1 00:00:00,080 --> 00:00:02,080 This is Carly Beam with the Becker Spine 2 00:00:02,080 --> 00:00:04,559 and Orthopedics podcast, and I'm thrilled to be 3 00:00:04,559 --> 00:00:07,599 joined today by doctor Franco Vina. Doctor Vina, 4 00:00:07,599 --> 00:00:09,679 thank you for joining us. Oh, thank you 5 00:00:09,679 --> 00:00:11,839 for having me. So before we dive into 6 00:00:11,839 --> 00:00:14,320 some questions, can you introduce yourself and tell 7 00:00:14,320 --> 00:00:15,924 us a bit more about your work and 8 00:00:15,924 --> 00:00:16,425 background? 9 00:00:17,524 --> 00:00:18,504 Sure. So 10 00:00:18,804 --> 00:00:21,224 I am an orthopedic spinal surgeon. 11 00:00:22,004 --> 00:00:23,204 So I have a little bit of an 12 00:00:23,204 --> 00:00:25,304 unusual background coming into medicine. 13 00:00:26,484 --> 00:00:28,964 Funny, I graduated college. And after I graduated 14 00:00:28,964 --> 00:00:29,464 college, 15 00:00:29,780 --> 00:00:32,380 I went into finance. Actually, I went into 16 00:00:32,579 --> 00:00:33,640 Really? Yeah. 17 00:00:34,260 --> 00:00:36,899 I went into financial planning. I went into, 18 00:00:37,539 --> 00:00:40,359 working with people and sending up retirements and 19 00:00:40,579 --> 00:00:42,820 savings and and goals. I I had a 20 00:00:42,820 --> 00:00:43,640 series seven 21 00:00:44,179 --> 00:00:46,475 license to trade stocks. I had a set, 22 00:00:46,475 --> 00:00:48,094 had an insurance license and, 23 00:00:48,475 --> 00:00:49,994 you know, I kind of realized as I 24 00:00:49,994 --> 00:00:51,515 was doing that, one of the things that 25 00:00:51,515 --> 00:00:53,454 attracted me to it is 26 00:00:53,835 --> 00:00:54,814 I really liked 27 00:00:55,674 --> 00:00:58,234 the personal connection to people. I liked helping 28 00:00:58,234 --> 00:01:00,229 people and I liked helping people 29 00:01:00,609 --> 00:01:02,549 achieve their goals or achieve their dreams. 30 00:01:03,010 --> 00:01:04,930 And I liked it, but I always felt 31 00:01:04,930 --> 00:01:07,650 a little bit limited because there wasn't as 32 00:01:07,650 --> 00:01:10,129 much of a personal connection as I was 33 00:01:10,129 --> 00:01:11,969 looking for when I was in the financial 34 00:01:11,969 --> 00:01:12,469 industry. 35 00:01:13,489 --> 00:01:13,890 And, 36 00:01:14,424 --> 00:01:16,185 it's kind of funny. My, my, my father 37 00:01:16,185 --> 00:01:18,045 was a physician and he was an anesthesiologist 38 00:01:18,344 --> 00:01:20,025 and, you know, I grew up and we'd 39 00:01:20,025 --> 00:01:21,305 go to church or we'd go out to 40 00:01:21,305 --> 00:01:23,064 the store and people would pull my dad 41 00:01:23,064 --> 00:01:24,424 over in the store and they would give 42 00:01:24,424 --> 00:01:26,744 him a big hug. And they'd say, doctor 43 00:01:26,744 --> 00:01:29,259 Vina, you took such good care of my 44 00:01:29,259 --> 00:01:31,979 mother or my child. And they just they 45 00:01:31,979 --> 00:01:34,400 they they had this great connection to him. 46 00:01:34,459 --> 00:01:36,379 And I realized, I said to myself every 47 00:01:36,379 --> 00:01:38,540 time, I said, I want that. Right? I 48 00:01:38,540 --> 00:01:41,340 want that connection. And I wasn't experiencing it 49 00:01:41,340 --> 00:01:42,319 where I was working. 50 00:01:42,944 --> 00:01:45,424 So I I decided I wanted to go 51 00:01:45,424 --> 00:01:46,405 to medical school. 52 00:01:46,784 --> 00:01:47,525 And so 53 00:01:48,145 --> 00:01:49,344 How old were you when you decided to 54 00:01:49,344 --> 00:01:50,944 go to med school, if I can ask? 55 00:01:50,944 --> 00:01:53,045 Oh, my gosh. I was about 25. 56 00:01:53,105 --> 00:01:55,105 Uh-huh. So I'd been out of college for 57 00:01:55,105 --> 00:01:57,569 a few years. Right? And so I had 58 00:01:57,569 --> 00:01:59,829 to go back. I did some post baccalaureate 59 00:02:00,049 --> 00:02:00,549 premedical 60 00:02:01,170 --> 00:02:01,670 courses. 61 00:02:02,450 --> 00:02:05,250 And, and I actually, I I got my 62 00:02:05,250 --> 00:02:07,649 EMT. So I worked as an EMT during 63 00:02:07,649 --> 00:02:09,569 that time as well because I wanted to 64 00:02:09,569 --> 00:02:11,729 test this theory that medicine is what I 65 00:02:11,729 --> 00:02:13,784 wanted. I had to test this idea of 66 00:02:13,784 --> 00:02:14,844 a personal connection, 67 00:02:15,224 --> 00:02:17,465 this idea that this is where I wanted 68 00:02:17,465 --> 00:02:18,525 to spend my life. 69 00:02:18,985 --> 00:02:21,544 Mhmm. And, and I loved it. And I 70 00:02:21,544 --> 00:02:23,805 said, you know what? This is for me. 71 00:02:24,185 --> 00:02:24,685 So, 72 00:02:25,389 --> 00:02:27,870 that is actually how I kind of came 73 00:02:27,870 --> 00:02:30,189 into medicine. And along that time, you know, 74 00:02:30,189 --> 00:02:31,870 my dad had had a few health problems. 75 00:02:31,870 --> 00:02:34,750 It really kinda connected me to to what 76 00:02:34,750 --> 00:02:36,750 I wanted to do and and where I 77 00:02:36,750 --> 00:02:39,145 wanted to be. And so that was kind 78 00:02:39,145 --> 00:02:40,824 of my transition to medical school. So I 79 00:02:40,824 --> 00:02:42,504 went down to New Orleans. I went to 80 00:02:42,504 --> 00:02:45,064 Tulane University Medical School, and I I got 81 00:02:45,064 --> 00:02:47,784 my master's in public health simultaneously with my 82 00:02:47,784 --> 00:02:50,560 MD and, you know, came out and and 83 00:02:50,560 --> 00:02:52,879 decided orthopedics was what I wanted to do. 84 00:02:52,879 --> 00:02:53,860 Right. It just, 85 00:02:54,400 --> 00:02:56,080 I, I like to fix things. Right. I 86 00:02:56,080 --> 00:02:58,080 like to make people feel better. Right. I 87 00:02:58,080 --> 00:03:00,080 like, I like to see a problem, fix 88 00:03:00,080 --> 00:03:01,840 it and look at an x-ray or something 89 00:03:01,840 --> 00:03:03,939 and say, wow, that looks great. So 90 00:03:04,400 --> 00:03:05,460 went into orthopedics. 