Dr. Matt Sherrer (Host 1): Welcome to this edition of The Fresh Flow Podcast. Mitchell, how are you today, sir?

Dr. Mitchell Tsai (Host 2): I'm good, sir. How are you?

Host 1: Man, I'm fantastic. So, I always try to stump you with something at the very beginning. I want to get you again. Tell me, what is the latest thing that you've taken your son to do for fun? I'll give you mad respect. You and your son always do cool and interesting things. We've talked about Cirque du Soleil, we've talked about Savannah Bananas. What's your latest adventure, man?

Host 2: We had the AACD meeting last month and this was the first one that he has not been to since he was three years old. So, it was a little sad. But mostly, he decided halfway through the ski season this year that he wanted to snowboard. So spending a lot of time at up in the mountains learning how to snowboard and the snow, I think, it is still up there. We're hanging on. But I think this week's rain's going to wash it all out.

Host 1: Wow. That's interesting. Hopf was telling us that in Utah, they've had a terrible problem with snow this year. And so, you guys are fortunate to have it. So, all right, you want to introduce our guest today?

Host 2: Absolutely. I'm about to distill a 90-page CV. And I'm actually just going to use the summary that he sent us. But I got the pleasure of introducing Dr. Zeev Kain. He's a pediatric anesthesiologist from 1994 to 2008. He was a chair administrator from 2007 to 2016, and now he's currently the head of innovation for all things anesthesiology here in the United States and around the world. So without further ado, Dr. Zeev Kain.

Dr. Zeev Kain: Good morning, and thank you, guys. I like the introduction, very factual.

Host 1: And that's us. That's us, very factual all the time.

Host 2: So, you know, amongst all the titles that you have, Dr. Kain, one of them is that you're the distinguished professor of the UCI system. Tell us about a typical day for a distinguished professor.

Dr. Zeev Kain: Oh my God. Well, what it means is that after clinical and administrative careers, I now get to do innovations and research. That's what it means. I'm much more in control than I used to do be. And it's all about now research, innovation, and our society. That's about it.

Host 1: So, I've texted you in the past, and sometimes you're state side and sometimes you're elsewhere in the world. I mean, how often are you in Southern California? And then, where else do you go in the world?

Dr. Zeev Kain: I travel once every three weeks maybe all around the world. Last time I think you texted me, I was in New Zealand. That was a lot of fun, although there was some work involved. But really all around the world, i think if you mention the country, I was probably there.

Host 1: Well, so you said innovation and you sparked my interest right off the bat, and getting to focus on that all the time sounds incredible. So since you live in that space these days, how can we advance our specialty through innovation?

Dr. Zeev Kain: Oh my God. How much time do you have?

Host 1: long as you need, as long as you need.

Dr. Zeev Kain: Well, okay, I think the first question is how do you define innovation? And if you ask Mitchell there or Mitch, he'll tell you how he defines innovation. I'm going to say that within our specialty, you can talk about technology. Well, we can divide it to the usual, right? We can divide it into infrastructure process and people. And each one of them can move dramatically forward. And honestly, I don't want to tell you when I did my residency, but it was better years ago. And if you look at what I did during the residency and the process of administering anesthesia, it's not dramatically different than today. Yeah, we have a few new things. Obviously, regional has jumped dramatically, but not a lot of everything else. Look at the ASA standards. Did they actually change in the past 30 or 40 years? Not really.

So, I think if we start in infrastructure, and just stop it when you want, we can start with what does that mean to have an EHR and all these monitors and why is nothing connected to anything. And why is there is no positive feedback loop. I'm not even talking about machine learning or AI or anything like that. You walk into an OR today and all the machines are talking to themselves, nothing talks to anything else, and you as an anesthesiologist are still not getting any meaningful information—differentiate that from data, please—from all these machines. So, I'll just stop there and just throw you that and before we continue with everything else.

Host 2: Well, Govindarajan at Tuck Business Schools talked about the data. I think he calls it data fusion. And we've used this example before, but General Electric, Rolls-Royce and Pratt & Whitney have sensors on every jet engine in the world, every plane flying around. So, they're gathering information that they're actually capitalizing on. And this idea that we're doing something that most of the world is trying to do, just tells us that you got a lot of catching up to do.

Dr. Zeev Kain: When we look in the perioperative environment, generally and in the OR specifically, I really don't see why do we have the barriers that we do. We have all these monitors. They really don't talk to each other, right, guys? I can't tell you why, but I just don't talk to—I mean, you have the EHR, it draws all the information in, but that's about it. It's just documenting. It's no different than driving the car and looking at the speed at the speedometer. That's about it. That's all it does. It doesn't provide you anything else. Thirdly, it doesn't give you any information on what else is going on physiologically with the patient.

