Featured Guest: Paul Casamassimo, DDS

What he does:  Dr. Casamassimo is a board-certified pediatric dentist, Professor Emeritus at the Ohio State University, and an attending dentist at Nationwide Children’s Hospital, in Columbus, OH.  Dr. Casamassimo currently is Chief Policy Officer at the American Academy of Pediatric Dentistry's Pediatric Oral Health Research and Policy Center, as well as a past-president and editor emeritus.  He is a past-president of the Ohio Dental Association and currently serves on the American Dental Association’s Council on Advocacy for Access and Prevention as well as the Dental Quality Alliance.  He is author of over 450 publications on pediatric dentistry and care of patients.

On risk:  "The patient is at the center and around that patient are layers like an onion and within each layer there is the potential for risk and also opportunities to mitigate or prevent risk.  There are risks based on inadequacies in our training, inadequacies in our insurance coverage, our lack of continuing education in some cases, the challenges of mastering new equipment, and other areas that really enter new risk into the environment … Dentistry has barely scratched the concept of risk and safety. And so we really have to do the same thing that medicine did and look more closely at what we do. And to determine what is preventable risk. What are the challenges that we face, some of which can be pretty significant, and try to identify those … One of the things that we don't really appreciate is hidden risk … There has to be a culture that encourages people within the system to be willing to say this is not right, this is a risk, what you're doing is not safe for the patient.  And that's a huge, huge step … It's really understanding risk, the different layers of risk, and to begin to ask yourself am I covered, am I protected, what is my risk, what is my exposure, and to really get a global picture of what risk is … It's almost impossible for the individual dentist to think of everything that could possibly happen"

Transcript

Scott Nelson  0:01  
Welcome to The Risky Health Care Business Podcast, where we help you prepare for the future by sharing stories, insights, and skills from expert voices in and around the United States health care world with a mission to inform, educate, and help health care organizations and individuals, ranging from one doctor practices to large integrated systems and organizations throughout the dental, medical, and veterinary health care industry with risk, while hopefully having some fun along the way. I'm your host, Scott Nelson, a guy that grew up in Ohio and has been working all over the United States during my 20 plus year and counting career in the health care industry, with a commitment to accelerating health care performance through creativity, not just productivity. Let's dive in.

Tooth decay and gum disease.  Over time both can unknowingly occur in a mouth, and cause cavities and damage to soft tissue around teeth that can destroy bone that supports teeth.  Tooth decay and gum disease are examples of hidden risks that can be prevented. The same can be said about a dental care business.  There are hidden risks that occur every day in a dental practice, at every level throughout:  staffing issues, financial management, technology, attracting and retaining patients, economic conditions.  All can cause a negative outcome if unknown. Dental practices were some of the most affected groups by the covid pandemic at the initial outset and recovery.  During the pandemic the American Dental Association published a research brief noting an analysis that estimated the impact of the COVID-19 pandemic on dentist net incomes through 2020 and found that for general practitioner dentists, the pandemic led to a 17.9% drop in net income in 2020 compared to 2019. Coupling together unknown hidden risks with an unexpected adverse event can cause negative consequences.  How would your health care business respond?  Would you or your business survive? Today we're speaking with Dr. Paul Casamassimo about risk in dental care, including hidden risks. Dr. Casamassimo is a board-certified pediatric dentist, Professor Emeritus at the Ohio State University, and an attending dentist at Nationwide Children’s Hospital, in Columbus, OH.  Dr. Casamassimo currently is Chief Policy Officer at the American Academy of Pediatric Dentistry's Pediatric Oral Health Research and Policy Center, as well as a past-president and editor emeritus.  He is a past-president of the Ohio Dental Association and currently serves on the American Dental Association’s Council on Advocacy for Access and Prevention and the Dental Quality Alliance.  He has authored over 450 publications on pediatric dentistry and care of patients. Let's talk with Dr. Casamassimo about risk in dental care. 

