Point of Care Ultrasound is Changing the Practice of Medicine
Dr. Arun Nagdev is one of the leading international authorities on Point of Care Ultrasound, or POCUS. He practices clinically and also is the Senior Director of Clinical Education at Exo, a company that is on a mission to modernize medical imaging through its high-performance handheld ultrasound platform and artificial intelligence. In this episode Dr. Nagdev discusses the evolution of ultrasound in the practice of medicine, how point-of care ultrasound impacts procedural success and patient care, the challenges with educating established physicians, changing the curriculum of residencies, POCUS reimbursement, the differences between clinical medical teams and a medical device start-up, and his vision for a connected, low-cost, ubiquitous point-of-care ultrasound technology.
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Episode Transcript
This transcript was generated using an automated transcription service and is minimally edited. Please forgive the mistakes contained within it.
Patrick Kothe 00:31
Welcome. Some technologies come and go, and others evolve and take on whole new lives. Ultrasound is one of those that continues to evolve. Today's guest Dr. Arun Nagdev, is one of the leading international authorities on point of care ultrasound, or it's referred to as POCUS. He's the Director of Emergency ultrasound at Highland Hospital, and clinical associate professor of Emergency Medicine at the University of California San Francisco Arun started the point of care ultrasound program at Brown University. And he's published more than 90 Peer Reviewed papers on the subject including its use in pain management, cardiac arrest and volume resuscitation. He's a current chair of the emergency ultrasound section of the American College of Emergency Physicians are ACEP. And we're going to talk a little bit about that today. Aroona is also involved in industry. He's joined a company called Echo, and that's spelled Exo as a Senior Director of Clinical Education. Exo is a health information and devices company. And they're on a mission to modernize medical imaging through a high performance handheld ultrasound platform, and artificial intelligence. The company just recently closed on a $220 million dollar Series C round in mid 2021. So the company is really on the move. In this episode, we discuss the evolution of ultrasound in the in the practice of medicine, and more specifically, how point of care ultrasound impacts procedural success and patient care. We also talk about the challenges with educating not only young physicians, but established physicians, and changing the curriculum of residencies. What reimbursement looks like the differences between clinical medical teams and a medical device startup, which I found to be particularly interesting, and then a ruins vision for connected, low cost, ubiquitous point of care ultrasound technology? Here's our conversation. So we both just returned from the American College of Emergency Physicians annual meeting. Not quite annual, it's the first time it's occurred in the last two years. What was your experience? Like? That was the first time that I've attended the meeting in two years? What was yours your experience? Like?
Arun Nagdev MD 03:14
Yeah, it was, I mean, it was really it was great to go back. I've been faculty at the conference for a guy I think, since 2011, maybe 2010. So it's kind of a yearly track to go out and reconnect with, you know, more than 10,000 emergency physicians from all walks of emergency care from clinical in the middle of nowhere to large academic centers. So it's a chance for all of us, really, to convene and talk about what's going on in our field. And it's, it was so nice to be back. It was a obviously the volume wasn't as high in participants. But it was a really excellent chance to get back together. And I think hopefully build for next year, which is going to be in my hometown in San Francisco. So I'm very excited.
Patrick Kothe 04:02
I thought it was an excellent meeting, too. As you said attendance was down, probably about 35 40% of what it what it is normally, but it seemed like the people that were there, we're very excited to be there. And it wasn't that much different. This time around, aside from the safety precautions that everyone was,
Arun Nagdev MD 04:20
yeah, it was it was done very well. I really commend them for running a meeting that was almost seamless. It was it was easy to navigate, and they did a wonderful job.
Patrick Kothe 04:32
So you're an emergency room, physician, emergency medicine physician. And when you think of Emergency Medicine, you don't automatically think about ultrasound. How did you get involved with ultrasound?
Arun Nagdev MD 04:43
Yeah, so this is something that's fascinating. I, I was looking into fellowships, when I was just a yet a resident in New York. And one of my mentors really talked about the emergence of imaging at the bedside, how it's gonna fare larger role in the way that we practice medicine and specifically emergency medicine. And I had a chance to do a rotation. And then I read this book, it was written by a few physicians out of Highland Hospital in Oakland, California, that were talking about how they were using ultrasound, really dragging the old radiology systems over and doing optimal care for their patients. In this little hospital, which didn't have radio, you know, Radiology at night, weekends, afternoons, and I was like, This is amazing, this is this is great. And I got a like, kind of chance to go interview there. And I got a spot at Highland Hospital in Oakland, California. And so it was like just a great opportunity come to a place that at that point, and I say this with no joke, I don't know my interview, at a second year resident, walk out of a room, they want to introduce me to him as the incoming fellow or the fellow who was applying. And he's like, Oh, the ejection fraction on this patient was poor, the need to admit this patient and I literally looked at him and thought he was crazy, that this second year resident, this is a 2005, was defining cardiac function. And I'd never used an echo in my clinical practice. And I either I thought he was crazy, or he was making it up. So I was fascinated by the, the application that they were talking about in real life. And that year changed the way that I thought of medicine, it was a chance to really see what you could do as a clinician with the tools that were there right in front of you just you just needed to understand how to use it. And it was completely revolutionary to me, and made me I think the clinician I am today, somebody really wants to change the way we practice. And it was, I still remember that year so well, it was like one after the next of like, wait, you do it this way. And they're like, yeah, why wouldn't you do it this way? This was, in large part due to some real pioneers, Barry Simon and Eric Snoopy, who are the two that started at Highland, who really kind of adopted something that I felt was not prevalent, where I was training in New York,
Patrick Kothe 07:13
let's kind of step back for a second and talk about the technology in general ultrasound, in general, because there's a lot of different types of ultrasound, it can be used in a lot of different places in the body. So let's just talk about ultrasound in general. And then we're going to real really dial down into what we're talking about today point of care. But in general, what does ultrasound do? And where is it applied?
