.png)
Patients Win
More than a podcast, Patients Win is a movement to restore healthcare to its true purpose: serving patients. Hosted by Dr. Jonathan Bushman and co-host Troy Reichert, Patients Win invites decision-makers to join a movement: making patients the real beneficiaries of healthcare. Through stories, case studies, and candid conversations, the podcast reveals how current systems fail patients, and highlights leaders designing benefits where people, not spreadsheets, come first. Each episode equips CHROs, CFOs, brokers, and physicians with tools to lead change in their own organizations. The message is clear: healthcare only works when patients win.
Patients Win
Restoring Joy in Medicine Through Better Care and Stronger Communities
Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.
Welcome to another episode of Patients Win. Today, we’re joined by Dr. Saju Joseph, a renowned surgeon based in Las Vegas with a fascinating journey from surgical training in Boston to an extraordinary fellowship in Scotland. Alongside hosts Dr. Jonathan Bushman and Troy Reichert, we dive deep into Dr. Saju Joseph’s evolution from oncology research to cutting-edge regenerative and sports medicine, and his unique, patient-centered approach to care.
In this candid and insightful conversation, we’ll explore the challenges and joys of practicing medicine today, the importance of returning to basic science, and the ways in which Dr. Saju Joseph has built a practice focused on true patient outcomes and community impact. We’ll also discuss the struggle to find and redefine joy in medicine, the failure of traditional reimbursement models, and the power of mentorship and collaboration.
Join us as we discuss stories that highlight what it means to truly put patients first, how small changes can create positive ripples across entire communities, and what the future might hold for both physicians and patients striving for better healthcare experiences.
Timestamps:
00:00 Unique surgical fellowship experience
09:01 Balancing surgery and academic training
13:55 Explaining stress and hernias
16:52 Discussing patient-doctor relationships
23:16 Understanding osteoarthritis and blood flow
30:45 Balancing work and family life
36:43 Office visits and unexpected benefits
39:47 Personal goals and family aspirations
49:14 Managing a Small Practice
50:53 Flexible curriculum in medical school
58:24 Helping a School Counselor
01:01:00 Dr. Joseph's values in medicine
Show Website - https://thepatientswin.com/
Primed Healthcare - https://primedhealthcare.com/
Troy Reichert - Show Host - LinkedIn - https://www.linkedin.com/in/troy-reichert-67606b5/
Dr. Jonathan Bushman - Show Host - LinkedIn - https://www.linkedin.com/in/jonathan-bushman-do-106821191
Media Partner - TopHealth - https://tophealth.care/
“Disclaimer: Informational only. Not medical advice. Consult your doctor for guidance.”
When residents or fourth year medical students come through my rotation here at the clinic, I was talking about develop your professional team. You need a good attorney, a good CPA, a good counselor and a financial planner. That whole example you used at 55 is exactly what I did with my financial planner. When do you want to retire? And I'm like, retirement's not a word in my brain right now. But at what age would you like to have the ability to do really whatever you want because financers are no longer an option? Okay, well now the age is 55. Just don't say retirement. My co-host Troy Reichert with me. We have a special guest today, Dr. Sajiru Joseph from Vegas. And we are excited to get into a conversation about his um extensive uh surgical history and training and the fun things that he's gotten to be a part of. And ultimately, as we do in all of our episodes, uh the conversation starts and ends with Did the patient win? We are passionate, passionate um change agents in healthcare. And part of our mission is to make sure that the people we work with, the people that are involved in your everyday health care decisions, uh are there for that same reason. And so, Dr. Joseph, thank you so much for joining us today. It's a pleasure to have you. Yeah, I appreciate it.
SPEAKER_02Well, Jonathan, you know, when we first started our uh broadcast uh a number of months ago, uh one of the first doctors I put on the list was uh Dr. Saji Joseph. I met him a number of years ago when uh he and a team came to Oklahoma to visit uh the surgery center of Oklahoma and to uh learn some different things. And uh there was that that uh first lunch I had with Sazu that I learned about his family, learned about his passion for cooking, but also about his passion for patients. And so I'm just again so excited as we've talked over the years. Uh every time I talk to him, it's inspirational because uh Sazju is one of those stamp putting the patient first. Uh when they see Sazju in any situation, we know the patient's taking care of it and even wins. So uh Saju, welcome. We're happy to have you on the uh program today.
SPEAKER_00Thank you. Thank you, Troy. It's been a pleasure, uh, especially meeting you all those years and continuing to work with you all through the years. It's been great.
SPEAKER_02Yes. Well, thanks. Well, Saju, tell us a little bit about your background. Now many people won't go to your website and uh read about it, but uh you've got a pretty uh stout pedigree uh in terms of uh where you were educated and what you did to bring you to this point. And this is gonna be important for later when we get into some of the stories about the the stuff and the work that uh Dr. Joseph does.
