1 00:00:00,080 --> 00:00:02,159 This is Carly Beam with the Becker Spine 2 00:00:02,159 --> 00:00:04,799 and Orthopedics podcast. I'm thrilled to be joined 3 00:00:04,799 --> 00:00:07,759 today by doctor Dan Chen at Geisinger. Doctor 4 00:00:07,759 --> 00:00:09,919 Chen, thank you so much for being here 5 00:00:09,919 --> 00:00:12,815 today. Thanks for having me. And so before 6 00:00:12,815 --> 00:00:15,054 we dive into our questions, could you introduce 7 00:00:15,054 --> 00:00:16,495 yourself and tell us a bit more about 8 00:00:16,495 --> 00:00:17,155 your background? 9 00:00:17,614 --> 00:00:19,454 Of course. So like you said, you know, 10 00:00:19,454 --> 00:00:21,614 my name is Dan Chen. I'm a double 11 00:00:21,614 --> 00:00:25,295 board certified orthopedic spine surgeon at Geisinger Health. 12 00:00:25,769 --> 00:00:29,370 We're based primarily at, Northeast Pennsylvania and Central 13 00:00:29,370 --> 00:00:29,870 Pennsylvania. 14 00:00:31,050 --> 00:00:32,810 I serve in a couple different positions outside 15 00:00:32,810 --> 00:00:35,130 of just my political role. I'm an I'm 16 00:00:35,130 --> 00:00:37,450 an assistant professor and senator at the the 17 00:00:37,450 --> 00:00:39,630 Geisinger Commonwealth School of Medicine. 18 00:00:40,335 --> 00:00:42,895 I also do, a lot of core faculty 19 00:00:42,895 --> 00:00:46,274 key core faculty teaching for the orthopedic residency 20 00:00:46,335 --> 00:00:46,835 programs, 21 00:00:47,615 --> 00:00:50,034 both in the Northeast and, Central Pennsylvania 22 00:00:50,975 --> 00:00:51,635 in Danville. 23 00:00:52,380 --> 00:00:52,619 My, 24 00:00:53,340 --> 00:00:56,460 my clinical focus is mostly on minimally invasive 25 00:00:56,460 --> 00:00:56,960 techniques, 26 00:00:57,579 --> 00:00:58,719 outpatient surgery, 27 00:00:59,420 --> 00:01:01,840 and then comp, complex spinal reconstructions. 28 00:01:03,259 --> 00:01:05,019 You know, for in most of my clinic 29 00:01:05,019 --> 00:01:06,540 kinda deals with a lot of these, like, 30 00:01:06,540 --> 00:01:07,760 degenerative and 31 00:01:08,105 --> 00:01:10,105 deforming pathologies of the spine, 32 00:01:10,585 --> 00:01:12,525 as well as, you know, a sprinkling of 33 00:01:12,585 --> 00:01:16,185 trauma and infections and some spine oncology here 34 00:01:16,185 --> 00:01:16,765 and there. 35 00:01:17,225 --> 00:01:19,545 In terms of my educational background, I, did 36 00:01:19,545 --> 00:01:21,484 my undergraduate studies in, neuroscience, 37 00:01:22,185 --> 00:01:24,630 at Dartmouth College and Harvard Harvard University. 38 00:01:25,090 --> 00:01:26,930 I went to medical school at the Michigan 39 00:01:26,930 --> 00:01:27,590 State University, 40 00:01:28,130 --> 00:01:31,329 College of Human Medicine, and I completed my, 41 00:01:31,569 --> 00:01:33,109 orthopedic surgery residency 42 00:01:33,490 --> 00:01:34,950 at the University of Toronto. 43 00:01:35,570 --> 00:01:37,270 I stayed in Toronto to complete, 44 00:01:37,730 --> 00:01:38,390 a combined 45 00:01:38,954 --> 00:01:41,054 orthopedic and neurosurgical fellowship, 46 00:01:41,674 --> 00:01:44,734 in complex spine and, trauma surgery, thereafter. 47 00:01:45,754 --> 00:01:47,594 Great. So sounds like you've done a little 48 00:01:47,594 --> 00:01:49,935 bit of everything throughout your entire career. 49 00:01:50,875 --> 00:01:53,219 Yeah. A little bit of everything. Traveled, you 50 00:01:53,299 --> 00:01:54,819 know, to a lot of different places, you 51 00:01:54,819 --> 00:01:56,819 know, meet a lot of different people, different 52 00:01:56,819 --> 00:01:58,659 background. I think, you know, it's been a 53 00:01:58,739 --> 00:02:00,200 it's been it's been quite the ride. 54 00:02:00,659 --> 00:02:02,420 You know, but I think it's been, you 55 00:02:02,420 --> 00:02:04,920 know, it's it's eye opening. Correct. Definitely. 56 00:02:05,614 --> 00:02:07,134 And, you know, when you're looking into the 57 00:02:07,134 --> 00:02:09,474 2025, 58 00:02:09,694 --> 00:02:12,254 what are some of the biggest headwinds you're 59 00:02:12,254 --> 00:02:12,754 anticipating? 60 00:02:14,254 --> 00:02:15,935 Yeah. So I I I kinda think of, 61 00:02:15,935 --> 00:02:17,955 you know, there's kinda two different 62 00:02:18,379 --> 00:02:19,979 categories that I see in terms of kind 63 00:02:19,979 --> 00:02:21,680 of the the upcoming challenges. 64 00:02:22,379 --> 00:02:24,139 And I I kinda broke it down into, 65 00:02:24,139 --> 00:02:26,139 you know, the there's, like, this the the 66 00:02:26,139 --> 00:02:28,620 individual and the the surgeon challenges, like, the 67 00:02:28,620 --> 00:02:29,979 one that I have to deal with myself 68 00:02:29,979 --> 00:02:31,925 and then also the one that are, you 69 00:02:31,925 --> 00:02:35,625 know, more systemic or hospital based, issues. So, 70 00:02:36,004 --> 00:02:37,125 you know, with the first, 71 00:02:37,525 --> 00:02:39,384 with the first challenge, it's just individually, 72 00:02:40,405 --> 00:02:41,224 as a surgeon. 73 00:02:42,165 --> 00:02:43,685 You know, I've I've kind of one of 74 00:02:43,685 --> 00:02:45,284 the biggest challenges that I see is to 75 00:02:45,284 --> 00:02:47,044 figure out how to continue to push the 76 00:02:47,044 --> 00:02:47,544 envelope, 77 00:02:47,949 --> 00:02:50,829 in terms of developing these new, minimally invasive 78 00:02:50,829 --> 00:02:53,310 techniques and to fine tune my own surgical 79 00:02:53,310 --> 00:02:53,810 repertoire, 80 00:02:54,269 --> 00:02:55,569 to better help my patients. 