Arun Nagdev MD 07:39
Yeah, it's a it's a fantastic question. My parents still think I'm a radiologist. So I think I upstyles a, it's a non ionizing so doesn't give radiation basic tool that has been a part of medical imaging for years. You know, look at the baby, when you're when you're pregnant, you can get your carotid arteries examined. If you're worried about stenosis ever, maybe people have gotten echocardiography. So it's this amazing tool that allows you a glimpse inside the body in a way that other imaging modalities can't even though they may be better. So you're saying I have a CT scan, I can look inside the body. The problem with CT scans is it's a lot of radiation. It's a great test. MRI doesn't have a lot of radiation, but it's static, it's a picture. The beauty of ultrasound is it's not radiating or non ionizing. Plus, it's in real time. So it gives you functionality that some of those other imaging modalities don't, it's relatively inexpensive. And I think we'll get even more inexpensive as technology improves. But it also gives you something that the other imaging studies can't it, it gives me real time imaging, if I'm looking at if I get an MRI of your shoulder, I get to see the anatomy, the muscles, the bone. You can also put a probe or an ultrasound probe and ultrasound that shoulder and along with looking at it maybe not as clear of an image. But I can manipulate your shoulder and actually see what's happening with motion with ranging it. So in some ways, it's it has real at you know, it's really advantageous for the clinician, be it in a radiology suite, be it in a obstetrics ward or the emergency department to make decisions that are I think, based on real information.
Patrick Kothe 09:36
I think what you're saying is that there's not one tool that does everything, but there are tools specific for what you're trying to accomplish. And this tool is pretty unique in that it can give real time information, but unlike fluoroscopy, where you're using x ray to do that, and there's some some damage could be incurred with it there's this is a relatively safe modality.
Arun Nagdev MD 10:05
Yeah, it's about as safe as it gets when it comes to medical imaging. And it's what you just said is exactly correct it it is really, as a clinician, as a good clinician, you have to kind of fit the puzzle on what the best imaging is for your patient. And sometimes, there's a lot of different tools you can use. And I think of sound is just a piece of that puzzle that a good clinician understands is, you know, optimal for great patient care.
Patrick Kothe 10:33
So there's different types of machines for ultrasound, depending on what the what the application is. We've heard terms like 2d 3d 4d, Doppler ultrasound, transcranial ultrasound, different types of things. What are what are all of those terms about? And what type of ultrasound are we talking about? We're talking about point of care. Ultrasound,
Arun Nagdev MD 10:59
yeah, primarily point of care, it's going to be called 2d or two dimensional ultrasound or B mode, which is brightness mode. That's the kind of the classic. Most of our scans are done in. So this is the, if you're going to get an ultrasound of your carotid artery, you're going to look at the neck in a seat in a two dimensional image. And then you can throw things like color Doppler, which is a way to look at vasculature or flow in certain vessels. Those are two big tools that we use. There's also 3d and 4d ultrasound, something that hasn't really stepped into the, into my realm of imaging, but I know the really good snog refers and really impressive ultrasound technology out there that's doing that. But that is a little bit more in the future. A lot of places are doing it currently. But in the point of care market, the market that I work in, and we can discuss that it's really hasn't shown to be much use utility yet. But again, like any technology when you when you build something people find uses for it. And this is kind of the the movement that we're going in when it comes to ultrasound.
Patrick Kothe 12:07
So when many people many of us, people that are not in the ultrasound market, we think about it, many of us have had children, we know that ultrasound is using stretch obstetrics. And we see the big machine that's not exactly we're talking about with point of care technologies for it. So what does the machine look like today? For point of care ultrasound?
Arun Nagdev MD 12:34
Yeah, that's a that's a great question. At the place I currently work, we had er physicians who needed to get studies done on patients because it was two in the morning and they would literally walk over to radiology department and grab this large machine. You've seen this when you've done your OB scans or when you've gone to the hospital for for a cardiology visit. These are big, probably not very mobile, they take a little while to boot up and they have that array of buttons. Technically, it's can be challenging the learning curve for it. The point of car market evolved because of clinicians who were using it as a part and parcel of their examination. And because of that, they changed the user interface, they change the size, they made them smaller, they made it easier for us to use. So we could go from patient to patient rather than the patient coming to us if I'm in a radiology suite or an OB suite, the patient comes to me I get the ultrasound and the patient goes away. merchandisers don't practice like that I go from room to room. So I needed something that was smaller, I need something that was also not as complicated. Because again, I have a zillion things going on. Having every ER physician get to a point of comfort, like a really experience in ographers is tough. So the company's listened to us and built systems around our user interface, our user experience, and really built these smaller they call cart based systems. So they look like a laptop, or a computer or laptop stick on a cart. That's kind of the easy way of putting it. They got a lot press in it. Remember the show emerged, er back in the day, they actually had a bunch of these systems that were suicides at a time around the ER and the doctors would, you know, put the probe on the person's heart be like the person's dying. Let's do this, that that's really, really kind of became in the public view and kind of in the zeitgeist of healthcare.
