1 00:00:00,080 --> 00:00:02,080 This is Carly Beam with the Becker Spine 2 00:00:02,080 --> 00:00:04,480 and Orthopedics podcast, and I'm thrilled to be 3 00:00:04,480 --> 00:00:07,200 joined today by doctor Shalun Bira, chief of 4 00:00:07,200 --> 00:00:11,059 orthopedic spine surgery at Banner University Medical Center. 5 00:00:11,359 --> 00:00:13,199 Doctor Bira, thank you so much for joining 6 00:00:13,199 --> 00:00:13,939 us today. 7 00:00:14,719 --> 00:00:16,454 Thanks Thanks for having me. And so before 8 00:00:16,454 --> 00:00:17,814 we dive into questions, I'd love if you 9 00:00:17,814 --> 00:00:19,654 could just introduce yourself, share a bit more 10 00:00:19,654 --> 00:00:20,954 about, your work. 11 00:00:21,814 --> 00:00:24,774 Yeah. I'm a spine surgery surgeon at Banner 12 00:00:24,774 --> 00:00:26,394 University Medical Center. 13 00:00:26,855 --> 00:00:28,410 I've been here for about two and a 14 00:00:28,410 --> 00:00:29,210 half years. 15 00:00:29,690 --> 00:00:31,390 I help lead, the OrthoSpine 16 00:00:31,690 --> 00:00:32,429 service line, 17 00:00:33,770 --> 00:00:36,890 in the Phoenix Valley. It's a very rapidly 18 00:00:36,890 --> 00:00:38,829 growing part of the country, 19 00:00:39,289 --> 00:00:41,789 and, we're seeing a lot of, increase in 20 00:00:41,929 --> 00:00:45,054 in, volume and then people with spinal pathology, 21 00:00:45,054 --> 00:00:46,114 both for degenerative, 22 00:00:46,575 --> 00:00:48,094 conditions and deformity and, 23 00:00:48,734 --> 00:00:50,255 as well as trauma and tumor, kind of 24 00:00:50,255 --> 00:00:52,494 the whole gamut of spine conditions we treat. 25 00:00:52,494 --> 00:00:54,914 So it's been a a great, environment. 26 00:00:55,789 --> 00:00:57,789 Very exciting to hear about, you know, increased 27 00:00:57,789 --> 00:01:00,750 growth, increased volume. Can you talk about how 28 00:01:00,750 --> 00:01:02,850 you see your role with the spine department 29 00:01:03,309 --> 00:01:04,530 at Banner evolving, 30 00:01:04,829 --> 00:01:07,069 and what does growth look like to you 31 00:01:07,069 --> 00:01:08,450 in 2026? 32 00:01:09,254 --> 00:01:10,715 Yeah. Part of it is 33 00:01:11,655 --> 00:01:13,834 really sort of supply to to meet demand 34 00:01:13,894 --> 00:01:16,614 quite simply. So as we grow at different 35 00:01:16,614 --> 00:01:18,775 sites of service, as banner expands across the 36 00:01:18,775 --> 00:01:20,155 valley and across Arizona, 37 00:01:20,614 --> 00:01:21,834 really having people, 38 00:01:22,960 --> 00:01:24,640 meet that demand at different points. So we 39 00:01:24,640 --> 00:01:26,480 are growing as a service line. We're actively 40 00:01:26,480 --> 00:01:26,980 recruiting 41 00:01:27,520 --> 00:01:28,020 surgeons. 42 00:01:28,640 --> 00:01:29,380 We function 43 00:01:30,400 --> 00:01:32,180 with very well with neurosurgery, 44 00:01:32,880 --> 00:01:35,295 colleagues. And so the neurosurgery department has certainly 45 00:01:35,295 --> 00:01:37,055 grown in terms of their service line, and 46 00:01:37,055 --> 00:01:39,215 so coordinating with them has been a great, 47 00:01:39,454 --> 00:01:39,954 joy. 48 00:01:40,575 --> 00:01:40,975 And, 49 00:01:42,174 --> 00:01:44,094 so part of the growth for 2026 50 00:01:44,094 --> 00:01:45,875 is going to be increasing 51 00:01:46,174 --> 00:01:48,734 our capacity to do surgery at different sites 52 00:01:48,734 --> 00:01:49,395 of service, 53 00:01:49,829 --> 00:01:51,849 and part of it is to continue to 54 00:01:52,870 --> 00:01:53,770 increase new technologies 55 00:01:54,950 --> 00:01:55,689 and incorporate 56 00:01:55,990 --> 00:01:56,730 new technologies 57 00:01:57,510 --> 00:01:59,370 at the different sites of service. 