Dr. Matt Sherrer (Host 1): All right. The Fresh Flow Podcast. Welcome in. Mitchell, I got a question for you. It's baseball season around here. And in Birmingham, Alabama, we have a minor league team, not a major league team. We're not big enough to have a major league team. We have the Birmingham Barons, which are Chicago White Sox's farm team.

But around here, if you ask who's the favorite Major League Baseball team, you're going to find a lot of Atlanta Braves around here. I see lots of Atlanta Braves hats. I was thinking, are you in Red Sox territory up there? What's the primary team for people in the Burlington, Vermont area?

Dr. Mitchell Tsai (Host 2): I think if you're a Vermonter, you're either looking at the New York Yankees or the Boston Red Sox. But since I'm a California transplant and my parents are from Taiwan, I'm going to go with the Taiwanese team in the Little League World Series. Congratulations to the Taiwanese team this 2025.

Host 1: Did they win it?

Host 2: Yeah, they won it.

Host 1: Cool.

Host 2: This was the second time that the head coach had been there, and the last time he was there was 18 years ago. My youngest son was telling me that they have a kid who pitches on that Little League field over 80 miles an hour, which is equivalent to over a hundred miles per hour in the major leagues.

Host 1: Good grief, man.

Host 2: So yeah, my little kid's teaching me something. See, I can learn. See, I can learn, man.

Host 1: All right. Well, speaking of people that can learn, we are fortunate to have someone here today who has quite learned in the perioperative space. Mitch, do you want to introduce Dr. Tom Durick?

Host 2: I mean, I can do a brief introduction.

Host 1: Yeah, we don't do formal things around here.

Host 2: Matt and I have the honor and the privilege of listening to Dr. Durick from the Ohio State University, simply because his chair, Dr. Richard Urman, threw him under the bus and he lectured at the Association of Anesthesia Clinical Directors. But, Dr. Durick, you're going to bring, I think, to this podcast a breadth of experience from both the private practice world and now you're in academics. And I'm really excited to talk to you today.

Host 1: Tom, welcome, buddy.

Dr. Tom Durick: Thank you. I'm also a Minor League Baseball fan. I'm Oakland A's fan. So, we play in a minor league park. We're a farm team for every other American league team. In fact, we're not even called Oakland anymore. We're just the Athletics. We don't even have a city.

Host 1: Sacramento?

Dr. Tom Durick: So, we don't count that. We don't say Las Vegas or Sacramento. We're just the Athletics, ATH.

Host 1: So while we're on this baseball theme, because I know we're going to end up talking baseball in a little while, but you're in Columbus area. That's basically slap right between Cleveland, Cincinnati, you've got Pittsburgh nearby. What's the primary allegiance to baseball teams in that area?

Dr. Tom Durick: I'd have to say Cleveland. I think most of the people I work with are still Cleveland fans. They refuse to call them the Guardians. Yeah, you still see the Indian shirts walking around, and we had the privilege of going up to the Guardian Stadium last year and watching Oakland lose three straight. And they only lost one game, like by two runs. So, that was a victory for us. Basically, it was like almost winning.

Host 1: I like it. I like it.

Host 2: Moneyball.

Host 1: Moneyball. So, let's jump in. Hey, if we're going to keep this thing relevant, let's keep it relevant. The reason baseball was on my mind is because I was reading up. Contrary to popular belief, I do try to prepare for these. I know Mitch is shocked right now. But you gave a talk back in 2015, a series of lectures entitled Moneyball in the Operating Room: the Art of Winning An Unfair Game. Tell us more about that. That's for our audience. Moneyball, Billy Beane, was a book turned into a movie, Sabermetrics and all of that. How did you take that and how did you apply it to the perioperative space? And then, the big question is, are we measuring the right things?

Dr. Tom Durick: I've listened to so many of the Fresh Flow podcasts, and you have so many people just brighter than me. Like, you had Drew Franklin on last time, Peter Nichol, Jay Mesrobian. Every time, I shake Jay's hand, I think I just get smarter just from shaking his hand. But Moneyball is important for me because I was running a very small surgery center in Oakland, California for about a dozen years back in the 2000s. And we were private practice fee-for-service with two physician owners. And I ended up being medical director, like their financial officer. I ended up doing everything. I ordered supplies. I ordered the meds. I ended up running our billing office, so I was editing the op notes, doing all the coding, sending our electronic claim submissions out. I ran the billing office.

