Better Orthopedic Surgery with the Help of My Brother
Doctors Grayson and Dustin Moore are practicing orthopedic surgeons, who also happen to be brothers and partners. In this episode they share their unique hybrid practice model, how they built their practice, why they choose a medical device, and what good sales reps do. They also cover how they, along with their Dad who is also a partner in their practice, rely on each other to learn and deliver top-notch medical care. Many of the things they discuss about their practice can be directly applied by people working within medical device companies. Grayson and Dustin practice in the Austin area, and are co-owners of Legacy Bone & Joint Orthopedics, along with their Dad, Dr. Frosty Moore.
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Episode Transcript
This transcript was generated using an automated transcription service and is minimally edited. Please forgive the mistakes contained within it.
Patrick Kothe 00:31
Welcome. Oh, we've got a good one for you today. We've got two up and coming orthopedic surgeons, who also happened to be brothers, doctors Grayson and Dustin Moore join me today. And we cover a lot of ground. We talk about orthopedic surgery, their practice, which is pretty unique. It's a hybrid model. So I think there'll be a lot of things to learn about with, with this practice model, why they choose medical devices, what good sales reps do and a bunch of other topics. But to me, one of the most interesting topics we covered was, how they work along with their dad, who's also a partner in the practice, and how they rely on each other to learn about new techniques, new products, different ways of doing things, how they challenge each other, and how they together can deliver top notch medical care. I think it's really a fascinating look into how this practice is, is operating, and how these three clinicians work together along with their team. So I think you're really going to learn a lot and enjoy this episode. Dr. Grayson Moore earned his BA in biology from the University of Texas and his MD from the University of Texas Health Science Center in San Antonio. He then completed a residency in orthopedic surgery at the University of Texas Medical branch. Dr. Dustin Moore earned his undergrad degree at Boston College and his MD from the University of Texas Medical branch in Galveston. He then completed an orthopedic residency at Texas Tech Health Science Center, Grayson and Dustin practice in the Austin area. And they're co owners of legacy Bone and Joint orthopedics along with their dad, Dr. frosty more. Here's our conversation. Dustin Grayson, thanks for coming on the podcast.
Grayson Moore MD 02:25
Happy to be here. Thanks for having us.
Patrick Kothe 02:28
I've got a pretty good idea. But could you explain to me how you got interested in medicine and how you got interested in orthopedic surgery.
Dustin Moore MD 02:37
I'll start us off. Thanks, Dustin. Sure thing are our dad is interested or her dad works in orthopedics, he's actually our partner and we grew up going to the hospital with dad. I remember going to the emergency room for fractures and we'd watch him put casts on. Now when I put casts on myself the sound of that cast material going on kind of takes me back a lot of times to when I was a kid watching dad put put those casts on but that was only part of the story. I think some of it was playing sports growing up having injuries, things like that. I think that's what got me interested in medicine. I went to med school thinking maybe I'll be a pediatrician, maybe I'll do something else but but really doing my rotations and everything orthopedics it just kept coming back to orthopedics looking at problems and solving problems by kind of fitting them back together. We're kind of the considered the carpenters of the bone or of the human body. You know, that has always been an interest to me, you know, putting things back together, taking them apart, putting them back together. And orthopedics kind of speaks to that. I don't know for you, gration what kind of drew you to it.
Grayson Moore MD 03:52
Yeah, to echo what you said, we kind of come from an interesting background. There's a lot of physicians in our family. Our grandmother, on my mom's side was a little jack of all trades in Brooklyn, New York, she kind of took care of everyone, even the mafia story say they would trade services for Hey, you delivered my baby. Here's some lobster. So the stories go in the myths go. And then my father and my mother are both physicians and my dad, obviously orthopedic surgeon, my mom is a general practitioner who practice for a little bit a little while and then she retired just because she had four boys she had to take care of and I got into it as well for very similar reasons that Dustin did. Growing up instead of you know, playing baseball with your dad, maybe we were at the emergency room hanging out, trying to figure out what the heck we do while he sets a wrist or finger and yeah, we picked up some tricks along the way. And yeah, we did all the other things. To baseball, football, all that stuff, but it was kind of unique that we got to watch these people get their bones put back in place. And this was, you know, in the 80s and 90s, when things were a lot different than they are now, that got us interested. Plus, we played a lot of sports and just naturally our father being an orthopedic surgeon, we were, we had all the knowledge, assume middly from, you know, all the people that came to talk to us, they thought we knew everything that dad knew. So anytime they had an injury, they said, Hey, Grayson, what's going on my ankle? I'm like, I don't know. I'm not an orthopedic surgeon. I'm in high school. That came to me enough to where I was like, I better I better figure out what how I'm supposed to answer these questions at some point, and then it just became Okay, well, let's go down that path. And I like Dustin, also, kind of considered other specialties. I like urology, I like things that had a lot of toys. in orthopedics, we have a lot of toys, meaning devices, a lot of products that help us do our job. And not just our hands, we get lots of tools. And so in urology, I considered going into that. I did general surgery for a year after med school, then I just kind of decided, well, orthopedics is kind of where I kind of gravitated to, and I like the lifestyle. I like the types of injuries and the people I was dealing with. And what's interesting is there's four boys in our family and three of us went into orthopedic surgery, the I'm the oldest, Dustin is second oldest, we have another brother named chance because he was the last chance for a girl. And he also went into orthopedics. And he is in San Antonio. And then our youngest brother kind of went the other direction he went into politics. And you know, that's kind of my story. He kind of followed me and kept tapping me on the shoulder and said, Hey, orthopedics way they
Patrick Kothe 07:00
it. Wasn't the family plan for you guys to all all join up and have a practice together?
Grayson Moore MD 07:06
Yeah, I think dad probably had it in the back of his mind. Ideally, in a perfect world, all his sons become orthopedic surgeons and join him in practice. What do you think does? Yeah,
Dustin Moore MD 07:19
I think so. But they also encouraged us to do other things. I did real estate for a little while dad wanted me to move out to Hollywood and be an actor. I was like, I'm not pretty enough for that. No, we tried other things. I think Grayson did a stint with some manual labor for a while. And we just found that, you know, orthopedics really spoke to both of us seeing the complex problems that come in, I think, you know, every day I enjoy going to work, I think that speaks to making the right choice for it.
