Improving Surgical Quality Through Transparency, Data and Video Integration with Dr. Peter Nau, University of Iowa

I think, honestly, probably, private practice is better than academics because they are much more of a business than academics typically is just because of the size of the institution, but we don't really know what anything we do costs. You don't know what it gets paid because my salary isn't really linked to that as much. You're listening to data nerds in the OR, a surgeon's journey toward value-based care. The podcast focused on data and data science as the keys to a better healthcare system. Ideas brought to life by the vision and experience of host Dr. Bruce Ramsha. Each week Dr. Ramsha sits down with different players in the healthcare system to discuss how data is used today and what it could do if it were used effectively. How it could improve surgical quality, education, outcomes, and drive better patient care. Let's dive into the latest episode. Here's your host Dr. Bruce Ramsha. Thanks very much. Today I'm joined by Dr. Peter now, Pete's at the University of Iowa, and I've had the pleasure of working with Pete on a variety of projects over the past couple of years, and so what I like to do is ask Pete to introduce himself, tell us what you would like us to know about you, and then begin to talk a little about your experience as a busy clinician and also an academic educator about what you have experienced with healthcare data and opportunities to have a better data science driven world in healthcare. Maybe if you can start with the introduction and talking about your experience with data in healthcare, so far. Sure. Thanks for having me. Like Bruce said, I'm at the University of Iowa. I have about a three-part practice, really. I do about a third bariatrics, a third of Down in the Wall, and a third of Beninus ophagus. We do have a fellowship here, which is where I do most of my teaching as an academic person. We do have residence, obviously, but the majority of our longitudinal teaching is with the fellows we had each year for our MIS biiatric program. For me, as far as my experience with data, we do get data from the MBSA QIP data harvest, but it's really not helpful data in the sense that when you look at the MBSA QIP reports, it's as expected for outliers, and it's very not transparent, and it's hard to know where their quartiles fall. It's hard to know what to use with that data, and when we start trying to respond to the data, it's also hard because if you just have two or three events, it might take you from as expected to an outlier, but you really don't have any weight from what they're collecting to do any sort of deep dive into what happened, or how to change it, and so then if you have outliers, which is thankfully uncommon, you have to create a QIP or a poly improvement project, but really without any data to sort of make a transparent, "Hey, this is what's going on, we need to fix it," and so it was always frustrating before I started working with care simtats because the only data that we had wasn't super helpful, and then when we were trying to respond to it, it was difficult to really know what we were responding to. Is that mainly through the hospitals, the hospitals provide you with that data? If you're an MBSA QIP center, you have to have a data extractor, and so that person pulls all the cases done by the very atrix surgeons as well, if someone comes in with emergency general surgery with a perperated septic abdomen, and they do an x-lap and take apart their GJ, and then we help them put that back together, and they put it back together, that all falls under the same umbrella, and so that very atrix person will capture any very atrix case, and then very at your data extractor will capture any very atrix case done at the emergency vial, and that's part of the MBSA QIP registry process, very similar to NISCLIP, just for very atrix cases only. So you're limited to very atrix, do you get any other kind of data from your other cases, like Hernia? No, but the best thing that we tried to do with me, probably seven or eight years ago, myself and I a couple of my partners decided to really try to streamline our Hernia, not our abdominal wall practice, because we had so much variability of both the outcomes and the approaches, and I was still quite a few people doing I-poms, and really what defects are the same Hernia repair for the same for different Hernia regardless of what was appropriate. So we tried to stream line it and create some data driven practices, A-1-C, 20 defects, obesity, smoking status, things like that, to try to get better outcomes, but it wasn't as much data driven as it was, perceived inconsistencies in the institution with people, and how they practiced that, how they practiced abdominal reconstructions. Yeah, it's disappointing. I had the same issue in my practice, there just wasn't really any good data infrastructure so that I could monitor my outcomes, and then the other piece is data entry, maybe talk a little bit about a lot of the people listening probably are clinicians, but maybe not, so maybe talk a little bit about your experience in data entry into the electronic Mac record, what's that like? So as far as extracting it for research, or just in general? No, just having to enter it into the electronic medical record. And I think a lot of it's just driven by Billy, right? Any more, it's not, you know, it's the data that you collect is only, it's not good data. For instance, I just realized this, but if you do a recurrent paratissophageal Hernia repair, this is the same