Dr. Kosinski: “GI is more vulnerable today than it was before” (SF interview)
“GI is more vulnerable today than it was before” (SF interview)
Dr. Larry Kosinski needs no introduction. As a leader, he’s known for innovating, for breaking away from the norm and be a guiding light for the industry. After a successful private practice career, he helped his group transition to a PE platform to work on SonarMD, a venture-funded company he founded. Now, he’s onto a surprising new startup, a stool-smelling e-nose called Voconomics (patent filed).
In this freewheeling interview, we chat about everything that GI doctors must pay attention to. The risks of running non-diversified “colonoscopy factories” (as he calls them). The shift to digital that would catch most of the industry by surprise. How doctors can find the time from their busy lives to innovate by mastering the basics. And finally his take on private equity.
This is such an important interview. It could quite easily alter the trajectory of many GI careers. It’s time to wake up to the vulnerability that private practice GI is in. Dr. Kosinski’s message is quite clear. Listen closely.
Praveen Suthrum: Dr. Larry Kosinski, thanks so much for coming back on The Scope Forward Show. You, of course, require no introduction, but I still want to introduce you. But before I do that, very, very warm welcome. Thank you for coming back.
Dr. Lawrence Kosinski: Thank you Praveen. I always enjoy talking to you because we always talk about challenging topics. So hopefully this one will be entertaining.
Praveen Suthrum: Yeah, I’m really looking forward to it. But before we begin, after a long and successful career as a gastroenterologist that led to a national leadership position, you’ve turned your interest to value based care. In 2014, you founded SonarMD that develops next generation of chronic care management for patients with high beta chronic disease. SonarMD, as we all know, is a patient engagement platform that generates significant savings by decreasing hospitalization rates in patients with IBD and SonarMD has been funded by Blue Cross Venture partner fund and Arboretum Ventures. And today, Larry, you’re going to talk about? Yet another startup, smelly one at that, and I’m excited to learn more. But before we get to that, I want to roll back the clock a little bit. We did an interview in December 2020 for The Scope Forward Show, and at that time we talked about SonarMD. We also talked about colonoscopy factories, as you called them. I want an update first on Sonar.
Dr. Lawrence Kosinski: Thanks for asking Praveen. Sonar continues to grow. I spend most of my time, my professional time speaking to health plans. And we have been pouring health plans into the sonar funnel and have expanded further. We are in three states operationally right now. New Jersey, Minnesota and Illinois. And in Illinois we’ve revamped our original contract into a new one, but we have many more in our pipeline that we are very close to operationalizing. You never mentioned them until they’re actually inked, but you’re going to be hearing about a lot of growth in Sonar. A lot of these contracts are being finalized and so I do believe that we’ve gained momentum and now what we’re seeing is some FOMO, interest from other plans, everybody you know health plans. Most health plans don’t want to be the first one out of the door. They don’t want to be the first one over the wall. But when they see others have successfully made it over the wall and are running free, they do want to be part of it. So we do have tremendous momentum there. So Sonar’s been a significant success. I’m still in the national leadership. I’m back on the AGA governing board, on the the board councillor for Development and Growth, and I sit on the Physician-Focused Payment Model Technical Advisory (PTAC) which reports to HHS, to the Secretary of HHS. So I’m still involved nationally, and Sonar continues to grow and I’m having fun, but I have other initiatives that are growing as well.
Praveen Suthrum: How do you manage to do all this and juggle so many roles?
Dr. Lawrence Kosinski: I live by the one wife, one child concept, so I guess that gave me a lot of extra time. But you know, there’s a lot of time in everybody’s life. And so I tend to try to be as productive as I can with the time I’m allotted. And I’m constantly trying to think of new things to get involved with. So I have time. I have time to do these things.