Patrick Kothe 07:48
So let's talk about about your practice. Let's start on the clinical side. We'll get to the business side in a second. But what is your practice about clinically,
Dustin Moore MD 07:57
we're all all three of us. We're in partnership together, Grayson dad, myself, and we are general orthopedic surgeons, meaning we didn't do a subspecialty or fellowship necessarily after training. So in orthopedics, you do five years of training, and then you can do a subspecialty for one year afterwards, called a fellowship. And I think there's five or six different ones, cluding, hands, spine, and some other things. But as general orthopedic surgeons, we kind of take care of a little bit of everything. I enjoy it for the community where we both are, we're kind of on the little bit on the outskirts of Austin. So we kind of have that hometown feel for the orthopedic surgeons in the areas that we are, we have patients that will come in for shoulder problems and will end up taking care of their knees as well because we do a little bit of everything. So we take care of sports injuries, fractures, total joints, a lot of different things that come through our doors. Do you do trauma, we do a little bit of trauma, we take call at some of the local hospitals here, none of the big traumas, like pelvis injuries, but you know traumas that include risk fractures and ankle fractures and tibia fractures and hip fractures and those types of things.
Patrick Kothe 09:17
What about your your patient base, explain what your patient base looks like.
Grayson Moore MD 09:23
I think most of our patient base is a family just like you would go to your family doctor, you know, anybody from pediatric age all the way to geriatric age, we take care of all ages. So you know some people focus in especially if they did a fellowship and total joints still get you know, people who have arthritis which tend to be older people. The nice thing about our practice is we do take care of the whole family. So we will see pediatric wrist fracture, take care of the kid and then you know mom brings kid in mom. just so happen happens to have, you know, shoulder problem that's been bothering her for a long time. And we take care of mom. And then mom says, Oh, my grandma, or sorry, her mom also has an injury. And we take care of that as well. So, all ages, we're out, kind of in the outskirts of Boston, like Dustin said, and, you know, you don't have the luxury of big medical communities like Houston, although Austin is growing significantly, you don't have that hyper focused, very specific specialties, as much as you do in some of the bigger cities, we are almost like the first line of orthopedics. And, obviously, if somebody needs to have something that's more complex taken care of, we will send them to somebody who specializes in that body part if it's very complex, but as far as our practice, we kind of try to take care of most things on our own. Unless it's something we don't feel comfortable with. And then we'll, we're actually pretty good about communicating with the other physicians around us that maybe have a subspecialty and get them referred quickly so that, you know, the care is not delayed, so they're not stuck, waiting for months. We have those good relationships with other doctors that we can get them in quickly.
Patrick Kothe 11:22
Let's talk about legacy, bone and joint orthopedics. What the practice is all about how you're structured, business wise, and we'll get into some of the other more business types of things. So tell me about the the practice
Dustin Moore MD 11:36
legacy, bone and joint like you, like you said, the name kind of speaks for itself in the sense that we're, we Grayson and I are the legacy of our father frosty. We kind of came up with the idea we had a drink or two and kind of trying to figure out, hey, what should we call ourselves and that's when legacy was born. But we were leaving another practice and trying to figure out how how to structure ourselves. We had a close relationship with one of the local hospitals at that time. And we ourselves are set up as a equal partnership between the three of us. But we have a close relationship with Ascension Seton, which one is one of the main hospitals here in the Austin area. And we set ourselves up with a PSA or a professional service agreement, which essentially is where we partner with that hospital. It's a close relationship in the sense that, you know, a majority of our practices run by ascension, even though we own our practice, it's run in partnership with ascension. So as far as billing goes, most of the billing goes through ascension. And you can kind of think about it almost like an employed practice where it's an RVU base, where if you don't know what an RVU, it's called a relative value unit. And what that is, is it's set up by I think, a national standard where you know, a total hip is X number of RV use, and then we are reimbursement is based on that RVU. So we negotiate a price per RVU, with our relationship with our parent company, that numbers then applied to the RV use, and that's kind of how our reimbursement is set up. Practicing in this day. And age is kind of an evolving structure. I think back when dad was starting out, they were still trying to figure out how much is a total hip worth How much is this and, and really, as that evolved and it became more complex overhead started going up and up before you could, you know, have your front desk you could have your biller and then you know the surgeon and maybe an MA and that was all the overhead you needed besides an X ray machine. Well, now you've got to have five biller coders. You got to have your front desk, you got to have people that assist them and your management company, it starts to grow and grow and grow even though you're just those same individual. As far as overhead expanding from that standpoint, it really made or kind of forced practices to group together and become these big groups. Well, we wanted to kind of stay small, you know, it's easier to make decisions and things like that with, you know, just three people or four people. So in partnering with ascension, we have been able to keep our autonomy in that sense. We hire our own people, we, we have our own decision making meetings and things like that. But we do have a partnership with Seaton where they have certain standards or metrics that we meet, and we come up with ideas of how to grow both their practice and our practice at the same time. So it's a relatively newer concept of it's a semi employed semi private practice mentality. Whereas before it was you were either an employed physician or you were a totally private practice, and there is still that going on. But in the private practice world, I think a lot of groups have joined forces, as strengthen numbers to negotiate their, their RVU, or their, their amount that they can get paid per surgery through their contracts with insurance companies.
