Bones, Bytes, and Bottom Lines w/ Steven Gorin DO

Erik Sunset: [00:00:00] All right. Hello and welcome back to the DocBuddy journal. I’m your host Erik here at DocBuddy. Of course, we deliver solutions that take the pain and costs out of broken healthcare workflows. And today we’ve got a really cool guest. It’s Dr. Steven Gorin. Dr. Gorin is a Miami based orthopedic surgeon and sports medicine specialist.

Erik Sunset: He was passionate about helping patients of all ages, maintain active and healthy lives. Dr. Gorin. Thanks for joining us.

Dr. Gorin: Thank you for having me. I’m really excited to have a lot of discussion today.

Erik Sunset: Oh, it’s, it’s our pleasure. Good to chat with you after what feels like a really long time. And we’re, uh, we’re together today on the show. There was a couple of great takes, uh, that I saw on LinkedIn sort of coming into the new year and out the other side into January and. Our listeners will know that kind of coincides with the release of that 2025 final payment schedule from CMS.

Erik Sunset: So let’s start with a big question here, Dr. Gorin. What can either CMS, the government, or any payer be doing, should be doing, at either [00:01:00] small or large scale, to stop finding ways to pay physicians less?

Dr. Gorin: I think really the the best way for them to do that would be to minimize the bureaucracy and it kind of goes along with what we’re seeing happen with government. But it’s something that I think I’ve noticed over the years. I’ve been in practice now 18 years and just noticing there’s more and more steps between the patient and the care.

Dr. Gorin: And there’s always other people that are involved where If we can get rid of a lot of the middle, a lot of the stuff in the middle, if it gets bogs, the whole system down, you know, it’s like a trend. It’s like a high speed train and you keep throwing the weight on it. It used to work nice and fast. And now you just have a way more weight and it slows it down and it’s going to get to where it needs to get, but it can’t get there because we’re just adding all this extra load and all that extra load puts a big burden on the whole system.

Dr. Gorin: Not just. And the office and hospitals and surgery centers anywhere. [00:02:00] It’s just the more in the middle, the tougher it is. And like everything else, we want to get healthy. The world needs to get healthier. We all need to get healthier because we’re all getting bloated. Well, same thing with health care.

Dr. Gorin: Health care is bloated in the middle. Get rid of that. It’s going to help us a lot. So really, it’s that. And the antiquated payment schedule that Medicare uses. I think you need to have a PhD in math to understand the reimbursement model. up with a much better equitable system for everybody and really give doctors and I’m going to say independent doctors because I’m an independent doctor.

Dr. Gorin: I’m not employed. I’ve always been independent. Um, they’re fair share where the hospitals, uh, is actually taking a lot more making more for the same work that we do. So I think we’re able to even up field for everybody would be better.

Erik Sunset: It’d be a good place to [00:03:00] start. And, you know, before we started to record, we talked a little bit about the, uh, the automated payment denial. So using more steps to treating patients and reimbursement, obviously paying physicians less and less over time. I mean, the reimbursements are down centrally across the board.

Erik Sunset: It’s killing the profession. And then on top of that, there’s regulation around certain health I. T. softwares that have to be used, which are more administration. And you’ve lived this. You’ve seen it come. It’s here to stay. What can we do to improve all these boxes that need to be checked?

Dr. Gorin: Yeah, it’s tough because there’s so many different things and the size of medicine, the way it is, you know, in a specialty field, you know, which kind of focus on what we do, but I see it with the primary care doctors. You know, with certain insurance plans, getting referrals is at night, so a patient will show up to the office and they’ll come in for their left knee, but the [00:04:00] referrals for the back, because they had back pain a month ago, but then all of a sudden their knee got worse, they called a primary doctor, and the primary is like, they’re trying to work the system, they can’t work it, but by the time they get to the office, there’s still a, a knee pain is there, but the back pain is gone, And all of a sudden we can’t see them, you know, and it, and we want to take care of the patient.

Dr. Gorin: And oftentimes the patients don’t understand it, and then we end up becoming, uh, explainers of their, the system. Just like we become explainers of their service policies, which unfortunately people who sell insurance don’t explain to their patients and people. What exactly it means to buy a Medicare Advantage program, because oftentimes patients think they’re still Medicare patients. And don’t realize, oh, wait a minute, I’m not a Medicare patient. I’m a QT Med, I’m an AveMed. Well, simply, they think they’re still Medicare patients, but they happen to have this other name. And so I think educating, uh, [00:05:00] patients would be the best thing in the world, but it’s gotta be done by good insurance.

Dr. Gorin: They’ll it’ll be less headaches, and I think that’ll bring in some accountability to something I will discuss a little bit more about later. But that’ll help bring accountability into the process.

Erik Sunset: And interpreting and understanding the insurance contract you sign, whether it’s through your employer or whether it’s a plan that you get on yourself, you would need many attorney hours to make sense of it. And even then it still isn’t going to totally make sense.