58 00:01:59,750 --> 00:02:01,609 Yeah. So, like, are you are you planning 59 00:02:01,670 --> 00:02:02,170 to, 60 00:02:02,665 --> 00:02:03,484 you know, absorb 61 00:02:04,024 --> 00:02:04,524 practices, 62 00:02:04,984 --> 00:02:06,524 build a new banner, 63 00:02:07,384 --> 00:02:07,884 facilities? 64 00:02:08,264 --> 00:02:09,485 What does that look like? 65 00:02:10,264 --> 00:02:10,764 Mostly, 66 00:02:11,544 --> 00:02:14,584 more from a personnel standpoint growing in terms 67 00:02:14,584 --> 00:02:15,084 of 68 00:02:16,240 --> 00:02:16,740 nonoperative 69 00:02:17,040 --> 00:02:18,580 and operative spine providers. 70 00:02:18,879 --> 00:02:20,560 So I think Banner has a great platform 71 00:02:20,560 --> 00:02:22,719 in terms of having insights of services, whether 72 00:02:22,719 --> 00:02:24,979 it's hospital, surgery centers, clinic locations, 73 00:02:25,360 --> 00:02:26,659 and but really bringing, 74 00:02:27,120 --> 00:02:29,759 the spine like, high quality spine providers to 75 00:02:29,759 --> 00:02:30,500 those locations. 76 00:02:31,145 --> 00:02:33,564 Yeah. So then you talk about, your strategy 77 00:02:33,625 --> 00:02:35,805 for recruiting and then keeping, 78 00:02:36,344 --> 00:02:38,125 spine surgeons and nonsurgical 79 00:02:39,385 --> 00:02:40,365 spine specialists. 80 00:02:41,465 --> 00:02:44,444 Mhmm. Yeah. So really growing a good collaborative 81 00:02:44,665 --> 00:02:46,044 environment, a good jovial 82 00:02:46,580 --> 00:02:47,080 environment, 83 00:02:47,620 --> 00:02:49,239 looking for people with good camaraderie, 84 00:02:50,180 --> 00:02:52,280 and people who work well in a large 85 00:02:52,340 --> 00:02:55,620 institutional setting. So really just, hiring carefully and 86 00:02:55,620 --> 00:02:57,799 hiring people who've had great training, 87 00:02:58,099 --> 00:02:59,699 been to been to you know, we have 88 00:02:59,699 --> 00:03:02,025 people on our, faculty who train at all 89 00:03:02,025 --> 00:03:03,485 the best places around the country 90 00:03:03,944 --> 00:03:05,944 and, who wanna be in a in a 91 00:03:05,944 --> 00:03:08,344 very exciting part of the country, Phoenix and 92 00:03:08,344 --> 00:03:09,004 and Scottsdale, 93 00:03:09,544 --> 00:03:11,784 and the surrounding areas is is a great, 94 00:03:12,425 --> 00:03:14,205 place for people to live, raise families, 95 00:03:14,509 --> 00:03:16,109 and stuff like that. So has has there's 96 00:03:16,109 --> 00:03:17,549 been no shortage of people who've been, 97 00:03:18,189 --> 00:03:20,349 been interested in. So we've been, you know, 98 00:03:21,229 --> 00:03:22,209 forming a team 99 00:03:23,150 --> 00:03:25,069 that includes people with different skill sets. So 100 00:03:25,069 --> 00:03:26,189 we have people who are really good at 101 00:03:26,189 --> 00:03:27,949 minimally invasive type of surgery. We have different 102 00:03:27,949 --> 00:03:29,329 people who are really good at intradural 103 00:03:29,795 --> 00:03:30,295 surgery, 104 00:03:30,754 --> 00:03:32,275 spinal cord surgery, and then we have different 105 00:03:32,275 --> 00:03:34,034 people who are really traditional in deformity training 106 00:03:34,034 --> 00:03:34,775 like myself. 