Grayson Moore MD 15:32
I think the best way to describe it is a hybrid model. Traditionally, when you are in residency, and they talk about how do you join a practice? What are the options out there, and in the past, you used to not get much training or information about this during your residency about, yeah, you learn medicine for how many years, you know, five years of residency and four years of med school, but you didn't learn about how to start a practice how to run a practice, how to join a practice, how to make sure that you're joining a practice that's healthy, and is going to support you. And I think there's some crazy statistic, when you leave residency or fellowship around 75%, that you're going to change jobs within two years. And two years is, you know, up very quickly, and then you're like, Well, what do I do What went wrong? And that happened to both of us. And we, you know, we had to figure out how do we start a new practice, that's going to be viable for the future as as a small business and trying to cover overhead, you have to either join a bigger company, or you have to partner with somebody. And so this is a hybrid business model, where you essentially are not fully employed, but you're not fully independent as private practice. And it's our way of trying to meld the two together, in order to survive in a, in a world where reimbursement is going down for procedures that we're doing that are getting more and more complex. For example, if total knee is getting less reimbursed, as time goes by Medicare is paying less and less for it. But the complexity of the procedure is going up, because we're starting to use more computerized versions that are requiring more kind of integration with images and computers. And, yeah, this is all stuff that you maybe didn't learn in residency, and has evolved after the fact. But technology is moving so quickly that you're having to keep up up with that kind of practice and keep your skills sharp and, and it just seems like in a small practice, it's hard to run your business, treat patients keep up with literature, all that stuff. It's very hard financially unless you do one of these models. And I think, from what I understand, we're one of the first models within the ascension group that has done this kind of hybrid model. And they're essentially trying it out and see how it goes. And so far, I think both sides are fairly happy, it's still a work in progress. And like any partnership, there's ups and downs, and we always want more power, and they always want more power, we're always struggling for who gets the edge on each other. But it's kind of an interesting model. And we've actually talked to, you know, newer guys coming out that want to know what they should do coming out of residency. And it's hard for them to understand our model, because it's so ingrained the other two pillars where it's either private practice, or fully employed. So a lot of the newer guys coming out don't understand this kind of a model. So I don't know that this might be something more, more common in the future, we just have to see what what the popularity of this model and the sustainability of this model, how it does in the future. But we've been doing this I want to say for four or five years now. And it's it has been sustainable for both sides.
Patrick Kothe 19:06
from your standpoint, a lot of the back office stuff is being taken over by ascension. And that's the benefit to you guys. What's the benefit to Ascension?
Dustin Moore MD 19:16
I've spoken to some of the employed physicians and I've spoken to the the higher ups at ascension and doctors notoriously don't like being told what to do, right? They found that sometimes in when you are strictly employed physician, that motivation to keep you know you get paid this amount, no matter if you do 12 surgeries or you do three surgeries, you know it doesn't matter, you get paid this salary. Well that model can sometimes struggle with the motivation to get things done. This pilot program essentially keeps that same mentality of that hustle with private practice. So You eat what you kill model where as hard as you want to work as as much money as you can bring into the practice. So for ascension, partnering with a community physician that's involved with out in the community in Dripping Springs and became where they didn't have a footprint unnecessarily. They were able to partner with us who had already kind of established ourselves out there. And that's a new book of business that they were able to bring in under the ascension envelope, we work with them in the partnership to help take care of a hospital, one of the smaller hospitals out in kind of the Oak Hill area. And we work with them on partnering Well, how can we make things better? How can we make ourselves more efficient? How can we make that hospital thrive, both from a surgical standpoint, but from the day to day, and they get our perspective on that? And with that partnership, I think that brings them the benefit of what we bring to the table not only a book of business, but also expertise in Well, what what is the surgeons perspective on running that hospital? How can we make it more efficient, and that has been, I think, a benefit on both sides.
Patrick Kothe 21:16
So it's still your your business, they're your books. And it's your profits that are coming in? They're benefiting by having your services at their facilities. That's kind of their big, big benefit.
Dustin Moore MD 21:30
Correct. And I mean, the thing is, is because, you know, due to certain laws and restrictions, they can't strictly say we have to do them at ascension, we really can do them wherever. But in order to be good partners, since we've been building this practice at this hospital, in particular, Seaton, Southwest, we want to go to that hospital because we've been working and we have a say in how things go there and how they are bettered. So the streamline actually benefits us in the practice of saying, well, this works better if we do it this way. And they listen to those suggestions. And it almost encourages us to go there because we were making that place, a better place for us to go.
Patrick Kothe 22:16
So Grayson, who do you have at, at your facility, who's in your business? How many people
Grayson Moore MD 22:23
so right now, and that's always a changing thing, based on the needs of the practice. Right now, we have three physicians all so happened to have the last name more and it becomes a little confusing when you say doctor more. So we all go by doctor first name just because it makes it easier. Each doctor then has a medical assistant, which basically is your right hand person to keep up with our records. We have also personally hired scribes that will help us to type the note because the documentation has to be there for insurance authorizations for, you know, getting stuff approved, and that can be burden burdensome later on. You know, when you go home at night, you don't really want to be typing notes and finishing paperwork. And then we also have a PA that helps us in clinic physician assistant is basically, under the watch of each physician, which can do minor procedures, such as injections can help prescribe medications can help diagnose can help treat, they'll help us be a little bit more efficient. So that's in clinic. In addition, we have a physician's assistant that helps us in surgery at the hospital, we have one in each setting. And what they do is they help us in surgery, and they help us be more efficient in the operating room. And they also help us in the hospital and as far as routing checking up on people discharging people admitting patients to the hospital. So that's our clinical staff. In addition, we have an X ray technician, we have one for each location, we have two locations, so 2x Ray technicians, and then as far as our clerical staff, we have four front desk that assist with checking people in checking people out scheduling appointments, answering phones, and they also overlap with some of the other staff who also check insurance. And then we have a surgery Scheduler. And then on top of that we have a management company. What they do is they basically help us manage the business part of that, you know, they have degrees in business, and we don't and so they are basically consultants that help us make good decisions in the business setting smart decisions if we're considering adding a partner or change your agreement with ascension. And I think that's it. Dustin, Can you think of any other governance? Definitely. Yeah.
Patrick Kothe 24:52
So you said that legacy is what four years old?
Dustin Moore MD 24:55
I think so.
