1
00:00:00,000 --> 00:00:04,880
And because I can tell them, oh, you know, there's this, this is a finding, you know,

2
00:00:04,880 --> 00:00:06,380
how's the patient doing?

3
00:00:06,380 --> 00:00:08,880
Are they having pain in this location still or is it improved?

4
00:00:08,880 --> 00:00:09,880
If it's improved.

5
00:00:09,880 --> 00:00:13,760
Welcome to the part two of our very interesting conversation with Dr. Gautam.

6
00:00:13,760 --> 00:00:18,600
Previously in the part one, he gave us brief introduction about himself and so many other

7
00:00:18,600 --> 00:00:24,120
information concerning vision radiology, how it was founded and how he manages to wear

8
00:00:24,120 --> 00:00:32,200
two hearts as a nuclear engineer and a medical professional, especially as a consultant radiologist.

9
00:00:32,200 --> 00:00:35,160
I guess you want to find out so much more about him.

10
00:00:35,160 --> 00:00:39,520
Go back to the part one with the link you have found below, click it and then join the

11
00:00:39,520 --> 00:00:41,080
flow in part two.

12
00:00:41,080 --> 00:00:45,960
With him, Gemma and Bazo as the hosts and Theodora Ijoma as the co-host.

13
00:00:45,960 --> 00:00:46,960
Thanks.

14
00:00:46,960 --> 00:00:53,800
What was the element that contributed to that increased confidence?

15
00:00:53,800 --> 00:00:59,320
Was it your competency or your communication skills or your personal?

16
00:00:59,320 --> 00:01:00,820
It's not me.

17
00:01:00,820 --> 00:01:01,820
That's what I'm saying.

18
00:01:01,820 --> 00:01:06,440
Like when physicians hear something from another physician and there's a back and forth exchange,

19
00:01:06,440 --> 00:01:08,800
you feel it's called a disposition condense.

20
00:01:08,800 --> 00:01:12,200
I know what to do with the patient and I feel confident about doing because I've spoken

21
00:01:12,200 --> 00:01:17,160
to another doctor that, you know, so it's like you're sharing some of the load.

22
00:01:17,160 --> 00:01:20,000
It's like a team based approach, right?

23
00:01:20,000 --> 00:01:21,000
Yeah.

24
00:01:21,000 --> 00:01:22,000
I quite agree with you.

25
00:01:22,000 --> 00:01:26,920
This is really, really important because I remember when I was in my lab, when I, like

26
00:01:26,920 --> 00:01:30,680
my professor gives me some tasks and then I take it back to him.

27
00:01:30,680 --> 00:01:37,240
Like, although I put in my best, like my very best to execute any task he gives me, either

28
00:01:37,240 --> 00:01:40,120
in research or in administrative stuff.

29
00:01:40,120 --> 00:01:45,520
So when I go to give him some report because we normally do some presentation, so he will

30
00:01:45,520 --> 00:01:47,680
say, Jeremiah, I trust what you say.

31
00:01:47,680 --> 00:01:50,720
I'm going to take it like without any editing, you know?

32
00:01:50,720 --> 00:01:56,680
So there is a very strong point of building confidence and I think it's really and rightly

33
00:01:56,680 --> 00:02:02,400
corroborates what you said about the doctors trusting you and not having to order for more

34
00:02:02,400 --> 00:02:06,920
images to verify their maybe curiosity or stuff like that.

35
00:02:06,920 --> 00:02:08,840
So I quite agree with you.

36
00:02:08,840 --> 00:02:16,240
There's an interesting downstream effect of this too because not ordering excessive images,

37
00:02:16,240 --> 00:02:19,960
not ordering excessive consults has actually a great value, right?

38
00:02:19,960 --> 00:02:21,360
One, it saves a lot of cost.

39
00:02:21,360 --> 00:02:25,920
Two, it saves anxiety because you think about a patient waiting for results.

40
00:02:25,920 --> 00:02:29,320
It's nerve-wracking if you're not feeling well and you're waiting.

41
00:02:29,320 --> 00:02:36,080
So this idea of being able to improve the speed and quality simultaneously is very valuable.

42
00:02:36,080 --> 00:02:38,680
And think about a busy ER.

43
00:02:38,680 --> 00:02:41,880
There may be 50,000 admissions a year and half a million patients that they're being

44
00:02:41,880 --> 00:02:43,880
seen in a given year.

45
00:02:43,880 --> 00:02:49,640
If you order 12% less cases and less clinical consults, you're saving millions, if not dozens

46
00:02:49,640 --> 00:02:55,280
of millions of dollars in healthcare at just that one hospital every year.

47
00:02:55,280 --> 00:03:00,760
And so even though it takes me a couple extra minutes to talk, it saves the system huge

48
00:03:00,760 --> 00:03:04,080
amounts of time, money and effort.

49
00:03:04,080 --> 00:03:06,440
I totally agree with that.

50
00:03:06,440 --> 00:03:09,360
I can give one experience I had recently.

51
00:03:09,360 --> 00:03:16,440
We are a doctor sent a patient for an examination and after I had done the radiological examination

52
00:03:16,440 --> 00:03:21,360
and sent the patient back, the doctor called to confirm.

53
00:03:21,360 --> 00:03:23,520
What did you see and how is it?

54
00:03:23,520 --> 00:03:25,720
Because I've seen the report, but I just want to be sure.

55
00:03:25,720 --> 00:03:26,720
This is where they presented.

56
00:03:26,720 --> 00:03:32,600
And by the time we finished talking, he was so sure that, okay, he doesn't need to send

57
00:03:32,600 --> 00:03:34,680
this patient for any further evaluation.

58
00:03:34,680 --> 00:03:36,280
He can work with the results.

59
00:03:36,280 --> 00:03:39,640
And yes, what he has been thinking is actually the correct thing.

60
00:03:39,640 --> 00:03:43,680
Like the report confirmed his suspicion.

61
00:03:43,680 --> 00:03:48,960
And then it saves the patient a lot of extra cost of going around or doing some unnecessary

62
00:03:48,960 --> 00:03:49,960
imaging.

63
00:03:49,960 --> 00:03:54,520
And the doctor too has his confidence backed up by the report.