SPEAKER_00So yeah, so I I started um medical school residency in Boston. Um uh was lucky enough to have some really impressive mentors, and uh was really interested in surgical oncology, uh, had come from a research background, really interested in in angiogenesis and also in uh in kind of some advanced molecular virology things, um, had a really unique opportunity to go do my fellowship in Scotland. And I always tell people, you know, your US medical school and residency doesn't count in the UK. So if you're gonna go do your training of any sort in the UK, you either repeat all of your medical school training or you have to have some really, really powerful people help you. Um my mentor in Boston was pretty famous. He reached out to my mentor in Scotland, who happened to be a Regis professor of surgery and the head of surgery in Edinburgh. He, and this was 20 years ago, politely, I I'm assuming politely picked up the phone and called the Queen and got me exempted from all those rules so I could come and do my fellowship. Um, so very unusual, very few people have done it. Uh unbelievable experience into not only obviously operating in Scotland and doing the volume of complex surgical oncology, but also just seeing a whole new health system that is very different, right? Most US patients have never seen a nationalized health service, how that works, the pros and cons. Um, and so that really gave me deep insight uh into kind of the simple things we as providers can do to make sure that we are helping patients succeed. Um and so becoming back here, I've been in academic practice since uh started as an assistant professor, working my way up to being the chair of surgery, uh the building departments of surgery, and then working, transitioning into kind of working on new devices, new techniques in surgery to get better outcomes for patients. And uh that's uh Troy, how you and I met was really looking at that. Um I always kind of jokingly say my entire life uh has been failed experiments in oncology that have led to really cool things in other sides of the world. Uh a long time ago we met uh because I was uh running residency programs and I was really struggling when you use a lot of different faculty, you don't know the resident experience, you don't know what they're doing, what they're not doing. And so kind of by fluke dove into hey, all of these things from laparoscopy to arthroscopy, colonoscopy, all of them are being done through a video camera onto a screen. And that actually becomes a great pinch point where we can capture that video and we can assess a resident separate from the attending in the room. And interestingly, that assessment, you know, and again, American College surgeons, great people figured out, hey, there's scoring metrics that if you score a certain number, you're gonna have better outcomes for the rest of your life than if you score a worse number. And so kind of really got into that for residents, but then quickly realized you know, we can use this in a training model for attending surgeons. Like, you know, if you're a uh you know a health insurer and you've got a complex patient, I can actually help drill down in your region who is the surgeon that will get you the best outcome on that specific patient, taking their pre-operative risks, you know, heart disease, diabetes, and the operation itself, and then actually going kind of in the background, watching videos of the surgeons as they're operating and scoring them out. And I give I will give a huge shout out to uh Intuitive and the Robots, because that's what they've been doing. They have pretty much every case ever done on a robot recorded and they can assess it. Not a huge fan of the robots, so I also admit my own biases. It's a little bit triggered what it does, but neither here nor there, that's a different conversation. But that's where you know we really did a deep dive and understanding that both from a resident training standpoint, but then also for quality improvement for surgeons, and then helping patients find the right surgeons because you know your 20-year-old healthy person is different from your 65-year-old smoker, and they're not always you know, Google Yelp, patient reported outcomes, none of those go into the nuance that like a surgery residency program has to go into in order to identify when a resident is safe to go out into the community and practice. It's not just number of cases or years trained, it's actually learning curves. Um, so that's where my evolution has has taken me. Um and then, you know, now is I I've flipped most of my practice into kind of sports and regenerative medicine because there's this huge gap in in kind of the industrial athlete and sports athlete injury and injury avoidance, and then avoiding those like major operations.
SPEAKER_02Well, I tell you what, I you know, we can have a program on each of those three categories. You just talked uh Dr. Jimerson will probably have you back for sure. But uh, you know, when I lived in California, my son was looking at medical schools, and we were actually looking at uh University of Las Vegas, uh University of Las Vegas, and I know you were instrumental in uh standing up that program, correct? I helped a little bit.
SPEAKER_00It was already uh uh kind of stood up when I got here. Um the growth overall in Las Vegas is tremendous. You know, it and I always jokingly say it's like Californians move out here, no state income tax, the city is diversified. We're probably the sports capital in the world at this point, between all of the pro sports, UFC. I give them, I tip my hat to them. They saw this before anybody else and said, this is where we are going to stake our claim. Um but now we have you know, world-class Nevada Ballet, we have sports development. So, you know, some of the top junior high schools, high schools, we obviously, you know, Bishop Gorman is right down the street from me, and they're probably one of the top high school football programs in the country. They just are a factory of world-class athletes. But it's really that that development from the ground roots of you know high school, junior high school education trickles up to the university level. And now we have Toro University, we have UNLB School of Medicine, Roseman University. We've really developed our uh UME, our undergraduate medical education in the city and in the state, and then follow that with the GME programs. The GME programs continue to grow. Um, and it's important to train residents. Um, and I think the big key, and this is where you know we stumbled into it, um, is you know, when you train residents in non-academic centers where you're relying on private practice physicians, you really have to be mindful of not only their their, in my case, surgical volume, getting their cases and making sure they're learning, but also their academics, the rigors of reading books, understanding, not and I I tell people all the time, I'm not here to train a resident on what I do today. Because what I learned 15, 20 years ago is pretty much malpractice today. You know, like if you did open AAA today, A, I don't think there's many vascular searches out there that would know how to do it, and B, people would look at you and be like, why? You know. Um and so the point is I'm not I I'm not there to teach a resident how to do a colosystectomy or an appendectomy or a hernia. I'm there to teach them to disease process the tools that I have today, whether it be a robot, a laparoscope, a mesh, a this or a that, and then have them understand when they're in practice, they're gonna have different tools. And the disease is gonna be better understood. So you better be able to understand that disease and then apply the technologies that you have today. And then for someone like myself who who probably has some pretty severe untreated ADHD, like if I see a spot where the technology isn't where I want it to be, I then immediately go into, hey, let's develop a new technology or let's re-look at the disease and understand it on a much more basic science level. You know.
SPEAKER_01Yeah, that's uh gosh, you got my head going in a lot of different places. I've untreated as well, so we'll try to stay on stay on the subject here. But yeah, my mind wants to go in so many different directions because uh the whole training, uh uh we you know, we have a local training program as well that's uh you know, um it's an academic sponsored, right? There's an academic institution behind it, but it's it's an FQH. And thinking like, how do you how do you make sure that the the curriculum, but of course I'm primary care. Yeah, um I've I've uh I've never found myself uh envious of the training process until you just described it right there. Uh but um we we um yeah this goes into so many different subjects. You talk about mental health, you talk about cardiovascular health, talk about pulmonology, talk about I mean we got so many different areas that are are progressing just as quickly as what you were just referencing, but it's happening everywhere. Everywhere. How do we keep keep up with that? And with the advent of AI, it's even more important.
