Ep. 31 Investing in Yourself, Sobtech, and the Evolution of AI in Teleradiology with Dr. Vik Sobti

this week on the Backtable podcast. If you're not a radiologist, I'm going to put it in terms of generalities, like I do, for everything. Currently, we have lane detection and blind spot prediction for your car. It doesn't drive for you. My infinity doesn't drive for me. It tells me if there's a car in my blind spot, and it'll beep, and we have that, right? That's essentially AI that we have in medicine, the same thing. Hey, look, you better look at this head CT. It doesn't look right to me. I don't know how to read it, but it just doesn't look right. What I'm talking about is what Elon Musk is talking about in 20 years, where we don't have drivers in our cars anymore because it's driving for us. Hey, everyone, welcome to the Backtable Innovation Podcast. You can find all previous episodes of our podcasts on iTunes, Spotify, and our Backtable.com. This is our next installment in the Backtable Innovation Show where you will hear stories from physician entrepreneurs who are hoping to drive healthcare forward through MedTech Innovation. First, a brief message from our sponsor. All right, Backtable listeners. Our next partner has a product that I use literally every day. I started using AG1 because my trainer uses it, or uses it, and I asked him why. He said, "Well, I feel like I get faster recovery and I sleep better at night." So I learned more about it, and I actually got some free samples, and I started taking it, and then I told Mike and Sabine about it. What do you guys think about it? Yeah, I mean, I started taking AG1 because my brother-in-law, he was actually taking it for the past year, and he kept on telling me how awesome it is, and then you asked me if I wanted to try it. Aaron, and I thought this would be a perfect opportunity, to get some free samples. Exactly. I don't have time in the morning, he breakfast or anything, so I was like, "This would be perfect. Let me give it a shot." So I started taking it because I am susceptible to peer pressure, and you guys did it, and also because I got free samples. But the free samples was a big part of that for me. Yeah, so you're taking supplement. You kind of want to ask me, what's in this stuff? With one scoop of AG1, you're actually absorbing 75 high-quality vitamins, minerals, whole food, source, superfoods, probiotics, and adaptogens. What exactly are adaptogens, Michael Bratza? Do you know? I think they come from space. That's amazing. They aid apt technique. They suck out toxins. Yeah, like you're doing a throw them back to me. It's a suck out thing. That's science. It's literally green. I feel healthy drinking it because it's green. Anything I see when they say superfoods or the smoothies there, it's super greens. This thing is green. It actually, to me, I like the taste. It's green, but when you shake it up, it starts to turn white a little bit. I think that's the adaptogens that are alive and that are working. Look, man, if it's in my head, it's working. That's right. It does support mental clarity and alertness. Your subscription comes with a year supply of vitamin D, which is very important for us radiologists. I know mine was critically low, my vitamin D level when I checked it. That helps. It comes in this little dropper. I just drop one little drop in my topochico every day and I know my vitamin D to make it easy. Athletic greens is going to give you a free one year supply of immune supporting vitamin D and five free travel packs with your first purchase. All you have to do is visit athletic greens.com/backtablevi as in vascular and interventional. Again, that is athletic greens.com/backtablevi to take ownership of your health and pick up the ultimate daily nutritional insurance. Now back to the episode. This is Aaron Fredz as your host this week and I'm very excited to have a peer and colleague in the radiology world. Today we have Dr. Vikram Soapty on the innovation show. Vic is a board-certified radiologist and physician entrepreneur whom I met by a mutual friend, Eric Gantwerker, also one of the innovation hosts. Today we're going to talk to Vic about how he built his tele-radiology business from the ground up and how AI plays an important role in that business and I also want to pick his brain on the forecast on AI into the tele-radiology industry, how he feels like it's going to play out in the coming years. Welcome, Vic. Thank you Aaron. Before we jump into the meat of it, I want you to tell the audience a little bit about your background, you know, your training, your current practice, just a little bit of background about yourself. Sure thing. So engineer by trade went to the best engineering school in the nation, University of Illinois, Go Fighting Align. It was the toughest time but I knew that I wanted to meld something within biology and engineering, did bioengineering there and then felt the best course of action was going to medical school. Went to Rush University where I met Eric, my wife and I were in his same class. Great school had fun and within there I wanted to meld something to do with technology, engineering and medicine and it was either radiation oncology or radiology that were the most forefront in terms of engineering and medicine. Some of the things that were coming out at the time of when I graduated med school was nodule detection for lungs, etc. So I knew radiology was a good field for innovation, a good field for technology. Went to Cook County Hospital, which is one of the most well-known trauma centers in the world. The show ER is based on it. So got a lot of good training in, hit the ground running, left there did a fellowship at University of Chicago, where I was, you know, afforded the time to sit in a couple of lectures of informatics, learn under one of the radiology gurus in Informatics Paul Chang who is so far beyond where I will ever be. But also got to see, you know, people like Samir Badlani and other super genius technologists within the medical field learning and doing their work to push forward technology. So I was afforded that opportunity during my fellowship as well as at night they allowed me to go to business school at the University of Chicago to forward my innovative spirit, my entrepreneurial spirit, where technology could play a role. And that's sort of my training background. So really haven't left the Illinois Chicago area. Very cool. And I do want to hear more about the clinical informatics. We're going to dive into that a little bit. But first just tell us about your current practice. Is it purely tele-radiology? Are you going into the hospital? Tell us about how you currently practice. So sure. So we are purely tele-radiology. My company, innovative radiology PC, we have now a total of 12 part time, some full-time radiologists and we never step foot outside of our house. The bandwidth for receiving images and fiber optics and the gigabits beads for receiving images is so unbelievably fast from where it used to be. And now we are afforded the ability to see images almost in real time and essentially put a report in and it goes back. Most of the reads I do are actually not even in the state that I'm living in. Most of my reads are thousands of miles away. And the reporting turnaround time is decreased so drastically because