81 00:02:56,509 --> 00:02:58,590 Over the past couple years, I've I've been 82 00:02:58,590 --> 00:03:01,009 a pretty heavy proponent of the, MIS, 83 00:03:01,389 --> 00:03:02,370 TLIF technique. 84 00:03:03,025 --> 00:03:05,105 It's become a very powerful technique in my 85 00:03:05,105 --> 00:03:07,284 hands with, pretty strong outcomes. 86 00:03:08,064 --> 00:03:10,224 But I think there are times when, there 87 00:03:10,224 --> 00:03:13,105 are alternative fusion option that may actually better 88 00:03:13,105 --> 00:03:13,605 serve, 89 00:03:13,985 --> 00:03:15,205 a specific patient's, 90 00:03:15,504 --> 00:03:16,004 pathology. 91 00:03:16,919 --> 00:03:17,659 And so, 92 00:03:18,199 --> 00:03:19,799 one of the biggest challenges for me in 93 00:03:19,799 --> 00:03:21,479 the last year or two is to develop 94 00:03:21,479 --> 00:03:23,560 some of these other alternatives and fine tune 95 00:03:23,560 --> 00:03:24,620 those, skills, 96 00:03:25,239 --> 00:03:26,620 one of which has been, 97 00:03:27,799 --> 00:03:29,819 to develop a more minimally invasive, 98 00:03:30,280 --> 00:03:30,780 pronelateral 99 00:03:31,159 --> 00:03:32,379 spine surgery. So, 100 00:03:32,814 --> 00:03:34,495 you know, I think prone lateral surgery has 101 00:03:34,495 --> 00:03:36,735 been growing in the last couple years with, 102 00:03:36,735 --> 00:03:39,055 you know, growing in popularity for, you know, 103 00:03:39,055 --> 00:03:40,414 a whole bunch of different reasons. I think 104 00:03:40,414 --> 00:03:42,414 there's, you know, many benefits of of prone 105 00:03:42,414 --> 00:03:44,034 lateral surgery because it allows, 106 00:03:44,895 --> 00:03:45,395 simultaneous 107 00:03:45,775 --> 00:03:48,950 access to both, the posterior and anterior columns 108 00:03:48,950 --> 00:03:49,689 of the spine. 109 00:03:49,990 --> 00:03:51,590 So it allows you to do all your 110 00:03:51,590 --> 00:03:54,889 your decompression work, your screw and rod placement, 111 00:03:55,030 --> 00:03:56,250 as well as access, 112 00:03:57,030 --> 00:03:58,710 the disc space in the front all in 113 00:03:58,710 --> 00:04:00,490 one go instead of having to, 114 00:04:01,014 --> 00:04:03,814 reposition the patient, like, more like so for 115 00:04:03,814 --> 00:04:06,055 an a lift or for, like, traditional lateral 116 00:04:06,055 --> 00:04:06,555 surgery. 117 00:04:07,175 --> 00:04:09,335 So I think that certainly helps with, operative 118 00:04:09,335 --> 00:04:09,835 efficiency. 119 00:04:11,254 --> 00:04:13,014 And then the the second the, 120 00:04:13,495 --> 00:04:15,254 the second kind of front that I look 121 00:04:15,254 --> 00:04:16,459 at from from my 122 00:04:16,759 --> 00:04:18,759 own, you know, my own personal development is, 123 00:04:19,079 --> 00:04:20,860 you know, developing a, 124 00:04:21,479 --> 00:04:21,979 orthopedic 125 00:04:22,360 --> 00:04:22,860 endoscopic 126 00:04:23,240 --> 00:04:24,060 spine practice. 127 00:04:24,439 --> 00:04:27,240 We've we've been working with our local, same 128 00:04:27,240 --> 00:04:28,540 day surgical center 129 00:04:29,194 --> 00:04:30,875 to try and build up this program. I 130 00:04:30,875 --> 00:04:31,375 think, 131 00:04:32,074 --> 00:04:34,714 you know, certainly there's regulatory and and the 132 00:04:34,714 --> 00:04:36,814 financial, difficulties with that. 133 00:04:37,675 --> 00:04:39,595 But I think endoscopy, you know, endoscopy has 134 00:04:39,595 --> 00:04:41,675 come a long way since since its first, 135 00:04:41,995 --> 00:04:43,535 development many years ago. 136 00:04:44,360 --> 00:04:46,120 And, certainly, there are benefits that I can 137 00:04:46,120 --> 00:04:48,120 see, you know, if we can bring this 138 00:04:48,120 --> 00:04:50,519 program to our our system. You know, certainly, 139 00:04:50,519 --> 00:04:52,839 that's that's another, area that you know, it's 140 00:04:52,839 --> 00:04:56,459 another treatment option that patients patients can have 141 00:04:56,694 --> 00:04:59,035 versus our traditional open, techniques. 142 00:04:59,574 --> 00:05:02,314 Could you dive into how you're tackling 143 00:05:02,935 --> 00:05:06,055 some of the regulatory and financial challenges both 144 00:05:06,055 --> 00:05:07,194 with endoscopic 145 00:05:07,574 --> 00:05:08,055 and, 146 00:05:08,455 --> 00:05:08,955 anything 147 00:05:09,735 --> 00:05:12,314 standing the way of proned lateral spine surgery? 148 00:05:13,310 --> 00:05:15,009 Yeah. So I think I think what pronelateral 149 00:05:15,230 --> 00:05:15,730 surgery, 150 00:05:17,150 --> 00:05:18,129 so so the 151 00:05:18,670 --> 00:05:19,150 the, 152 00:05:19,550 --> 00:05:21,550 I think one of the biggest challenges is 153 00:05:21,550 --> 00:05:22,050 to, 154 00:05:22,589 --> 00:05:23,970 bring in the right vendors 155 00:05:24,430 --> 00:05:25,069 to have, 156 00:05:25,389 --> 00:05:27,470 the right retractors and the right implants. A 157 00:05:27,470 --> 00:05:27,915 lot of 158 00:05:28,714 --> 00:05:30,555 the pro lateral work that I'm doing right 159 00:05:30,555 --> 00:05:32,314 now is, in many ways, is kind of 160 00:05:32,314 --> 00:05:33,375 MacGyver from 161 00:05:33,835 --> 00:05:36,415 more traditional lateral or or posterior, 162 00:05:37,035 --> 00:05:39,694 lumbar surgeries that I'm kind of putting together 163 00:05:39,835 --> 00:05:41,295 to make to make it work. 164 00:05:41,819 --> 00:05:43,579 But there are companies out there that are 165 00:05:43,579 --> 00:05:46,800 very focused purely on pro lateral surgeries, and 166 00:05:47,180 --> 00:05:49,419 and so they have these, like, you know, 167 00:05:49,419 --> 00:05:52,560 these very specific implants or very specific retractors 168 00:05:52,620 --> 00:05:54,539 that make this make the technique a lot 169 00:05:54,539 --> 00:05:55,039 easier. 