TeleRadiology: RightReadMD and Founder Matthew Hermann, MD

Many thanks to Matthew Hermann, MD, a radiologist and Founder of the teleradiology company Right Read MD. Dr. Hermann began his career as a conventional radiologist but soon saw the virtues and opportunities of off-site practice. 

Now based in Puerto Rico, he leads a team of physicians who provide high-quality radiology care to multiple hospitals. Matt loves Puerto Rico’s culture and doesn’t object to their low tax rates either!

During our 40-minute discussion, Dr. Hermann discussed the potential downsides of conventional telemedicine models. For example, groups that are incentivized solely by productivity, especially those run by private equity companies, may yield suboptimal results.

Radiologists working at home can also feel isolated and miss out on learning from colleagues that would occur in a more traditional patient care setting. Dr. Hermann explored whether teleradiology is a good long-term career option. While today’s demand is great, it’s unclear what the future holds for this type of medical service.

Dr. Hermann emphasized the hidden value of dedicated on-site radiologists who can develop professional relationships with referring physicians. Relationships between radiologists and surgeons, for example, have proven to influence surgical decision-making.

However, when hospitals lack the resources for permanent on-site radiologists, teleradiology becomes a clinically necessary and attractive option. Chart access for teleradiologists, along with a focus on patient care rather than pure productivity, can help mitigate the negatives of operating off-site. 

Dr. Hermann’s company handles licensing and credentialing. He also ensures that radiologists on his team are appropriately compensated. Right Read MD continues to grow.

To learn more or to contact Dr. Hermann, please check out his website: www.rightreadmd.com

or email info@rightreadmd.com

#teleradiology #entrepreneur #burnout #hospitalmedicine #radiology #telemedicine

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Transcript

(0:08 - 0:30)

Welcome to the Art of Medicine, the program that explores the arts, business, and clinical aspects of the practice of medicine. I'm your host, Dr. Andrew Wilner. I've planned a great program for today, but first, a word from our sponsor, locumstory.com. Locumstory.com is a free, unbiased educational resource about locum tenens.

(0:30 - 0:52)

It's not an agency. Locumstory answers your questions on their website, podcast, webinars, videos, and they even have a locums 101 crash course. Learn about locums and get insights from real life physicians, PAs, and NPs at locumstory.com. My guest today is Dr. Matthew Hermannn.

(0:52 - 1:11)

Matt is a radiologist and founder of the teleradiology company, Wright Reed MD. He's here to tell us his background in medicine and how he became an entrepreneur. Perhaps he'll weigh in on the future of telemedicine and offer some financial advice to younger physicians as well.

(1:12 - 1:15)

Welcome Dr. Hermann. Thanks so much. Thanks for having me on.

(1:15 - 1:41)

I appreciate you allowing me on the show today. Yeah, well, we haven't done a teleradiology program and I remember I used to work a lot of locum tenens. I remember one night I was at a hospital that I didn't know and I got a call at like two in the morning from a radiologist about, I had a critical patient and the CT scan and we started talking about it.

(1:41 - 1:54)

And I said, this was quite a while ago, and I said, why don't I just come down and we can look at it together? He goes, well, because it's not really going to work. He goes, I'm in Iowa and I think I was in South Dakota. He goes, “I'm in my basement.”

(1:55 - 2:04)

And I was like, what? I think there was a company in Nighthawk. Do they still exist? Something like that. Yeah.

(2:04 - 2:11)

They evolved into one of the bigger private equity players. Yeah. But that was my intro into this concept.

(2:11 - 2:31)

So I don't know, you're minding your own business, a studious medical student. And so how did this happen? From medical student to tell a radiologist, I would say that what happened, because no one really goes to medical school not to see people. So I was interested in radiology because of interventional.

(2:32 - 2:54)

And then I actually did a fellowship in pain medicine, but I was at Stanford. And then after that, I, in terms of just the market, it just seemed like it was just a little more opportunistic for me to go into the radiology space. So I didn't do pain medicine and I just started reading remotely for a hospital system as a dedicated radiologist.

(2:54 - 3:12)

And then I switched to full teleradiology when I moved to Puerto Rico. Right. So, you know, radiology seems perfectly suited for this because, I mean, even at the hospital, the radiologist is reading down in the radiology department and the patients, you know, upstairs.