91 00:03:07,004 --> 00:03:09,564 And throughout that time, like disc replacement was 92 00:03:09,564 --> 00:03:11,645 just starting out, like we were doing these, 93 00:03:11,645 --> 00:03:13,724 you know, SB share a t lumbar disc 94 00:03:13,724 --> 00:03:16,205 replacements were just starting. It was becoming a 95 00:03:16,205 --> 00:03:17,905 really exciting time in spine. 96 00:03:18,205 --> 00:03:20,459 And I had a couple really good spine 97 00:03:20,459 --> 00:03:23,680 mentors. I I Andrew Marola and Tom Hair 98 00:03:23,979 --> 00:03:24,299 were, 99 00:03:24,780 --> 00:03:26,539 in in New York as part of my 100 00:03:26,539 --> 00:03:27,039 program. 101 00:03:27,979 --> 00:03:28,219 And, 102 00:03:28,780 --> 00:03:30,219 I really liked the guys and I liked 103 00:03:30,219 --> 00:03:32,379 the work we were doing. I liked working 104 00:03:32,379 --> 00:03:33,039 the biomechanics 105 00:03:33,340 --> 00:03:34,319 lab. And so 106 00:03:35,544 --> 00:03:37,384 I decided to go into spinal surgery because 107 00:03:37,384 --> 00:03:38,824 I I thought it was kind of where 108 00:03:38,824 --> 00:03:41,084 the kind of the cool stuff was happening 109 00:03:41,224 --> 00:03:42,664 and where I could really make a big 110 00:03:42,664 --> 00:03:44,604 difference in making people feel better. 111 00:03:44,984 --> 00:03:47,305 And so yeah. So so I did my 112 00:03:47,305 --> 00:03:48,764 fellowship with Paul McAfee 113 00:03:49,530 --> 00:03:51,310 at, Maryland Spinal Reconstructive 114 00:03:51,689 --> 00:03:52,509 Surgery Fellowship, 115 00:03:53,129 --> 00:03:55,229 and we did some great work in biomechanics 116 00:03:55,849 --> 00:03:58,489 with, Brian Cunningham in the lab and Anton 117 00:03:58,489 --> 00:03:58,989 Dimitryev 118 00:03:59,849 --> 00:04:01,049 in the lab. And, 119 00:04:01,805 --> 00:04:04,705 we were involved in disc replacements and biologic 120 00:04:04,925 --> 00:04:05,985 studies, biomechanical 121 00:04:06,365 --> 00:04:08,625 studies. And that really is what what 122 00:04:09,245 --> 00:04:10,865 really made my career 123 00:04:11,405 --> 00:04:14,605 interesting and really take off. And even though 124 00:04:14,605 --> 00:04:15,665 I'm a private practitioner, 125 00:04:15,965 --> 00:04:18,319 I'll still do I've still been involved 126 00:04:19,100 --> 00:04:20,160 in FDA studies. 127 00:04:20,540 --> 00:04:22,860 I'd like to design implants. So I've worked 128 00:04:22,860 --> 00:04:25,519 with companies in divining, designing implants. 129 00:04:26,860 --> 00:04:29,899 And I've again worked in biologic studies. So 130 00:04:29,899 --> 00:04:31,600 I really try to stay active 131 00:04:32,524 --> 00:04:33,024 academically. 132 00:04:34,605 --> 00:04:36,204 And I've also been part of the North 133 00:04:36,204 --> 00:04:37,504 American Spine Society, 134 00:04:39,004 --> 00:04:42,524 committee on basic science and research. So again, 135 00:04:42,524 --> 00:04:44,625 I've tried to not just be 136 00:04:44,990 --> 00:04:47,550 a private practitioner, which I love being, but 137 00:04:47,550 --> 00:04:49,629 also keep my hands in the academics a 138 00:04:49,629 --> 00:04:50,290 little bit. 139 00:04:50,670 --> 00:04:52,750 Definitely. And before I dive with some spine 140 00:04:52,750 --> 00:04:54,990 related questions, I'm curious. Yep. Was there a 141 00:04:54,990 --> 00:04:55,490 particular, 142 00:04:57,714 --> 00:05:00,055 time in your EMT, a particular 143 00:05:00,754 --> 00:05:03,014 call that you did that really solidified 144 00:05:03,394 --> 00:05:05,175 your interest in medicine? 145 00:05:06,514 --> 00:05:07,175 You know, 146 00:05:07,555 --> 00:05:08,375 so that's 147 00:05:10,355 --> 00:05:11,955 I I will say, and this is this 148 00:05:11,955 --> 00:05:12,615 is interesting. 149 00:05:12,949 --> 00:05:15,750 It was more a personal experience in my 150 00:05:15,750 --> 00:05:16,250 family. 151 00:05:16,709 --> 00:05:16,949 Yeah. 152 00:05:17,750 --> 00:05:19,930 My dad started to have some health problems, 153 00:05:20,069 --> 00:05:22,790 and I saw just the interaction that the 154 00:05:22,790 --> 00:05:23,290 doctors 155 00:05:23,669 --> 00:05:24,884 were having with him 156 00:05:25,365 --> 00:05:27,225 and my mother and my family. 157 00:05:27,925 --> 00:05:30,404 And so I took away the good parts, 158 00:05:30,404 --> 00:05:32,245 like the doctors that really impressed me. I 159 00:05:32,245 --> 00:05:35,685 said, man, I wanna be like that physician. 160 00:05:35,685 --> 00:05:37,860 I wanna do that. And then I saw 161 00:05:37,860 --> 00:05:39,540 the doctors who were not impressing me. I'm 162 00:05:39,540 --> 00:05:41,300 like, oh, I never wanna be like that 163 00:05:41,300 --> 00:05:43,379 person. I'm never gonna treat people that way. 164 00:05:43,379 --> 00:05:45,939 Right? So so it was really that that 165 00:05:45,939 --> 00:05:47,639 part of that personal connection. 