Dr. Gorin: Yeah, the insurance landscape has gotten so much more difficult over the years and so confusing for patients and even for us in the office. You know, a lot of times I think I can do something or something and it gets denied and denied. In my world, I have a patient who comes in with acute injury and many insurances that are out there will deny, you know, MRI just because they think that [00:06:00] therapy is appropriate care. And it’s like, I don’t understand why they would wait, would rather waste 6 weeks of physical therapy, spend the money on that, haven’t come back to the office. And then literally just say, okay, we need to get MRI. So, so too many times we get stuck with these stupid phone calls with insurance topics. But typically, we’ll see this, but Cigna is the worst one, right?

Dr. Gorin: I often tell patients, um, if you can afford to go outside your insurance to get an MRI. Go outside insurance as probably when you deductible, it’ll cost you less to go out of pocket and through your insurance. Plus, we can skip the 6 to 8 weeks of physical therapy because by the time you get into therapy and by the time you come back, it’s going to take 2 to 3 months level process. So that’s a huge issue that I see, and it puts a bigger burden on the healthcare system. Instead of letting us take care of patients. I mean, imagine a patient having a heart attack, they show up to the, to the [00:07:00] hospital. They go, no, you got to take Aspirin for a month. Let’s see how you do after, how you feel, you know what I mean?

Dr. Gorin: Because the person on the insurance side, it’s just a pencil pusher. There’s no medical, the problem is they don’t have any healthcare degree. You can be a high school graduate and just sit behind a computer and just follow an algorithm. And the algorithm says, oh, this is the diagnosis, this is next. Yeah.

Erik Sunset: I was going to say in your example, that patient having the heart attack in the ER, take aspirin and then roll them out into the curb for the meat wagon to pick them up. I just heard this from a guest this week, Dr. Yaft, who’s a CMO at Baylor Scott White out there in Dallas, that a lot of times these utilization review folks on the provider side may not even be in your specialty if they’re a physician at all.

Erik Sunset: So you might have a practitioner saying, uh, or making, uh, decisions on orthopedic cases that maybe they don’t have any business doing. So how do you overcome that?[00:08:00]

Dr. Gorin: Well, what we’ve done in my office, I have an excellent MA, and whenever I have to do these peer to peers, which patients don’t even realize all the extra lengths to go to try to get their things approved, she’ll always request for me to talk to one of the PETAs, because every one of these insurance companies, especially with work and stuff, and sometimes they have a work PETA on their panel, and I can say I’m fortunate to deal with some of them, and they’re very good at helping us understand their system.

Dr. Gorin: And then be able to talk to him before I used to talk to the nurses and the nurses, we just be like, well, you need therapy. So, you know, the patient doesn’t need therapy because they’re going to get worse. They’re going to get injured even further. Well, that’s what the plan says, the therapy person, and we’ll figure it out. So that’s one of the biggest hurdles. Even surgery, same thing. They’ve done eye surgery because they don’t feel that it’s. It’s appropriate because again, not a physician that’s taking care of them. It’s a insurance plan. That’s the biggest problem. And[00:09:00]

Erik Sunset: Well, that, that hits at the core of what seems to be wrong with, with healthcare at scale in the U. S. is a misalignment of incentives. You know, it’s supposed to be a three legged stool, the patient, the provider, and the payer. But the, the payer leg Uh, seemed to have a lot more sway and a lot more say in some of these decisions than maybe it would in a more aligned, uh, chain.

Dr. Gorin: that’s the, I mean, that’s the biggest problem with health care to me is the insurance company. They become very big and powerful. They become huge moneymakers, and it’s just, it’s stronger for them. And for the rest of us who are dealing with and working on the other side of it, you know, they add more layers and more layers that just make it thicker and tougher for us to work with.

Erik Sunset: And obviously their actuaries have it figured out, but you know, common sense would say if you delay claims long enough for what is routine or preventative care, you know, eventually you’re going to have the big, the big whammy. Maybe it is that heart attack in [00:10:00] the ER, God forbid. At some point, that surely must cost more for the payer, but evidently not since that’s the system we’re in.

Dr. Gorin: well, I think they’re playing the odds. Yeah, that’s that. Health care is just, for them, it’s just about playing the odds. And they know that they’ll win in the end. Households win.

Erik Sunset: Yeah, I know that better than most that the blackjack table doesn’t always go your way. Rarely goes your way.

Dr. Gorin: but that’s what it is. Insurance, the insurance company is the house.

Erik Sunset: Yeah, that’s true.

Dr. Gorin: don’t change what the rules of the house. Well,

Erik Sunset: that’s just it, what we started this thread on, that it’s tougher and tougher to be a provider, especially to remain independent. And you see the pendulum sort of swing back and forth, or used to see it swing back and forth between employed and independent, you know, in the 2000s, early 2010s, it seems that that pendulum is kind of stuck on the employed side.