Praveen Suthrum: Let’s get to the colonoscopy factories point, it’s always a fun point. And to see the turn that the industry has been taking, it’s taken very clearly a digital turn and more and more. Are you surprised or not surprised? At what is happening, with the whole digital aspect of GI, do you still feel that people are stuck with their head in the sand? And busy in the endoscopy room, but the average GI do you think has a clue of what’s happening outside or do you think that you know, there’s so busy they have no idea that the shifts that are taking place?
Dr. Lawrence Kosinski: I don’t think anything has changed in the GI practice world. In the GI practice world. You know, COVID was a bit of a temporary assault on the GI practices since so much of the GI practice income is realized from elective procedures. And during COVID, those elective procedures went away. So now the GI practices are extremely busy doing colonoscopies, catching up with all those people who put off their colonoscopies during the COVID. Plus the age, it’s been lowered to 45 for screening, so there’s been no abatement in the focus on colonoscopy. GI practices are still colonoscopy factories. That is still the case, if not more so than they were before. As far as the digital world is concerned. I think what you’re seeing is that digital world develops outside of the GI practices. What I see from the companies that are developing in the GI space, they are disintermediating the GI practices. They are setting up their direct-to-consumer businesses. It’s a B to C it’s not a B to B to C. They are going around the GI practices and so unless the GI practices take their heads out of the sand, there’s going to be other arrangements. When you see large self-funded employers. Big ones, and you know the names of the big ones becoming providers or payviders. They’re becoming payviders, they’re paying for the care, and they’re employing providers to provide the care in their retail outlets. And they’re building this on primary care. Do you really think they’re going to go knocking on the doors of all the individual GI practices to see if they want to participate as specialists in their national networks? No. They’re going to engage large companies that are industrializing this space while Disintermediating the GI practices. I think this is a big threat to GI. The companies are starting it in the functional disease space, the IBS space. But they’re starting to nibble at the IBD space. And once they have that, you know, that isolates that just makes the GI practices more colonoscopy factories. The patients want services. They want services. They want only the services they want when they want them and they want to pay as little as they have to pay to get them. And the proprietary nature of private practices makes it difficult for patients to satisfy those 3 needs. And they go to these other companies, these B to C companies, they find them, they engage them. Now, I don’t know whether that’s a real business model for those companies. I’m not sure. There are many of them that are really showing significant profit. Time will tell. I think ultimately, they have to be married to the provider space and become an adjunct to the provider space. But right now, I don’t see the GI practices engaging a lot with the digital health world. They’re still going with the strike. Why do you rob the banks? Because that’s where the money is. Why do you do the colonoscopy? Because that’s where the money is. That’s really what’s driving activities.
Praveen Suthrum: So are GI practices more vulnerable or less vulnerable in the last couple of years?
Dr. Lawrence Kosinski: I think they’re more vulnerable. I think they’re still very, very narrowly focused on one single revenue stream that is still elective that is vulnerable to a technological advance. You’re seeing liquid biopsies coming into the market now, definitely seeing this. You’re seeing non-GI starting to do, non-physicians starting to do colonoscopy. And so the market will find the lowest cost way of providing services and so you know Exact Sciences isn’t in this business to lose money and. They know patients will put their arm out for a blood test 100 times before they will go in to get a colonoscopy. I think colonoscopy, although it’s still for the next few years, going to be a great revenue stream. There are vulnerabilities on the horizon for colonoscopy. The infusion business is already vulnerable. I can show slides that the trends in biologics and small molecule drugs are self-administered and oral now. And so those IV infusion centers built for GI practices are seeing declining portions of the biologic space, so that revenue stream is vulnerable. Look at the functional bowel disease space. It’s going to be to see with these third-party companies. So the GI space is more vulnerable today than it was before.
Praveen Suthrum: Do you think you know this vulnerability, this disruption that’s coming, it’s sooner or later, but it’s coming. Would it appear as though it came all of a sudden? Like so sudden disruption?