there's no middleman. There's no throughput. I don't have to drive anywhere. I don't have to set up a special packs anywhere. We're web-based as a pack. So purely tele-radiology, all of my rads are tele-radiology and we're practicing in 22 states. That's very cool. How many rads are in the practice? So we just signed on our 11th and 12th, but they're all part-time. Predominantly, I'm the only one that's reading more than full-time. Yeah. And that's another thing about tele-radiology, which is great is I don't have set hours. If I wake up early one day, it's work. If I go to bed late one day, it's work. If I take a day off, it's also work. So that's sort of the good and bad of it. Yeah, for sure. I'm so curious about how it works with scheduling everything. But first, let's take a step back. I want to talk a little bit about clinical informatics because I was telling you how I'm a bit oblivious. I co-trained with some people who I knew kind of waited and did a fellowship in clinical informatics and I don't know if I really got it at that time. This is back in 2012. What did you feel like was the need to pursue in clinical informatics as part of your radiology training? And then what advantage do you think it has given you in developing your current tele-radiology practice? So that's a great question. I did not do a full clinical informatics fellowship. So the people who've done it are so far beyond what I've ever done. But the reason that I felt I needed more training in it, more exposure to it, is that, you know, I would find at the county hospital, most predominantly, we would have patients coming in and they would walk in with stage four cancer. They would come from everywhere. You know, we serve the indigent to underserved. And a lot of the problems that I would notice is that we didn't know what their prior scans showed. We didn't know if this was disease progression or disease regression. We didn't know anything about these patients yet. When they would walk in, they'd say, I had a pet scanned on two weeks ago at another hospital. Can't you just tell me if I'm getting better or worse? And that very simple theory, and which still is a very big problem today, where image transmission, but more importantly, following a patient with their imaging, God forbid, they move across state lines. But even to a different hospital down the street, we couldn't get the images to follow unless you had the disk. And if you didn't have the disk, you're kind of S.O.L. Right? That stuck with me for four years in my residency. And I'm thinking to myself, there's got to be a better way, a cloud-based system. What is the technology behind radiology? Because I grew up, my mother is a radiologist and a fantastic one. She was my attending. And she lived through the time of Dictaphones. And then she literally morphed and transitioned into the dictophone on a computer and there wasn't any film anymore. It was literally a pack system. So I saw that growing up that this is what could happen. And she could look at images from home, should it be a stat scan. She didn't have to sleep in the hospital with a film. And I just thought, look man, we've made such strides in technology. In the time I've seen radiology from my mom practicing, why can't we do the same thing in the future? And in 2013, when I went to University of Chicago, it was still an issue to get images following patients. It was still an issue to have patients put their scans up in a cloud and have them follow them rather than holding a CD or a disc. And that simple sort of thesis stuck with me is why can't we innovate further upon radiology and do so many great things? Yeah, it's still an issue, right? I mean, I'm an intervention radiologist and getting patients to bring their disc so we can look and see if a lung nodule is safe and accessible. It's difficult to this day. And you know, you're right, why is there not a cloud-based system? It exists for everything else. It exists in a drop box. All my family photos, we can all share in a cloud-based system. Why can't we do that from hospital system? What I've heard is a lot of that has to do with the hospital systems themselves trying to hold on to patients and not making that information easily shareable. We can talk more about that another time, the informatics training. How did you feel like it was good? You just wanted that to help spur ideas to help innovate the space. You're asking phenomenal questions. The thing I felt is, and I've always felt this, if I don't have a basis or an understanding of something hard to build on it, right? So if I don't know algebra, I can't go to geometry. If I don't know geometry, I can't go to calculus. Same way, if I didn't know, HL7 was the language that radiology used or why is it that when I put in a report which looks phenomenal in my e-rad or in my pack system or whatever pack system you use, when it goes into the EMR, it looks like it's a word document which is very poorly written. Why are there errors in my dictation when I'm saying the thing correctly and it doesn't pick it up properly? So I wanted to know the background. How does the technology within radiology work so that I could make it better? Right? So I found out a lot in the informatics background. I realized, look, the language we use is so specific, not only to radiology, but it's specific to pathology, it's specific to EMRs and then within radiology, each vendor, whether it be Macchesson, GE, you know, e-rad, whatever you use, they have their own set of rules, they have their own set of formats. Now, it all runs on die-com imaging and I need to know what is die-com imaging even mean, right? So all that stuff led me to believe that it's not just an easy, oh, I have a disk, why don't we put it in a cloud and cloud goes everywhere? I had to realize that it's a bigger issue. And then from there, once I understood there's die-com images, how can we manipulate die-com images to help us with in the future artificial intelligence in the future, computerated detection in the future? So all those things, I was just getting a foundation. I knew that and I've always been this guy. I'm never the smartest in the room. I'm not. I'm just a dumber than everyone. So with my experience with all the things that I can do, whether it's getting more exposure to clinical informatics, whether it's getting a business degree in understanding accounting, understanding economics, it just gives me more experience where I can speak more clearly to things that I'm thinking of. So I have a broader base. I may be dumber, but I have a broader base and can understand how many things work together. While you may be a savant in radiology, I can tell you that if you're great and it takes you 45 minutes to read one cancer scan, it's not really good for the economics of radiology because you got to turn and burn. If you're really good at finding one thing in a brain and all you do is that one thing in a brain, you're leaving so much on the table with spine and with knees and stuff. So it's really good that I got the background to start and that's sort of why I wanted, I was really investing in myself. Tells about pursuing an MBA. To touch upon what you were just saying, it's like you wanted to learn the language of informatics and the data behind what we do, the imaging, right? So that you could