SPEAKER_00Yeah, and I will tell you, Dr. Bushman, like if you think about it, what we're really doing, I and it's sad to say it this way, but we're returning to basic science. Right? And I Troy and I had this conversation ages ago. Uh in fact, we might have had this discussion in Oklahoma City, I don't even remember, but you know, when I look at a hernia, for example, right? Most surgeons think of a hernia, okay, you have a hernia stuff sticking out, we gotta push it back in, we gotta you know put some mesh in, so it blah blah blah. However, the failure rate on that is sky high. Now, I will tell you, you know, we talked about it with Walmart people, they will tell you that the failure rate's 40% in two years. But the reason they say that is if you have a right ingwed hernia, we push it in, we fix it, and it pops out on the left, they call that a recurrence because it wasn't there before the surgery and it popped out, right? Now surgeons will tell you that's not a recurrence, I didn't operate on that side. Well, wait a second, right? Because the basic science is abdominal hypertension causing pressure. That pressure leads to microvascular ischemia at the level of the muscle conjunction points. That microvascular ischemia then ultimately leads to tissue necrosis, that tissue falls apart, and lo and behold, you have a hernia. So when we're pushing it back in and we're sewing it back up, if we don't reduce the abdominal tension, if we don't bring new blood flow or new muscles to that area, and I will jump to an architecture thing, and I'm not an architect, but right, if you build a building or a house on the side of a cliff and you put a big post in to hold that house up, that post is not flexible. So it is a stress riser that causes the stress to be dispersed over three stilts over rather than the four. So now that you've shoved it in on the right and you put a big piece of concrete in there on the right hand side, the pressure's only gone up in the abdomen, and that hernia is going to pop out elsewhere. And if you follow these workers, right ingro hernia, left ingrown hernia, umbilical hernia, hiatal hernia, right, you're playing whack-a-le, right? You are playing whack-a-mole because you've not understood the basic science of what is going on. And that's true in cardiology, that's true in pulmonary. All of us are ultimately, whether we know it or not know it, returning back to, you know, sadly, the Krebs cycle, angiogenesis, um, you know, immune system. Like you look at, you know, from infection to oncology, everything's immunologic, right? We're trying to understand how the immune system interact with ourselves so that we don't kill ourselves, but we also don't develop cancers and we don't get infections. And it's like that's what the future implementation of a medical practice is going to look like.
SPEAKER_01Yeah. No, that's incredible. I love the description and I love the detail. I actually love the physiological detail in that example. Um, I love mental health personally, and because in in primary care, um, they were I think they told us in medical school that I don't remember it was like 70 or 80 percent of people that come into the into your clinic if you're in primary care are going to have some form of psychological disorder, and they underestimated it by either 20 or 30 percent.
SPEAKER_03That's a hundred percent, right?
SPEAKER_01It's a hundred percent. Everybody, everybody has the emotional um uh threshold, the eventual underlaying of of their disease processes. Right? It's a total of illness, right? Like But I think too, like a lot of times what we're hearing at the clinical level is the symptom, as much as the the inguinal hernia is the symptom. Yeah, let's get back to okay, okay, you're telling me that this is happening and you're not sleeping. So insomnia is the symptom. Let's go back. Why are we having them so and you and layer, layer, layer, layer, layer. Oh, it's because we've got this unresolved conflict in your life between this individual that you you care for, you that you live with, or whatever it may be. You know? Yep. It's like, okay, okay, okay. There's not a medicine for that.
SPEAKER_00Yeah, and the the unfortunately, and the sad thing is that's not a reimbursable model today, right? Uh like today, sitting and spending 45 minutes to an hour working through, figuring out what the problem is and coming up with a solution actually is not viable. Because like that our reimbursement's gonna be, you know, if you're lucky, 100 bucks, 200 bucks, like your overhead expense in your office is sky hike above that, right? And so the unfortunate thing is most physicians go to, hey, if I get whatever, sixty bucks doing fifteen minute visits, if I can just do two hundred of those, I'll be okay, right? And and there isn't the counterpoint of you know, how do we actually go and dig in? How do we develop a relationship between our patient and ourselves long enough that we can actually do the hard conversations? I have a a friend of mine, as I said uh earlier before we started recording, a lot of my patients are like dear friends now, but like there was one patient who had all sorts of symptoms and we kept like working it up, and I finally I was just like, listen, Jeremy, like this is anxiety, right? And he's like, No, no, no, I'm not. I'm like, all right, dude, here's the deal. Like and I looked at it, I was like, I'm like, you're gonna take some pro for 60 days. Give me 60 days. We're gonna keep doing your workups, we're gonna make sure your heart's okay, all those things. But for 60 days, you're gonna take this medicine, no questions asked. And he was like, Absolutely not, I don't believe. And okay, great. I I hear you, and you just have to give me this trust, right? And in 60 days, if you're no better, we'll stop it and we'll like keep working on all these other things, so on and so forth. And like the funny thing is, like day 58, he called me, he was like, Oh my god, Lexapra's the greatest thing ever. I can't believe this is the exact. You're like, that was three months of like multiple, like twice a month sitting in my office for hours, like you know, working it through with them. Um, but that that just doesn't happen in today's practice anymore. You know. No, but that's the most rewarding piece of the practice. And the funny thing is, like, he's one of our dearest friends. In fact, I'm going to dinner with him tonight, and then the only reason, like, you know, he's the first one that's like, hey man, like, whatever I can do for you, right? Whatever I could do to help you, your practice, like, you know, my staff, and we we're very lucky. We take care of a lot of athletes, professional of all sorts, and you know, performers and all these things. And it's like, you know, if we want to go to dinner or we want to, you know, go to a uh game, like my MA will just be like, hey, I want to go to this soccer game. Text whoever's playing, because we take care of that person, they'll get us tickets. It's like I haven't given her a pay raise, I haven't given her a bonus, but she sure as heck yes to like go to it. Right. So yeah.
SPEAKER_02Well, it's those little things, Saj, that they help people, whether it's the patient or your staff. Because again, I know your staff, you take care of your staff, you you depend on them, and they you value them. So and they in turn then take care of the patients. And so it's this incredible cycle, this ecosystem of of care for the patient, and you're care for all of them.