170 00:05:55,419 --> 00:05:56,925 But, of course, one of the biggest problem 171 00:05:56,925 --> 00:05:58,685 with adopting that is to bring, you know 172 00:05:58,764 --> 00:06:00,925 especially in a in a cost health care 173 00:06:00,925 --> 00:06:02,544 system that's as big as Geisinger. 174 00:06:03,245 --> 00:06:05,084 You know, there is a lot of, moving 175 00:06:05,084 --> 00:06:07,564 parts and, you know, there are, you know, 176 00:06:07,564 --> 00:06:09,430 major contracts that have to be changed in 177 00:06:09,430 --> 00:06:11,589 order to bring these smaller companies in. There's, 178 00:06:11,589 --> 00:06:12,949 you know, then then, of course, there's the 179 00:06:12,949 --> 00:06:14,790 financial aspects too. You know, how much is 180 00:06:14,790 --> 00:06:15,770 this gonna cost? 181 00:06:16,389 --> 00:06:18,250 You know, what is actually is the reimbursement? 182 00:06:18,550 --> 00:06:20,410 What's the return on something like that? 183 00:06:21,274 --> 00:06:23,035 So, certainly, you know, right now, it's I 184 00:06:23,035 --> 00:06:24,475 think it's still a bit of a MacGyver 185 00:06:24,475 --> 00:06:26,415 technique, but it does work. 186 00:06:27,595 --> 00:06:28,954 It just may not work as well as 187 00:06:28,954 --> 00:06:30,095 I would like it to. 188 00:06:30,875 --> 00:06:33,294 So, certainly, that's that's, my area of, 189 00:06:33,879 --> 00:06:36,839 you know, for for for development later on 190 00:06:36,839 --> 00:06:37,660 in the year. 191 00:06:38,120 --> 00:06:39,560 Kind of this I would say it's about 192 00:06:39,560 --> 00:06:40,519 the same thing with, 193 00:06:41,079 --> 00:06:43,000 the, you know, the endoscopic side of things. 194 00:06:43,240 --> 00:06:44,939 You know, endoscopy is upcoming. 195 00:06:45,399 --> 00:06:47,595 I think there are still major issues with, 196 00:06:47,595 --> 00:06:50,095 you know, figuring out the the, the CPT 197 00:06:50,154 --> 00:06:50,654 codes 198 00:06:51,194 --> 00:06:53,595 and the exact reimbursements. You know, some some 199 00:06:53,595 --> 00:06:55,595 of these insurance companies are still is still 200 00:06:55,595 --> 00:06:56,654 calling it experimental. 201 00:06:58,235 --> 00:06:59,995 Certainly, that that's gonna cause a lot of 202 00:06:59,995 --> 00:07:01,615 issues for for reimbursement. 203 00:07:02,810 --> 00:07:04,410 And so, you know, when the when the 204 00:07:04,410 --> 00:07:07,050 health care administration, when they look at when 205 00:07:07,050 --> 00:07:08,089 they look at it, you know, whether or 206 00:07:08,089 --> 00:07:10,410 not they're gonna approve of bringing such a 207 00:07:10,410 --> 00:07:10,910 program 208 00:07:11,610 --> 00:07:12,589 into the system 209 00:07:13,289 --> 00:07:15,129 and they start looking at the returns on 210 00:07:15,129 --> 00:07:16,810 that, it it it sometimes it can be 211 00:07:16,810 --> 00:07:18,029 very hard to justify 212 00:07:19,425 --> 00:07:20,564 why we should spend, 213 00:07:21,024 --> 00:07:22,805 you know, $6.06 figures 214 00:07:23,264 --> 00:07:25,605 to bring in these trades and these these, 215 00:07:25,985 --> 00:07:26,725 these instruments 216 00:07:27,104 --> 00:07:28,004 and these towers 217 00:07:29,345 --> 00:07:30,404 when the return 218 00:07:30,865 --> 00:07:34,004 the financial return doesn't really make any sense. 219 00:07:34,759 --> 00:07:37,080 Mhmm. So that's that's that's certainly a fight. 220 00:07:37,080 --> 00:07:39,500 That's an ongoing fight, I'm sure, at many 221 00:07:39,720 --> 00:07:40,459 many places. 222 00:07:42,759 --> 00:07:44,600 So we'll so we'll see. We'll see how 223 00:07:44,600 --> 00:07:45,259 that goes. 224 00:07:45,720 --> 00:07:48,134 Yeah. And then turning to you mentioned, 225 00:07:48,455 --> 00:07:49,435 some systemic 226 00:07:50,055 --> 00:07:51,915 headwinds as well in health care. 227 00:07:52,375 --> 00:07:53,675 How are you thinking about 228 00:07:54,055 --> 00:07:56,074 that in in your work? 229 00:07:56,935 --> 00:07:57,435 Certainly. 230 00:07:57,895 --> 00:07:59,654 And I'm sure this is gonna sound like 231 00:07:59,654 --> 00:08:01,355 a broken record at this point. 232 00:08:02,214 --> 00:08:04,110 But, you know, I think, you know, this 233 00:08:04,110 --> 00:08:05,629 is I think this is an interesting time. 234 00:08:05,629 --> 00:08:07,550 Right? We we live Right. In a in 235 00:08:07,550 --> 00:08:08,210 a period 236 00:08:08,750 --> 00:08:10,370 where the, you know, the 237 00:08:11,790 --> 00:08:14,990 the the the regulatory environment is constantly changing 238 00:08:14,990 --> 00:08:15,730 and evolving. 239 00:08:16,274 --> 00:08:18,354 And, you know, physician reimburse at least the 240 00:08:18,354 --> 00:08:21,095 relative physician reimbursements continue to draw. 241 00:08:22,274 --> 00:08:24,035 You know, now we have kind of these, 242 00:08:24,035 --> 00:08:26,115 you know, questions about what's gonna happen to 243 00:08:26,115 --> 00:08:27,954 a lot of the, you know, the the 244 00:08:27,954 --> 00:08:30,055 patients that have, like, government insurance. 