(3:12 - 3:32)

But he could be reading in Puerto Rico. It doesn't really matter, you know, with the quality now of digital films, I'm still calling them films, right? So digital MRIs or whatever it is, you can send them along on the Internet and they show up in just as good shape as when they left. And it really doesn't make a whole lot of difference where you are.

(3:34 - 3:59)

Yeah, I think there's some advantages. I think for teleradiology is really good for off hours radiology coverage, because usually it's emergent directed questions such as, does this person have appendicitis? Where's the aneurysm? I think that's allowed radiology to be commoditized. But I think for studies where it's such as like tumor follow ups or things where you need chart access, that's where it's good to have a permanent radiologist that might be a dedicated reader.

(4:00 - 4:17)

But yeah, I definitely see that point. I think that's that's why radiology is kind of gone where it's gone. Well, I will I would be remiss if I did not concur, because there is nothing better than continuity and continuity of care is always a good thing.

(4:17 - 4:32)

And we struggle with that where I work. I work in downtown Memphis at the county hospital and we are surrounded by five other hospitals within a five mile radius. And it just never fails that we'll get a very complicated patient who's been to all four of the other hospitals.

(4:33 - 4:47)

And the records don't transmit easily. And we're always reinventing the wheel. And it's like, can you just pick one hospital and go there so we would have all of your stuff? You know, that that would be a great cost saver and help patients.

(4:47 - 5:00)

I mean, one day that will happen. But making it happen, it's just a lot of we've done other shows on that, the political and economic challenges. But yeah, nothing better than having the same rate.

(5:00 - 5:05)

Gee, I read that study a week ago. Let's take another look. And that's just wonderful.

(5:06 - 5:31)

You know, I was out of practice for a while. This must go back almost 20 years doing full time medical journalism. And when I came back, what was different was there were these computer screens all over the hospital that in the old days, every doctor would go down to radiology at seven in the morning with a cup of coffee.

(5:32 - 6:01)

Talk to the radiologist about their patients. Somebody you may not be old enough to remember this, but, you know, put up the films would literally hang the films on this rotating thing. We would all look at them and we would talk about them and you would get a curbside consult.

You turn to your buddy and you say, you know, maybe maybe it's a GI thing. Maybe you ought to see him, you know, or surgical. Could you do it? So a lot of business was done in that first hour because everybody had to see the films from the day before.

(6:01 - 6:22)

And all the films were in the radiology department and that was the only way you could do it. And when I came back, all of a sudden there's these screens everywhere and you could just pull up the image and the report because now the reports were dictated, you know, instantly, which was not the way it was done. You had to wait a couple of days in the old days to get the report.

(6:22 - 6:32)

So that's why you had to go down the next day and talk to the radiologist because somebody was busy typing it somewhere. But that's all gone. So this instantaneous report and instantaneous film.

(6:33 - 6:51)

And then the question is, well, what about the sort of the the unwritten input from the radiologist? Because I was in the habit of discussing the film with the radiologist. I even talked to a radiologist who told me, you know, I really miss the old days. It's kind of lonely down here now.

(6:51 - 7:12)

You know, he considered himself a consultant, you know, and now I mean, so now we do it on the phone. We say, OK, can you pull up image 26-17, you know, on this MRI and we can kind of do it that way. But I take the residents physically to radiology at least a couple of times a week.

(7:12 - 7:28)

So we can it's usually a fellow or a resident that we can talk with. And and it's just amazing the insights you get from being in person that you don't get, you know, in a remote setting. So I'm going to emphasize that that's always better.

(7:28 - 7:36)

But on the other hand, a lot of times you don't need those insights and you need coverage, which is the other issue. Right. And right.

(7:37 - 7:41)

Right. I totally agree. I think for a large I think that's the downside of private equity.

(7:41 - 8:28)

Commoditizing radiology is that it's viewed as something like any other commodity. But in past 10 years, University of Michigan came out with a study that when general surgeons round with radiologists on whether or not to operate, it influences their decision by 36 percent about whether to or not operate. And so I think for health systems that can have dedicated radiologists that work for them and have chart access and are get known by their colleagues there rather than being like a frac in a fractional pool that's with a thousand other hospitals just all mixed in.

I think we're starting to see the downsides of that with patient quality. You know, there's things that are I guess you'd call them like implicit costs or costs that aren't necessarily seen on a balance sheet. And that's, you know, lawsuits, sentinel events, communication breakdowns, things that you may have seen because you've seen both models.

(8:30 - 8:37)

It's great to hear you say that. I actually wasn't expecting that point of view. So very refreshing.

