Thank you all for joining us today as we talk about the future of medicine. In the spirit of the future of medicine, we are going to make this an interactive process. So no sleeping after you've been eating and to start us off with that, I turn to our president of AECOM, Dr. Saito. Wonderful. Thank you. Good afternoon, everyone. So we are going to try this, a live polling modality. So there's a QR code that you see on your screen right now. If you can go ahead and use your phones, you should be able to log into that website to be able to see our polling questions. And while you're doing that, we'll go ahead and introduce ourselves. So I'm Jill Rosenthal. I'm the chief medical officer at Zenith Insurance Company. I've been there for 14 years. I am board certified in occupational environmental medicine. I'm a fellow of the College of Occupational Environmental Medicine. And I've been a member of AECOM since Dr. Linda Forst made me sign up as a resident at the University of Illinois in Chicago. And I haven't looked back. It's been an incredible journey so far. I'm your current treasurer and your incoming vice president. So thank you for that honor. Michael. Oh, thank you. So my name is Michael Chu. And I am currently the chief medical officer for Workers' Compensation Division for Paradigm. And for those who may not know Paradigm, Paradigm is a very unique national care management company where we've been focusing on and specializing in care managing catastrophic injuries and complex care conditions for workers' compensation for the past 33 years, where we actually guarantee outcomes, clinical outcomes, for a fixed price. So we've been doing, I guess, kind of accountable care, value-based care for 33 years. And we continue to make some progress there. My background is in emergency medicine. I'm a board certified emergency medicine physician through the ABAM. But I also did a mini-residency in occupational medicine in Cincinnati. So I have a good, at least some understanding of occupational medicine now that I'm leading the Workers' Comp Division for Paradigm. And I'm here as a participant to share with you my experience and how all the medical technology innovations are impacting health care. Wonderful. And hi, I'm Kenji Saito, currently the AECOM president. My day job is at Owings Corning as their new global corporate medical director. And thank you. I have my whole team up here front and center for me. And I've been with AECOM for about 10 years now. And prior to that, I worked at a consulting firm looking at medical legal issues. I am both a medical doctor, but I'm also a lawyer. I'm here as a doctor today. And nothing I say today is considered as legal advice. So thank you. Thank goodness I don't ever have to say that. My list of disclaimers is even longer than that. But let's go ahead and get started. I think this is a great opportunity for us to get in a room and talk about the future of medicine. You know, what do we see as an opportunity for occupational medicine? And for some reason, the slide is not coming up. OK. Well, the question is, you know, when you talk about occupational medicine and you hear the word sort of innovations in OEM, what are you seeing? And I don't know why my slides aren't projecting. Is the AP team still here by any chance? I see the response. I see the response on my, nope, I see the response on my, give me one second. I think I know what it is. So let's talk about that. Maybe I'll go down the line here and start off with some ideas of what we think innovations sound like and what we're thinking about in this talk, specifically around what does innovation mean to us and what are we looking to do in the future of occupational medicine? Yeah. So if I think about innovations, I mean, innovations can mean a lot of different things. I think we think about technology. We can think about the business of medicine, the practice of medicine, communication styles. So to me, innovation can be expressed in lots of different ways. If I think about one of the more recent examples of innovation and its impact on workers' comp, I have to talk about robotics and robotic surgery for hernia repairs. So I'm not talking about joint replacements where the robots can help align the joints with great precision. I'm talking about what I would consider a surgical procedure that probably we could all do if we had to after a little refresher from medical school and general surgery rotations. But imagine that you have called an office when you have the right to direct care in a state such as this one, Florida, and you call the office of the surgeon and you say, can you do this procedure laparoscopically versus a robot? And the office says yes. And then you see the medical records, you see the op report, and lo and behold, they've done it robotically with no indication why because there were no criteria that were met necessitating a robotic surgery. And then you get the bill and it's $100,000, no joke. And you sit and you think, gosh, what is the return on that $100,000 for that hernia repair? And there's no literature to suggest that that hernia repair, again, not the joint replacements, but that hernia repair has now led to faster return to work, to faster recovery of any kind, to fewer side effects, fewer complications. And so I'm left wondering about this innovation in occupational environmental medicine and how it's impacted work comp and just questioning its value. Yeah, it's a great topic to first start by discussing the merits of the topic. I mean, obviously, innovations, as I'm reading through the words that are coming up, it's interesting that technology is the biggest word followed by AI. But I think innovation have different meaning for many people. Obviously, innovation can be maybe some care intervention that is new to the industry. It could be maybe a technology that actually enhances the care and delivery of medicine or it could be business. And specific to the robotic intervention, I know the intent behind robotics has always been can we do it in a way that is safer, that can be minimizing the complications and that can actually have impact on the outcomes because as clinicians, I think we want to know is there a better way of doing things. And certainly, you know, obviously, robotics is one of those technology advances that has, I guess, incorporated the microprocessor computer algorithms along with, you know, some very high resolution visualization tools to access, you know, body parts that could be very precarious for an open technique, even laparoscopic techniques, which sometimes can be associated with some complications. But to your point, Jill, I agree with you. I think what happens is the business side of medicine sometimes takes over and you say, well, if we did it from a robotic perspective, does that somehow benefit the, you know, the provider or the facility who is doing the procedure and it may not have the clinical benefits but does it actually have some financial benefits. And sometimes I do wonder whether the choices that we make as clinicians as to which procedures to do can be influenced by the economics. And I think we all know that sitting in this room. The other thing I do want to point about robotics is that, you know, I see a number of these procedures moving into the more complex care management side of things for two reasons. One is, obviously, the promise of better clinical outcomes, but I do think that the residency programs are now specializing on this type of technique, which are new, and I think it's very sexy, it's very innovative with the promise that it's going to be, you know, better outcomes for patients. But at the end of the day, there is a learning curve with these procedures. And so, when I talk to my age colleagues, which, you know, obviously, you know, we did things with open technique much more so than the minimally invasive, you know, their concern is that, you know, the newer surgeons who are coming out of training are getting less experience with the open technique because they don't have to do those procedures that much anymore. And so, number two, you know, the residency programs are focusing on these minimally invasive procedures because, for whatever reason, you know, either because of outcomes or cost, so they're coming out of the residency programs and fellowships without the experience. So, therefore, I think the complications rates and the outcomes that you can actually absorb or appreciate in, I guess, pushing these