Patrick Kothe 24:57
Your dad is is a veteran. Other practice? How did you do practice building when you went out on your own? and went to geographies that were a little bit different than what you were in previously? How did you build the practice?
Dustin Moore MD 25:12
A lot of discussion with dad kind of getting getting tips on? Well, what do you do because he, when he first started, he started his own practice back in, I think, 1986. Him and two other surgeons, some of the main tips that he talked about was to go out and get involved in the community, if you know, the people that you're operating on, they'll kind of start coming in. So we, we started covering high schools, and then we started kind of going out and meeting other physicians. So I would go do cold calls and set up meetings with, you know, primary care physicians, just to let them know, introduce myself, let them know who I was, and what I was interested in. One of the big referral sources that we've really capitalized on, I think, was getting to know the ER physicians, because one of the newer things is these freestanding ers that I feel like pop up all over the place by getting to know them. I think we've been able to create referral sources and being available. One of the main things is they have my the ER physicians have my cell phone number. So if they ever have questions, they can call me day or night. And I'll answer just being available to answer those questions has really developed those relationships so that somebody comes in with a risk fracture, we've got him in clinic either that day or the next day to come in and be seen. So that has helped a lot. And then just word of mouth from there has grown.
Grayson Moore MD 26:47
I think word of mouth has been a big builder of business for us. Most of the primary care doctors that are out there have a favorite orthopedic surgeon, and you're just the new guy on the block. And, you know, how do you make yourself different or stand out from someone that's established in the community that they've been referring to for 2030 years that they've been happy with? You come in and say, Hey, I'm bracing more, I'm new here. Hey, send me some patients, you know, that doesn't work very well, the way that I had to build my businesses. You know, the few patients I have, at the beginning, I made sure that I listened to every word they said, and address every problem. And you know, most of patients are not used to that. It's kind of crazy to say, but a lot of patients get five to 10 minutes with their orthopedic surgeon, and then it's out the door they go. And I think that we being a smaller practice, we have staked our claim on trying to spend time with each patient. If that makes us run a little bit behind, then. So be it, we really try to take our time and answer all your questions, I want to go through every MRI image with you and make sure you can understand what you're looking at. You don't know what an MRI looks like you've you know, most patients have not seen an MRI, they don't know what it is they don't know how it works, let alone looking at the anatomy and the instruction, the structures that you're looking at. You start talking to him about all these structures, ACL, medial meniscus arthritis. me a lot of times they don't have a clue what you're talking about. And I'm not saying that everybody needs to know exactly as much as an orthopedic surgeon, but my job is to try to get across to you in laymen terms, what's going on and have the best understanding you have the best understanding and make sure that if you go and tell your buddy, what happened, you can tell them in layman terms what's going on and not say, I don't know, he said, I did something to my knee and I need surgery, if they if you walk out of the clinic, and that's your answer. I feel like I've failed in my job describing what's going on to you. So I think, early on, I made sure that that was a very important topic to me. And I've tried to keep that going in my practice, even as I got more busy. And I think the feedback I've gotten for most people is thank you so much for spending the time about what my injury is and what the plan is. And they just want to know the plan. You know, don't tell them what right now what we're going to do. That's what they want to know right now. But they also want to know if this doesn't work, what's the second what's the third step so they have a idea of what's going to happen and not always ends, you know, offering surgery right off the bat, if it's not necessary. And they patients appreciate that. And when you do that to a patient, they're going to tell their buddy, they're going to tell their family and word of mouth is going to is probably the biggest way that I have built my business. And I think Dustin has done the same on those principles of making sure that patient is heard and they understand what's going on now. Not ever Nobody's gonna walk out of there, you know with a five degree, five year degree orthopedic understanding of what's going on but at least be able to tell their buddy Hey, this is what I tore. And this is what's gonna happen.
Patrick Kothe 30:15
Thank you grace and it was really a nice way of describing how you're building your business. Grayson, you stayed in Texas for all your training for most of your life. Dustin you you went up to New York City or Austin for a little bit and was in college for a few years. You also have I think, both have a relationship with Justin in the rodeo. Tell me about that and how that's impacted your business.
Dustin Moore MD 30:40
So dad got started with rodeo when he first started here. I think he actually did rodeo for a while in college but he got started with the Austin rodeo through them met Justin sports medicine and I think Justin sports medicine has grown with dad's practice. You know, it's uh, you know, he's grown at the same time they have been developed. We grew up going to the rodeo here in Austin. We grew up going to the concerts going the rodeo and seeing the Cowboys get injured dad would bring us down to the trailer and show us how to do different things. So actually, when I was in residency through dad's connection, he introduced me to some of the trainers through Justin sports medicine, and I did some of the rodeos up in Lubbock and New Mexico. And then when I got back here, I joined Grayson and dad and we are the team doctors for the Austin rodeo. Every year when they come through town. It's a two week whirlwind where every night one of us is covering the the floor for when the Cowboys go out there. And you see some some interesting things and cowboys are some of the toughest in some hardheaded. You know, you give him some advice. And they're like, Nah, I'll be fine. Just put it back in place. And I got to get on to the next rodeo. But I think it's been a lot of fun. And I've learned a lot through the rodeo. Sometimes you know how to take care of things that don't necessarily follow the the normal structures of how you did it in in residency, and things tend to turn out okay, but it's been a lot of fun. You see a lot of characters. And it's it's been a really good relationship. Grayson, how's it been for you?