Host 2: I've often quipped in the past that, when we migrated to the EHR, anesthesiologists moved first with anesthesia information management systems. But in a lot of ways, we merely just digitized our analog workflows with that, actually trying to figure out what the technology could help us do.

Dr. Zeev Kain: A hundred percent. And, you know, I don't have a good answer because I've tried to do it when I was a chair, and then when I was a chief medical officer, and then when I was a dean of clinical operations. And the barriers are just enormous. Some of it has to do with legislative issues or legal issues. And some of it has to be with where's the money? I think it's a combination of all of the above.

Host 1: You said, where's the money? And I remember, when you actually hosted me on the Anesthesia and Analgesia podcast, and we talked about the fact that follow the money. "Hey Matt. Your ideas sound cool, but people don't want to change because they're making good money right now." And that kind of continues. If you talk to people about new technology and new whatnot, a lot of times, you'll get, "I'm pretty happy with the way things are." Follow the money and you'll find your answers. So with that being said, you've been an innovator in the perioperative surgical home space, enhanced recovery, and whatnot. Where do we stand in that advancement in 2026? Where do we stand now and where can we move forward as a specialty in the realm of perioperative medicine?

Dr. Zeev Kain: Well, you articulated where we should move on, which is perioperative medicine. And I wish I could tell you that there were dramatic improvement in the past decade where we actually started the perioperative surgical home. But in reality, not a whole lot has happened. That's just in reality. And, yes, we have a center of perioperative medicine for the ASA and, yes, it's trying to have a consensus statement. And I'm very appreciative of it and I think it's great. But I don't see it fundamentally any different than a decade ago. And so, the question is how are we moving forward probably has to be with collaboration with other specialties. And I think it's happening right now, finally. But it starts and finishes with the business model. And I'm really sorry to go back to where's the money, I know I'm harping on it.

Host 1: It's okay. It's perfectly fine. Perfectly fine.

Dr. Zeev Kain: Yeah. But here is the reality, anesthesiologists are now getting paid more than ever before. I think they had the 40% increase in salary in the past two to three years. They're still staffing in one to 1:1 to 2, 1:3, or 1:4. No changes in the past decade or two. We're still functioning like taxi drivers to the degree that we get paid for what we do in the OR. That's that's Amer's example. And so, we don't have any incentive to do anything different than before. And I'm just going to go back to what Warren Buffet said. Just give me the behavior and I'll tell you where the money is. That's just the reality.

Host 2: So when you talk about, the perioperative surgical home, and I think for us, the discussion in healthcare probably about the same time 15 years ago was about Porter and Value-based Healthcare Delivery. I haven't seen anything published by Porter in the past five years. But when you think about the National Health Service in England, when they deemed that a process is helpful, it's beneficial to the patients, the government will set aside the money. So, we're talking about this, "Where's the money?" Is that possible in the American healthcare system where policies are put in place, where we can actually implement and affect that the clinical processes that we know will help our patients.

Dr. Zeev Kain: I am going to say yes, and remember that we are a very different system than the NHS in the UK. The closest thing we have here is Medicare, which is about 40% of the entire insured population. And people don't realize it, but the government is the largest insurance company that we have.

So, let's take that to decide just for a second. And then, the next market is totally disjointed. United, you have Blue Cross and another 45 of them. And each one of them is in fact separated by state, as you know. So, it's a very disjointed marketplace. And that's it. A lot of these companies are in the stock market, so their mission is to make money.

And we're getting off the topic quickly because the next step is you're going to ask me, "Well, why don't they want to have preventive care?" And I'm going to tell you because healthcare in the US is provided by employers. And the reality is that people change their job every four years. So, they change their insurance companies. So, the insurance companies don't have a long-term view of the patient, which is very different. And that includes Medicare by the way as well, because you got to Medicare at 65 or so. And I don't know how much runway you have there. Although you do have, hopefully at least 10 to 15 years. So, it's a very complex system.

Now, to be totally fair, you have CMMI now, which is part of the HSS, the Departments of Healthcare Services. And I think that they are now—for those of you who don't know—are really trying to make an impact with the payment systems. And so, over the past literally 12 months, we have the team model, the access model, the AMS model, and just the day before yesterday, the new CJRX model were announced. All these are essentially payment model and clinical models that are all together. So, it's not exactly answering your question about clinical guidelines, just like the NHS adopted ERAS, but the US is trying to make an impact, at least that way.