CPC code as a primary repair, and when you're talking about risk for recurrence, certainly if you're doing a recurrent repair, it's more likely. There's nothing in an electronic Mac record about the number of stitches that you put into the cura, how big the Hernia is, it's all subjective, and so when you look at a forgot operation, I think one of the reasons why we don't really know what the recurrence risk is, or haven't defined how we fix it is, everybody's measuring it differently, they're using sutures differently, they're using mesh differently, they're fixing mesh, they've done law differently. What's a big Hernia meme? It'd be a huge one or a small one, if someone else, and how we highly get into the meaniest items. You know, there's really no good way to document that stuff, except individually, so you can go back in. For instance, more recently in the past year, I've started documenting how many stitches I put in the cura and repair it, because I think that if I go back and there's eight stitches placed in the cura, that was clearly under more tension, than if I put two, and I think that hopefully will help me in five or six years when I go back in, and this person's come back and not come back. Similar with the abdominal wall, we've more recently had the data that we put in, really, it's just again based on billing, based on the size, and it doesn't have anything to do with the complexity of how we do it. It could be a very straightforward, Swiss cheese, hernia, that's 12 centimeters tall, and two centimeters wide, but it's all documented, it's greater than 10 centimeters versus one that's nine by nine centimeters, that you're doing a really difficult complex with a posterior sheet, doesn't reach in and you're doing towers, is brilliant, posterior sheet. That one will actually show up the less complex, and so the data going into the electric medical record is really for billers, and it doesn't really help people that are trying to figure out their quality, or why they lack quality, or why their quality is better, or why they're struggling on a certain basis. And ideas to get better, you know, if we can't see our data, we can't learn from it. And I imagine the residents are the ones that enter data into the EMR for you, is that true or so? So I do all my own net operaports, super anoretino, which I've come to dress up, but I think also, when I first started, and I wasn't as busy, I came to realize that my billing wasn't good, and so I had to meet with our billers a lot, because I would do a case and they wouldn't bill it accurately. And I wasn't getting credit for the work that I was doing, or we had to think around outside the boxes, I'd do a laparoscopic gist and get an unlisted stomach procedure for ARU, which is wildly insufficient. I had to start working with them to figure it to make sure they were doing the right stuff, and that's when I realized that I had to put, you know, if I need to do an abdominal reconstruction, I list, like the borders of my dissection, the height of my dissection, the size of the mesh, where we put the mesh, I put all that in there, because it's the only way for me to know that I was getting billed correctly. That's why the data goes in the way it goes in, is that again, it comes down to making sure that I get paid with ARUs, I'm supposed to, because that's what my salary is based on. What about your H&D data, and other clinical data? Who enters that? I have residence occasionally at clinic, it's very hit in this. For very actresses, it's very, again, it's to meet their qualifications, so we put in the stuff that we need to put in so that the patients get to our surgeries approved. You know, for me, for my hernias and forgets stuff, that I have templates that I've developed that I hope that I can get them, the residents to use, because it's streamlined stuff for them, but also it gets the information we need in there. But again, when you look at forgot stuff, when I say a massive of a parasavagel hernia, that's like the spleen is the only thing left in the abdomen, and I have transors calling a small vowel, but if you look at a radiologist, they'll say giant hyalhernia, or large parasavagel hernia, and it's only be a moderate or a small moderate for me, and so it's always, are we comparing apples to apples, or are we using the same perturbations, not often not? Yeah, there's so many. You described it well, the limitations of the current data repositories that EMR systems and how they're more geared towards documentation for coding and billing rather than actual high quality data, so we can use it for learning and approving. I think that's one of the biggest flaws in our system as a designer. There was actually a publication out of University of Pennsylvania, I think a year or two ago, and they studied many years worth of all of the documentation and all of the clinic notes, hospital notes, and they found that over 50% were just copied and pasted. I'm sure you're not surprised, right? In fact, I do residents in the medical students, I asked them to just, because if you look at our notes, it'll say, "Very atric surgery," or the most common thing is they've had a gashon bypass, and they've had a sleeve, or they've actually had a VVG. And so if you look at notes that are written by me, I don't use any of them. I'll verify it in the electronic medical record, but then I erase everything that's self-populated, so I know when I go back that it's actually real, because so often, I mean, I don't care about ortho procedures, that's not a great specialty. It doesn't influence my practice, and so I'll just