(8:38 - 8:42)

So you got into this. You were a teleradiologist. You were dedicated.

(8:43 - 9:06)

Well, you were an offsite radiologist full time. And they said, you know, I could live in Puerto Rico and do this. Right.

Right. And so then what happened? I mean, it's not how do you start a company? To me, that seems kind of overwhelming. Yeah, so I moved to Puerto Rico and I didn't start a company.

(9:06 - 9:13)

I just was a contractor. So I just had my own little LLC and was ten ninety nine. My wife and I try to do an adventure every five years.

(9:13 - 9:23)

So the last adventure was riding my bicycle across the United States. And so then I wanted the next adventure to be go to go somewhere new. And it was from a tax perspective.

(9:23 - 9:33)

It was I was advantaged. I had been working kind of remote in my old job. I would go on site if, you know, the computers went down and I had to be, you know, 10 minutes from a hospital.

(9:35 - 9:52)

But I just we were in covid and I just figured let's try something new because we were just in Pennsylvania and wasn't really aligning with what we wanted. And we just wanted to try to get in a new environment. And the people we knew down there was from a networking and social perspective.

(9:52 - 10:05)

It was people that aligned with us and we could talk topics with them. You wouldn't really talk about in suburban environments such as, you know, crypto and investing and markets. So it's been a good move for me.

(10:06 - 10:16)

So you are full time located in Puerto Rico. Yeah, even though I say this from I'm in the States right now, we're getting our house remodeled. I like living there.

(10:16 - 10:22)

There's two types of people that move to Puerto Rico. There's people that are there just for the taxes. And they're only there like six months in a week.

(10:23 - 10:30)

Hard to form relationships with those people because you don't really see them as much. And then there's people like me who I'm there. I like living there.

(10:30 - 10:37)

So I'm there as much as I can. I have friends there, both local and U.S. based. I'm, you know, interested in the culture.

(10:38 - 10:55)

I'm I'm a full timer. So now. So if you can do this in in in a minute, what are the I know some states in the United States, like I live in Tennessee and Tennessee does not have income tax.

(10:55 - 11:08)

So some people will choose Tennessee for that reason. And there's a half dozen states or so that are like that. Other states like Massachusetts and Rhode Island, in addition to paying federal tax, you also pay a state income tax.

(11:08 - 11:26)

What's the deal with Puerto Rico? Why is that appealing? Yeah. So in comparison, like if you look at the extreme, like Boston, where you pay borough tax and local tax and state tax in Puerto Rico, you would pay if your company has less than three million in revenue, you would pay two percent. And then after five years or any other situations, four percent federal tax.

(11:27 - 11:42)

And then there's no state tax. And besides that, the biggest thing I think would drive that could drive people there is you don't pay tax capital gains taxes on most asset classes. And so if you go ahead.

(11:43 - 12:08)

So the federal tax is not based on the same formula. Let's say that I pay. Correct.

So let's say that you make five hundred thousand dollars, you'd probably be looking at a tax bill. Of maybe like ten thousand a year total, but then you still have to pay accountants and other stuff, but it really equates to maybe five to seven percent of your burden. Well, it would be closer to thirty nine percent here.

(12:09 - 12:21)

Right. So it's pretty substantial. And then if you sell, let's say you have a million dollars in Tesla and you sell it in the state, you pay whatever capital gains rate it is in Puerto Rico at zero percent.

(12:22 - 12:29)

Well, so that those. So why doesn't everybody live there? So visiting is different than living. Some people, the culture is different.

(12:30 - 12:38)

I think a lot of people think they just set their little feet down and they just stop paying taxes. It's a lot more complicated than that. I'm a W-2 employee in my corporation.

(12:39 - 12:44)

The infrastructure is different. Ever since Maria, 75 percent of professionals left. It has a declining population.

(12:45 - 12:54)

You have to donate to the local community and that's what we do. You have to own real estate. And so it's things are a lot harder in Puerto Rico than the states.

(12:54 - 13:01)

I couldn't. I just went to Chicago for a business conference. I couldn't believe that I could get something to an Amazon locker in a day.

(13:02 - 13:26)

I mean, in Puerto Rico, it'd probably take about a week. Yeah, right. So it is different, right? Right.

And I actually, when I was working locums, I spent a lot of time in Southeast Asia, particularly the Philippines. And, you know, that's just like an entire other universe. Right.

And it is quite different. I did. I lived there kind of like you.