innovate and that's great. That's very smart of you because it's like me going to France. I want a foundation of French so I can go get groceries, you know. And so I think that was very like forward thinking of you. And again, let's talk about the MBA. You probably had an idea that you wanted to start a business. So tell us about that decision. Absolutely. So I wanted to innovate, right? I wanted to be an entrepreneur. I wanted to do something with technology. Even to this day, I have a very minimal level of knowledge of business. There's so many aspects to business. It's not simply you go to business school and learn how to be a businessman. There's, you know, major focuses within business school, whether it's accounting, whether it's economics, whether it's sales, whatever, maybe management, operations, et cetera. And all these things, I had no clue what they were. So again, investing in myself and the good thing about University of Chicago is because I was one of their fellows, they paid for my business school, which was huge because they wanted to invest in me as well. And knowing a little bit of the technology, knowing radiology, having passed my boards and having at least a foundational knowledge in all the things that are done in business, I could make myself a well-rounded machine to innovate, to become an entrepreneur, to be a technologist because again, if I were purely a research monkey building a AI platform, I couldn't tell you the costs, I couldn't tell you the operations, I couldn't tell you the technology behind it in terms of how it's throughput for actual clinical workflow, et cetera. So this gave me sort of the jack of all trades, master of none type mentality, but also it opened my eyes to understand that radiology that I thought was a field that everyone's sort of we're working together. It's really not. It's a business. It's a very large business that's dominated by major sectors, major players within the field. And within that field, it's good to know how they operate, what they have, what their trade secrets are. And essentially this gave me the best leg forward to build my own company, to give myself a head start because I knew I wanted to do something along those lines, didn't know what I was going to do, but I knew that it was something bigger than just being a radiologist at a hospital. I know offense to those people, they're better than I am. They really are because I couldn't do it today. I really couldn't. They can go to a hospital, they can read very complex things and sit there for nine to 10 hours, discuss cases at a level that I could not do. I just can't. But you know, with my background now, I feel like I can do things that they can't do and that might innovate in a space where they don't want to play. So that's really the reason. Yeah, it's different levels of problem solving, right? You want to solve these more systemic problems and innovate on that. And I'm with you, man. I can't sit there for eight hours and read studies and go to tumor board. And that's why I chose I are because I could get up and do a procedure and kind of move around a little bit. So I feel you, but that being said, I still love radiology. I still love that I have those skills and that I can do that. I do have a question about the NBA, just like a personal question, because I've considered doing an NBA and we were talking to Eric Eskigl, who's not so long ago, and he's a CMO of the Novant healthcare done. And I think it's North Carolina. And he was saying that he pursued a general business NBA and not a healthcare NBA, because he wanted to learn, like you were saying, foundational business. And I kind of feel the same way. And I don't know if you have any like recommendations for to our audience, because I know there's a variety of different type of NBA programs out there. Do you know enough about them any advice you would give for anybody who's thinking about pursuing one? Who's a physician? So the first bit of advice I will always give everyone is if you have a dollar and I was told this by my attendings at U of C, they said, if you have a dollar, only put it on one thing. So what they meant is if you have a dollar, put it on radiology and just focus on that. And I will, to my death, disagree with that. If you have a dollar, you put it in your pocket and you invest in yourself, whatever that may be. So number one, if you're thinking about doing an NBA, because you think it's going to help you become a better person, meaning better in business, more rounded in terms of your operations, better in terms of what you can bring to this world. Do it. And 100% to it. NBAs aren't really about what you learn. I mean, for me, it was because I didn't know debit and credit on accounting. I barely even balanced a checkbook, right? A radiologist is saying that we use credit cards. We don't have Bitcoin. No. So I didn't even know credit debit. I didn't know, you know, economics, what is economics, micro versus macro? So for me, it was very foundational. I needed a wide breath in the NBA, not purely healthcare focus, because I didn't know what I was going to do. I will tell you if you're more seasoned in your career and you're doing something where you think the NBA specific to a healthcare would help you because it's a problem that's going to help you solve. Do it. Do it. You don't have time to learn about the operations of a Toyota plant in what do you care about cars and the on-dons and stuff. At this point, knowledge is the only thing we have that differentiates us that can make us better, right? So I would always say do an NBA if you think it's going to help you, even then the networking within an NBA can be phenomenally good. The relationships you can make, the ways that people think about problems actually are phenomenal. Amazon can be a method of thinking that if brought to a hospital system could probably revolutionize it tomorrow. Amazon has nothing to do with healthcare, but now Amazon is in healthcare, right? That's their biggest foray, Microsoft same thing. So for me, I would say yes, number one, do an NBA, whichever way you can. NBA, MPH, PhD, whatever you want to do. If you're going to ask me, should I ever do more to better myself 100 percent? Yeah. I'm fat. I should work out. Should I work out? Yes, Yes, of course I should. I just don't have like eating pizza, right? So if we're going to ask me what should I do? you should do an MBA because it's great knowledge, it's great networking, it's great opportunity. If you're asking me, what am I going to use the MBA for? I would have to know who you are, right? If you're the CMO of a large corporation that needs to tackle a problem within healthcare, a healthcare-focused MBA probably would be better. But again, innovative ways of thinking are not always only within your field. You can take how Toyota built a car and take it to a hospital, maybe you innovate there. It's really up to you how you learn, but I would always say you got that $1 put in your pocket invest in yourself. Yeah, I think that's solid advice. I was actually talking to a gambler or yesterday about formal versus informal learning and how some people can just read all the business books out there, right? You talk about Amazon. I have working backwards on my shelf. I have a cold start problem, never split the difference. I try