put ortho procedures, but for abdominal wall stuff, I want it in there, and I want it correct. If it's very atric, it can't just say very atric surgery, or abdominal surgery, it's got to have some sort of relevance, and so I actually don't use the electronic medical record to document for them, because it's so often incorrect, and I just don't. And you put that extra work in, because you care about the quality of the data that you're adding, but you're an outlier, right? When you don't have abdominal wall stuff, or, you know, if you're trying to go back into someone's abdomen for the, however many times, even if you're not doing an abdominal wall case, and you don't, it says, "Abdom and Surgery," and you get in there, and it's, there's a squirrel running around in the air versus there's nothing that's happened before I mean it. You have to know how to educate patients on what to expect, post-op, and what the risks are, and if you don't go through that information, get a clear idea of what's actually happened, you can't tell them how much it's going to be dangerous, or it should be straightforward. Yeah, that's one reason why we work together. It's a pleasure working with you, because you're passionate about your data, and that's so important to get good quality data. We'll talk about that some more. I want to do a little pivot right now, because there's another type of data we haven't talked about yet, which is video data. I think the University of Iowa has had our six advanced platform with video data for a few years now, and so I want you to talk about some of the uses you found with video data and some of the value of using video data for a variety of applications. The biggest thing that we've used it for is our fellow. I really like teaching residents. The whole of my practice here is a couple of parts with them. One is, my forget practice is pretty, we just don't see a whole lot of small learnings, a lot of them are pretty veges, because the smaller ones get sucked up by the private hospitals surrounding, and so a lot of times when we're dissecting seven, eight, nine, ten centimeters into the media styling with a third year or fourth year, it's just beyond our expertise, and so they don't get to do it as much, and so I can teach them with a video, but getting them to actually do the operations is a little bit frustrating, because they're on our service for a month, then they rotate off. They may send one operation. It's a pretty difficult operation for them to deal with. They say, "Oh, I've seen one. Now I can go out and operate in between the heart and the arteries." A little bit outside of scope of their abilities, whereas with fellows, we have this longitudinal experience where we're with them all year, and that for me is really rewarding and fun, because you get to see them, so you know where you can trust them, you can know what their limitations are, whether they appreciate their limitations, and know what to expect from them, which is really important when you're trying to keep that thing from happening, but also learn how to teach them. Some people need to be to gas, some people need to be to brakes, but with the video, it's been great, because every year the fellows come in, and they have a doctor layman bypass, and a doctor Smith bypass, and a doctor now bypass if they can watch, and they have examples of those on a hard drive, so they can say, "This is what I need to do when we do this case," and then early on, though they can watch that a lot, and get comfortable with it, and then later on, when they start doing more and more, every Friday that we have bypasses on Wednesday, we'll go Friday, we'll watch the cases, and we can sit down, because in the operating room, we have to be efficient, right? We have people that aren't necessarily healthy, it's on the operating table, but also, we need to get our cases done, so the nurses don't stay late, so I don't get less time to do the cases I need to do, and lose access to the OR, and so by saying, "Okay, we're going to give you a chance to fix it or to do it," and then I'll say, "We'll go over it afterwards," then we can on Friday, we can sit down, and just with any computer, pull up the website, pull up the video, and stream it, and show, "This is what I meant," and you got to hit the stapler. For instance, last week, the fellow was struggling to get the stapler in free to create the common gas runner off to me, and he got it, but then on Friday, and you can sit down, and I can say, "See, this is what I'm saying," and I think that the light bulb turns on a lot faster, because it's not just me telling them during the case when it's high stress, and I'm trying to get it done, they don't want me to take that part away from them, and they want to finish the case themselves, but then they can do it, and then Friday, we can sit back, and I think that they realize a whole lot quicker when it's de-stressed, or when we de-escalated the stress, how much faster they'd take it up, because they can watch it, and learn from what they just did a couple days ago. And you hear this all the time, but other industries, including sports, used to do it all the time. I remember, and I played high school football in the 1970s, and we watched video of our games and reviewed Kate. This is not new, but it's just not common in health care, unfortunately. I think we've had to get past, I think one of the nice things about care syntax that makes people comfortable when you talk about it is this idea of the patient safety organization, right? Because I think for a long time, I didn't record stuff because