Patrick Kothe 14:30
That was what, a 10 years ago. What's the technology evolved to today?
Arun Nagdev MD 14:38
Yeah, like 20 years ago? Yeah, our data was like 20 years ago. The technology has improved immensely. The quality of these car based systems now probably is much better rivals and is much better than the top of the line $200,000 systems that are now priced at $40,000 or better than those be a huge behemoth, you know, big, huge large machines that were the best of the best. Now, I've been miniaturize into the smaller cart base, the ones, that flat screen that looks like you're a large iPad, like maybe on your Tesla or on your, on a big iPad reader, that's all touch based, that's new. They have, you know, all this functionality that wasn't even a part of the old systems they have. We talked about all this like transcranial Doppler, some have attachments to different probes, like transesophageal echo probes that can be shoved inside the body and look at the heart from the inside. So the technology has improved rapidly, because the market has demonstrated that all emergency physicians now are being trained, how to use ultrasound as part and parcel of the residency. So every residency program has to have training. So all these new physicians want ultrasound systems, internal medicine is training in this hospitalist medicine, orthopedics, almost every field is now touching the imaging space. And using ultrasound as a modality to improve patient care.
Patrick Kothe 16:10
What you mentioned earlier is really kind of interesting, because it seems like we may have, you know, two competing things. One is technology is is being developed and allows you to do more. But the user interface is so important, because the simplicity of the technology is really what's going to cause it to be widely adopted. So what's what's the balance been like? With those two? Two competing items?
Arun Nagdev MD 16:35
Yeah, I mean, this is this is the same. I mean, I think I remember back in the day having an mp3 player, right. I mean, the iPod wasn't a novel device, it was just a device that allow the ecosystem to function allowed me to have an easy experience, rather than downloading my music, putting it on a system up, you know, they just made it simple. And so I think the companies are racing to this too, because they realize that, along with just the imaging aspect, I mean, great imaging is important, I want to be able to see what I want to be able to see and I want you to help me get better images, I also want to make it so easy. So the kind of common term is UI or UX or user interface, or user experience. Those are, I think, as important and sometimes even more important, when it comes to how we employ technology in the hospital. And when you look at these new optional systems, I think it's probably going to be 50%, or maybe even larger importance. If I if I have a great system that shows me great imaging. But my novice user, my new med student, my new resident, is really uncomfortable using it, the adoption is gonna be low, they're gonna not want to use it. So that has to be such an important part. I mean, the biggest company in the world, Apple is based on user experience. And that is not because they don't want the best product, they recognize their product is useless unless people like using it. And that experience that the user has is very important. And that's a thing I'm very interested in. I did a little work at Stanford on this. And I really find this to be fascinating, and very important.
Patrick Kothe 18:17
So let's go to the emergency department and the types of patients that are coming in that you're using ultrasound on, what are those patients? presenting it? And how are you using it to provide better better patient care?
Arun Nagdev MD 18:33
Yeah, so I worked all weekend, and I'm going to give you just a glimpse, it's kind of two big buckets, we think of it one is, I'm gonna make it really obvious one is diagnostic. So making the diagnosis or helping you make the diagnostic, the diagnosis, excuse me, the second is procedural. And that is helping me do a procedure safely and with less error, and I'm gonna start off with a procedure one because I think it makes most sense to people. So when I was a resident, we would put large IV lines in people's necks are called central lines. And we would literally stab their neck over and over again, with a needle until we got blood back. And we would base it on what the anatomy is of the patient. So in everybody, the internal jugular lies lateral to the carotid artery. And we would have errors, we would hit the wrong structure we would miss. Ultrasound allows us to visualize where to go and simplify the processes. It makes me see what I need to do rather than guess I hate to say that we use the term landmark based versus ultrasound based and essentially it's, am I guessing where to go? Or am I being safe about it? And so ultrasound really has changed the game for any procedure done the emergency department, if you're going to come into emergency department get an IV line, they can make it safer if it's hard to find with ultrasound, if they're going to put a deeper line. They can use ultrasound if they're going to injection into a joint or pull out fluid from a joint, we use ultrasound. If you're going to do a painless a block on your hip, we use ultrasound. So now it is it's completely revolutionized the way that we do procedures in the emergency department. On the other hand, it's also helpful to diagnostics. People come with abdominal pain, is it gall stones? Is it just a little bit of you know, upset stomach, I can tell you three seconds into your visit or three minutes into your visit rather than sending you downstairs for an hour stay, get a radiology scenographer to do and send you back. I can also tell you if your heart is having problems immediately because I can just put the probe on your heart and define it, I can tell you if your lungs have fluid in them in during the COVID epidemic, this was a standard operating procedure for us to evaluate the heart and the lungs to define why the patient was having a hard time breathing. Sometimes it's really confusing because it asthma is it a pneumonia is your heart bad, all those things can be differentiated in under a minute, two minutes. With up sound rather than what we used to do is maybe guess a little bit based on our exam and get a chest X ray, which again have been shown repeatedly to be inaccurate. So it has completely revolutionized the way I practice almost all my patients from abdominal pain to chest pain, to you know injuries to you have a you have a big abscess in your leg you have a cellulitis or, or infection of your leg, I can differentiate all this really easily with ultrasound.