Host 1: So actually, I saw a post of yours on one of the sites recently. I think about this and your question to everyone was who owns this? And is this an opportunity for our specialty to step up and say, "We see this coming, and rather than just talking about it in a meeting, we own it"?

Dr. Zeev Kain: I think it's a huge opportunity, Matt. Just huge. But the question is, again, do we want to step up to the plate? And that's the only challenge that we have. Now, I'm going back to the money issue, And in this case, we do have a money issue because especially with the T model. Within the T model, you have an opportunity of what I'm going to call church savings, which means that you can get into an agreement with the hospital that the hospital will pay you for part of the money that they are going to make. That's legal right now. So, huge opportunity there to make money.

The AMS model, for those of you who don't know, has a number of conditions in it. Chronic back pain is the biggest condition with relevance to us. And what does that mean? It means that that particular model is owned by the provider and not the hospital. And that's the first-time the provider owns model. And it basically says every anesthesiologist who takes care of more than 20 patients per year for back pain now has essentially—I'm not going to call it a bundle payment. I'm going to call it a payment arrangement with the government that they never have before. So yes, we have a huge opportunity in front of us right now.

Host 2: So Zeev, just for clarification, is this for like a private practice pain physician or is this for an employed anesthesiologist wh can take care of a population of adults with chronic back pain. And then, I guess the last part of my question here—I'm sorry, I'm just rambling—how do we prevent—not how do we prevent—but I'm assuming that there will be other specialties that are interested in this, especially with the specialties that are entering interventional pain.

Dr. Zeev Kain: Well, the nice thing about the government is that they don't care if you are private practice or employed. So, this is about any—and I'm going to say any—provider that takes care of more than 20 patients per year with back pain, period, if you're part of a university, if you're part of private practice, they don't care. That's just the reality. It does not include only anesthesiologist. It includes everyone in the back pain space. Why did they choose back pain and heart failure? Because these are the two conditions that Medicare spends a lot of the money on.

So if you noticed, the CJRX, for example, is about lower extremities replacements. So we're talking about specifically hip, knees. The team model has in it the orthopedics, cardiac, and colorectal. So. what's coming to all this? This is where the money is being spent by the government. So, CMS now is going where the money goes to those conditions, and to the degree that we as anesthesiologists, are in those spaces, we're going to get impacted.

Host 1: So, that's interesting. And I think a lot of our colleagues in anesthesiology are head down doing the work, right? There's so much work to be done. It's hard to look up and see some of the other stuff like what you're talking about. So, who is right now looking up and paying attention to this, and kind of keeping an eye on it. Is this something that the Center for Perioperative Medicine is looking into as an ASA initiative? Is it just something that Zeev Kain pays attention to? Or do we have kind of some of our higher governing bodies in our specialty paying attention to this?

Dr. Zeev Kain: Oh, I'm sure the ASA is paying attention to this, there's no question about it.

Host 1: Good.

Dr. Zeev Kain: And we paid attention to it a decade ago with the perioperative surgical home, if you read it, that's exactly was the model. And then, it was CJR. Now, it's team and everything else. The question is, can the ASA rally the membership? That's the question, alright? And I don't really have a good answer for it because it depends on the membership.

Host 1: Yeah. So when you say rally the membership, that gives us an opportunity to transition a little bit here. That then to me what you're talking about is leadership, right? Will people follow? And so, Conroy, Lubarsky, and Newman wrote an article a few years ago, Anesthesiologists As Health System Leaders. Is there something intrinsic to our specialty that helps us pivot like you have done into a leadership career?

Dr. Zeev Kain: Yes. I think that when you talk about the operating room, it's a very high stake, dynamic environment with multiple stakeholders and large personalities. And the ability of us to manage all that to gather, although no surgeon wants to be managed, but all of them are managed. That's what we do for a living. And then, once you grow out of one operating room, now you're talking about 40 or 50 operating rooms and now the perioperative environment, I always remember one of our CFOs who used to tell me that the ORs are the ATM of the hospital. That is the reality guys. By estimates, it's about 40-60% of the entire hospital revenue go through the operating rooms.

And so, it's a very high visibility area. So, anesthesiologists are getting a lot of exposure and that's how they move on from there. If you follow the career of the individuals who just mentioned and others, that's how they move to that space.