Dr. Lawrence Kosinski: Yeah, a technological advance can make it look sudden. Ok, so CMS has already approved use of blood based screening for second level and you know all you need is one of those to catch. And you’ll see a significant drop and everybody will say, Oh my God, where did this come from? How did this happen? It will look like it just happened all of a sudden when it does happen.
Praveen Suthrum: Very interesting. You know, I just want to reflect something with you about these technological changes because you brought up liquid biopsy. Recently I spoke to somebody in the RNA stool testing space. I found it fascinating. Then there is another large company that’s coming up with AI in GI in the endoscopy room. But when you think about RNA, you’re trying to go to the source even before something shows up. And so you’re trying to detect cancer at a level before it becomes a polyp. And there are a whole slew of startups coming in from that angle. So when you put all this into a cauldron and mix it up and then it’s going to multiply, companies are going to acquire each other and all this is going to happen. Even a stool DNA test can be vulnerable to an RNA test or even a company that’s helping you improve your ADR through AI may be vulnerabl. I’m just wondering how all this is going to play out from a digital biology standpoint. Any reflections, thoughts?
Dr. Lawrence Kosinski: I think this will be a steady trend in the future away from invasive screening tests to more sophisticated blood-based screening tests I would imagine as time goes on, we’re going to see the entire industry moving in that direction. That’s one of the reasons I got into the stool space, the volatile organic compound space because at Sonar we’re detecting earlier. But we’re still detecting based upon symptoms. So there’s something happening in those patients. Inflammatory induced that’s causing symptoms. We’re catching them earlier because we are proactively moving forward down the biology of the disease. And so during COVID, I sat there and I said, well, how do we go even earlier? How do we identify patients even before they’re symptomatic? Is that possible? And there’s been a plethora of companies that have developed Air sensors, air quality sensors. Because the technology has become inexpensive to do that, the sensors themselves have become commoditized. They’re very inexpensive. And so I was looking at an ad for these air sensors and although the companies were trying to detect impurities in the air and make changes so that companies could decrease the impurities in the air. My mind initially went to what if it’s good to have some impurities in the air? Can these sensors tell us how good things are when there’s more volatile organic compounds in the air? Any nurse who works in a hospital or any GI Doc who’s been in a hospital can tell you that I know what room the GI bleed is in. Before I even go in there, I look at the charts. I know which room patient has seen death. You can smell it. And patients will tell you that their IBD flair was associated with a change in the smell of their stool. I heard it so many times over the course of my career. Every human being knows you’re stool smells differently day-to-day depending on your diet. Sometimes it’s more, sometimes it’s less. And so I took two disparate pieces of information and put them together. I said, well, maybe one of these VOC monitors can actually correlate with the VOC’s that are being released in the stool from fermentation by the fecal microbiota. So I drove my wife crazy because I went out and bought six of them, and I put them in our bathroom, and we’re in COVID, so we’re not leaving the house. So the two of us are living in this condo, you know, like, we’re on house arrest without ankle bracelets. And and so I’ve got these six VOC monitors in the bathroom, and their lights are flashing and everything. We had to close the door in the bathroom at night so that we could actually go to sleep. And what I did was for six weeks, I monitored my fiber intake using a MyPlate app and at the same time I monitored what came out of each of these devices when I had my morning bomb. And I plotted and what I found was two of the six correlated pretty nicely with fiber intake and I thought we got something here. So I did a bunch of research through 2021 contacting the two companies that made these monitors and learning everything I could about the sensors and how the devices are made, consulted some people and finally I linked up with I have a good friend of mine who I wrote a book with back in 2012. She’s a dietitian and her son is a bio engineer and so I started working with him. We created our own prototype. We bought a 3D printer; we tested a few sensors in it. Basically, the device has the sensor, it’s got a tiny little motherboard, it’s got Wi-Fi connection, and it’s got a couple buttons on top of this so more than one user can use it during our testing phase. And so it sits in the bathroom just plugged in, nobody needs to do anything with it, and it’s measuring the volatile organic compounds levels in the air, sending its reading to the cloud, and then we have data analytics in our cloud based server and we’re using AI so we can determine whether there was a bowel movement that occurred, whether someone was spraying deodorants, hairspray. Haven’t really measured if they’re smoking dope or anything in the room. But you know, we can’t identify a lot of the activities and differentiate them from what happens with the bowel movement. And so when someone sits down to have a bowel movement. The air that’s released from