Episode 21: When Will Robots Replace Anesthesiologists? w. Dr. Jack Neil

Jul 5, 2019


This Episode

Interview with Dr. Jack Neil


You Will Learn

 – How an interdisciplinary approach to problem solving allows for the introduction of disruptive technologies and solutions.
 – Where technology may replace physicians and where it may augment physicians’ capabilities.
 – Why early attempts to replace anesthesiologists for simple G.I. surgeries have ultimately failed.
 – Which parts of healthcare are most ripe for technological advancements.

Resources & Links

In This week’s episode I interview Dr. Jack Neil.  Jack has taken an unconventional path into medicine, doing undergraduate work in computer sciences.  He has a unique perspective on the role of tech and artificial intelligence in the OR, and he himself is working on cutting edge technologies that may revolutionize some of the most annoying parts of being a physician.  So if you’re wondering how AI may impact the world of anesthesia, and if you’re in any danger of losing your job to a robot, you won’t want to miss this episode.

Show Transcript

[[this transcript was auto-generated]]

Dr. Neil: [00:00:00]especially things that have more Burton time doing an efficient processing are the ones that you’ll need less of. Those people are longer term. We’ll still need those, but if you can augment them and take away the waste, that’s actually the perfect spot.

Justin: [00:00:16]Hey, this is Justin Harvey, your host of the anesthesia success podcast. My wife is an anesthesia resident and I’m a financial planner and I work with anesthesia and pain doctors as my clients. This podcast is designed to help the anesthesia community be informed about their careers, the finances, and more by taking important questions straight to the experts. Thanks for tuning in. In this week’s episode I interviewed Dr. Jack Neal. Jack has taken an unconventional path into medicine during undergraduate work in computer sciences. He has a unique perspective on the role of tech and artificial intelligence in the o r and he himself is working on cutting edge technologies that may revolutionize some of the most annoying parts of being a physician. So if you’re wondering how AI may impact the world of anesthesia and if you’re in any danger of soon losing your job to a robot, you won’t want to miss this episode. Okay.

Justin: [00:01:07]Hello everyone. Welcome to the anesthesia success podcast. I’m your host, Justin Harvey. I’m really excited to introduce to you our guest this week, Dr. Jack Neal. Jack is a pediatric anesthesiologist and an entrepreneur and he has an extensive background in computer science and tech applications in medicine. He’s on the Asa Committee for Electronic Media and information technology and as an expert specifically in the area of applications of artificial intelligence in medicine. So Jack, thanks a lot for being here today.

Dr. Neil: [00:01:33]Pleasure to be here. Thank you. Justin.

Justin: [00:01:36]Starting off, why don’t you just tell us a little bit about the current scope of your interests as well as professional responsibilities? Cause I know they’re quite diverse.

Dr. Neil: [00:01:43]Oh yeah. This can take up the entire hour, so I’ll very tight. Yeah, I still, I’m still a practicing clinician. I probably gets about five or six clinical days a month. I have the current time that was as of this past January. I dropped down to that. We’ve got a start up that’s funded do in artificial intelligence, doing cognitive automation and healthcare, specifically starting with medical coding and that space. And I’ve spent a good amount of time on other intellectual property patenting on Blockchain, virtual reality, different topics that are applicable to the combination of tech and healthcare places that we’re just doing it wrong. It’s nobody, it’s nobody’s fault, it’s just the way that it’s been. So trying to come up with new ways to do old things. it’s been a big passion of mine and my first passion was computer science. And so now I’m, thankfully and happily getting to do more of that because medicine is a a second love at best. Technology’s definitely my first love.

Justin: [00:02:43]Yeah. That’s interesting. So I noticed looking at your CV that you’ve taken what I would call an atypical path to and through med school. So tell us a little bit about your background and your interest in tech and how that evolved into med school and what that means for today’s–

Dr. Neil: [00:02:54]I have no idea how it started. I mean, I just, when I was 10 and 12, I’d always tried to start companies just to sell in bubble gum at school and telling people not to chew it because the rule was they couldn’t chew it, not have it a started a peaking and cracking company I sold or I, I gave away burnt cds off of Napster for donations, whenever I was, you know, 13 until my dad wiped that out. But I was a computer guy all through in, through without, without a doubt. And then in 2003, so I’ve, I graduated high school at 16 and then college at 19 and I was trying to get a job in computer field in 2003 at 19 years old. And I live in South Carolina. There were no computer jobs for in 2003 for a 19 year old.

Dr. Neil: [00:03:39]And I didn’t have an entrepreneur. I didn’t know. And I didn’t have the guts to try to start something on my own, I guess. And so instead I took the AFO QT and applied to the air force. Took me, what does it mean? Hmm Gene Gee man, I don’t know, whatever the thing is for in the MBA school. And I applied to the Darla Moore School of business at South Carolina, get my interview and he says, there’s no way we’re letting you in at 19, our average person is 27. So after all those struck out had a year of scholarship and I said, well I’ll do Madison. And so, so I switched to chemistry, took chemistry one on one in one oh two in the same semester cause they wouldn’t let me take organic till I had both cause I worked on a deal with them and got that done.

Dr. Neil: [00:04:17]Then I did premed, I did all my premed in one year except for the second semester of organic and I wasn’t going to take that unless I got into med school when I got into med school. And then I had to take that the summer before I started med school. But yeah, all along the way and it, you know, my heart never changed. My Heart’s always stayed, you know, every, every game system I ever had. I tore it apart and packed every thing. I hope I don’t get in trouble for saying that. I never stole anything. No, no, no, no. What, I mean, I just, I just whittled with it. but, I mean I just love Tivo, everything. I just take it all apart and figure out how it runs and make it work better than it did originally. So

Justin: [00:04:52]yeah, some of my earliest memories were order ordering the tiger direct catalogs that are for you.

Dr. Neil: [00:04:57]I know what they are. Yeah.

Justin: [00:04:59]The wholesale computer parts. And I was all about like I, my own CPU tower

Dr. Neil: [00:05:03]and then bitcoin came around

Justin: [00:05:04]and that very much resonates with me.