techniques sometimes are not realized unless you as clinicians know how proficient the surgeon is doing those procedures. So, to go back to my story, and this is perfect, I did call the surgeon and I said, hey, we called your office, we established that this is going to happen laparoscopically. And she said, well, I don't know how to do it laparoscopically. I only was trained robotically, which I'm not sure is true, but let's say it is. And then I thought, well, what if there was a complication? Would she even be able to then convert it to an open? And that made me very nervous. And in certain states, you know, in occupational medicine, we can direct care to certain physicians either through a network or directly to a doctor. And so that prompts one to wonder, do we have the right doctor in our network? Yeah. I think that's a good point. And I think also the use of, you know, looking here at AI is becoming a top question for us is, you know, can those AI institute worry about, are you worried about AI replacing what you do, right? Because a lot of these algorithms that can be captured, whether it's technical and skills and whether it's more thought process and decision-making and like what kind of protocols people are following, all that is data collection, right? With machine learning, you're starting to able to predict and analyze some of this data, whether it's complications or outcome that we're looking at, what kind of methods or modality of you're doing, whether it's open, laparoscopic or robotic. I think the question then becomes is AI is going to use that technology and start predicting outcomes before we even do the procedure. So what do we do then? And when robots start to use machine learning to even learn even more on their own, where is that parameter we need to look at around that? So the question here is, you know, are you worried about this? And most of us seem like we're not, but we're pretty close, right? 45% or almost half of us are almost 50-50 here. Well, now we're 50-50. So I mean, what are your thoughts? Well, I think it's a matter of staying on top of technology, staying on top of how AI can help the people. So it's people process technology working together. Like I think about it and in my role as the chief medical officer of an insurance company, I think about how could this potentially support the nurses who are quite overwhelmed? How could this support me in identifying the riskier cases so that I can be more proactive about those? And like, what does it tell me that I can act on, making it a safer experience potentially for the patient and a faster recovery? What do you think, Michael? Yeah. So, yeah, again, AI is a sexy topic. I think everyone, it's in the news everywhere and it sounds like all the big tech companies are doing this, making a lot of money doing it, but I think it depends on what AI means to healthcare. I think AI is very different for healthcare, partly because our data that's out in the public sector or in private sector are not as clean as some of the other industries. So I think there is an inherent problem with AI and data extraction and data, I guess, algorithmic manipulation or interpretation. But with that said, I do think that AI is going to make a huge difference in healthcare from one big perspective. And I think the impact is going to be really how quickly we process information. For example, AI, they talk about how AI can pass board exams now, medical board exams. They talk about how AI is highly accurate when you're doing multiple choice questions. And the reason why they're so good is because they are so quick and able to assimilate and filter through thousands and thousands of pages of data and then be able to come up with an answer. So what that tells me is that the AI is really good in the ability to pull data that is factual, that's out there, that's published. And so it gives you information really quickly. So I think, as a clinician, it will help us to gather data real quickly. And so where I see this app applying itself in medicine is that, you know, when I hear symptoms from patients and they give me a whole list of all their symptoms when they started, the history acquisition process can take a long time, but AI could actually condense the time and really make things faster and they'll give you the 10 or 15 or maybe even the top five differential diagnosis that we can use as physicians, which we've been doing it, we've been trained to do this all along, where we're thinking through the, you know, the symptomatology and timing and we try to figure out what's the most likely the diagnosis that this injured worker is presenting with. But the reality of the matter is AI can make it much faster. So I think it can be very, very helpful. But what it can't do is actually say, this is the diagnosis. And this is the reason why I don't think that physicians will replace, be replaced by AI, but I think that the physicians will be augmented by AI. Now that's probably the reason why I'm seeing 50-50 in the answer, because we all know that, you know, from experience, that only about 20% of, you know, diagnosis really present like the classic textbook, right? The other 80% present atypically. I mean, it's true whether it's dealing with chest pain or heart disease or abdominal pain. I mean, whatever the condition, I know what I've learned in life is that patients don't present the way that you read about in textbook. And also when you're giving the diagnosis to a patient, I certainly don't want to hear it from a computer, right? I want to hear it from a human who can understand how it impacts my life. And if, let's say there was a patient who had a disabled spouse and that was then going to impact how they were able to care for their loved one, how, you know, how will AI put that together and then emote and empathize with the patient? And that's the challenge we have right now, right? Because with an AI, you know, we have two sort of schools of AI, right? Originally, it's iterative AI, meaning it's basically feed data into it, it'll feed, it'll spit back out what you fed it. Then there's generative AI, the era of chat GPT version four and whatnot. It's where now AI is actually coming up with ideas and introducing it back to you, not from a canned response that you created, but something that they're actually taking data from the internet or somewhere else and generating ideas that are new. The challenge with generating new ideas and with speed and accuracy is a problem, right? There's a terminology called hallucination. Has anybody heard of that for within AI, right? Yes, some of us do, right? Because they don't know what's going on, they fill in the gap. And that gap is called hallucination. It's just like humans, right? It's not set in reality in that they have data supported by it, they use predictive analytics and they guess what they can to fill in the gap. And that's where the danger exists, right? And I think when you see AI as a tool, like we did with the stethoscope, the ophthalmoscope, right? We're able to see now through telemedicine, a lot of things we couldn't see before because we're able to digitize what the heart sounds like, what does the eye look like. But when we do that, we're looking and using our judgment to make that determination. It's still a tool, however, just like the calculator. When it came about, we can't say nobody can use a calculator, use a slide rule. No, we had to adopt and we had to adapt, right? And I think AI, especially in healthcare, needs to be thought in the same way. We need to use it as a tool, otherwise we'll be left behind. But a tool that we use in a very meaningful way and an ethical way. So luckily, the UN actually took this issue up about ethics. How do we minimize hallucination? How do we minimize the idea of misinformation being spread through generative AI? And the framework is actually outlined on the UNESCO website, outlining specifically around labor and policies around labor and economy. So if you look at that UN report, I'll be happy to give that citation out after this. And it gives a good framework, at least, for us to think, as we start to adopt and use it as a tool in healthcare, what kind of ethical parameters we should use to put that in. You talked about telemedicine for a second there. Yes. I mean, you're all welcome to answer these questions as they pop up. But what I've seen is a lot of overuse of telemedicine. Yes. It comes in handy when you're talking about a rural area, when