245 00:08:30,595 --> 00:08:32,029 You know, are they gonna get kicked off 246 00:08:32,029 --> 00:08:33,309 of it? Are they gonna you know, how 247 00:08:33,309 --> 00:08:35,629 many people are are are going to, you 248 00:08:35,629 --> 00:08:38,429 know, have insurance? Right? And and so that's 249 00:08:38,509 --> 00:08:40,110 I think for some for a system as 250 00:08:40,110 --> 00:08:42,429 big as Geisinger, it certainly is going to 251 00:08:42,429 --> 00:08:44,285 be a I I foresee it as being 252 00:08:44,285 --> 00:08:46,945 a problem. You know, Geisinger overall is is 253 00:08:47,245 --> 00:08:47,904 a rural, 254 00:08:48,924 --> 00:08:49,904 health care system, 255 00:08:50,684 --> 00:08:53,085 and we have a pretty large government payer 256 00:08:53,085 --> 00:08:54,924 mix. You know? And I think that's the 257 00:08:54,924 --> 00:08:57,165 truth. And then so, you know, if all 258 00:08:57,165 --> 00:08:58,384 these patients are, 259 00:08:58,899 --> 00:09:00,419 you know, are are they gonna lose their 260 00:09:00,419 --> 00:09:00,919 insurance, 261 00:09:01,299 --> 00:09:02,659 yeah, I think it's gonna cause a lot 262 00:09:02,659 --> 00:09:03,240 of issues, 263 00:09:03,620 --> 00:09:05,559 in terms of staying financially viable. 264 00:09:06,179 --> 00:09:06,839 And so 265 00:09:07,220 --> 00:09:09,320 I think, ultimately, what is that gonna translate 266 00:09:09,379 --> 00:09:10,839 to? Well, typically, 267 00:09:11,459 --> 00:09:13,085 you know, when that when something like that 268 00:09:13,085 --> 00:09:14,784 happens, it often means, you know, 269 00:09:15,164 --> 00:09:16,625 major staffing cuts. 270 00:09:17,004 --> 00:09:19,725 It means, cut cutbacks on on the services 271 00:09:19,725 --> 00:09:20,784 that we can provide. 272 00:09:21,085 --> 00:09:23,725 And, typically, from a physician standpoint, it often 273 00:09:23,725 --> 00:09:26,284 means that we're expected to do more and 274 00:09:26,284 --> 00:09:26,784 more, 275 00:09:27,269 --> 00:09:28,570 but with less and less. 276 00:09:30,070 --> 00:09:31,750 So, certainly, that can be a strain on, 277 00:09:31,750 --> 00:09:34,230 you know, the whole system. And, hopefully, we 278 00:09:34,230 --> 00:09:36,710 have some plans in store, in place to 279 00:09:36,710 --> 00:09:39,590 to counteract that. You know? I I think 280 00:09:39,590 --> 00:09:41,264 I think there's, you know, I'm I'm all 281 00:09:41,264 --> 00:09:43,424 for running like a like a lean efficient 282 00:09:43,424 --> 00:09:45,264 practice. I think that's great if if it's 283 00:09:45,264 --> 00:09:45,764 possible. 284 00:09:46,784 --> 00:09:48,144 But I think it's we had we had 285 00:09:48,144 --> 00:09:49,985 to be really careful to, you know, not 286 00:09:49,985 --> 00:09:52,464 let, like, the the quality of our patient 287 00:09:52,464 --> 00:09:54,705 care and outcomes, like, suffer because of that, 288 00:09:54,705 --> 00:09:56,529 you know, with a limited resource, we it's 289 00:09:56,529 --> 00:09:58,549 always this kind of careful balance between 290 00:09:59,490 --> 00:10:00,230 being efficient 291 00:10:00,610 --> 00:10:02,389 but also having the good outcomes. 292 00:10:02,929 --> 00:10:04,629 Like a tight rope, it sounds like. 293 00:10:05,009 --> 00:10:07,889 It is. Absolutely. Ex especially for for a 294 00:10:07,889 --> 00:10:08,950 system like Geisinger. 295 00:10:10,514 --> 00:10:12,695 You know, I I I think I think, 296 00:10:13,154 --> 00:10:15,014 you know, with with the number of government 297 00:10:15,475 --> 00:10:17,795 government insurance patients that we have in our 298 00:10:17,795 --> 00:10:19,955 in in our, you know, in our overall 299 00:10:19,955 --> 00:10:22,355 patient population here, you know, I think that's 300 00:10:22,355 --> 00:10:23,654 gonna be a major headwind, 301 00:10:24,470 --> 00:10:26,629 you know, in the next six months, year, 302 00:10:26,629 --> 00:10:29,350 two years. So Yeah. And, you know, you 303 00:10:29,350 --> 00:10:30,170 think it has. 304 00:10:30,549 --> 00:10:31,450 How are you 305 00:10:31,830 --> 00:10:32,970 talking about these 306 00:10:33,509 --> 00:10:34,009 developments 307 00:10:34,470 --> 00:10:37,190 with your residents that you work with? How 308 00:10:37,190 --> 00:10:38,735 are you preparing them 309 00:10:39,035 --> 00:10:41,914 to face these challenges then when they go 310 00:10:41,914 --> 00:10:45,054 on either in private practice or with a 311 00:10:45,195 --> 00:10:46,654 health system like Geisinger? 312 00:10:47,355 --> 00:10:48,634 You know, that I think that is an 313 00:10:48,634 --> 00:10:51,274 excellent question. Thank you. When when I when 314 00:10:51,274 --> 00:10:53,610 I was going through residency in fellowship, I 315 00:10:53,610 --> 00:10:54,910 I really had no 316 00:10:55,850 --> 00:10:57,850 no training on any of this stuff, like, 317 00:10:57,850 --> 00:10:59,529 about, you know, the health care, like, you 318 00:10:59,529 --> 00:11:02,090 know, health care policies and the reimbursements and 319 00:11:02,090 --> 00:11:04,090 all that. Like, all the, like, the the 320 00:11:04,090 --> 00:11:06,009 practical matters, I didn't get any of that 321 00:11:06,009 --> 00:11:07,790 stuff. And I think most people don't. 322 00:11:08,165 --> 00:11:09,225 But I think nowadays, 323 00:11:09,845 --> 00:11:11,925 you know, not only do do these residents 324 00:11:11,925 --> 00:11:13,764 have to learn all the all the medical 325 00:11:13,764 --> 00:11:16,085 and surgical education and the techniques and all 326 00:11:16,085 --> 00:11:17,524 that stuff, but I think it's really important 327 00:11:17,524 --> 00:11:18,745 that they start to understand 328 00:11:19,365 --> 00:11:20,904 just like the the different, 329 00:11:22,160 --> 00:11:24,080 