Dr. Neil: [00:05:06]I think bitcoin came around and I got into, like when I was in residency at the time, I got to whittle a little bit back into my, you know, I made a couple egg crates full of mine. GPU hated my eye. He did my house in Michigan when I was up there doing fellowship, with the mining rigs. I didn’t have to run the heat at all. So I was an apartment, a two bedroom apartment. I didn’t have to turn on the heater all winter, even when it was minus 19, those two mining repeated the whole apart.

Justin: [00:05:32]So why don’t you explained briefly for people who are listening, like what exactly that means.

Dr. Neil: [00:05:37]Oh, easiest way. Oh, this is terrible. so it’s like farming but for make believe treasure, but the treasure is algorithmically important and it’s trackable. Bitcoin. Yes. It’s basically, it’s, that wasn’t exactly as a mining that you couldn’t find that when GPU is with turns and graphics processing units in the computer, they were already mined by six, those advanced circuits that were made just to mind bitcoin. So you had to use gps for things that were memory intensive because [inaudible] were computationally grade, but memory terrible. So anything I get to mine other stuff. Okay. So that’s what I was doing then. But yeah, that’s just a cryptocurrency. And as of yesterday now, Facebook’s in the game with a stable coin. They’re doing the labor, all that. So I saw, so yeah, that’s always been, I’ve said the way to make the money in Crypto was do a stable coin. People put money into it. You just live off the interest and you have almost no risk for the money in the bank. Live off the interest as long as you got enough money in the back because that’s a whole different topic and that’ll be all I have on blockchain today.

Justin: [00:06:38]Cool. So let’s talk for a minute about, you know, your trans that you went through med school at. So how old were you when you finished med school?

Dr. Neil: [00:06:46]I did a year of computer work before I started med school. and I was a systems administrator and wrote a bunch of software for some companies during that year. But that was was probably 23 it might’ve been 24 because of that year off. And then did you go straight into residency from there? Yeah, I, I tried not to. I tried to, I wrote letters back in that time when I was in med school, I wrote a letter to apple and a letter to Google and I begged them to get into the EMR game because at the time EMR is were starting and they were awful. And even at that time, Microsoft, I didn’t trust like their windows was getting worse, not better. I think now they’re, I love Microsoft, but but at the time, the only too trustworthy that I thought knew how to make elegant or efficient systems were Google and apple.

Dr. Neil: [00:07:29]I tried, Google said they were working with the three vendors ad supported. I was like, well that’s gone. And then Apple’s didn’t respond, so, oh well I’m trying to get him to do a healthcare cloud in 2003 or [inaudible] six. Well, yeah, God, he’s didn’t have the guts. I didn’t get guts until a little later in life, so I didn’t, I just didn’t. Yeah, I whittled, I program, that kind of stuff and I just always made it work and then I move on to the next thing. I never stuck. It just didn’t have the business mind to make it further than a fun, awesome project.

Justin: [00:08:03]Yeah. Well, it’s clear that you’ve been ahead of the curve all since the beginning. So you went through med school, you tried to not go to residency, but you ended up doing that. I saw that you did a year in here, which sounds not too bad. And then he did anesthesia, your anesthesia residency, stateside. So how was that experience for you and you know, being I would guess on the younger side of your resident class was that,

Dr. Neil: [00:08:26]that was close to average by then. because of the year off and then, and I had switched specialties. I started as I was going to do general pediatrics originally. and that was my goal was to move back home and open a little clinic in my hometown. And at the time I was married and we were from the same hometown and that was going to work great. But then during that first year we separated and I was like, I ain’t moving back there. So, that’s when I switched specialties to anesthesia and then did the surgery here. So I ended up like blowing another year there or you know, learning extra things I didn’t need to learn. I mean, residency sucks now, you know, and never is going to be any good. And it’s an awful experience from probably any, even the pediatric, and it was all, it’s just awful.

Dr. Neil: [00:09:07]But I mean, you, you could never do it again. Right. It’s one of those things that you say, I made it through once, but if you told me I had to go do that again, I’d quit. I’d do something different. But you can do it once. Everybody can do it once. So you make it through it. And you know, once you’re started, I mean, as long as you haven’t been grit attitude and just the don’t give up attitude and you know, I got a giant Tattoo on my back that says failure’s not an option. So, I live at, just, just set your goal and set a bad goal, learn, but you got to get there to go finish out. But, so yeah, that’s residency in a nutshell.

Justin: [00:09:42]So did you have any experiences during residency? It sounds like you kind of went in with a mindset of, I’m you in particular cannot not see the world this way, where you’re looking for opportunities for technological optimization and existing processes and things. So in that residency timeframe, were you seeing things where like, oh, I want to do this, I want to do that, I want to improve the EMR, I want to find other tech applications for surgery or anesthesia or what have you.

Dr. Neil: [00:10:04]Yeah, I did. I think I didn’t quite, because it’s so overwhelming and like, so honestly, when I, when I got into med school, I didn’t know anything about medicine, nothing. I didn’t know that there was, I didn’t know that residency was a thing. Right. I didn’t, that was blindsided me third year when I started my third year and I got all these weird hours. I’m like, what the hell? Like what happened here? Like I thought the hardest part was getting in, like, and so yeah, residency shocked me. It was complete shock. I didn’t, I did not know that was a thing. And so, so I was just, I think I was never quite caught up mentally to think past that. I mean, I still wrote a bunch of software, like in med school I wrote software to record the lectures and including the clicks so that it can put it onto a web feed.

Dr. Neil: [00:10:48]So people are in India. I think we had that. We’re watching and learning from us. So I wrote that software and then I wrote one to do a paging system throughout the hospitals. So you could, there’s an icon on the desktop that you could click and it would page stat team to come to that. Or because we had no team that could, we had no way to notify people. You just stuck your head out the door and screamed. So we made it where you can just double click an icon on the desktop and call for help to them. So I mean, I did a little project constantly all along, but never with an idea of more than just fixing the bandaid, you know, it’s, it departments and hospitals, you know, bless their hearts. I mean, if they had ideas of changing the world, they probably wouldn’t be in the it department of the hospital.