And I remember, you know, hearing about Moneyball back in the day, which people don't know, Michael Lewis wrote the book about the 2002 A's and Billy Beanes' attempt to, as their general manager, trying to become competitive. And their salary was anywhere from like one-tenth to a quarter of every other team. So, they were using Sabermetrics, which as a baseball collecting kid back in the day, it comes from the Society of American Baseball Research, SABRmetrics from the '70s where you look at the statistical on the feel of how guys play and trying to find players that are undervalued from a salary-wise standpoint, but who can actually compete in the big leagues.

And it just struck home with me because we were a tiny surgery center. Everybody else around us was either owned by a hospital or partially owned by a hospital. We didn't have any of the insurance contracts they had. We were mostly Work Comp, about 72% Work Comp and about 14% Medicare with a hodgepodge of really crappy private insurance contracts. You know, how do you make that work? And in the one scene where the scouts are all sitting around, Billy Beane is trying to explain to them what the problem is and they don't get it. And he says, "The problem is that there are rich teams and then there's poor teams." Then, there's 50 feet of crap, and then there's us. It's unfair. We've been gutted. We're like organ donors for the rich. Boston's got our kidneys, the Yankees got our heart. And you guys talk about the same old crap. And everybody, all of my staff, they were all doing it the same way. They were telling me, "Well, we've always done it this way." And I kept saying, "Don't ever tell me that again." Because what if the first person who did it was an abject moron? Then, we're all just doing it the same stupid way. So, Billy Beane said, "We've got to think differently. We're the last dog at the bowl, and you know what happens to the runt? He dies."

So, we started to get creative about how we did things. We had to be the path of least resistance. Everybody is your customer. It's not just your patients. Your surgeons are your customer. Your GI docs are your customers. Your staff are your customers. Your housekeepers are your customers. Any one of them leave you, and all of a sudden you've got a gap in your entire process. So, I had to become just absolutely creative in how we did that. So unfortunately, my phone was on 24/7. Every surgeon's office knew they could call me straight away. Five o'clock on a Sunday, I'm checking insurance benefits, "Yeah, we can do this case here." But it was really ultrasound that separated me from everybody else. I was an early adopter of ultrasound-guided nerve blocks. I think I bought my first ultrasound in 2004. So, I could do a case faster, better, fewer side effects, no narcotics. The surgeons wanted to come to my surgery center because I could do more cases in the same time, and they're part owners. You go to your surgery center, you're doing five cases a day, and the patients are puking all night. They come to my surgery center, we're doing seven, we're done by noon. Nobody throws up. It was those kind of things that I took that Moneyball and then it was the side effect of looking at every single thing we do with our direct and indirect costs. Do we need to have that maintenance contract for our C-arm? What's the most expensive piece on there? Okay, the tube is 10 grand. The contract's $5,000 a year. I'm going to roll the dice. I'm not going to sign that service contract. And if I go three years, then I'm ahead. We did that with everything from our fax machine to our electricity, to our HEPA filters in the OR. And basically, we played Moneyball trying to improve our contribution margin everywhere we could without compromising quality.

Host 2: Tom, I'm going to ask you, with the Big Beautiful Bill, and we try not to talk about politics here on this podcast. But I don't think that the Big Beautiful Bill was anything new. I mean, NIH funding has been decreasing over the decades. And I think this just merely accelerated it. But when you think about large academic institutions, right, where does Moneyball come in? And is this even more important today than it was a decade ago?

Dr. Tom Durick: I don't think it's ever stopped being important. I think the good and the bad of big institutions is you have the ability to suffer through those deep bottom out pits like COVID, I spent 30 years in private practice Anesthesia. I only came to the Ohio State-- and you didn't say it properly, Mitch. You had to start off with "the" Ohio State.

Host 2: The Ohio University.

Dr. Tom Durick: Yeah, I've been in the Ohio State University a little over five years now. And it was a big adjustment because I was used to being a souped-up jet ski on a little pond, and now we're on this Destroyer on the ocean that just can't turn quick enough. So, I still struggle five years later. But the advantages of the big institutions is they can pivot slowly so they can handle all those little bullets being shot at them. But the downside is you have private practice hospitals in your same city-- you have it in Birmingham, you have it in Vermont, we have it in Columbus-- that are trying to do things.