to read these books, but I know myself at this point. I'm 44 years old. I need a structured curriculum to really get the foundation of business down. I will tell you this. The greatest amount of learning I've done is starting this corporation in 2017. I was already four years out of an MBA, five years out of residency, whatever. And the five years now, it's taken to run this company. I've learned far more in running a company in my own company because I've made mistakes and I'm learning from those mistakes. So I'm a very experiential guy. If I made a mistake, I won't make the mistake again. If I can see what's been working for me, I'll expose that and make it work across the board. So, you know, it's all about you. And I love that about radiology too because we have the option to see what we like and how we can do better at that or do what we want to do. But there is opportunity within radiology. For instance, for you, you're an IR, you're a badass. You're doing stuff that no one can do in this world. But yet, you're making yourself better with business with other things. So, that's the beauty of radiology. We have the opportunity to continue to keep on growing. Not to true and vascular surgery, wherever it may be. You're busy doing that. That's all you'll do, right? Well, thank you for the bad ass comment. We think of ourselves as glorified plumbers too, you know. I had to. My brother's an IR. So he'll kill me if I don't say something about him. He's great. Argin, you're the best. Is he older or younger brother? He's older. He's in Virginia. He works for a private practice company with a bunch of hospitals. He's an interventional radiologist. Oh, nice. Which group is he with? Tidewater. Okay. So I think they have a couple hospitals in the Virginia Beach area. Willie was a burgueri, I should say. Got it. Got it. I'm sure I know some people. I know him, you know, I know a bunch of the Alexandria group and then Sunny Baglan those guys. You needle Jackie's. You needle Jackie's stay close. That's right. One monkey's needle. That's right. Well, so let's talk about now the shiny. I want to hear about sob tech. Tell us about it. Sure. So I obviously started the company, innovative radiology tech, innovative radiology PC. And I was afforded the opportunity to have a little bit of capital to deploy. So creative this company, sob tech, where we invest in many different fields. So essentially it's a very small micro VC firm venture capital firm. And one of the greatest funds I participated in or investments I did in my past was a company called Multis Medical, which was essentially doing 3D animation for spinal MRI. And eventually it evolved into surgical animation. And this would be used within trials for demonstrative purposes. Not really a descriptive or diagnostic purposes, but more for demonstrative purposes. But it was a wonderful rendition with high definition of a 3D rendition of a spine. And you could see literally areas of the nucleus propulsive or areas of the disc herniating in certain areas and pinching on nerve roots to a level that was so granular that it would make lay people understand, you know, what type of disease you had in the spine, whether it be a disbalged disherniation. Right. So so using that they had technologists that were using a snipper tool that allowed them to do the 3D rendition. And happy accident many of our texts were saying, why don't we just make a program an AI platform that can do the 3D rendering and do the disc pathology rather than us actually cropping a disc on diecom. So they built a 3D tool and the 3D snipper tool slowly started in 2017. I joined the company 2019. So 2017 it started to grow 2018 was sort of okay by 2019 when I came it was essentially doing about 30% of the work on 3D renderings of a spine. So essentially it was taking the diecom images that we get the 90 images we see on axial and sagittal cuts and making a 3D rendition by itself. And we found out that hey, if it can just take the diecom images, maybe it can start showing us where the herniation is by itself. And we thought well that's the beginning of AI. If it can just start taking diecom images putting them in a 3D rendition and showing people like a layperson, hey, this looks abnormal to this side. And it's impinging this nerve root. Let's paint it a different color. And we started honing that. So from 2019 through 2021, we just kept on feeding it and feeding it and feeding it. And it's still very far. I don't even want to give you the theory that this thing is reading scans because it's not. But it's the beginning legwork of an AI platform that is going to read spines. And that I think, you know, using my VC firm, my background, my tech, my, you know, business acumen, the culmination of all of my experience in what can be done within medicine, right? What can be done within radiology? If we could get a robot in any form, to look at scans, whether it's a CT, whether it's an MRI, whether it's an X-ray, and say, I'm going to paint it in a certain way because it needs it in its mind's eye and allows people to say, wait a second, that looks abnormal. And then it has a database of all things that look like that that are abnormal. That's the beginning of an AI platform reading its own scale, right? I don't want to scare people because right now people are already throwing things at their iPhone because they're like, Vic, they're going to start terminator two judgment day. And it's not the case, right? We're not in trouble yet. We're 15 to 20 years away. And the reason I say that is there are companies out there doing AI. And whether you bury your head in the sand or not, AI is coming. And I want to tell you right now, it's among us already, right? The UFOs have landed. Computerated detection and mammography has been there for a while. When I started my residency in 2009, we had nodule detection for lung cancer, for lung screenings. So AI and computerated detection exists two days. So I was perfecting that technology also takes years, years and years and years. So if people see I saw AI doc is getting $400 million on a $4 billion valuation, you're right. You're right because they're the starting of AI coming into our field. And we're the one field that I think you can do that. It's pattern recognition on a computer. And maybe pathology as well, right? Oh, sure. Sure. And you know, whether you like it or not, you use intelligence currently in everyday scans. When you go to stat DX or radiopedia or any of those, or you look up a report on something or anything you see, you know, you're using intelligence. A computer will have that database built into it. So it is doing the same thing you are doing. Just it has the pattern recognition to say this is normal, this is abnormal. What does this abnormal look like? And then it'll give you the differential diagnosis. To hone that technology is still 10 years away. I'm 40 years old. I look like I'm 100, but I'm 40 years old. Right. So at 40 years old, I think in 10 years, we'll have the technology out to do pattern recognition. At 50. And then there's going to be a handoff because there's just no way it can do it on its own. So for another five to 10 years, there's going to be a slow perfection of the technology into a point where it doesn't need a radiologist in 20 years. So yes, by the time I'm 60, maybe 