166 00:05:48,579 --> 00:05:50,579 I I think on the ambulance was just 167 00:05:50,579 --> 00:05:53,354 more of me really realizing 168 00:05:53,894 --> 00:05:55,894 that, you know, this is this is gonna 169 00:05:55,894 --> 00:05:57,334 be my life's calling. This is what I'm 170 00:05:57,334 --> 00:05:58,074 gonna do. 171 00:05:58,375 --> 00:06:00,294 That's incredible. And I know you have a 172 00:06:00,294 --> 00:06:02,474 fascinating background also with 173 00:06:02,774 --> 00:06:05,300 finance, and I imagine that probably helps a 174 00:06:05,300 --> 00:06:08,660 lot with your, private practice in just the 175 00:06:08,660 --> 00:06:09,160 business 176 00:06:09,779 --> 00:06:11,460 end of things. So I wanna ask you 177 00:06:11,620 --> 00:06:13,220 I know I know, like, a lot there's 178 00:06:13,220 --> 00:06:15,540 some other spine surgeons out there who they've 179 00:06:15,540 --> 00:06:16,759 also, you know, pursued, 180 00:06:17,860 --> 00:06:18,360 MBA, 181 00:06:19,220 --> 00:06:21,735 extra business education. But is there a particular 182 00:06:21,875 --> 00:06:24,675 business skill that you think every single spine 183 00:06:24,675 --> 00:06:27,394 surgeon, especially in private practice, but, you know, 184 00:06:27,394 --> 00:06:29,175 in any setting, is there a particular 185 00:06:29,875 --> 00:06:33,334 business or financial skill that every spine surgeon 186 00:06:33,474 --> 00:06:34,214 should know? 187 00:06:35,029 --> 00:06:35,529 Yes. 188 00:06:36,550 --> 00:06:38,229 And the the number one is how to 189 00:06:38,229 --> 00:06:39,689 read an Excel spreadsheet 190 00:06:40,470 --> 00:06:42,250 and how to come up with your own. 191 00:06:42,709 --> 00:06:45,430 Mhmm. So it's it's knowing how to do 192 00:06:45,430 --> 00:06:47,829 a spreadsheet and putting the numbers out in 193 00:06:47,829 --> 00:06:49,750 front of you and making sure you have 194 00:06:49,750 --> 00:06:50,504 good data. 195 00:06:50,985 --> 00:06:52,345 So that a lot of that may come 196 00:06:52,345 --> 00:06:53,944 from your billing company or if you have 197 00:06:53,944 --> 00:06:56,444 in house billing. But a really big 198 00:06:56,985 --> 00:06:58,904 issue is a lot of doctors try to 199 00:06:58,904 --> 00:07:01,625 make decisions without good data. And if you 200 00:07:01,625 --> 00:07:03,225 don't have the good data and you can't 201 00:07:03,225 --> 00:07:04,345 put it in front of you and see 202 00:07:04,345 --> 00:07:06,959 it, it's impossible to make a good decision. 203 00:07:07,740 --> 00:07:10,060 Got it. And, you know, kind of thinking 204 00:07:10,060 --> 00:07:12,079 about that as well, obviously, you know, reimbursements 205 00:07:12,459 --> 00:07:16,079 have been huge headwind for just all 206 00:07:16,459 --> 00:07:18,535 all of, all of health care. And I'm 207 00:07:18,535 --> 00:07:19,675 wondering how you're, 208 00:07:20,774 --> 00:07:23,574 tackling that, how you're anticipating any of those 209 00:07:23,574 --> 00:07:24,875 challenges in your work. 210 00:07:26,055 --> 00:07:26,535 Sure. 211 00:07:27,735 --> 00:07:28,954 So reimbursement 212 00:07:29,334 --> 00:07:30,074 has been 213 00:07:30,560 --> 00:07:32,560 quite an issue. And and I'll say it's 214 00:07:32,560 --> 00:07:34,560 it's a little different for me because I 215 00:07:34,560 --> 00:07:36,639 had practiced I was a private practitioner up 216 00:07:36,639 --> 00:07:39,139 in Buffalo, New York for about twenty years. 217 00:07:39,759 --> 00:07:40,259 And 218 00:07:40,800 --> 00:07:42,879 so I was used to New York insurance 219 00:07:42,879 --> 00:07:45,425 companies, let's say, New York workers' compensation 220 00:07:46,284 --> 00:07:46,784 rules. 221 00:07:47,245 --> 00:07:48,604 And then about a year and a half 222 00:07:48,604 --> 00:07:49,104 ago, 223 00:07:49,564 --> 00:07:51,164 we moved down. My family and I, we 224 00:07:51,164 --> 00:07:52,064 decided to 225 00:07:52,524 --> 00:07:53,024 kind 226 00:07:53,564 --> 00:07:55,245 of move out of the 227 00:07:56,089 --> 00:07:57,689 as my wife likes to call it, the 228 00:07:57,689 --> 00:07:58,589 Arctic Tundra 229 00:07:59,050 --> 00:08:02,170 and, moved down to Florida where we would 230 00:08:02,170 --> 00:08:04,410 vacation, love to come. So we just moved 231 00:08:04,410 --> 00:08:06,569 down to Naples, Florida, and we live in 232 00:08:06,569 --> 00:08:08,569 Naples, and I practice out of Naples and 233 00:08:08,569 --> 00:08:09,310 Fort Myers. 234 00:08:10,004 --> 00:08:12,085 And so the insurance down here is much 235 00:08:12,085 --> 00:08:12,585 different. 236 00:08:13,125 --> 00:08:16,004 It's a much different population. So I'm gonna 237 00:08:16,004 --> 00:08:17,605 answer this and what I've seen over the 238 00:08:17,605 --> 00:08:19,925 past year and a half practicing down in 239 00:08:19,925 --> 00:08:20,425 Florida. 240 00:08:20,965 --> 00:08:23,225 Mhmm. When I was up in New York, 241 00:08:23,764 --> 00:08:27,919 the insurance cutbacks weren't as, significant to me 242 00:08:27,919 --> 00:08:29,519 because I was doing a lot of, like, 243 00:08:29,519 --> 00:08:31,379 the New York workers' compensation 244 00:08:31,759 --> 00:08:33,279 or, you know, we had some of the 245 00:08:33,279 --> 00:08:35,139 the auto accidents. We had, 246 00:08:36,000 --> 00:08:37,459 you know, other other insurance 247 00:08:37,904 --> 00:08:39,044 policies and programs, 248 00:08:39,424 --> 00:08:42,225 but down here, it's very heavily Medicare, which 249 00:08:42,225 --> 00:08:44,544 I wasn't doing so much up there. It's 250 00:08:44,544 --> 00:08:45,284 very heavily 251 00:08:45,664 --> 00:08:47,824 HMO, which I was not doing up in 252 00:08:47,824 --> 00:08:48,324 Buffalo. 253 00:08:49,264 --> 00:08:49,679 So 254 00:08:50,559 --> 00:08:53,440 these cutbacks insurance rates are have really, I 255 00:08:53,440 --> 00:08:54,179 guess, affected 256 00:08:55,120 --> 00:08:57,039 down here a lot more than I was 257 00:08:57,039 --> 00:08:59,279 used to up there. So I will say 258 00:08:59,279 --> 00:09:01,779 that the cutbacks in insurance are very challenging. 