Dr. Neil: [00:11:26]So when you ask for stuff, their mindset, and a lot of times, I mean, again, there’s plenty of good people I’m sure, but a large percentage, you know, five o’clock is what they’re looking forward to and yeah, for watchers ask and it’s going to mess that up then not likely to happen. So most of the time I just do it on my own Id, you know, I just, I’d find a way to get through it. So, so I did those things, but I never, I just didn’t quite think further along than that. I didn’t quite that open. I though I was blinded by the time constraints or just the time that was required. He was mentally fatigued after residency, during residency. So yeah.

Justin: [00:12:04]So at what point then, so I know you’ve got Zach, either you got Hank and you got the med stream situation, all three of those I would call like different separate endeavors of yours. Why don’t you maybe unpack what each of those are and maybe if there’s, I know there’s some other stuff to just kind of describe in brief what each of those represents and then kind of when those came into this onto the scene for you.

Dr. Neil: [00:12:27]Yeah, so the anesthesia company I worked for, and it’s about, 150 docs, about 300 crns, something that’s changing, but something around there. We’ve got about 55 hospitals and then when I started there, there are a lot of smaller hospitals, four to eight o r hospitals and they have a lot of trouble getting anesthesia medical record systems because they don’t have good networks. our group is like a contract group, so most, a lot of them don’t want to spend a bunch of money installing systems for us because it’s sort of our responsibility, at least in their mining and the rules put out by the government for meaningful use and stuff. It’s always excluded anesthesia because there was, we lobby strongly for it because there wasn’t those issues. We’re content, so we weren’t pushed to do EMR so much. A lot of anesthesia records, you know, probably even at this point, probably, I’m guessing 30 to 40% are still on paper.

Dr. Neil: [00:13:19]Maybe higher than that.

Justin: [00:13:21]Really?

Dr. Neil: [00:13:21]Yeah. So large for them. The anesthesia part is still on paper. So we wrote in aim system, anesthesia information management system for our people that can sync with bad network. So if your network is bad, it didn’t matter. It was a big client. So, and pull all the day to day on. So even if we expected your network to be bad. So we basically plan for cyber attacks constantly, right? So all the things that large institution sphere now, which is a cyber attack, which takes out their network and disrupts their care, we built it because that happened to us just by the nature of the networks to the hospital. So, so we made that. And, so then over time I kept doing stuff along those, you know,

Justin: [00:13:57]so med stream it sounds like is a, is like a, a private group of physicians and crns and in addition to your clinical practice, there’s a tech element where you’ve got this anesthesia that the AME system that you mentioned, right. And you are involved in sounds like both of those things.

Dr. Neil: [00:14:13]I helped to build it up, sort of handed the, and I was involved when we started that. So for the first year and a half of that company called blue nine. So I helped develop that, inspect that and build that up. And then after a while I kind of just had other interests that pulled me away. And, you know, the guy who’s running that now is doing great. So I don’t do much with that piece anymore. And still from med stream, which is the actual provider group, that’s what I’m the CTO of. And so, so we do different projects with technology. A lot of us with communication from our stand point, but so Zigler came about because you know, we haven’t talked about AI yet, but for AI, any of these artificial intelligence systems, anything that’s using deep learning or neural networks or these fancy computational things, they need training.

Dr. Neil: [00:14:58]There are different ways, but in general, any training data, they need a lots of samples, a lot of examples to learn. They don’t learn like you or I do where somebody tells you, you know, if you wanted to tell me how to, you know, know that, you know, if you, if you held up a cat and a dog and you were going to tell me why this is a dog, you might tell me. Because when it barks, it makes that noise. Like, you know, and, but if I was going to try to learn it without you teaching me and I just needed to see a bunch of examples, it would take a lot longer to figure out the difference between two things to learn. So in medicine, it’s like you’re just the easy one to think about sepsis or not sepsis, right? Scepticism when your bloodstream infection, when your heart rate fast, blood pressure’s low and let stuff like that.

Dr. Neil: [00:15:39]So if you’re going to teach somebody, you’ll tell them what to look for. This deep learning systems need lots and lots of examples. The problem is if they get lots and lots of examples in the wrong situation, they’ll learn the wrong thing. So we were sitting in a lecture one time and are in the conference and I’m, I was sitting beside this Guy Chit, who’s from London and they were, the guy was presenting, the system that was trained to look at a wolf or a Husky and it was getting it wrong about 30% of the time. Right? And they were like, why is it getting it wrong? So they worked on this lot. The system, like it’s all fine, but it doesn’t back propagate. So we tried to figure out why in the picture the system looked at to figure out the difference. And what it found was that it was getting, it was saying it was a wolf when it was a husky too often and when I looked back at found it was because there was snow.

Dr. Neil: [00:16:26]It wasn’t even looking at the dog or the animal. It was like it’s out of a snow. And so what happened was their training samples, they had too many wolves and snow. A lot of their pictures that they traded on and wolves and snow. So the system learned to guess wolf when it sees snow and so it’s not even looking at the actual animals. I said, man, you, this brings up the point you need. How would you train the system to not be that way? You need giant diverse, unbiased training sets and so that’s where Zatar came from. It was way to crowdsourced large, unbiased training sets, pay people to do it, hand it off to Steve that needed, if you need a ton of audio samples of a brake belt or the brake squeaking on a F-150, how are you going to get that?

Dr. Neil: [00:17:08]If your cord, and that’s going to be really hard to go send your people out to get it and all kinds of different humidities and all kinds of different locations. So instead just offer it up. If you’ve got an F-150, submit an audio sample and we’ll pay you two bucks, you know, so they can get it quickly. Reps, that’s what Zach there came from that sort of being led by a group out of London. The chat and other people in London are leading that. You know, my main thing is Hank AI, which is the, we called cognitive automation. It’s a way to learn the way that you and I learned some of the IP is still pending on that, so I can’t be too, too graphic on how it works. But in general it captures explanations and knowledge similar to I would teach you something you can teach it.

Dr. Neil: [00:17:51]So we do typical machine learning, looking back at large data sets and creating predictions based on seeing a bunch of examples, but also it gets reinforced and train on top of that by humans telling us why when they’re wrong. That’s, that’s kind of big picture thing. But so that’s going and that sort of my main baby, that sexually named after my kid. So it really literally is my baby. So that one’s moving along, we’re funded on it and we’ve got a good bit of traction and it’s got lots of different applications. We’re initially doing it to do medical coding, any, you know, basically anything that takes digital inputs and crates and digital output in general. It’s sad that humans do those jobs. I mean it’s, yeah, we’re stuck doing ’em because they came about as we became sort of entrapped by computers.