What I always say is bigger, better, faster, stronger. That's your goal. They can pivot quicker than we can. We have the ability-- I know we have the ability to stave off some of the offenses, but I think that it all boils down to looking at your case costing. Whether you're in the ICU, whether you're in the OR, at the main hospital, you're in the Cardiac, you have to look at your case costing and you have to have somebody who is just ravenously passionate about doing that from breaking down preference cards. You find one instrument that you are opening up a tray every single day to pull that one instrument out of, you're wasting everybody's time. The circulator who has to leave the room, the tech who has to go and take that thing back down to central supply, the central supply person has to clean that whole tray, the money, the paper, to reprocess that because you need one instrument. One little thing doesn't sound like much, but that inefficiency, it just spreads out like the bottom of Christmas tree. So, big institutions still have to act like small institutions. You have to do realistic case costing. And the problem with the big institutions is they can't always get that data. So, I think that's where universities, big hospital systems, doesn't matter if you're USP or, you know, a two-room surgery center, the devil's in the details.

Host 1: So, I'm sitting here listening to all this, and I'm picturing our residents, we have residents that listen to our show, which we're thankful for. But I think I can see some of them right now going, "Um, I don't know any of this stuff. How am I supposed to know any of this?" I myself, I call myself a private practice flunky, right? I've been here at UAB, for six plus years after a decade plus in private practice. And when you're in private practice, you are most assuredly running a business, yet we get trained absolutely none on that, right? I come through residency, even me, undergrad, medical school, never had a business class, never had a leadership class. And here I am, running a private practice group. And I found myself pretty much overwhelmed. Are we doing our residents a disservice? And if so, how can we start to impart some of this stuff earlier? Is there a solution out there?

Dr. Tom Durick: The answer to the first question is yes, and the solution is to start them early and often. When I came to Ohio State years ago, they had one person doing a "business talk". It was abysmal. He was talking about CPT codes, and he didn't even know what a CPT code was, but giving this talk, it's like, "Blah, blah, blah." And we were talking to a first-year resident, it's just bouncing off their head. They're just trying to figure out how to put an IV in without sticking themselves with it. I mean, that's like if they get through the day and they don't jam themselves with a hollow-bore needle, you know, it's, "I made it." And I kept telling the residents when they start, you focus so much on "I got to learn everything." No, you don't. You just have to get through. You do three things right in one day. Don't worry about the stuff I'm going to teach you when you're a CA-3. Just get through the day. Okay? So, you didn't get this art line, you couldn't get that intubation. What are the three things you did right? And go home and celebrate those three things. Don't beat yourself up and then come in tomorrow like you just threw an interception. You have to forget that last pass.

So, what we've been trying to do, at least at Ohio State, is I'm trying to give them lectures when they first start, just to put the terms in their head. I want them to know there is a thing called the CPT code. There is an ICD-10 code. This is the procedure, this is the diagnosis. They have to match, or you don't make money. And they go, "Huh?" They don't make money. Okay. Then, that's how they start to understand that. Because you know a lot of the residents, they think they're going to go out and somebody's going to hand them a check for a million dollars, pay for their first two born kids' college. It doesn't work like that. They come out just really ill-prepared to walk into my OR-based surgery center with Bob Eppley doing seven shoulders and he wants to finish by 2:00.

So, part of that preparation is getting them started with the terminology and then doing intermittent, whether it's morning report, grand rounds on here's three little things you need to know about billing when you're doing your charting so that you establish those habits early about, yeah, you capture a picture for an art line, so you can build that one unit with ultrasound. You teach them what field avoidance is and it just becomes a habit on there. So when they become a CA-3, and they get to me and I'm doing a lesson at the surgery center that I run, going through how to bill, code, collect-- I talk about both facilities on there. Some of this stuff, they've already had these lectures and they're, "Yeah, I remember that lecture last year, I really wasn't listening." But now, they're craving it because they're going out to private practice in two to four months. But if you haven't put those things into their heads first, they're never going to absorb it. And some of them don't want to absorb it. Some of them, "I'm doing a fellowship in Pediatrics, I'm going to go work for university. I don't need to know this stuff." Okay, I don't need to teach you.