70, there will be computers. But for now, I don't think in the next 10 years, it's anywhere close to doing our job. So you mentioned some of the existing AI platforms out there. Let's distinguish for anybody who's not familiar with those. That versus what you're talking about. So rapid AI, a doc, vis.ai, those guys are out there to detect basically emerging things that can be treated immediately. Triage, yeah. Yeah. Triage. Yeah. Triage AI basically. Yes. Yes. Yes. Stroke, aortic dissections. You got even starting pneumothorax nodules in the lungs. Yeah. Cod for nodules. And so that's for triaging list, basically. So that it climbs the list, the attention of the radiologist still requires a read in everything, correct, official read, and somebody to overlook it. So that's where we are right now with current companies. And what you're talking about with Maltis is basically an AI platform that eventually, once you feed enough data that will basically be able to compute a report after reading a spine that lays out the pathology, just the same as you I do now. Correct. So if you're not a radiologist, I'm going to put it in terms of generalities like I do for everything. That's essentially AI that we have in medicine. Same thing. What I'm talking about is what Elon Musk is talking about in 20 years where we don't have drivers in our cars anymore because it's driving for us. Now granted, everyone's going to say the test will already does that. Sure. We don't have that in medicine. We don't have a machine that can say, I've got to read in. This is a nodule. in the lung, I'm going to give you the lung rads criteria and you're good. Don't even look at this camp. It doesn't exist, right? And just like driverless cars were 10 to 20 years away, I think, personally, I think at the same way AI is going to be evolving from, hey, this is triage to look at this head CT. It might be a bleed to I read the head CT. It's a bleed bunch to sign off to I read the head CT. It's a bleed. I guarantee it I already called the physician. That's a huge leap. It's a huge leap. And for me to even put those in succession is like years and years in between. So for every radiologist who's elder who's saying, my job is in threat. No, it's not. You're fine. Keep reading. We need your help. There's too many scans to read anyways. Yeah, it's more for like the med students who think you're gonna get hurt. That's right. So that's the issue I have because, you know, it's four years medical school. It's one year internship four years residency and one year fellowship that's 10 years. Then you do junior years of your attending ship or you're learning just as much as you did in your fellowship for five years. So 15 years until you can really start becoming a partner and making your money. If you told me 15 years from now, what we're going to be doing in radiology, I would never know because 10 years ago, we didn't even know the iPhone could be doing what it is today, right? 2020 February. If you told me 2020 March, the world's going to shut down because of a virus. I'd have been like, what the hell are you smoking? Give me some of that. So I couldn't tell you what's going to happen in 15 years. I will tell you that technology has to play a role. And the reason I tell you that is because we are scanning 20% more scans every year, year over year. People are getting older at a clip faster year over year than it's ever been before. So there are more scans and more patients that we need to see and fewer and fewer radiologists to do so. So technology's got to play really does. Otherwise, there's going to just be turnaround time lags. There's going to be quality issues. There's going to be outsourcing, whatever we have. Well, I think it was Susie Basha, but it, they eyes going to help us recapture some time, hopefully, right? By triaging, helping basically capture things that are more emergent, also helping us with those blind sides, right? Detecting the colon cancer or the lung cancer that we may have flown by. So it should help us in the near future with time with improving our workflow, making it more efficient. What are we going to do at that time? Are we going to just read more scans? You know what I mean? I guess. And we interject very quickly. That's what's happened. So reimbursements have gone down. So what have we done to combat reimbursements going down? We read more scans. When 100 scans a day was sort of impossible, it's the norm for locomotendants now, right? And what's happened is now images are transferred faster. We get 90 images total with five sequences for a spine. We read them in five minutes rather than it used to take 30 minutes when we'd have them on a film. So we've already seen technology decrease our time, increase our efficiency. But what is that done? We just read faster and more. And we make probably bigger mistakes. I don't know the true answer, but I don't see it where it's taking over our job. I think it's just going to make our job where we have a lot more volume. And then we have to just trust the computer to fill in those quality gaps that we have. Obviously there's a fear of being replaced and we kind of already addressed that. But what about just the fear of the cost of AI, right? You have AI companies out there. Obviously that software costs money that cuts into your bottom line. And then also if the government starts seeing you charging more codes, there might be reimbursement cuts. What do you think about the possibility of that? So I love that question because we can see it play out in the real world again and going back to that EV analogy. So we're oil, we're commodity, right? We are a finite amount on this world. Whether you like us or not, we are powering the world of radiology. It's radiologists. The technologists are great. The physicians are great. But it's really the radiologists that are doing radiology. We are oil. EV is a looming thing that's going to replace the combustion car. And AI is a looming threat that's going to really replace us, right? But again, these are so forward thinking 20, 25 years because number one, the technology has to be better to the point where it's at a quality level of a radiologist, the worst radiologist you can be currently per the core scores is at a 93% quality rate, meaning you're missing only 7% of things over a thousand images, it's a you're amazing. I mean, that's insane that you're seeing that. And that's a standard board certified radiologist to standard deviations above the failing. So we're bad ass whether we like it or not, we're all bad ass. So first of all, the technology of AI needs to be better. It needs to be better. It needs to be at our level to replace us. But to do that, like you said, costs millions and millions of dollars just like Tesla. There was a hundred thousand dollars to originally buy a Tesla. No one bought it. So expensive. You could have bought a Porsche. So not only does the technology need to become qualitatively better, but quantitatively it needs to become much cheaper because you're right. There's only a finite amount. They reimburse for an MRI. It could be like 300 dollars. And that's got to go to a technologist. It's got to go to the, you know, the payer. It's got to go everything. So I don't know where it's going to land in terms of the billing. And that's always a huge issue. Always