their bowel movement contains ions that trigger a change in the resistance of the mono of the sensor, and so you get a downward curve. And so the if you flip it, you have an area under the curve you can measure as an effect of the bowel movement on the VOC levels, and it correlates with fiber intake. So we’re now in multiple studies around the country at several institutions to try to validate and replicate my initial work. I filed a provisional patent in July. So the technology and I started the company, VOCnomics probably a crazy name, but VOCnomics. I started VOCnomics as the entity to hold the intellectual property that’s represented in the patent application, and I signed an agreement with Sonar where they recognize I have the IP rights to this initiative, but I also in return gave them an exclusive license in a space to license the E- nose. This is my new startup. This is my new initiative. I think it makes sense because it helps us move earlier in the process, but if you think about all the places this can be used. How about more than 50% of the patients I had in my practice, I had on a high fiber diet. I said that all the time. So if they have IBS, if they have diverticular disease, if they had a history of colon polyps, they all should be on high fiber diets because they have fermentation performed by the bacteria on the resistance starch that are coming through the bowels. You know, has positive benefits, but it has goes beyond that. It goes into the nervous system. Parkinson’s disease, you know, diabetics can benefit from diets like this certainly cardiovascular disease. So in the patent application I have a lot of use examples in there as to how this can be utilized and so we’ll see how far this goes and how we take it forward. But it’s very interesting and to be sitting here at my age having so many interesting things to do and think about, I consider a gift.
Praveen Suthrum: What an amazing story and it reminds me of how you started Sonar. You know you narrated it, you know you are curious, and then you find a challenge and a big enough challenge that interests you, I think more than it troubles you. It interests you. You’re curious about it and then you go about playing, you just playing and innovating and then figuring out. But Larry, I want to ask a question on behalf of many younger gastroenterologists out there. Many of them reach out and they, you know, for career advice or they’re moving from one location to another and so on. There are multiple reasons. But I’m seeing a trend. I’m sensing a trend. It’s unlike the earlier set of gastroenterologists who stuck it out in private practice in one mode. You know, this group of younger GIs, they’re doing all the private practice stuff, but they’re constantly alert to what else is going on, on the digital side, they want to do what you’re doing. You know, they want to innovate, they want to do this, all this other stuff, but not everybody is able to do it. They can’t take out the time they have the loans to worry about. They have productivity targets, you know, within the group. So they’re struggling with all those day-to-day issues. What would you advise somebody like that? How do they innovate? How do they get to play like you do?
Dr. Lawrence Kosinski: I’ll use myself as an example. I went through the same thing. I mean, you finish your training, you’re 32 years old, you’ve got loans, maybe you have a new family, young family. You got kids, you have obligations. You got mortgages. You got to put money away for college funds. Maybe you have your parents to worry about too. You get sandwiched in between the kids and the parents. I totally get it. I think the best advice I can give to young GI’s when you come out. You invested to get to where you’re at. You studied hard, you worked hard. And I think I said this same statement in my previous interview with you– master what you’re doing, master. You’re going to do colonoscopies, you’re going to do 15 of them a day, get really really good at doing that. Make sure you have honed your skill so that you can do it efficiently. That will buy you the time you need. You know I said earlier, you know, I followed the one wife and one kid rule, you know, so. If you have other interests, don’t go out and get yourself so levered with huge mortgages and huge payments where you don’t have the ability to carve out some time for yourself so that you can follow your initiatives. Stay reasonable and master what you’re doing and open yourself sometime and then keep your eyes open to things that are happening right around you. This E-nose is a perfect example. I was reading an ad. For these VOC monitors and I thought, wow, isn’t that cool. If you don’t give yourself freedom of thought time, you’re gonna miss opportunity. But my best advice, master what you trained to do, keep a focus. Make sure you don’t overextend yourself. And open up thinking time for yourself and then go to meetings. Talk to people. I’m astonished when I go to I love going to meetings, and I go to the meetings and I see the same people over and over again at the meetings. You know, too many docs get pigeonholed into their area where they’re working. They lose contact with what’s happening outside, and you don’t go to the meetings necessarily. In your 30s and early 40s, because you need to learn anything, you’re pretty sharp. You got it all in your head ,you just passed your boards. You know, you you know more than most of the people at the meetings. You go there to network, go there to meet with other people. You’re going to learn from everybody around you. So that’s my best advice.