Host 2: Was there a difference? I mean, you came from private practice, you came to an academic center, and we've talked about training the future, right? The future anesthesiologists. And we've had multiple individuals in our specialty talking about the impact that we have beyond what we do with our hands, beyond taking care of the patient in the operating room.

But I would assume that at a large academic institution, you arrived, you believed what needs to be done for the future, but how about the individuals in the department that sort of have that same belief that it's something that they don't need to worry about? I'm assuming that they exist. So, we'll start with that assumption.

Dr. Tom Durick: And I think you both know they exist in private practice. They exist at the bus stop they exist everywhere. In our environment, we have a lot of staff. And again, there's nothing wrong with that. I mean, my aggressive-- and I mean that in a good way-- my aggressive attitude was with me, I think, when I came out of the uterus. My dad says the first time he put training wheels on my bike, I took off down the street pedaling as fast as I could, like I'm out of here. He literally had to clothesline me about 10 houses down the street to get me off the bike, and I was still trying to get away. So, that attitude, and I believe there are people like that, Mitch, a hundred percent. But when you just keep hammering them and pressuring them and setting the bar higher a little bit each time, they have to follow along at some point. When you see everybody else around you doing it and you're like, "I don't need to do this. Everybody else is doing it." So, you just continue to set that example. And I will say I am fiercely proud that your buddy Richard Urman, who has been a phenomenal chairman by the way, started our first ever departmental awards, and I got the Clinical Excellence Award. And I was absolutely stunned, because I'm very sequestered at our one surgery center, half our new attendings, they've never even seen me or met me. But because I hammer them so frequently at grand rounds and at lectures in our department meetings, I think they understand that you have to do this. So, I think you're never going to get everybody on board. You're just not. But if you can bring 50% of the people with you, then you know the whole boat floats when everybody's working together.

Host 1: So, Thomas, as I listened to you, all the different hats that you've worn, the different roles that you've taken on, I think leader, right? The term leader comes to my mind. There was an article by Conroy, Lubarsky, and Newman, anesthesiologists as health system leaders. And I have kind of taken that and run with it with a fellowship program. I do think that our specialty, because of what we do, lends itself to leadership. What do you think about that? Do we as part of our job-- Is something in the day-to-day of our job, make us better leaders? Are people born with it? Because as you talk, that's just kind of what I see as your value proposition. Wherever you've been, you've led.

Dr. Tom Durick: I think that's one of the things in the good ways that we take advantage of and we miss out on. That's why I have no hair. You can't see them on the podcast, because I've changed. You know, I switch hats so often. I just worn my hair down over the last 35 years. The leadership does have to come from within. You can't coach height, you can't coach length. You can coach people to be better leaders. You can teach them to see the holes in the schedule. You can, again, leading by example, say, "Look, we shouldn't do the general anesthesia case last at the surgery center when you know the patient's going to puke. Let's do that first. So, we give them time to recover." And you can groom people to see things better. You know, I've heard both of you talk. And Mitch, every time you speak at the AACD meetings, you're talking about this book and that book. First of all, I don't know when the heck you have time to read all that, because I'm too busy looking at webpages about used cars. So, that's like my rabbit hole.

But part of that then is again, I really think it's setting that example with leadership. So when I get some of the newer junior attendings that come out to the surgery center, I go over, here's how we do things, here's why we do things, and that's what we miss out on. I think teaching leaderships is not just telling them, "Here's what you do. You have to let them know the why." Because if you just keep teaching them what, it's just going to keep bouncing off their head. But when you teach them the why, then their what becomes a lot more impactful. So, that's how we have to train our younger leaders. We have to teach them, "This is why I'm trying to move this case up." It's a lap chole. That patient might puke. They might be here for four hours. This surgeon likes to keep this laparoscopic hysterectomy. So, they can be here for six hours, which is just silly to begin with. So, let's not do them at Friday at three o'clock when we don't have extended recovery. Let's do them the first case, because I don't want to be here until 10 o'clock at night. "Oh, that's a good point."