Dr. Neil: [00:18:36]But it’s a shame that we’re doing those jobs. They’re so saddening. So maybe take a minute and describe sort of beginning to end how that process looks right now in sort of a sad scenario and then describe how Hank AI may engage to streamline it and how it would look and, and the impact it would have. So in general that that, you know, there’s lots of different nuances to it. So I’ll take up almost an example approach that sort of, I think representative, but you know, when, let’s just do primary care cause everybody goes to primary care and understands it. This isn’t specifically anesthesia, but let’s say you go to your doctor, he or she sees you, they get some information, some vital signs and different pieces of laboratory results or whatever they order, then they dock, they dictate a note or they type it in the computer and use a template or dragging or somehow they get a note in the computer.

Dr. Neil: [00:19:25]and then that whole set, basically the, the labs and vitals and the things they get built in a separate way than the provider services and provider services can really only be build based on the notes, right? The documentation that’s in there. The problem is, you know, 80 to 90% of the information that we have in healthcare is in free text, right? So you gotta get out of free text and then once you do that and now you still got work to do, it’s not, you just, you know, and that’s not an easy process. Number one, it’s still not done. When you get the information pulled out, you still have to figure out how, what, what was your goal? Sure. You know, there’s some nouns in there and you know, there’s a few diagnoses, but what is by itself is not worth much. Humans take the free text, typically that’s how it works.

Dr. Neil: [00:20:06]Now that information goes to a billing company or somewhere else and that, and a human looks reads through it, fingers out what codes. There’s a different for procedures, they’re CPT codes for anesthesia, there’s an asa version of the CPT code. And then, for diagnoses in general, we use the ICD 10 coding system. and so a human assigns these things and sends it and for payment, and this is in the fee for service model. There a little bit of nuance when you get into a value based care and stuff, but a, that’s too complicated and who knows where it’ll go. So I’m not going to bother. But and even in that, you still need to keep track. You still have to do something similar but you’re not exactly paid based on it. But in the fee for service, you’re paid based on those things you submit.

Dr. Neil: [00:20:52]Well, a couple of things, couple of issue in there. One clearly that sucks, right? That’s a, that’s like when you use the transcribe and somebody sat and listened to it the next day and put it back into a computer. You got to wait for that stuff to happen. It can’t happen live. if a computer doesn’t mean you don’t automate it, it can’t happen live. So all the benefits of doing that stuff live. Like if you’re dictating live, you can fix stuff, right? We love it. Now doctors are do it. You can’t imagine that I would have to come back tomorrow and reread that and I would, I’ll change it while I’m doing it. So now as you document your record, you would start seeing what’s coming out of it live as you document. So then you’ve seen the codes, exactly the CPT see and want you to support what is your documentation support as you do it.

Dr. Neil: [00:21:34]And if you can do that and now you take out that back and forth in efficiency that you were having, you also do it faster and I need to achieve for, and you’ll hit different opinions on this, but my opinion is the objectivity of not having a human do it and at being at the mercy of someone who has read the last doc, the rit last updates, the ICD manual, whatever. Having that objective not subjective I think is a huge plus. Even if it’s slightly wrong, you know, even if even if it’s even if it has to make a few guesses. this is in the, you know, the low stakes environment, there’s no patient lie there. There’s stakes, right? You’ve got something that might go on a medical record forever because it predicted, you know, it came up with the wrong code, but humans do it too, right?

Dr. Neil: [00:22:17]Humans put the wrong codes on it. Plenty. All as long as they do it better, I think we’re in a better place. So doing that live and then, you know, big picture. I think that they should also, because you know, up coding and fraud and there’s so many different ways of the game, the system making that objective, you have to lie in your documentation to up code. And if you’re doing that, you’re going to get busted. but you can’t just hedge everything up to a slightly more expensive code for every office visit. Just because, man, I’m thinking this is an asa or for us in anesthesia and I don’t think that’s an asa. Sorry, I’m gonna get a three. No, let’s make that object. They, that’s the benefit, I think. Objectivity, efficiency, speed. You know, that, why interactions? So you know, what’s coming out of this and would the price transparency that the government’s pushing for.

Dr. Neil: [00:23:07]And I think that everybody wants, some people want actually, when they’ve done surveys, not literally, people are like 40% of people don’t care. But I’m surprised. But I think that’s a huge value that also you’ll never get price transparency until you can do live coding. You know when you do your preop and it can tell you what your pre all, you know, if you can automate preauthorizations prior authorizations, that’d be huge, right? You don’t have to go through the back and forth. Tons and tons of things that will get better by automating that process. It’s a complicated and difficult technical process and they will be humans in that loop for a long, long, long time. It’s just about speeding up helping and in the places where you can double check things like before you send your claims in at night to be able to double check, but there’s no egregious errors that you overlook something or that what we predicted, the codes are nothing like what your humans, maybe you’re going to read the wrong records, who knows? But like just those types of things, the assistance is huge too. That’s probably way more than you ask for.

Justin: [00:24:06]That was pretty good. So, so Hank then is going to be the, the way that the free text gets read and interpreted into the relevant CPT codes that the physician who’s entering the text can see in real time and evaluate. You know, if those codes are appropriate.

Dr. Neil: [00:24:23]Correct. That’s one of the many places that it would fit because in my mind, longterm speaking, insurers should pay based on the documentation, not based on the codes you apply. It’s a archaic system that we needed to filter the medical record into a few codes for the insurer to pay. Patients are far more complex and as a provider we all know, even though this is all this says that supported I t I was way more complicated. I should have been paid way more than this code supports. Right? So by I think longterm by automating the process, making an objective what you, you put a similar system on the insurer side and now that we have interoperability, the insurer can pull the record and for initially they can just audit that you’re not upcoding longer term. That can be how we get paid if moving the coding that their side is a far more efficient process than doing it for every single provider. And every small clinic has to deal with this. And everybody know if instead it’s just the insurers pull, now the doctors are going to say, well, I don’t trust the insurers. And that’s true, right? That’s why you need to run the same objective system before you send it in so that you know what the hell’s gonna happen. right.