Host 2: We have a propensity of building a time machine in this podcast, but we're going to do something different this time. We're actually going to build a time machine and bring the chair, Dr. Zeev Kain, to the current state of affairs for academic chairs in this country. We got workforce issues. You've talked about the recompensation challenges and the market dynamics. Would Dr. Zeev Kain have survived in this era? Was it different back then? If you look at a lot of faculty practice groups where there's a faculty practice president that sits over a chair, that role has changed. What do you see that's different? What advice would you give to the chairs in this country?

Dr. Zeev Kain: What has changed is a significant loss of control for the chairs, vis-a-vis the financial control of their departments. There is more and more integration of the departments within—you want to call it faculty practice plan? That's fine. You want to call it hospital? That's fine. You want to call it university? That's fine. They're being slowly managed by larger constructs. And so, the triad of, I'm going to call it for a second, Discover Teach Heal is very difficult now to accomplish, and that's the triad that I had when I was a chair. It's complicated.

You're both in esteemed academic practices. But the reality is that both of your universities or university hospitals have a challenge in the part of the Discover, especially. You know, the Teach is a bit complicated because when you talk about residency programs, just remember who funds the residency programs, and it's the government. And so, I'm just going to say, I don't want to sound too bad, but there's not a whole lot of worry or innovation there, right? It's a workforce issue. You need residents to run the ORs. The government will pay for them. They're much cheaper than anything else. Fine, that's done. But the Discover part is really the part that is suffering at the moment. I would've had a very hard time with that part in particular at this time point. I think that the recent publication of the NIH funding in this country, specifically in the perioperative, you have seen that the dichotomy—and they used to talk about it a lot—of those who have those don't have increased now dramatically, and very few academic places now that have NIH funding in a significant way.

And I don't see that's going to get fixed because you need money for that. And for those of you who don't understand it, I'll just give you a one-minute synopsis. There is something called the NIH salary cap, and the NIH salary cap is around $210,000 per year right now. And so, if you got an NIH grant and the NIH grant says that you need to be involved at 40% level at that grant, the NIH will give you 40% of $210,000. Well, who's going to pay the rest of that salary? The department. Where's the department going to pay it from? That is the challenge these days, right? who is going to cross-subsidize that amount of money? That is the challenge with NIH right now. And that is the challenge with research right now, is who's going to pay for it.

Host 2: So, we've talked about this in the past, Zeev, whether it's private enterprise or public investment, and it is obvious that the public investment's not there. When I think of private enterprise and innovation, one of my favorite stories is the Bells Labs, right? AT&T as a monopoly was allowed to keep its revenue stream as long as it licenses technology for free. Do we have that in America?

Dr. Zeev Kain: We may have it, but not in our specialty. I think that is just the reality. I think that in our specialty, we can talk about startups. So, one good example, I think, is the concept of hemodynamic stability and administration of fluids and vasopressors by computer algorithms. And that's something that was published significantly for about five or six years. And it actually started from our department with Maxime Cannesson, who I'm very proud of. He's now the chair at UCLA, obviously. And that's something that started by them from within the department, and then later on was purchased by Edwards Lifesciences. So, I think that's a great example of something that can be done.

The next question, however, is that classical research, and I can't answer that question, right? Because it is classical research to the degree that how do you manage hemodynamics and so on. But at some point, it becomes more about technology development, which you really are talking about, Mitchell, and not research. And technology development is phenomenal. It's important. I'm so invested in it, but I don't know if that's research

Host 1: And that brings us to one of the things that you mentioned, the Edwards, which has since been purchased by bd, who also owns the Alaris pumps, who's likely putting together some sort of closed loop system. You bring that kind of stuff up in the operating room to people and some people say, "Cool, innovation. Neat." That's going to let me be smarter. And some people go, "Hang on. Time out. That's what I do right now. Why am I going to be needed in the future?" And you mentioned earlier, infrastructure process and people. As we change, as our technology grows, will we be able to use our people differently? And is that necessarily a bad thing given the current constraints that we have on sheer numbers of people in our specialty?

Dr. Zeev Kain: Well, that's part of change management, which is almost more important than all of these three variables. And you two know that. The question is how are you going to manage the change? if you're not going to manage it, you're doomed. I'm going to remind you guys, do you remember the sedation closed loop system that we had 10 or 15 years ago?

Host 1: SEDASYS. Yep.

Dr. Zeev Kain: What happened to it?

Host 1: Got shot down. We've never been more aligned with our nurse anesthesia colleagues than right then and there.