64
00:03:54,520 --> 00:03:59,160
So what you see is true and the reality.

65
00:03:59,160 --> 00:04:02,120
And if your lawn is shared something that's more clinically tangible, right?

66
00:04:02,120 --> 00:04:06,520
Like I'll just give you an example of something that happened to me, a patient and a clinician,

67
00:04:06,520 --> 00:04:07,520
right?

68
00:04:07,520 --> 00:04:11,320
So I was looking at a CT scan, a CAT scan.

69
00:04:11,320 --> 00:04:14,920
And so the patient was coming in with pain in the right upper quadrant.

70
00:04:14,920 --> 00:04:17,960
So kind of along where the liver is, right?

71
00:04:17,960 --> 00:04:21,760
So the history that I get is just R U Q space P N.

72
00:04:21,760 --> 00:04:23,200
That's the entire history.

73
00:04:23,200 --> 00:04:24,200
Five letters.

74
00:04:24,200 --> 00:04:25,200
That's all I have.

75
00:04:25,200 --> 00:04:26,200
Right.

76
00:04:26,200 --> 00:04:27,200
Exactly.

77
00:04:27,200 --> 00:04:28,200
So I'm looking at this.

78
00:04:28,200 --> 00:04:29,200
It looks normal, right?

79
00:04:29,200 --> 00:04:30,200
It's a middle-aged woman.

80
00:04:30,200 --> 00:04:31,520
She's a little overweight.

81
00:04:31,520 --> 00:04:35,920
And so typically when you hear middle-aged woman overweight with right upper chronic

82
00:04:35,920 --> 00:04:40,000
pain, you automatically think, oh gosh, it could be the gallbladder or the liver, duct

83
00:04:40,000 --> 00:04:41,240
and things like that.

84
00:04:41,240 --> 00:04:42,840
So I'm looking at this.

85
00:04:42,840 --> 00:04:45,040
It looks normal, completely normal.

86
00:04:45,040 --> 00:04:47,120
I didn't see a single thing, the gallbladder is normal.

87
00:04:47,120 --> 00:04:48,120
There's no stones.

88
00:04:48,120 --> 00:04:49,120
There's no dilatation.

89
00:04:49,120 --> 00:04:51,280
There's nothing, nothing that would indicate anything.

90
00:04:51,280 --> 00:04:55,360
So most radiologists, when they see something that's normal, they don't press any further.

91
00:04:55,360 --> 00:04:57,720
They just, they call it normal and move on, right?

92
00:04:57,720 --> 00:04:58,960
That's not how I do things.

93
00:04:58,960 --> 00:05:00,560
So I called the doctor.

94
00:05:00,560 --> 00:05:03,280
I'm like, hey, it's looking pretty normal.

95
00:05:03,280 --> 00:05:06,840
Anything going on with this patient is like, man, the doctor said to me, he's like, man,

96
00:05:06,840 --> 00:05:07,960
this patient is really ill.

97
00:05:07,960 --> 00:05:10,280
Like she is extremely tender in the right upper quadrant.

98
00:05:10,280 --> 00:05:16,000
I'm pretty sure she has a gallbladder attack, meaning colostiitis or something like that.

99
00:05:16,000 --> 00:05:19,640
And so, so I, you know, I told him, I'm like, this is definitely not colostiitis.

100
00:05:19,640 --> 00:05:22,600
There's no finding here that would be consistent with that.

101
00:05:22,600 --> 00:05:23,880
Does she have any fevers?

102
00:05:23,880 --> 00:05:26,760
Does she have any white count, any, you know, liver function tests out of whack?

103
00:05:26,760 --> 00:05:28,720
He's like, no, everything's stone cold normal.

104
00:05:28,720 --> 00:05:30,360
I'm like, this doesn't make any sense.

105
00:05:30,360 --> 00:05:31,840
And like, is there any other histories?

106
00:05:31,840 --> 00:05:32,840
There any other information?

107
00:05:32,840 --> 00:05:34,920
He's like, nothing that was contributory, right?

108
00:05:34,920 --> 00:05:35,920
Nothing that would make sense.

109
00:05:35,920 --> 00:05:37,920
Like, well, what was non-contributory?

110
00:05:37,920 --> 00:05:42,960
You know, like, and so he's like, Oh, well, she fell like five days ago, but she didn't

111
00:05:42,960 --> 00:05:44,560
have any problems when she fell.

112
00:05:44,560 --> 00:05:47,200
Of course now I'm going, how could I have missed a rib fracture?

113
00:05:47,200 --> 00:05:50,920
You know, I'm not looking specifically for like, and I go through all the ribs and I'm

114
00:05:50,920 --> 00:05:54,800
looking and there's no rib fracture either that I can see.

115
00:05:54,800 --> 00:05:57,640
And so, and so I'm like, you know, Hey, man, I just don't see anything.

116
00:05:57,640 --> 00:06:00,320
He's like, man, this patient is really tender.

117
00:06:00,320 --> 00:06:03,880
It's, and, and he said something so specific to me.

118
00:06:03,880 --> 00:06:10,000
He said, this is along the lower part of the rib margin, four centimeters from the xiphoid

119
00:06:10,000 --> 00:06:14,280
process, which is the little tip of bone that's at the end of your sternum at the bottom,

120
00:06:14,280 --> 00:06:15,280
just before you get to there.

121
00:06:15,280 --> 00:06:16,280
Right?

122
00:06:16,280 --> 00:06:17,280
Yeah.

123
00:06:17,280 --> 00:06:23,640
So then I move, so I go straight to the, that area on the CT scan and there is a hairline

124
00:06:23,640 --> 00:06:28,600
fracture that's not displaced through the cartilage, which is an exceedingly hard diagnosis

125
00:06:28,600 --> 00:06:29,600
to make you.

126
00:06:29,600 --> 00:06:35,440
And I would never make it was on a single image that I could see it and, and, you know,

127
00:06:35,440 --> 00:06:38,160
an incomplete fracture through this area.

128
00:06:38,160 --> 00:06:43,440
So, so interestingly, the thing that he thought was non contributory was actually quite contributory.