Justin: [00:25:40]So in a perfect world, then the, the physician just enter essentially dictates the notes real time and then ships it off and the insurer

Dr. Neil: [00:25:48]real time, he knows back what’s going to happen. Right.

Justin: [00:25:52]Okay, that makes sense. And you know, with regards to transparency, I’m a, I’ve been beating the transparency drum and all different ways a lot in my industry with financial advising, but also in medicine it’s, it’s confusing to me. I, a couple of years ago I had a benign cyst taken out of my wrist and as an experiment I was like, I swear I’m not gonna get the surgery done until I know how much it costs. And it was like the person at the hospital and the doctor, the P, I was like asking everybody and everybody was pointing somewhere else. And finally I just, I literally just gave up, for something as simple as, you know, having a, a little thing taken out of my wrist and I thought, oh my gosh, if you have a complex surgery or some kind of procedure that’s like a multistage how on earth are you ever going to have any sense of what this is actually going to cost you?

Dr. Neil: [00:26:35]And 21 years ago, well, 20 years ago you’d probably been, it had been easier. Right now one of our issues is when the consolidation, we get so separated from billing as a provider, right? Like the anesthesia or like even other surgeons probably are a little more close to the billing process. They probably know a little more about, but still a lot of them are hospital employed and they will know very little about what that person may know, what our views are. I mean they know what they’re getting at the end of the, you know, they, they know those things, but they don’t know what this cost cause they’re not involved with that process because we’ve gotten so many levels of administration between us in that process. So bringing that all the way back together I think would be, it would help us choose better too if we care about costs, which some people do, some people don’t. But in good people,

Justin: [00:27:23]I think ultimately we must, as a society, like if nobody knows or cares how much anything costs, it cannot continue to be affordable. Just it just can’t.

Dr. Neil: [00:27:31]Right. And that’s [inaudible] you’re supposed to do and we’ll see. But I agree. Now I’ll say that, you know, when we had, we’ve got a two year old and whenever we had him, that was my first and I been pretty healthy. I haven’t had many experiences with the hospital system, just primary care. And that’s very much simpler. Much, you know what the Copay, that’s much. And actually we’re a healthcare shear. We’re not even, we don’t have health insurance. We use Christian healthcare sharing plan. So, even though we’re both, my wife’s a pediatrician, but we still don’t have health insurance. but, but when we had, when we had our son, it was mind numbing how we just kept getting bills and I’m like, I paid him, like I’d pay him and I get another bill. And finally I said, I’m not paying any more bills.

Dr. Neil: [00:28:13]It’s like I’ve already paid for three days. What am I getting bill after bill after bill? Why are there, I’m getting, what am I getting a bill? And the multiple were coming from the hospital, but it was different pieces of the hospital lab was sending me one the other. And so finally I just couldn’t pay in it. And then I said, I’m not gonna pay this. I pay that three times and I’m not paying this for a year. I’m gonna wait on everything to get together and then I’ll pay it all at once. I am not going to keep it. I don’t, I don’t have that many stamps in my house. so, so then, yeah, so I waited and they sent me to collections and then I paid it from collections. But that was easier. That was easier than the other way. Yes, it is crappy.

Justin: [00:28:49]Yeah. Okay, cool. Well that is one approach necessarily you personally recommend, but that’s one way to do it. so I’m interested, you know, with, with all the time you spent running around in the AI and advanced technological applications in medicine, to what extent have you seen it in your field of anesthesia or a to what extent? You know, I, I know that every now and then we’ll see an article like the one that you wrote in the asa magazine last year, like, is tech, is a AI going to enhance you as a physician or replace you? And I know you, you referred to Sudan assists the, the J and, j, a sort of Prodo automated anesthesiologist that was used for some simple GI cases that eventually kind of was phased out. Maybe talk a little bit about that and a little bit about how do you see AI impacting your specialty in particular?

Dr. Neil: [00:29:38]Yeah. I’ll start with saying the, when you’re just looking at what I’ll call augmentation or assistance, those two I would use interchangeably. Even though the linguists around us will probably say they’re not. So for augmentation things that’ll help us, that’s definitely in my mind, without a doubt, the things that are coming first. Right. Even for the stuff, even for the Hank AI projects, even the things we’re doing assistance as a first step, right? But in the higher stakes environments where there’s lives at risk, I mean, if you think about, yeah, 25, I’m just guessing how long a 2030 years ago, he kgs and he wrote some expert systems, look at the wave form and it spits out a reading on the EKG. Right? And it tells us good. Pretty, pretty good. Right? I’m gonna need, if these, the others, I can read the EKG, but I still look right.

Dr. Neil: [00:30:24]I don’t look first because I don’t want it to Jane, me, but I do, I, I really EKG and I look and if it says something I didn’t see, well it might be a better EKG reader than me. I don’t know. I mean, so I can’t ignore it. Okay. With that. Even when that’s been around for 20 to 30 years and it’s really good, we still have to over read every single EKG. Right. So that technically is an automated system or could be, but regulation and compliance and what’s the word I’m looking for? risk and risk. You know, we need a human to blame. Well, yeah, you always want a human to blame. We’re still in a society that needs the human to blame no matter what goes wrong. A plane, a car. Yeah. Anesthesia machine. You want, you want a human, again, blame on machine or even the machine maker.

Dr. Neil: [00:31:08]So the humans always the lowest you’re going to get blamed when you’re using the machines. So be careful if you’re using machines that are automated, I would say in the provider because you will be blamed if it malfunctions. But, the grill problem there is if, if your goal, like set asis, which was trying to sort of replace, like they missed their value proposition, right? What is the value of the machine? Is it that you don’t need a, is it a replacement? So you don’t need a provider there? Well the problem is you can’t even get rid of the cardiologist read any EKG. There is no way you’re going to get rid of a provider who can give airway support. Right? And it’s just not going to happen. And even if it could the provider, the PA. So what happened is you had to understate the patients with those machines a lot of times.