you're talking about areas that are challenged, like for geo-access to find a specialist. But from what I've been reading lately, telemedicine has not prospered the way it was anticipated to. Do you anticipate that it will have a better chance of improving healthcare through AI and the incorporation of AI with telemedicine? Yeah. Michael, do you want to start first? I know you had a great perception on telemedicine. Yes. I can chime in. It's my perception and my perspectives. But I think telemedicine has a huge role in medicine. I mean, it really allows, I think, treatments to be delivered without the constraints of space, I mean, and distance. And I think you can actually allow expertise to be provided across miles away, where typically in the past, people couldn't access those expertise if needed because of the distance they may have to travel. So I think telemedicine has a huge benefit, potential, I think, for improving diagnosis, improving health literacy, in terms of understanding, you know, the conditions, the medical conditions that are complex. But also, I think it's also easily accessible. So it is very convenient. I particularly was surprised to hear that telemedicine utility has been going down since the pandemic, because what I thought was going to happen was the pandemic has proven the benefits of telemedicine from a whole host of ways, not just from a physician-clinician contact but also rehabilitation. There's a lot of telemedicine being done, tele-rehab, as well as telebehavioral health. And I think there are so many types of services that actually can be delivered to people, patients, injured workers, who need this type of service but not be constrained by the distance. And so I was surprised to hear that telemedicine component is dwindling or diminishing. And I think part of that has to do with maybe the payer's perspective on whether they want to pay for it or not, which I think, unfortunately, the payment, the reimbursement side of things do wag the head of the dog. So I know there's been some discussions about CMS cutting back on the Medicare, not reimbursing for telemedicine unless they have certain criteria. Some of the health insurance, the commercial health insurance, do not always feel that they want to pay for telemedicine. I think the health insurance comp might be different. I think comp is different, but that will impact the survival ability of telemedicine itself if the group health world isn't on board, too. Absolutely. So as I know, the two big companies that I know, the Teladoc and Amwell, are the two big ones that I know of. And I know both of them are actually having some difficulty due to the declining utility. Yeah. And this goes back to your original question, well, how can AI potentially help or maybe hurt it? I think it's both perspectives because the data now is all digitized. That's the one good thing about telemedicine, right? Everything you see on the screen can be captured. All that is information. So it's all zeros and ones that data can now track and say, okay, these are how long you've been on this telemedicine visit. This is what you discuss. We have AI that can actually summarize your visit and you're no longer writing notes anymore. It generates a soap note right after you're done. And using telemedicine, they're able to digitize all that encounters and use that data now to analyze and predict what's going to be done in the future. So I think as utilization kind of slows down, I don't think it's going to go away regardless of reimbursement because there's still a lot of data that can be collected there, especially in a workers comp realm where we're using a lot of 24 seven manufacturing services that require off our services. You know, those tend to be telemedicine services because, you know, if we use a global economy or a global network of workers, there's always someone awake during the day, whether it's night here, it might be morning in China, right? It might be differences and whatnot. So we can utilize a global network in that telemedicine world where it will be subsidized by the employers. So perhaps the employers might be the one now generating the data out of AI usages and telemedicine and telehealth. The question is, what do we do when that data comes in? How do we use that in an ethical way and then use that to predict and utilize that for outcome studies as well in the future? So I think there's a lot of opportunities there. Absolutely. And I just want to make two comments. One is that I think the telemedicine is a very powerful tool. I think it works. I think we all realize it works. And I don't think it needs to be proven it works because it has been proven over the pandemic. But, you know, right now, I think the two biggest obstacles that I see with the telemedicine use beyond the reimbursement issue is actually our current healthcare delivery system. Because, remember, we're still in the fee-for-service activity reimbursed mode. And I think that, you know, everyone's looking at their reimbursement and checking to see how many times can you bill for a certain activity. I would say this with confidence, that if we actually moved, truly moved from the activities-based reimbursement to a value-based model, where, you know, everything, all your activities are kind of bundled into one, you know, one reimbursement, where, you know, you're not keeping track of all the activities, but at the end of the day, the outcome of the, you know, the injured worker or the condition, then I think the telemedicine will be utilized much more robustly because, you know, it's not going to be based upon activities like telemedicine, but rather, how convenient is it to give information back to the injured worker or the patients? How quickly can you process information and share information that's needed for, you know, communicating diagnosis and treatment and just being available for the patients and connecting the dots with the clinician? So I do think the telemedicine will be much more robust if our value-based reimbursement movement does take place. And that in itself, of course, is an innovation, right? An innovation doesn't have to be this tangible object. It can be a way to think about reimbursement, a way to think about processes. So in our survey here, and thank you for taking the time to do this, so telehealth, I don't know if it's because we were talking about it. Yeah, perhaps. A little bias. But, I mean, the utilization of integrative and complementary medicine, that's one that we actually hadn't talked about before. We had talked about things like communication, improved communication, which would probably get to the case manager comment, if you could scroll a little bit there. I can comment on complementary medicine if you like. So by the way, you can actually click on like, so that way we can pick the top three or four to discuss. So if you see one of the options on your phone, you can click like and it'll go to the top and we'll discuss it. But since, in order, we're seeing integrative and complementary medicine as number four votes here, you know, we'll talk about that briefly. If you look at the VA health system, actually, traditionally, stuff like acupuncture or herbal medicine and whatnot wasn't reimbursed, so a lot of people didn't practice it. We had, you know, people going out to natural paths and whatnot, and I had the opportunity working with several Native American reservations and working with medicine healers and looking at ideas of herbal medicine and how does that interfere with some of the Western medicines that we use, spent some time in Japan and looking at those as well. And even acupuncture, right? There's always some good studies initially done maybe 20 years ago, but recently there have been some evidence-based RCT studies showing the results of acupuncture around pain management, around complementary medicine and integrative medicine as a modality for holistic care for well-being initiatives. And the outcome is strong enough that where someone like a VA system are willing to fund it and say, we're going to reimburse it and actually hire acupuncturists as part of the alternative care or complementary care to their physical medicine rehab team, they're also having independently well-being initiatives around ideas of alternative care around nutrition, for example. So all that really ties in around integrative and complementary medicine where using that kind of technology or evidence-based, they're starting to use