129
00:06:43,440 --> 00:06:47,080
She just didn't realize she had, you know, that level of pain or this and now she's got

130
00:06:47,080 --> 00:06:48,720
a non displaced fracture.

131
00:06:48,720 --> 00:06:49,720
Okay.

132
00:06:49,720 --> 00:06:54,600
So you think, well, taking that extra time, like, did I save the patient's life?

133
00:06:54,600 --> 00:06:55,600
Absolutely not.

134
00:06:55,600 --> 00:06:57,440
They weren't in any imminent threat or harm.

135
00:06:57,440 --> 00:07:01,480
And had I even missed the finding, they probably would have gone on to eventually heal on their

136
00:07:01,480 --> 00:07:02,920
own, no problem.

137
00:07:02,920 --> 00:07:04,920
But what was the impact to the patient?

138
00:07:04,920 --> 00:07:05,920
Right?

139
00:07:05,920 --> 00:07:09,720
Well, had I, had I just said that it was normal in the ER that night, they would have gotten

140
00:07:09,720 --> 00:07:13,320
an ultrasound because the clinician would have thought that there was still a gallbladder

141
00:07:13,320 --> 00:07:14,720
problem, even though the CT was normal.

142
00:07:14,720 --> 00:07:20,920
So they would have had an extra test and they may have had another test later as an outpatient

143
00:07:20,920 --> 00:07:26,440
to do what's called a hepatobiliary scan, which is a type of nuclear medicine test where

144
00:07:26,440 --> 00:07:30,480
they check to see the gallbladder function and the liver function and the, the, the ducts.

145
00:07:30,480 --> 00:07:31,480
Right?

146
00:07:31,480 --> 00:07:36,760
So, so this woman would have had multiple excess tests.

147
00:07:36,760 --> 00:07:39,400
It would have occurred, you know, typically over the next week or two or three, she would

148
00:07:39,400 --> 00:07:43,760
have waited for results and, and none of it would have been relevant because she had a

149
00:07:43,760 --> 00:07:45,720
hairline fracture.

150
00:07:45,720 --> 00:07:49,520
And to give you a sense of like, you know, you may have, let's say 500 images that you're

151
00:07:49,520 --> 00:07:58,680
looking at, this is on one of those 500 images, each image has 500 million, I'm sorry, 500,000

152
00:07:58,680 --> 00:07:59,680
pixels.

153
00:07:59,680 --> 00:08:06,120
So out of, you're talking about reading something like 250 million pixels and finding eight abnormal

154
00:08:06,120 --> 00:08:09,000
pixels in a single image.

155
00:08:09,000 --> 00:08:13,640
No human being can do that, except when you know, like it's like a needle in the haystack,

156
00:08:13,640 --> 00:08:14,640
right?

157
00:08:14,640 --> 00:08:16,960
When you know where the needle is, you know the color and you know the position, it's

158
00:08:16,960 --> 00:08:17,960
easy to find the needle.

159
00:08:17,960 --> 00:08:18,960
Right?

160
00:08:18,960 --> 00:08:19,960
Yeah, yeah, yeah.

161
00:08:19,960 --> 00:08:23,960
It makes me think of rare events and probability in my, right?

162
00:08:23,960 --> 00:08:31,400
So, so it's very hard to find these things, but when you take the time to talk to the

163
00:08:31,400 --> 00:08:33,960
clinician, you can produce a better result.

164
00:08:33,960 --> 00:08:35,760
And I think that's the key.

165
00:08:35,760 --> 00:08:40,920
That's the most crucial thing because at the end of the day, you know, you're really trying

166
00:08:40,920 --> 00:08:45,360
to help this patient and the clinician figure out what's going on.

167
00:08:45,360 --> 00:08:50,000
And I think that's the great privilege of being a radiologist and being, you know, a

168
00:08:50,000 --> 00:08:55,800
physician in general, like, think about how incredibly good you feel when you help somebody

169
00:08:55,800 --> 00:08:56,800
in this way.

170
00:08:56,800 --> 00:08:57,800
Yeah, that's true.

171
00:08:57,800 --> 00:09:02,120
I didn't say the person's life, but I helped them and I helped relieve their pain or suffering.

172
00:09:02,120 --> 00:09:07,120
You know, I helped get them to the right answer to what, you know, to what's causing their

173
00:09:07,120 --> 00:09:09,720
life to be miserable at a given time.

174
00:09:09,720 --> 00:09:13,440
That's a very empowering, amazing feeling, I promise.

175
00:09:13,440 --> 00:09:16,040
Very, very fulfilling too.

176
00:09:16,040 --> 00:09:22,040
Okay, so I quite appreciate this great, in fact, you've dealt so much and then explained

177
00:09:22,040 --> 00:09:24,560
quite a lot of very useful details.

178
00:09:24,560 --> 00:09:32,120
As you try to send these images to the doctors, you transmit these images through some electronic

179
00:09:32,120 --> 00:09:33,120
means.

180
00:09:33,120 --> 00:09:40,760
So I wonder, like, what measures are in place to preserve image quality or how are the image

181
00:09:40,760 --> 00:09:44,360
transmitted to preserve their quality and diagnostic value?

182
00:09:44,360 --> 00:09:48,360
Does it add to the overall cost of your service or patient's care?

183
00:09:48,360 --> 00:09:49,560
It doesn't actually add to the cost.

184
00:09:49,560 --> 00:09:56,080
In fact, we can dramatically decrease the cost because we can aggregate multiple patients

185
00:09:56,080 --> 00:10:01,400
across multiple hospitals so that we can keep, you know, keep the cost low.

186
00:10:01,400 --> 00:10:06,480
The reason being, like, let's say at a given hospital, you have to sit there at night, you

187
00:10:06,480 --> 00:10:09,720
know, let's say there's 10 cases overnight, but you have to be there.

188
00:10:09,720 --> 00:10:11,960
You have to sit there in the hospital reading cases.

189
00:10:11,960 --> 00:10:14,840
For a radiologist, that's very inefficient because at nighttime, you may not have the

190
00:10:14,840 --> 00:10:17,320
same amount of volume or work as daytime.

191
00:10:17,320 --> 00:10:21,720
And so when you think about it from a work or a cost standpoint, to keep a radiologist

192
00:10:21,720 --> 00:10:26,480
up for, you know, the whole night is very expensive, right?