Dr. Casamassimo, welcome to the show.

Dr. Paul Casamassimo  2:57  
Thank you. Good to be here.

Scott Nelson  2:59  
Before we begin our conversation about risk in dental care today, let's take a moment to look back.  How did you get into dental care and where you are today.

Dr. Paul Casamassimo  3:06  
My father was a dentist and I was inspired to choose dentistry as a profession because of his experiences and seeing him work.  I went to college and then went on to dental school and then specialized in pediatric dentistry and have taught at the University of Iowa, University of Colorado, have a little private practice experience, and now have been at Ohio State and retired from there in 2017. So I'm pretty active in organized dentistry and continue to work as a in the policy area of pediatric dentistry with our national specialty organizations the American Academy of Pediatric Dentistry. So that's kind of my quick background and I got interested in risk because among our dental specialty organizations pediatric dentistry along with oral surgery are probably the two that really have taken safety and risk seriously, from the patient standpoint and also the practitioner standpoint. So we have a very robust risk and safety program in our specialty.

Scott Nelson  4:23  
Well, that's a great place to start. So I'd like to start by getting your thoughts on what is risk in dental care. You've been involved in dental care, like you mentioned, from many different vantage points. How do you view and think about risk in dental care?

Dr. Paul Casamassimo  4:36  
Well, I think the best way to think about risk is conceptually to use a concept that one of my medical colleagues who's very active in oral health, Dr. Susan Fisher-Owens from University of California, San Francisco, and her colleagues came up with and that is related to caries initiation which has very little to do with risk but the concept that they applied, I think it's very relevant. And I use it for a lot of phenomena that I that I get into. And that is, the patient is at the center. And around that patient, like layers of an onion are the dentist and the dental staff, the system, the society, the family, and you can just have all these different layers. And within each layer, there is the potential for risk, and also opportunities to mitigate or prevent risk. And if you think of that concept with the patient at the center, and the next layer being the dental team, and then everything that affects us from that point on, you can get a sense of of areas that have the potential to generate risk. And I'll go into more detail as we continue with the podcast.

Scott Nelson  5:57  
Sure.  Why do you believe it's important to think about risk in dental care and actively plan and be prepared?

Dr. Paul Casamassimo  6:04  
So I think the simplistic way of viewing that is that in addition to our treatment, we really want to protect our patients, number one, and then number two, from a personal standpoint, we really want to protect the investment we've made in our education and our career choice. And so with risk being out there, we really need to think about not only the good things that we do for our patients, but the fact that there are risks, there are risks based on inadequacies in our training, inadequacies in our insurance coverage, our lack of continuing education in some cases, the challenges of mastering new equipment, and other areas that really enter new risk into the environment, or, or have risks associated with the gaps that we have in the various things I mentioned. So I think the best illustration is about two or three decades ago the Institute of Medicine published a report called "First, Do No Harm" from the Hippocratic Oath. And they looked at a couple decades of data from hospitals where we think we go to get better, or to get cured and come out, when in fact what they found were 10, literally 10s of 1,000s of deaths associated with hospitalization. Patients who went in with minor illnesses and never came out because of medical error, accidents they experienced while there, or other causes. All of which were largely preventable. So dentistry has barely scratched the concept of risk and safety. And so we really have to do the same thing that medicine did and look more closely at what we do. And to determine what is preventable risk. What what are the challenges that we face, some of which can be pretty significant and try to identify those. So it's really about protecting our patients, ourselves, and our investment.

Scott Nelson  8:16  
For a long time dental care viewed risk as complicated legal issues like patients and lawsuits. You mentioned some things just now. There has been the dental record and patient chart. Technology is a growing consideration among other clinical and business areas. Where the risk is in dental care for you, in the examples that people should be watching or monitoring, how can they begin to engage with those and be proactive as you mentioned preventable risks? There was recently the American Dental Association had released their Economic Outlook and Emerging Issues in Dentistry, and talk about recruitment needs, and staff pay and benefits, and difficulty and challenges in recruiting hygienists and dental assistants, and specifically even looking at ways that the economy are affecting the confidence in dental practices. How, from a perspective of risk, can people begin engaging and addressing those things to improve the confidence and and be a little bit more preventable and proactive in their approach?