that as an innovation for some of the comp care as well. Yeah, as I'm sitting here listening to you, I'm also realizing I'm wearing an innovative Yes, your wearables. So if you have an Apple Watch or a Fitbit or this is a Virgin Max Buzz, something like that. So this is collecting data constantly and that's ideally helping me to live a healthier life, which should prevent me from having a work comp injury. Yeah. You know, it's interesting that I'm reading that no, I found it kind of interesting that nothing new was the top three. And that's kind of surprised me because if you, in the medical industry, I mean, I've been living in the world of catastrophic injuries and complex care conditions. And I'll tell you that the amount of the new interventions that are coming to the market is huge, is significant. And it's changing, I think, the landscape of health care where I find it fascinating and actually very encouraging that such innovations are coming into play. Because it's not only, I guess, what I would consider to be, you know, preventative of mortality, you know, so-called damage control, you know, innovation, but also some incredible restorative and rehabilitative strategies that are coming into the market that actually can change people's, you know, impairment, disability and function. So with that said, you know, I do think that the question that I'm going to ask, everybody who's here, is how aware are the occupational, you know, environmental physicians of all of the so-called new technology that are out in the industry, surgical techniques or approaches that are making a difference in health care? And I'm going to just kind of mention two real quick ones that I know is making an impact. How many of you take care of couple tunnel syndromes? Probably a lot, right? Exactly. So it's more of a common condition we see all the time in the workers' compensation world. And typically, you know, I think 80 percent of the people with diagnosis of couple tunnel syndrome will get surgery, you know, as a definitive procedure for couple tunnel. But over the years, two techniques has come about to change that. One was the kind of the endoscopic, you know, couple tunnel syndrome release, which they do a little tiny little incision in the wrist, and then they put this tiny scope in, and they go ahead, and then they visualize your anatomy, and then they release the couple tunnel, which was much quicker, safer, faster recovery. And I think a lot of the surgeons started to use the new technique because it was fast recovery and better outcomes. Although, I will tell you, in certain parts of the country, many surgeons are still doing the open technique, and where it takes about three, 30 days to 60 days to recover and return back to work. There's a new technique that came out, I don't know whether you heard about, back in 2015. It's called the incisionless thread couple tunnel syndrome release, where basically there's no incision made. It's actually done by ultrasound-assisted visualization of the soft tissues and anatomy, and they put a small needle into the skin, and then they thread this little metal thread around the anatomy, and they just kind of pull it, and they basically release the couple tunnel in entrapment. And it takes six minutes to do, and many times people go back to work within 24 hours. So we work with an orthopedics group that introduced me to this concept, and I thought, no, come on, you know, no way. Sure enough, this is real, and this is the future of couple tunnel surgery, no doubt. And the thing is, but it's been done in a few places, and a few surgeons have been trained to do this. Mayo Clinic has been driving this as well. But very few of the clinicians out there know about it, and the reason why I'm bringing this up is that it's very important that occupational medicine physicians need to understand the new techniques that's out there, and we don't leave it to the surgeons to figure things out, but you understand the benefits of this innovation. The other technique that I know, I'm sure you've heard it before, is the treatment for, you know, chronic, you know, tendinopathies, where, you know, in the past, and if you didn't get relief with the usual considered therapy, the only way you could do it is to send them to a surgeon, and they had to do an open technique and do a tenotomy. And over the years, I think they've come up with some different ways to, minimally invasive way to go ahead and really remove the scar, and I think the tenot is the one that was very popular. It's also sound. It's a needle. It just, like, vibrates really quickly, and then they put it into the, you know, your lateral epicondylitis or your other tendon area, like Achilles tendon, and they go in, they'll go ahead and shave the scar. Now they have, they do it with the very high-pressure fluid as well, and these are things that can be done in the doctor's office, orthopedic surgeon's office, and it's really, really effective. It's great outcomes, fast return to work. The problem is you have to understand who does them, who's proficient at it, and they're not just kind of going to a day course and then doing them and knowing who to refer to. So I think there's a lot of incredible opportunities that are out there in the medical industry, but the unfortunate thing is it's, the knowledge is not as prevalent. Information isn't as disseminated as easily. So I think a lot of us clinicians are, in fact, in the dark. And the two conditions I just talked about were just in the everyday arena. There's tons more things that are going on in the catastrophic injury world. I mean, some incredible care. What about Neuralink? What about Neuralink? Well, yes. The brain-machine interfaces, all that. I think... There have been some issues with that lately, and so that's one of the things when you've got these new technologies and the innovation, you have to make sure that they're well studied before we... Absolutely. ...subject our patient population to them. So just to, I mean, of course, I, as part of my role as the Chief Medical Officer for Paradigm, I'm in charge of making sure that I know about all these innovations because we guarantee outcomes for a fixed price at the beginning of the case. So if you're going to guarantee an outcome for a fixed price, we have to know exactly what's coming down the pike that could be the new standard of care that could actually improve the function and the potential outcome. So, you know... As a payer, that's where we would be willing to pay more for the technology, like an incision-less carpal tunnel release. That's worth it because that return, you're getting someone back to work within 24 hours. They're not on TT. They're back to work in their life. Absolutely. So... They don't have time to get a lawyer. But the satisfaction rate is significant. So the brain-machine interface you just brought up, I think people probably read about that at the... I think more people found out about the technology probably from Elon Musk, Neuralink, The Wall Street Journal. But, believe it or not, the brain-machine interface technology has been around since I think 2012. And the reason for it is... I don't know if you guys follow some of the medical journals, but in 2012, the BrainGate, which was a research group out of Brown University, actually had two incredible publications where they showed a lady who had high-level cervical tetraplegia. She couldn't move her arms and legs. But they put a probe in the brain, and she was able to control the robotic arm that was external to her through the computer and actually got her to drink, and she actually drank from this cup. And that was groundbreaking technology. The idea behind it was that we figured out that when people think, or they call it motor imagery, when they think about something, your brain is still working, so therefore your brain actually fires these electrical signals, and they do it in a consistent manner. So what they were able to do was they actually had a computer analyze the electrical signals that's coming from the brain when you ask a person to think about doing something, and they were able to create this electronic signature, which then they translated into the machine, and then they had an external limb animation device, like a robot, which actually would do whatever the person was thinking. And I think Elon Musk kind of took the same concept and now showed that they could have somebody move the cursor. It's quadriplegic. Yeah, all