be done live
in person because it, you know, that's just the nature of the work.
But aside from those things, we pretty much cover everything else.
Okay.
So can experts outside the US join you?
If I will, come and join you.
We have a fairly rigorous vetting process.
And this is also fairly unique in the industry.
You know, over the course of my life, I found that, you know, a CV or a resume only tells
you a tiny fraction about what you need to know, right?
And most of, probably the most important things is very hard to even know from, let's say,
an academic record.
So I have seen people who look like they should be able to walk on water.
You know, they come from the most prestigious institutions and they've got the best scores
and the best grades and they're not very good at the radiology part of it.
You know, like, I, you know, and then there's people that came from, you know, some no-name
place with, you know, you wouldn't ever think twice about this.
And they just, they're incredible radiologists.
They have the eye, they have the clinical knack, they have the intuition, the judgment.
And so a CV or a resume only gets you so far, right?
That's when, you know, that's when the real hard work comes and, you know, interviews.
We actually test every radiologist, not joking.
We will show them case after case after case and see, you know, how do they approach something
when they don't know what's going on, right?
And that's actually kind of valuable when you think about, like, you know, because it
tells you that the person has a general tool set that's really good.
So much of medicine and much of life, right, much of your professional career will be figuring
out how to achieve something when you don't know the answer, right?
Because you can go off into crazy solutions and crazy ideas and you can go off into a
measured reasonable approach.
And it's hard to figure that out on a resume, right?
It's also hard to figure out, what is this person's desire, conscientiousness, right?
You know, will they take the extra time to go the extra mile for this patient?
And it goes back to a kind of a foundational ethos for us, right?
When Ray and I started the company, one of the things that we talked about was, well,
what should it be our basic foundational principle?
And we both kind of came up with the same answer independently.
And it comes from a very simple question.
Is this how you would want your family member treated?
Okay.
So if you answer yes, you're doing the right thing, right?
If you answer no, you're clearly doing the wrong thing, but here's the trick to all of
it.
If you pause and have to think about it, you're likely justifying something to yourself,
which means you're probably doing the wrong thing, right?
I mean, definitely adjust to do the right thing.
Yeah.
And so you wouldn't do the right thing.
Right.
And so you have to do things, you always have to carry yourself, your practice, your care
in a way that you know you're doing the right thing for the patient.
How do you figure that out on a resume?
You can't.
I mean, you've got to know, yeah, so you've got to talk to people who have worked with
this person for years.
And so we do a lot of, a lot of vetting.
So to answer your question, again, you'll find I have very long-winded answers to simple
questions.
But to answer your question, can experts outside the US join?
Absolutely.
And we do have a few people that are working from outside of the United States, but they've
been highly vetted in their exceptional human beings and exceptional radiologists.
And so it's not, it's not something like you just kind of say, oh yeah, you know, yeah,
it is really, yeah, it's a process to say the least, but we're happy with the process
because we, we know that when they're through that process, this is somebody that you would
stand shoulder to shoulder with, you know, kind of doing battle with, and you know you
can trust them.
Yeah, but do you do something like internship?
Do you give room for others to come and learn on the job?
The type of work we do, it's not quite conducive to that because when you're practicing medicine,
you kind of have to be through that medical process and you have to have a state medical
license and you have to have credentials.
So it's not, it's not like an academic university where you can have trainees doing that stuff.
You know, we don't have that kind of reach.
We're not a university.
And so yeah, we, it would be very difficult for us to, to create an internship level or
a training level thing for, let's say, somebody who's learning the practice.
Yeah.
All right.
That's also cool.
And then quite acceptable and understandable.
Yeah.
Doctor, you've really delved into so much.
I kind of think the Tokyo 2020 slash 2021 should have a room to acknowledge such a great
feat you have achieved in the industry.
I think you deserve some medal more than those that you have on the field.
No.
I definitely don't want any medals or adulation or congratulations.
I get satisfaction in just doing a job well and doing it for the patient.
And if the patient does well, I'm more than satisfied and I don't need credit for it.
I just need to know that I did the right thing by the patient.
That's all the, that's all I need.
Yeah.
That's quite evident already from, from before going in and the explanations you've been
making.
It's really evident that you have the passion for the job you are doing.