(13:26 - 13:45)

Part time, three months on, three months off, that sort of thing. And I loved it. And let's see.

But there were two kinds, as you say, there were two kinds of foreigners there. There were foreigners that that loved the Philippines. It's beautiful.

The people are friendly. There's beaches. It's warm.

(13:45 - 13:56)

And then there were there were people that hated it. You know, they were there because their company sent them and they just couldn't stand it because, you know, you'd want to get something done. And you couldn't even get an answer whether it was going to get done or not.

(13:56 - 14:08)

It wasn't like, how long do I have to wait? You know, it was like, well, what are you even talking about? Right. Right. In Puerto Rico, in Puerto Rico, there's definitely people like I'm there probably about 10, 11 months a year.

(14:08 - 14:19)

This year, I'll be there 11 months. And usually people there who are just there just for the taxes, they usually last about three years or whenever their company sells. And I don't have many of those friends because they complain a lot.

(14:19 - 14:28)

And they're just kind of telling you when they're going back to the States. Like for me, I don't I'm just in a different earth than I'm like, I like it and I like the people. I have a lot of friends.

(14:29 - 14:57)

Yeah, I think you got to embrace it. And it sounds like you have. That's very exciting.

Well, I know who I'm going to visit now when I'm on my way to Puerto Rico. This sounds this sounds great. Yeah.

What about teleneurology? Do you have any slots for teleneurologists? You know, my sister does. She's the head of Telestroke at the VA, so I could get you in contact with her. There we go.

There we go. My employers, I don't think they watch the podcast, so I think we're good. OK, so, you know.

(14:58 - 15:06)

So I'm a I'm a resident, hypothetically, in radiology. I'm trying to figure out what I want to do. And I hear about this teleradiology thing.

(15:06 - 15:15)

I could live in Puerto Rico. I mean, what what's the downside of that? The downside of living in Puerto Rico is. No, I'm teleradiology.

(15:16 - 15:25)

I'm teleradiology. So I think right now the radiology job market's really good. I think that the problem is that things can change really rapidly.

(15:25 - 15:37)

When I went into radiology, I thought I'd be a member of a private practice and have upside. And then I found out it really wasn't like that. And then I just became kind of a hamster in a large cog and I kind of blue pilled into it.

(15:39 - 15:54)

You know, when you see companies, when they can get sold by private equity, you can see the value system change. And so I think that teleradiology is good. But if you're the type of person that maybe wants to be an entrepreneur or wants upside, you're not going to get that.

(15:54 - 16:09)

It's just you just trade more time for money. And so that's I think that's the downside. I think there's going to be newer models like mine that will hit the market where physicians can be rewarded for other metrics besides how much revenue they generate.

(16:10 - 16:27)

Right. You know, I think for most physicians, that the hamster wheel plan is very unsatisfying. Right.

You know, which is productivity widgets. You know, the more patients see, the more money you make. Well, there's a certain sense to that.

(16:29 - 16:48)

But, you know, I'm I'm in academic medicine. And when we get a patient who's very complicated, it takes a lot of time to review the chart, talk with other specialists, talk with the patient, examine them again. And, you know, I explained to the residents, you know, this is what we do.

(16:48 - 16:56)

We're learning, we're teaching, we're helping. But when you're a private practice, a complicated patient is just wasting a lot of time. You know, it's costing you money.

(16:57 - 17:20)

So, I mean, that's that's not a good alignment of incentives, right? Incentives should always be to take care of the patient. And frankly, one of the reasons I'm in academics is relieve somewhat of that productivity priority burden. But of course, you know, you need to get your your work done for sure.

(17:21 - 17:54)

You know, the other thing I was concerned about about, you know, telemedicine in general is that is your colleagues, you know, where are they? You know, you're in your bedroom or your basement. And like you said, when surgeons were consulting one on one in real, what do they call it? IRL in real life with radiologists, the outcomes were better. So as a career, do you think it's it's it's limiting for doctors just to be at home by themselves? I think it depends on your personality type.

(17:54 - 18:14)

I think in terms of the personality type of some radiologists, I think they're OK to be at home by themselves because they may have families or other needs. But I think one thing that can limit being at home is you might miss like corporate culture interfacing with people. And so I think you can lose some intrinsic benefit being removed.

(18:14 - 18:41)

But if you are regularly talking with providers, if that's your type of person, you get better patient care. And it's an asset, especially when providers get to know you. Yeah.