SPEAKER_00Yeah, and our patients also then learn to care for each other, right? So we have like we have lots of pretty wealthy patients, and you know, we charge them, and and there are numerous where we we take care of patients for free all the time, right? There's a young girl here, terrible problem, been two years. She actually got suicidal and attempted a suicide because she was in so much pain. And like when she came in, and it was funny, like you know, somebody was like, generally in Las Vegas, if you've got a real significant problem and it's nothing that anyone can figure out, like my name pops up. So she comes in and you know, and I'm looking through everything, I kind of figure out what's going on with her, and I'm like, okay, we can fix this, but like out-of-pocket expense for our office is gonna be pretty high. And these this is a family that is, you know, they're good people. Like, I think one's a teacher, you know, like they don't have a lot of money. And my wife runs my practice, and I love her to death. And I'm like, I looked at her, I was like, hey, this is gonna cost a lot. And she was like, Yeah, go for it. It's no big deal. Like, just go treat this person. And we have patients who literally leave their credit card on our file with us and they go, Hey, you need to take care of somebody that's really on death's door and doesn't have the money. Call me and I'll cover it. I'll help cover it. And it's like, Wow, yeah, like you, you know, that's just a community that cares for a community, and you're like, you just you're so thankful in those moments to practice medicine. And I say it every year at the end of our holiday party. It's like, it's just another year we get to do medicine the way we want to do it. We don't know if we're gonna be able to get to do it next year, and whenever day it stops, it's the day it stops. But at least for the five years we've been doing this, we've been doing it the way we like to do it, you know.
SPEAKER_02So well, you let's take that as a uh springboard because you did mention that you said, Hey, I had a chance to you know learn and experience the you know uh the English, the British, the the Scottish you know, ecosystem with healthcare, and now I'm in the U.S. working that, and you just said, Hey, I'm working outside of that. I'm I'm working my own thing here. I've been doing that for five years. Tell us what that looks like, and tell us how you're doing that, because we have a lot of other providers that listen to this podcast and they're interested. You know, doctors come to Dr. Bush all the time and say, Hey, how can I escape this mess? And so tell us about that.
SPEAKER_00Yeah, uh that's a great question. Um, I I've been lucky enough for my research side of my life. Uh I have been lucky enough. to work on some pretty cool products. And Troy, I think you and I talked about some of the hernia mesh products that kind of regenerate muscle rather than using, you know, kind of synthetic devices. At this point now, do a lot of ability to regrow blood vessels. So Dr. Bushman, I will walk you through the whole scenario I tell my athletes all the time. You know, someone comes in, basketball player has a meniscal tear and is in pain, right? And I I point out like the 2013 UNED Journal Medicine article where they showed no difference between arthroscopy and just injecting saline in. And now they just published the 10 year follow-up where it was like not only was orthoscopy not better, it was actually much worse for the patient. And everyone's like, what's going on? And you know, famous basketball players who have you know knee scopes or football players and then they wake up and they're still in pain. So I always tell them, you know, and again I'm making all the numbers up but you know imagine you had a million blood vessels bringing oxygen nutrients to your knee when you were a kid. After the age of about six or seven your ability to regenerate that blood flow begins to diminish because of thymic involution. And so now today you're a basketball player but you're at 5000 blood vessels. So your meniscus gets weaker, the pressure in your knee starts going up, the meniscus starts to tear and fall apart, the higher pressure on the tibia leads to osteoarthritis because when that pressure increases in the bone, the bone starts to thicken just like when you bring a baby home and they start crawling. However, and this is where I take a pretty sharp left turn from the orthopods, their argument is that the meniscus tear is what's causing your pain. I actually make the argument that the same microvascular ischemia that led to the meniscus tear also led to poor blood flow to the nerves in your knee. And now you have an ischemic nerve that is leading to problems. And so whether they sow the meniscus down trim it away throw PRP, whatever the heck, unless they get new blood flow to that nerve, you're not going to wake up out of pain. And it's great because like the athletes right all for for 20 years they've been getting tortured by physical therapists have done shockwave, red light, dry needling, hyperbarics, right? Every time they've done anything they looked at that person and said, this is designed to bring more blood flow to your knee, your shoulder, your back, wherever it was, because they knew that that was the issue. So that is where I've returned back to that kind of base level of, you know, how do we help nerves improve? How do we improve blood vessel flow? How do we get tissue to act more normal, regenerate laminate, elastic fibronectin, whether that's in hernias, whether that's in sports, whether that's in a patient who has some other condition, that A got me to the point where lots of random people who were pretty sick all around the country would start showing up to my office having heard from me by word of mouth thankfully most of them were pretty wealthy. So I was able to say hey you know what we're just going to stop bothering with the insurance side. Like and I'm happy like if if you know a steroid injection or something that is basic is your right answer, like we're just going to treat the patient correctly, right? But the counterpoint to is I'm going to get out of the loop of being controlled if that and I don't know if that's the right word by the insurance company, right? Right. Like we will do whatever we can. We're going to do what's right for you first and foremost. Whether the insurance company covers it or doesn't cover it, that's a separate issue. But once we as a patient and doctor agree that this is what's best for you, then we'll figure out how do we either get it through the insurance company, sidestep the insurance company or do some other methodology. And it's been great. I've had lots of people help me along the way I think many of us you know in the medical community are pretty tired of working for hospitals, working for insurance companies, working for big private equity groups that are really just driving both us and our patients into the ground. And the other part of that is you know the counterpoint which is my own personal development of like hey I don't need that much I don't want that much like I'm happy to sit on my couch and watch TV and be left completely alone. I I you know I don't need to drive a fancy car I don't need like I just want to like you know I want to be able to wake up in the morning and feel good about what I'm going to try to do for the day. I want to be able to go home at night spend time with my family I stopped taking calls I stopped doing a lot of my surgeries because it's just too taxing right like your own health goes down our mental health our physical health right and as a physician especially post-COVID like anybody who worked through COVID could tell you like the the joy of medicine is dead and gone for most of us that walked through that. Like it was god awful and you had you know everyone else make tons of money but we didn't you know like there's no impump in reimbursement so it was nothing to think you know the physicians that were the front line right nursing staff shortened up so now they're getting you know travel nursing is fantastic and I congratulate them like you know hospitals are oh like are complaining about their nursing costs and I'm like thinking no no man they deserve every dollar and then some like you are underpaid now right right like am I getting underpaid a hundred percent but that doesn't grudge me for someone else finally getting the close to reimbursement level. So I do think there's for providers that are interested I tell them number one like find out what really drives your passion and go after it. Number two, accept that life is going to look very different um financially but then also time wise right I went from I think for 20 years I probably averaged about a hundred hours a week of work between every other night I call and office and everything else and it's like that's not worth it. It's not worth my family so you know accepting like hey I am going to work 40 50 maybe 60 hours a week but that's it. And then number three you have to kind of empathically feel for the patients and then you know especially when you get to my age you are a patient like you are you're seeing other doctors and all of a sudden you're like boy this can be done a lot better. So I think those are the three big keys and I think people will find you like you know patients are looking for the exact same thing. It's not like they're running around going boy insurance companies are great and the hospitals are fantastic.