259 00:09:03,120 --> 00:09:04,100 The the constant, 260 00:09:05,394 --> 00:09:07,414 peer reviews are very challenging. 261 00:09:08,514 --> 00:09:09,014 And 262 00:09:09,475 --> 00:09:11,315 I I will say that the thing that 263 00:09:11,315 --> 00:09:13,095 I found the most archaic 264 00:09:13,954 --> 00:09:17,014 is the way that these insurance companies reimburse 265 00:09:17,075 --> 00:09:18,695 us, and I'll give you an example. 266 00:09:19,919 --> 00:09:21,459 So I was going through, 267 00:09:22,959 --> 00:09:24,100 with our billing team, 268 00:09:25,039 --> 00:09:26,559 really my AR, and I was looking at 269 00:09:26,559 --> 00:09:29,439 accounts receivable over ninety days. And I saw 270 00:09:29,439 --> 00:09:31,039 that let's say if I was doing a 271 00:09:31,039 --> 00:09:32,179 two level ACDF, 272 00:09:33,315 --> 00:09:35,415 they wouldn't pay me for the first level, 273 00:09:35,875 --> 00:09:37,394 but they would pay me for the second 274 00:09:37,394 --> 00:09:39,495 level and deny the first level. 275 00:09:41,075 --> 00:09:43,415 Or they would decide that they would reimburse 276 00:09:43,554 --> 00:09:44,855 my physician assistant 277 00:09:45,235 --> 00:09:46,375 to assist me 278 00:09:47,059 --> 00:09:48,820 on a code, but they wouldn't pay me 279 00:09:48,820 --> 00:09:49,879 to do the code. 280 00:09:50,820 --> 00:09:53,299 Mhmm. And it's this constant back and forth 281 00:09:53,299 --> 00:09:55,639 of these insurance companies just 282 00:09:57,379 --> 00:09:59,320 I'm gonna say screwing with us. 283 00:09:59,699 --> 00:10:01,320 I mean, honestly, in any other 284 00:10:01,964 --> 00:10:04,284 industry, this would be illegal and these people 285 00:10:04,284 --> 00:10:07,084 would be in jail. Like, we have a 286 00:10:07,084 --> 00:10:10,044 major problem with our insurance carriers in the 287 00:10:10,044 --> 00:10:11,904 way they are treating physicians. 288 00:10:12,444 --> 00:10:14,544 They're treating us as second class citizens. 289 00:10:15,324 --> 00:10:16,304 They are devaluing 290 00:10:16,684 --> 00:10:17,584 what we do 291 00:10:18,250 --> 00:10:21,230 and they are delaying as much as possible 292 00:10:21,610 --> 00:10:23,690 to pay our bills. And so what I 293 00:10:23,690 --> 00:10:26,730 saw down here is if they have sixty 294 00:10:26,730 --> 00:10:29,149 days, we we can't for example, 295 00:10:29,850 --> 00:10:31,709 we can't get reimbursed until 296 00:10:32,009 --> 00:10:34,144 they have our op note, but I'm not 297 00:10:34,144 --> 00:10:35,745 allowed to send them the op note until 298 00:10:35,745 --> 00:10:36,884 they ask for it. 299 00:10:37,264 --> 00:10:40,304 Mhmm. So they'll wait until almost sixty days. 300 00:10:40,304 --> 00:10:42,225 On day 59, they'll ask for my op 301 00:10:42,225 --> 00:10:43,904 note to stretch it out as long as 302 00:10:43,904 --> 00:10:45,665 they can. And then we'll get my op 303 00:10:45,665 --> 00:10:47,985 note, and 50% of the time, they'll lose 304 00:10:47,985 --> 00:10:50,039 it. And thirty days later, they'll ask for 305 00:10:50,039 --> 00:10:50,620 it again. 306 00:10:51,320 --> 00:10:52,059 And then 307 00:10:53,079 --> 00:10:55,100 we run into the problem of, again, 308 00:10:55,559 --> 00:10:58,440 they'll approve the second level, but not the 309 00:10:58,440 --> 00:10:59,419 primary level. 310 00:10:59,799 --> 00:11:01,879 They'll pay my PA, but they won't pay 311 00:11:01,879 --> 00:11:04,085 me. And so that just drags out these 312 00:11:04,085 --> 00:11:06,565 billing cycles. And it's something that I wasn't 313 00:11:06,565 --> 00:11:07,544 as used to, 314 00:11:08,325 --> 00:11:09,845 up in New York as I see down 315 00:11:09,845 --> 00:11:10,665 here in Florida. 316 00:11:11,524 --> 00:11:13,924 Got it. Thank you for breaking that down. 317 00:11:13,924 --> 00:11:15,600 And then, you know, I also wanna pick 318 00:11:15,600 --> 00:11:18,420 your brain on spine innovation and biologics. 319 00:11:18,960 --> 00:11:21,279 First off, can you talk about just some 320 00:11:21,279 --> 00:11:23,840 of the spine innovations that are really exciting 321 00:11:23,840 --> 00:11:25,519 you the most right now? I know you 322 00:11:25,519 --> 00:11:28,500 touched some on disc replacement earlier and biologics 323 00:11:28,639 --> 00:11:31,074 as well, but love to hear your thoughts 324 00:11:31,074 --> 00:11:31,735 on these. 325 00:11:32,274 --> 00:11:33,414 Oh, yeah. So 326 00:11:34,274 --> 00:11:35,954 so what really excites me, and I know 327 00:11:35,954 --> 00:11:37,794 everybody wants to hear about, you know, some 328 00:11:37,794 --> 00:11:40,995 new implant or technique, but I'm gonna be 329 00:11:40,995 --> 00:11:42,940 a little more basic than that. I think 330 00:11:42,940 --> 00:11:45,839 what really excites me is now 331 00:11:46,220 --> 00:11:47,039 we're having 332 00:11:47,419 --> 00:11:50,000 patients start to take ownership of their health. 333 00:11:50,699 --> 00:11:53,980 We're start we're having patients understand that what 334 00:11:53,980 --> 00:11:55,679 they eat really matters. 335 00:11:56,794 --> 00:11:58,894 How they exercise really matters. 336 00:11:59,355 --> 00:12:00,955 And being down here in Florida, the fact 337 00:12:00,955 --> 00:12:03,115 that people can walk outside twelve months a 338 00:12:03,115 --> 00:12:05,695 year, that really matters in their recovery. 339 00:12:06,154 --> 00:12:08,820 So what excites me the most is being 340 00:12:08,820 --> 00:12:10,980 able to work with patients to try to 341 00:12:10,980 --> 00:12:12,200 optimize their biology. 