you know, the different types of practices that 330 00:11:24,080 --> 00:11:26,240 they can join, the the pros and cons 331 00:11:26,240 --> 00:11:28,160 of each one, whether, you know, it's a 332 00:11:28,160 --> 00:11:31,040 a major academic hospital, whether it's an employed 333 00:11:31,040 --> 00:11:32,899 model, whether it's private practice, 334 00:11:33,440 --> 00:11:35,584 you know. And and not to say one 335 00:11:35,584 --> 00:11:37,184 is better than the other, but but they 336 00:11:37,184 --> 00:11:39,044 all have their own pros and cons. 337 00:11:39,504 --> 00:11:41,745 And I think it's really just about it's 338 00:11:41,745 --> 00:11:45,024 about informing them of, like, these you know, 339 00:11:45,024 --> 00:11:46,464 just try to give them as much of 340 00:11:46,464 --> 00:11:48,389 the information as possible and kind of let 341 00:11:48,950 --> 00:11:50,790 let let them make their own decisions on 342 00:11:50,790 --> 00:11:52,389 on what they wanna do with their life 343 00:11:52,389 --> 00:11:53,210 and their career. 344 00:11:53,750 --> 00:11:56,070 Mhmm. But just try to keep them as 345 00:11:56,070 --> 00:11:57,129 informed as possible. 346 00:11:57,750 --> 00:12:00,389 Absolutely. And then, obviously, you know, we're discussing 347 00:12:00,389 --> 00:12:01,894 a a lot of the challenges, but I 348 00:12:01,894 --> 00:12:04,014 also want to pick your brain on some 349 00:12:04,214 --> 00:12:06,154 what are the most exciting areas 350 00:12:06,695 --> 00:12:07,914 of spine technology 351 00:12:08,455 --> 00:12:10,794 for you? I know you touched someone endoscopic 352 00:12:11,254 --> 00:12:11,754 endoscopic 353 00:12:12,134 --> 00:12:13,034 and proned lateral, 354 00:12:13,495 --> 00:12:15,034 but, like, what other areas 355 00:12:15,819 --> 00:12:18,079 in spine surgery make you optimistic 356 00:12:18,539 --> 00:12:20,480 about the next coming years? 357 00:12:21,339 --> 00:12:22,699 Yeah. So I I think I think, you 358 00:12:22,699 --> 00:12:25,279 know, from from a technology and and, 359 00:12:26,220 --> 00:12:28,904 implant implant standpoint, I think spine surgery is, 360 00:12:29,144 --> 00:12:30,665 at at least in the last maybe five, 361 00:12:30,665 --> 00:12:32,185 ten years, I I feel like it's a 362 00:12:32,185 --> 00:12:34,585 kind of undergoing or renaissance of, you you 363 00:12:34,585 --> 00:12:36,904 know, all these, like, small and large companies. 364 00:12:36,904 --> 00:12:38,605 You know? They're all coming up with these 365 00:12:38,745 --> 00:12:40,585 new new toys and new, 366 00:12:41,899 --> 00:12:43,740 new devices. You know? They're all trying to 367 00:12:43,740 --> 00:12:45,440 experiment. They're all trying to innovate. 368 00:12:46,139 --> 00:12:48,000 And it kinda reminds me of, 369 00:12:49,019 --> 00:12:50,639 you know, maybe about fifty, 370 00:12:51,340 --> 00:12:53,899 sixty years ago when when when hip and 371 00:12:53,899 --> 00:12:55,680 knee or when the hip and knee arthroplasty 372 00:12:56,445 --> 00:12:58,365 field was kinda like the same thing where, 373 00:12:58,365 --> 00:13:00,285 you know, everybody's coming up with their own 374 00:13:00,285 --> 00:13:02,205 designs for for, you know, the ball and 375 00:13:02,205 --> 00:13:02,705 stem, 376 00:13:03,165 --> 00:13:03,825 you know, 377 00:13:04,365 --> 00:13:05,804 you know, and then they're all just trying 378 00:13:05,804 --> 00:13:08,225 to to to find what's the best thing. 379 00:13:08,365 --> 00:13:09,884 And I feel like slime is kind of 380 00:13:09,884 --> 00:13:10,285 in that 381 00:13:11,029 --> 00:13:12,870 kind of entering that phase now, which is 382 00:13:12,870 --> 00:13:13,610 really exciting. 383 00:13:14,149 --> 00:13:16,009 For me, you know, I I I see 384 00:13:16,309 --> 00:13:18,970 I kinda see three areas of major growth, 385 00:13:20,149 --> 00:13:22,070 for spine that I'm I would say I'm 386 00:13:22,070 --> 00:13:23,450 the most excited about. 387 00:13:24,074 --> 00:13:25,434 First one we kinda talked about already is, 388 00:13:25,434 --> 00:13:27,914 you know, endoscopy. Endoscopy, you know, it's been 389 00:13:27,914 --> 00:13:31,034 around like, the the idea of endoscopic spine 390 00:13:31,034 --> 00:13:33,294 surgery, it's it's been around for, like, 391 00:13:34,154 --> 00:13:36,074 I don't know, like, forty, fifty years or 392 00:13:36,074 --> 00:13:36,574 so. 393 00:13:37,350 --> 00:13:38,789 But, really, I think only in the last, 394 00:13:38,789 --> 00:13:40,809 like, maybe five to ten 395 00:13:41,269 --> 00:13:42,089 years has, like, 396 00:13:42,629 --> 00:13:43,289 the technology 397 00:13:43,750 --> 00:13:45,830 really grown. You know, we nowadays, we have 398 00:13:45,830 --> 00:13:46,889 much better visualization. 399 00:13:47,429 --> 00:13:49,350 We have, you know, all these new techniques. 400 00:13:49,350 --> 00:13:50,970 We have these new, expandable 401 00:13:51,269 --> 00:13:53,605 implants that that can go down the tube 402 00:13:53,605 --> 00:13:55,605 to help you produce you know, not only 403 00:13:55,605 --> 00:13:57,945 do a decompression or a discectomy, but also 404 00:13:58,085 --> 00:13:59,764 do, like, a, like, a endo lift or, 405 00:13:59,764 --> 00:14:01,705 like, endo endo endoscopic fusion. 406 00:14:02,404 --> 00:14:04,245 And then on top of that, you couple 407 00:14:04,245 --> 00:14:06,664 that with with all the navigation technologies nowadays. 