193
00:10:26,480 --> 00:10:31,720
And thousands of dollars per night, and if they're reading 10 cases, you're going to

194
00:10:31,720 --> 00:10:33,280
be losing money.

195
00:10:33,280 --> 00:10:37,440
But what if you could pay a tiny fraction of that only for the cases that come through?

196
00:10:37,440 --> 00:10:41,280
And some nights you may have two, some nights you may have 16, but you're only paying for

197
00:10:41,280 --> 00:10:42,920
what you actually use.

198
00:10:42,920 --> 00:10:47,920
And at a given time, those things are being done read faster and more efficiently than

199
00:10:47,920 --> 00:10:49,880
even if the radiologist was in house.

200
00:10:49,880 --> 00:10:54,280
Because our average reporting times are faster than the local radiologist, despite being

201
00:10:54,280 --> 00:10:57,200
thousands of miles away, our average reporting is faster.

202
00:10:57,200 --> 00:10:59,760
So you can actually reduce the cost.

203
00:10:59,760 --> 00:11:04,440
Now, going back to your initial question a little bit about, like, how do you ensure

204
00:11:04,440 --> 00:11:08,880
the validity of the information because it's acquired in South Carolina now it's coming

205
00:11:08,880 --> 00:11:10,920
all the way to Nevada or something like that.

206
00:11:10,920 --> 00:11:15,680
Well, this is what I had talked about a little bit earlier when I said that, you know, this

207
00:11:15,680 --> 00:11:19,000
stuff had been standardized 25 years earlier.

208
00:11:19,000 --> 00:11:23,080
And this is it has something called the DICOM standard, right?

209
00:11:23,080 --> 00:11:24,080
D-I-C-O-M.

210
00:11:24,080 --> 00:11:28,600
And this is, yeah, this is a standard in medicine and radiology specifically that was developed

211
00:11:28,600 --> 00:11:31,920
for, for this process to standardize it.

212
00:11:31,920 --> 00:11:36,640
And interestingly, we have these like very specialized powered monitors, right?

213
00:11:36,640 --> 00:11:41,480
That it doesn't matter where I am in the world, what the lighting conditions are in the room

214
00:11:41,480 --> 00:11:45,400
that I'm in, the monitor will perform so it'll detect the background lighting.

215
00:11:45,400 --> 00:11:51,240
It'll make it so that the image looks the same whether I'm in Timbuktu or, you know,

216
00:11:51,240 --> 00:11:53,720
New York City, doesn't matter.

217
00:11:53,720 --> 00:11:59,280
And so that in that way, I'm getting the exact same thing that somebody would be getting

218
00:11:59,280 --> 00:12:03,360
there sitting right there next to the, you know, console reading the case in the reading

219
00:12:03,360 --> 00:12:04,360
room.

220
00:12:04,360 --> 00:12:07,200
So those monitors must have cost you a lot to purchase.

221
00:12:07,200 --> 00:12:08,200
They do.

222
00:12:08,200 --> 00:12:09,200
They're very expensive.

223
00:12:09,200 --> 00:12:13,320
They're not like your standard home monitor because they've got tons of light sensors

224
00:12:13,320 --> 00:12:21,360
in them that detect, you know, light reflection, temperature, color and a grayscale temperatures,

225
00:12:21,360 --> 00:12:27,360
you know, for how, how luminant the monitors, the receiver operating characteristics, you

226
00:12:27,360 --> 00:12:30,240
know, from a radiologist from my eyes, it has to be the same, right?

227
00:12:30,240 --> 00:12:37,880
So the monitor has to be able to produce that or mimic that across a wide range of parameters.

228
00:12:37,880 --> 00:12:41,520
And so that's another part of that standardization, that dichom standardization.

229
00:12:41,520 --> 00:12:45,840
Don't you have any concern for cyber security threats, maybe any breach in the process of

230
00:12:45,840 --> 00:12:48,560
image transmission in this?

231
00:12:48,560 --> 00:12:54,640
Not so much in the process of image transmission, but let's go back to a more general question.

232
00:12:54,640 --> 00:13:00,360
Are you, you know, is anybody dealing with patient data concerned about cyber threats?

233
00:13:00,360 --> 00:13:05,760
The short answer is, of course, I mean, that is centrally important to, you know, kind of

234
00:13:05,760 --> 00:13:08,920
what we do from the security standpoint.

235
00:13:08,920 --> 00:13:09,920
Yeah.

236
00:13:09,920 --> 00:13:14,960
So, you know, we use, for example, when we connect to a site, we do a point to point

237
00:13:14,960 --> 00:13:15,960
VPN, right?

238
00:13:15,960 --> 00:13:21,560
And that's a fairly secure method of moving data from point A to point B over the internet.

239
00:13:21,560 --> 00:13:26,240
None of it, none of our traffic can be unencrypted.

240
00:13:26,240 --> 00:13:30,440
All of it is encrypted, typically with very strong encryption protocols.

241
00:13:30,440 --> 00:13:31,440
Right.

242
00:13:31,440 --> 00:13:36,320
And in addition, you know, you have, you go through certain types of security certifications

243
00:13:36,320 --> 00:13:39,800
and those are ones that we've, you know, gone through as part of this process.

244
00:13:39,800 --> 00:13:45,880
So we've done it to the point where external third parties look at our workflow and say,

245
00:13:45,880 --> 00:13:46,880
this is definitely secure.

246
00:13:46,880 --> 00:13:49,880
We're giving you kind of our signed off stamp of approval.

247
00:13:49,880 --> 00:13:53,640
So, and we take a lot of time, money and effort to maintain that.

248
00:13:53,640 --> 00:13:56,520
Of course, it sure has to cost a lot.

249
00:13:56,520 --> 00:13:59,440
Of course, it's going to cost a lot.

250
00:13:59,440 --> 00:14:00,440
It does.

251
00:14:00,440 --> 00:14:04,160
It's not inexpensive, but it's manageable.

252
00:14:04,160 --> 00:14:05,160
Okay.

253
00:14:05,160 --> 00:14:06,160
Okay.