342 00:12:12,899 --> 00:12:14,600 We talk about their nutrition, 343 00:12:15,700 --> 00:12:16,200 sleep, 344 00:12:16,899 --> 00:12:17,399 exercise, 345 00:12:18,259 --> 00:12:19,720 and also nutraceuticals. 346 00:12:20,100 --> 00:12:23,024 And I'm very interested in more some of 347 00:12:23,024 --> 00:12:23,684 the naturopathic 348 00:12:24,304 --> 00:12:24,804 nutraceuticals 349 00:12:25,424 --> 00:12:27,125 to try to bring down inflammation 350 00:12:27,825 --> 00:12:31,924 Mhmm. Rather than always taking NSAIDs or other 351 00:12:32,304 --> 00:12:34,004 types of prescription medications. 352 00:12:34,460 --> 00:12:36,960 And so we're working with our patients there 353 00:12:37,019 --> 00:12:37,759 as well 354 00:12:38,539 --> 00:12:40,379 as the, you know, kind of an ERAS 355 00:12:40,379 --> 00:12:40,879 protocol 356 00:12:41,500 --> 00:12:42,000 of 357 00:12:42,539 --> 00:12:43,039 eating 358 00:12:43,419 --> 00:12:45,039 right before the surgery, 359 00:12:45,340 --> 00:12:47,980 through the surgery, and after the surgery to 360 00:12:47,980 --> 00:12:49,440 optimize wound healing 361 00:12:49,944 --> 00:12:50,764 and success. 362 00:12:51,225 --> 00:12:53,704 So that's the stuff that's, that's exciting me 363 00:12:53,704 --> 00:12:56,444 that along with the biologic stuff, 364 00:12:57,464 --> 00:12:58,284 the PRP 365 00:12:58,904 --> 00:13:01,004 stem cells, the allogeneic nucleases. 366 00:13:01,384 --> 00:13:04,350 So I'm, I'm very interested in not just 367 00:13:04,350 --> 00:13:06,509 the implants, but I'm very interested in the 368 00:13:06,509 --> 00:13:09,169 biologics because without good biology, 369 00:13:10,029 --> 00:13:11,970 we can't have a successful surgery. 370 00:13:12,830 --> 00:13:15,809 Definitely. And, two quick follow ups. I'm wondering, 371 00:13:16,115 --> 00:13:17,014 you know, in terms 372 00:13:17,714 --> 00:13:19,174 of the ERAS protocols, 373 00:13:20,115 --> 00:13:21,254 what have you found 374 00:13:21,554 --> 00:13:24,694 to be the most effective across your patients? 375 00:13:25,794 --> 00:13:27,714 Sure. Well, number one is we gotta bring 376 00:13:27,714 --> 00:13:28,615 up their albumin. 377 00:13:29,309 --> 00:13:31,070 So we see a lot of, you know, 378 00:13:31,070 --> 00:13:33,710 patients come in, especially in the in the 379 00:13:33,710 --> 00:13:36,509 in the Florida market. They're sarcopenic. Right? Maybe 380 00:13:36,509 --> 00:13:37,730 they're they're a little underweight. 381 00:13:38,110 --> 00:13:39,710 Right? They don't have a lot of muscle. 382 00:13:39,710 --> 00:13:41,330 They're not eating a lot of good protein. 383 00:13:41,629 --> 00:13:44,144 I know starting this and I'm talking starting 384 00:13:44,144 --> 00:13:45,605 six weeks ahead of surgery. 385 00:13:46,144 --> 00:13:46,644 But 386 00:13:47,184 --> 00:13:48,865 when you get into it, there are also 387 00:13:48,865 --> 00:13:49,524 some good 388 00:13:50,144 --> 00:13:52,644 products and I've developed one that 389 00:13:53,024 --> 00:13:55,679 works with carbohydrates in the first week before 390 00:13:55,679 --> 00:13:58,019 surgery and then having carbohydrates 391 00:13:58,639 --> 00:14:00,820 about three hours prior to surgery 392 00:14:02,080 --> 00:14:03,620 and then a carbohydrate 393 00:14:04,000 --> 00:14:04,740 and protein 394 00:14:05,360 --> 00:14:06,419 following the surgery 395 00:14:06,879 --> 00:14:10,414 for about two weeks. So these are good 396 00:14:10,414 --> 00:14:12,195 protocols that have been shown to 397 00:14:12,735 --> 00:14:15,695 benefit patients in terms of wound healing and 398 00:14:15,695 --> 00:14:18,975 recovery. You know, particularly your diabetic patients, your 399 00:14:18,975 --> 00:14:21,990 older patients, your patients with, you know, real 400 00:14:21,990 --> 00:14:24,410 wound healing issues and wound healing, 401 00:14:25,430 --> 00:14:25,930 problems. 402 00:14:27,029 --> 00:14:28,950 Got it. And then in terms of spine 403 00:14:28,950 --> 00:14:29,450 biologics, 404 00:14:30,470 --> 00:14:31,769 how do you see innovation 405 00:14:32,629 --> 00:14:33,129 there, 406 00:14:33,910 --> 00:14:36,170 evolving, you know, in 2026? 407 00:14:37,774 --> 00:14:39,695 So I think in biologics, what we're gonna 408 00:14:39,695 --> 00:14:41,534 see in in 2026, 409 00:14:41,534 --> 00:14:42,914 we're seeing a few things 410 00:14:43,534 --> 00:14:45,134 come out in 2026. 411 00:14:46,014 --> 00:14:46,834 One of them 412 00:14:47,134 --> 00:14:47,634 is 413 00:14:48,254 --> 00:14:50,355 when it comes down to Infuse. 414 00:14:51,110 --> 00:14:53,610 And, you know, North American Spine Society 415 00:14:53,990 --> 00:14:56,309 comes out with their opinion papers and their 416 00:14:56,309 --> 00:14:56,809 guides, 417 00:14:57,350 --> 00:14:59,429 and they just put out an opinion or 418 00:14:59,429 --> 00:15:02,070 a guide that's out right now for public 419 00:15:02,230 --> 00:15:04,629 it's in the public comment period about use 420 00:15:04,629 --> 00:15:06,884 of Infuse, where for a while it was 421 00:15:06,884 --> 00:15:07,945 only for 422 00:15:08,404 --> 00:15:11,284 anterior lumbar interbody devices, you know, in a 423 00:15:11,284 --> 00:15:13,065 cage in the front of the lumbar spine. 424 00:15:13,365 --> 00:15:16,105 And so when we, we look about the 425 00:15:16,485 --> 00:15:19,845 indications that North American Spine Society has brought 426 00:15:19,845 --> 00:15:23,070 together as, as guidelines for usage, we're seeing 427 00:15:23,070 --> 00:15:23,809 it now 428 00:15:24,589 --> 00:15:25,889 in the posterolateral 429 00:15:26,269 --> 00:15:27,809 spine and long fusion constructs. 