SPEAKER_01I'm so glad you know so what are I mean that's yeah we could have a whole nother hour on on specifically the joy in medicine. So like from your perspective what do you feel like it's going to bring that back? I mean so like you've done what you did in your family and in your household your your business you you made the necessary change. I did the same thing for me I and this was even pre-COVID like about a year before COVID. And I'd actually already had a broken family at that point, you know and uh you know you so you don't blame everything on that but to say it didn't contribute heavily absolutely in many ways. I came home a per a shell of the person I left the house of in the morning. And um and and and I love it. I love people I love taking care of people I love medicine in in general but yeah it what do we do? Like what are we gonna do to redeem the joy?
SPEAKER_00Yeah and uh that's uh I think a couple parts to that like I think that everybody has a different like expectation of joy or what brings them joy. I also will tell you it changes over time right like when I was younger like traveling the world doing big cases like really taking care of the most complex stuff that everyone else was like dude that's not doable like it brought me joy right made me feel great but like everything like and I I actually will give a shout out to a guy named Kevin Bernetti played nine years in the NFL Kevin and I give a talk for uh the opening med school class where we talk about him being drafted into the NFL and me being a surgeon and the two things overlap almost perfectly right Kevin actually jokes about you know he was you know top of his school in high school he went to Tennessee he graduated he's actually I think in the SEC Hall of Fame like he gets drafted by the Cowboys and like his first three years no one even knew his name and no one cared because he went from top of you know Tennessee to you're just a schmuck in the NFL right and then there are lots of other people trying to take your job and uh and so today poor Kevin is dealing with lots of medical issues right I mean lots of medical issues from the beating he put his body under both in the NFL and college and all the years before right so the price comes due. So the joy for a young person is can be very different from the joy of someone like my age right like and some of that is family right like you have a child and all of a sudden you see that child growing up and you're not there. And when you are there like I came home one day and I like I was wrecked exhausted and my like nine year old kid like had set the couch up with pillows and a blanket because she knew I was just going to go lay down and she like put a little sign that was like if you need a massage and like I would lay down on my back and she'd just start walking like directly on top of my body to like help my body because it's like boy when your nine year old knows that you're dead to her world like because you're so exhausted like there's a reality check moment there right you're like so I do think I I think physicians need to be able to find that joy define it and I do like you know once a year twice a year to sit down and like I do it myself it sounds corny but literally once a year I sit down and write like a like a letter I literally type up a letter just going through my own head of things that I've done as like an affirmation of hey good job and then the end of it that letter is like a what can I do better next year to make myself happy and and many of those things have nothing to do with medicine. It's like hey I want to you know I I decided I really wanted to learn about wine so I passed my sommelier exam I was like you know this year's goal was like hey you're gonna read and learn a ton about wine to become a sommelier and we're like cool why I have no idea no reason whatsoever right but I want it so I did it. So you know finding those things engaging your brain because it's the practice of medicine is really just a practice of using your brain on complex things and it can be charred to complex issues not in medicine. So yeah.
SPEAKER_01That's a top I I was actually uh so we just got back from a conference together, Troy and I, and uh many different wonderful conversations both with colleagues and then people in the benefits industry it's uh and one of the things that came up multiple times was a similar conversation like this where we're all talking about the things that really just drive us what what you know and and in certain ways what distracts us of course you you you mentioned a little distractibility you know when with with AI coming to the table it's like man I can get so much stuff done but I can also see all the possibilities and I have to quiet that side of my mind. But ultimately I'm coming home from that conference and I I'm sitting there in the airport and I'm just thinking what a blessed man I am. I get to go home. I can't wait for those warm arms around my neck and little kids on my lap and like that's the joy and being away for even just three days was just that almost an emotional reset of saying what I'm doing in my day-to-day work is making a difference in people's lives patients' lives yep uh but man there's nothing better than knowing I'm going home to the people that I I care about most and then looking even first day back in clinic today um I had somebody uh I came around the corner I start talking a little bit and they go what's up with you you act really really calm like what's you you look very what's different do you take a medicine like no am I not always this calm they're like no you look really really relaxed and I was like I just I feel very grounded right now I feel very grounded but it takes practice and takes really just being aware you know yeah and like yeah and this is like again that realization moment for me was you know hey especially for what we do it's like okay most people would want to like cram as many patients in you know because you're making money um but I I you know again kind of reverse engineered my life I was like okay how much do I need to make every month to pay all my office bills I don't even take a salary because I got you know like other stuff I'm like okay like how much do I need to bring in to get that done and you know that answer is this that like I'll do a 20% over that number in any one month the moment I'm 20% over that number for that month it's like hey we're we're just gonna shut down like we're at we are literally in my office we see patients pretty much one day a week.
SPEAKER_00The rest of that week is just spend hey catching up the like organizing you know like think about you know Dr. Bushman if you had three days to get all your prior look at all your imaging and follow up on all the things that you can't do because you've got 10 patients you know like that's the type of thing where I hey have gotten to that point where it's like hey these are the things that are valuable to me. Right? It's not just me looking at the report of uh MRI it's me looking at the images as well comparing them to 2025 2024 doing the deep dive of everything that's been going on with this person so that I have a clear cut conversation with them so when they come in on Thursday we're ready to go. And then for my office side it's hey we're gonna max at 10 people on a Thursday we're not we're not going above that because everyone gets at least 45 minutes right at least doesn't matter if they're just stopping by to check in like great stopping by check in hang out right we have tons of patients and friends who like stop by because we order some food and we like yeah and they'll just pop in and out like it's like a you know a fun event to be in the office on that day but it also helps us catch things right so the funny thing is so you know two weeks ago we had a patient that friend came in was coming stopping by to grab some food and they were walking just a little bit funny and we like you know my MA was like hey we need to get you your new insoles because you know we need to order you to rotate your foot differently and it was like we would have missed that if they hadn't stopped by and it would have been an extra month which again to that person they may not have noticed but they are a pretty high level basketball player and that can be a career ender in two years if we didn't you know so those types of things that really have to help define. I think the other part of that and I tell this to young people all the time when you're young and you're getting a decent salary and you don't have the family you don't have all the other obligations that really take away like find somebody you trust, invest heavily like get that money working for you so that when you are my age you are less reliant on your job and you can start doing that job in a much more joyful way. You know and and just you know kind of keep that in mind. Like you know then like set goals. Like if you want to retire at 55, great how much do you need to make that retirement great how are you planning on getting that by the time you're 55 and let's work backwards from the end of your life all the way to the beginning right we do that for patients all the time right like you're treating heart these not because they're actively having a heart attack but because you want them not to have the heart attack right and so why we don't do that for ourselves is like laughable.