Grayson Moore MD 32:22
Justin sports medicine rodeo is like no other medicine that you've ever practiced before. You cannot speak to a cowboy the same way you speak to any other type of patient, it's got to be very blunt, and you have to be extremely organized in your thought process on what needs to happen next. Sometimes that doesn't involve choices, it just says this is what you need to do. Because that's the kind of structure they need. And you have to talk to them in a very different way that you talk to, you know, the normal public. And that's just because of the fact that they need to know what their job is going to be like in the next 24 hours because they're on to the next money making event. And so it needs to be very literal, it needs to be very direct. And they need to know what the realist realistic expectations are, and what their body can actually accomplish. But yeah, we've done this for a while now. I feel like I've been doing it even during residency I was I was doing that. And then we've done other rodeos outside of Austin rodeo, which are really interesting when you get the amateur people out there it really gets very scary sometimes and you're like man, we're in the middle of nowhere and Marble Falls you know, just out in the country and it's just a small arena and there's you're wondering oh my gosh, if we need an ambulance, how are we going to get here? But yeah, it's it's it gives you butterflies when you're out there you it keeps you on your toes. You never know what the next injury is going to be. Could it be a flag girl falling off the horse? Is it a ball rolling over? a cowboy is a guy getting kicked in the face by a horse? dislocating their shoulder you know, all kinds of injuries. And then you also see injuries that are non orthopedic and they look to you for you know, I got something in my eye What do I do is it you know, I can't see this one side or a good taste or you know, all these kinds of other non orthopedic injuries which keeps it fun and, and we do have other doctors that we consult with and that come out there and it really is a team. The the trainers that are out there some of the best trainers I've ever worked with. And these guys know, each cowboy by name, who their girlfriend or wife is all their kids names. And so it really is a team and it's not just us and every town they go to they work with different orthopedic surgeons and different doctors, not just with pedic surgeons, and so we get to, you know, meet a lot of people, it's good socializing, it's good networking. And a lot of the new people who are interested in training will come out and watch it. And it's a great experience for them. So we do some teaching as well. So I enjoy just because camaraderie and team building and also, you know, educational, some different?
Patrick Kothe 35:25
Well, cowboys are certainly very independent, as our physicians are very independent. You've got three of you. And not only do you have three physicians and the dynamic with three physicians in their beds, you've got family, and you've got the family dynamic in there. Do you guys try and standardize on procedures that you do? Or how you're doing a procedure? Or do you operate a little bit differently independently? And how you approach a different, say, a hip or a knee or something clinical?
Dustin Moore MD 35:57
We We definitely talk a lot about cases, do we do them exactly the same? No, you know, there's a, there's a lot of different ways you can get to the same end result, I think we all take good care of our patients. But sometimes we get there in different ways. I think Grayson and I, since our training was closer together, tend to do things a little bit more similarly. But there's a lot of things that haven't changed in 30 years that, you know, the dad still does the same thing that we do. As far as fracture management and things like that. And there's a, there's a lot to be said for experience that that dad can bring to the table that we just don't have, because we haven't been doing this for 30 years. Each way has its benefits. And each way kind of has its drawbacks. But the nice thing is being able to bounce ideas, I think if we all did it exactly the same, then we wouldn't have different experiences and different things we could bring to the table. As far as advice on different things that come in. Probably once a day, there's a text going back between Grayson and I and dad saying, hey, how would you take care of this? How
37:09
would you do this? What
Dustin Moore MD 37:10
approach would you use for that, and that really, I think, helps take some of the anxiety sometimes because like you said, as physicians, we kind of are independent. And it sometimes does feel like an island, where you're by yourself, but having the ability to bounce ideas off, I think is is worth its weight in gold. I love being able to bounce ideas off each other
Patrick Kothe 37:36
person or there's some procedures or some approaches that you guys do differently. And how do you when you have that discussion? You know, I do it this way I do it this way. How do you have that discussion?
Grayson Moore MD 37:49
Well, actually, we operate together fairly frequently just to assist each other number one, but number two, to kind of see if we're doing something maybe a little bit differently, that might be better, one way or another, hey, I've never seen, you know, a rotator cuff done that way before. And so yeah, I think we do do things differently. And specifically, we started doing our total joints with the assistance of specifically Dustin and I started doing our total joints with the assistance of some navigation, which essentially is a is a computer device that kind of helps you become more accurate in the placement of your components. And you know, dad's been doing it by eyeball for how many years. So usually, he's very consistent on his how his x rays look and his placement just by muscle memory. He's doing it the same way every time. I found in my practice, I like having that confirmation with an X rayed taken intra operatively, before I put the final implant in, I like having the double check with the navigation or computer to kind of make sure that I'm in the right position. Because these things have been shown that if you put them in a certain position, they're more likely to have a better longevity, they're less likely to cause issues as far as rubbing or caused pain later on the implants just gonna last longer, because it's distributing the forces correctly. And so, you know, that's one thing that we've kind of brought in that dad was not doing using this navigation technique. And now we're starting to incorporate the use of robots and computers. And I think that's something that we have brought in as a younger generation to the older generation, if you will, and then specifically to hips. I know Dustin does his hips through a post your approach. I think in residency he did, you know, a lateral approach and now he's, you know, transition to a post you're approaching and I'm transitioning to the anterior approach. Which is, you know, kind of front side approach. And all these things are just different ways to get into the hip joint. And there's literature that shows that, you know, they're both very good approach. And the end result is great, because you're replacing a disease joint with something that's artificial, that moves way better way smoother. And I may argue that, you know, the anterior approach might be more beneficial in certain patients, because of the fact that I feel like you're not cutting as much muscle. And I feel like my dislocation rate is a lot lower through that approach. And I feel like the patients get up and get moving quicker. But, you know, that can be argued, and in the literature, you know, there's people that argue that one is better than the other. And this, this debate goes on, with every orthopedic surgeon in America. And you could find, you know, 10, people that argue anterior is just God's gift to earth, and post tears, you know, just not great. And then there's 10, people that would argue the exact opposite. And then there's other approaches, too. And so, I've found that in my hands, what I basically tell a patient is, no matter what approach you do, or have done on you, you want your surgeon number one to be comfortable with the approach, you do not want them to be doing something that they don't feel comfortable doing, or if something goes wrong, they can't figure out how to, you know, fix it from that approach, and get stuck and say, I don't know what to do, we're gonna have to close you up. And number two, you want to make sure that, you know, you're going to have a good end result, either way, you're going to have a joint, that's going to be something that functions better than the way than the way it did before. And so, in my opinion, I like the anterior approach, it's just seems more extensible. I feel like I can see things better now that I've done quite a few of these. And then actually, to be honest, I never really did any anterior approach, hips in training, I had to kind of learn it through laboratory work on cadavers, and then go do a bunch of courses. And then, you know, do some surgeon visitations where I just watched them. And then I actually started doing them on my own, letting patients know, you know, this is a newer procedure for me. And then I had, you know, mentors, come watch me and make sure I'm doing it correctly. And now I'm to the point where I'm doing these on my own, and I feel very comfortable. And I feel like it's a better approach in my hands. For somebody who's the right candidate. Now, there's some people that I would still argue that would benefit from post your approach occasionally, in my hands, but, you know, there's other surgeons that will tackle anything from the front. But I know that Dustin has his feelings about the other approach. And that's something we debate all the time. And I keep trying to get him to come over to my side, and he says, I'll come back over to the dark side. And, you know, if you talk to people in Austin, other surgeons in Austin, that they'll have the same response, I would say, and, yeah, it's always, medicine is always evolving. And we can only go on the literature and the experience we have right now. And, you know, say Dustin, actually really looks at the literature again, and sees that the anterior approach is better, he might, you know, crossover to this side here,
Patrick Kothe 43:30
I think, you know, kind of what you said, it's kind of like, if I went down to a racetrack, and somebody put me in a Lamborghini, I'm not going to do that, well, a driver is going to do well, that guy, but I'm not going to. And I think it's the same thing. Here, the surgeon is the one who's who's controlling the outcome of that procedure. And if the surgeon is more comfortable doing one approach than another, that's what he should be doing, he or she should be doing. And I get it with the debate between, uh, between different things, because there are many ways to do similar things.