I was a little bit nervous about recording it. Where do you keep it? What do you do in it? Are you putting yourself at risk? There's a lot of people that don't want to record stuff, because they're afraid if they record it, and then there's a complication, then all of a sudden it's discoverable. And so I think having to be a PSO where the patients know it's there, where it's under the auspices of a safety, gathering, improving quality situation, it makes it a whole lot easier just to record everything versus, or to record this hard case, and then if there's a complication, then there's this recording that's out there, and I know that there are a lot of people being done shy about recording, which is an unfortunate reality in medicine, in my opinion, normal, but I think that's something that this platform gets around in a good way. Yeah, and it's very positive. There's a lot of science behind safety and system science, and it really is important what exactly you said, not to use data for blame and shame and punitive purposes. Vast majority of people in healthcare are trying to help patients and have good intentions. But we're all human, so we make errors. It's important to have a safe environment where we can learn from any kind of errors, most of which are not intentional by far, but they happen. We have complex patients like you described. My hernia practice has had a lot of complex predispressions, and you know, you knew there were going to be some complications because somebody who's had 10 prior abdominal wall, hernia repairs, and they're loss of domain with intestines down to their knee, that's not a simple operation. Yeah, you need a safe environment. That's really important that we get comfortable with transparency of data and the fact that we don't use data to blame shame and punish people. We use it for learning and improving in the right ethical supported by science, a kind of environment. Let's pivot a little bit again because there's another group set of data that we haven't talked about yet. And I think we can bring all this together to bring video data with clinical data, but how about financial data? I know in the last few months we've worked together on some financial data to put it with clinical data. We talk about value-based care recently all the time in health. People all the time talking about value-based care. And yet I haven't I've very rarely seen anybody put financial data without comes data to truly measure value. And we've begun to do that. What is your view on that? You know, what kinds of benefits do you see with that? So our hospital and I think a lot of hospitals think this way is their idea of improving what we take in is just to run the system leaner. To do more with less. And I think the reality is is that you can only run the system so lean. And then you start decreasing quality. If it's not quality, then you just have nurses that are overworked or surgeons that are overworked. And then you lose good people because you're making them do more. And so I think that's the first thing that we have to get past is stop saying, oh, we're just going to do more with less. So we're just going to put more cases in the OR because at some point the system can't really run more efficiently. And you're actually on the wrong side of the slope. And you're either losing people, losing surgeons, or having quality go bad. And so I think that's part of it. I think the other thing is, you know, I think honestly probably private practice is better than academics because they are much more of a business than academics. Typically it's just because of the size of the institution. But we don't really know what anything you do costs. Sort of a little bit, but not in any transparent way. So I don't know what the hospital, I still don't know what the hospital gets for a parisology, a hundred repair for a bypass. I know what my dollar's priority use and the data that I get. But I don't know how real that really is because collections is way different than billing. And I don't, you know, and if you start doing the robot, are you including how much the robot costs or the person that our robot coordinator with a one-off FTE equivalent and all the benefits and the contract that keeps it going every year, like, you know, if we're using the mesh or using the mesh that someone who's on contract or using them, it's not on contract and what's the difference in price. We don't have any idea what that is. And the only thing I ever ran into really was when I started trying to do links because I could never get links fixed. And so the only way for me to really do links here would be to do a parisology or a hernia repair and then write off the cost of the links. But I think at that point, the margins in the negatives. And so I never did it because I think the positive take home might be $6,000 or $7,000 in the links is seven or eight grand. And so that's the tip of the iceberg when you talk about how we approach stuff. And so if we want to start making more money or running a more profitable business or reimbursing our, or paying our surgeons or our nurses or wherever better, we can't just do more. We have to do more in a way that's thoughtful and maybe it means that we have to get rid of mesh or we have to study it so we know that mesh is worth it. We shouldn't be doing robots for gallblets because they lose too much money or we should never open a ligature for a gallbladder without some super-extenduating circumstance because the marginal for a gallbladder is too small to use certain stuff. And I think that no one knows that because we