Dr. Zeev Kain: Right, right. And why was it shut down? Because they did not manage change management. They did not market it correctly. You know, here's a perfect example of, honestly, a very good piece of technology that just . So, the answer to your question about technology, if you are not going to manage it correctly, it's going to die. People, the providers have a lot of power in their hands and you need to manage them, first of all. And so, close hemodynamic loop, perfect example, you better manage it correctly. And BD better manage it correctly if they want to see a cent out of that.

Host 2: So, change management's one thing. Then, there's also the social technical forces that, not only as we as anesthesiologists, but we as citizens of the world kind of are up against. And Astro Teller, the CEO of Google X talks about the story of the inflection point of 2007 as the age of acceleration, where machine learning connectivity, super connectivity is making the evolution of everything that's happening faster than the human mind can sort of adapt to. So, we're going to go back to change management. How do we as anesthesiologists tackle, embrace what might be coming down the pipeline when it comes to AI and machine learning, or is it even important?

Dr. Zeev Kain: Oh, I I think it's very important. I think Bill Gates said—since you're mentioning names here—that people tend to overestimate what a technology can do in the next five to 10 years and underestimate what it can do in the next 15 to 20 years. I think that LLMs and adaptive AI, I think, people don't appreciate what it can do. I wish I was wrong, actually. But I'm telling you guys, you just can't estimate what it does.

In my work, in our society my research program, which we're not going to talk about today, but I'm funded by the NIH to do pediatric pain research and pediatric stress research since 1996, I now use LLMs and machine learning so heavily, I can't even tell you. So, I'm exposed to that technology, probably more than most anesthesiologists. And it's scary and I think we need to get ahead of it and understand it. Not that it's going to replace us, us anesthesiologist maybe. But we need to understand it, and we need to learn it. And we need to figure out how it can actually help us.

And here is a perfect example. Why can't we—and I understand all the medical reasons—but why can't we embed it in the monitors that we have already? So, it can actually provide us some guidelines of why is the blood pressure lower at this particular time point. That's a model I talked about a decade ago, my God. And they tried to do it a decade ago. And it's still not out there, right? So now is LLMs, it's just going to move. I mean, it can pass the anesthesia boards now, I'm sure you know that. These things pass anesthesia boards and better score than us. So, I think it's naive to think that our world is not going to change. The question is when and how are we getting ready for it? That's all.

Host 2: Matt mentioned that a lot of us are just, our heads are down. We're just working hard and very few of us pick our head up. the other story of this is I have a cardiologist here at my institution, Dr. Bill Hopkins, that I've had since medical school. And I was talking to Bill one day. And we were talking about publishing and working with the EHR. And he made the comment, because he is about 15 years older than I am, that the one thing that he really, really wished he learned in high school was to type, right? Because he is a very slow typer today. So with that framework, when it comes to LLMs machine learning AI what's one or two things an anesthesiologist should understand?

Dr. Zeev Kain: How to use the technology to help them. So, rather than view it as a threat to our livelihood, it's not a threat, guys, okay? They're going to need us forever. I don't see a world where an LLM can intubate somewhat, okay? So, just forget about that. But can we use it to actually help us to become even better.

Now, when you say even better, you're going to get back to me and say, "What are you talking about? Look at the intraoperative mortality related to anesthesia. It's at a six sigma level." And I'm going to tell you, "You're absolutely correct. And tell me how the perioperative mortality in the first 30 days changed over the past 20 years." And the answer is going to be it didn't. We have the same perioperative mortality we have today as we had 20 years ago.

So, we, as a specialty, I think we have a responsibility not to just look at can we get the patient alive into the OR and alive out of the OR?" But maybe what's happening to them in the next 30 days. And so, I think that's part of our responsibility.

Host 1: So, we had Dr. Sessler on and he talked about this. He's written extensively about it. The first 30 days post-surgically being the third leading killer, I believe, in the country. And so, he's kind of pushed for this more attention in the postoperative phase.

Tom Vetter actually came to the AACD meeting and gave a talk about how in the preoperative phase we can impact that significantly. And that was very interesting because it changed the way I thought about that. What do you think as our best path to intervening on that first 30 days after surgery?

Dr. Zeev Kain: Well, it goes into the pre, intra and post periods. I think Tom, who was very wise, is correct that the preoperative period is the time that has the most opportunity and the least resistance. That is absolutely correct. I think the intraoperative period, honestly, I don't know how much opportunity you have intraoperatively to do things that will change the next 30 days. Sure, we can talk about avoidance of hypotension so on. Okay, I got that part. I know Dan Sessler's work exceedingly well. And so, okay, I get it. No damage to the kidneys, all that stuff.