Grayson Moore MD 44:06
Yeah, we have a debate on it pretty, pretty much every week. And I, you know, I not only provide him literature, and he does the same to me. And, you know, we also have these certifications that we have to do every 10 years. And we go back and look at the literature again together. And we kind of say, Well, I guess we're both right.
Patrick Kothe 44:31
It doesn't let me switch gears for a second. Let's talk about implants. And let's talk about medical devices. So there's a lot of different orthopedic implant devices. How do you go about choosing what devices that you're going to use? Let's let's say it's a hip or a knee, how do you go about choosing
Dustin Moore MD 44:52
Sure. You know, there, there's five major companies that we call them the big five and they're actually probably Combining into fewer than that at this point and, and I really think if you really look at them, they'll have good products. So from my standpoint, you can argue this one has better shoulders, this one had better hips, this one's had better knees. But for me, what it boils down to is having a rep that shows up knows what they're doing and brings the products in and knows their product. Well. And for me, in particular, you know, I've used multiple different products. In training, we used some diffusivities. And in, we use some other Stryker products. And then in practice, I've found that I use now Zimmer Biomet, which I didn't use in training at all. And really what it boils down to is having a rep that shows up. So dad, actually, I went to high school, actually, the elementary school with the rep we use now, he and I were in the same elementary school class, and he went to a&m, got out of college and was like, What do I do now he played football there, and then was trying to figure out what he was going to do. And a few years back, he before I was out of med school, dad brought him on and kind of helped show him how to do orthopedics and kind of trained him along with, you know, his fellow other reps training him. But he and dad worked very closely for many years. And when we got to town, he was kind of already trained at that point. So he in the O r, as the the rep for the company was able to give pointers, sometimes, you know, hey, this size would probably work better than that size going in. If you you know, if you're splitting hairs on, is it a size for size five? Well, hey, yeah, in the past, this is what we've done in this has worked well. So having that relationship and having that knowledge really done tremendous wonders for both our practice and our confidence in the Oh are the same thing with sports medicine. So we've used we've tried a couple different companies for sports medicine, again, with the anchors and things like that, for the most part, all the companies have good products, it's really having a rep that can show up and know their products so that if something goes wrong, oh my gosh, this this product broke. What do we do now? Is there a bailout? Do you have more? You know, that anchor fell right in? Do you have a bigger anchor? Or do you have an idea of what do we do at this point, and some of that comes from experience yourself. But also the rep sometimes brings a lot to the table with that. And that for me has a big, big factor on how I pick the company that I use is, is really reliant on the rep of knowing their product, price and similar similar for you.
Grayson Moore MD 47:47
Yeah, it's similar for me. And, you know, in residency where I did my training, we were fortunate to where our attendings would let us use whatever product we want, you want to use a project product, because you've never used it before. Go ahead, use it. And so we use all kinds of different products in and you found the, there's nuances with each implant and the reps know these little nuances most of the time, which is kind of nice, just to kind of give you reassurance that you're on the right track, or just those little things because the O R is very stressful environment, you're thinking about a lot of things. And you may not know the exact measurement from here to here on the implant. And when you jump up one size, how much does that link in the leg? Well, you've got basically somebody who's got a guide right there. And they can tell you well, this is gonna give you two millimeters of lateralization or two millimeters of length if you put this implant in. So having that kind of teamwork approach is very helpful, especially in a stressful environment like that. And I again, like to periodically use other products and try them out in in what's called a sawbones setting or cadaver lab, just to make sure I'm not getting too comfortable with the implants I'm using because I always fear Hey, am I missing out on something new on in another product? For example, the first company to bring out the robotic total knee was Stryker in something called the Maiko and the other companies did not have that. So do you just stick to the brand name and say, Oh, I'm only using Zimmer Biomet because that's what I know. Now, I went out got trained on the Maiko robot and that's something that you need to do, you need to make sure that you're well versed in all the implants that are out there. And you make sure you stay up to date on all that stuff. And I think the rap has a lot to do with it again, but reps in the end are not on the line for when something goes wrong. You're on the line. So you need to make sure that you know everything. And a lot of this is having to do preoperative planning and we do that with the reps is Well, making sure that we have all the revision parts that we need, say it's a big case like that. But, you know, it's it's through experience of using certain implants and knowing that, if this fails, you've got a backup plan, I don't want to use some fly by night implant company, I did that one time, just because I was put into a situation where I had to do that. And I didn't like it because the patient actually had a fall. And she tore one of the ligaments and, you know, had I use the different company, I could have just revised the plastic on the total knee. However, this company didn't make it yet. Because there were new. And from that day forth, I've told myself, I'm not going to use a company or an implant that does not have some sort of backup and have all the bevy of backup plans in case something goes wrong. And I think it's just not fair to patients to put them in that situation. And so I picked that base based on my familiarity with the implant. What kind of backup plans and revisions to are there available? What kind of reputation does the company have have, they have a lot of had a lot of recalls, you know, the last thing you want is to get something in the mail that says, this implant that you've been using, turns out has been an issue because it erodes fat faster, or fractures more easily. And over overweight patients, you know, that's not something you want to go back into all your patients and get and have to send them an email, or have a conversation with them and say, you know, I put in an implant that might not work later on. And that's not something you want to ever have a conversation, it happens sometimes. But, you know, using these companies that are well established, it's less likely to happen. And just making sure you know, the product, the history of the product. That's that's kind of how I pick it.