So yeah, I, I kind of wonder like, do you, what was the future of tele radiology?
You said it was even there before telemedicine, but I kind of wonder what's the future of
tele radiology, especially in developing countries where consistent access to quality images
is an issue.
Like, I think this tele radiology model is predicated on these basic infrastructure things.
Right.
So for example, if you don't have high quality internet or you won't be able to do the
tele radiology, so as a communication systems, as these infrastructure things start to increase,
right, the penetrance of tele radiology will increase as well.
Telemedicine, I mean, tele radiology is a subset of telemedicine because you could have
tele dermatology, tele, you know, general internal medicine, telecardiology, tele orthopedics.
It doesn't really matter what it is.
It's the idea that you can pool expert, you know, expert clinicians, physicians to affect
a larger or wider range of patients and improve their access.
Because right now there's not enough doctors and way too many patients.
So we are going crazy fast, right?
I think in the United States there's, I was reading some article, you know, you said that
the average 15 minute appointment that a physician spends with a patient, there are two minutes
spent talking to the patient and doing exam and 13 minutes in documentation.
That is upside down to me.
That's the exact wrong way of doing things, right?
And because the patient frequently has the answers, you've got to talk to them.
So this idea of telemedicine is essentially, I mean, it's a way to reduce that burden and
allow the clinician or radiologist or whatever to spend more time with the patient rather
than in the bureaucracy of medicine, which is, especially in the United States, is just
astronomical.
That's very true.
Okay.
So I quite appreciate the time with you, doctor.
You've really dealt with a whole lot of issues.
And we are very thankful for the time you've given us to interact with you and also with
what you are doing in the industry.
I think we should recommend you for Biden's award.
That's so great.
That's so artistic.
You said you don't need any award or adulation in that regard.
So yeah, I quite appreciate already the time.
I am looking forward actually to meeting you physically someday in the future.
So I don't know if you have any last words, maybe any future, maybe any research frontiers
you think should be explored in this field of yours?
I rarely have ever have any kind of wisdom or, but I would say, particularly to students
out there that are in engineering, nuclear engineering in particular, it's an incredibly
valuable skill set.
The type of analytical thinking, reasoning, it will serve you.
It doesn't matter if you go into something that's nuclear or nuclear adjacent or something
else entirely.
The skill sets that you learn, the rigor that you learn in this field can serve you in just
about any discipline I can imagine.
And so, and then the last thing is kind of just be on the lookout for those mentors.
They will help you in this world.
And then the next step is after you have gone through that, you have to do the same.
So I have to be that mentor for the next generation.
And I think having that idea that you're paying it forward is very important because we get
a lot and we always have to be cognizant of what we give in this world because that's
how you make a life.
You make a living by what you get, you make a life by what you give.
Wow.
Quite inspirational.
I can imagine that you will be giving this kind of deep inspiration.
Thank you so much, Doctor.
I really appreciate the process through which we came to actually meet and finally have
this conversation was really a testation to the fact that you are very detailed and very
committed to what you are doing.
And I'm very grateful for the time you even allocated to have this conversation with us.
I'm very also very grateful for the future and those that will be listening to this episode
will be sure really enlightening in the way that they've never had before.
So I want to say thank you and hope that we can have some other time in the future with
you, sir.
Yes, absolutely.
You are too kind and it's been my privilege.
Thank you.
Okay, so Teodora, do you want to say anything?
I want to say thank you.
Out of your very busy schedule, you are able to make out time to be on this podcast today.
We appreciate your time and we still wish you more success, more advancements in your
chosen field and we know you keep touching the lives of your patients positively.
And I've also learned one or two things, you know, putting more efforts to see that I get
in touch with the physicians that send their patients for radiological examinations so
that we can be able to communicate further, get details and do the best for the patients.
And I know anyone listening to this podcast would have learned one or two things, importance
of paying attention to detail, doing your best and then improving on, you know, whatever
you do, you keep improving, you don't stay where you were at the beginning, you keep
going forward, you follow the trends with technology and all.
So thank you so much, doctor.
We really appreciate it and we wish to have you again on our show.
I would love that.
And again, let me re-emphasize, it's been my privilege.
Thank you guys for setting this up.
It's been really fun.
Thank you very much.
Appreciate that.