Postoperatively, huge opportunity, but there are many specialties there. And they don't want us. That's just the reality, guys. This is from somebody who tried, who actually implemented about 26 models around the country of the surgical home. And I can tell you that obviously the hospitalists don't want us, and the surgeons don't want us. And it's problem.

Preoperatively, that's a huge opportunity because nobody really cares and it's very disjointed. So if you ask me as a specialty your chances are in the pre-op time, that's when you can really go beyond optimization of diseases and talk about optimization of the individual, right? Now, we go back to the work that was done years ago by the Michigan Healthcare Initiative, the surgical initiative, and talk about start people walking, decreasing their intraabdominal fat, you remember their studies with CAT scans and MRIs. They show that there is a direct correlation between that and surgical outcomes. That's a huge opportunity for us as a specialty. So, I really hope that's where we're going to put our fire because that's where the opportunity is.

Host 2: I'm going to go back to the time machine. Thirty years ago, did you ever expect that you'd be doing what you were doing today, Zeev?

Dr. Zeev Kain: Yes, that's the short and the long answer. I think that I was always very interested in behavioral sciences to be honest with you. And I was always very involved in research from when I was a child. I still remember trying to fly these little rockets up to the air. And so really, I'm doing today what I really always liked, which was innovation.

I did take a detour on the way into administration and everything else I did in my career. But I think I closed the circle from my perspective as far as this is really what I like. And I'm going to say that even within administration there is a lot of opportunity for innovation guys. So, we kind of like to think about administration and this very non -nnovative, frozen in time. That's just so not accurate. And there's so many new technique and new modalities and new structures, and so on. And so, I think that innovation is really what I kind of always liked.

So, I'm right there. And I could tell you that every day I read, I don't know, three to four hours on everything that has happened in multiple areas. My wife said I'm an information junkie. The two of you are not that different than I am.

Host 1: We're geeks for sure. We embrace the nerd here on the Fresh Flow Podcast. Yeah.

Dr. Zeev Kain: There you go. That's just the reality. I like information junkie more than geek, but that's okay.

Host 1: I'll adopt that. I like that too.

Dr. Zeev Kain: Yeah. Yeah.

Host 1: So, one of our biggest group of listeners is our residents. And you've spoken a little bit about, residents along the way, and you said it's complicated. And gosh, our perioperative world is complicated. If you're giving them some advice for the future, how do they sort through that in their career? What advice do you give our trainees coming out into this complicated perioperative world?

Dr. Zeev Kain: You know, of course the first advice, always do the right thing for the patient, period. That's the beginning, the middle, and the end of things. I think they just need to be adaptive. Understand that you have seen one OR, you have seen one or. You have seen one system, you have seen one system. So, just adapt yourself to the system around you and bring all the knowledge that you have and now adopt it. Now, well, they adapt it to the patient, but that's kind of obvious, right? But you really need to adapt to this system itself. So just don't be too frozen and insist to do things just one way. Just experiment. Just see the way other things have been done before, and then things that you want to do in the future. I think that's the biggest differentiation I've seen in my practice. The people are really good, are open-minded, and just want other people to show them how they do things. And when you finish your residency, by the way, you're not done learning, are you?

So, your first job, you have somebody who is in their 60s, look how they do things, maybe they didn't learn the most recent technique in focus ultrasound. Hey, but they have some tricks that you'll never see again. So, I think that's just adaptability, flexibility, open-mindedness. And at the end of the day, it's all about taking good care of the patients. So, just keep that as your true north.

Host 2: Matt, you and I will be able to teach the blind technique for central line placement for another decade.

Host 1: If you just suggest doing that these days, people look at you like you have lost your mind. So yeah, you're right. Landmarks, baby, landmarks. Well, Mitchell, this is why we do podcasts, because you get to talk to cool people. I have learned so much from this one, from others. It is changed my perspective on so many things. So, Zeev, thank you for doing this, man. This has been incredible. Thank you for coming on and thank you for being part of our podcast. And thank you for what you've done over the years for our specialty.

Dr. Zeev Kain: My pleasure, guys. And thank you for what you guys are doing because, honestly, if you will not disseminate information in the way you guys are doing, then it wouldn't be worth anything. So, thank you.

Host 1: Awesome. Thank you. All right. That's it guys. Another edition of the Fresh Flow Podcast. Thanks for tuning in. We will catch you the next time.