408 00:14:06,960 --> 00:14:08,660 I mean, I think I think endoscopy 409 00:14:09,360 --> 00:14:10,920 is is I'm hope I think it's gonna 410 00:14:11,040 --> 00:14:12,100 it's here to stay. 411 00:14:12,559 --> 00:14:14,420 I think it's gonna continue to develop. 412 00:14:15,440 --> 00:14:17,200 You know, right now, most people, when people 413 00:14:17,200 --> 00:14:20,705 think endoscopy, they think, you know, laminectomies, decompression, 414 00:14:20,845 --> 00:14:21,345 discectomies. 415 00:14:22,044 --> 00:14:24,205 But I think later on, as as the 416 00:14:24,205 --> 00:14:26,445 technology continues to grow, I think it's gonna 417 00:14:26,445 --> 00:14:27,504 become the new 418 00:14:27,965 --> 00:14:30,625 minimally invasive lumbar fusion surgery. 419 00:14:31,019 --> 00:14:32,940 You know, the the the new MIS T 420 00:14:32,940 --> 00:14:34,800 lift or the new MIS lift. 421 00:14:35,580 --> 00:14:37,500 I think at some point, once the once 422 00:14:37,500 --> 00:14:39,340 the technology gets there, it's gonna be I 423 00:14:39,340 --> 00:14:41,600 think it's gonna grow a lot, especially with, 424 00:14:42,139 --> 00:14:43,179 you know, if if the 425 00:14:44,045 --> 00:14:46,305 you know, from an insurance and reimbursement standpoint, 426 00:14:46,445 --> 00:14:48,144 all that stuff gets figured out, 427 00:14:48,764 --> 00:14:50,705 I think there's gonna be much wider adoption 428 00:14:50,845 --> 00:14:51,665 of these techniques. 429 00:14:52,365 --> 00:14:55,165 So that's really exciting for me. The second 430 00:14:55,165 --> 00:14:59,024 area is cage design. So so, I'm I'm 431 00:14:59,179 --> 00:15:01,579 I'm really for one reason or another, I'm 432 00:15:01,579 --> 00:15:04,139 really into, talking about cages and, like like, 433 00:15:04,139 --> 00:15:04,639 different, 434 00:15:05,339 --> 00:15:08,319 technology involving, you know, interbody cages. And there's 435 00:15:09,100 --> 00:15:09,679 and nowadays, 436 00:15:10,699 --> 00:15:12,639 I feel like there's been, like, this explosion 437 00:15:13,100 --> 00:15:13,179 of, 438 00:15:14,875 --> 00:15:17,355 variability in in cage design. You know, every 439 00:15:17,355 --> 00:15:19,914 company has so many different types of cages, 440 00:15:19,914 --> 00:15:22,394 you know, different footprints, different materials, different, 441 00:15:24,235 --> 00:15:25,214 expansion mechanisms. 442 00:15:26,649 --> 00:15:28,490 And I think I think the fact that 443 00:15:28,490 --> 00:15:29,870 there are so many 444 00:15:30,409 --> 00:15:30,909 different 445 00:15:31,289 --> 00:15:34,490 options available right now means that nobody really 446 00:15:34,490 --> 00:15:36,509 knows what what the right answer is. 447 00:15:37,370 --> 00:15:38,730 And so, you know, everybody kind of you 448 00:15:38,730 --> 00:15:41,245 know, it's like a renaissance. Everybody's everybody's experimenting. 449 00:15:41,625 --> 00:15:43,325 Everybody's trying to see what's the best. 450 00:15:44,264 --> 00:15:46,024 Yeah. I was gonna I was gonna just, 451 00:15:46,424 --> 00:15:48,745 interject here real quick. So and, you know, 452 00:15:48,745 --> 00:15:51,625 without, like, naming names, if you can give 453 00:15:51,625 --> 00:15:53,065 just kind of, like, an when it comes 454 00:15:53,065 --> 00:15:54,904 to spying pages, can you kind of just 455 00:15:54,904 --> 00:15:56,840 give, like, a a real quick, 456 00:15:57,480 --> 00:15:58,379 sixty second 457 00:15:58,759 --> 00:16:00,059 overview of the most 458 00:16:00,840 --> 00:16:01,340 exciting 459 00:16:02,279 --> 00:16:05,000 change or improvement you've seen in these designs? 460 00:16:05,000 --> 00:16:07,960 Again, without necessarily naming company names, but just 461 00:16:07,960 --> 00:16:10,039 kind of overall what's, like, a general trend 462 00:16:10,039 --> 00:16:11,259 in design that's 463 00:16:12,065 --> 00:16:12,725 you noticed? 464 00:16:13,024 --> 00:16:14,465 I think one of the biggest so as 465 00:16:14,465 --> 00:16:16,465 a as a MIS surgeon, I what I've 466 00:16:16,465 --> 00:16:18,644 noticed is that, you know, the the traditional 467 00:16:19,024 --> 00:16:19,524 expandable 468 00:16:19,904 --> 00:16:20,404 cage, 469 00:16:21,424 --> 00:16:24,225 it goes in and it expands only in 470 00:16:24,225 --> 00:16:26,625 the cranial caudal direction. So so, basically, it 471 00:16:26,625 --> 00:16:29,720 gets taller, and that's it. But nowadays, there 472 00:16:29,720 --> 00:16:31,799 there are more and more companies developing these, 473 00:16:31,799 --> 00:16:34,279 like, what we call bivector cages where it 474 00:16:34,279 --> 00:16:36,600 goes in. You know, it essentially goes in 475 00:16:36,600 --> 00:16:37,820 as small as possible, 476 00:16:38,279 --> 00:16:40,585 and it and it's able to expand not 477 00:16:40,585 --> 00:16:42,904 only in the cranial caudal direction, but also 478 00:16:42,904 --> 00:16:45,325 the the medial lateral direction. So the thing 479 00:16:45,465 --> 00:16:47,465 the thing starts to open up, like, its 480 00:16:47,465 --> 00:16:47,965 footprint 481 00:16:48,825 --> 00:16:51,144 starts to, like, double to the point where 482 00:16:51,144 --> 00:16:52,924 it's almost the size of an ALIF. 483 00:16:54,409 --> 00:16:56,089 And so, you know, there there are many, 484 00:16:56,089 --> 00:16:57,629 many benefits to that. So 485 00:16:58,009 --> 00:17:00,089 one is you get a lot of theoretically, 486 00:17:00,089 --> 00:17:01,929 you get lower subsidence rates. You have a 487 00:17:01,929 --> 00:17:04,329 much bigger graph window. You know, if you 488 00:17:04,329 --> 00:17:05,930 have a bigger footprint, it means that you 489 00:17:05,930 --> 00:17:08,505 have you're usually able to put more force 490 00:17:08,505 --> 00:17:10,365 on your reduction. So when you expand, 491 00:17:10,664 --> 00:17:12,585 you might be able to produce more lower 492 00:17:12,585 --> 00:17:14,105 doses or a better, 493 00:17:14,505 --> 00:17:15,005 correction, 494 00:17:15,625 --> 00:17:16,444 for the patient. 