Dr. Paul Casamassimo  9:17  
I think there are a lot of areas. What I would say, the first thing, is to try to understand the big picture of risk. So read about it, read about risk in medicine and other areas, and try to extrapolate that to dental care. One of the things that we don't really appreciate is hidden risk. And I think the best example, or examples, I can give are things that are in our own society, the natural disasters, the threats of the social media on people's thinking, false information, and those kinds of things. And then legal issues. I mean, so I think the first step for all of us is to really step back and try to learn as much as we can about risk in health care. And there are a lot of sources of information for that.

Scott Nelson  10:12  
Who are the stakeholders and actors that are typically involved in a dental practice? And how do they or can they address risk? And who should be involved if those people typically aren't involved?

Dr. Paul Casamassimo  10:22  
Well, that's a great question. And again I will use the medical experience, the journey of medicine in safety and risk. And dentistry is a top-down, has always been a top-down, captain of the ship phenomena, where the dentist, you know, logically has invested in the practice and has the education, and then transmits his or her intent to the staff members who have defined jobs and tells them what they need to do and what not to do. So but in medicine, it took a while, but finally they determined that everyone has to be involved. And that the hierarchy that we experience in health care, because the surgeon in the operating room used to be the king or queen, and would tell everybody what to do and was never question. And same in dentistry. But what has to happen is there has to be a culture of, of safety and a culture that encourages people within the system to be willing to say this is not right. This is a risk. What you're doing is not safe for the patient. That's a huge, huge step. And medicine took many, many years to be able to to get generalized agreement that that, in fact, is the right thing to do. You know, the example of there was in some cultures, pilots were considered in the same way and the copilot did not or could not or would not question a pilot's decision and there are plane accidents and crashes that killed dozens and dozens of people. Because of that hierarchy and the unwillingness to create a system where everybody is invested in safety.

Scott Nelson  12:14  
How do you go about creating a culture of safety? I mean, when you bring up some of the examples of some of these other industries, I mean, that's more than I always look at that as culture is created by people. Whether or not it's top-down, bottom-up, from the middle, you know, you have to have the people that are involved. And it's more than just having a binder or a book and putting that into play. That comes from everybody, like you mentioned with having the doctor or even the staff that are involved. Is that something that just it's a long, iterative process that just isn't an overnight switch?

Dr. Paul Casamassimo  12:45  
Absolutely. It's you have to build a culture of safety. And you know, I certainly, in our short time, can't talk about every element of it. But the first is to have a commitment by the person who owns the practice and the person who's in charge and say, this is a priority for us, you meaning the staff and everyone we are in this together, we are your your ideas and your opinions are valued, there is no repercussion for pointing out a risk, and be creative and be willing to propose a solution and realize that in this instance of patient care, patient safety, risk mitigation, we all have a contribution to make. So that's that's kind of the first thing. That that's a hard piece to bite for many staff who are in this hierarchy, top-down hierarchy, it's hard for them to get to the point where they're willing to question the dentist. The same was true in hospital care, where nurses would not question what a physician did. And there were negative consequences when that didn't happen. So the first thing is to say this is a priority for us. The second thing is to create an environment and not criticize or create retribution for someone who points out a safety issue, but in fact, compliment them and reward them in some cases, for taking it seriously and participating. So it's hard for the dentist, it's hard for the staff to change that whole hierarchical relationship, but that's what has to happen.