that. Yeah. The problem they found earlier on is that it caused some degradation of the sensor they had to put in the brain. It's a very invasive procedure. They put a circuitry in the brain, so over time, it would get degraded, and the signal strength would decline and cause some trouble. But there was a company out there two years ago that they actually came out with an incredible innovative idea, and it's called, the company's name is Synchron. And the Synchron is a company that actually capitalized on the cardiac stents. If you recall, when someone has a heart attack, they go in and they put a stent in your blocked arteries so that it keeps the blood vessels open, and this has progressed to putting small stents in the brain. You know, of course, people have aneurysms and stuff. I'm sure you heard about these stents that people go in, the neurosurgeons will put in to prevent the aneurysmal rupture. What they did was they created a stent that's a very powerful micro-sensor, and they are able to put this in the blood vessels near the certain areas of the brain that control certain function, and they were able to show that the signal strength was still so strong that they can actually move, you know, robotic arms or what have you to help get the injured worker or patient to return to function, which is incredible. And there is a clinical trial going on right now in the U.S. to show that it can work. So these are kind of incredible stuff that's out there, you know, that I think is changing the ability for people with significant neurological impairments to actually recover function and get back to life, which I think is amazing. Yeah, and I think some of the other items on that last one, please keep it where it is, but the radiology, so more accuracy of reads. I think we all are aware, what is it, like 30 percent might be accurate in the reads for musculoskeletal reads if not read by a fellowship-trained musculoskeletal radiologist. Like that's a problem, right, because if the radiologist is not reading it accurately, then it sends the whole person down the wrong path for lack of recovery. And then the other thing on there was prosthetics, and I know that I've seen the development of prosthetics through the work with the military and also with vendors, such as Paradigm, and the myoelectric hands, I mean, these are very expensive, and oh my gosh, so worth it. The people are able to hold their children, they're able to fish if they need to fish, like it's an unbelievable technology. I don't know if you wanted to quickly comment on prosthetics, since that is the world in which we live. My gosh, yes, so another exciting field, prosthetic world is really benefiting from technological advances in this day and age. So one of the more, I think, exciting prosthetic that people talk about is the myoelectric prosthesis. Now before, most prosthetics were body-powered, mechanical, and they work fine, but the myoelectric ones are incredible because what they're doing now is that actually, when the surgeons amputate the limb, they're actually using TMR technology, which is targeted muscle renovation, where they actually will put the severed nerves into different parts of the other muscles that exist in the amputated limb. And what they've discovered was, number one, they do it because it decreases the frequency of neuromas. So now you prevent someone with an amputated limb not to experience chronic pain from neuromas, but also on top of that, since they innervate the other parts of the muscle, by training them to actually move that muscle, then they can go ahead and apply the sensors on the skin over that muscle, and then they will allow them to learn how to move a certain mechanical portions of the prosthesis. So by flinching your deltoid, you may be able to maybe cause a prosthetic to squeeze down and make a fist. So it is a part of the rehabilitation process where, in a kind of a new way, your brain is being taught how to move a certain body part without actually giving you a new body part. But with that said, the intervention of transplantation has evolved as well. We're now actually doing hand transplants and facial transplants. It's called the VCA, which is a vascular allograft composite transplant, where people are actually transplanting whole body parts that has more than two or three tissues. So that's been around for about 10 years. And there are seven centers across the country in the U.S. that are actually doing these limb transplantations and facial transplantations. So prosthetics, making some incredible advances, as well as surgical techniques. I will tell you that there has been a new update in the CMS Medicare guidelines that actually you probably see some of these happening this year, because CMS has now approved a payment for microprocessor orthotics. So I'm sure you guys heard of like C-Brace or even MyoPro. These are orthotics that have microprocessor, bioelectric-powered elements. And so people with weakness of the upper extremity or weakness of the lower extremity from strokes or peripheral nerve injuries, what have you, they're being fitted with these orthotics. They're not prosthetics, they're orthotics that actually amplifies the function of these limbs so you can actually walk, you know, do self-care, go back to work. And it's going to change the whole, I think, landscape for people with limb weakness in this country. And why it's going to change is because CMS Medicare has now allowed the code to be approved and they also have applied a price tag on it. So you're going to see a lot of this stuff coming down the pike for a worker's comp as well. So we had a slide that asked about complexity in the cases that you're seeing. And, you know, 52% are seeing more complicated cases. I think that's in line with what we're all seeing, that the frequency's down but the severity's up. And that leads to the need for innovation. So if we go to the next slide where you all were answering about virtual reality, and I would love for you, Kenji, to touch on that. Yeah. And this ties into the other question we asked about, you know, what are you seeing in innovation? And one of the questions was, you know, encounters of how we approach the configuration for electronic medical records by integrating with telehealth for mental health as well. So in that realm, you know, we have a lot of different entities out there now working on cognitive behavioral therapy or IDT with cognitive behavioral therapy and CBT and offering that in a virtual reality world, right, in the metaverse where we're creating different avatars that look at the different interaction with the human. We know now, you know, post-pandemic that human connection is just so important, that the data supports that people have loneliness as an issue pre-pandemic, but during the pandemic it actually worsened. And even our Surgeon General in the U.S. wrote a nice report about how loneliness is a deadly disease and it's one of the public health issues that was looked at in previous administrations. So because of that, you know, I think one modality that we're starting to see now is in the virtual world, how do we recreate that environment, that connection that we're lacking? Can we do that in a virtual reality where it's almost similar to human connection? Is it releasing the same kind of endorphins that we see when we connect with people? You know, it's a challenge, right, but we're still developing it. The data supports it, though. There's some good evidence now coming out that's going to be published shortly, actually, reviewing right now is looking at, you know, what kind of morphine equivalence decreases are we seeing with people with CBT going through virtual reality? Their pain symptom actually improves if we're distracting them playing video games in the virtual world. You know, if you're cutting fruit in the 3D space and then all of a sudden you forgot that you have pain in this limb that you're moving right now, is it part of the therapy or is it part of the mental health stretching of that? How do we manage pain and perceive pain is really changing how the virtual reality is using that. The other piece is we're talking about minimally invasive surgery. I saw that as one of the previous responses. You know, is anyone familiar with the Da Vinci robot? Right? A lot of them are using those in surgical centers now, and if you ever see it, the console is like a video game joystick. If you look at a PlayStation or a Nintendo, those joysticks are