So, you teach them the why. And I think that's where we're missing out. We spend so much time hammering our residents on "Here's what you do. Blood pressure drops, you give this." The only difference, we're just monkeys with opposable thumbs and that's how we have to separate ourselves. You know, we're really not. We're not just nameless, faceless plunger pushers. And that's how we have to present ourselves as leaders to the C-suite, that we can make effective changes, even with just the cases on the schedule without adding more cases. We can rearrange them and make that schedule more efficient and decrease PACU time. Or we can, "Let me use these medicines that you think are 'too expensive' even though there's a HCPCS code form and I can give bill form and they're cost-neutral." I can stop somebody from puking on the spot in recovery, patient satisfaction score, surgeon satisfaction, staff satisfaction. You have to go to the C-suite with your RO-why, not ROI, but RO-why. Why do you want this drug? It's going to cost me money, because I can save 22% of our time in PACU and increase our patient satisfaction scores. That'll save you money.

Host 1: Yeah. Mitch knows right now that my Simon Sinek radar is going off with your Know Your Why stuff here. So, I'm going to be quiet. I'm going to bite my tongue and not bore our listeners with more Simon Sinek garbage from Matt. I'll be quiet.

Host 2: We could step away for an advertisement announcement for a Simon Sinek book.

Host 1: Hey, we will happily take some endorsements. Yeah, for sure.

Host 2: No, I mean, Tom, I think, the things that you're talking about reminds me of John Wooden when he was the basketball coach at UCLA winning national championships. And the freshman would be out there getting ready to play basketball, it's their first day of practice. And John Wooden sits everybody down and he says, "This is how we tie our shoe laces," right? Because Wooden knew that if you tied your shoes right, you wouldn't get blisters because nobody had Air Jordans at the time. All you had were the Converse basketball shoes. And so, kudos to you.

And just a shout out to Rich Urman, right? I mean, I think one of the most important things in my career is that you don't necessarily want to be the one on top. You definitely want somebody in your department that's going to support you in your endeavors. And I think, Dr. Urman recognizes what he has in you. And that was just my little plug so that Dr. Urman actually listens to this podcast even though he's the treasurer of the Association of Anesthesia Clinical Directors.

Dr. Tom Durick: Well, I got to tell you, I owe a lot to Dr. Urman. Because again, when I came to Ohio State, some of the stuff I told just wasn't held true. When you come from 21 years running surgery centers and you find yourself doing like partial hepatectomies and cases like that, I'm like, I ran surgery centers for 21 years. I mean, I coded cases. I did claims management, I used to use the UB-04 forms. I used to reset the printer so it lined up so the ink didn't touch the red blocks on there. I mean, what are we doing here? I went to him and he created this role for me, which now I actually also am very involved in the financial running of the surgery center, looking at our billing and coding collections for the ambulatory surgery center. And they've never had a physician doing that. And the one thing I get all the time is, you know, when I find something that we've been doing wrong for however length of time, some of the administrators are like, "How do you know this? You know, no offense, but you're a doctor. How do you know this?" And my response is, "You of all kind of people who are-- How do you not know this? "

And I knew this because, Matt, I know you have your MBA and we heard Drew talking about getting his MBA and how he had two years. He saw his family for like four minutes a night. One of the guys I report to, Jarrett Heard, who's, a great guy, very bright, has his MBA, but we did a paper, a journal club a couple years ago. And it was about private practice versus academics versus private equity firms. And I was involved in all of those. And I was also completely solo, like on my own for many years. So, I'm running the journal club and I'm looking, I'm like, "There's nine MBAs in the front row." And I'm standing up here giving this talk. I said, because I have what I call a street MBA, which stands for my business attitude.

So when I go in and run a place, I'm coming in like, "This is my business, and I'm going to run it like-- even though I never got a penny from doing it, I'm going to run it like it's my business. Every Penny matters. That's my business attitude and that's what I try and teach the residents. And I told that to Dr. Urman, and it must have resonated. So, there I am.

Host 1: So, you mentioned those different models, the academic, the private practice, private equity, et cetera. You've seen it all. There's arguments over which one of those is the best. And I think each has their own strengths and weaknesses. What's the path forward? If you got to set up your ideal, perfect group, which one of those models would you choose or would you choose little bits and pieces from each one?