Scott Nelson  14:23  
You and I have talked before about data in dental care. Forbes had a recent article titled "Addressing The Data Deficit: Improving The Future of Dentistry" that noted critical issues such as a significant lack of high-quality, standardized data, and accessibility that consume valuable time and resources, and instead of enhancing patient care and streamlining practice operations can lead to lack of trust, missed patient education opportunities, and reduction in case acceptance.  From a broad view over dental care, what should be done overall to strengthen and manage risk and decrease vulnerabilities?

Dr. Paul Casamassimo  14:57  
Well, you know, we are in dentistry, where it comes to data where primitive man was with fire. We haven't really taken it seriously. Our medical colleagues, on the other hand, are data driven. I mean, they, in fact, when you listen to talks about Artificial Intelligence and things like that, that is being based on accumulated data and decision making that is based on factual information, as opposed to a bunch of people getting around a room saying, hey, this is what we'll do. Dentistry is way behind on that. And one of my previous jobs has been to be the Chair of the Dental Quality Alliance, which is the group within the ADA that's responsibility is to look at data and to improve care quality, by using data as the source as opposed to looking for randomized clinical trial data and things like that. And we just haven't had that. Our systems within individual practices don't have that. Although the ADA has begun to has created a system whereby an insurer can buy into it, and a practitioner can buy into it, and by buy into it I mean use it and have their data entered and have their data compared with millions, literally, of other claims data and see how they're doing and look at that. But that's extremely rare. It's just has not permeated. And then the the dental consciousness of how we're taught is not the focus on use of data. It's the focus on how precise our dentistry is within each patient. And while that is important, that, you know trends and what is working, what is safe, what is not risky, or less risky, really comes from from looking at data. So we're getting there, we're approaching that I think, more and more insurers and payers are looking at incorporating data into patient care and rewarding dentists who do use data to improve their care.

Scott Nelson  17:07  
When you go back to think about the concept of the patient at the center, and then you have the the dentist and the dental practice, and then you have and you mentioned insurance previously, and you bring in government and you bring in all of these other different areas, data helps make the decision. While it may not be involved in driving the clinical service, but I would think that it would give the patient information, it would give the insurance company information, and it would give the doctor information to then everybody be working together in a collaborative way in the best way to deliver overall care.

Dr. Paul Casamassimo  17:40  
That's true. And the good thing about data is it can show what works and what doesn't work. And dentists tend to be isolated or somewhat parochial. They get a technique it seems to work, you know, people are happy with it. And a new finding or a new scientific discovery may make it not as good as what could be. And without data and without looking at organized information the dentist may never know and continue to do something that that has become substandard. So it's really where we have to go in terms of improving care.

Scott Nelson  18:20  
What actions can doctors and groups take to strengthen and manage risk and to decrease vulnerabilities in their own clinics or practices or groups? So if an individual or an organization wants to plan for risk, how could they?

Dr. Paul Casamassimo  18:34  
Well, it's complicated. They can begin by reading about it and trying to understand quality and safety and controlling risk. The example I gave at the very beginning about these different layers, each one of those is fascinating in the type of risk. When you talk about patient risk, its mistakes, its complications, its poor care techniques, and things like that. But then you can move out to the dentist and the dental team and you can have risks associated with exposure to chemicals from infection control, radiation, noise that's associated with all the equipment we use, and over years and years those can have an accumulated effect. And so that's the next level. The next level is is you know, our electronic age and our systems and the liability to hacking and ransoming data. It's happened to some of my colleagues where they have had their you know, their information and taken over and ransomed till they can come up with the money or figure out a way to get around it. Then there's the you know, the layer of risk that that most of us don't even think about and that's natural disaster. And we we're seeing that now with with climate change, whether you're a believer or not, we have floods, we have tornadoes, we have forest fires, we have earthquakes, and all those affect a practice in a couple of ways. One is they can damage a practice and, and put it out of business for a while. And that if that risk isn't managed with insurance or something else it's a problem. But the other thing is it can destroy a community. So you may have this beautiful building that's actually left intact after some natural disaster, but the community around it is gone. I have a resident who wanted to go back to practice in Paradise, California, her hometown, and Paradise, California, isn't there anymore. It's just the, you know, a bunch of burned trees. And, you know, it's really understanding risk and the different layers of risk. And to begin to ask yourself Am I covered? Am I protected? What is my risk? What is my exposure? And to really get a global picture of what risk is. That's that's the way to start.