is a huge issue. And if they're going to take from our bottom line, I highly believe that no radiologist is going to say, sure, take 50% out of my pocket. I'll make sure this thing is doing okay. Doesn't make sense. Right. So it needs to be so cheap and so amazingly good that it's almost stupid not to use it. And I bet it's going to be years and years away. Right. And naturally, just the iteration of technology, if it cost me a million dollars to use an iPhone, I wouldn't use it. It just I wouldn't. Right. There's plenty of things out there that are awesome. I don't fly private. It's just too expensive. But if it came, the cost came down. It was that easy and it helped everyone. Everyone would do it. So that's a great question because it's a whole axis that no one sees on the AI side. Everyone just thinks it's going to solve every problem. But if it's too expensive, why would you do it? And then same with the car analogy, who's accountable when it crashes into a crowd of people, right? So let's say, you know, a healthcare system is going to start replacing their radiologists with this algorithm. Then are they taking all the liability? The AI company taking the the liability? How do you feel about that? And what kind of conversations have you heard around that conversation? So far, we've talked about timeline. We've talked. It needs 10 years for technologically sound measurements and technologically sound innovation for AI to even become a discussion point. So first of all, we're 10 years out before we even have a modality driven AI machine. Right. We don't even have it. It doesn't exist. But after that 10 years, once it exists, what's the handoff? And that's the question you're asking. What is the litigious or legal aspects of AI? Do we need to babysit it? The music going to take me longer to read a scan now? Because I've got to read my own scan, then babysit this scan and make sure they're congruent. Do I use it? Is it built into my pack so that it's automatically brought up or report? And I have to refute or deny or or agree with? I mean, how is it going to be? So that process, the handoff quote unquote, is another five to 10 years. So we're looking at 20 years at the earliest where this thing can help us. In 20 years, first of all, we don't know if there's a scan built, not only an MRI or a CT, a new version of a scan with a new earth metal that allows us to read something so much quicker. Right. We don't know what's going to happen in the innovation of because for everything that we're doing with AI, they're also building faster MRIs, open MRIs with stronger magnets. They're building different core earth metals rather than gadolinium. They're testing other things. What do I know? I don't know anything. And I'm sure people are again throwing popcorn at the TV when they hear me speak. But the truth is, we don't even know. But if it can help in the short term, the way it's going to help is prioritizing us what to read, which it's done. That's a very important role for emergent radiology. Now, I'm very fortunate. Nothing I do is emergent. Everything I do is outpatient, non-emergent. I very rarely have stats. There are more and more outpatient imaging centers being built because it's just for ease of patients, for cost of patients. It's just the new way to do it. And that's an innovation that's also being done versus the hospital, the old paradigm of hospital. Now outpatient imaging centers, you can get an MRI of the knee in 30 minutes. You walk in and walk out. So I will tell you this, it seems scary that whatever I'm telling you, my job, if I were truck driver, I'd say the same thing, I'm not going to have a job in 20 years. But that's a big 20 years for a leap, huge 20 years. And I think that things need to be done at a drastic level for that to make it. Just like with electric vehicles, I think, you know, oils here to stay. We haven't harnessed the power of the sun. We haven't harnessed the power of the eye. So I think at some point, yes, sure, I might be very old and my son might be a radiologist saying, oh my god, I'm getting replaced. But for now at the short term, I think we're fine. I think it's going to be a boom for radiologists in the next 10 years. Well, you make a great point. What if there's a whole new imaging modality in five years, but you're starting at zero with data. So you got to feed the algorithm with data. And then it's like, well, we're not going to really use CT anymore because this new modality doesn't use radiation. We don't need to use radiation anymore. We can use MRI ultrasound in this new modality. And then it's like all that data from CT is out the door. Insane, right? So cancer testing. I remember the pet used to be a wizard of Oz type machine. Oh, if you have to get the pets, you know, days gone, you're in a dark room. Now pet CTs are like on every corner. They're like fused quickly. Everyone's doing them. I just imagine what we're going to see. We get a new tracer or we get a new iodine contrast that's even better that just lights up tumors because it's monoflonal antibody targeted or whatever it is. know, there's so much innovation going, which is why I love medicine, right? I'm a geek at heart. And the technology where we're doing each day, not only within radiology, but everything is so awesome. So again, I don't know, but I will tell you, if we are on this path, AI will play a role. So get used to it. Don't put your head in the sand. It's not going away. It's going to be here. But I don't know how it's going to play a role. And I don't know at what point is it germane to everyday living. I don't use it every day. I don't even use it once a quarter because you know, I'm only doing it to test my AI. I don't use it in my daily scans. I can't, right? It's not FDA-cleared. So for that, it would only be a hindrance to me reading. And right now, when I read a scan, I make money. Why would I waste my time doing anything else? Okay. So that's a great segue. I wanted to take a quick step back. So sob tech is actually your VC firm. Correct. One of the companies that you've funded is Multismetical. Correct. Any other companies currently that you guys are working with? We had a company that went under, it was essentially doing a vitamin distribution method. We had another company that was trying to get into the space for a drop of blood for genotypic cancer screening. We got crushed because there's huge companies that do that now. Exact sciences and the video, et cetera, funded to billions of dollars. But we were trying to get into that space. We had another corporation that was doing podcasts oddly enough for healthcare and for learning. And then we had an investment arm that was just looking at healthcare stocks and how we could have a unified consultation service for all healthcare stocks. So if doctors had questions regarding whether it be a psychiatry or tele-psychiatry, you could phone into the consulting arm. We could put you in touch with a tele-psychiatrist. I have a tele-psychiatry company that does this for behavioral issues after injuries. We do neuropsychiatric testing, tele-healthwise. We have a bunch of different companies. None of them as far along as Maltis. One of them the tele-psychology company for personal injury cases for neuropsychiatric testing is probably the most profitable because it's an