Erik Sunset: And there’s a lot of great independent physicians fighting a good fight, like with you and [00:11:00] your practice, but it seems to be more and more alluring than ever to just go, I don’t want to put up with all of it. Let me treat patients and I’ll go deal with being a health system employee. What’s your perspective on that?

Dr. Gorin: yeah, you know, that’s what we had a discussion last night with some doctors. We’re talking about it a little bit. And that’s, you know, coming out of residency, the way they train today is a lot different than they trained back when I was in my training. And, and the attitude of the young physicians also, and they don’t want to deal with the headaches.

Dr. Gorin: They just want to work as a matter of the field. They don’t want the headaches of, of dealing with the office staff, credentialing, dealing with insurance topics. I, what I see is they think it feels just easier to go work for somebody. I don’t have to deal with all those headaches and I’ll just get things done.

Dr. Gorin: But at the end of the day, typically we go to the medicine because we want to work for ourselves. We wanna be our own, you know, our, the captain of our ship. We don’t wanna be on somebody else’s ship getting [00:12:00] guided, whichever they want. And again, if you’re an employed physician, you’re an employee, which means you’re dependent. Doesn’t mean they can always come out, especially in South Florida, which is notorious. Once you start to making a little too much, you know, they might pull with somebody younger and cheaper, get a younger, newer, cheaper model and see what we can and work that one and work and said, that won’t work until, you know what?

Dr. Gorin: Let’s get another younger one and cheaper one. Just keep going until it keeps going over. You know, so being an independent private physician is difficult. What I did, I actually joined, we have an IPA, Independent Physicians Association in the state of Florida, for orthopedics. I joined the Louvre Le Pal, 13 years ago, because you know, negotiating contracts with insurance companies that sold practitioner at that time. It was terrible. Today, it’s got to be in Boston. I sat down, you know, I’ll never forget. I sat down with the CEO of the company at the time, [00:13:00] and we had our NDAs, and he had his insurance contracts in front of him, and I had mine in front of me. So I signed the paperwork. He hands over the insurance contracts.

Dr. Gorin: I look at the contracts, and I go, Oh, okay, so where do I sign? I’m not even going to show you mine. You don’t need to see mine. And I don’t care what your management fee is, because I’m still going to make so much more with your contracting system versus. Whatever wasn’t even worth it. And so that’s, it’s not an employee model, but we have, it’s a way to keep Laura, make a large, large independent position group where each practice runs its own way.

Dr. Gorin: Everybody does their own thing. Oh, we, we all go into 1 tax ID and it’s pretty much to negotiate best rates because, you know. Like you said, early on rates are going down, you know, my, my rent, my office is still going up. My staff, their salaries aren’t going down and we’ve got to keep them up. We have, you know, they need to be able to earn a good wage.

Dr. Gorin: You know, we have [00:14:00] to keep on top of it and, you know, insurance and everything. All that goes up, but the insurance companies and every just want to keep cutting back. So, it’s, it’s quite a fight.

Erik Sunset: What, uh, what happens to patient access through the lens of orthopedics if everybody’s employed? What’s, what would that be like,

Dr. Gorin: Well, if everybody’s employed, if we had a strictly off everyday employee model, it would be. Almost a quota system, where I think you’re in the office, they tell you, you know, here’s your schedule of patients for the day, and because there’s really no incentive for them to see more, because you’re an employee, you know, you see your patients and then you go. And at the end of the day, you know, you don’t need to keep adding on because for them, what’s the incentive of seeing more?

Erik Sunset: right?

Dr. Gorin: isn’t. It just means I have to do more notes. Work harder, but for what? I mean, I hate to say it at the day, it’s about [00:15:00] reimbursement getting paid, but money goes, makes the logo work, you know, and, you know, positions we have, houses, mortgages, you know, everything, a lot of especially young positions have a lot of debt coming out of a residency and fellowship is tons of debt that needs to be paid off.

Dr. Gorin: And a lot of people don’t even understand that.

Erik Sunset: That, that hits back at that misalignment of incentives. That’s, uh, that, I’m not a physician, obviously, but that’s not why physicians go to medical school to hit a minimum number of patients in a day and go home. It’s to, it’s to help people.

Dr. Gorin: And you want to help as many as you can, but when you have so much debt, You know, it doesn’t matter what you do and you know, you kind of get skewed like for me I don’t mind seeing beneficial selected because I know that if they don’t see me today They’re gonna have to wait two or three more weeks to see

Erik Sunset: Yeah.

Dr. Gorin: a lot of the big health care systems That’s three four months [00:16:00] to per follow, you know, because they they’ll put in a certain amount and that’s it There’s no extras and no double booking.

Dr. Gorin: There’s no overbooking. It’s This is what we have on our schedule. The curfew shows up for 8. The curfew doesn’t show up. It happens, but if you’re employed, it doesn’t matter if they all show up or if they all don’t show up. Yeah, as long as you’re there, sitting there waiting, it works.