very similar to what we're seeing now with the future of robotics and surgery is that you can sit behind a box and not necessarily be 100 feet away from the patient. You could be 100 miles, 100, a thousand miles away. As long as you have a surgeon or someone else sitting there in the operating room to deal with complications that we talked about converting to open if need be, the ones that are specialists could be anywhere in the world. They could be training in this virtual world and all of a sudden do operations in accesses where at locations where we don't have access to this kind of specialist. We can sitting on a yacht in Italy in the Mediterranean doing surgery in South Africa or you could be sitting here in Manhattan or here in Orlando and doing surgeries in Japan. So it's very unique innovations where we can use that virtual world to really bring a specialist and innovation to a new level of care that we've never seen before. And then I was thinking about one of the uses that we've applied to VR to virtual reality is patients who have had motor vehicle accidents and then are afraid to drive. And so we've worked with a group where they simulate the driving experience and having other drivers around you and minimizing the fear that they experience with driving so that they can drive again. I mean we're thinking about driving to work but also to the grocery store to see their family to be involved in the community. And so not being able to drive seems so basic almost, but it's so overwhelming, yeah, especially here in our country. But it's so overwhelming for some of these people who've been in a significant car accident at work to be able to have access to the virtual reality. Yeah. I will say the virtual reality is one of those incredible innovations and technology that really could change the healthcare intervention landscape for sure. I'm going to be a little bit different than my colleagues. I think virtual reality has shown to have lots of promise, but I think it still needs to be proven. So from a catastrophic perspective, I think virtual reality has been helpful in literature to be potentially effective in treating acute and chronic pain, although I think there's a lot of talk about chronic pain, and I think there was a couple of studies that came about that actually showed that the pain reduction for chronic low back pain has been pretty significant. And there's also some good studies that actually came out that actually showed that they may be able to go ahead and control acute pain in the inpatient hospital setting as well. But these studies were very kind of involving small number of cases. None of these studies were randomized controlled trials, and even the low back pain, pain management, they were able to show significant reduction in pain management, pain level, but it didn't seem to impact any functional improvement. So the pain reduction for sure, but it didn't really seem to do a lot from a functional improvement. And that's what we focus on and from Paradigm. And so I think there still needs to be a lot of research that needs to be done, but I do think it's very helpful for the impact of virtual reality in treating certain type of conditions. So for example, the exposure therapy, the PTSD, I actually think it's very beneficial because you can control the virtual reality, immersive environment to kind of help people, I guess, deescalate their anxiety level after trauma. And I think it starts to show that there are some good studies that show that it has impact. There's some incredible studies going on right now where they're combining virtual reality with direct current stimulation of the brain, where if they stimulate the amygdala, which as you know, is the organ that controls your, I guess, reward system, your fight responses, that when they stimulate the amygdala while you're doing the VR for exposure therapy, PTSD, it had a significant impact. So there's a lot of research going on with VR. I do think there's a lot of opportunities for virtual reality to not only impact pain, but also PTSD. And I will say one thing, for neural rehab, virtual reality has a way to really improve the rehabilitation process because, you know, we all talk about neuroplasticity, right, which means if you do something 10,000 times, you know, the more you do it, it retrains your brain to somehow function better. And I think that the virtual reality definitely has a way to allow that to occur. And I know a lot of the rehab facilities across the country has adopted virtual reality as a way to improve their rehab process. Yeah. And the other use of VR, I think, is in medical schools. Yes. Right? So the training of medical students now involves virtual reality, it involves robots, it involves the David. Yeah. And it's really important now that we know, you know, formaldehyde is a carcinogen, right? It's been identified and truly there's a connection behind that. So all of us remember from anatomy, the smell of anatomy labs, right? That's one thing that sticks in our mind that we can't forget. And I think, you know, one of the things is we've been breathing in toxins, you know, we have pathologists or anatomists who actually work in this area that has been exposed to us. Now they have to remove that. So as part of that remediation, they're looking at VR as an opportunity for these holograms and these projections of anatomy. But then what you lack from that is the tactile, right? And the deviations from human, we all are variants, right? We're not identical in our anatomy. So our students really learning good anatomy, especially surgeons, lacking tactile use of the scalpel, like how do you get that pressure when you make that cut? I think that's really important. And we're kind of understanding that now how to use technology. But people are starting to use VR for that reasons. And VR now are trying to match all the senses, whether it's tactile or whether it's smell even. I remember walking through CES, which is a consumer electronic show, and people are spraying stuff all over. I'm like, what am I smelling? Because people are understanding that pheromones, you know, play a role in this as well. So in VR world, they are starting to have tactile, you can feel, sense, see, now smell the environment you're in. So it's a whole new world out there. But education is definitely one area that where they're innovating very quickly because we have carcinogens that we know that we haven't found a workaround yet. Yeah. Thank you. So moving to this question, not surprising to see this, right? The level of comfort regarding business of occupational environmental medicine. And why is this in an innovation talk? So if you think about the innovation of business, the innovation of healthcare, hospitals buying up doctor's practices, let's talk about that for a second. What does that mean? That means that these doctors who had their practices are now employees of maybe a, what is it, VC? Is that the right word? Yeah, venture capital. Venture capital controlled hospital. And they are told to whom they can refer. It usually has to stay in-house, even if that's not the best place to refer someone to. And they are almost puppets sometimes of these hospital systems. And that is the result of VC ownership and of the business of occupational medicine and how that's changed. I mean, how do you all experience that? The business of OEM? Oh, yes. I mean, I think it's a big problem. I think healthcare, the business side of healthcare has changed over the years where I think even you brought up the point of physician employment. I think in the 90s, you know, only about maybe 30% of the physicians were probably in an employee practice. The majority of the practice, 70%, they owned their own practices and they controlled their destiny per se. Today, I think 70, 80% of our physicians, clinicians are actually employees of I will call business enterprises. Either you're working for a large hospital system or you're working for private equity-owned businesses or some, you know, publicly owned entities. And unfortunately, I say unfortunate because, I mean, even though people talk about quality and the interests of the patients, I think at the end of the day, the number one priority has been to make sure they hit their financial targets. So if the financial target is the most important priority, unfortunately, then the quality piece can be impacted. So there is, I think, definitely, I think, a movement where the activity level of our