Dr. Tom Durick: Jay Mesrobian talked about that. I forget, three or four of your Fresh Flow podcasts ago. And Jay is just an unbelievably bright guy, and I mean that. I think the right mix just because most practices, if not all anesthesia practices, have some degree of subsidy that they almost have to get just because our reimbursement has dropped almost logarithmically over the last 20 decades. I get spasms right before the CMS releases both the physician and now the facility fee schedule, looking at what they're going to cut. So, I think you have to have the deeper pockets that come from private equity, but it has to be a private equity that allows good physicians to run it, and that's the difference.

When I eventually left my completely solo, I mean, look, I'm paying my own health insurance. I'm paying my own life insurance. I'm paying my own disability. I'm paying everything. And I did that for 14 years. And then, I joined the MAC Anesthesia group, which no longer exists in Northern California, which I went from being this unicorn, still trying to fight with Blue Shield for my money, and then, we had like 172 anesthesiologists covering most of the facilities in Northern California. They got bought out by Envision, which was good initially because Envision was sucking up all these practices. And they were trying to standardize all the contracts, which eventually I think got them in trouble. Then, KKR comes in private equity, and all transparency stopped, I mean, overnight. You didn't know who to talk to. You didn't know who your practice manager was reporting to. So, we just went dark. And then, COVID hits and you couldn't get-- do I have a job? Am I still going to get paid? Am I going to get furloughed? Whoever thought, you know, you're a physician, you're going to get furloughed. Are you kidding me? And then, there's Ohio State that never laid a single person off, or not one anesthesia provider lost a penny. I had friends in Texas that were paying their APPs while they weren't taking a salary just to keep them on the payroll. You do what you got to do.

So, I think the ideal practice-- to go off track-- you need those deep pockets of private equity that understands that you need the anesthesiologist to get the cases done. You know, they see us as money suckers. We can't create value, but yet we can. Because if I can do something, you know, my little plug for high flow nasal oxygen, which has allowed us to do eight cases on Friday instead of four for one of our surgeons, because we can do prone MACs instead of doing generals. I've just doubled our income every Friday by spending an extra, like, $120. But you have to know how to do that. So, you have to have people to think about that global cost of care. What does it cost from the time that patient walks in the door until their butt breaks the plane of the door on the way out? What does it cost me? You can't look at your silos, that farm mentality. And I think that's where you have private equity, where you have business people, you can go to them and they're going to understand that better. They're going to give you a little more liberty. So, private equity money, good physician leadership, and then never, ever, ever take your eye off of patient safety. You practice safety, your costs will come down.

Host 2: Matt, is there room on the 2026 agenda? Because I think we should have a panel with Dunn, Mesrobian, and Durick, and then the best parts of all the different types of how we build training the future. You got private equity financing the academics training the future anesthesiologists of the country. But we know that Team Health is already doing that, right? USAP, they're opening up residency programs. I want to go back to your one comment you made at the beginning about the path of least resistance, right? OR throughput, getting the cases through. But yes, we're trying to do that at large academic programs. We are taking away administrative time, research time, just so that we can make sure we can staff the operating rooms, and some programs are actually closing operating rooms just because we don't have the staff, right? So, what do you see as the future state for anesthesiology? Like, what are the implications for our specialty given everything that's happening right now?

Dr. Tom Durick: The C-suite sees us as a necessary evil. And I have always told my surgeons, I have never, ever canceled a surgery. I've canceled the anesthetic, I've canceled the anesthesia part, but I've never canceled a surgery. So, you can still do this cranio under local. I'm just not going to do the anesthesia. So, administration has to realize that again, we're just not nameless faceless puncher pushers with opposable thumbs, we bring value by preventing complications. So, you look at the NACOR studies, you look at the closed claims studies, you see where those lawsuits come from, and you see that most of those are substandard care. We just have to teach our residents to do it right. I think that most academic programs are going to go to what I call the privademic practices, where there's going to be some mix of anesthesiologists, either they bring in a private practice firm to handle this pod, or they bring in some physicians who are just non-teaching because they either stink at it, they don't want to do it, you're forcing somebody to be unhappy, and yet they're decent clinicians.