Praveen Suthrum: Let’s talk about the group that’s in their 50s. You know, this is the mid-career GI and you and I have a common friend. I don’t want to name the friend, but you know, whenever I chat with this person, I say that you’ve got to stop doing this because it’s, you know, you got all this precious knowledge in your head and it has to be channelled much more widely. But he’s too busy as he is very, very busy and multiple interests, multiple engagements, you know, leadership roles and so on and so forth. And there are many like that. We know that we interact with them. What advice would you have for someone like that? They need to innovate, otherwise the industry is going to be in trouble. So sorry, go ahead.
Dr. Lawrence Kosinski: Praveen, I know exactly we’re talking about. We both love him well and know him well and I’ve given him this advice, so I’m not saying anything I haven’t said directly to him. You have to not feel like you have to do everything. Pick things that really interest you. And focus just on them. And you have to learn to say no. That’s been one of my biggest problems. As I say yes all the time. The people and I have to give my wife credit. She’s taught me how to say no. You have to recognize your limitations and not suffer from being a FOMO. You know, you can’t be so afraid of missing out on everything, that you spread yourself too thin and that then you never enjoy any one thing to its fullest. So that’s hard for people to do it but that’s very, very appropriate. For GIs in their 50s, they can see the end, it’s far in the distance, but they can see the end. And I think you need to have a game plan on how you’re going to get there because it’s going to be there before you know it. I set up. I set up. I had a plan and I pretty much stuck to it. When I turned 60, even though it meant less income for me. I stopped taking call, I stopped going to the hospital. I limited my office time I stopped taking new patients. And that allowed me the bandwidth to go in other directions. I would never have Sonar today if I didn’t do that. And over the next few years, I slowly, gradually cut down even further and pushed more of my energies into my other initiatives and I was actually going to retire in 2018. But I stayed on another year because my group was negotiating a private equity deal and they wanted me to help them negotiate it. I was ready to retire at 67. I stayed to 68. But I was only part time through all my 60s. I could have done that indefinitely if I wanted to because it really wasn’t taxing me and I had a lot of time and energy to do other things.
Praveen Suthrum: I want to push back on one of your earlier responses on mastering colonoscopy so that you get time. That’s good advice for now, right? But going back to your earlier response, you know, on if all this is going to shift and get disrupted. Here you’re mastering a skill that’s not going to be useful. For you, that won’t take you through to the horizon. So then what do you do?
Dr. Lawrence Kosinski: Well, it will buy you the free time now, though, I think I’m saying the same thing I said before. Right now, you’re going where the moneys at. You’re going where the income is coming from. Master your revenue stream, master the thing that’s given you your income so you can build new ones. But if you’re too scattered at first, you’re never going to build. So I think if you take the 1st 3-4 years, you’re in practice and totally master so that you know your revenue is stable. And you can do this efficiently. Then you open yourself up to opportunity to find other revenue streams from other fields of interest. I think I’m consistent in what I said, maybe I didn’t say it the right way. But, I think you got to master it and then build something else. Like we were just talking about don’t try to build 10 things. You know, find something else and give it your energies. I always I push back when there’s a company and the doctor founder is also the CEO, most of those companies don’t go too far. You can’t be everything to everybody. You can’t ever practice full time practice and be a full time CEO too. One of the two is going to suffer. And so you’ve got to know how to be strategic with your time, strategic with your knowledge, bring in people that. And do the job, let people run with their responsibilities.