practice have been increasing to make sure that we generate enough revenues to support the financial needs. And I don't know. All my colleagues, I still practice, and I can tell you that, you know, the demand to see more and more patients every day has only been increasing, and for those, if anyone's out there that says, oh, I have an easier shift, then I want to know where you work because that's where I want to work. I remember working for a clinic where they had buzzers outside the door, and the alarm would go off. It's like, you're taking too long with your patient. I'm like, I'm just trying to connect. I'm trying to understand. I'm trying to treat. And the buzzer would keep going off. Yeah. Absolutely. But I think the pressures, I think the business side of healthcare is pressuring clinicians to focus on activities and volume. But I do think, I mean, philosophically, as clinicians, we need to go ahead and become more engaged. We need to understand better the business side of healthcare because if we don't understand it, if we don't have time to understand it, then basically, you know, we have no, we're not guiding, you know, where the future healthcare will go. So it's tough because when you're working really hard every day, grinding it out, the last thing you want to do is go home and think about how to impact business side of healthcare when you have so many other priorities. But I think we, as a whole, I think as clinicians and as a medical industry, we need to go ahead and make sure that we try to get involved. Yeah. And I think especially in OEM specifically, it's unique, right? Because not all of us are practicing full-time clinical occupational medicine. And those who are, you know, RVUs is one of those worst enemies of clinicians, right? Especially in OEM. You know, we're seeing surveillances and we're doing occupational health evaluations that doesn't really equate to the RVU standard units that we have, you know, and some of the procedures, sure, you know, it makes sense. But here, you know, it's very unique when we're doing thinking type-based modalities and especially with business, you know, we have to understand what does productivity mean for a CFO or a chief financial officer. Productivity means something very different for someone who's in medicine. We're saying, well, outcomes are what we're looking for, right? We want to mitigate complications and improve outcome. But when you look at it from a financial perspective, it's a totally different meaning. So I think sort of reconciling that difference is where the challenge is. And I think that's why I suspect most of us are not comfortable talking about when we talk about business is that that's one piece. The second piece is legal, right? There's so many contracts we have in OEM when we deal with different vendors, we deal with the different specialists, you know, how do we manage some of those interactions amongst them from a legal perspective, but also how do you negotiate a contract? You know, everything is negotiable. Some people are like, oh, that's the rate they offered. So that's what we have to stick with. And that's not the reality of it. And the reality is you have to negotiate. And that makes it hard, right? Because as an occupational medicine trainee and a practitioner, you want to be able to say, I want to refer where I want to refer to and not worry about that. Whether it's VC telling me this is the end network provides, we negotiated the lowest price possible. They don't care about quality, but you got to use them. And that's an ethical question now, right? And that's part of business as well, is how do you understand the ethics of it? How do you manage and set expectation, level set with the employers that you work with or your employer, if you're employed in a corporate setting, you know, you have people to answer to. And that's hard sometimes when you're a physician advocating for your patient. But if you're an occupational medicine, you might not have a patient in front of you. It might be a claimant for a disability claim, or it might be a person who is a pre-employment evaluation. So not an employee yet, there is a person coming in doing evaluation. And those ethical standards are very different depending what kind of relationship you have with that individual sitting in front of you or the population you're looking at and around some of the privacy concerns. So a lot of business consideration that comes into that. And I think that's why a lot of us are not surprised as to the answer of not being comfortable about it. Yeah, when it comes to business, I think we all have to, when we're in clinic, have to look at our electronic medical record or electronic health record. And if we pick different ones, and it makes it very hard to this question here to communicate with the specialists to whom you refer, because if you're on different systems, you have to make sure that you're sharing that information. But how do you do it efficiently? So I don't know if either of you have thought about the communication, but I think that's where perhaps the payer in comp should be the liaison and make sure that the doctor who referred gets the referral notes and that the person to whom you're referring gets the preliminary notes and the primary care notes. And I don't know that that's always happening. Yeah, it's hard because we often rely on case managers to get those reports for us. And sometimes that's late, right? It's like two, three weeks later, since the patient's seen someone before a bill has to be paid and that claim being paid gets a note, then that's a challenging conundrum we're in right now, because now we're reacting to something that we see versus trying to be proactive and say, hey, this is what we think we need to do from a prevention measure. But also, how do we get this employee back? And it's hard when the communication deteriorates because there's two or three middle people and not necessarily just one. Yeah, we have very little time left, but we've asked you a lot of questions. We would love to know if you have any questions for us. We have three minutes and 30 seconds left to be in this room before you all can go network for a little bit before the next. Yes. Next thing. Yes. Dr. Yeah, I have a quick question. You've talked about innovation, technological innovations in medicine and in finance and computers, but there's been a huge lot of work on technical innovations in measuring hazards in the environment, in measuring hazards in industry, in performance of job tasks. What is happening to incorporate our occupational physicians working with having access and making improvements related to that sort of data? Yeah, well, I think Dr. Hughes actually touched on that. He did, actually. And for those of you who don't know, Dr. Emmett is the founder of a lot of different occupational health programs in Philadelphia, one of my former mentors at University of Pennsylvania. And I recall when he's teaching all his residents and by now it's putting the thousands, you know, if you can't, if you can't measure it, you can't manage it. And it's exactly what Dr. Emmett is reminding us today is, you know, these data coming in, it's how you measure it. It's going to really dictate how you change your management of it. So bad data in, bad data out. And we can't really manage that as well. And Dr. Duncan, he was actually mentioned this yesterday, too, you know, that measurements is going to be so important because you need to react to that. When we're looking at new fitness for duty valuation, he talked about, right, when you're flying all the 4.8 G's, your physiology is very different. So he's collecting the data to respond to that very quickly to say, hey, these are the metrics we're seeing. We need to respond by developing maybe a seat that fits us better. So I think you're right. There's a lot of opportunities for us to look at that. And that ties back to the question about being comfortable understanding data, because a lot of this data might come back in forms of economics, right, saying, hey, you might want this best thing, like this chair is going to cost you $10,000, but if you're paying $400,000 for an air ticket to go to outer space, $450,000, sorry, you know, to get a ticket to outer space and you're going to have to accommodate your chair by spending $10,000 to make you a custom molded chair, maybe that's doable. But if you're thinking about a manufacturing perspective where the incentives now are to