Erik Sunset: And I’m in the more southern part of the county than you, Dr. Gorin. Coral Gables. You can guess the health system. It’s about eight months to get a primary care visit right now. You know who I’m talking

Dr. Gorin: Yeah, the big pineapple.

Erik Sunset: Oh yeah. That’s the one. Love them. They’re slow. A little slow.

Dr. Gorin: But that’s what it is. And part of the other issue that we have is, some of that I would say is on them, but the other is You know, the lack of positions across the country. It just aren’t enough positions as there is, because that’s another problem. I saw a statistic recently in [00:17:00] orthopedics. I think the next couple of years, we’re looking at, like, 5, 000 position shortage in just orthopedics. And that’s because, excuse me, the older generation is getting older. And a lot of those positions, you know, baby boomers, the big generation are retiring. And there’s just not enough medical school, you know, there’s a lot of medical schools that have popped up. But there’s not enough residency positions to fill. So, and that’s a whole nother issue when it comes to health care. How do you fund, you know, who funds the residency positions? It’s typically Medicaid that funds it. And so opening up new residencies is a whole nother topic. Are you expanding residencies?

Erik Sunset: Yeah. You, you, I’m glad you mentioned that because no news that I’ve seen on the TV or even in the normal spots online that isn’t like a Becker’s healthcare. We are rolling off a cliff as we speak in terms of number of physicians of any specialty versus the number of patients, especially with the patients that are getting older and needing more care, our alarm bells [00:18:00] ringing with, uh, your, your academies with your colleagues, like are people talking about this because we patient access is kind of a catch all term at this point.

Erik Sunset: Some of it’s applicable, some of it’s not, but I’m waiting eight months for a primary care visit. Yeah. Okay. Maybe I could find another physician, but what happens when you’re waiting eight months for a broken leg?

Dr. Gorin: Yeah, and it’s, I mean, even in my office it’s happened where I’ve had patients, I had them yesterday. They took them because of a parole issue and just being able to get on my schedule and people not knowing how to talk and explain what’s going on. This poor lady broke her elbow in December and didn’t come into my office until yesterday. And she was, you know, and the bigger issue is she has dementia, she’s not really with it, and she was able to get an x ray, and the caregiver, her caregiver manager was like, look, we tried to get in the last few weeks, they just couldn’t get in, and for whatever reason, and it just gets delayed. And that’s, and I’m [00:19:00] a, we’re a small two man practice.

Dr. Gorin: So, you know, I, I’ve sent patients to the university. And I know even there, you know, I’ve always been so patient. So you’re going to be waiting 3 or 4 months to get it done. Because they work it, you know, they’re not going to overload their staff with patients.

Erik Sunset: Well, I’ll be curious to see, I mean, I’ve got my feelers out when this is starting to be reported on your cable news networks, you know, more broadly online, it’s just, uh, it’s going to take systemic change to open up more residency spots, get more people interested in becoming physicians. Cause that’s the other half of this is that prior to COVID, it was all technology driving burnout and you look at the surveys, it still does.

Erik Sunset: Uh, but now it’s even, I think might be even tougher to solve for, it’s staffing, lack of support staff, too many administrative tasks. I have, uh, other physicians on the show with kids and they’re actively steering their children away from going into medicine.

Dr. Gorin: I did that.[00:20:00]

Erik Sunset: Do anything but become a doctor.

Dr. Gorin: told, I have three daughters and all three of ’em, I told ’em, you can do anything else with medicine. And it’s not because of the medical side. And that’s what I, and I have students that rotate in my office of residents and fellows. Residents and fellows have already bought hand. But I’m had students, you know, I’m in college and I say, look, if you want to do it, you better love because it’s not what you think it’s gonna be.

Dr. Gorin: And I, and I get very honest with them in my office. ’cause I want ’em to understand what they’re getting into. So also having single with me, I’m doing a peer to peer. I’ll have them see one where we’re denied of issues because we don’t learn that in medical school, we don’t learn that in residency. We don’t understand the true side.

Dr. Gorin: A lot of kids think it’s Grey’s Anatomy or ER. You know, that what you see, and it’s not. And that’s completely wrong. And you’re never going to learn that. And so I always tell them, look, I’m trying to deal with this insurance plan because I can’t do surgery for this kid because he wants to go play [00:21:00] football again next year.

Dr. Gorin: But it’s true. Now position with plan. So that’s the problem. So they don’t teach it in essence.

Erik Sunset: I’ve heard this said about writing a book that it better be more painful for you to keep that book inside your head whatever it is you want to say, it better be more painful to keep it in your head than to go through the pain of actually writing the book editing the book, finding the publisher doing all the stuff that’s uh associated with finally writing that book.

Erik Sunset: Sounds like medicine is kind of the same.

Dr. Gorin: It is, it’s become painful. It’s become painful. And like I said, not the medical side, you know, I still love the taking care of patients, helping people with their issues. Obviously the surgical side. That’s the concept. That’s why I always tell the students, if you really love that part, go for it. But realize there’s a whole other side, administrative side.