Patrick Kothe 21:39
So in the past, physicians haven't performed the procedure, it's like a physician won't do a CT scan or, or an x ray or an MRI, MRI or an ultrasound been ultrasonographer that would do that. What we're talking about now is physicians are actually doing the ultrasound. How has that transition been? Because it's a different a different part of training. So let's let's let's spend a little bit time on adoption. Yeah, I mean, this is
Arun Nagdev MD 22:08
this is definitely correct. This is a this is a huge point. In difficulty. This is not what we call point of care, right? So we're doing these exams at the point of care rather than sending the way for imaging from the snog refer. When I started doing this, I remember I went to the east coast and started a program at a large academic institution, these coasts and nobody was trained, it was zero and they looked at me like I was completely insane that they were going to attain this knowledge. And again, the user experience, the user interface is really important because I had to demonstrate how to use this and teach people how to use this in a basic manner to answer specific questions. Rather than when you go to get your liver scan to see if there's anything wrong with your liver I was defining Do you have gallstones or not? So I was making very directed questions. And initially, we didn't have many training standards in American college emergency physicians. And we actually put it before my time put out a standard operating training program. And then we started training our residents at every program in the nation. It was not easy. I'm not I'm not gonna tell you that it was an easy ask. But training young residents is not that difficult, because they're still learning the art of medicine. And this progressed into training other departments and other hospitals. And it was really not easy.
Patrick Kothe 23:30
You just say that it wasn't easy. What was it? Why was it so difficult? Was it changing people's minds? Or was it? No, you're taking away from something else in order to add this in? That's exact.
Arun Nagdev MD 23:42
This is something that I've thought about in such detail. It's a really fascinating point. For me to train a new learner how to use ultrasound from a PA student, to a medical student, to a resident, it is not hard, is I have med students from UCSF now rotate 12 years in a row by the end of the month. They're excellent, excellent, Winnie Kerrison ographers. They're not it's not an excellent point Kerrison ographers, they can define cardiac function, they can define free fluid, they can define anything I want in a very clear manner. But I think it's because they're integrating this into their learning of how to assess patients. That same change that happens in clinicians, be it you know, our APS or mid level providers who are physicians 10 1215 years out have a really hard time because they've always said when I see a patient with shortness of breath, I do XY and Z. Having them pivot has been much harder. And that that is something that we have worked at tremendously to to really integrate that into care. It has to be done with a level of I'm going to make your life easier. I'm going to make errors less I'm going to improve patient care. And if we stand on those ethos that this is all about it. improving patient care, I get some buy in from them. But it is harder, it is harder when you've always done it XY way for some young doctor to come out and say, hey, you've been doing it, okay, we're gonna make it better. It's a really hard pivot, and a really hard change. But I think when you base it on patient care, and they see I remember, I used to work at a little hospital out in central California. And remember this are all older physicians, I was the young guy come out there, I was off sounding everybody, the nurses would laugh at me, because I've carried that machine with me. And I'm one of the physicians called me over for this woman who had been seen twice with chest pain, like, can you see her because I just I would like it all shot, don't know how to use it. So I walked her over, I showed her how to do it, though the woman had pretty moderate pericardial effusion that ended up getting transferred to for cardiothoracic. And I remember, she looked at me, she's like, I would have missed this. And I'm like, I know. And she's in, she suddenly recognized the importance and how she wanted to be a better doctor. And I remember after that, every single time I worked, she would find me she like, show me how to do this, show me how to do this. And she still emails me once in a while with images of patients you're seeing. I think that's it, I think getting people to recognize that this improves care, and makes their job better and makes them better, I think is a ticket for us to improve education in populations that just have worked differently. And the young people, it's easy. I literally it's like giving candy to a baby, they eat it up. That's all they want to do.
Patrick Kothe 26:37
That's really interesting. Because, you know, I, I've talked to a lot of physicians over the years. And when you quote the literature and say, Hey, there's a failure rate of this procedure of 10%. I've never heard anyone say, Well, mine is higher than that I've ever heard. Other people say mine's nowhere near that. And so getting people to admit that there's an issue is an issue. Yeah, getting to admit it. Number one, you mean? So having those proof sources are really important for you? The other question I've got is, is there something with younger people being able to learn better because of what they've grown up with? Is with, with video games and everything? Is it easier to teach somebody that hand eye version virtual space, then somebody that's a little bit older?
Arun Nagdev MD 27:29
Yeah, yeah. This is a question that everybody asked me. This is a question that gotten this long conversation. My chairperson, my chairman, that such a great clinician, he's in his 60s. And he's and I was talking about how our interns, I will do a block with them, or central line, and they just get it right away. And he's like, is it because the video games? Is it because they're just so much more comfortable doing this? And I, I'm gonna say maybe I would love to say, Yes, I wanted I want to believe that clinicians. I think learning is is part and parcel of what we do. I think a lot of us resist learning because it's new, I don't want to try something new. I think once you give people in any age group, in any skill, set the opportunity to do blocks or to do procedures with our sound. It just happens. We we went to Peru, we run a fellowship. And I've watched numerous one of our Peruvian fellows and their attendings through procedures, they get it, I think, because they recognize the utility, we were in Africa with an NGO that we did more than like, I think, like 7000 procedures. And these were ortho Tech's doing blocks. This is not a, you know, a population that is like, I'm really comfortable needle visualization. I don't think they're playing video games in in the Congo, but they got it. And I think is just people's desire that yes, this is going to be easier. And I think I hate I would hate to say it's just because they're playing a bunch of video games and their spatial recognition is better. I think if you want to do this, I think this is something that every clinician or even every, you know, anybody's grasp to be able to do this comfortably and safely.