254
00:14:06,160 --> 00:14:10,960
Do you have like any archival system for images you have worked on or do you discard

255
00:14:10,960 --> 00:14:13,480
them rightly after your work?

256
00:14:13,480 --> 00:14:16,560
No, we keep everything in accordance with the law.

257
00:14:16,560 --> 00:14:20,680
So for example, in the United States, there's certain laws on medical image retention.

258
00:14:20,680 --> 00:14:25,640
One thing that I'll state is that we're technically not the final repository.

259
00:14:25,640 --> 00:14:29,560
The local hospital is going to keep that study in that image permanently, right?

260
00:14:29,560 --> 00:14:33,160
Or according to that state law or other law.

261
00:14:33,160 --> 00:14:38,200
But in addition to that, we keep that data essentially permanently.

262
00:14:38,200 --> 00:14:40,040
We haven't had to delete any of the data at this point.

263
00:14:40,040 --> 00:14:42,520
So we keep and maintain it.

264
00:14:42,520 --> 00:14:46,000
And part of the reason is what happens if the patient, you know, let's say they bonk

265
00:14:46,000 --> 00:14:48,800
their head or they did, you know, had belly pain.

266
00:14:48,800 --> 00:14:50,960
What happens if you come back two months later, right?

267
00:14:50,960 --> 00:14:53,720
Well, I'd love to have their old study and what I said about it.

268
00:14:53,720 --> 00:14:57,640
And so we keep and record all that information just because it'll.

269
00:14:57,640 --> 00:14:58,640
Yeah.

270
00:14:58,640 --> 00:14:59,640
Yeah.

271
00:14:59,640 --> 00:15:03,120
Because it will improve the results, the future results too.

272
00:15:03,120 --> 00:15:06,320
So that's why it's hard to kind of delete or let go of that information.

273
00:15:06,320 --> 00:15:07,320
Okay.

274
00:15:07,320 --> 00:15:08,440
I mean, it's not hard on a technical level.

275
00:15:08,440 --> 00:15:10,760
It's just, it's hard on a medical professional level.

276
00:15:10,760 --> 00:15:14,960
Like I would want that information because, you know, in the end, you know, as a patient,

277
00:15:14,960 --> 00:15:18,720
you would want your doctor to have access to all your information, right?

278
00:15:18,720 --> 00:15:20,360
So they can make the right decision.

279
00:15:20,360 --> 00:15:21,360
Same thing.

280
00:15:21,360 --> 00:15:23,360
Has it been used for any litigation?

281
00:15:23,360 --> 00:15:29,280
Like, can you also say that's one of the reasons why you keep some of those images?

282
00:15:29,280 --> 00:15:35,200
You do have to keep them legally and that it does delve into this idea of, you know,

283
00:15:35,200 --> 00:15:41,200
litigation, because if you did get into a lawsuit, you would have to be able to produce

284
00:15:41,200 --> 00:15:42,200
the records, right?

285
00:15:42,200 --> 00:15:44,200
So you do have to maintain it from that standpoint.

286
00:15:44,200 --> 00:15:48,320
And I'll tell you, one really interesting thing, and this is not, you know, we don't

287
00:15:48,320 --> 00:15:52,400
necessarily talk about this much, but, you know, we practice at fairly large scale.

288
00:15:52,400 --> 00:15:56,040
We cover about 4% of the hospitals of the United States.

289
00:15:56,040 --> 00:16:01,200
So one in 25 patients in the United States is coming through our portals, right?

290
00:16:01,200 --> 00:16:06,360
And so despite that, and you know, I've done this for, you know, 18 years or 17 years

291
00:16:06,360 --> 00:16:13,800
now, we have never had a malpractice judgment or settlement to date, which means, and there's

292
00:16:13,800 --> 00:16:19,400
no practice in the country that's operating at scale that can make that claim, not one,

293
00:16:19,400 --> 00:16:20,400
right?

294
00:16:20,400 --> 00:16:23,720
And so again, the story hopefully comes full circle.

295
00:16:23,720 --> 00:16:27,120
Take care of the patient, do the right thing, take the time with the doctor, and you'll

296
00:16:27,120 --> 00:16:28,680
get the best results and answers.

297
00:16:28,680 --> 00:16:31,920
And when you do, liability is less of a concern.

298
00:16:31,920 --> 00:16:32,920
Yeah.

299
00:16:32,920 --> 00:16:35,960
Following best practices actually pays, pays off.

300
00:16:35,960 --> 00:16:36,960
It does.

301
00:16:36,960 --> 00:16:39,080
But you have to have a long term view.

302
00:16:39,080 --> 00:16:42,840
If you have a short term view of it, you know, money, money, money, money, money, money,

303
00:16:42,840 --> 00:16:46,200
then you're going to have a very different type of practice.

304
00:16:46,200 --> 00:16:48,280
That doesn't ever drive us.

305
00:16:48,280 --> 00:16:54,520
Our driving ethical principles are very different than, you know, what you traditionally find

306
00:16:54,520 --> 00:16:56,520
in, let's say, companies and businesses.

307
00:16:56,520 --> 00:17:02,280
Don Silver, you've given us a lot of insights into the model of your work.

308
00:17:02,280 --> 00:17:06,920
Would you like to know, are there any major modalities you don't cover or report?

309
00:17:06,920 --> 00:17:08,280
Yes, in one sense.

310
00:17:08,280 --> 00:17:12,720
So we cover everything that makes sense to cover via tele radiology, right?

311
00:17:12,720 --> 00:17:15,840
So there are things in radiology that you can't cover.

312
00:17:15,840 --> 00:17:18,360
For example, like interventional procedures.

313
00:17:18,360 --> 00:17:21,120
I can't do that from 2,000 miles away very easily.

314
00:17:21,120 --> 00:17:25,400
Now, that's not to say, you know, 20 years from now that we won't be able to do that.

315
00:17:25,400 --> 00:17:30,160
Maybe robotics and remote type things, you know, can develop and I would be, right?

316
00:17:30,160 --> 00:17:32,240
Like, that could be amazing.

317
00:17:32,240 --> 00:17:36,600
But there are things where you actually need to be present, particularly procedure driven.