SPEAKER_01Like for the worst patients for that reason right yeah but I think I think you make a great point and I've I've I've made this point to our our local medical school that that part of the curriculum they don't make time for it. Right. And and so when when when residents andor or students like fourth year medical students come through my uh rotation here at the clinic I was talking about develop your professional team okay and that's not your attendings that's not your colleagues you need a good attorney a good CPA a good counselor or someone that you can go to when you need something okay that's that is independent and and and a financial planner. And I even if you're just filing W-2 taxes and you're not doing anything more special than that you still need someone to to think through and give you that advice and that whole example you used at 55 is exactly what I did with my financial planner. When do you want to retire? And I'm like I retirement's not a word in my brain right now. Like that's it's just not but at what age would you like to have the ability to do really whatever you want because financers are no longer an option. Okay well now the age is 55.
SPEAKER_00Okay yeah exactly just don't say retirement okay because that's just not and and the funny thing is I always like you know and my wife always jokes because I'm like I'm gonna quit and I'm just gonna sit on the couch and she just laughs. She's like you could never sit on the couch. Like there's no chance in hell you're ever going to sit on the couch. So let's just talk really like what you're gonna do. Like that's fair right but uh it's it's that whole concept of you know here are the goals that I have set out for myself but here are also the goals I set out for my family for my staff right how do we and Troy this gets back to what you were talking about. How do we enrich everyone around us right like you know I like my ame has been with me since she was 19. She's 25. Like we've like she's like an older sister to my daughter right it's like and it's like I've walked in I'm like yeah you I signed you up for this course she's like I'm sorry I'm like yeah you're gonna get certified you're gonna get IV certified like you're gonna learn to do all these things she's like why like because like listen like we are evolving as a practice and you are as going to as well and like you know and she's then you know we have a corporate credit card I'm like discharge it to the corporate credit card like we are going to make sure that you too grow as a person um because whatever day this comes to an end you are going to be better enriched as an office staff as patients as providers right um and you you have to have that view and and there are tons of providers I like you know I get a referral and I'm like you know what let's send you to this person over here. A they they're great B they need the business and C like we we have our 12 like we our our our eight patients are booked up for that day. So this is and helping your surrounding medical community is is huge. I can't tell you the number of providers and family members that I've taken care of free of charge. And they like if I have an issue or if one of my patients have an issue they take care of me and my patients as well. So you know Vegas is a small town like that um but every community is the same way. Like you have to have that bigger picture um to to kind of make that work.
SPEAKER_01Yes absolutely I find it interesting too uh Dr. Joseph that um when I first came to residency in my community and I've stayed in the same community um my grandfather who was in his mid 80s at the time uh wanted to give me a little tour of the community and uh he um was a pastor 50 plus years as a pastor he had this really small church and he wanted to show me what it was there. He was basically it's his little retirement gig and he was doing jail ministry and he was doing all these and he was he owned up several different homes in a lower lower economic status where he was maybe charging rent and uh and he takes me uh into this one particular neighborhood I'll never forget it he goes this is probably where you would end up and I go well what does that what does that mean? He said well I I just I think you'll end up here sure enough I was I was not far off but he said to me he said have you considered going into academic medicine I said no I don't want to do that and he said okay have you considered teaching and I was like I don't know that's just not I don't know I'm not sure that's for me because at that point you know being about 27 years old all I could see was speed right yeah speed volume let's go let's go let's go and as you mentioned what brings the joy at that time was I doing good things and making you know doing great having great care towards patients absolutely but again as time has gone on the more I I wouldn't say more joyful but definitely it's more joyful than it used to be is just giving back to those around and within the community within your professional community and the reason he said that to me and I'll never forget it of course he was a pastor right um but he said you know when you mentor and you train you're influencing all the people around them as well you might see you might have a thousand patients yourself but when you've been able to give back to the Future to the you know the upcoming future physicians. Yeah. Yeah. Just the impact that you could have. And so I kind of dismissed it at the time, you know, because that's what 20 somethings do. Yeah. Especially their grandpa. Yeah, yeah. You know the one that's exactly over well. Um, but yeah, it's it's it's it's beginning to hold more and more true as time goes on, is like, man, that that is joy. And really, going, you know, going back to the theme of our discussions too, is like, how can we make sure the most people win in this healthcare system as we give back? We we we teach others how to make sure that patients maintain the priority where they should be. And uh Troy and I we sometimes get mad about this and then sometimes we laugh about it, but it's when we're talking to industry, business, yeah, brokers, etc. And uh and even some physicians, I I have to say. And they start talking and it doesn't take long. You figure out what they're in it for and what's the focus of the conversation. And I don't know how many, and they're probably not listening to this, but doesn't matter. Um uh I don't know how many of them realize how quickly I I pick up on that. And just like, yeah, we're not doing business together. Yeah, like yeah, it's just it won't happen. Same is true for employers sometimes. You listen to what they say about their employees, and it's like, I don't hey, I'm good. I'm not gonna serve you.