Patrick Kothe 29:04
So what was it like to change the physician groups or ASAP? What was it like to make that change in the educational component of a training program?
Arun Nagdev MD 29:17
Yeah, that was before my time. So I give credit to a lot of really amazing people that were part of ASAP before I was even around. It's been around for more than 20 years. I'm sure it was not easy. I'm sure there were people who are saying there's no reason to mandate this as part of residency training. There's no reason to approve a protocol that says you must do all 150 scans and 25 gallbladders and 25 aortas. I'm sure there was a ton of resistance. But now you know, I'm now the president of the ACEP Pottstown section there we're we have 1600 members out of it is by far our how many times larger than any other subcommittee in that organization, and it is now from I remember giving two talks as the only two ultrasound talks at asef. Now, I think they're like 10. So it is, they saw the future. And I think I'm sure they fought a little bit, but they recognize how important this was for optimal patient care. So I'm sure it was difficult. And it's been difficult when I was when I was at Brown for a little while, I had to fight with other people, including other departments to let us do echoes on patients who were sick in the ER, because they felt that we were going to kill patients. This is the classic line, you will hurt patients, you don't know what you're doing, you're not trained. And slowly after a while, they realize that that's probably not true.
Patrick Kothe 30:43
So what is the adoption of ultrasound within mergency departments right now? Is it fully adopted? Is it halfway adopted? How would you estimate? That's
Arun Nagdev MD 30:53
it? That's a great question. It's hard because we have our blinders on. Right? We all work, when we sit in our meetings, we all work at Stanford, and Harvard and Hopkins, and our residents just eat it up. But when I drive 40 miles outside of San Francisco, where we have, you know, everybody here is doing ultrasound at the bedside, I work in a central valley once in a while, very few. So it really is, the residents that have been trained that now or for last 10 years probably are pretty good. And they're using it as part of the practice, that age group, maybe 10 years out and farther, it's probably I want to say maybe 20, even lower 20% adoption, I think it's really not there. And you'll see this when I go work at places and they have misses or they will have you know, we have our m&ms, we have our morbidity, mortality conferences, and I'll talk about cases. And these all would have, I think, been reduced with having some type of imaging at the bedside.
Patrick Kothe 31:53
So let's talk a little bit about reimbursement. Because when you order a scan, it's independent scan that's done it but now you're part of a procedure. What does reimbursement look like? Is there a separate code for with scan without scan?
Arun Nagdev MD 32:06
Yeah, yeah. So this is a, this is something that again, people before me really pushed and recognize that, that we needed, we were doing this extra imaging, we should probably billing for that, if not, we're trying to hurt patients. But again, if you come to a hospital and you're very sick, you want your doctor to have all the capabilities to do the right thing along with having the equipment which is costly, and departments have to buy it, but also allowing somebody some free time to train those doctors how to do it. So CPT codes were developed around all the basic ultrasound imaging, all the basic point of care imaging. So if tomorrow you come into my ER with horrible chest pain or shortness of breath, and I do an echocardiography on you, that's limited. There's a certain CPT code that's billed, if I document it and store the image in some type of archive and get certain specific views, I indicate you can for shortness of breath, I got obtained two or three specific views. And I define my interpretation. If I'm able to do that and store the image in some type of, we generally put it in our packs server, you can build for it. And CMS reimburses based on that. So there is an avenue for us to allow us to buy systems and I think, offer better care. And so I think it has to we have to offer that otherwise, if we stop that, then all education goes away. All the purchases go away. I mean, we know how hospitals work where money is the primary is the river that we all flow off of right. So it is a these codes have been done and built around that concept.
Patrick Kothe 33:52
Is it adequate at this point? Yeah, I
Arun Nagdev MD 33:54
mean, that's that's a that's a tough question. Right? I think it is. I don't spend too much time in that space. Looking at numbers specifically. I know our numbers from our hospital. But I think it is adequate right now. It gives us enough income to run my division to buy all sound systems, and allows us to continue on pushing the field forward.
Patrick Kothe 34:18
Earn we've kind of focused on the US marketplace. But we're working on a global marketplace. Has it evolved the same way outside of the US as it is in the US? Or is us further along? Or how would you?