Praveen Suthrum: Let’s shift gears to private equity. I want to talk about it and anything that you can share. How has it played out?
Dr. Lawrence Kosinski: Well, I think it’s done exactly what we expected it to do. If someone’s had a money out for you, you’re going to go at it. It’s only natural that there’s been growth in private equity driven by the financial incentives to sign on. I don’t know, I think what if there’s about 7000 private practice gastroenterologists in the country, maybe a 1500 of them are in a private equity owned practice. The great majority of GI’s are still not in that, but we’ve seen growth. We’ve had seen exactly what we anticipated would happen. And now we’re seeing the maturation of the early practices that so we have a couple of what they call second bites that have occurred and we’ll have to see how this second round of investment. And these private equity owned practices materialize. Do they continue on the same route of growing and adding practices? Or do they transform and build themselves in a more quality basis so that they can occupy an earlier position in the value chain? I would hope it’s the latter. I’ve yet to see that though. I think in fact I’m going to have Jim Leavitt on my podcast, on recording it next week. I’m going to ask him exactly these questions because I think if these entities are going to succeed, their clinical infrastructure has to be as vertically constructed as their billing infrastructure is. Right now when the PE firm buys most of the practices, they build the operational side around the billing and coding and collecting and all that. That becomes really focused. And but the clinical side remains relatively flat and I think it’s important that their clinical side becomes vertical as well and you build infrastructure on the clinical side because then I think the real value of these practices will be realized. Do the private equity firms want to invest to make that happen? I’m not sure. But I would hope that that’s where it goes, because I think to survive and thrive, that’s what has to happen.
Praveen Suthrum: Do you think the private equity game will continue for the next several years? If so, how long?
Dr. Lawrence Kosinski: I think you’re going to see other alternative models, I think the model, the way the first ones rolled out. I don’t think that’s going to be the model in the end. You’re already seeing hybrid, we see the you know PE, Capital Digestive. Well that’s sort of a hybrid model not typical of the others. I think you’re going to see VC enter the space. I think you’re going to see, you’re going to see VC enter with more of a long term higher return investment model. I can see that happening. There are companies out there that are already doing this in non GI space, but I think it’s going to enter the GI space as well and if that can be used to build the clinical infrastructure so that the true value of the entity is more than just the sum of its parts. Then I think that’s worthwhile, but I think what you’re going to see is alternative types of investments. You’re not going to stop the investment phase. I mean that that’s going to continue, practices are going to continue to consolidate, but I think you’re going to see a different model going forward.
Praveen Suthrum: So what advice would you have for someone who has FOMO? You know, as far as peace concerned, they’re concerned, they’re confused. There are many out there, you know, in the middle. They’re not sure because everybody’s knocking on their doors. They’ve done the pitches, they’ve listened to it, so they’ve not made a decision and then they’re thinking, why do it? So there’s that other side of the story. I mean, I’m not looking for a answer. I’m looking for, I think, the type of thinking that can help them go through these decisions.