Dr. Neil: [00:31:48]And then as the GI guy was pissed off because the patient’s wiggling around and then you know, and they did, if they made them to sleep, it was like an airway problems and that’s a risk. So it just, if they miss, they miss their value prop. So augmentation is really more, I think where they should have focused that they had focused on interoperatively dialing in the dials based on this monitoring or other things. That’s probably got some muster. Right. Hey, in a little more attention, don’t make them too deep or too light in half if you’re not paying attention. You know? And we all pay a lot of attention in the or, but every now and then somebody probably doesn’t pay as much attention as they should when things are smooth sailing and the patient wiggles and they’re sound asleep but they wiggle a little bit.

Dr. Neil: [00:32:27]It’s just how anesthesia works. A system that auto dials it based on this monitor other which are best is like a EEG monitoring brainwaves and things like that probably would prevent that. So augmentation would be, but automation is sort of where I think we should stay away from. And the last piece on this will be the, the concept that I wrote in that article, which is when we think of like AI, right? You have to think hardware and software just like humans are hardware and software. I mean our software is our brain, our central nervous system that controls and tells everything what to do. That software that co the problem with, you know, we, we have arms and legs and miles with that. That’s our hardware. And so if we, we need, we need to think about the systems the same way. We need to still separate out machines and hardware and software.

Dr. Neil: [00:33:13]So if the task you’re trying to automate involves a lot of hardware, we’re not very close with hardware. Hardware does not advance on its own [inaudible] right? We might be able to write software that can advance hardware on its own, but that’s two layers deep, right? That’s not what we’re doing right now in any real manner. So if your job is a completely cognitive task without much hardware involvement, that’s one the, I mean, just think is this really a job a humans should be doing in the first place? or you know, that’s a complicated, very politically device or a challenging topic to go into. But yeah, I’m still something we’re thinking about.

Justin: [00:33:55]Yeah. And I, and I know something that I’ve heard with radiology and interpreting scans, that’s something that, is, you know, hypothetically a little closer or it would be more easily replaced because there’s, there’s not the procedural element when you’re interpreting a scan. And so perhaps that might be a specialty that might be a little closer to, again, it doesn’t seem imminent based on the things I see or hear. But yeah,

Dr. Neil: [00:34:22]in theory and technically speaking you’re true. The problem there is not the technology. Just like the problem with the EKG is not the technology. The problem is acceptance and we won’t, we want a person to blame. So I think it will speed things up. It will probably, you know, every day a lot of radiologists, you have to read all the x rays coming in from the, in the tracheal tube depth and a lot of the just mundane things that you can automate. But I think they’ll still need an override for a long time because we need a thing that we need a human to blame as the main reason.

Justin: [00:34:57]And I would also note that I was looking at the a physician compensation benchmarking from Becker’s that came out the other day and radiologist’s had the highest year over year compensation increase in about 7% of all the, all the specialties. So clearly they’re not in danger of going away at the dinosaur

Dr. Neil: [00:35:14]And one thing could come out on their benefit is the fear of jobs going away may lead to a shortage of them, of people going into those residencies and they might be really well off. But most of it, most systems, a few, you know, my challenge to people is always look at the job you’re doing and see how much of this is waste. And of course we all know like most of what we do is waste. just we inefficient just clicking buttons and things that are definitely not adding value to the system. but if you automate it, if you improve those things with technology, not with just lean movements telling you to work harder with less, like the lean movements have pushed us about as far as the high deductible plans can push us, you know, health insurance costs. Like you can’t push it any further.

Dr. Neil: [00:35:55]We’re probably at the limit of how fast I can turn over a room and how many, whatever. So you need technology to help. It did help though. And you had that 80% of your time back, would they need as many of you? Isn’t the question really more than anything that I would say for whatever the specialty is, especially things that have more burn time, doing inefficient processes are the ones that you’ll need less of those people. Longer term you will still need those people, but if you can augment them and take away the waste, I mean that’s a, that’s actually the perfect spot. You know, my wife’s pediatrician I see are spend so much time just charting and thinking that’s it. If you didn’t have to do any of that, if you truly just see patients, how many more patients do you think you can see in a day and still be happy, right and still be satisfied with your, with your life, you know, and it’s, it’s probably 50% to 100% more based. Almost see twice as many patients in a day. If you took away all the junk work around it and she’s still be satisfied. Those are the things that I think we have are the big things we need to do as a society. When it comes to applying technology, that’s where the money’s at. I would say.

Justin: [00:37:01]Yeah. And this isn’t unique to medicine in any way. And in fact in medicine I would, I would imagine is probably one of the most, I’m totally guessing, but it’s, it’s difficult to replace a doctor. It’s not like in five years it’s going to be a robot taking your palace in a robot, doing your surgery and a robot administering anesthesia. Like physicians again seem like there’s no danger that on the horizon.

Dr. Neil: [00:37:24]Yeah, I just, I think that just like, and you know, this is a con on, I’m not sure who listened to this podcast, probably controversial. I don’t mean to step on anybody’s toes. I love [inaudible]. But I will say that the, one of the things that allows for less amount, less length of training to get to the same point is the technology that makes it safer. And if you keep making it safer, you’ll need less and less training. So, you know, with even with the asa and with the anesthesiologists I’m at, what do we do to defend our profession? If we do keep making technology that makes it safer and safer and safer, wants the end results of that. With doctors, you still need doctors. You know, you still need people who understand cause things don’t always go right and no computer system doesn’t have bugs, right.

Dr. Neil: [00:38:10]No matter what. And not all the data is digital. A lot of it is looking at it, the sniff test, you know that I looked at this patient and they don’t look good, so you’ll still need doctors, but it does change the number. Probably even the ratio and even the crns something might come under them. You might not need a full nursing and RNA training. You may just need airway support training at some point. Right? You just need to know how to handle an airway. All the rest of it’s automatic. I’m sure. I think that can definitely happen, but there will be a person there because I am convinced completely [inaudible] as far forward as I can see. We’ll want a person to blame until cars don’t get, until Tesla gets blamed for the car wreck in itself, not the driver who’s in it. I don’t think cars will drive themselves from the foreseeable. We’ll always, we’ll blame a person for at least 20 years.