495 00:17:17,065 --> 00:17:18,845 Oh, that's fascinating. That's fascinating. 496 00:17:19,305 --> 00:17:21,785 And then can you dive in, into the 497 00:17:21,785 --> 00:17:24,025 last, area of spine technology that you were 498 00:17:24,025 --> 00:17:24,890 gonna discuss? 499 00:17:25,349 --> 00:17:26,710 Yeah. So the last one, I think, is 500 00:17:26,710 --> 00:17:27,210 arthroplasty. 501 00:17:27,910 --> 00:17:31,049 It's specifically lumbar arthroplasty. I think, 502 00:17:31,589 --> 00:17:34,410 you know, I think cervical and lumbar arthroplasty 503 00:17:34,789 --> 00:17:36,549 ideas have been around for for quite a 504 00:17:36,549 --> 00:17:38,809 while, kinda like kinda like, endoscopy. 505 00:17:39,704 --> 00:17:42,424 I think at this point, cervical arthroplasty is 506 00:17:42,424 --> 00:17:44,424 very well accepted, you know, because we already 507 00:17:44,424 --> 00:17:47,304 do ACVFs all the time. It's quite simple 508 00:17:47,304 --> 00:17:49,144 to just you know, instead of putting in 509 00:17:49,144 --> 00:17:50,984 a cage, you put in a, you know, 510 00:17:50,984 --> 00:17:52,904 an artificial disc. That that part, I think, 511 00:17:52,904 --> 00:17:53,404 is 512 00:17:54,039 --> 00:17:54,539 more 513 00:17:54,920 --> 00:17:57,099 or less, I would say, well accepted. 514 00:17:57,480 --> 00:17:59,000 I think the thing that's not as well 515 00:17:59,000 --> 00:18:01,960 accepted nowadays is is Luvart disc arthroplasty. And, 516 00:18:02,119 --> 00:18:03,559 I think, you know, there there are some 517 00:18:03,559 --> 00:18:05,559 major centers around the country that are doing 518 00:18:05,559 --> 00:18:06,299 them routinely, 519 00:18:06,884 --> 00:18:09,125 But I would say for the average spine 520 00:18:09,125 --> 00:18:09,625 surgeon, 521 00:18:10,404 --> 00:18:11,924 I don't think it's a common thing to 522 00:18:11,924 --> 00:18:14,664 see. And I think the evidence is not 523 00:18:14,805 --> 00:18:16,644 not quite there yet in terms of, you 524 00:18:16,644 --> 00:18:18,484 know I think the biomechanics is not quite 525 00:18:18,484 --> 00:18:19,945 the same as as a 526 00:18:20,349 --> 00:18:21,649 as a cervical arthroplasty. 527 00:18:22,349 --> 00:18:24,029 But I think for for me, you know, 528 00:18:24,029 --> 00:18:26,589 what what's really exciting about this motion sparing 529 00:18:26,589 --> 00:18:27,089 technology 530 00:18:28,269 --> 00:18:30,429 is is that nowadays, there are these companies 531 00:18:30,429 --> 00:18:32,289 that are coming out where, 532 00:18:32,785 --> 00:18:34,545 you know, not only are you trying to 533 00:18:34,545 --> 00:18:36,884 change the disc in the front, you're also 534 00:18:37,345 --> 00:18:40,065 addressing the pathology in the back. So, you 535 00:18:40,065 --> 00:18:41,345 know, the way I the way I think 536 00:18:41,345 --> 00:18:41,845 about, 537 00:18:43,184 --> 00:18:45,649 lumbar arthroplasty, it's kinda like, you know, if 538 00:18:45,649 --> 00:18:47,089 you if you have a tricycle, right, so 539 00:18:47,089 --> 00:18:48,210 you got a big wheel in the front, 540 00:18:48,210 --> 00:18:49,750 you got two little wheels in the back. 541 00:18:50,130 --> 00:18:52,369 Well, if if those wheels are starting to 542 00:18:52,369 --> 00:18:53,190 wear out, 543 00:18:53,490 --> 00:18:55,490 usually, it's not just the front wheel that 544 00:18:55,490 --> 00:18:57,169 wears out. It's it's the front and the 545 00:18:57,169 --> 00:18:59,154 ones the little guys in the back. So 546 00:18:59,154 --> 00:19:00,994 when you do a disc arthroplasty, all you're 547 00:19:00,994 --> 00:19:03,234 doing is that you're addressing the pathology in 548 00:19:03,234 --> 00:19:05,634 the front without without addressing the stuff in 549 00:19:05,634 --> 00:19:07,875 the back. So nowadays, there are companies that 550 00:19:07,875 --> 00:19:08,355 have, 551 00:19:08,674 --> 00:19:12,055 facet replacement or facet arthroplasty where you're addressing 552 00:19:12,434 --> 00:19:13,974 the pathology in the back. 553 00:19:14,890 --> 00:19:17,849 You have other companies that are actually, you 554 00:19:17,849 --> 00:19:20,890 know, purely through through a pure posterior approach 555 00:19:20,890 --> 00:19:23,150 and sometimes even minimally invasive approach. 556 00:19:23,930 --> 00:19:24,829 You can address 557 00:19:25,130 --> 00:19:26,509 both the front pathology 558 00:19:26,809 --> 00:19:29,234 and the back pathology. So, you know, it's 559 00:19:29,234 --> 00:19:31,355 like it's like changing out all three wheels 560 00:19:31,355 --> 00:19:33,275 of the tricycle instead of just replacing the 561 00:19:33,275 --> 00:19:34,335 big wheel on the front. 562 00:19:34,714 --> 00:19:36,174 A great way to put it. 563 00:19:36,795 --> 00:19:39,515 And my last question is just worse are 564 00:19:39,515 --> 00:19:41,375 there any other big opportunities 565 00:19:41,914 --> 00:19:42,734 that you're 566 00:19:43,039 --> 00:19:44,640 seeing that you're excited for in terms of 567 00:19:44,640 --> 00:19:45,140 growth? 