Dr. Lawrence Kosinski: I will say exactly what I’ve said in public presentations. I gave a presentation to Eastern State Medical Society and I said basically what I’m going to answer with you now. Physicians have to have long term view. You have to have a longitudinal, long-term view of your decisions. You had to invest long term to get to where you are. Don’t take a short- term payment and give up a long term future that is what you should not do. So whatever the deal is, whether you’re signing up with a hospital, whether you’re signing up with a with a private practice that’s independently owned or one that is owned by private equity, whether you’re joining Kaiser, you know, working for, you know, CVS, I don’t care what this is. You have to make sure you’re not tying one hand behind your back going forward. A lot of these entities have termination without cause clause. Most of them do independent practices. Most often do not. They have restrictive covenants. Look at those restrictive covenants that they can really limit. You know you don’t ever want to look at your spouse and say we have to leave the state because of this restrictive covenant. Out clauses gotta be able to get out. Columbus didn’t burn the Nina, the Pinta and the Santa Maria at the shore when he got to the new world. You can’t burn the ships at the shore. You’ve got to have an escape route for yourself. And if the agreement doesn’t give you an escape route. You better not do it, because you’re going to be stuck in a bad situation. And look at the organization you’re going into and say, are they growing locally? Not are they growing nationally. Are they able to get other doctors to join them locally? Are they commanding their local service area? Do they have the best contracts with the health plans? Do they have a diversified revenue stream? Do they have a plan for a diversified revenue stream? Can you see yourself working in this place 10 years from now? So people will dangle treats out in front of you, but you’ve got to make sure there’s something beyond that treat that you’re going to be able to benefit from in the long term.
Praveen Suthrum: Let’s say, someone does not see something like this, making a hypothetical situation, right. So they’re concerned. They say, hey, like 10 years, that’s too long. I have no idea. They say the horizons are five, seven years and so on. So I’m not able to see that long. I have no idea. I’m not very comfortable, but I’m concerned and I have concern about my practice right now because there’s so much of pressure from the insurance companies, from the health systems locally and so on. So they’re confused. And this is very typical of you know a lot of groups out there. How should they think about, do they have the bandwidth, they negotiating power to change the governance? I don’t know.
Dr. Lawrence Kosinski: Let’s imagine you’re in 100,000-person town in central Illinois. And I’m just making this up, OK? It doesn’t pertain to any practice particularly. But you’re in a town and you’re afraid. You hear, you read about all the groups growing and you, you think, oh God, they’re going to, they’re going to come in and take my practice away. You know, the hospitals are going to buy up all my primary care doctors. You know what’s happened. I still come back to something I said earlier. Look at your local area. Are you the dominant group? Do you have wonderful relationships with your primary care doctors that send you business? Do you have a patient population that’s growing. The payors, the health plans are not going to want to eliminate you if you have a successful practice that’s doing a good job that has a strong patient base and the hospitals, where is the hospital going to find? Let’s say you have a 5-doctor group. Where’s the hospital going to find 5 GI’s to hire to put you out of business. It’s not that easy. So I think there’s fear out there that is easy to feel because of what you hear and then there’s real fear of what’s actually happening. But if you have a weak practice, if you’re not taking really good care of the patients and you’ve got a lot of outflow from your practice and maybe you don’t have strong relationships with your primary care doctors and you haven’t really shown them the respect you should. And you’ve been an alien to your hospitals and you haven’t participated on committees and haven’t been part of what they’re doing. You could be in trouble, but. Joining another commercial entity that comes in your town. May just be a temporary band-aid on what your real problem is. So, I think it’s still comes out this some basic blocking and tackling and private practice. You gotta keep the patients happy. You got to keep the primary care doctors happy. You’ve got to be respected by your local hospital. And if you’re doing those things, it’ll be very difficult for anybody to really put you out of business.
Praveen Suthrum: Very nicely articulated. I think that’s going to be very helpful for people listening or watching. I have a fundamental reflection of question. Let me see how it comes out when I talk to physicians. There’s a lot of conditioning at play here. There’s a lot of conditioning at play that’s been at play for decades, for many, many years. And that conditioning is being limited not in reality, but in the mind. The mindset is limited to the existing norm and the existing model. Even though they know, they see, if they look out the window, you know, they see the emergence of digital. Like if you see some of the new startups, they’re not saying I’m going to be in one state and they’re saying I’ll go wherever the customers are. They’re going to all 50 states. They’re not saying that I’m going to, you know, raise money from only this source. They’re figuring out, like, you know, new sources of funding. They’re doing things differently. So if you look out the window, you find all those examples. But yet physicians, particularly, I see that they’re quite limited in the boundaries that somebody else has choked and continues to chalk like. So if the industry says do this or if their colleagues say. Do this, then they do that. And if there’s a shift and they say do that, then they follow that norm. But it’s extremely hard to break away from the norm, though you do see certain examples. I think what I want your reflection on, Larry, is why is that? What is the underlying fear here? Why is the mindset so narrow?