Arun Nagdev MD 34:33
Yeah, I think you know, I don't know the answer. When it comes to Europe. Europe has probably this Europe and Australia probably the most advanced I think out of outside America. Us is has been a leader of point of care. And also on imaging. I know that I've given talks in Australia I've given talks in Europe, and I've had I know friends who are in all these places around the world, and they look at look to us as leaders in the space but they are starting to do some amazing stuff. I don't know the billing and educational aspects, they they reference a set a lot, because we were the first ones out of the gate. Once you go away from those two markets, Europe and Australia, it's really a dearth we're in, we run a fellowship out in Peru, and our proven residents have nothing. They this is all just their university saying, we want to improve care. There's no reimbursement issues at this point in countries like that. And that's a real issue, that I think it's a huge growth market. I can't imagine 10 years from now, other countries not adopting something as simple as visualizing putting a needle into people's bodies and knowing what they're doing. I think they'll recognize that and I think this is why I think driving the price of these products, because for India, or for Africa, or for South America, then you're the $40,000 system is a lot driving down that price and getting something on the front end for usage, ease of use, and also even the back end of TELUS monography, which I think is going to be the future I think really can expand this market make it humongous. It's a huge market.
Patrick Kothe 36:14
So a ruin. You're not only practice medicine at Highland, but you're also the Senior Director of Clinical Education at a company called echo x. Oh, so what is Echo? And what are you what are you doing with them?
Arun Nagdev MD 36:29
Yeah, so this is this is really such a such a fun thing for me to talk about. We kind of talked about how ultrasound became miniaturize and smaller for the point of care space became cart based. This amazing I mean, it really is an impressive company. And smart people took that technology and miniaturize that even more, instead of using the classic of sound probes that are expensive. Built on this thing called PISA look, he's electric technology, it's crystals essentially, that vibrate with with electricity. They shrunk that down and built this thing called a Pima they use Pima technology. To complicate it, they essentially instead of having these crystals, they've put semiconductors on the probe. And the beauty is like you know, your iPhone, your iPhone one or your iphone four is very different than your iPhone 13. They've built this amazing probe that has almost as good I think, a little better imaging than our cart based systems on their first iteration. And the company's idea is to a to get great imaging. So one, that hardware is amazing. Build a probe that's inexpensive, under the 3000 $2,000 price point, to allow that probe to image everything classic ultrasound world, you have one probe that does one thing. So your heart, one probe that does your skin or your soft tissue. So this probe is kind of dual in that sense, that allows it to image at Broad ranges. And three, which I think is even more interesting is along with the price and technology, build a software around it, because we're all very comfortable now using our phone as a tool for communication as a tool for documentation as a tool for entertainment. Use the same user experience the same user information like the same idea and build that into this technology. So I think that's like the big thing that they're trying to do it. And when I when I met them, and I met the CEO and I met the other people who started this company, I was so kind of taken back by their desire to really look at medical imaging and make it a part and parcel of every every clinician, and not just the people could afford the $40,000 systems and have the high level training. So they brought me in to help them with the training aspect. How do we get novice users? Like I got this, I can look at the gallbladder or has a novice user get comfortable doing a procedure. And so that's maybe the nut that I have to crack and using from gamification to ease of use ideas that allow people that are new to be like, Oh, I can do this. You talked
Patrick Kothe 39:15
earlier about making sure that it fits within the system that in order to get reimbursed you have to capture so many images and needs to go. So it needs to be connected to something else. Let's let's discuss the connectivity and the workflow aspect of using this in point of care.
Arun Nagdev MD 39:34
Yeah, this is so this has been a you know, a real issue for for us for a long time. And I again, you go to these conferences, and this is a yearly conversation. You can imagine when we would bring a radiologist system into our ER, this system had all these inputs, and then would get put on to they would plug it into a wall and that data would get sucked up and put into a PAC server at a hospital. We were moving Any systems around, they were going from room to room. So wireless technology had to be more robust hospitals became more wireless, then we have to figure out a way to put this data into a server into a pack server. And then, you know, I'm not a radiologist, I can't I don't go sit around and not to not my radiology friends, but they sit in a room for eight hours a day and read scans. I can't do that. Because I'm also emergency physicians, how do you bring that all together was a real difficult proposition. A few companies developed software, they call it middleware that allowed us to both document correctly, store correctly, have ability to find our data that we needed. And this is really a problem. And again, not to bring it back to echo. But this is something that all of us, I mean, when I share data with you on my Instagram, or Facebook or whatever, it's easy, it's clean, the iPhone is built around this. So leveraging that technology, that growth in this handheld space is going to really allow us to integrate this, I can image your abdomen on my phone, I'm going to easily with my thumb, put data in there, quickly gives me the you know what I need, and it gets stored on a cloud server that's attached to my electronic health record. That is something that can be done today, which 10 years ago, we were like putting jump drives into ultrasound systems, pulling out data, putting it on a hard drive, make an Excel spreadsheet, sending an email to you know, Dr. Smith, that your gallbladder scan was abnormal. All that work is now been condensed to something that's powerful is in my hands. And so leveraging both the technology up front, which is the imaging, and then the technology on the phone, I think allows us to happen.
Patrick Kothe 41:50
So you described earlier about companies listening to physicians say this is what I need, I need, I need a better UI with this. I needed smaller, needed cheaper. And they delivered that. And now the next phase of that is it needs to fit within the ecosystem needs to be seamless within that seamless. And that's the work that's going on right now.
Arun Nagdev MD 42:10
Yeah, yeah, that's exactly right. As you look at
Patrick Kothe 42:13
challenges to the training that you that you talked about, what are the challenges as you sit here today?