Dr. Gorin: Like you said, support staff. It’s so difficult to find support staff today, or [00:22:00] many years ago, you could. Find people anywhere nowadays, especially with everything that things online and certain apps that are out there. People would rather do become influencers or try to become an influencer and, you know, you can’t find people that would normally work in offices, which I still think is a great position for most people because it’s, it’s almost a 9 to 5 job. You know, you don’t have to worry about, worry about working on weekend or late evening. You know, that’s still gonna, we do as physicians, the home, other part, but if your support staff, you know, come in, show up. Yeah. It’s, it is tough. I’m never say it’s easy, but it’s, it could be a very fruitful position.

Erik Sunset: And I’ve heard this from some of the more influential folks that like oversee ASCs across the country that they have a challenge and I’m sure you have the same challenge that the hospital could potentially pay you more than what I could pay you for the same work. [00:23:00] Not saying that’s true for you and your practice, but there’s always the threat of big, bad health system paying just a little bit more, but you miss out on a lot of the culture and culture is what really drives.

Erik Sunset: Uh, retaining staff, being able to hire new staff to the degree it’s possible. Do you have any pro tips for listeners out there on having great culture in your practice?

Dr. Gorin: I think it’s in your practice, you always, you have to keep your opinion on the pulse of the staff. I think you, you can’t have. You know, doctors here, staff there, I think you really have to intermingle your staff, your management, everybody, you know, work as a team, but understand there is a hierarchy. It’s not.

Dr. Gorin: You know, everybody’s at the same level, but there’s enough respect mutual respect and people understand their positions. It’s still good to have a good, warm environment. We’re very lucky. We have a great office staff, and patients are always telling me how wonderful my check in girl is, and the check out person is.

Dr. Gorin: And this woman did a great job. You know, it’s really nice to hear. But people [00:24:00] get so used to hearing, like, Ugh, I gotta go see this doctor. It’s terrible. And then you wait, and go up front, and you look at me, and she’s rude, and all these terrible things. So you have to find, it’s tough to find a good mix. Um, to get to work.

Dr. Gorin: And once you have a great culture in the office, the patients feel it and they get it and they’re happy to come back. I have many times I’ve had patients who want to come back just because they want to come back and I go, well, I can’t. I’d love to give you time, but my time costs my office. So, even though if something hurts, everybody has bad things.

Dr. Gorin: There’s totally a bad thing.

Erik Sunset: Yeah, right. Oh, that’s high praise. That’s really high praise.

Dr. Gorin: but it’s tough. And when you’re in a corporate environment. You know, the corporate man, you know, the staff could be good, but the management is all about the numbers, you know, and most of the management companies, you know, are hospitals, hospital systems, and all we care about is the bottom line. One of the fights that I had years ago with one of our hospitals was that nurses on the floor were [00:25:00] telling me, look, we need more nurses, we get more nurses. And the hospitals said, no, we can’t get them, and the nursing ratio was really high, and at the time I was working on an MBA. And it happens to look at the financials for this one hospital, uh, in our area, because we look at the national system and then, oh, let’s look at what’s going on locally. And we saw that that company, the local hospital, had made a profit of over 80 million. We were on a medical exec meeting and I said to the CEO at the time, I go, look, don’t you think maybe we can invest one to two of your profit of just nursing? And that will make patients’ experiences better. People be much happier, that they’ll have better nurses because they’re not be overworked and no good burden.

Dr. Gorin: We’ll, all the extra minutia that they have to deal with in charting, because half the time it’s been charting, not even taking presentation. And uh, the answer was, let’s talk about the sleep. I didn’t like that I had found out that they made [00:26:00] all this, but the money, but it was out, it was a publicly traded company. So the data was out there, there was nobody to look at it. So when he got called out on it, he wasn’t sued on it. But that’s the problem, you know, they’re not willing to invest in the culture of the system.

Erik Sunset: Yeah. And pivoting a little bit into, uh, investing into culture or even investing into your own health outcomes. I want to shift this a little bit towards patient accountability. Um, we talked about this before we started to record that for better or worse, kind of the American healthcare consumer and more broadly than just America too, but something’s wrong.

Erik Sunset: I go to the doctor and they fix it. But maybe not taking into account lifestyle choices, diets, things that can give you the best chance for the best possible outcome in a scenario. I know you had a couple of thoughts on

Dr. Gorin: Yeah, so, you know, I often have these conversations with patients, because It’s important, and we need to change the culture. We need to go person by person. I don’t often [00:27:00] talk about, you know, diet and the regular general health, because it’s not my thing. I do have an overweight patient. I often tell them, look, it would be better if you were, if you weighed less, it would be better for your joints.