unmet need, psychiatrist and psychologist or grossly in demand. And after injury, there's a lot of acrophobia. There's a lot of people that don't want to leave their house. They don't want to drive. So getting them the psychological testing for post-traumatic stress is very difficult. Either you have to go to their house or we did it and we innovated a way to do it through tele-psychology. That company is called co-gent health COG-ENT. We work, I think it's 33 states for personal injury cases. We do tele-psychology. So a lot of different things, nothing within my field of radiology besides Maltis. There's two things I want to talk about before we finish up at the hour. One is tell us a little bit more about building a tele-reology business from the ground up. You start with yourself clearly and then how difficult was it to get contracts? And then once you get contracts, you realize there's probably a point where you can't handle all the volume yourself and you got to start hiring. Can you tell us about that sort of origin and how it's grown? That's exactly what happened. That's a great way for me to sort of bring up another entrepreneurial way within radiology. A lot of tele-readiology in building contracts is sales. I learned that in business school. I was fortunate enough to be a radiologist for a tele-readiology company. Here in the Chicago Land Area, we were a hybrid sort of on-site off-site tele-readiology company. And I had seen that model and I said, "Why does it need to be on-site at all?" So I had made contacts just throughout the world and frankly speaking a lot of coal-calling, but then a lot of them were also, "I had something to offer saying that I'm building a tele-readiology company. My goal is to use AI, which was multis medical. I had a specialty within a certain field of radiology where I would just focus on outpatient spines or something like that. And I would go to these large imaging groups and I would sell myself. Why can I help you? Well, I'm cheaper, I'm faster. I have the ability to receive your images same day and I'll put a read in the same day because I have the technology to do so using my packs. I spent a lot of money on building the packs that was really good for throughput, really good cloud-based. I didn't need to be plugged into a system at a hospital. Lives in the cloud, we have dictaphones that work and then we have a full report that's generated. And one imaging center began two, two became three, three became nine, nine became, you know, 27 and a group. And then there was a point you're right. There's an inflection point where I couldn't read, not even close. And my turnaround time was horrible. I would promise within the day, it became 24 hours, it became 36 hours, hired someone, got it back down to 24 hours, hired another guy, got it back down the same day. And it slowly grew. And since 2017, really because of two things, my name has grown across 22 states. And that's number one quality. And number two turnaround time, which is sort of within quality. And then number three is accessibility. Man, as a tele-radiologist, the big thing people say that you can't do is you can't sit in the dark in the reading room and discuss a case with a referring provider or you can't tell a patient that what they have because if you're sitting at the hospital, you'll be able to say you have can't. I flipped it on here. Call me on my cell phone. I talk with referring providers all the time. I share screens. We have methods on my tele-radiology company that we're able to show people what they have based on significant images that are clipped onto our report. And the report has that picture directly with what I'm looking at. We have significant images that are saved. My cell phone is on a lot of the reports to get to the referring provider so they don't have a question. Hey, I had to go through an administrator. The administrator took three days to get to you. Bubble block. So I am as accessible as someone sitting next to them, which they love. My report quality is the paramount of what I believe we have to do. Right. We have to be perfect. 93% is great. 97% is better. And then not only that, if we're fast, they love it. They get the report the same day. And if they look at the report, I just saw that guy the same day. You know, I thought it was the right side that was hurting out the left in his spine. He's got the right side of ridiculous. Let me call this doc. They call me. I'm able to go through what I saw. It really is a labor of love that grew. And I do a lot of the reading. Right. So if someone doesn't read one of my nine or 12 radiologists, don't read. That's me picking it up. My life is tele-radiology. But then I know that in the background, if I can get some AI to help me to formulate reports, at least we have new methods for our packs where we get the history, the technique and comparisons already plugged in based on die-com headers. That's huge. So it takes 10 seconds. Right. And every second when you read report is worth money for me. So we get 10 seconds for that. We have macro templates that are guaranteed that show up right away when you pop up your report. Those reports are popped in. So you know what you're looking for. It's always the same candid report and can't reports. It doesn't look any different. You can stream through. You have selected significant images that E-rad allows you to do. So it's really easy, which we're going to try and work harder and harder to get it built so that a lot of the thought is taken out and really are allowed to just look at images and make your own decisions. So for instance, if the technologist can put in for an ultrasound, can put in the appropriate measurements in appropriate die-com fields, it'll auto-populate our report for a pelvic. It'll auto-populate the report for an arterial Doppler when we're looking at at vascular speeds, velocity. Right. So those things, those little things that take 30 seconds to a minute, when added up after 100 cases a day, you saved yourself two hours. That's huge. Huge. Because now you can read two more hours worth of work, right. I never let you off the hook. You got to read more to make that more money. Yeah. I mean, that's what I like and I've told you, Vick, that I still do tele-radiology stuff here in Dallas and the accessibility thing's huge. I won over so many referring docs just by giving them my cell phone and it's because they had never had radiologists do that before. They weren't used to it. It might have been because I'm used to that as an IR and I was just like, yeah, of course. Like why wouldn't we talk, right? That's exactly it. But some of the other tele-rads, they were not accessible and it led to referring docs writing my name on the order saying, please have Dr. Fritz read. And that's great. And that's how you build a business. It sounds like that's exactly what you did. You got to put your sales hat on and like you said, there's people that they don't want to do that. They want to show up in the hospital, read their list for eight hours and then go home and not worry about any of that stuff. And that's okay. But if you want to be your boss and have that autonomy, then that's what you got to do. You got to go out there and do those sorts of things. But the other funny thing is that one of the imaging centers I was reading