430 00:15:28,190 --> 00:15:30,049 We're seeing it in antibody devices, 431 00:15:30,509 --> 00:15:31,169 right? We're 432 00:15:31,549 --> 00:15:34,595 seeing it used in the posterior cervical spine. 433 00:15:34,894 --> 00:15:36,894 So it's it's really kind of interesting. So 434 00:15:36,894 --> 00:15:38,835 I think there's going to be some development 435 00:15:39,134 --> 00:15:40,995 of more of the BMPs 436 00:15:41,455 --> 00:15:42,894 because we're starting to see that people want 437 00:15:42,894 --> 00:15:44,675 to use them outside of just that interbody 438 00:15:44,735 --> 00:15:45,855 cage. So I think we're going to see 439 00:15:45,855 --> 00:15:48,035 a lot of more BMP coming forward. 440 00:15:49,350 --> 00:15:51,269 I also think we're going to see in 441 00:15:51,269 --> 00:15:52,250 terms of biologics, 442 00:15:53,670 --> 00:15:54,649 again, more 443 00:15:55,269 --> 00:15:57,370 stem cell products. And I mean, 444 00:15:57,750 --> 00:15:59,910 autologous stem cells that we take from the 445 00:15:59,910 --> 00:16:00,345 patients 446 00:16:00,904 --> 00:16:02,764 and we put back into the patients. 447 00:16:04,345 --> 00:16:04,845 Allogeneic 448 00:16:05,225 --> 00:16:06,524 nucleuses. So, 449 00:16:07,064 --> 00:16:10,264 a donated nucleus pulposus to inject back into 450 00:16:10,264 --> 00:16:11,964 the patient's nucleus pulposus, 451 00:16:12,504 --> 00:16:14,524 we're going to see more of that happening. 452 00:16:15,560 --> 00:16:18,899 So I think it's really gonna be biologics 453 00:16:19,759 --> 00:16:20,259 first 454 00:16:21,039 --> 00:16:22,419 because remember the hardware 455 00:16:22,879 --> 00:16:25,120 that we put in is only there to 456 00:16:25,120 --> 00:16:28,320 hold everything in place until the biologics take 457 00:16:28,320 --> 00:16:30,774 effect and the fusion takes place if we're 458 00:16:30,774 --> 00:16:32,075 doing a fusion surgery. 459 00:16:32,534 --> 00:16:34,455 Yeah. In terms of we can change the 460 00:16:34,455 --> 00:16:36,934 biology in the disc, we could change the 461 00:16:36,934 --> 00:16:39,495 biology in the joints. That's when we really 462 00:16:39,495 --> 00:16:40,475 have a home run. 463 00:16:41,174 --> 00:16:43,654 Got it. And then my last question for 464 00:16:43,654 --> 00:16:46,720 you, how are you thinking about practice growth 465 00:16:46,779 --> 00:16:49,519 over the next, twelve to twenty four months? 466 00:16:50,139 --> 00:16:50,639 Sure. 467 00:16:51,179 --> 00:16:53,259 My practice growth, it may sound a little 468 00:16:53,259 --> 00:16:53,759 counterintuitive, 469 00:16:54,459 --> 00:16:56,620 but to grow my practice, I plan to 470 00:16:56,620 --> 00:16:57,600 see less patients. 471 00:16:59,664 --> 00:17:00,164 So 472 00:17:00,705 --> 00:17:03,424 so to grow my practice, really, what I'm 473 00:17:03,424 --> 00:17:05,825 what I'm looking what I what I'm doing 474 00:17:05,825 --> 00:17:07,984 and starting to do is start to decrease 475 00:17:07,984 --> 00:17:10,244 the number of insurance carriers that I accept. 476 00:17:10,779 --> 00:17:13,180 Mhmm. Because they have become insurance carriers have 477 00:17:13,180 --> 00:17:14,559 become very difficult. 478 00:17:15,180 --> 00:17:17,740 Right? And I'm not someone that can plow 479 00:17:17,740 --> 00:17:20,000 through 40 or 50 patients a day, 480 00:17:20,460 --> 00:17:21,980 but I can't give the patients the time 481 00:17:21,980 --> 00:17:24,539 they need. I'm just wired that my new 482 00:17:24,539 --> 00:17:26,025 patients are forty 483 00:17:26,484 --> 00:17:28,505 minutes. I'm wired that before surgery, 484 00:17:28,884 --> 00:17:30,345 it's gonna be half an hour. 485 00:17:30,644 --> 00:17:31,865 Right? Follow-up patients. 486 00:17:32,244 --> 00:17:34,884 I I can't do ten or fifteen minutes 487 00:17:34,884 --> 00:17:36,404 with a patient because I don't think that 488 00:17:36,404 --> 00:17:38,025 I'm giving them the care they deserve. 489 00:17:38,359 --> 00:17:40,920 And to do that, I can't see some 490 00:17:40,920 --> 00:17:42,779 of the low paying insurances. So, 491 00:17:43,160 --> 00:17:45,400 really, I'm looking to move more out of 492 00:17:45,400 --> 00:17:45,900 network. 493 00:17:46,440 --> 00:17:46,940 Mhmm. 494 00:17:48,039 --> 00:17:50,840 Looking to do I would say the the 495 00:17:50,840 --> 00:17:53,320 better paying insurances. I'm looking to take cash 496 00:17:54,255 --> 00:17:54,414 Mhmm. 497 00:17:55,375 --> 00:17:57,055 And move along with more of, like, an 498 00:17:57,055 --> 00:17:58,755 accelerated access program. 499 00:18:00,494 --> 00:18:02,494 And that being said too, more do more 500 00:18:02,494 --> 00:18:03,154 of my 501 00:18:03,855 --> 00:18:04,355 restorative 502 00:18:05,375 --> 00:18:06,990 or regenerative spine work 503 00:18:07,470 --> 00:18:09,150 and take the time with the patients that 504 00:18:09,150 --> 00:18:12,190 are really interested in healing more naturally and 505 00:18:12,190 --> 00:18:13,410 healing in a way 506 00:18:14,109 --> 00:18:14,609 where 507 00:18:15,150 --> 00:18:16,589 I can take the time with them in 508 00:18:16,589 --> 00:18:18,690 the office. We can talk about their nutrition. 509 00:18:18,750 --> 00:18:20,349 We can talk about their sleep. We can 510 00:18:20,349 --> 00:18:21,089 talk about 511 00:18:21,470 --> 00:18:21,970 their 512 00:18:22,534 --> 00:18:23,434 their activity. 513 00:18:24,375 --> 00:18:28,134 Mhmm. So to build my practice, I'm thinking 514 00:18:28,134 --> 00:18:29,755 about seeing less patients. 