cut costs, higher production, better quality, you know, those are hard to do when you're looking at measurements and responding to that in real time. Mike, do you want to add to that? Yeah, I definitely want to because I think there is a tremendous focus on measurement in health care, because I think we are realizing that it not only impacts care, but also I think it goes really far into justification of, I think, payments and all the reimbursement issues that are currently in existence. I will say this, though. I think the measurement piece, one of the concerns I have with the measurement is that at least from what I've seen, there is a lack of consistency in what's measured. So and this is true, I think, across all medical specialties. I think in research, you know, centers have their own measures that they think is important. It's very highly academic. But the frontline clinical practices don't hardly measure anything at all if they did measure anything. And there is a lot of variations across the country. So it's hard to kind of collect the data and really make any sense out of it. That's number one. Number two is, you know, oh, I lost my train of thought there. But that's OK. That might give a little break. I know we're running out of time, but we have one more. We have one on on the. Can we do that in person? Yeah, we can do it in person. Let's do it in person first and we'll go online. Yeah. You've been waiting patiently. So go ahead. Kurt from Charleston, a little more sanguine like urology is VR porn really better than anything on a flat screen in terms of demand for technology. If demand always seems to be the the death of innovation, what do you think as of May 20th, 2024, the demand for these new technologies will be? Do you think it's going to live up to the expectation or do you think it's going to be a little more muted? I'm interested in hearing that. I can't hear him. I'm sorry. So my innovation that I usually wear is a hearing aid and I forgot it at home. So could you repeat that last bit, please? Because I couldn't hear you. A little demand. Do you think the demand for these technologies is going to equal the excitement that we have today? Now, I think if you think about, you know, they say necessity is the mother of innovation and you're saying demand is a killer of that. And I think there's a balance between the two. I think there is a demand is, you know, because you need something, maybe there is a role there because there is a need for it. There's going to be a demand for it. So, you know, we live in a capitalistic society, right? That's how we kind of monetize on demand means, hey, if you could meet those demand, you'll be first to market. That's where the incentives and that return on investments are. So my thinking is, and this ties into our online question, is, you know, where do we look for these innovations? You know, where do we go and invest in these technologies that might fulfill the needs, whether it's necessity or demand, to be able to equate and actually make a company from this? And if you look at some of the digital startup companies that we've seen this past couple of years, even though it's slowed down a bit this year, you know, we have a whole new group of ESG, right? The investors that actually go out and look at companies say we only will invest in these companies. And these companies are innovating, whether it's green technology or if it's looking at sustainable resources and looking at the circular economy. I think it's really important that we look and understand how the demand is sometimes created artificially because we say there's a need for it. Right. Decarbonization is an example. Or if we're looking at examples of human workforce and capacity building. Right. As as we look at a global workforce, it's shifting. Right. The economies in some of the Latin American countries or East Asian countries where labor is much cheaper, they're migrating to areas where the jobs are and countries are welcoming to that. And then that all competes with the demands for automation and robotics. Right. Because the ROI on these robotics and technologies coming out for the workplaces to mitigate and reduce injuries have a cost to it that sometimes outweighs the cost of labor of human labor come from different countries. So I think there's a global economy we can look at to be able to answer that question in terms of demand and to answer the question about resources. That's what you need to go on is looking at investors. They're they're doing their research heavily because they're investing their money into this. So trust me, they're going to do their due diligence. So if you read those reports and read multiple reports, don't just read one. I think that's where you can when you can look at resources, innovation. So I think about four resources that I go to. One is the Wall Street Journal. I read that every day. It provides me with a lot of great information about innovation technology because of startups and the business of health care is often represented in their conferences for specialty groups like ortho PM&R. Whenever I can, I'll I'll go and I'll just go around the exhibit halls and see what's exhibiting and then also attend the lectures journals, especially those around neuromuscular and orthopedics. And then finally, partnerships with centers of excellence and understand what they're researching, what they're excited about. And in terms of excitement, I mean, I'm a different personality than Kenji. So I think if it proves to be to do that, which it says, I'll be excited about it. If it gets people better and back to life and work, I'll be excited about it. And so that's my answer to that. I'll just have two additional comments that I will add to my colleagues thoughts. One is with innovation. Again, I will go back to the delivery of health care system. Our current health care system, the reimbursement model is such that innovations that sought tend to be more expensive because that's how it works. Whatever it costs more money, wherever they can make more money, wherever they can be reimbursed more of the innovation that seems to be sought after of innovations that actually reduces costs. I don't see a lot of companies trying to come up with those innovations that will do that because they're not incentivized to. So I think there's one is we have we have a kind of a barrier to overcome as we look at innovation across the whole, you know, the whole globe, where other countries that don't have the private equities and resources, they are innovating appropriately because they don't have the funds and they are able to come up with a really inexpensive way to solve problems as compared to United States, where we tend to be much more focused on those high, high cost items. That's number one. Number two, the comment I want to end with, he did come back to me. The point I was going to make is I was surprised to see the questions, the question, the answer to the question that was, do you feel like you're in control of your cases? And the reason why I asked that was, you know, what surprised me was that a majority of you said you are in control of your of your cases or your patient. But in my world where I see catastrophic injuries or complex conditions, there are no I mean, if I will say, I don't think I have seen one case where there was an occupational environmental medicine physician driving or overseeing the care of my injured worker. And the reason why I ask that is because it goes to the measurement piece. I do think very, very strongly that the occupational environment medicine as a field is looking at the global picture. It's not just looking at the care piece, right? You're looking at it from the higher level of understanding the impact of the injury on the patient or the injured worker, but also the company and in the industry, the measurements that are out there, measuring hazard ratios and all that. I mean, you have the data, but I think that you have more information that can be utilized by the specialists who are out there caring for these catastrophic conditions. They may be the experts in maybe managing that condition, but they don't have the knowledge that you have. And I do feel that there is a gap, but I was surprised that most of you felt that you were in control. Well, we are well over time. Thank you for sticking around and thank you for your attention, your participation. Thank you so much.

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