Arun Nagdev MD 42:20
Oh, wow. That's That's a fantastic question. So I'll tell you, one challenges is to get older users and I hate to use that term, I'll say, not
Patrick Kothe 42:30
experienced, experienced,
Arun Nagdev MD 42:33
experienced users to believe that when a care or imaging at the bedside makes a difference. And I think, in my space, right, in emergency medicine, it has happened. And I think that the physicians or the clinicians who are not adopting this technology, recognize it, they're leaving soon. And I hate saying that they're that it's generally not the new user. Mercy medicine is a small subset segment of medicine, internal medicine, right? Every time you go see your doctor, they're going to feel your tummy to see if you have early signs of a triple A, which is an abdominal aortic aneurysm that you just look at when you come in for shortness of breath. And they're like, Well, I don't think it's cardiac, I can just look at when they when you come in for domino pain to your clinic clinicians office, is it a gallstone? Or is it a kidney stone? Is it like that level of honesty and education I have, we have to impart to our colleagues in internal medicine, in hospitals medicine, in orthopedics, when they do an injection into one of your joints, the hard part is education. How do I get them to realize that benefits? Because it did is out there, right? I can pull up articles on articles I talked about, but data points on a paper nobody cares about, like how does it affect me. And I think the key is making that process easy, useful on your phone short, quick and useful, I would love to have the ability for the first time you do a maybe a joint arthrocentesis gonna put a needle on some of these knee and you've done it this way, you know, 100 times and you're like I get it 80% of time. 90% time 95% of time. If I had a video that just showed you right then and there on your phone, the same one you're using for your for your probe that delineated it, maybe had some just such ease of use that you're like, Oh, this is so easy. I can do this. And then what happens is when that when the ease of use happens, and it's built into the way you work, people will respond, I think and adopt.
Patrick Kothe 44:35
So we're talking about procedural based. We're talking about emergency medicine, things that are going on with procedures but when we're talking about point of care, it's not only procedures its general use. So as you as you describe the internal medicine family physician that seeing patients and can have things that they're screening for using with within the office, it's a little bit better. different business model, because that $40,000 machine may not make sense in that in that setting. So marrying the cost of the device, the utility that a device, the different things that you're trying to accomplish with that device, I think is also going to be something that under percent, that's gonna be important as well. Yeah, the
Arun Nagdev MD 45:20
barriers to me are price point, that this is, you know, the clinic down the street, where I live, is price point. So you drop that price point you you get artic, our technicians, our supply chain to drop that price point. That's one, but then it's education and ease of use. And that I think is also another big ask. When I see my fellows improved, diagnosing early mitral stenosis over and over again, in a population, that's a high risk. And they're like this, you have to do it. Because if we pick up mitral stenosis early, we prevent it from progressing. If they pick up pulmonary hypertension in the in the Andes early, it prevents it from progressing. I mean, all these case scenarios are these case examples that I'm like, Oh, that would have made sense to me, as a young physician, once we get these probes in the hands of our colleagues who are working in the frontlines of internal medicine, pediatrics, they will make their own use cases, they'd be like, oh, you know, we realize we're picking up interception in these children is strictly kind of twisting his bowel or, or telescoping, a bowel in pediatrics at the bedside. And it's so much better than just sending him to the radiology or sending them home. And so I think the use cases is going to explode. I think once we give smart people technology, the use cases that I want you to think about will be part and parcel of what we do in healthcare 10 years from now.
Patrick Kothe 46:36
And then reimbursement as obviously, a big, big part of that, too, because a triple A screening. Sounds like a great application, but if someone's not gonna get reimbursed for it, yeah, that's a barrier.
Arun Nagdev MD 46:47
Yeah. But you know, I totally agree with you, it just that today, AAA screening is pushing on your stomach. And we know that this is insensitive. And I think once you show people who people go into medicine for I really do think for the right reason, it's always about being really caring and doing the right thing for patients. And once they get a little bite of that it is I see that change happening right away in patients, it's like the first time you make an impactful, and you've probably heard it from clinicians, you've talked to like, oh, I this great case of X, Y and Z, right? I picked up this, and I can't believe it happened, that person. And I think that once you get them hooked, the building, it just becomes a byproduct. And then it's about patient care.
Patrick Kothe 47:36
So from an adoption and training standpoint, you've experienced it within mergency medicine, and now you're going to apply it to other other specialties. What have you learned, in your experience in emergency medicine that you can apply to other specialties?
Arun Nagdev MD 47:52
Well, I think the biggest learning point is that the people who are going to train the internist are going to be internist. So for me, it's it's I remember starting out my career and doing these large courses for 50 people. But when we went to Peru, we changed our model, because we realized we just need two people or one person. So I think training the leaders of Internal Medicine, which is already happening, training, the leaders of hospitals, medicine, which is already happening, I have friends who are now really pushing this field forward, and helping them go helping them through our struggles, making our struggles, 20 years making their struggle, maybe a year or two. And helping them along the way with education. Billing, like you mentioned, ease of use, making sure their user experience is great, will really speed up this process, because they're gonna have to do a tremendous amount of work. There are a lot more internist in America than their emergency physicians, and to train all those residency programs, and all those physicians is going to take time, but I think we can really be advocates for them and help them along the way.
Patrick Kothe 48:56
So you've been in clinical medicine for a long time, and you've just recently been involved inside a company. And you've gotten to meet and interface with a lot of a lot of people that work in industry. What's the difference? What do you think about people inside industry?