for and I think you know I'm talking about they were still transcribing. So I would talk to the Dictaphone. They would transcribe and I have to sign up on reports and I was like, please guys, get power scribe. It's going to save so much time and energy and they still might be transcribing to this day. I mean, this was only like a year ago, a year and a half ago. And it's just goofy. It's because they had other rads who were old school who liked it being transcribed. They didn't want to use power scribe. And you talk about the time savings in your day when you don't have to go back and review their edits and make edits. I mean, it's ridiculous. It's absolutely ridiculous. I mean, I don't even think we'd I'd never even did that in training in the mid 2000s. We didn't have transcriptionists. So if you think about it, imagine an AI platform that builds a report, you still got to edit that report. You still got to edit what did it see versus what I see. So again, if you talk about the time waste, it's all built in there as well. They used to think that the Dictaphone and the transcription services would actually save time, right? Because now I don't have to type a whole report. Now someone else is going to type a formula. I can just say, you know, put in a right knee macro and that means there's a, you know, minuscule tear or something. The new wants of radiology has grown so much because you're right. There's still radiologists out there that use a tape, a Dictaphone tape and use a transcription service. When to me that's like archaic right you don't use even dragon which is like archaic you don't use new answer you don't use power scribe or whatever so I love it because honestly also tele radiology allows me I'm not a jail if I can't read for an hour because I want to go work out or walk my dog I can right and I don't have an emergency and that level of autonomy is so amazing I mean I couldn't tell you there's a game on in the background on a Sunday I can watch the game while reading obviously I'm paying attention I'm not you know not some of practice but I will tell you that it's just the beauty of being home in your own familiar surroundings you can pick up your kids hang out with them for a little bit it's just it's a different level of love that I have for radiology that it would have never had you'll find yourself being more productive that way people think oh there's distractions at home but it's actually no you can get more done because you can go in these sprints like I'm a big like okay I'm gonna read for 30 minutes and then take a 10 minute break and I can like you said I'll go do the dishes real quick it's a mental break and then I'm fresh to come back was if you're sitting there reading room for eight hours I'm done I'm toast after like for a drink yeah yeah right and then you have that whole I had to get into the work which is another 30 minutes I had to go back from work which is 30 minutes I had to decompress for another hour your day if you actually work in a hospital is like 10 hours really it is because you're in that reading room for eight nine hours and even then you're eating lunch at your desk 30 minutes to wind up to go to the hospital 30 minutes to wind down from the hospital I mean it's a long day just I couldn't do it I really do you guys are far better than I am really really are honestly I go into like and do procedures and that's hard enough yeah so I'm a radiologist I want to learn more about this space I want to learn more about AI what would you be your advice to somebody who's interested in getting involved where do they start and especially for the trainees who might be listening is this being integrated into training programs or do they need to take their own path and then learn about this stuff on their own so you know I don't know if it is being taught yet because it doesn't exist right so what are they teaching if just like I'm saying fear mongering or whatever it is I'm doing on this podcast but I will tell you that number one take initiative right learn the basis of the technology of the field you're in how is AI going to play a role within the technology that you have obviously the internet is now so much more available and accessible than when we were training in med school right now I can learn things on YouTube that could never learn in books and books in books so number one if you have any wish to learn about the future just literally pick up the internet and just turn on anything there's a bunch of AI number two there's companies doing this right so AI doc you product biz tech riverine all of them are doing it so you can look at what they're doing and I'm sure there's tons and tons of white papers out I'm sure there's tons of lectures by people much smarter than I am who are far far more knowledgeable in what the future will hold listen to those lectures because they exist and then three is if it's not being taught in your curriculum ask for it to be taught in your curriculum because it's something that's coming down and there's someone within your curriculum that knows something about it whether it's a Pax Administrator whether it's the technologists themselves that are seeing it at other hospitals or whether if it's you some of the radiologists you work with that are either using it here or at another institution just ask as many questions there's courses about this stuff to I'm sure in all of the new informatics courses which is now I believe it's its own fellowship if you're that much interested in it you can get a fellowship in informatics do that if you have an interest in it and then obviously whatever you know you choose to do do it to the most rigorous degree but also remember to diversify yourself learn everything you can whenever you can that's all great advice I appreciate that Eric has Google mentioned there's a new board created by Anthony Chang it's called the American Board of Artificial Intelligence in Madison yeah that's pretty cool you know that's smart yeah yeah yeah just so brilliant I mean because honestly you know AI is being used not only in radiology it's got facets if you use epic which is a humongous EMR if you try and type in give this guy penicillin he's got a penicillin allergy it's like no you can't that clinical decision support is a form of AI it's the future of itself writing its own prescriptions so yeah it's just so cool just the features in everything we do is super cool well Vic thank you so much for coming on the show I really appreciate your your insight into this field and it's fun to geek out as a fellow radiologist I look forward to talking to you offline more about your tele-reology business as well of course who's a pleasure thanks Eric major the best now thanks buddy thank you so much for listening if you haven't already make sure to subscribe rate the podcast five stars and share with a friend if you have any questions or comments DM us at backtable innovation on instagram linkedin or twitter backtable innovation is produced and hosted by Brian Hartley Aaron Fritz and Eric Gamacher our audio team lead is Karen Yannin with support from Caleb Hodson Josh McWirter and Ness Smith Savidoff design and digital marketing led by Brian Schmitz with support from and Deng social media and PR by Chi Deng and Dana Parker thanks again for listening see you again next week