Patrick Kothe 51:48
So when your dad was younger surgeons working, and whatever products they wanted brought into the hospital were brought into the hospital, we're in a little bit different situation right now, where you got buying groups, and you've got a group purchasing organizations that have contracts and things. Are you guys primarily operating at hospitals, surgery centers, where he operating? And do you have those constraints?
Grayson Moore MD 52:13
Yeah, we're operating at both surgery centers and hospitals. Recently, with the bundled payments, if you don't know what those are, basically, the insurance companies are trying to pay a bulk bundled price. For one procedure, for example, here's $50,000. And these are not actual numbers, but $50,000 for Miss Jones is total hit. And that includes, you know, the surgery, the implants that are bought to go into that person, the hospital stay the rehab afterwards, you know, everything involved for 90 days of that patient's care. And so when you're looking at that chunk of change, how do I make sure I don't go over my expenses are not over $50,000. Otherwise, it's not a sustainable business. So in these negotiations, which sometimes surgeons are involved in, sometimes it's just hospitals, and sometimes it's everyone, price has to be negotiated upon. And these companies will either come to the table and negotiate or they'll stand firm, and based on those negotiations, that will determine sometimes what implants a hospital is willing to use. So yes, these costs do factor in when they're trying to do these bundle programs, which are becoming more and more common, because of the fact that it's not a sustainable business, if you're spending more than you're getting paid for it, some of these implant companies will not negotiate. Therefore, they will say they're not on contract, they'll charge more for their product at one hospital, maybe more than another hospital. But, you know, this, these things are all complicated, because I feel like they all happen behind closed doors. And, you know, a lot of times the surgeons are involved, which is nice, because then we can say, you know what, this implant is worth the extra money, because it's better. Or in this situation, we should do this extra cost but for a routine, you know, total joint there's there's, you know, standard prices that the hospital negotiates with these implant companies and they try to negotiate as a entity say ascension, United States or essentially Texas so that they can get better contractor grace, it's almost like buying wholesale, for example,
Patrick Kothe 54:36
doesn't have you had any opportunity to go to bat for a particular product that you wanted brought in.
Dustin Moore MD 54:43
Yeah, in our partnership with Ascension we were constantly bringing new products that we hear about because we get bombarded all the time with Hey, there's this there's that there's this with new products that we bring to to the table and say hey, we think this product will would be beneficial to patients for x reasons. And we've had a few that they've been able to bring in, get on contract and do negotiations with, you know, use one company mainly for my sports med. But there are some things that they don't make that I need to use a different company for, even though it might be more expensive or not on contract going to the hospital and saying, hey, I need to use this product for x reason it you know, the the surgery will go faster, the surgery will be more effective, it'll be better for the patient, which is ultimately, the most important thing is taking care of the patient and making sure that they are getting the best outcome with the most efficient surgery. I think. I think cost is important. It is a factor that you week, I think historically ignored, but I don't think it can be ignored anymore.
Patrick Kothe 55:47
How do you guys hear about new products,
Dustin Moore MD 55:50
reading the you know, the yellow journals, things like that, that come out. There's always new things coming out their reps coming and talking to us is another way. I'd say probably majority for me specifically is reps coming into the office and talking to us about new products and new things. And talking to other surgeons, hey, what do you use for this? What do you use for that? And just kind of like we've been hitting on over and over again, for medicine in general, it's a team effort. So learning from each other, I think is a is a big thing.
Patrick Kothe 56:21
Grayson, how active? Are you on social media? Is that does that enter into learning about new products at all? Yeah, I
Grayson Moore MD 56:31
mean, I don't know, if social media so much helps me to learn about new products. I mean, I am on some ortho Twitter accounts, they present, you know, complex cases and and they say, oh, man, can you look at what they did here? How would you do this differently? Or Oh, man, I got this really blown up. You know, tibia, how would you fix it? And there's a discussion that goes on there. But as far as new products, no, I don't I don't think social media is a big, big outlet for me. I think most mainly, it comes from orthopedic meetings is number is probably a high one. And we have CME continuing medical education that we do. yearly that updates us on, why is this technology warranted? Is it leading to better outcomes? And you know, reps are constantly bringing us new things? And half the time? I'm like, Okay, yeah, it's just a new, new gimmick. But it definitely requires critical thinking, investigating, I'm definitely not going to bring something new something just because somebody brought it and said, Hey, this is a cool new thing. Why don't you drive now or next time? Yeah, we don't, we don't do that. Most of the time, it involves investigating it, using a lab, talking with other surgeons talking in these conferences. Before we do it,
Patrick Kothe 57:57
you use a lot of different devices from a lot of different companies. Is there anything that you you'd like to say to people working in companies that supply you with products that you're implanting and patients?