Yes. OK. So what about doing teleradiology or telemedicine as as a side gig? Does does does right read MD allow that? You know, I say I want to do, I don't know, 20 hours a month.

(18:41 - 19:19)

Or is it a full time sign up with you? How does that work? The way we've structured our model is we try to find people to do salary daytime work where they have chart access and the things that it's kind of like a unique selling proposition to hospitals, because even though it's more expensive, it brings more value rather than being grouped into some enormous pool with a thousand other hospitals. And so for daytime work, we really try to do a staffing arrangement where we're kind of the group that services the hospital for off hours work, where it's more directed questions from the ER. We do teleradiology for because of the size of our company.

(19:19 - 19:36)

It's we're not really at a point where we could have just people that just kind of pitch in as like a side hustle. I think one reason why a lot of larger companies, you can have that is because they try to grow so aggressively and they have so many clients. There's always studies to read, which means horrible turnaround times.

(19:36 - 19:44)

But if you're on the radiologist side, that means there's always work to do. You could always sign on and read a case. I'm just we're just structure a little bit differently than that.

(19:46 - 19:55)

Give me a ballpark number of how many radiologists work in right read MD. It's about eight. We're signing on some more.

(19:55 - 20:20)

And then so we're on the smaller end. But right now, with active hospital interest, we're probably going to increase that by about probably about eight to ten in the next six months. What about licensing? Oh, we have in-house licensing and credentialing.

(20:21 - 20:33)

That's are you saying like the like the headache of having like 30 physician licenses? Yes. Well, explain explain that. That's we manage that because I've done it myself.

(20:33 - 20:51)

And it's very tedious, time consuming, error prone. I think that's something where, you know, if you think about it, let's say a radiologist and your time is worth four hundred dollars an hour, six hundred dollars an hour. That's your your genius zone is reading, reading studies.

(20:51 - 21:13)

It's not looking to see what privileges you have at hospitals. And when your next expiration date is. At one point, I had 10 state licenses for locum tenens, because, you know, if you say like me, I would be in in Philippines for a few months and then say January one, I want to be working.

(21:14 - 21:24)

So I would have to tell my staffing agent, find me something January one. Well, it might be in Minnesota or South Dakota or Arizona. But if you don't have a license.

(21:25 - 21:41)

The guy with the license is going to get that assignment, because by the time you get that license, there's that assignment's going to be taken. So to position yourself well, there's no magic number, just kind of depends. Right now I'm down to, I think, four licenses.

(21:41 - 21:56)

I got a few backups in case this Tennessee thing burns itself out. But, you know, the keeping up with the licenses because they're all maturing on different days. And these days they have different CME requirements.

(21:57 - 22:23)

You know, you have this one needs two hours of risk management and this one needs two hours of HIV and this one needs three hours of hand washing. So I ended up with this giant spreadsheet, you know, that at at my rate probably cost tens of thousands of dollars to to keep going. Right.

Yeah. Instead of that was not my genius zone. I did learn a lot more about Excel, but yeah.

(22:23 - 22:48)

So how many licenses would you guys need to sort of do what you do? If you're a dedicated reader for a hospital, it's one. And then if you're doing teleradiology, it's more than that. I've just found out, especially from a CME perspective, that once you hit 25 state licenses, all your CME requirements can be met just by doing the requirements for each state for hand washing, HIV, things like that.

(22:48 - 23:37)

So for me personally, I try to hit like probably about 50 to 60 radiology specific category one CMEs just so that I'm not keeping my CMEs only on child abuse in Pennsylvania or, you know, hepatitis B in New York. Right. You know, better to just, you know, well, I mean, the whole point of CME is to learn.

Right. And so, you know, I like to do the ones where I'm learning something in addition to do the ones that I've done 10 times and probably don't have a whole lot left to learn about hand washing, but still have to do it. Yeah.

So you take you just take care of that in house, which makes a lot of sense. Right. People always ask about malpractice.

(23:37 - 23:46)

How does that work for radiologists? So it's cheaper for a group policy. So I have group policy where a radiologist will join and people ask about tail. That's all taken care of.

(23:46 - 24:14)

I think that it's more expensive on an individual component than a group component. It's just I just found out through applying that it's kind of done differently. My carrier, they just kind of incrementally increase the rate as the more radiologists you get.

But the more people you have, the rate will go down. But interestingly enough, in malpractice, your yearly premium goes up because they're covering you for more years. Right, because, well, the the tail effect.