107 00:03:35,555 --> 00:03:36,534 And so, really, 108 00:03:37,075 --> 00:03:38,754 just just as a football team or an 109 00:03:38,754 --> 00:03:41,795 NBA basketball team is formed, you know, we 110 00:03:41,795 --> 00:03:42,534 try to 111 00:03:43,075 --> 00:03:44,534 recruit all stars 112 00:03:45,530 --> 00:03:47,610 who are in who touch the different areas 113 00:03:47,610 --> 00:03:50,250 of spine and then comprise and then come 114 00:03:50,250 --> 00:03:51,050 up with a great, 115 00:03:51,530 --> 00:03:54,090 overall team, which I with expertise in different 116 00:03:54,090 --> 00:03:55,449 fields. And that same thing goes to the 117 00:03:55,449 --> 00:03:58,009 nonoperative side as well. That's excellent. I love 118 00:03:58,009 --> 00:04:00,745 the analogy you're using here of, like, an 119 00:04:00,745 --> 00:04:01,724 NBA team. 120 00:04:02,504 --> 00:04:04,425 And then, doctor Vierra, I wanted to ask 121 00:04:04,425 --> 00:04:06,365 you, you know, specifically some questions, 122 00:04:06,745 --> 00:04:07,564 related to, 123 00:04:08,264 --> 00:04:11,865 spine technology, especially, with robots. You know, spine 124 00:04:11,865 --> 00:04:14,025 robots, they Mhmm. Often, you know, they offer 125 00:04:14,025 --> 00:04:16,099 lots of promise when it comes to precision 126 00:04:16,240 --> 00:04:17,699 and consistency, but they're also, 127 00:04:18,000 --> 00:04:20,100 you know, really expensive. So 128 00:04:20,560 --> 00:04:23,139 how should health systems and practices 129 00:04:23,680 --> 00:04:25,620 weigh these types of purchase decisions? 130 00:04:27,125 --> 00:04:28,985 Yeah. I think the very first question 131 00:04:29,605 --> 00:04:32,644 that either administrators and surgeon leaders have to 132 00:04:32,644 --> 00:04:34,745 ask themselves is that, does these tools 133 00:04:35,285 --> 00:04:37,764 solve a problem that we truly have at 134 00:04:37,764 --> 00:04:39,064 the volume we have? 135 00:04:39,910 --> 00:04:41,349 One of the things I learned from my 136 00:04:41,349 --> 00:04:43,689 training at Cleveland Clinic was that 137 00:04:44,310 --> 00:04:46,709 whenever evaluating a new technology, the first thing 138 00:04:46,709 --> 00:04:48,310 to ask is that, is this solving a 139 00:04:48,310 --> 00:04:48,810 problem 140 00:04:49,430 --> 00:04:51,349 that that I had in my practice? You 141 00:04:51,349 --> 00:04:53,475 know? And that just that scales to not 142 00:04:53,475 --> 00:04:55,475 just the individual surgeon, but the institution as 143 00:04:55,475 --> 00:04:57,335 well. You know? A lot of times, 144 00:04:58,275 --> 00:05:00,855 the the a lot the clinical benefit, 145 00:05:01,875 --> 00:05:04,855 is questionable beyond the marketing optics. You know? 146 00:05:05,990 --> 00:05:07,110 You know, I've had the pleasure of going 147 00:05:07,110 --> 00:05:08,550 to business school as well, and so we 148 00:05:08,550 --> 00:05:10,649 learned a lot about capital allocation and, 149 00:05:11,350 --> 00:05:13,769 have a, you know, whole background in finance, 150 00:05:14,470 --> 00:05:14,970 prior, 151 00:05:15,350 --> 00:05:17,430 you know, during during my college days and 152 00:05:17,430 --> 00:05:19,694 went on. So, you know, we looking at 153 00:05:19,694 --> 00:05:20,995 the return on investment 154 00:05:21,535 --> 00:05:23,875 becomes very interesting when you go beyond 155 00:05:24,334 --> 00:05:24,834 the 156 00:05:25,294 --> 00:05:26,035 the marketing 157 00:05:27,214 --> 00:05:29,954 aspect that gets, you know, highlighted in in, 158 00:05:30,495 --> 00:05:33,449 you know, newspaper, magazines or platforms like Becker's. 159 00:05:33,850 --> 00:05:35,710 And looking at that this what 160 00:05:36,090 --> 00:05:38,730 does it change in terms of reliability? What 161 00:05:38,730 --> 00:05:40,270 does it change in terms of training? 162 00:05:40,970 --> 00:05:42,990 Does it build resilience in the system? 163 00:05:43,449 --> 00:05:45,449 So I have a a recently started a 164 00:05:45,449 --> 00:05:47,790 substack, basically, a blog on 165 00:05:48,625 --> 00:05:50,324 business strategy and spine surgery. 