Justin: [00:39:03]Yeah. So and, and because of the social resistance to that, I think. Yeah, exactly. I think that’s absolutely on point.

Dr. Neil: [00:39:08]Yeah. It’s not a technical challenge really. It’s just a societal acceptance culture. Hey, you might be able to do it in other, your first place you’ll do a lot of this automated stuff is on Elan’s first trip to Mars. Right. Perfectly. How many options? It’ll all be automated.

Justin: [00:39:24]Build his new society with all cars that are going to be [inaudible] and there will probably be no accidents.

Dr. Neil: [00:39:30]That’s right. It’ll be better. You will realize it’ll take something like that to tell us all, hey look, it’s way better. Just don’t point. Don’t blame people all the time. Like, yeah, that’s a whole different podcast.

Justin: [00:39:43]It is. So I want to pivot a little bit before we wrap up and, and just talk about sort of the personal side. Cause I know as a physician, somebody like you who you’re a clinician, you’re a business owner, you’re writing code, you’re doing software implementation, you’re brainstorming new ideas and new applications for these things. You’re a busy guy and you’re also married. You have a two year old son and these things are also important to you. I remember seeing in your linkedin profile you had husband and father right there in your byline next to you know, entrepreneur and physician, which I thought was unusual and also commendable. So I was, I kind of appreciated that. And I’m interested in, I know, you know, how do you, how do you balance these things and how do you and your wife as too busy doctors presumably like how do you, how do you make life work together?

Dr. Neil: [00:40:27]Yeah, not very good at it. I will start out let’s say, and I am no master. It takes constant attention. I mean, and I am wired naturally to, you know, maybe if you study much about flow and states of flow and how you get into the moments, like it’s got video. Every, everybody plays a video game. Our mind say, anybody can, this is me. But I guess most people can have something in their life that maybe it’s knitting or whatever. And when you get into it, like the world stop time stops. Like you do it for an hour and a half and then you realize, oh wait, this time went by. That’s how I am with writing software. Right? I mean, I, when I practice anesthesia, say this all the time, but when I practice anesthesia, I look forward to two things, launch in 3:00 PM or it depends on where it is.

Dr. Neil: [00:41:08]It might be five feet. but whenever I’m writing code, like I’ll skip lunch and it’ll be seven and my wife have to come and get me for stuff, right? That I have. I have, that’s what can happen. And I know that can happen. So I have to pay special attention to not let that happen. and it’s not a natural thing because naturally you can never have written all the code, the software, you know, the program. There’s always some bug. There’s always something better some way. Yeah. So I have to pay special attention to it. a lot of light helped me. This might not work for everybody, but, and that a year and a half ago I met this dude who was, he didn’t really market himself as anything in particular, kind of a CEO coach. He’s also sort of my in that, that’s a way to say you have a psychiatrist that you don’t call a psychiatrist or a psychologist.

Dr. Neil: [00:42:00]You had basically what that say and you don’t wanna admit it. But, but he’s, he’s great cause like, you know, I talked to him, you know, every other week or so, and just go through things and make sure that I’m keeping things on track, keep the two year plan, five year plan life plan, and then make sure we have a life coach. She would say, yeah, it’s basically, it’s those things that now, you know, you say my, you know, it’s so cliche. Every comedian talks about, you know, I’m good, I got a therapist. so we all want a therapist and we all want somebody that doesn’t come across as maybe a nice, but I mean I think everybody could benefit from it. Some people like truly need it. I think without one I’d be personally okay. Like me, Jack would probably not my whole family.

Dr. Neil: [00:42:40]Right, right. I think having something or someone that keeps you the, make sure you’re not forgetting about an important part of your life when you’re really wrapped up. Cause you know, everybody who’s been through med school or residency always knows. You look at that line that you’re trying to cross and the moment you cross it, there’s another line. Right? And you never crossed the last one until you’re dead. So if you don’t stop every, if you don’t continue, if you don’t think about that, you never stopped. Maybe that’s just me or people like me, but like you, you will chase that line for em. So it takes a lot of stop now. It also helps to year olds are cute and fun and call from the Daddy. That helps too. So, so when I’m working in my office and I hear him be able there screaming daddy, I can’t like that gets me out of it and I go play. But it is a challenge. Definitely a challenge. And you know, we set some rules. Sundays are, we know we go to Sunday school, Sundays are our day unless something crazy. 90% of the time, Sundays are our day. And that’s sort of the man

Justin: [00:43:41]that’s good. And I’m mostly asking for myself because you know, my wife’s in residency and it’s a very demanding time and I’m starting this business and doing a lot of financial planning and wanting to show up my clients really well. And also the two of us trying to like, you know, keep the household running and we don’t have kids yet, but that’s probably on the horizon then. It’s a wanting to have a healthy family life and a healthy marriage and eventually the healthy household, whoever, whoever it is. I know that takes a lot of focused effort cause your job will take and take and take and take and will not. My wife very astutely points out like it won’t love you back.

Dr. Neil: [00:44:14]And, and I, I say the other key is having the right spouse and once you’re married it’s too late to change. But, but I think if you, like I happened, I’ve even on Linkedin, I think I say, you know, I have the most amazing angel life in the world. So I mean she really is an angel life. I mean she is just very understanding her. her brother runs a big company and Silicon Valley and Austin. So, and then our other brother, is a army major and lives on a farm in south Georgia, not, not Georgia, the country, Georgia state. So, so there’s, I’m somewhere in the middle, like I am like, I’m like the nerdy computer doctor redneck cause I hunt and fish and do all that stuff too. So like I’m, I’m like, I think that’s what gets me forgiveness from her. So it’s mostly her that were doing well. But I try and give her most of the credit.

Justin: [00:45:05]That’s good. Well it takes two and I’m going to say the same for me is that I definitely married up and my wife is incredibly strong, resilient and forgiving and it’s a, that’s why it’s going as well as training. cool. Well Jack, I really appreciate your time and I want to close with one last question. you are a guy with a lot of spinning plates, a lot of pursuits, a lot of accomplishments. I’m curious as you think back about the, you know, all the things that you’ve done, what’s, an accomplishment of which you’re particularly proud or has been particularly impactful or something that you’re really excited about the potential that it has looking forward?