515 00:18:31,174 --> 00:18:33,274 And spending and then spending more time 516 00:18:33,654 --> 00:18:36,130 with the ones that you are seeing. Spending 517 00:18:36,130 --> 00:18:37,029 more times 518 00:18:37,410 --> 00:18:39,569 exactly. Spending more time with the ones that 519 00:18:39,569 --> 00:18:41,329 I am seeing. And then just real quick, 520 00:18:41,490 --> 00:18:43,109 this you mentioned this accelerated 521 00:18:43,490 --> 00:18:45,569 access program. Can you just kind of dive 522 00:18:45,569 --> 00:18:47,429 a little bit more to what that entails? 523 00:18:47,974 --> 00:18:50,934 Sure. So some some of the private, sorry, 524 00:18:50,934 --> 00:18:52,455 some of the primary care guys would call 525 00:18:52,455 --> 00:18:55,755 it, like, a concierge service, a concierge medicine. 526 00:18:55,974 --> 00:18:57,815 Because right now, we've got patients that wait, 527 00:18:57,815 --> 00:18:59,255 you know, six weeks to come in and 528 00:18:59,255 --> 00:19:00,695 see us. And when people really hurt, they 529 00:19:00,695 --> 00:19:02,490 don't wanna wait six weeks, but they're gonna 530 00:19:02,490 --> 00:19:04,349 get wait six weeks to get into anybody. 531 00:19:04,650 --> 00:19:06,910 So it's more of like a subscription program 532 00:19:07,369 --> 00:19:07,869 where 533 00:19:08,329 --> 00:19:10,650 for a certain monthly fee, I'll have a 534 00:19:10,650 --> 00:19:12,329 couple spots open during the day. And if 535 00:19:12,329 --> 00:19:13,690 someone needs to come in that day, they 536 00:19:13,690 --> 00:19:15,404 come in that day. If we need to 537 00:19:15,404 --> 00:19:17,485 come in and let's say they have Medicare 538 00:19:17,485 --> 00:19:19,404 part b and we don't need authorization for 539 00:19:19,404 --> 00:19:21,884 an injection and the injection would be the 540 00:19:21,884 --> 00:19:24,305 right thing for the patient at that time, 541 00:19:24,445 --> 00:19:26,365 then we could do the injection that day. 542 00:19:26,365 --> 00:19:27,105 We're not 543 00:19:27,720 --> 00:19:29,900 kicking them out another four or six weeks. 544 00:19:29,960 --> 00:19:32,039 So it's really it's it's it's to make 545 00:19:32,200 --> 00:19:33,980 it's to give patients the ability 546 00:19:34,440 --> 00:19:37,400 to have better access to myself and to 547 00:19:37,400 --> 00:19:38,059 my team. 548 00:19:38,919 --> 00:19:40,934 Yeah. Doctor Rovinj, can you talk more? Is 549 00:19:40,934 --> 00:19:43,194 there anything else you're doing to really, 550 00:19:43,815 --> 00:19:46,154 optimize patient outcomes and care? 551 00:19:47,015 --> 00:19:47,494 Yes. 552 00:19:47,974 --> 00:19:49,974 As a matter of fact, I am. So 553 00:19:49,974 --> 00:19:51,595 I've been you know? 554 00:19:53,140 --> 00:19:55,140 And you can imagine as a spinal surgeon, 555 00:19:55,140 --> 00:19:57,319 people have come to me for twenty years 556 00:19:57,539 --> 00:19:59,700 always asking what they can take for pain. 557 00:19:59,700 --> 00:20:01,779 And, you know, patients are smart. They've they've 558 00:20:01,779 --> 00:20:03,700 realized that narcotics are a very bad way 559 00:20:03,700 --> 00:20:04,359 of life. 560 00:20:04,900 --> 00:20:07,240 That, you know, they've been taking these NSAIDs 561 00:20:07,299 --> 00:20:09,765 and their kidneys are shutting down or they're 562 00:20:09,765 --> 00:20:12,505 burning holes in their stomach or or just 563 00:20:12,964 --> 00:20:15,525 they're counteracting all these other medications that they're 564 00:20:15,525 --> 00:20:16,025 taking. 565 00:20:16,724 --> 00:20:17,784 Alright. So 566 00:20:18,085 --> 00:20:19,924 patients have always been asking me, doc, is 567 00:20:19,924 --> 00:20:22,164 there anything all natural? Anything all natural I 568 00:20:22,164 --> 00:20:24,049 can take? Anything that'll work? And, you know, 569 00:20:24,049 --> 00:20:25,190 I went out there and 570 00:20:25,490 --> 00:20:26,390 I I looked 571 00:20:26,769 --> 00:20:28,869 and I tried to find something all natural 572 00:20:29,089 --> 00:20:29,829 that would 573 00:20:30,609 --> 00:20:32,609 be a good product for patients and their 574 00:20:32,609 --> 00:20:33,109 inflammation. 575 00:20:33,490 --> 00:20:35,089 And I really saw that there wasn't really 576 00:20:35,089 --> 00:20:35,589 anything 577 00:20:36,450 --> 00:20:37,190 out there. 578 00:20:37,705 --> 00:20:39,545 And so I was talking with my my 579 00:20:39,545 --> 00:20:41,884 physician assistant at the time, Justin Surratt, 580 00:20:42,744 --> 00:20:43,065 and, 581 00:20:43,545 --> 00:20:45,305 you know, he and I decided we'd start 582 00:20:45,305 --> 00:20:46,904 to do a literature search. And we went 583 00:20:46,904 --> 00:20:48,825 out and we found out in the scientific 584 00:20:48,825 --> 00:20:49,805 literature, like, 585 00:20:50,309 --> 00:20:53,130 what all natural ingredients do help with inflammation? 586 00:20:53,509 --> 00:20:56,630 What helps bring down c reactive protein and 587 00:20:56,630 --> 00:20:57,369 blood tests? 588 00:20:57,829 --> 00:20:59,130 What helps to, 589 00:21:00,470 --> 00:21:02,329 have patients recover faster 590 00:21:02,845 --> 00:21:05,424 after working out or after their physical therapy. 