166 00:05:52,384 --> 00:05:54,225 Encourage readers to to look at it and, 167 00:05:54,544 --> 00:05:56,404 recently wrote an article about robotics 168 00:05:56,865 --> 00:05:58,865 and where I introduced the concept of surgical 169 00:05:58,865 --> 00:06:01,669 fragility. So just as, you you know, financial 170 00:06:01,669 --> 00:06:04,229 fragility is a well established topic in the 171 00:06:04,229 --> 00:06:05,129 economic space, 172 00:06:05,669 --> 00:06:07,930 in terms of bank fragility and and, 173 00:06:09,589 --> 00:06:12,470 capital allocation in that in that world, you 174 00:06:12,470 --> 00:06:14,949 know, what I have a concern of in 175 00:06:14,949 --> 00:06:18,274 robotics is that is it deskilling surgeons, and 176 00:06:18,274 --> 00:06:21,074 is it creating surgical fragility in, in a 177 00:06:21,074 --> 00:06:21,814 sense that 178 00:06:23,074 --> 00:06:25,235 having getting too used to whether it's not 179 00:06:25,394 --> 00:06:27,095 or getting too used to our robots, 180 00:06:27,475 --> 00:06:30,050 will that result in case cancellation if those 181 00:06:30,129 --> 00:06:32,129 if that robot or if that alarm or 182 00:06:32,129 --> 00:06:32,629 navigation 183 00:06:33,009 --> 00:06:34,529 breaks down or is not working on that 184 00:06:34,529 --> 00:06:37,430 day? You know? And so I look critically 185 00:06:37,569 --> 00:06:38,069 at 186 00:06:39,009 --> 00:06:41,670 systems and developing banner as an institution 187 00:06:42,764 --> 00:06:45,425 to in to be antifragile, meaning, 188 00:06:45,884 --> 00:06:47,824 can we function? Can we do these cases? 189 00:06:47,964 --> 00:06:50,464 Can everybody in our department do these cases 190 00:06:50,685 --> 00:06:52,384 with or without robots? And 191 00:06:52,845 --> 00:06:53,504 and capital 192 00:06:53,964 --> 00:06:55,584 decisions should be based on 193 00:06:56,339 --> 00:06:58,040 being active and making the system 194 00:06:58,420 --> 00:07:01,399 more antifragile or more resilient as opposed 195 00:07:01,699 --> 00:07:03,560 to making decisions that lead 196 00:07:04,580 --> 00:07:06,120 to fragility or dependence. 197 00:07:06,899 --> 00:07:08,580 And that's a great point you bring up 198 00:07:08,580 --> 00:07:11,639 about surgeons possibly becoming dependent on these technologies. 199 00:07:12,634 --> 00:07:15,194 How are you approaching this and ensuring that 200 00:07:15,194 --> 00:07:17,295 spine surgeons are becoming skilled 201 00:07:17,835 --> 00:07:21,035 with these without falling into that trap of 202 00:07:21,035 --> 00:07:21,535 fragility? 203 00:07:22,235 --> 00:07:24,154 Yeah. So one of the and I I'm 204 00:07:24,154 --> 00:07:26,459 not an expert on this, particular 205 00:07:26,759 --> 00:07:28,360 subject. I I kinda borrow from one of 206 00:07:28,360 --> 00:07:31,160 our business school professors, Kartik Hosnagar at Wharton 207 00:07:31,160 --> 00:07:31,660 School, 208 00:07:32,199 --> 00:07:33,079 where he, 209 00:07:33,800 --> 00:07:36,300 talks about AI and how that's deskilling 210 00:07:36,680 --> 00:07:38,459 different workers in the tech world. 211 00:07:39,004 --> 00:07:40,925 And so I kind of adapted some of 212 00:07:40,925 --> 00:07:42,225 his teachings to 213 00:07:42,605 --> 00:07:44,605 propose some of these guardrails that we're working 214 00:07:44,605 --> 00:07:46,605 on. You know, one is human first planning 215 00:07:46,605 --> 00:07:49,165 rounds, you know, define trajectories and and bailout 216 00:07:49,165 --> 00:07:52,044 options before using a robot or before using 217 00:07:52,044 --> 00:07:52,785 a navigation, 218 00:07:53,269 --> 00:07:55,449 you know, protecting core skills. So 219 00:07:55,830 --> 00:07:58,230 freehand screw placement, you know, reasoning based on 220 00:07:58,230 --> 00:08:00,330 fluoro shots, intraoperative adaptability, 221 00:08:00,949 --> 00:08:03,029 that should remain as the cornerstone of how 222 00:08:03,029 --> 00:08:05,589 we train residents and fellows and how we 223 00:08:05,589 --> 00:08:06,970 advise our junior faculty. 