Dr. Lawrence Kosinski: Yeah. I think you’re absolutely correct that this exists, but I think you have to realize what type of person becomes a doctor. And what does that person have to do to get through all it takes to become a doctor? They have to learn habits. And grain habits in themselves that produce doing well in school right. You know, they have to know they build ingrained habits that help them remember what they have to remember. For instance, doctors get very accustomed to certain drugs they use. Just ask a pharmaceutical company how difficult it is to get a doctor to change what they’re doing because we want to feel comfortable that we know what we’re prescribing and we we build a comfort zone around it, I think Physicians in general are besieged by such a huge, enormous need to master knowledge. That they build and then ingrain habits in themselves so that they can master this knowledge and succeed in their profession. And then when we asked them to go out of their comfort zone we get pushback. Because we’re not comfortable outside of our comfort zone. And I just think I think your observation is totally accurate. And I think it reflects. Just my opinion, but I think it reflects the type of person that’s capable of going through education till they’re in their early 30s. And then go out into practice and succeed. And then you leave your residency and fellowship, and now you’re you’re hit with everything that’s slapping you in the face, and you learn how to control. Your risk and control your exposure and you continue to build ingrained habits and it’s hard to get people to change out of that. That’s why I say master something that really comfortable.
Praveen Suthrum: The concern I have is that that could have been OK for the last 15 years, 20 years, 30 years. Right now, you know, with all the shift to digital that’s coming, it’s a concern. Because these shifts are going to be sudden, like we discussed. And my concern is it’s going to have a psychological effect on physicians. And I sense this, it’s a sense because here comes, let’s say a technology, whatever, that’s telling you that all this mastery, all this effort, all this, you know, you locked yourself up in a room, studied so hard, succeeded in your life and career, and here you are now somebody, something, an entity, a technology, a piece of software, whatever. An app is now telling you that, hey, like it doesn’t matter, and you’ve got to unlearn all this, Stop that.
Dr. Lawrence Kosinski: Well, I’ve I’ve been very opposed to the companies that are disintermediating the doctors. If you look at Sonar, we work to be an extension of our doctors. And I think the companies, and I don’t know that these companies that are disintermediating are succeeding now or will have heavy success in the future. Because I still do believe the companies that figure out how to help the doctors expand their technological space are the ones that are going to succeed the most. I think there’s an opportunity there. Certainly the physician community is highly intelligent, highly educated, capable of expanding into technological space. They just have to make sure that it can gradually be built into what they’re doing rather than be forced upon them and force them to exit their comfort zones. We’re going to see it happen. It’s inevitable. But, you know, like people talk about that AI is going to replace human work. What you’re actually going to see is AI assisting humans to work and make us better at what we do rather than necessarily replace us. So I I think any company that’s building technology has to understand that their technology can’t just give a small subset of patients a quick access to something that may have partial value form. It’s got to be part of their entire healthcare solution. So, We’re going to go through some ugly times, though, before we get there.
Praveen Suthrum: Yeah. Doctor Larry Kosinski. Thank you so much for sharing your thoughts and going through this conversation. It was amazing. Lot of insights once again. And any final words of wisdom as we close this interview?
Dr. Lawrence Kosinski: Have fun. Innovating is fun. Finding solutions is fun. And don’t be afraid to try something because you know everybody. They will all line up and tell you you’re crazy. But you know, if you’re right, you’re gonna have a good time.
Praveen Suthrum: Awesome. On that note, let’s close. And it was a lot of fun chatting with you once again. Thank you.
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