SPEAKER_00Yeah, and I I will tell you, it's funny because I wonder how many people know the layers, like who they count on, who they don't count on. Right. There are employers that I work with that are like all in it, and like I hate saying this, but like we work with a lot of professional teams, and they're like Miami has like a list of like professional teams that she it's like her naughty list. Like, you know, they just they're terrible. They're terrible to their players, they're just they're just not like you know, that's not what they're there for, right? Um, and then we have other teams that are just fantastic, right? Like we call and they're like, go. Like they, it's like, you know, and again, like we have probably multiple, you know, professional teams credit cards like on file, where they're just like, you take care of them, charge a target credit card, no questions asked. Um, but it's that's it's tough. That's probably the area that brings me the least amount of joy or my greatest sadness is how do I advocate or navigate a patient through a complex situation when either their employer, their insurance plan, their financial, something is substantially holding them back, right? And to some extent almost actively trying to harm them. Not not because they know it's harmful, but because they're either complicit or don't care, right? Um, which actually is worse, right? If if someone's actively trying to kill you, so be it, right? But like for someone to be like, yeah, I just don't care enough to like listen to an expert because I have no interest, it's like, boy. And it really gets annoying when they're the same exact people who like show up in my office and want me to take care of their loved ones. Right? Right. Like I had it with like Aetna because they just would not allow us to take care of something. And then, you know, their head person was in here with their husband to be like, hey, he's really screwed up, like can you take care of it? I'm like, oh, come on. Like, come on. You know. Um that's it it's it it's tough and and I that's actually part of the reason why I also like turtle in my practice, because it's like I I don't I the more involved I have to be, the like the more difficult it becomes, like the harder and I to some extent I think the the smartest or worst thing that insurance companies ever did was they pick the labor position with bureaucracy.
unknownRight?
SPEAKER_00And they knowingly know that that they know that that is the thing that will kill that person's soul. Right. It's not a no right away, it's a I'm gonna make you jump through 26 hoops, and the first time you'll jump through it, second time you'll jump through it, but the hundredth time you're gonna start giving up, and you will finally wear down to the extent that now all of a sudden from you know going forward, you're just not even gonna try.
SPEAKER_01And that's I think I think of that in terms of the strings coming off of Pinocchio. Yeah. It's like I know I'm I know I'm supposed to move in this direction, do these things, and I'm starting to get really annoyed about why I don't know who's got control of me. Yeah, yeah. Like you start looking up, like what's going on? That's going on.
SPEAKER_00The military, I think they call it mission creep, right? Like it's um, and so that's where you know, keeping a small practice, doing very specific strategic things allows me to stay away from a lot of that. Hub up and then number two, like my staff is great. My office manager, she's the person who has to like slam her head against the wall every day. Like she's the one that's fighting with you know the insurance companies getting approvals for medications to MRIs to like fighting with everybody in the world. And I'm like, that's a you fight, because I don't want to be involved per se. And the occasional times where I do have to step in, I step in, but like, yeah, similar to your staff, like recognizing a difference, like that the day I have to step in is like I show up grumpy as hell, and it's pretty funny because I snap nose and they're like already pulling like wine in the back, like, okay, as soon as you know we're done, we're taking some wine, and uh we're gonna we're gonna have to uh do a little meditation, calm everybody down, right? Like but it's that's dude, that's the world as we know it today, and it's uh in healthcare. Now I have a great deal of hope for the young kids coming out. Um, I think they are smart enough to recognize that the structure of their education is wrong. Like I I I like graduate medical education is the best example I can give you. Like you teach residents, but the hospital gets paid for that. Then they're gonna pay you. But the hospital's the one getting that money like makes zero sense, right? Like zero. Similarly, like medical school education, okay, yeah. Like, you know, like the you know, double AMC or whatever says you have to cover all this curriculum and there's not a lot of extra wiggle room space in there. But like when you look at undergrad, undergrad was great. Like, yeah, you had your major and you had to take these classes, but then you had all this other time where you could just go pick classes to do. Why can't we have some version of that in medical school? Right? Here are your core classes, you must take them to graduate, but then here are a whole slew from financial literacy to social media, AI, whatever the heck it is, that you can pick and understand so that you can grow in your strengths or strengthen your weaknesses. But either way, like, you know, students should have a lot more freedom to do those things. You know, same with residencies. Like I laugh, I I learn more from spending time with nephrologists and cardiologists than they ever do, you know, hanging out with surgeons. Because we all taught the same thing. They're all it's like a you know, like it's a group thing, right? It's totally like you know, JFK at the Bay of Pigs, we're all sitting around telling each other we're all doing the greatest things ever. And you're like, yeah, except nothing's changed, like the outcomes aren't any different. Like, you know, oh, they're great. Okay. Like, yeah. And it's like you go show up to uh, you know, like oncology. I love tumor boards. Like, yeah, the oncologist would be like, oh, I could do this, I could do that. And as a surgical oncologist, I'm like, listen, I hear you, but if you can shrink this tumor by this much in this one spot, I can operate on this first. And the radiation oncologists and the oncologists are like, okay, great, that's what we're looking for, right? Going forward, that's our goal. Is we don't care if it gets bigger or smaller or this or that, but this is the spot we need to look at every time. Great. There's a plan, you know. Um, and then the evolution of all this new biologics, all these new cool therapies, it's like, well, it's totally different today. Yeah, you know, and and the funny thing is, like, you know, we're also at that age where you know, loved ones have cancer. And you know, my wife's a medical oncology nurse practitioner, she's like, data says this. I'm like, yeah, that data's old. She's like, it was published last year. I'm like, exactly, it's old. What are you what are you thinking? Like, you don't think that three years from now it's gonna be a totally different world? Like, come on. Yeah. So we're sure.
SPEAKER_02Yeah, uh, have you do you ever look at yourself as a concierge medicine doctor? Because you know, Dr. Bushman and I look at you know, DPC direct primary care doctors, we talk about how they serve us, how they spend more time. And that's one of what you're describing, but you're a specialist, you're a surgeon, yeah. But you're concierge.