224 00:08:08,264 --> 00:08:10,125 You know, analog quotas and drills, 225 00:08:10,425 --> 00:08:13,145 you know, routine off robot off practice. That's 226 00:08:13,145 --> 00:08:13,884 one of the 227 00:08:14,185 --> 00:08:16,525 the ideas that I'd adopted from professor Hosniger 228 00:08:17,384 --> 00:08:18,444 about, you know, 229 00:08:19,625 --> 00:08:20,125 providing 230 00:08:20,585 --> 00:08:23,910 opportunities for cases that obviously do not use 231 00:08:23,910 --> 00:08:26,170 a lot of stuff. And so that keeps 232 00:08:26,310 --> 00:08:26,810 your 233 00:08:27,110 --> 00:08:29,110 precision and keeps all of our skills up 234 00:08:29,110 --> 00:08:29,769 to date, 235 00:08:30,629 --> 00:08:32,009 and that ensures resilience 236 00:08:32,389 --> 00:08:35,370 Mhmm. And and credentialing emphasis on baseline mastery 237 00:08:35,429 --> 00:08:36,250 before robotic 238 00:08:36,629 --> 00:08:37,129 usage. 239 00:08:38,014 --> 00:08:40,095 And so if a robot becomes the only 240 00:08:40,095 --> 00:08:42,414 path a surgeon feels comfortable taking, that's not 241 00:08:42,414 --> 00:08:43,794 progress. That's just fragility. 242 00:08:44,735 --> 00:08:46,815 Got it. And then, doctor Viro, I was 243 00:08:46,815 --> 00:08:49,455 wondering, you know, what are three top trends 244 00:08:49,455 --> 00:08:51,774 you're following in health care, whether you're looking 245 00:08:51,774 --> 00:08:54,809 at it broad scale or very specific to 246 00:08:54,809 --> 00:08:55,709 spine itself? 247 00:08:56,730 --> 00:08:59,370 Yeah. It's interesting. You know, 2024 and 2025, 248 00:08:59,370 --> 00:09:01,129 you see in the tech world outside of 249 00:09:01,129 --> 00:09:03,450 our space, the AI arms race by a 250 00:09:03,450 --> 00:09:05,309 lot of the big tech companies, you know, 251 00:09:05,690 --> 00:09:07,309 and valuations have skyrocketed 252 00:09:08,125 --> 00:09:10,684 based on on the the growing adoption of 253 00:09:10,684 --> 00:09:13,004 AI. Now I think in 2026, what we 254 00:09:13,004 --> 00:09:14,865 see from the tech industry is that 255 00:09:15,245 --> 00:09:17,745 these we're looking at ROI now, not just 256 00:09:18,044 --> 00:09:18,544 adoption. 257 00:09:19,404 --> 00:09:21,419 And and so I think that is also 258 00:09:21,419 --> 00:09:23,839 there. The parallel universe happening in spine. 259 00:09:24,299 --> 00:09:26,720 One is capital discipline and med tech adoption. 260 00:09:27,179 --> 00:09:27,919 So robotics 261 00:09:29,100 --> 00:09:29,839 and AI 262 00:09:30,539 --> 00:09:33,500 are in now being scrutinized in 2026 for 263 00:09:33,500 --> 00:09:35,039 ROI, not just the novelty. 264 00:09:35,725 --> 00:09:38,684 Hospital leaders are demanding clear and measurable value 265 00:09:38,684 --> 00:09:41,664 before deploying, you know, these multimillion dollar technologies. 266 00:09:42,524 --> 00:09:43,804 One of the other trends I see is 267 00:09:43,804 --> 00:09:46,205 resilience and skill creation in clinical practice. You 268 00:09:46,205 --> 00:09:47,884 know, as as this AI and the robotics 269 00:09:47,884 --> 00:09:49,345 hype has kind of settled down, 270 00:09:49,960 --> 00:09:51,879 what I was talking earlier is that we're 271 00:09:51,879 --> 00:09:55,480 getting focused on preserving clinician judgment and building 272 00:09:55,480 --> 00:09:56,220 anti fragility, 273 00:09:57,159 --> 00:09:58,940 especially in terms of our training systems 274 00:09:59,320 --> 00:10:01,799 that ensure that care continues even when tech 275 00:10:01,799 --> 00:10:02,299 fails, 276 00:10:03,105 --> 00:10:04,964 and as the tech continues to develop. 