Dr. Neil: [00:45:39]I’ll give you my most impactful one was my first year of surgery residency. I called my mom one day and now I wasn’t, this was one other than Hawaii, right? So I had moved out there. I was like three weeks in, I was in a whole new place. I didn’t know by you. I was in a weird, so I called my parents a lot. So I called my mom one day and I tell her mom, today is the day that I really feel like if it weren’t for me, a patient would have died. Like this is the first day I think I saved somebody’s life. And my mom said, what’d you do? Call in sick.

Dr. Neil: [00:46:13]Hi. I was so angry. I was so angry at here because she is not going to tell a lot of jokes. Right. Do not act funny. That’s what are even worse.

Dr. Neil: [00:46:27]There’s one of my most that, that’s one of my most memorable moments of my entire career.

Justin: [00:46:33]Your family will never let you forget that you’re just the small town AI from wherever. Whenever you’re a big accomplished CEO, they’re going to keep your feet on the ground for, that’s good.

Dr. Neil: [00:46:43]Yeah. It keeps me humble. So I mean that’s, that’s why I mean if it’s just something that sort of, I don’t know, getting into med school I think was a big one. And you know, it just as a small town guy, nobody, you know, my family was, they were all smart and they do stuff, but there was nobody that was a physician and my family at all, I never considered it until I couldn’t get a job. And, and the Darla Moore wouldn’t take me in the air force, said my eyes are too bad to fly a fighter jet. And I said, blind join them. So that’s, that’s why they medicine. But when I got in, I think that was, you know, now it’s just look forward, you know, and, and the most impactful thing I will say, I guess I’ll say it publicly, but the most impactful thing was probably that, you know, I’m married when I was young and like going through that divorce was the most, it did so many good things longterm for me.

Dr. Neil: [00:47:34]And just everything, putting everything in perspective keeps you humble and makes you realize that nothing is forever without work. and that’s within, you know, within two years is when I got the tattoo on my back, just saying failure is not an option. Like, whatever, you start, set your goal and don’t stop before you reach it and be careful and where you set the goal, you set the goal too short, you might fail cause you’ll reach that goal and stop. So make sure if it’s a company, set your goal at profit, don’t set it at prototype, whatever it is you’re doing, set your goal in the right spot. And you know, my, my high school football coach, we had 19 people in our high school team and we won the state championship and this guy was the most impactful person in my whole life.

Justin: [00:48:14]Wait, I’m going to say that again. You had 19 people on the team. Yes, we won the state championship. So 11 on offense and 11 on jazz. He played both pretty much everybody’s playing, right?

Dr. Neil: [00:48:24]And so, so this high school football coach, he did it all the time though. The name was coach Stanley Gruber at Dorchester Academy down in South Carolina. And for my whole life I’d wondered what it was about him. You know, I always wondered what, what was it about him that got so much out of these people? Cause he could do it year after year. We were not a big school. We weren’t that like we weren’t born with giant, you know, amazing genetics or anything. We were just, he could get 100% out of you and you wanted to give him 100%. And I always wondered what it was. And it wasn’t until about two years ago that I came across what it was and I was reading a book and it’s called radical candor and I can’t remember who wrote it then, the lady’s name.

Dr. Neil: [00:48:59]But she had been high positions at a lot of different, I guess silicon valley or just California companies. And she was talking about like, how do you give radical candor, which is how do you give direct, meaningful feedback and the time you need to give it and not have to sugarcoat it. And her point was you have to have preestablished that you care. Right. And coach Gruber was mean as a snake. I mean, he would cuss you out. He would spit in your face. Not like literally spit, but he’s just screaming where it’s spitting as he’s screaming and you know, he can’t be a coach nowadays. He, he just can’t do that. That’s not allowed. But he, he taught me a lesson in that which was if you establish you care, cause like whenever that book, it brought tears in my eyes when I heard this cause I’m like that is what he did.

Dr. Neil: [00:49:44]He didn’t even know he did it. I doubt. But he, outside of football season, we were his kids. Like he would take us hunt, he would do anything for us. But while season comes, you better be given every bit of your entire body and effort to this team or he’s going to destroy you. And when I, when I read that it, it brought back, you know, my, in me, I’m very technical. I put a value on everything. I try to evaluate everything’s cost benefit. And a lot of times emotional or personal things are hard to do. That too. It’s hard to say this has x value. Whereas if I write this software, it has this, or if I go to the store twice, it’s whatever, you know, I don’t, that’s too inefficient. How do you do that for personal stuff? And that, that story, that book and that process reminded me that establishing that you care before you need it, you can’t, you can’t get, you can’t give that kind of feedback if people don’t think you care when you’re giving it.

Dr. Neil: [00:50:34]You have to have already built that. So all those emotional things, all those personal things, all those caring moments that you can’t put a value on, they do have a value because they have a value in the moment that you need to give radical candor. And that’s what coach Gruber did. And that, that whole process I think was probably the most, you know, in, in the most building of myself that I reaped all back on constantly. That’s one of the most valuable things that just to my core, helped restructure my thinking on what matters. Yeah. So

Justin: [00:51:06]awesome. Well, I think that is a great note to close on and I love that idea. So doctor Jack Neil, thank you very much for joining us on the anesthesia success podcast. It’s been a pleasure.

Dr. Neil: [00:51:15]All right, Justin, thanks so much. Keep up the good work.

Justin: [00:51:18]Hey Justin here. This may shock you to learn, but I am actually not a fulltime podcaster. I also run a financial planning company called quantified planning where I work closely with anesthesia and pain docs to build and implement customized financial plans. If you’re interested in working with a financial planner who knows many of the ins and outs of your profession, shoot me an email or head on over to quantify planning.com for more information. If you’re resident or fellow, I can also offer you a free student loan analysis if you’re interested, but there might be a waiting list, so check out the link over there to see if you’re interested in learning more about the topics we discussed today. Head over to anesthesia, success.com to join our community, residents and attendings and others to ask a question or get more free resources. It’s, and only if you liked this episode, please leave us a review and subscribe. Thank you very much for listening to the anesthesia success podcasts.