(24:15 - 24:26)

Yeah. And that depends on which state you're in, I guess, how long you're liable. But it could be a long number of years that a case could surface from, you know, I don't know, five years ago, 10 years ago.

(24:26 - 24:31)

And you're still responsible. Right. You know, legally.

(24:33 - 25:12)

OK, so what about, you know, I'm thinking which suitcase I'm going to pack for Puerto Rico. What what kind of license? I've never had a port because Puerto Rico is not yet a state, if I'm not mistaken. So how does that work? Does Puerto Rico have a medical license that's specific for Puerto Rico? Yeah, from the Departamento de Salud, they have their own medical license and you have to complete CMEs in Spanish and you have to get recommendations from people in Puerto Rico.

But they have their own licensing board, even though they're not a state in their U.S. territory. Everything's managed through them. And I mean, things are a little different.

(25:12 - 25:18)

Like I mean, even notaries down there, they're only lawyers. There's no because it's all Spanish law. So there's no actual notary.

(25:18 - 25:25)

You actually have to go to a lawyer to get something notarized. It's this whole process. So that's what I had to do there for my licenses.

(25:28 - 25:41)

I heard what sounded like a pretty natural Spanish accent. Is that is that a quiet shine in the States? It's easy to shine the States in Puerto Rico. If you speak Spanish, they'll say it's amazing.

(25:41 - 25:50)

If you don't know that much in the States, if people don't speak perfect English, you know, it's just all a relative way you look at things. It's been acquired. I've gotten better.

(25:50 - 26:10)

There's grades of language proficiency and I would probably there's A to C and I'm a solid B, but I'm working to get to C. But the only way you can do that is just maximize exposure. I go to jujitsu gym three to five times a week and it's all in Spanish usually. And then I have lessons and I aggressively try to speak Spanish with locals.

(26:11 - 26:29)

So how do you say ow in Spanish? Yeah, you know, it's interesting for it depends for where you are. But in Colombia, where I I'm only two hours from Medellin in Bogota, when I go there, the way to say cheese for a photo is you say whiskey. They actually say whiskey.

(26:30 - 26:48)

So like when they're smiling before you take the photo, they'll be like whiskey. Yeah, it sounds like some sort of World War Two era American military kind of, you know, leftover thing from the Philippines or a lot of those things. You know, hi, Joe.

(26:48 - 26:59)

That goes back to World War Two when they see a tall white guy that they don't know. So it's fun to study cultures. I find that very, very stimulating.

(26:59 - 27:10)

It sounds like it works really well for you. Yeah, it's been it's been going well. It's fun to talk to people and just you realize that sometimes what's projected is different than what's in reality.

(27:10 - 27:29)

So every time there's a hurricane, people in the States will call me and they'll show me these horrific pictures that and for me, I was like running outside during Fiona, all of our windows in our apartment leak. And so we were. You know, going through about 30,000 hours, but besides that, I mean, it wasn't horrible, but people thought I got swept away.

(27:30 - 27:37)

So, yeah. What about the power? Wasn't the power out for a while? It's out a lot of the time. So I have a generator in my house.

(27:37 - 27:47)

Most apartment buildings have dedicated generators. The infrastructure is decaying. And part of that's the population decrease and timeliness of reinvesting.

(27:47 - 27:57)

But I have a cistern at my home and two Internets like we discussed before the show started. I have even Starling. So three and then I have you learn to have backups for backups.

(27:58 - 28:08)

Right. Starling, that's the Elon Musk system. Yeah.

Yeah. I've seen that more and more. There was a guy at the airport in Tonga a few weeks ago.

(28:08 - 28:18)

I was visiting to see the humpback whales and he had a Starlink in his backpack. Yeah. And he said you could just take it with you.

(28:18 - 28:23)

And as long as you had a plug to put it in, it would work. Yeah. Eventually it'll be connected to your cell phone.

(28:23 - 28:31)

So it kind of makes cell phone towers unnecessary. You'll just have a satellite phone. I mean, that's I've been following that.

(28:31 - 28:45)

There was a there was a there was a satellite company. Oh, must be 15 or 20 years. Iridium.

You remember Iridium? And they were way ahead of their time and they were launching. They were doing just what Elon Musk has done. But I don't think they succeeded.

(28:46 - 32:41)

You know, they were they were literally ahead of their time. And the financial model collapsed before they could really make it work. Right.