318
00:17:36,600 --> 00:17:41,440
There's certain breast imaging where you want to be there because in real time you're adjusting

319
00:17:41,440 --> 00:17:44,680
the imaging based on what you see and you'll take another shot.

320
00:17:44,680 --> 00:17:45,680
You'll reposition the breast.

321
00:17:45,680 --> 00:17:50,840
You'll put pressure here just to make sure that, and so that stuff has to be done live

322
00:17:50,840 --> 00:17:54,880
in person because it, you know, that's just the nature of the work.

323
00:17:54,880 --> 00:17:58,480
But aside from those things, we pretty much cover everything else.

324
00:17:58,480 --> 00:17:59,480
Okay.

325
00:17:59,480 --> 00:18:01,800
So can experts outside the US join you?

326
00:18:01,800 --> 00:18:05,760
If I will, come and join you.

327
00:18:05,760 --> 00:18:10,760
We have a fairly rigorous vetting process.

328
00:18:10,760 --> 00:18:14,040
And this is also fairly unique in the industry.

329
00:18:14,040 --> 00:18:21,640
You know, over the course of my life, I found that, you know, a CV or a resume only tells

330
00:18:21,640 --> 00:18:24,960
you a tiny fraction about what you need to know, right?

331
00:18:24,960 --> 00:18:31,520
And most of, probably the most important things is very hard to even know from, let's say,

332
00:18:31,520 --> 00:18:32,880
an academic record.

333
00:18:32,880 --> 00:18:36,760
So I have seen people who look like they should be able to walk on water.

334
00:18:36,760 --> 00:18:40,600
You know, they come from the most prestigious institutions and they've got the best scores

335
00:18:40,600 --> 00:18:44,880
and the best grades and they're not very good at the radiology part of it.

336
00:18:44,880 --> 00:18:49,920
You know, like, I, you know, and then there's people that came from, you know, some no-name

337
00:18:49,920 --> 00:18:54,680
place with, you know, you wouldn't ever think twice about this.

338
00:18:54,680 --> 00:18:56,720
And they just, they're incredible radiologists.

339
00:18:56,720 --> 00:19:00,800
They have the eye, they have the clinical knack, they have the intuition, the judgment.

340
00:19:00,800 --> 00:19:05,120
And so a CV or a resume only gets you so far, right?

341
00:19:05,120 --> 00:19:09,880
That's when, you know, that's when the real hard work comes and, you know, interviews.

342
00:19:09,880 --> 00:19:12,000
We actually test every radiologist, not joking.

343
00:19:12,000 --> 00:19:16,120
We will show them case after case after case and see, you know, how do they approach something

344
00:19:16,120 --> 00:19:19,080
when they don't know what's going on, right?

345
00:19:19,080 --> 00:19:23,560
And that's actually kind of valuable when you think about, like, you know, because it

346
00:19:23,560 --> 00:19:27,480
tells you that the person has a general tool set that's really good.

347
00:19:27,480 --> 00:19:32,000
So much of medicine and much of life, right, much of your professional career will be figuring

348
00:19:32,000 --> 00:19:36,680
out how to achieve something when you don't know the answer, right?

349
00:19:36,680 --> 00:19:39,960
Because you can go off into crazy solutions and crazy ideas and you can go off into a

350
00:19:39,960 --> 00:19:42,120
measured reasonable approach.

351
00:19:42,120 --> 00:19:46,560
And it's hard to figure that out on a resume, right?

352
00:19:46,560 --> 00:19:51,920
It's also hard to figure out, what is this person's desire, conscientiousness, right?

353
00:19:51,920 --> 00:19:57,840
You know, will they take the extra time to go the extra mile for this patient?

354
00:19:57,840 --> 00:20:02,000
And it goes back to a kind of a foundational ethos for us, right?

355
00:20:02,000 --> 00:20:07,000
When Ray and I started the company, one of the things that we talked about was, well,

356
00:20:07,000 --> 00:20:10,800
what should it be our basic foundational principle?

357
00:20:10,800 --> 00:20:14,440
And we both kind of came up with the same answer independently.

358
00:20:14,440 --> 00:20:17,560
And it comes from a very simple question.

359
00:20:17,560 --> 00:20:20,680
Is this how you would want your family member treated?

360
00:20:20,680 --> 00:20:21,680
Okay.

361
00:20:21,680 --> 00:20:25,680
So if you answer yes, you're doing the right thing, right?

362
00:20:25,680 --> 00:20:29,400
If you answer no, you're clearly doing the wrong thing, but here's the trick to all of

363
00:20:29,400 --> 00:20:30,400
it.

364
00:20:30,400 --> 00:20:35,840
If you pause and have to think about it, you're likely justifying something to yourself,

365
00:20:35,840 --> 00:20:38,840
which means you're probably doing the wrong thing, right?

366
00:20:38,840 --> 00:20:42,400
I mean, definitely adjust to do the right thing.

367
00:20:42,400 --> 00:20:43,400
Yeah.

368
00:20:43,400 --> 00:20:45,880
And so you wouldn't do the right thing.

369
00:20:45,880 --> 00:20:46,880
Right.

370
00:20:46,880 --> 00:20:53,320
And so you have to do things, you always have to carry yourself, your practice, your care

371
00:20:53,320 --> 00:20:57,880
in a way that you know you're doing the right thing for the patient.

372
00:20:57,880 --> 00:20:59,400
How do you figure that out on a resume?

373
00:20:59,400 --> 00:21:00,400
You can't.

374
00:21:00,400 --> 00:21:04,920
I mean, you've got to know, yeah, so you've got to talk to people who have worked with

375
00:21:04,920 --> 00:21:06,640
this person for years.

376
00:21:06,640 --> 00:21:10,360
And so we do a lot of, a lot of vetting.

377
00:21:10,360 --> 00:21:14,280
So to answer your question, again, you'll find I have very long-winded answers to simple

378
00:21:14,280 --> 00:21:15,280
questions.

379
00:21:15,280 --> 00:21:18,880
But to answer your question, can experts outside the US join?

380
00:21:18,880 --> 00:21:19,880
Absolutely.

381
00:21:19,880 --> 00:21:23,280
And we do have a few people that are working from outside of the United States, but they've

382
00:21:23,280 --> 00:21:28,160
been highly vetted in their exceptional human beings and exceptional radiologists.