Dr. Gorin: But, one of my biggest treatment programs is physical therapy. And, exercise doesn’t matter. I talk about every patient. I’m a huge, full source for therapy because I think if we can, we get patients moving their bodies, they’ll feel better. And I often, a lot of times patients will say, oh, I don’t believe in therapy. And then I have to go into my discussion and look, therapy’s going to work, it’s going to do this, the A, B, and C. They’re going to teach you a program, now it’s on you to do the program, right? If you want to get better, you have to do the work. If you don’t do the work, you’ll never get better. It’s just like when you tell your kids they have to go to homework, they’re not going to pass, that’s not going to work.

Dr. Gorin: I use that line. Another line I use with patients is, look, so if you only go to therapy once or twice a week, and you don’t do anything [00:28:00] at home, this is not going to get better. It’s like saying to your dentist, I brush my teeth twice a week. Yeah, your mouth is full of cavities, right? Right. But I brush my teeth twice a day.

Dr. Gorin: It’s not enough. You need to do more. You have to be accountable to yourself. And I have that discussion with pretty much every single one of my patients that I send out for therapy. Even the ones that don’t want to go there. They come back and they go, you know what? I’m so much better. And I’ve been doing the exercises. And sometimes I’ve got patients who are very reticent to go. And they come back and you know what? I should have listened to you first. Because I am feeling better. And I am. And then typically my last visit is, now you know what you need to do. You know what’s going to keep you better, whether it’s your knee, your back, your shoulder. You have to keep doing what you were doing, and Listen to this. If all of a sudden your pain starts coming back and you realize, you know what, I haven’t exercised, I haven’t moved, I haven’t done anything in a while, maybe I should go back to doing this exercise to see how my body responds. So oftentimes I have patients, you don’t even need to come back to [00:29:00] see me.

Dr. Gorin: You know what we need to do. You know, you know how to take care of it because we’ve been through the process. And so they’re happy to hear that. And then a lot of times I have patients and they’ll come back for a totally separate issue and say, yeah, I did the other exercises and I feel great. I’ve been walking, I’ve been moving and it really helps.

Dr. Gorin: Yeah. And they feel much better about it, rather than you just throwing them a pill and saying, here you go. You’re fine. We’re just saying, look, let’s take you to surgery and I’ll figure it out and you’ll figure it out after it’s certainly not always the case.

Erik Sunset: Sure.

Dr. Gorin: I don’t like to hear that, but

Erik Sunset: that’s true. What I was going to say there is that it may be tough to get started working out, but you never regret having worked out, you know, until you get to that 001 extreme end of the spectrum. There’s literally no downside. Obviously, that’s not medical advice. That’s just personal, uh, personal anecdote for

Dr. Gorin: tell you, I never tell patients to stop. It doesn’t matter what their status is. There’s always something that they can do, [00:30:00] whether it’s, if you can’t go walk, I say, walk in a pool, you know, get your body moving, just offload the weight, you know, if you know how to swim, you can go swimming, if you can get on a treadmill, get on a treadmill, I mean, if you’re bedridden, of course not, if you’re in a wheelchair, but even in wheelchairs, there’s a lot of exercises you can do with your arms,

Erik Sunset: Sure.

Dr. Gorin: if you’re, if you’re someone, there’s too much pain for you to walk, like I said, get into the pool, there’s a lot of different ways to do it, and it’s, they, patients need to also be proactive, because it’s We can’t fix everything, you know, oftentimes patients ask me, isn’t there just something you can do that can get fixed?

Dr. Gorin: And I go, look, if this was the era of Star Trek and I could take a magic wand. And wave it up and down and you’re fixed. Great. But we don’t live in a Star Trek, you know, we live in today. So you got to do the work.

Erik Sunset: This, um, this is maybe a little bit off topic, but we are kind of hitting at a Star Trek based world or a Star Trek based reality with some of these GLP ones. I know that’s [00:31:00] probably not a conversation you have with a ton of patients based on your specialty. Do you have any thoughts on, uh, the Ozympics and the Mujarras of the world?

Dr. Gorin: So, you know, it is like you said, it’s brand new. Um, the discussion I have from the little knowledge that I know about those is, it’s just more of a big sentence. I think concerning how much people are using that even. If they need to lose 10, 15 pounds, they decided to do it, which makes no sense to me. But the problem with those GLP 1s, they’re great at losing fat, but they also lose muscle, and also bone.

Dr. Gorin: So from an orthopedic standpoint, it’s not a good thing, because it makes it even tougher. So if people don’t listen, or they go to some clinic to get their shots, and they’re not really educated properly, and they just take the shots, and they, they just eat less, and they don’t exercise, then, especially women, who already have osteopenia, may have osteoporosis. And then let’s have a more practice that could have compression pressures in the spine and hip fracture because, oh, yeah, I lost a lot of weight. But, yeah, you also lost muscle on this. [00:32:00] Those people that are on these computers needs to definitely do weight, a sexist, at least two times a week to help stave off the loss of muscle.