568 00:19:46,319 --> 00:19:47,919 You know, I think outside of, 569 00:19:49,119 --> 00:19:51,940 I think outside of the implant implant space, 570 00:19:52,559 --> 00:19:55,200 I think, you know, artificial intelligence is certainly, 571 00:19:55,200 --> 00:19:56,914 you know, it's it's been kinda like this 572 00:19:56,914 --> 00:19:59,394 hot topic, and, you know, everybody's kinda publishing 573 00:19:59,394 --> 00:20:01,634 on, you know, the benefits and the pros 574 00:20:01,634 --> 00:20:04,195 and cons of AI AI. You know, I 575 00:20:04,195 --> 00:20:05,955 think I think the overall consensus is still 576 00:20:05,955 --> 00:20:07,795 up in the air about how great AI 577 00:20:07,795 --> 00:20:09,414 is. But I think, 578 00:20:09,789 --> 00:20:11,150 you know, with more and more of these 579 00:20:11,150 --> 00:20:13,230 studies coming out looking at how AI can 580 00:20:13,230 --> 00:20:14,769 be can help us predict 581 00:20:15,390 --> 00:20:16,289 patient outcomes, 582 00:20:17,069 --> 00:20:18,829 I think at some point down the line, 583 00:20:18,829 --> 00:20:20,910 once we have enough data, once we have 584 00:20:20,910 --> 00:20:22,049 a a strong enough 585 00:20:22,430 --> 00:20:24,369 system or predictive system, 586 00:20:25,325 --> 00:20:25,984 I think 587 00:20:26,525 --> 00:20:28,365 one day, we may be we may be 588 00:20:28,365 --> 00:20:29,505 able to use that. 589 00:20:30,045 --> 00:20:32,224 You know, we can input patient demographics 590 00:20:32,684 --> 00:20:33,664 or radiographic 591 00:20:34,045 --> 00:20:35,345 out you know, radiographic, 592 00:20:35,805 --> 00:20:36,305 numbers 593 00:20:36,765 --> 00:20:39,805 and have AI essentially recommend to us, like, 594 00:20:39,805 --> 00:20:41,950 hey. Based on these things, 595 00:20:42,490 --> 00:20:43,549 we think that, 596 00:20:43,930 --> 00:20:45,529 you know, if you do, you know, a, 597 00:20:45,529 --> 00:20:46,430 b, and c, 598 00:20:47,130 --> 00:20:48,910 this patient is gonna have the best outcome. 599 00:20:49,609 --> 00:20:51,049 You know, if we can get to that 600 00:20:51,049 --> 00:20:52,490 point, I think that would be that would 601 00:20:52,490 --> 00:20:53,070 be amazing. 602 00:20:54,065 --> 00:20:56,384 Absolutely. That we can then standardize we really 603 00:20:56,384 --> 00:20:56,884 standardize, 604 00:20:57,265 --> 00:20:59,585 spine care because I think, you know, unlike 605 00:20:59,585 --> 00:21:02,305 unlike hip and knee arthroplasty nowadays, you know, 606 00:21:02,305 --> 00:21:03,845 spine care is just 607 00:21:04,545 --> 00:21:06,565 there is, like, so much variability 608 00:21:07,450 --> 00:21:10,490 in in in what a spine surgeon would 609 00:21:10,490 --> 00:21:12,570 recommend. You know? My my my mentors have 610 00:21:12,570 --> 00:21:14,990 always told me, you know, if you have 611 00:21:15,609 --> 00:21:17,690 if you ask 10 spine surgeons for a 612 00:21:17,850 --> 00:21:19,850 for an answer, you're gonna get 11 ants 613 00:21:19,930 --> 00:21:21,390 you're gonna get 11 answers. 614 00:21:21,944 --> 00:21:23,804 And and I think that says a lot. 615 00:21:23,865 --> 00:21:24,765 You know? Like, 616 00:21:25,224 --> 00:21:26,765 because nobody really has, 617 00:21:27,625 --> 00:21:29,065 like, the I don't I don't think there's 618 00:21:29,065 --> 00:21:30,744 much of a consensus right now in spine 619 00:21:30,744 --> 00:21:31,244 surgery, 620 00:21:31,704 --> 00:21:33,865 which means does does that mean that everybody 621 00:21:33,865 --> 00:21:36,730 is does that mean everybody's right? I don't 622 00:21:36,730 --> 00:21:38,330 think so. Right? It can't that can't be 623 00:21:38,330 --> 00:21:40,490 right. So I think I think at some 624 00:21:40,490 --> 00:21:42,250 point down the line, you know, with AI, 625 00:21:42,250 --> 00:21:44,970 with with better outcomes with better outcome measures 626 00:21:44,970 --> 00:21:45,930 and and and, 627 00:21:46,490 --> 00:21:46,990 research, 628 00:21:47,664 --> 00:21:49,265 I think at some point, it's gonna become 629 00:21:49,265 --> 00:21:51,184 a lot more standardized, like, kinda like the 630 00:21:51,184 --> 00:21:52,244 hip and knee world, 631 00:21:52,704 --> 00:21:54,305 you know, whether or not somebody should get 632 00:21:54,305 --> 00:21:56,224 a hip replacement or knee replacement. I think 633 00:21:56,224 --> 00:21:59,204 it's gonna start to eventually head that direction. 634 00:22:00,009 --> 00:22:01,690 Definitely. And hopefully, it'll get there sooner than 635 00:22:01,690 --> 00:22:02,190 later. 636 00:22:02,890 --> 00:22:04,829 Maybe. Maybe. I don't know. I mean, 637 00:22:06,009 --> 00:22:07,529 I would say, you know, it took it 638 00:22:07,529 --> 00:22:08,669 took hip and knees, 639 00:22:09,929 --> 00:22:11,369 like, forty, fifty years 640 00:22:11,769 --> 00:22:14,009 Yeah. To kinda get there. I think I 641 00:22:14,009 --> 00:22:15,470 would say maybe in my 642 00:22:16,065 --> 00:22:18,144 in my career, I I I think it's 643 00:22:18,144 --> 00:22:20,224 gonna come, but I I suspect it'll be 644 00:22:20,224 --> 00:22:22,565 kinda near the tail end, maybe. Yeah. 645 00:22:22,865 --> 00:22:24,544 So we'll see. We'll see. But it is 646 00:22:24,544 --> 00:22:25,044 exciting. 647 00:22:25,505 --> 00:22:26,565 Definitely. Definitely. 648 00:22:27,264 --> 00:22:29,505 Well, thank you, doctor Chen for joining us 649 00:22:29,505 --> 00:22:31,125 today. This has been a great conversation, 650 00:22:31,627 --> 00:22:33,387 and I look forward to connecting with you 651 00:22:33,387 --> 00:22:35,547 again down the line. Awesome. Awesome. Thank you 652 00:22:35,547 --> 00:22:37,007 so much. I really appreciate it.