383
00:21:28,160 --> 00:21:33,200
And so it's not, it's not something like you just kind of say, oh yeah, you know, yeah,

384
00:21:33,200 --> 00:21:37,960
it is really, yeah, it's a process to say the least, but we're happy with the process

385
00:21:37,960 --> 00:21:42,360
because we, we know that when they're through that process, this is somebody that you would

386
00:21:42,360 --> 00:21:47,240
stand shoulder to shoulder with, you know, kind of doing battle with, and you know you

387
00:21:47,240 --> 00:21:48,240
can trust them.

388
00:21:48,240 --> 00:21:51,240
Yeah, but do you do something like internship?

389
00:21:51,240 --> 00:21:57,160
Do you give room for others to come and learn on the job?

390
00:21:57,160 --> 00:22:03,720
The type of work we do, it's not quite conducive to that because when you're practicing medicine,

391
00:22:03,720 --> 00:22:07,480
you kind of have to be through that medical process and you have to have a state medical

392
00:22:07,480 --> 00:22:09,560
license and you have to have credentials.

393
00:22:09,560 --> 00:22:17,040
So it's not, it's not like an academic university where you can have trainees doing that stuff.

394
00:22:17,040 --> 00:22:19,360
You know, we don't have that kind of reach.

395
00:22:19,360 --> 00:22:20,360
We're not a university.

396
00:22:20,360 --> 00:22:25,960
And so yeah, we, it would be very difficult for us to, to create an internship level or

397
00:22:25,960 --> 00:22:31,520
a training level thing for, let's say, somebody who's learning the practice.

398
00:22:31,520 --> 00:22:32,520
Yeah.

399
00:22:32,520 --> 00:22:33,520
All right.

400
00:22:33,520 --> 00:22:34,520
That's also cool.

401
00:22:34,520 --> 00:22:37,320
And then quite acceptable and understandable.

402
00:22:37,320 --> 00:22:38,320
Yeah.

403
00:22:38,320 --> 00:22:41,040
Doctor, you've really delved into so much.

404
00:22:41,040 --> 00:22:48,040
I kind of think the Tokyo 2020 slash 2021 should have a room to acknowledge such a great

405
00:22:48,040 --> 00:22:50,280
feat you have achieved in the industry.

406
00:22:50,280 --> 00:22:54,040
I think you deserve some medal more than those that you have on the field.

407
00:22:54,040 --> 00:22:55,040
No.

408
00:22:55,040 --> 00:22:59,280
I definitely don't want any medals or adulation or congratulations.

409
00:22:59,280 --> 00:23:03,920
I get satisfaction in just doing a job well and doing it for the patient.

410
00:23:03,920 --> 00:23:09,120
And if the patient does well, I'm more than satisfied and I don't need credit for it.

411
00:23:09,120 --> 00:23:11,640
I just need to know that I did the right thing by the patient.

412
00:23:11,640 --> 00:23:13,040
That's all the, that's all I need.

413
00:23:13,040 --> 00:23:14,040
Yeah.

414
00:23:14,040 --> 00:23:18,240
That's quite evident already from, from before going in and the explanations you've been

415
00:23:18,240 --> 00:23:19,240
making.

416
00:23:19,240 --> 00:23:21,800
It's really evident that you have the passion for the job you are doing.

417
00:23:21,800 --> 00:23:27,680
So yeah, I, I kind of wonder like, do you, what was the future of tele radiology?

418
00:23:27,680 --> 00:23:31,920
You said it was even there before telemedicine, but I kind of wonder what's the future of

419
00:23:31,920 --> 00:23:37,240
tele radiology, especially in developing countries where consistent access to quality images

420
00:23:37,240 --> 00:23:38,760
is an issue.

421
00:23:38,760 --> 00:23:44,640
Like, I think this tele radiology model is predicated on these basic infrastructure things.

422
00:23:44,640 --> 00:23:45,640
Right.

423
00:23:45,640 --> 00:23:49,200
So for example, if you don't have high quality internet or you won't be able to do the

424
00:23:49,200 --> 00:23:56,280
tele radiology, so as a communication systems, as these infrastructure things start to increase,

425
00:23:56,280 --> 00:23:59,600
right, the penetrance of tele radiology will increase as well.

426
00:23:59,600 --> 00:24:03,880
Telemedicine, I mean, tele radiology is a subset of telemedicine because you could have

427
00:24:03,880 --> 00:24:09,800
tele dermatology, tele, you know, general internal medicine, telecardiology, tele orthopedics.

428
00:24:09,800 --> 00:24:11,920
It doesn't really matter what it is.

429
00:24:11,920 --> 00:24:19,280
It's the idea that you can pool expert, you know, expert clinicians, physicians to affect

430
00:24:19,280 --> 00:24:22,120
a larger or wider range of patients and improve their access.

431
00:24:22,120 --> 00:24:26,280
Because right now there's not enough doctors and way too many patients.

432
00:24:26,280 --> 00:24:29,160
So we are going crazy fast, right?

433
00:24:29,160 --> 00:24:32,880
I think in the United States there's, I was reading some article, you know, you said that

434
00:24:32,880 --> 00:24:37,480
the average 15 minute appointment that a physician spends with a patient, there are two minutes

435
00:24:37,480 --> 00:24:43,240
spent talking to the patient and doing exam and 13 minutes in documentation.

436
00:24:43,240 --> 00:24:44,520
That is upside down to me.

437
00:24:44,520 --> 00:24:48,040
That's the exact wrong way of doing things, right?

438
00:24:48,040 --> 00:24:50,920
And because the patient frequently has the answers, you've got to talk to them.

439
00:24:50,920 --> 00:24:58,240
So this idea of telemedicine is essentially, I mean, it's a way to reduce that burden and

440
00:24:58,240 --> 00:25:03,360
allow the clinician or radiologist or whatever to spend more time with the patient rather

441
00:25:03,360 --> 00:25:08,640
than in the bureaucracy of medicine, which is, especially in the United States, is just

442
00:25:08,640 --> 00:25:09,640
astronomical.