Erik Sunset: The, some of the headlines, um, in recent weeks, even just this week, as you pointed out, they will help you lose fat, they will help you maybe not help you lose muscle. They do have people losing muscle and bone loss. People seem to have forgotten your heart as a muscle as well. Um, and this is recent research, uh, but I’m, I’m hopeful, or I hope for the people using them that it isn’t some terrible deal with the devil that yes, you’ve lost a bunch of fat, but you also lost a bunch of bone mass.

Erik Sunset: And then heart muscle tissue as well. I think that’s really scary to consider.

Dr. Gorin: yeah. And so it’s, I think you did too quick to start jumping on a bandwagon. It looks great. You don’t have to wait and see. Problem is they come out so quick and people are so happy to Find a quick alternative. I think that’s the problem is finding a good alternative.[00:33:00]

Erik Sunset: Yeah, yeah. I mean, not to put too fine a point on it, but move. Lift a weight. You can do

Dr. Gorin: Simple as you can do, get a walk and get a move, you know, you don’t have to be a gym rat. You don’t have to go out and run a 10 K. But just walk, you know, get your heart rate up. You do a walking, you don’t have to do a running, you don’t have to get on a bike. You can do a walk in, just put a little bit quicker than normal and you’ll get it.

Erik Sunset: And then, uh, an even more, uh, tangible Star Trek example. I like that theme. AI in healthcare has been the hottest topic for the last Almost 18 or so months, you know, 18 months ago, we were talking about what we might be getting soon. And now we’re starting to see some of the things that are in place. You have LLMs inside of EHRs now, good or bad.

Erik Sunset: I think that remains to be seen as well in terms of physician time using them. But as an orthopedic surgeon, What are some of the AI technologies that you’re seeing? Are any of them cool? Do you like where we’re headed? I mean, [00:34:00] just kind of open ended there, Dr. Gorin.

Dr. Gorin: So, some of the AI stuff that we’re seeing, I haven’t seen in my office yet, but I have seen some cool stuff in the OR, where we’re using a, I don’t know if it’s strictly AI, but definitely VR and, or VA, which is fully augmented, where you can actually see where to put hip replacements and shoulder replacements, where you put these goggles in and you get a CT scan preoperatively.

Dr. Gorin: And you can see the proper alignment, literally in front of your eyes, you can see the bones without all the muscles and everything around it. So, you know, exactly where to put the infinite specifically for that patient proper position, which is, you know, most of the time we learn the way we learn is hands on looking, but we can peel away all these pieces of onion and see everything.

Dr. Gorin: And then when we do the procedure, we get a little bit better fit, a little bit better position just to give us better longevity. That’s what we’re seeing in that. It is. In the office, [00:35:00] I fear, uh, that EMR company that I’m going to in the future is going to have an AI component built in. Um, the problem as a practitioner is you have to learn how to use it.

Dr. Gorin: And will it pick up appropriately? Will it give you the diagnosis that you need? Will it, you know, every physician is an individual. You know, we’re not, I treat patients one way, my partner treats patients another way. My buddies across the hall treat patients a different way. So the AI needs to learn how each of us works.

Dr. Gorin: Understand how to look at the process. If everything was simple cookbook, it’d be easy. AI would pick it up and it would say something, boom, there you go. But I don’t see where that’s going. Where it has helped me, you know, is dealing with insurance companies. Going back to the beginning. And writing letters to insurance companies.

Dr. Gorin: Where before, you know, I’d sit there for 10 minutes just trying to figure out, what am I supposed to say? Why do I need to get this MRI on this patient? I’ve done all this stuff. [00:36:00] Nowadays, I can put it in any one of these generators and a nice long two or three page letter with reference and material and everything is printed out.

Dr. Gorin: And it’s difficult for the insurance company to deny it, because here it is, everything you asked for, most references in medical literature, so we have, we have data on our side, so it’s difficult for them to, uh, disapprove of either an MRI or therapy or, for certain.

Erik Sunset: That’s kind of, uh, live by the sword, die by the sword for the payer. Because you better believe, and I know you know, they’re sending you, uh, LLM generated denial letters. Might as well feed them a little tape because they’re on medicine there.

Dr. Gorin: Exactly, just get it, get the right back. If all the other ones paperwork, that’s what they’re looking for. I mean, if you look a lot of the charting and do a lot of the charting is, is excessive and it’s just to meet the paperwork standards that they need. We have to do more, see, do more, you know, there’s a lot of requisite things from the government that we need to click certain [00:37:00] boxes.

Dr. Gorin: It’s important, these quality care measures that Medicare is about. They asked us to check blood pressures in the office. Well, if you’re a primary care physician, or a Cardiologist. That’s great. Somebody comes to my office with a high blood pressure. I look at them and go, who’s your primary? I don’t know.

Dr. Gorin: Last time I treated hypertension was a long time ago. So I don’t know if you’re supposed to take for it. You know, there’s so many different medications today, but because of the way the government is, we have to check off the box, which has more time, more headaches in the office. And those goal points change.

Dr. Gorin: That always moves. They’re never keeping it in line.