But yeah, I mean, technology continues to move along now since technology continues to move along. What do you think the future is of what you're doing? I mean, are you going to sell out in three years and go to the beach or is this a lifelong thing you think it's going to this telemedicine radiology is going to get bigger and bigger? So for me personally, I'm at a point financially where I don't have to work anymore, but I'm doing this not for the money. So I'm doing this to because I feel value in giving jobs and patients, radiologists that are kind of a cut above the rest and the interactive physician, the things we talk about.

I think radiology being heavily commoditized makes sense to private equity because they try to grow, grow, grow, accept as many contracts by radiology practices, take a radiologist like cattle and put them in a higher paying contract and then sell. And then the CEO will get like some sort of earn out based on KPIs and certain stages. It's part of my company resolution to never sell to private equity.

My goal is to make it, I don't even know what an ESOP is, but an employee owned corporation. I'd like to have that in the future once a company is big enough to support that and have like a PEO where they can get benefits and be W2s if they want. And so I think right now it's not, I think the differentiator will be showing that radiology, that a CT head is not the same thing as a ketchup bottle in the store, that it's a little more individualistic.

And so I think that if I can kind of show that I've been showing that to hospitals, I have a big meeting tomorrow with the hospital about it. Show that it doesn't really work like that and that you actually save a lot of money by having dedicated radiologists. I think that's where it's going to go.

So I think the differentiator is showing that MDs controlling an MD field is more powerful than an MBA. I mean, to give you an example, one company I worked with, there was a radiologist who was making about $300,000 a month. And the pushback I got when I brought up his quality issues was that he makes us so much revenue.

We can't be like, well, he makes so much revenue. And so I think from an MBA perspective, it makes total sense. But if it was your mom, like if those MBAs, if their moms were in the hospital, who would they want reading their scan? The multibillion dollar revenue first profit over people company? Or would they want an actual radiologist that is working for that hospital and is known by the physicians? That was my two second, that was my two minute ramble.

So yeah, I hope that answers your question. Oh, yes, that was wonderful. And it emphasizes the concept of, we used to call it patient ownership.

You know, when you were a medical student, you were assigned a patient, that's your patient. And you need to know everything about that patient. And you need to stay with that patient through their hospitalization.

So if any questions come up, you can answer that question. And to get that today is very difficult, that concept of accountability. Everything is kind of diffused.

And this was one of the big objections that that old guys like me had of the new system where residents have shift work. It's like, oh, all my residents go home at five o'clock and then a night flow comes. We never did that.

We just stayed there all night. Now, there was a downside to staying there all night for sure. But the concept that you're done at five really does not align well with the concept of ownership and accountability.

You know, it's like, well, it's almost five o'clock, the next guy can do that. I mean, that's human nature. So these things have to be, I think, really thought about carefully so that the patient's interests are always at the top, which I think a lot of people would agree with our current system is not often the case.

(32:43 - 35:53)

Right. Yeah, I agree with with a lot of that. I mean, I think if there's appropriate handoff of care, technically, the night flow team will still own the patient.

But I definitely I definitely see what you're saying. I mean, when I was at Stanford, I did the inpatient ward and we have people on ketamine infusions and other stuff. I was the only provider for 24 hours a day.

So I really got to know patients, especially when they're detox. You know, a guy who he was he had a he had twenty five hundred microgram fentanyl patches and, you know, five stacks of five across him. And I really got to know him when I took all those patches off them and detox him.

And the nurses were running away from me because I had this club with like a ball of like it was like a basketball of fentanyl patches. I was like, what do I do with this? They're like, do not touch with that all thing. So there's an advantage of that versus a night flow team, for sure.

But I think that's what you're going to see in the future is that cost could go down in some ways when you have at least I'm just speaking from radiology, not totally from clinical medicine. But when you have people that have the information with the patient or kind of integrated in the health care home, I think you could see indirect costs go down, such as communication breakdown, lawsuits, rereads, things like that. So, yes.

Well, I'm not being categorically against the new system, just that there need to be guardrails so that handoffs are done properly. And, you know, I don't think patient care necessarily suffers and it can suffer if a patient if a doctor hasn't slept for a day or two as well. So, you know, there's pros and cons.

But I think we just have to be careful when we change things that the patient always stays the number one priority. And as you say, not the private equity company, which is which is a company that comes in and buys up things looking to make money. Private equity does not come in and buy 100 radiologists and say, wow, let's make patient care better.