SPEAKER_00Yeah, and and you are correct. I actually, it's funny you say that. I do say I'm like a concierge doc. I don't do very much primary care, obviously, like you know, like we'll see people and whatnot, but we're not a primary care office. But for like athletes, a great example. I can tell you, you know, the basketball player was a great example, right? Guys in the league, you know, many years in. He's had multiple foot issues, multiple operations, and you know, he's got his team around him, right? You know, he's got the team docs and the orthopods and the diatrists and all the things. Right. He came in, I looked at him, I was like, hey man, let me see your insole. Just pull it out. So he pulls out his insole, and I'm like, run your fingers across your insole, tell me what you feel. And he's running around, and like his big toe, like the indent of that insole on that big toe was like cavernous compared to the rest of his toes, right? Base of his toes. He's like, Man, that's deep. I'm like, yeah. So you're seven feet tall and you're jumping, and you're landing and jumping off of your big toe. Where do you think your problem's gonna come? Like, it hasn't come yet, but it's coming. We know it's coming. Like, I don't need to be friggin' nostrodomist to know that in a couple of years' time, you're gonna end up with some big boy problems on your big toe, and at seven feet, that's not gonna go, right? So, and the funny thing is now you're into a complex fix because you not only have to rebuild his insole or roll his foot to offload his big toe, now you've completely changed his natural basketball movements. So now you have to sit down with his coaching staff, and and you know, he works over an Impact basketball, and I work over there really closely, and Joe, who runs Impact, is like a world-class basketball coach. Like, Joe and I have to sit there and work through drills to retrain this young man so that he can have a tenure NBA career because it's a total change in his entire lifestyle, how he plants his foot, how he shoots, how he pivots, how his foot feels in his shoe, right? We have to work within obviously his shoe sponsors and his agents and the team and the team docs, and but and I I laugh like Joe is the guy. Like Joe's the person, he's been doing it for so long that he's the one who picks up the phone and calls the team, is like, we're doing this. And they're like, Yep, no problem. And they have phone. They have no idea, like they don't care who I am at all, like at all, right? But I have a close enough relationship with him, but I can be like, Joe, we need to do something here. And Joe's great because he's the one that knows that he's got that relationship. So he looks at me, knows I can't take on that fight, and he's like, I'll call the team, I'll call the agent, I got you, right? And it's like I'm borrowing his credibility, right? And he trusts me enough to like listen, and I laugh because you know, he showed up one day in my office, like for you know, because a friend told him to come over, he had a lump on his head, I removed it and sent him on his way. It was like nothing big, but I'm pretty sure he didn't think I was a doctor until like after that was done, right? Like he just showed up randomly and like yeah, but that type of community effort, understanding the whole patient, whether it's a you know, I have a construction worker, I had actually a lawyer right now, I have a bunch of big people all walks of the life, teachers who have these complex issues where it's if you go to the orthopod, you get the orthopod answer. You go to the sports medicine doctor, you get a sports medicine answer, you go to your primary care, they're gonna right like you don't have somebody that's playing quarterback to all of it doing that deep dive and saying, hey, here's the plan. And then also we're gonna follow you pretty closely, either by phone call or in person, right? Because, you know, we can't Duck Bushman can't be seeing his primary care patients every month. That's not appropriate. Like he's got enough, right? The orthopod has zero capabilities, like, you know, he's six months out for the next appointment. Sports medicine doctor's like, good luck to you, right? So who's gonna stand there and monitor a game plan every month for two to three months and then change that plan if it's not working and quickly pivot and then recommunicate that back out? The answer is we will, because that's the way our office is gonna work. You know.
SPEAKER_02Wow. So incredible. So incredible. Well, Johnny, you can tell why I wanted to have uh Dr. Joseph on, and again, this is uh hopefully just one admitted because he's got so much. So are you if there's one story, one patient story that you would love to you know shout from the mountops, if you'd love to share and say, you know, this is what it's all about, what would that one story be?
SPEAKER_00Boy, you know, I have a bunch of them, but probably the one that jumps out to me most, and it's kind of close to my heart. I will I I tell the story. Uh uh, my kid goes to this great school, uh, one of the kids, and this is probably seven years ago, one of the ladies that worked there talking with her, she was a counselor or something, and I don't know how they actually stumbled on the conversation, but her dream was always to be a farmer. And they had an organic garden at the school. She could never work in the garden because she had frozen shoulders, she couldn't lift her arms above this. And she was like, I can't. And she'd gone to everybody, seen everybody, had done years from PT to surgeries to all these things. And so my wife was like, You should come in, like Saji can help. And so she came in and I was like, and it was like right at the end of uh end of school year. So we inject her, used a bunch of really cool regenerative medicine stuff, kind of forget about it, like she's off and about, and she's out front, like dropping kids off, and she's in like uh overalls and the whole thing. As I'm pulling out, she starts waving her arms, like so excited. So I rolled down the wheel window, and I was like, Stella, she goes, I'm farmer Stella now, and she just starts bawling, crying. And it was like it seems like such a little like thing, right? But like to fulfill, like to allow this woman who has been a teacher for 25 years to be able to live out like the weirdest dream. Like you're asking me, like, there is no part that I want to be a farmer in the middle of Las Vegas. Like, there's no part of that, right? But for her to be able to get that opportunity meant the world to her. Uh and that's like that's a patient win, right? That's not only a patient win, it's a family win. Like, let's keep in mind. That's a husband who now is a wife who can travel, they've been traveling the world. That's kids that are happier. Her parents, the school, right? The school now has a phenomenal curriculum that all sorts of kids can go play in this garden because they have a a gardener, a farmer. Right. Like those are the ripples. So darling, like, you know, I view it as like ripples. You know, you watch that cool slow motion video of like a raindrop hitting like a pond or a glass of water, and you see, like, we as physicians see that drop. We rarely ever recognize the ripples throughout that community, that family, and that employer, and all the other people they touch that our single action has. And uh, and don't get me wrong, there are some drops that suck and and we make mistakes like every other human being, but 99% of the time, those drops are magical.
SPEAKER_01That's awesome. Well, Dr. Joseph, thank you again for joining us. Thank you for the the insights and the the laughter. And also, I just appreciate um how you um, both on a personal level and a professional level, have recognized those things that matter most and that you've aligned your your values with your profession. And I love that. I love when people have brought brought their values into the business of medicine. And uh when you do, we we know that patients win every time when you do that. And and I love that. I love the story. Uh wish you the best in your continued ventures. Um, have to admit, I'm I'm in another screen. I have uh Southwest tickets to Vegas, just trying to figure out when I need to come visit you now. So you know let's make it happen. Let's make it happen. Absolutely.
SPEAKER_00Come on down. Troy, I tell Troy all the time. Come on down, like we'll hang out. It'd be great. We'd love to have you. Love to have you. It's such a pleasure. Thank you guys so much.