277 00:10:05,584 --> 00:10:07,904 And then third is smart integration across of 278 00:10:07,904 --> 00:10:10,384 data across care pathways. So how do we, 279 00:10:11,105 --> 00:10:13,105 harness data? There's no shortage of data, but 280 00:10:13,105 --> 00:10:15,345 how do we harness it to improve surgeon 281 00:10:15,345 --> 00:10:15,845 judgment? 282 00:10:16,889 --> 00:10:19,129 Excellent. And I was wondering if you're still 283 00:10:19,129 --> 00:10:20,889 kind of hook on. I really like what 284 00:10:20,889 --> 00:10:21,789 you're saying about, 285 00:10:22,569 --> 00:10:25,129 AI, thinking about, you know, shift towards thinking 286 00:10:25,129 --> 00:10:25,629 about 287 00:10:26,089 --> 00:10:29,069 ROI. What are some of the biggest metrics 288 00:10:29,209 --> 00:10:31,709 or advice that you have for 289 00:10:32,325 --> 00:10:34,404 physician leaders, not just in spine, but just 290 00:10:34,404 --> 00:10:36,884 in health care in general? How should they 291 00:10:36,884 --> 00:10:39,764 be thinking about ROI? What are the red 292 00:10:39,764 --> 00:10:41,144 flags, the green flags? 293 00:10:42,325 --> 00:10:43,764 Yeah. It's in you know, one of my 294 00:10:43,764 --> 00:10:45,524 articles that looks back is that there is 295 00:10:45,524 --> 00:10:49,220 no real KPI or clear ROI metric. 296 00:10:49,600 --> 00:10:52,320 It's really is the system being made more 297 00:10:52,320 --> 00:10:54,399 resilient? So it's not just about, you know, 298 00:10:54,399 --> 00:10:55,620 reduced hospital comp 299 00:10:56,240 --> 00:10:57,540 infections or reduced, 300 00:10:58,320 --> 00:11:00,980 complication rates in the way hospitals traditionally 301 00:11:01,519 --> 00:11:02,019 view 302 00:11:02,504 --> 00:11:04,345 performance, but in terms of, like, are you 303 00:11:04,345 --> 00:11:06,585 building a good system, which is not easily 304 00:11:06,585 --> 00:11:08,665 measurable. So I would say the real answer 305 00:11:08,665 --> 00:11:11,245 is that there is no real ROI metric 306 00:11:11,545 --> 00:11:13,465 or real KPI that you can use to 307 00:11:13,465 --> 00:11:14,904 measure this, but it's more of like a 308 00:11:14,904 --> 00:11:16,445 a you know it when you see it 309 00:11:16,504 --> 00:11:17,725 in terms of are 310 00:11:18,029 --> 00:11:20,430 people growing their practices well. Are are are 311 00:11:20,430 --> 00:11:22,370 people doing good quality work? Are, 312 00:11:22,750 --> 00:11:24,430 are people constantly doing, 313 00:11:24,910 --> 00:11:27,009 cases and are able to innovate, you know, 314 00:11:27,070 --> 00:11:30,269 and and expanding their surgical skill set or 315 00:11:30,269 --> 00:11:32,684 their practice skill set, things like that, and 316 00:11:32,684 --> 00:11:34,764 our the adoption of new technology due to 317 00:11:34,764 --> 00:11:35,264 judiciously. 318 00:11:35,804 --> 00:11:38,125 You know, we have multidisciplinary case rounds and 319 00:11:38,125 --> 00:11:39,884 and and all the usual which which most 320 00:11:39,884 --> 00:11:40,944 institutions have. 321 00:11:41,324 --> 00:11:43,324 But so it's more of a sense, an 322 00:11:43,324 --> 00:11:46,125 overall gestalt as opposed to any one clear 323 00:11:46,125 --> 00:11:46,625 KPI. 324 00:11:47,240 --> 00:11:49,500 Yeah. So it sounds like it's very qualitative 325 00:11:50,279 --> 00:11:53,559 then. Yeah. Great. Well, doctor Vierra, thank you 326 00:11:53,559 --> 00:11:55,799 so much again for, joining us on today's 327 00:11:55,799 --> 00:11:58,360 podcast. It's great talking with you, and I 328 00:11:58,360 --> 00:12:00,440 hope to connect again in the future. Thanks 329 00:12:00,440 --> 00:12:01,100 so much.