591 00:21:05,965 --> 00:21:08,445 So we really decided that we wanted to 592 00:21:08,445 --> 00:21:11,404 put together some new nutraceutical for our patients, 593 00:21:11,404 --> 00:21:11,904 kinda 594 00:21:12,285 --> 00:21:13,965 take the guesswork out of it because we 595 00:21:13,965 --> 00:21:16,710 found our patients were taking the wrong ingredients 596 00:21:17,089 --> 00:21:19,250 or they were taking a product with no 597 00:21:19,250 --> 00:21:20,869 real scientific backing 598 00:21:21,569 --> 00:21:23,490 or they may be they were taking the 599 00:21:23,490 --> 00:21:25,970 right ingredient like turmeric, but they were taking 600 00:21:25,970 --> 00:21:28,149 only about a quarter of the effective dose. 601 00:21:28,565 --> 00:21:30,325 And as you know, if you don't take 602 00:21:30,325 --> 00:21:31,464 the effective dose, 603 00:21:32,164 --> 00:21:34,005 then you're not gonna have any good effect 604 00:21:34,005 --> 00:21:36,505 from any type of medication or or nutraceutical. 605 00:21:37,204 --> 00:21:39,144 So what we did is we put together 606 00:21:39,204 --> 00:21:40,184 our own nutraceutical. 607 00:21:41,140 --> 00:21:42,900 So we have one called relief that is 608 00:21:42,900 --> 00:21:45,559 for inflammation as an anti inflammatory. 609 00:21:46,099 --> 00:21:47,859 We have another one for joint health. We 610 00:21:47,859 --> 00:21:48,919 have them for neuropathy. 611 00:21:49,539 --> 00:21:51,079 We we have multiple others. 612 00:21:52,660 --> 00:21:54,919 And so what we've learned to do is 613 00:21:54,980 --> 00:21:55,799 we've been 614 00:21:56,115 --> 00:21:58,194 providing these to our patients and patients can 615 00:21:58,194 --> 00:22:00,835 have subscription service. And so they come to 616 00:22:00,835 --> 00:22:03,154 their house every month. And really I'm also 617 00:22:03,154 --> 00:22:04,914 trying to help other docs do well, right? 618 00:22:04,914 --> 00:22:07,154 I'm trying to help other physicians build their 619 00:22:07,154 --> 00:22:07,654 business 620 00:22:08,035 --> 00:22:10,649 and help other physicians to help their own 621 00:22:10,649 --> 00:22:11,149 patients. 622 00:22:11,529 --> 00:22:13,289 And so what I've been doing is we've 623 00:22:13,289 --> 00:22:15,069 been white labeling these. So 624 00:22:15,369 --> 00:22:16,889 physicians are out there, they're a part of 625 00:22:16,889 --> 00:22:18,889 a practice and their patients are looking for 626 00:22:18,889 --> 00:22:20,029 something all natural. 627 00:22:20,409 --> 00:22:22,545 Well, they want something they can trust. Right? 628 00:22:22,545 --> 00:22:23,985 They want something that's made in The United 629 00:22:23,985 --> 00:22:25,525 States. It's non GMO. 630 00:22:26,065 --> 00:22:28,945 Right? It's nothing artificial is in it because 631 00:22:28,945 --> 00:22:31,184 people are not looking for all these artificial 632 00:22:31,184 --> 00:22:32,005 things anymore. 633 00:22:32,705 --> 00:22:33,205 So 634 00:22:34,480 --> 00:22:36,319 what we do is we help those physicians 635 00:22:36,319 --> 00:22:38,159 to have this program in their own offices 636 00:22:38,159 --> 00:22:40,000 and, again, white label it so their brand 637 00:22:40,000 --> 00:22:42,419 is on it. Right? And their their patients 638 00:22:42,480 --> 00:22:42,980 subscribe. 639 00:22:43,359 --> 00:22:45,519 And and physicians have found that their patients 640 00:22:45,519 --> 00:22:48,455 are incredibly happy that suddenly they're able to 641 00:22:48,455 --> 00:22:50,535 take something all natural, they're able to take 642 00:22:50,535 --> 00:22:51,515 something effective, 643 00:22:51,975 --> 00:22:53,815 and they're able to take something that was 644 00:22:53,815 --> 00:22:55,975 recommended by their physician. And, you know, it's 645 00:22:55,975 --> 00:22:56,875 got their physician's 646 00:22:57,255 --> 00:22:59,174 logo on it. It's got their physician's brand 647 00:22:59,174 --> 00:23:01,015 on it. So that's really something else I'm 648 00:23:01,015 --> 00:23:03,240 trying to bring out to the the other 649 00:23:03,240 --> 00:23:03,740 physicians 650 00:23:04,039 --> 00:23:07,000 and help other practices grow and become successful 651 00:23:07,000 --> 00:23:07,900 in this arena. 652 00:23:08,519 --> 00:23:10,440 That's really cool. And, I mean, honestly, you're 653 00:23:10,440 --> 00:23:12,440 not the first physician that I've heard who's 654 00:23:12,440 --> 00:23:14,299 also, you know, created 655 00:23:15,184 --> 00:23:17,025 their own kind of side hustle, their own 656 00:23:17,025 --> 00:23:20,065 little extra project to give patients just another 657 00:23:20,065 --> 00:23:22,724 way to really optimize their health just outside 658 00:23:23,345 --> 00:23:24,884 the the office or OR. 659 00:23:25,664 --> 00:23:27,105 Yeah. Yeah. And, you know, we're we're doing 660 00:23:27,105 --> 00:23:28,945 those also with an ERAS program for pre 661 00:23:28,945 --> 00:23:30,059 and post op nutrition. 662 00:23:30,460 --> 00:23:32,220 So, you know, I've been very interested in 663 00:23:32,220 --> 00:23:32,720 nutrition 664 00:23:33,100 --> 00:23:35,360 and, you know, some of the the nutraceuticals 665 00:23:35,820 --> 00:23:37,740 as a way to help our patients and 666 00:23:37,740 --> 00:23:39,279 and, you know, help our practices. 667 00:23:40,140 --> 00:23:42,460 Got it. Well, hey, doctor Vino, thank you 668 00:23:42,460 --> 00:23:44,474 so much again for taking the time to 669 00:23:44,474 --> 00:23:47,275 chat on today's podcast. This is a great 670 00:23:47,275 --> 00:23:49,275 conversation. And I think if if anything, I 671 00:23:49,275 --> 00:23:50,095 think it's important. 672 00:23:50,634 --> 00:23:53,115 The big lesson is that it's never too 673 00:23:53,115 --> 00:23:54,174 late to start. 674 00:23:54,731 --> 00:23:55,231 And 675 00:23:56,011 --> 00:23:58,331 Yeah. I look forward to connecting again in 676 00:23:58,331 --> 00:23:59,611 the future, and you have a good rest 677 00:23:59,611 --> 00:24:01,711 of your day. Great. Thank you so much.