don't have that data and it's not given to the surgeons and you know all they tell us is they can't pay us more, they can't get us more nurses and no one knows why. And I think that there's that disconnect between the administration with AC and what we, we see and this is probably way to bridge that a little bit. And that's what we're hoping, right? We're hoping to use the principles of systems and data science to show how to put data together around the patient process and financial data with outcomes data. So we're truly able to measure the improved value and the work that you're doing with us on that is just terrific. I think it's going to be as far as I know it's the first time we're going to have surgeon financial data with RVUs, hospital financial data and patient outcomes all together in one data set. And you know it's sad but true that I've never seen that in healthcare before. It's something that I think is going to be more and more looked at as, hey, this is a real solution and this is something that we should all be doing. Along those lines, talk about your, in that context too, talk about what your view is on this effort to transform from a fee for service system because you mentioned it. You know whether it's talking about cost cutting or volume driven, those are not sustainable. You can gain some improvement up to a certain point but you can't make a surgeon do more cases. There's only 24 hours in a day. There's always so much operating room capacity and then cost cutting. You can only cost cut so much then you start running into quality issues. Really, we need to shift the value from fee for service. But what's your view on that and our ability to do that as we learn the data science principles more and more? I just don't think the surgeons know what's going on and that's mean too. So I used to use a certain kind of mesh for my laparoscopic retro register pairs and then I actually had to pull the data and it was a difference if I used a different mesh as a difference of a thousand dollars. And I don't know if we know what that's actually influencing the outcomes. Maybe that mesh was worth it because they're less likely to come back or maybe it's not. So I think that until we can get some transparent data on what the cost is and how that influences the quality. And we can do some of that retrospective. We might have to do some of that prospectively. We say okay we have this mesh we're going to bring it in. We're going to see what the recurrences for a hydrohernia are at one year. And if their recurrences are better, maybe it makes sense. But if it doesn't, maybe we're just costing the hospital $2,000. And at some point, hopefully my hope would be that if we can find a way to engage surgeons and say this is helpful, you get to use this because this does make sense. But this is less helpful. Let's find a way that we can do something that's more financially beneficial that there can be some sort of cost sharing because I think the hospital usually tries to carry a stick a lot. And the stick only works for so long before people lose interest or they leave. And because if they keep getting told you can't do this or you're not doing this right, it wears on you versus saying hey we're going to dangle a carrot and say this is what your data shows. If you're willing to make these changes, maybe we can figure out a cost some sort of profit sharing so that you see some benefits to making these changes versus us just same do this do that. And so I think but until we get data, we just don't know. And until we get data that's meaningful for the surgeon and not just meaningful for the builders, it's hard to take any information as anything other than just the administration carrying a big stick and wielding it, you know, to what fits their priorities rather than what might help the surgeon for the patient. Yeah, and I think that's the situation a lot of surgeons are in around the country, maybe around the world. But if we can all work together around value-based outcomes and give the clinicians, because it really is you and your team who has the ability to make decisions, but you have to have good data, you have to have good analysis of data so you can take those insights and apply. And we're not doing that today in healthcare, but we're planning to do that now and into the future. I'm a little curious again, a little bit of a pivot as a bariatric surgeon. You're probably well aware of the recent GLP ones and the medications. And right now it's they're all over TV ads, right? So it's all cell, cell, cell, no discrimination. Who would it be best value in what patient in some population? I think data science can help identify the appropriate use of medications versus the appropriate use of bariatric surgery, which I think both will probably play a role. But I've heard even recently that some payers are starting to guide patients back to bariatric surgery because of the cost of these new medications. I was wondering what your thoughts are on that and the data science that could apply to that issue. I think it's a little bit dangerous how it's rolling out so quickly. Fortunately, or unfortunately, depending on how you look at Iowa, doesn't have a lot of people that have the liquidity of their finances to be able to support the cash pay that comes with it. We don't have, I know there were some states like North Carolina that they used to cover it, that have since stopped covering it, but we've never really covered it here for a weight loss medication. And a lot of people that are getting it, they're paying cash from a compounding pharmacy and