Scott Nelson  20:55  
You'd mentioned education, how does risk evolve or start at any point in education, whether or not it's in dental school, after dental school, or even if it's the education from the hygiene staff, the dental assisting staff, or the administrative and management of a practice or a group and evolve from there over time? How does education play into risk?

Dr. Paul Casamassimo  21:21  
Well, we're not very good at that. We don't, you know, we're so focused on technique and, you know, the precision of dentistry that we really don't look at those areas around it, including risk. We're getting better, we're starting to look at data now. You know, we've we've starting to use evidence in what we teach and what we do. But the comprehensiveness of a system that incorporates quality assessment, management of risk and and makes that as important in a practice as the delivery of care is a decade or more away. It's just not something that's going to happen. Now, many dentists would disagree with me that the move to corporate dentistry is good, but one of the ways it is good is that corporations are way ahead of individual dental practices in looking at and teaching and involving dentists in management of risk, and that's financial risk, it's patient care risks, and so on. So we'll probably see as that movement continues to grow with dentists practicing in a corporate setting, we'll see more and more education, probably on the job education, and that'll eventually filter back it'll take a while to to the education of dentists and other dental providers and health professionals.

Scott Nelson  22:51  
Corporate dentistry is a nice transition into my next question about resources. Resources comes up a lot in conversations, whether or not it's availability, capability of the resources, it seems to be a top issue, whether it's a single doctor practice all the way up to a large organization like a DSO, dental service organization, or an institutional setting. What resources can be helpful to the success of a dental practice when thinking about risk?

Dr. Paul Casamassimo  23:16  
Well, there are some as unknown as the risk management might be to a lot of dentists, there are a lot of resources available. For example, the CDC I'll use COVID and infection control, the CDC has a lot of information about protecting patients and protecting staff. NIOSH and OSHA have similar sorts of information that can get used in the workplace to protect staff and the dentist. The American Dental Association has a number of educational venues for risk management, looking at data protection, protection of patient records, HIPAA, and those kinds of things. The federal government has information, often it's very complicated and hard to sift through, but they not only have the information, but unknown to many dentists, they have requirements that about safety and risk management that need to be applied too. There are sources out there, small business for example, is very involved. Organizations that relate to small business are very involved with protecting those businesses against natural disasters, against things like flood and fire, and those kinds of things. And they have information, checklists, and so on as do these other organizations that I mentioned, where you can just simply go through and really increase your protection by going through those lists and seeing where you stand.

Scott Nelson  24:51  
Resources can sometimes be mentioned as a potential obstacle like we just mentioned. What are some other challenges and obstacles that a group or a doctor or an individual may come across during their day to day operations or during the, you know, the time period that they're in practice and how might they be able to overcome those?

Dr. Paul Casamassimo  25:12  
Well, you mentioned one earlier, Scott, and that is that we are a system of individual practices, you know, when you are a health professional working in a hospital, or health care system, you have a greater umbrella that can support you and risk management is actually overseen by someone outside the practice or they mitigate risk and they do a lot of the work for you, the data analysis and so on. We dentists don't have that. So that's really the first obstacle. We are largely individual practices or small group practices that don't have the resources to pay someone to address risk which is not the case in a larger health care system. The next one is one I already mentioned and that is our mindset is that this is so tangential to what dentists think about their you know, their thinking about the quality of their treatment, the precision of their treatment, and they don't get into some of the things that are outside that related to risk, safety, exposure to, to radiation and chemicals, things like that. And then the last thing I'll mention is keeping up with change. Because you mentioned earlier about data, can add artificial intelligence, we can add scientific discoveries, new equipment that works differently than what we're used to, there's just just keeping up with change is another huge challenge for a single practice, single dentist practice, they just don't have the kind of volume of participants that that enable them to, to keep up or to educate them on what they need to know. It all comes from them.