Erik Sunset: No, it’s changing rapidly. I know you and I first got to work together in Meaningful Use Stage 1. And, uh, your colleagues here in South Florida that are pediatricians had a lot to ask me about why they would need to check the smoking status of a four year [00:38:00] old little girl, and that’s a pretty valid question.

Erik Sunset: But these quality measures are, are going to be out of your hands now soon to a degree, um, with THA and TKA ProPM, where you’re actually surveying a patient ahead of the procedure. And then again, after the procedure, and you’re going to be reliant on a patient to provide a survey, not even about the quality of care, not even about how they said the procedure went, just sending in a survey at all, uh, that again just seems so out of alignment with what medicine really needs to have happen, which at a baseline is reimbursed providers.

Erik Sunset: You know, at an acceptable rate, but now you’re going to get paid less and you’re going to be chasing surveys for procedures performed. I mean, this would be the time to rally folks to write their Congressman or write a letter to a mean letter to CMS. It just seems crazy to me.

Dr. Gorin: yeah, because I mean, we have no, we have a hard enough time getting patients to fill out paperwork in the office. All right, and then to ask them to fill out [00:39:00] another survey, they just, we want to do it and then they don’t care because all they care about is if I want to get taken care of, well, we need you to do this because otherwise, if you don’t do it, then.

Dr. Gorin: We won’t care. Reimbursement or about our reimbursement. They’re like, well, that’s not my issue. That’s a huge issue. Well, they don’t understand. They keep doing that as time goes on. And then we’re, we’re seeing this, you know, with the reimbursement’s getting lower and lower. More physicians are dropping doing procedures.

Dr. Gorin: So, why is it, you know, I had a patient one time who asked, said to me, Doc, why don’t you give me some of that money that you’re gonna make on my knee replacement? What are you talking about? He said, yeah, yeah, yeah, I want some good money. Give me some good money. I go, well, let me ask you. Well, and I’ll ask you, how much do you think I will get reimbursed for your knee replacement? I go, I’m not talking about the hospital. I go, how much do you think myself or my practice is gonna get reimbursed for me doing this surgery? [00:40:00] That’s literally do going to change your life. It’s highly risky. And he goes, doc, you’re going to get paid like 10 grand for money with this. I said, okay, for me to get 10 grand, probably need to do about 7 of your needs.

Dr. Gorin: You only have 2. I go, if I’m lucky with 7 of them, we’ll get to the 10 grand. And he looks in the shop and go, yeah, we don’t get the hospital to get paid a lot. Then the hospitals will do everything they can to kick patients out of it after day 1 because they don’t want to keep them in because they need to turn over their debts. And they realized through the pandemic. All these patients that were doing these elective knees were going home, and they seemed to be recovering. Uh, but just keep doing that, and not realizing that not everybody is meant to go. The ones that we were doing during the pandemic were a little bit healthier than the ones that, you know, all the ones that we did.

Dr. Gorin: So I’ve seen more issues ever since they started making this discharge patients in [00:41:00] placenta. Yeah, it’s a whole nother issue.

Erik Sunset: Yeah.

Dr. Gorin: So for that, I’d rather just do them at knee replacements and shoulder replacements at an outpatient surgery center, because We’ve got to care.

Erik Sunset: Right. Right. I mean, that’s, that’s the shining star in healthcare. Now is the ASC where you have much better alignment of incentives, although. You can kind of debate that on some ends of it as well in terms of reimbursement.

Dr. Gorin: Yeah, but we’re able to get patients, you know, do a quality approach and have a whole well rounded system that you can set up beforehand, but when they go to the hospital, it’s difficult for us to have the post op reports to be laid out because we have to wait for the case managers and everyone in the hospital to be there.

Dr. Gorin: Right. We can take a lot of, get a lot of stuff out with it. And it’s

Erik Sunset: Well, Dr. Gordon, we’ve covered a lot of ground. Is there anything we glossed over or anything we want to circle back to?

Dr. Gorin: not even pretty in depth [00:42:00] with that.

Erik Sunset: Well, I’ve, uh, I’ve really enjoyed it. So before, before you go though, let listeners know where they can find you online. Are you big on any social medias?

Dr. Gorin: Yeah, so I’m in all of them, Instagram, LinkedIn, and you can definitely find me on LinkedIn, you can go from there, that’s probably the best way, um, Twitter, Facebook, uh, all the other stuff my kids are on.

Erik Sunset: Well, I’ll track down all your profiles and get them added to the show notes so listeners can click through and, uh, give you a follow, give you a like. And on behalf of the entire DocBuddy team, I want to thank you for listening out there. Dr. Gordon, thank you very much for joining us today.

Dr. Gorin: You’re welcome. Thank you for having me.

Erik Sunset: Our pleasure.

Erik Sunset: And be sure everybody’s subscribed to Apple Podcasts, and we’ll get you on the next episode of the DocBuddy Journal. Take care.

Dr. Gorin: Bye.