it may be only $500 a month rather than a thousand or something you get when you got a brand name. But we don't, we see it, but it's not maybe as prevalent. My concern with those, and I think this is what we have to watch, is there tends to be really bad circopenia or loss of muscle that comes with that. And so then when people come off those meds, they typically gain their weight back, but then they've lost a lot of their muscles that their metabolic rate falls like crazy, so their ability to lose weight after that is actually worse because they don't have the muscle that they need to learn the calories and the metabolism's all screwed up. And so I think that there's, it definitely needs to be a tool in the armamentarium of an obesity medicine surgeon to be some surgeon practice, but I'm not sure where it's going to fall because I don't think we know what the long-term effects are going to be for people that are taking it outside of diabetes. We've certainly spent around with diabetes for a long time, but we are seeing rapid muscle wasting in people to do they really want to stand for forever because when they come off, they typically gain their weight back and then there's the non-responders and a lot of the data on the medicines, typically in people that have lower BMI's. And the ones with a higher BMI's, it's not, they don't have a great data. And so I think that it's something we need to be pre, I think this is a pain to ours boxing. It's not going back in, but I think we need to be thoughtful about how we study it so we can find the way of population that helps because you know, the nice thing about a bariatric program is we see our patients at one week, one month, three months, six months, 12 months in an annual and we'll see them for whenever they want. And so they get a dietician whenever they want to get a dietician. We get to CS. And so there is a little bit of, they have some kind of skin in the games or at word, but there's some accountability. There's a lot of support and there's hopefully a lot of education. So it's not just go out and lose weight, but don't know why and don't know how to use it when you lose the weight, how to keep it off. And I think that in some ways we have to be careful how we roll out these meds because if they're not getting any education dieticians or any sort of learn taught anything about how to keep weight off and what weight is and what a coward even a coward and protein a father is. And I think there's a lot of people that aren't going to do well or when they come off and that don't even be in the worst situation that we're before. Yeah, and I think that's some of the concern with everything in healthcare that we do, whether it's a drug or a surgical technique or a diagnostics tool for that matter in a subpopulation may benefit them. Hopefully there is a subpopulation benefits, but there's no subpopulation may harm them. And then another subpopulation may be wasteful. It didn't help or harm them, but it costs money and time. And the data science tools we can begin to understand those subpopulations when we have a data analytics infrastructure to give us those insights. You mentioned sarcopenia and I know we've worked together a little bit. You have a team of data scientists there at Iowa who's looking at sarcopenia as a data point or set of data points to predict patients who may be not optimally prepared for surgery, especially major surgery. Maybe talk about that a little bit. So we always have that eyeball test, right? Everybody you can walk in the room in that nine-year-old lady like man, she's 70. In her actual age versus her chronologic age, and then there's the other person that you walk in, you think man, they're 70 going on 100, and I don't want to operate on them, but we don't have any way to objectify that or turn that into an objective measurement. For a long time, we did some, we started that when I first got here doing some research just with the single slice of the psilos muscle, which really isn't a muscle that you should be able to exercise. Looking at the density and volume, but it was a single slice, it was at a single level and relied on the false assumption that the psilos muscle is uniform and it's shape. And so we developed this program that can measure the volume and density of the entire psilos muscle, hopefully trying to prove that to take that eyeball test of this person, there's sarcopenic obesity where we know people that have a sarcopenia lower muscle quantity and quality, despite them having obesity as a comorbidity. We know that sarcopenia influences outcomes in multiple surgical and medical populations, but we don't have a great way of measuring it because some of these false assumptions on how we decide to choose to measure it and where, and so hopefully we can take something like that says, "Hey, this is an objective measure of a muscle that should be indicative of their entire body fitness instead of the trials and comorbidity index," sort of a nisquip calculator, which is really onerous and also just lots of ones and zeros. And so if you take Pete now, who sees his doctor regularly, he may have high cholesterol, high blood pressure, but they're both very well controlled, but they're both, you know, positive on some of these scales, it makes me look less healthy and it may not be an accurate indication of how healthy I am versus or not healthy versus something that's more of an objective muscle measurement. And so that's the goal we still have to prove it in bigger populations and try to get lots of data because I think the tough thing is if we take 800 