Scott Nelson  27:00  
How can people, if they're a single doctor practice or a smaller organization, again, that may or may not have those resources, what can people do to check their practice or test their practice to get an idea of their vulnerabilities?

Dr. Paul Casamassimo  27:14  
Well, one of the things that I mentioned earlier was a lot of the the sources of information have checklists. And, you know, it's very much like what a pilot goes through before takeoff. And these things will ask questions, is your practice ready for this? Does your practice do that? Do you do this? Do you do that? And I would say if somebody was interested, they could do a pretty good job assessing the safety and the risk control in their practice by simply going through those checklists. And government, professional organizations, small business organizations, and the like, are all have these things readily available to be downloaded or to be used online, as we talked very early those are the kinds of ways that you can engage your staff and get into this consciousness and this culture of safety is by saying, hey, how do we look? How do we do on this? Check this list and go through how do we stand. And you engage them and so those kinds of resources are available. Now, if you've got to fix some of that stuff, it could, then you may be talking about some expense and having to find experts to be able to help you do that. And the dental supply companies can help with those kinds of things, and your professional organizations can point you in the right direction.

Scott Nelson  28:44  
Now taking a look back through recent history, from a risk standpoint, what was expected versus unexpected in dental care? I know that we have gone through the COVID pandemic, which was absolutely something that none of us have lived through similar to that in our in our lifetimes, and it was an unexpected adverse event. What could have been seen previously? What could have been done differently? If we're taking a look at other things that we've gone through.

Dr. Paul Casamassimo  29:10  
Well, I'll tell you, the first thing is who would have ever imagined that the ease and the benefits of digital applications in our practices, appointments, record keeping, scheduling, those kinds of things, who would ever have thought that there were there were threats outside, people wanting to get that information, to hack, to ransom, and those kinds of things? So I think the first one is that just our naivety as a society, not just in dental care, of the risks involved. And you know, we're right now, as a society talking about artificial intelligence or AI, and we're doing a much better job, we're saying, you know, this could be like the Terminator. This could be something that overwhelms us if we don't take proper steps to protect. And we didn't do that when we first digitized a lot of our health care, particularly in dentistry. Nobody imagined how this was going to work. HIPAA was an early response to the vulnerability of digital applications in health care. So that's the first one. The second one is social media. And, you know, we are all at risk, you know, some of us, like myself, have, I don't do any social media, other than email and but others are engaged in it. And you know, in a practice, a small practice, if, if one thing goes bad and gets on social media, it can be deadly, and it can go viral. And so you know, who of us would ever have thought that something as potentially beneficial as social media for advertising and spreading the good word about our practice would ever have the risk of being a detriment and being lethal, in terms of our reputation, and so on. Then the last thing that I'll say is that a lot of what happens in society will ultimately filter down and so you can kind of predict the areas where risk will manifest. You know, one is consumerism, you know, the idea that people share information and that they exert pressure. The dentist was always someone who could be there and know that people needed them. And today, that's not necessarily true. There's a lot of competition. And so you know, consumerism is, is, has its share of risks. Another is just changes in medical care. I mean, we did you every day there's a new discovery, a new care technique, people are living longer with significant disease under control. And all of that changes what we do and that adds risk. And I think, again, most dentists wouldn't say well, you know, if someone had had a disease and they're cured they should be great. Well no, that's not necessarily the case. They may have a device implanted, they may have had organ damage that's irreversible, and so on. So you know, that's another one. Patient behaviors, our society has changed, we have people who do things that they shouldn't, and don't get in trouble for it anymore, that we have a lot of disinformation out there, and so on, and you know, who would have thunk it? Who would have thunk that that, you know, we would be dealing with that, that people wouldn't necessarily get in the mainstream of society. So we have to deal with that. So there's just a lot of things. But the general concept is, if it's happenings in society, the dentist should be thinking, how is this going to filter down to my practice? Because it will.