That's our goal. Right. I mean, they'll say it, but they'll say it.

But yeah, exactly. Their goal is growth and sell. So I agree with you.

And a lot of like, you know, for example, for what I pay radiologists per study is about 40 percent more than private equity because there's no PE blow. It's just I'm not doing this to extract value, but to create it. And so the radiologists are getting the money in the end of the day.

I reserve funds for growth and other things. But my business model, I think, is more sustainable because I'm not there to drive up the PNLs for two years, insanely high and then show a potential buyer how good the company is. It's it's essentially I'm not trying to grow to be the biggest company.

I'm growing to be the best. So that that changes a lot of things in terms of employee values and everything. Well, I really appreciate that there's at least one guy like you around and there's probably a lot of other ones that we don't know about who are just trying to do the right thing for patients.

And that's kind of heartwarming and encouraging when we see so much of the opposite. Yeah. Well, it's been a great discussion, Matt.

(35:53 - 36:11)

Is there anything you'd like to add? The only thing I'd add is that I think a lot of physicians, when they get out of training, they feel overwhelmed because it's the first time in your life you're really not being told what to do. Eighty percent of radiologists at least leave their job within two years and they go to another job. So don't be like that.

(36:11 - 36:37)

The first job you sign on is you're locked in. And I also think that there's other dimensions of your life that you never developed because you're so focused on your career that will pop up. I mean, for me, I rode my bike across the country after my pain fellowship at Stanford because I saw patients that said if I had not had this horrific thing happened to me and I didn't get like erythromyalgia or something like I would have done, why? And so I would realize that time is also an asset, not money.

(36:37 - 37:07)

And to try to do something that you think you want to do, because if you're just going to continue to jump through like hoops, the next hoop will be a grave eventually. So that's the main thing in that position. Burnout's real.

Don't be a wimp about it. Anything else I'd like to add is. People have different definitions of financial freedom, and I just be careful because I know Bitcoiners in Puerto Rico who net worth two hundred million dollars, they have all the money in the world, but now they don't necessarily have a sense of purpose.

(37:07 - 37:21)

So there's definitely a lot of drug use by some of them because they're kind of like living life on cheat codes. There's no there's nothing that gets them out of bed, you know, because they feel like kind of existential about the whole thing. So that was a little disjointed.

(37:21 - 37:39)

But yeah, that's what I'd add. Well, I would agree with you that purpose, very, very important and balance and taking advantage of time. It's one of the reasons I was swimming after humpback whales a few weeks ago and Tonga, and it's something I've always wanted to do.

(37:40 - 37:53)

And it's not really part of my day job, but I thought it ought to get done. And so I made it a priority. Yeah, I think that just sounds like very mature, wise advice.

(37:53 - 38:07)

And thanks for that. Yeah. All right.

What about are you recruiting? Is there should somebody is there a website people should go to if they are looking into this? Sure. There's right. Read mp dot com.

(38:07 - 38:34)

And I can give you the info. There's like the email address you could write is below it. Right.

Read mp dot com. We're recruiting for our next wave will be about quarter two of next of twenty twenty six. And we are recruiting for some on site positions currently.

So you can reach me through there. I'm also on LinkedIn and doximity if you don't want to go through all that. I check LinkedIn pretty regularly because that's how people connect with me.

(38:34 - 39:15)

I'm also on Facebook, but it's a pretty threadbare profile. I'm kind of a I'm not like the biggest fan of Facebook. I just think it's.

You're kind of you decrease the depth of human connection through it, so it's ironic, but you probably would agree because you're not I don't know, I get a little overwhelmed with Facebook. Yeah. So but no neurologist, you're not recruiting yet for neurologist for Puerto Rico.

Yeah, not at the moment, but maybe in the future. I am looking for some some hospitals are reaching out to me because of pain background to build pain departments. And so if you're a neurologist at a pain fellowship, we should talk.

(39:16 - 39:23)

OK, OK, well, Dr. Matthew Hermann, thanks for joining me on the art of medicine. All right. Thank you.

(39:24 - 39:50)

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(40:53 - 41:19)

Andrew Wilner M.D. is a professor of neurology at the University of Tennessee Health Science Center in Memphis, Tennessee. Views, thoughts and opinions expressed on this program belong solely to Dr. Wilner and his guests and not necessarily to their employers, organizations, other group or individual. While this program intends to be informative, it is meant for entertainment purposes only.

(41:20 - 41:39)

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