people for a study and there's only 20 complications, it takes more than 800 people to get really good meaningful data on whether the changes are out from the link to stay or the costs or things like that. But like you said, it gives us an objective way to say, "Hey, this person may not be optimally prepared for surgery, but then we need to move to a value model because we don't get paid to spend all that time and effort to help somebody in prehabilitation, counsel them about nutrition, exercise, even neuro-cognitive improvement." But yeah, I think it's where we're moving with data is being able to, you know, be proactive and help people have better outcomes through those kinds of data identifications. A couple of other things I wanted to ask you personally, just things I saw on the website in just general, I saw that your father was in pediatrics and that was some sort of influence in your career. But then you chose surgery, so I just curious maybe a little bit about the influence your dad had on you in terms of choosing medicine, and then why did you go into surgery instead of pediatrics? So I always wanted to be a doctor. Like I had no backup plan, and I just always thought through what my dad did was pretty cool. He used to take me to the NICU when I was 10 and walked me to the NICU, and I thought that was really neat. When I was 16, I had WPW syndrome, which is like a heart rate anomaly from a reentry circuit, and I actually did pediatric cardiology research for almost two years, and so I went into medical school absolutely certain I was going to be a pediatric cardiologist because I did research in it, and I had a pediatric cardiovascular condition. I was happy just gone. I got an ablation, but and then I went to my first rotation as a surgeon, and Dr. Havala, if he was cold as ice, we had a two perforated or two ruptured aortic aneurysms, came in at the exact same time. Oh my god. So the resident team was split very thin, so I was right up close, and I remember we opened up the abdomen. This is like 30 or med school, second day on surgery. I watched them open the abdomen, and then, you know, of course, it was like this big rush, and Dr. Havala took the interns hands and told her to put pressure on the aorta, and then he calmly dissected to plant the aorta with his hands just below the diaphragm, and it was crossing the street, and he said, "I have control of the aorta." Just like you just said, the sun's going to come out tomorrow. You know, I'm like, my eyes are huge. That was it. That was it. That was it. All it took, and so that was how it started. And then how all surgeons do it, right? I just got to Ohio State, and I really liked the guys that do the stuff that I went into, and I looked up to them, and I hung out around them, and I'm not sure if I was with them when I was at them, but I hung on around them, and soaked it up, and did research with them, and how I went into it. I went in. That's awesome. That's a great story. I think a lot of us went through that a hall moment where seeing somebody suffering or potentially dying, I can't imagine two ruptured aorta, ganyers, and coming at the same time. You went home, you walked out of the hospital, I don't know. Yeah. Most of us who go into surgery, it's not because we want like to use our hands, it's because we like to see somebody who's suffering or dying, and we actively do something, and it relieves their suffering. It's just, it's a privilege to be able to do things like that. Thank you. The last thing, just curious, if you've read any books or seen any movies lately that you think are worthwhile for somebody who's really interested in healthcare, surgery, or data science. I like to read that most in time of these days, with three kids and crazy sports I read and then I fall asleep. I do listen to a lot of books, but I haven't started listening to those kind of books because usually it's when I listen to them when I'm not riding my bike. I haven't done a whole lot of good reading that's anything healthcare-related. Mostly because it's just I'm so tired at the end of the day after being an Uber driver, after work. So we have sports Tuesday, Wednesday, Thursday, Saturday, Sunday, and so. Any good non-medical books that you've enjoyed lately? Man, I'd have to go back. Like I said, I'm a big Stephen King nerd. I really love his books. Whatever I listen to recently. Oh gosh, I wish I would have looked. I'd have to go back three. There's a book that I listened to recently that Tom Hanks listened to that he narrated. I'm a big John Sanford fan, so. Those are some good options. We'll put a list with this podcast when I publish it. I always go to Moneyball either the book or the movie. Have you seen the movie? I haven't read it, but I've seen the movie. It's a great movie. Yeah, I always defaulted. I hadn't seen it in a couple of years and watched it on the plane, so I was like, hey, yeah, that's the still makes sense for health care. Well, I'm a changed baseball, right? I think there's a guy named Howard. I can't remember his first name. You played first basement for the Phillies. I think he was basically put out of the game by the shift because he was the left-handed power hater and they put the shift in and all of a sudden his style of hitting became unsustainable because they learned how to pitch and pitch around them and play around them. They changed the scope of baseball and you see that now it's Steph Curry changed the way we play basketball because now they use analytics and they know that the way that he shoots will pass up a layup for him to jack up a three and analytics