So, I think that's when it can happen. I think the days of the purely clinical anesthesiologist with the white coat, and I do research on Monday and Thursday, it's going to be gone. At Ohio State, we have learner saturation in the ORs. I've heard that term so many times. We have interns, we have first-year residents, we have medical students, we have EMT students, we have SNRAs, we have non-anesthesia critical care. Everybody wants to come in and learn. So, you can have three people you're trying to teach and then nobody's really getting a good experience in there. So, sometimes you just have to go get cases done.

The other problem obviously at a learning institution is, when I first came here, I'm seeing that like a lap tubal takes two hours. I'm like, "We'd have done four of these and I could had time to have a sandwich in between in private practice." But that's how you learn. I'm just so far removed from that. So, you have to allow the teaching to occur. You just have to be a better steward of where that teaching occurs. Taking eight hours to do a one-hour case at a surgery center is just a dumb idea. When your profit margins are so slim, when your contribution margin is so slim, and this is what I've been fighting, the C-suite goes, "Ah, a hundred percent utilization in OR 2 today." Yeah, we took eight hours to do a one-hour case. So, sure, utilization, hundred percent. We lost four grand, you know, so good job. I would rather do four one-hour cases be done or flip flop rooms and keep all my staff happy than have them get pissed off and leave because we're closing rooms. Because remember when you OR staff leave, that's just not a person who's going to another job. That's experience leaving your operating room. Then, you got to hire somebody else to come in here. So now, you're paying two people to do one job when you already had one person doing it. So again, you have to think of the big picture. You might have to bite it a little bit one day and flip flop rooms to keep everybody happy and get done a little bit earlier rather than to have your people leave.

So, I think that's the future. We have to be efficient, but we have to be much more structured where we put those cases, the right case, at the right place, at the right time, with the right insurance, with the right patient.

Host 1: I think the Ohio State University should give you an honorary MBA, be cause you understand this stuff backwards and forwards. So as I hear you talk, Tom, you've obviously just picked up a ton of wisdom over the years. And I do hope your residents see that and take advantage of that.

If you look back, looking back and all that you've learned over the years and look back to you coming out of your residency program, on fire for the world, with your aggressive mentality, as you said, that used to always have been there, what would you tell yourself? What advice would you today give yourself coming out of training?

Dr. Tom Durick: What I tell my residents: one house, one spouse, one car. That's probably the best advice to start with. But what I tell the residents, first thing I ask them, "What do you want to do when you grow up? What do you want to be?" Some of them love research. They want to stay in academics, have at it. You want to go into private practice, I will teach you everything you want to know. If you want to sit on your computer and read something all day, have at it. I'm not going to beg you to learn.

So, young Tom Durick came out hot. I finished my residency in 1990. And by April of '91, I was running our practice and the Director of the OR. I think I would've told myself just to take a little bit of a breath. I've enjoyed the ride. There were times it took a toll on me, working as hard as I did. The 80, 90-hour weeks for decades took a toll on me physically. So, I think I would tell them, but think a younger generation already knows that, nothing is worth it anymore. Family's more important. Your life, your health is more important. I didn't know that. So, I think the young me would be like, "This stuff is all important, everything we're talking about and case costing and contribution margin. But you also have to know your own why. Why am I doing this?" I learned all this because I had a mortgage. And I was trying to pay the bills, and I'm running this private surgery center where the physicians, I had to meet with them every week with the financial report, one month post, that week, two month in the future, every week.

So, I didn't even have a contract. I was still a 10-99. So, I had to learn this out of just pure fear, trying to pay my bills and my mortgage. I think the young residents just know why you're doing this, keep your eye on the prize. Don't sacrifice family yourself for all of this. Do the best you can. But I always tell them, "Don't be me." Just don't be me. Don't work a hundred hours a week because you don't know what else to do, man. You know, get a life.

Host 1: Should that be the name of the episode, Mitch? Don't Be Me. Tom Durick: Don't Be Me.

Dr. Tom Durick: Don't Be Me: My Business Attitude.

Host 2: We're not going to name it that.

Dr. Tom Durick: I like that one.

Host 1: I Like that one. That's what we're going with.

Host 2: Tom, I think, our specialties, we're at a crossroads. I think Matt and I have said that in several manuscripts. And I also think that it's going to take a different mix of individuals. I teach my medical students and a reading elective that the current healthcare system's broken. And the current education system, resident training programs' not going to teach you how to build a different system, but you definitely are trying to light a way. So, kudos to you.