Arun Nagdev MD 49:12
It is, it's it's so funny, because it's such a different world. Some of the smartest people I've met have been in medicine, it's the smartest people I've met have been an industry is such a different world in so many ways. But yet, I think it's what you realize it industry is in a startup things move so fast. There's so many meetings, there's so much decisions, there's so much thinking about the future. And in medicine, you know, I work as a clinician, as a clinician, researcher, and educator. It is it is a completely different skill set, which I remember at one like kind of mentors in this space. He's on our board. He would make this joke he said when they're having meetings, have another laptop and understand what they're talking about. It's a new language. And the same way that I think if you if you If I brought a family member to one of our meetings, they'd be like, What are you talking about? It's all acronyms. So I literally spent the first few months decoding most of the language. And now I'm learning how to adapt to their process, which is a completely different world. It is, I'm honored and kind of lucky to be in this position of getting to learn both fields, because I think they both are really valuable when it comes to how to run a team, as a clinician, run teams in a different manner. I mean, I work two nights ago, when I had a, you know, a gunshot wound that was really sick. And we had nurses and, and clinicians, and I'm running that team, but in a different way. But they're really great at right teams making decisions, building out what the future looks like. And also, and you can imagine, at a startup, we're dealing with the hardware with supply chain issues, the software with a build issues, marketing, average, it's all these different things going at once, and they're all running in these weird parallel pathways. Our CEO, I give him credit, he, you know, I mean, he gets to sleep. But he's, but he's really focused on building these teams and making them kind of, you know, come together. Very difficult job. Seems really easy from the outside. And, you know, I'm glad to have one foot in.
Patrick Kothe 51:25
Well, you, you mentioned the future, and I wanted to ask you about the future. Let's assume that point of care, ultrasound really gets adopted worldwide. Yeah. And it's something that's ingrained, it's being used constantly, how's that changed the practice of medicine,
Arun Nagdev MD 51:43
I think the change is going to be huge. I mean, the same way I kind of tell the story to my friends, when I think of chip based or Pima based ultrasounds, I think that delta that happened with digital film, right with analog film and digital film, that it completely was this pivot. And I think that's what's happening right now, when we get imaging in the hands of everybody, the transfer patient that comes from two hours away, that's coming to my academic medical center, I'll have imaging at the bedside, the ICU patient that at three in the morning, gets sicker, we'll have a bedside ultrasound or point of care ultrasound done will be recorded in the chart in real time, this imaging is going to be real, it's going to change the way that we as clinicians practice, it is going to be this big pivot in healthcare, of what we did before, which I think is guessing to what we're doing now, which is imaging. And I think when that happens, I think healthcare is going to dramatically change in the States, it's going to change all over the world, I can see these point of care systems being in remember, I went to Ghana and did a course like 10 years ago, up and down Ghana for two years in a row, these probes in their hands, they would run with it, I mean, they would change health care for populations. And that's that's why I'm stepping out as a full time clinician to do this is because I recognize that the impact can be so huge and helps so many people. And when I see these probes in clinics in India, defining heart defects and children defining, you know, abdominal injuries and patients who are in traumas, to helping pain control in for him for nerve blocks, in a steer settings, I think it's gonna change the way we practice medicine. And I think it's going to have a huge, profound effect.
Patrick Kothe 53:35
A ruin really found his passion early in his career. And now he's transitioned from helping one patient at a time to helping train one specialty at a time emergency medicine, to now training all physicians. And you think about that, you know, what an impact he's going to have on medicine. A few of my takeaways from this conversation. First of all, I found it really interesting when he was discussing training young clinicians versus more experienced clinicians. And really, what it points to is learning starts with the students motivation, and the students attitude. The younger people, they haven't learned any bad habits, they're eager to learn. And they're, they're learning very quickly. Whereas the more established people, they've got an impediment to learning because, you know, they think they know, you know, the right way to do it, and they're more closed off to hearing new things. So I guess my question to you is, are you a dinosaur? Or are you open to new things? Because your attitude, and your motivation is really going to lead to how long it's going to take you to learn something new. The second thing is when he talked about your training and what he's learned from the merge To see medicine and how he's going to apply that into other specialties, and he says training should be done by your peers. I thought that that was really interesting and something that that he's going to put into practice, but it's also something that we can put into practice. First of all, how are you doing your employee training? Is? Is the manager always the one talking? Or are you allowing peers to get get in there and do some training? Because the people that are accepting it may accept it a little bit more. The second thing is, how are you doing your customer training? Are your reps always doing it? Are your company people are always doing it? Or are you doing it and having it conducted by physicians peers, obviously, you want the messaging to be there, but the message is going to be watered down if it's not given by one of their peers. The last thing that I found really interesting was when he talked about moving into the medical device realm, and specifically said decoding their language and learning to adapt to their processes, which is a completely different world. He recognized that the world of medicine is different than the world of startups, and I'll flip that to us. Have you taken the time to learn your customer's language and adapted to their process? If you don't, it's going to be a long road. Thank you for listening. Make sure you get episodes downloaded to your device automatically by liking or subscribing to the mastering medical device podcasts and Apple podcasts, Spotify or wherever you get your podcasts. Also, please spread the word until a friend or two to listen to the mastering medic device podcast. As interviews like today's can help you become a more effective medical device leader. Work hard. Be kind