and sports have changed the way they play the game. Yeah, we want to do the same thing they did to Howard to cancer and other diseases. If we just use data the right way in health care, two questions from the audience here through this conversation. Really quick doctor. Now it's Ryan Howard from the Phillies, the first basement. Yeah, he was out of the league in like two years after being hit. I don't know if I ever recognize that was a shift from the data analytics side that caused that, but he was an all-star and then he quickly exited right and unceremoniously. Yes, I'd like to go back early in the conversation. You're talking about your use of video data, especially in your ORs at the university. I know you're using it of course in the perioptive setting and then in training, learning moments on Fridays. Do you see video being, and I know there's restrictions or push back against it? Are you seeing your fellows, near residents taking it with them? Are they trying to expand the use of this for their practices? So Aaron and Ramses are the two fellows that we've had outside of our current fellow that have been a part of the video part. And I know Ramses records his cases because of this. Ramses didn't leave with any videos because I think that would technically be illegal because that would be not in the accordance with how we recorded them. But I know that Ramses left, like Aaron had a collection of videos that she left for Ramses that Ramses left for Leon. But I know Ramses playing non-recording cases and using them the same way because he's that in education. He has residents. Aaron's in private practice and so I don't think she's recording the same way. Although I wish that she worked because I think it'd be cool to see what changed after she left, both in how she became less efficient and how she became more efficient, just because necessarily you're less efficient after you leave. But so I know Ramses and I don't think it matters. Thank you for that. Appreciate it. That's all the questions we have here. Dr. Ramshal, let's you close it out. Yeah, I'll ask one more thing and follow up to that. I forget to mention that I don't know how involved you are. But in addition to the surgical video, we also do in-room video. And I know through Michelle and others, there's been a lot of work on the team building for the OR team, turnover in between cases, during cases, any view on the value of the in-room camera in addition to surgical video. I think that we're just very much skimming the surface of that one because you know, we really, we know that turnover can be improved and we have seen situations where we've looked back and there's just been no one in the room. And so we can see that and you can try to figure out why that's happening versus why don't we have three people in the room cleaning in a minute or out. And so we can use it like that. I think we also know that there are some anesthesiologists that are always on fire and they're just quick and efficient. In some that you know, when you see them, you're like, they're just much more methodicals. I think that we have the opportunity to even use that for anesthesia to say, hey, this is these are ways that your highest performing actors are doing it versus the people that are slower to try to help them improve their efficiency because turnover time is one of the things for a surgeon that we feel like is less in your control. I think sterile technique is ways that we've been using it in position, we've been using it for position and sterile technique in turning the room over. I think those have all helped a lot, but I still think there's opportunities for improvement specifically in how we make sure turnovers happening. And you know, I think we can do the same thing in the endoscopy suites. How are we getting the case going? Why are some people moving faster than other races? Because they're not safe or isn't because they're more efficient. If they are more efficient, how can we get that to trickle down to our partners? And so I think that they are, I don't think we really were fairly scratching the service and how we can use that. That's great. Well, again, Pete, it's a pleasure not only talking with you for this 45, 50 minutes, but a pleasure working with you. And I'm really confident that the work we do together over the next year or two is going to be pretty transformative. I'm looking forward to that. Yeah, I can't wait to see the data. Thanks guys. Thanks for joining us for another episode of Data Nerds in the OR, a surgeon's journey toward value-based care. You'll find links in the show notes to any resources mentioned in today's show. If you're enjoying our podcast, please subscribe so you never miss an episode. And if you want more content like this, you can always sign up for our smart surgery blog via the link in the show notes. Or if you want to ask Dr. Remshaw or the team a question directly, please send an email to [email protected]. This episode is brought to you by Care Syntax, the leading vendor-neutral surgical intelligence platform. The Care Syntax platform can ingest and analyze data throughout the surgical workflow, including clinical, operational, financial, and outcomes data to capture a complete picture of the surgical pathway. That data can produce actionable insights to enhance efficiency and innovation for surgical teams, hospital administrators, and MedTech developers, driving innovation for the future of healthcare delivery. Care Syntax impacts over 3,000 ORs and more than 3 million annual procedures across the globe. Learn more at www.caresyntax.com.