Host 1: Amen to that, Tom. This has been a blast, buddy. If you have any other message you want our audience to hear, what would it be other than don't be me, which I'm going to use that with my kids probably later today.

Dr. Tom Durick: The one message I want to give, and I'm going to kind of do, it's really not for me. It's a shameless plug for a guy that I heard talk at an ASA meeting two and a half years ago at the ASA Advance in 2023 in Orlando, a guy named Jake Poore, who was a former executive at Disney, whose father died from heart surgery, where multiple mistakes were made and nobody came and talked to them. And that day, Jake called his wife and said, "I'm done being the executive for Disney. This is not going to happen to anybody else's family."

So, Jake has dedicated the last, I don't know, 20 plus years to helping healthcare. He's partnered with hospitals, with physicians, with strategies. He has a book. In fact, I have a copy I'm going to send to each of you. It's called 99 Lessons Learned from Disney to Improve the Patient Experience. This has really become kind of like my bible because it boils down to kindness, little things like sitting down to talk to your patients than standing over them, touching your patients. He always says it shouldn't cost a million bucks to make somebody feel like a million bucks. And changing that culture, whether it's in residency, UAB, Vermont, Ohio State. It has to come from the people with the boots on the ground.

And my closing message is you can't have the C-suite telling us how we're going to do things, "Here's our mission." The mission has to come from the people who are getting bled on and spit on and everything else on them, they're the ones that make difference, because you have to be able to take care of patients. You have to turn those small moments into a lasting memory.

We had a guy come to us-- and I'll close with this-- last week talking about all of our metrics, you know, our KPIs or key performance indicators. And I'm sitting like, "Here we go again." And he was showing our satisfaction scores and I'm like, "I've seen this a thousand times." Yeah, woo-hoo, we're 98%. He's like, "That's great. But when you compare it to every facility around you, you're in the 48th percentile." And I was like, "This is what I've been telling everybody for the last 30 years that everybody who walks into your facility should expect excellence. Everybody, your patients, your surgeons, your nurses, your housekeepers, they should just expect everything to be excellent. They should have to get a squeegee and just like scrape the excellence off of them when they walk out."

And as the leader, you set that standard. And this is what Jake does. He wants everybody, the first person who greeted, you get one chance to make a good first impression. So when you answer the phone, it's not, you know, "Surgery center, can I help you?" You're never going to get that back. And once you set that bar low, you get that quiet discharge where the patient discharges you from the practice and goes to your competitor across the street and they go, "Man, you know when I was Ohio State, they suck. I had blah, blah, blah happen." They go, "Oh, we hear that all the time." So now, their bar is lower. It's easier for them to exceed it, whereas you want to set excellence every single time. I tell our surgeons, "When you're not working at my surgery center, I want you to pull your hair, gnash your teeth, and openly weep in the break room at the main hospital because you're not working with me today." I mean, seriously, I want you to just like pull your hair up. So, that's it. Expect excellence.

And I think when we teach our residents that to look at your purpose, look at your why, be a leader just by sitting down looking at the patient. Do those little-- Flip your name tag around just so they can see your name and what you are. Call yourself doctor. They don't want to know your name is Mitch. "I'm Mitch. I'm going to do your anesthesia today." Did you just get off the elliptical? You know, "Who are you?" It's those little things when you teach that every time from the beginning, then they start expecting excellence of themselves. So, I think that is our mission to teach our younger generation that you can still make a difference every single visit, every time you see a patient. Soapbox, man. Soapbox.

Host 1: Come on, inject this in my veins. My goodness gracious. Get up there and shout it from the rooftop, man. This has been awesome. Tom, this has been great, man. Thank you so much. Mitch, anything else here at the end?

Host 2: No, I mean, let's save the juicy gossip and questions about Dr. Urman for after the studio turns off the recording stuff.

Host 1: Yeah, we have question that we had talked about, spill the tea on Urman, but we'll save that for right after the recording stops. So, all right. This was awesome, Tom. Thank you so much. And thanks to all of you for tuning into The Fresh Flow Podcast. We'll see you next time.