Scott Nelson  33:00  
And how do they, how do they engage with that? Or how do they test that? I mean, you the big thing is, seems to be these days, that's rapidly changing the you know, listen to, you read about it, you hear about it, is AI, you mentioned AI, and then technology. There's a lot of things that just happen at a very rapid pace. How do dentists in their practices, especially the ones that are in communities that may be working with patients or have a patient base or community base where there are other dentists that they may be trying to figure out how to separate or differentiate their practice from other areas and still in deliver quality care, how do they approach this without opening themselves up to risk by by introducing technology, or introducing AI, or introducing these concepts, either too soon, or untested, or just not being familiar with it? And you know, then it just gets out of control.

Dr. Paul Casamassimo  33:57  
You know, that's a great question. And I'm going to kind of sound like I'm, I'm speaking out of both sides of my mouth. But I think the dentists that I know, who are in private practice, have a very, very reliable, consistent source of brief information. They get excerpts from different sources that that will give them the latest in what's happening in dentistry, in practice management, in clinical care, consumerism and those kinds of things. And they don't have to read extensively. They get headlines from several different news sources and they look at them religiously. They look at them every day to see it's like, you know, you're following your stocks, seeing how they're doing and that is the best thing I think a dentist can do. And the second is to belong to professional organizations that are contemporary and have access and provide access to information related to changes that will affect dentistry. It's almost impossible for the individual dentist to think of everything that could possibly happen. But there are people out there who do that for a living, maybe yourself included, you know, that have that have to do that to stay on top, and are willing to share that information in various ways. So I think that's the best advice I can I can give somebody. I do that every day, I get information from medicine and dentistry in chewable bites, and I look at it and I follow up on what I want to and discard what I don't so, but it's kept me apprised of things that have been very valuable.

Scott Nelson  35:45  
Well and it seems to me like we're at a really interesting point, like an inflection point or a time where when you mentioned where earlier where dental care has come from in terms of not using data now we're beginning to use more and more data and looking how to use that and working with it. And then the things you just mentioned in terms of just digital naivete, social media, consumerism, changing dental care technology, all those things are in the past, but they're also at a point now where they're just changing on a regular basis. So looking forward into the future we've identified these pieces that we're learning from in the past, but they're still happening in the future, and those are things that we still need to keep our keep our minds on, keep our eye on as we begin to continue to, to evolve in practice.

Dr. Paul Casamassimo  36:30  
That's right. I mean, we know it's we've got to keep moving, we got to get up we have our legs have to be moving when we leave the bed. And that's just the pace of life, and particularly professional life. I don't know that there's any way to get around it unless you can find an isolated village somewhere, that's sleepy and doesn't change, and so on. The real world isn't like that. The real world is changing. And that's part of professionalism is to stay current on not only your treatment but in the factors that are those layers I mentioned early in this podcast and how they influence in changing in the changing way of what we do.

Scott Nelson  37:09  
Well, that's a great point to conclude our conversation and definitely keep our legs moving. Dr. Casamassimo, thank you very much for your time and sharing your thoughts today. I greatly appreciate it very much.

Dr. Paul Casamassimo  37:19  
Sure, it was a pleasure to do. It made me think which is part of my point in this in this conversation. So thanks for having me, Scott.

Scott Nelson  37:30  
Thank you for listening to The Risky Health Care Business Podcast. You can listen to all episodes from the resource center page of the SpringParker website, springparker.com, or click the Listen link in the show notes to listen and subscribe for free on your platform of choice. And remember, accelerating health care performance is achieved through creativity, not just productivity.