Dustin Moore MD 58:10
One thing I'd like to say is, know your product. I mean, that's the that's one of the big thing is,
Grayson Moore MD 58:17
you know, you can really,
Dustin Moore MD 58:20
as a rep, I think, earn your stripes with a surgeon, if they ask you a question, and you can answer it, you know, it's not. And and when you're learning, you know that that's part of the game, but really knowing your product, and, but then also knowing when to say, I don't know, that is a big thing. Because the last thing that I want in an O R is doing something thinking that you do know the answer, and then it might not be the right thing. And then we've got a problem on our hands. You know, it's four millimeters, not five millimeters. And now this thing doesn't fit, knowing your product number one, but also knowing when to say I'm not sure, let me look that up. Because that can make a big difference in the operating room, especially when you're starting out. You know, me being a surgeon, there's times when I don't know things, and I tell patients Hey, I don't know, but I am happy to look it up for you and talk to you about it later. So that's one of the big pieces of advice if I can give one thing is knowing when to say I don't know. Yeah, I
Grayson Moore MD 59:26
agree knowing your product is the number one thing if you don't know your product, we're going to find it out sooner or later. And we're going to lose interest very quickly. So knowing your product is probably the number one thing and knowing that you have a good product versus a bad product is very important as well. I have a lot of people that come in and try to sell me a very not useful product that is not going to help me in any way besides increase the cost of the surgery or increase the cost of doing this. surgery that I could do without it. So just making sure you're not overselling your product, making sure that you have a good product, it's well tested, it's something that is well established. Even if it's a new one, there needs to be some literature behind, does it work does not work, and then being open to having other people around you that are not in your sales device sales team. You know, I can't tell you how many times we use products from different companies in the same surgery. And you have to be able to get along with your competitor. And if you can do that, and you can get along and be a team player, that goes a long way. Now, if you're bickering and trying to steal business from other people, in front of a surgeon, that is not going to fly as well. So you really have to make sure that you work well, even with your so called competitors or enemies. That's, that's another big one, I think a lot of people don't realize that you're being judged, even when you're not really selling anything. When you're in the room with another company, you're being judged on how you respond to that kind
Dustin Moore MD 1:01:12
of interaction, because that's the other thing is to piggyback on what he says, you know, not necessarily going for the sale, that specific case. Because if you play well, in the sandbox, we'll call you again. And we'll call you for a different product, or we'll call you for a different case. Because we know that you play well in the sandbox, and those are the kind of people that we want to be around. And I think that speaks volumes for character of people. But one other thing for reps specifically in the O R is know the steps of your case, because you can really help a case to speed up 10 1520 minutes, sometimes, if you can help the tech Now make sure that the tech is okay with you helping because there are some texts that get a little territorial but but knowing the steps and helping where you can to, you know, if I'm over here doing a dissection or something, you can get the next three set, step set up ready to go. So that we can be more efficient. And that for surgeons is huge. Medicine is an ever evolving thing. It's a it's a team effort. And I think knowing that it's a team effort is is huge. So for the people that listen to this, enjoy what you do, find something that you enjoy coming to work almost every day, maybe not every day, but almost every day, and then find a group of people that you can be around to get a good team that really can make taking care of patients not only easier, but better. Because that's what we're all here for is to take care of patients.
Grayson Moore MD 1:02:45
What I would like to add is be patient with doctors, we're human too, we make mistakes. Sometimes we have to spend longer with certain patients, because it's a very serious conversation that has to be had and involves a lot of hard conversations, maybe sometimes about life or death or loss of a limb or complete disability that's going to affect the rest of their life. And that conversation is not a conversation that can be had in five minutes. And maybe we're not able to schedule everybody exactly for the finite amount of time that they need every visit. And so just be patient if your doctors running a little bit behind. And a little bit can sometimes be an hour, sometimes it can be two hours. And it's not because we don't want to come see you. It's because we're stuck having a very difficult conversation with somebody prior to you and just try to put yourself in those people's shoes. If you had that kind of information coming to you would you want your doctor to spend five minutes about, hey, you're gonna lose your leg or, hey, you're going to be permanently paralyzed, or this is a very serious condition and then leaves a room and say I got 20 other people to see. No, you would want somebody to sit down, hold your hand, give you a tissue and talk to you about what matters over 15 to 20 minutes or maybe longer if it takes so that you feel like you know what's going on, you have a good idea of what's going to happen and what's going to come to you.
Patrick Kothe 1:04:27
That was such a valuable conversation. A few of my takeaways, first, the importance of being present. Grayson talked about that, and he explained how taking his time really assures that his patients understand what's happened, and what the recovery plan looks like and what they can expect. He said it helped him build his practice and it's how he continues to assure that his patients are happy and those patients actually We'll give him referrals as a result of that. But that really wasn't the main reason why he's doing it. It's just good medical practice. Secondly, teamwork. Dustin talked about how they text each other. They talk about cases they ask for opinions scan all day long. And these are confident individuals, these are accomplished cop confident individuals. yet they're humble enough and respectful enough to know that they might learn something by asking their parents, frosty and Pam Moore have done an excellent job, showing them the right way to do medicine, in addition to raising some really good men. Finally, their approach to medical practice is relevant to not only a medical practice, but it's also relevant to us in medical device. Think about these things. Take your time to understand your customer. Be respectful of other people's time. If you don't know the answer, say so. play nice in the sandbox. People are watching. You're part of a team. Are you hitting the standards? So who is on your team? Who's challenging you? These three men have each other that they're challenging each other that they're holding accountable each other that they're learning from who's on your team? Who do you call for advice? Who do you share things with? Who do you ask questions
1:06:49
of?
Patrick Kothe 1:06:50
And finally, are you open to learn? Are you closed off? Or do you think that there's still more to learn? great lessons from from today's conversation. I hope you really enjoyed it as much as I did. Thank you for listening. Make sure you get episodes downloaded to your device automatically by liking or subscribing to the mastering medical device podcast, on Apple podcast, Spotify, or wherever you get your podcasts. Also, please spread the word and tell a friend or two to listen to the mastering medical device podcast. As interviews like today's can help you become a more effective medical device leader. Work hard. Be kind