443
00:25:09,640 --> 00:25:11,640
That's very true.

444
00:25:11,640 --> 00:25:12,640
Okay.

445
00:25:12,640 --> 00:25:16,840
So I quite appreciate the time with you, doctor.

446
00:25:16,840 --> 00:25:20,360
You've really dealt with a whole lot of issues.

447
00:25:20,360 --> 00:25:27,680
And we are very thankful for the time you've given us to interact with you and also with

448
00:25:27,680 --> 00:25:29,920
what you are doing in the industry.

449
00:25:29,920 --> 00:25:34,400
I think we should recommend you for Biden's award.

450
00:25:34,400 --> 00:25:36,400
That's so great.

451
00:25:36,400 --> 00:25:38,200
That's so artistic.

452
00:25:38,200 --> 00:25:41,640
You said you don't need any award or adulation in that regard.

453
00:25:41,640 --> 00:25:46,040
So yeah, I quite appreciate already the time.

454
00:25:46,040 --> 00:25:51,440
I am looking forward actually to meeting you physically someday in the future.

455
00:25:51,440 --> 00:25:57,560
So I don't know if you have any last words, maybe any future, maybe any research frontiers

456
00:25:57,560 --> 00:26:01,920
you think should be explored in this field of yours?

457
00:26:01,920 --> 00:26:10,320
I rarely have ever have any kind of wisdom or, but I would say, particularly to students

458
00:26:10,320 --> 00:26:17,440
out there that are in engineering, nuclear engineering in particular, it's an incredibly

459
00:26:17,440 --> 00:26:19,640
valuable skill set.

460
00:26:19,640 --> 00:26:24,160
The type of analytical thinking, reasoning, it will serve you.

461
00:26:24,160 --> 00:26:29,320
It doesn't matter if you go into something that's nuclear or nuclear adjacent or something

462
00:26:29,320 --> 00:26:30,320
else entirely.

463
00:26:30,320 --> 00:26:35,880
The skill sets that you learn, the rigor that you learn in this field can serve you in just

464
00:26:35,880 --> 00:26:38,520
about any discipline I can imagine.

465
00:26:38,520 --> 00:26:46,680
And so, and then the last thing is kind of just be on the lookout for those mentors.

466
00:26:46,680 --> 00:26:49,200
They will help you in this world.

467
00:26:49,200 --> 00:26:56,440
And then the next step is after you have gone through that, you have to do the same.

468
00:26:56,440 --> 00:26:59,880
So I have to be that mentor for the next generation.

469
00:26:59,880 --> 00:27:06,560
And I think having that idea that you're paying it forward is very important because we get

470
00:27:06,560 --> 00:27:11,240
a lot and we always have to be cognizant of what we give in this world because that's

471
00:27:11,240 --> 00:27:12,800
how you make a life.

472
00:27:12,800 --> 00:27:16,080
You make a living by what you get, you make a life by what you give.

473
00:27:16,080 --> 00:27:17,080
Wow.

474
00:27:17,080 --> 00:27:18,080
Quite inspirational.

475
00:27:18,080 --> 00:27:21,360
I can imagine that you will be giving this kind of deep inspiration.

476
00:27:21,360 --> 00:27:23,360
Thank you so much, Doctor.

477
00:27:23,360 --> 00:27:29,840
I really appreciate the process through which we came to actually meet and finally have

478
00:27:29,840 --> 00:27:38,000
this conversation was really a testation to the fact that you are very detailed and very

479
00:27:38,000 --> 00:27:39,960
committed to what you are doing.

480
00:27:39,960 --> 00:27:45,760
And I'm very grateful for the time you even allocated to have this conversation with us.

481
00:27:45,760 --> 00:27:51,200
I'm very also very grateful for the future and those that will be listening to this episode

482
00:27:51,200 --> 00:27:55,920
will be sure really enlightening in the way that they've never had before.

483
00:27:55,920 --> 00:28:01,480
So I want to say thank you and hope that we can have some other time in the future with

484
00:28:01,480 --> 00:28:02,480
you, sir.

485
00:28:02,480 --> 00:28:03,480
Yes, absolutely.

486
00:28:03,480 --> 00:28:07,240
You are too kind and it's been my privilege.

487
00:28:07,240 --> 00:28:08,240
Thank you.

488
00:28:08,240 --> 00:28:10,560
Okay, so Teodora, do you want to say anything?

489
00:28:10,560 --> 00:28:12,040
I want to say thank you.

490
00:28:12,040 --> 00:28:19,000
Out of your very busy schedule, you are able to make out time to be on this podcast today.

491
00:28:19,000 --> 00:28:27,080
We appreciate your time and we still wish you more success, more advancements in your

492
00:28:27,080 --> 00:28:32,760
chosen field and we know you keep touching the lives of your patients positively.

493
00:28:32,760 --> 00:28:40,560
And I've also learned one or two things, you know, putting more efforts to see that I get

494
00:28:40,560 --> 00:28:48,960
in touch with the physicians that send their patients for radiological examinations so

495
00:28:48,960 --> 00:28:55,000
that we can be able to communicate further, get details and do the best for the patients.

496
00:28:55,000 --> 00:28:59,680
And I know anyone listening to this podcast would have learned one or two things, importance

497
00:28:59,680 --> 00:29:07,600
of paying attention to detail, doing your best and then improving on, you know, whatever

498
00:29:07,600 --> 00:29:11,560
you do, you keep improving, you don't stay where you were at the beginning, you keep

499
00:29:11,560 --> 00:29:15,680
going forward, you follow the trends with technology and all.

500
00:29:15,680 --> 00:29:17,480
So thank you so much, doctor.

501
00:29:17,480 --> 00:29:21,480
We really appreciate it and we wish to have you again on our show.

502
00:29:21,480 --> 00:29:22,480
I would love that.

503
00:29:22,480 --> 00:29:25,680
And again, let me re-emphasize, it's been my privilege.

504
00:29:25,680 --> 00:29:27,760
Thank you guys for setting this up.

505
00:29:27,760 --> 00:29:28,760
It's been really fun.

506
00:29:28,760 --> 00:29:29,760
Thank you very much.

507
00:29:29,760 --> 00:29:37,760
Appreciate that.