Why Breast Screening Access Needs More Than a Scan

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0:03 And what I mean by that is intelligence is not wisdom. If you still bring wisdom to the table, you're irreplaceable. You're not replaceable. so the compliance based on this went from somewhere about in the 30s, low 30% compliance to, I think it was close to 70 to 80% compliance. For us, we're looking at the logistics of how do you provide the whole service at site, right? And so now they come in and they walk off. They're done with us. When we're finished working together, that lady either everything's great, come back, we'll see you next year, or you need a diagnostic, we'll be here next week to do that part, you need a biopsy, we're going to figure out how to do that in the field.

So we're going to close the loop in the field. that's Revenue doesn't stall because your team stopped trying. It stalls because of friction. I sit down with other commercial leaders who find that friction and fix it. I'm Terry Coutsolioutsos. Let's get into it. Hey guys, this is Terry Coutsolioutsos. You are on with the Zero Friction Podcast. I have a great guest today and it's not very often that we actually get to have a clinician and a physician in the studio, but we do today with David Bodne.

David is the Chief Medical Officer of Clarity Imaging Partners. They're sort of an advisory group that is helping imaging centers sort of shift the way they do business, especially in the women's health arena. So David, you've been in the business for over 30 years. We're gonna talk a lot about healthcare today and where it's come from tomorrow, but give us a little background on yourself as a radiologist for more than three decades and tell us about why you were focused deeply on the women's health imaging and then what you and Clarity are doing in the market today.

So, okay, let's see, we can start with, I started way back in the day. I think I still have a little bit of a blue ink from zero which I think is finally washing off. That was the start of doing women's imaging, breast imaging, which then went into film screen, then went into digital. So it continued to evolve and every generation replaced the preceding generation until we got to tomosynthesis. Tomosynthesis, a little bit of a different piece, but it's a threshold. I think that tomosynthesis, when we look back in a few years, we'll realize that is a threshold to, like with everything in imaging, to CT.

And CT is really where I've got a lot of interest. Currently, I remember doing thing, I mean, ultrasound is always a critical part of breast imaging and MRI. I remember hearing the first lectures back in the early 90s when I was in Texas and Houston training, but it took a long time to actually have MR come into its stride because we had to figure out how to read the things and we needed, and we realized that it's, it's not necessarily about the MR per se. MR is a great modality, it's a great physics, but it's the contrast.

2:58 It's the physiology of giving the contrast that really is the key thing. I think we're starting to realize that, you know, with non-contrast, we're looking at anatomic change morphology. When we give contrast and how we're bringing something else into the mix and that is physiology, vascular flow, the flow patterns, cancers have a different flow pattern. So we're looking at that. And then we've evolved, like I said, to CT. And I heard about CT back in early 2000s. A friend of mine said, Dave, you got to look at this stuff.

This is great. I'm like, fantastic. But like all busy radiologists, and it's rare to find one that's not, that's not retired. It's like, that's fantastic. I'm too busy to think about this. And kind of you look at it, and people like it, and people that see it are realizing what it is. But you're busy. I mean, when you're sitting there, and you get there seven morning, and you're, you know, you're finally burned out at seven o 'clock, and I have to leave, the thought of adding something new is just it's not there.

Right? That's not that there's It's not interest. just, you're, you're, falling. Your plate is full. And so what happened for me was what got me interested in women's imaging. was it's kind of a strange thing. And part of it's my nature. I, I'd like to solve problems as one of the things I love. So I don't tell me what I'm doing. Right. Let me know what I'm doing wrong. I need to know what I'm doing wrong so I can maybe fix. my, Right. Let's assess what can I do better?

And so it really kind of flipped the switch for me for breast imaging was getting sued for a missed cancer. And so then it's like, okay, why did I miss that cancer? Why did I miss it going back? This is before you actually talked about this, but it was a subtle finding in a dense area of the breast, this dense breast tissue, which is what we talk about now, which I'm absolutely fantastically amazed and happy that we're finally talking about these things, starting to make it make sense.

Why do we miss that? You know, we're looking at a two-dimensional structure of a three-dimensional object, the breast, right? And so, you know, talk about, you know, with compression, I think the compression we do is, which is not the, it's the least favorite part of the exam, but it's important when you're imaging a breast upright because you got to hold it in place. if If you don't hold it in place with compression, It just plops down and you're not really getting an image. So you got to hold it in place. Does it change the density?

Plus Plus minus, and this makes it worse. I always do the analogy with compression. If you compress a block of cream cheese, you don't make it lighter. It's just cream cheese. If you take something that might be like cream cheese and fat or maybe a good piece of steak, one of the way you, whether it's like, or whatever the, you know, the fattier piece of meat, you know, you get a little bit of fat in there and you can compress it out, then you change it.

5:30 But, you know, that's a whole different discussion, which we're talking about things that make sense. But for me, the evolution was problem, solve the problem, then the interest. And then it's like, okay, I actually found that I enjoy this because because there's a lot that goes into women's imaging. There's the radiology component of it, but then there's also the patient interactions. It's face-fronting imaging. You don't really see that except for this and interventional radiology where you're actually doing things. But it's just, it's fascinating because it's focused on, you know, at the end of the day, I was taught, I had a professor that taught me about breast imaging.

He said, you know, you can sit there, you can give the 90 different things you think it is, But women are hearing, like the adults in a Peanuts cartoon or the Peanuts comic, and that is, is it cancer, is it not cancer? Do you care if it's this, no, is it cancer, is it not cancer? If it's cancer, what do I do? You know, hopefully we find it early so you can treat it earlier. There's all these things. And S4 mammography has really done a fantastic job because what it's done is it's allowed us to find cancers before they become something that's detected clinically. and that's when you can treat it, you have more effective treatment.

There are certain types, we talk about lobular cancers, which actually looks like normal breast tissue until it doesn't, which is why it's so hard to find it. But for me, again, I got into this because, you know whereas normal people that don't have a brain like this will say, oh, I got soot, I don't wanna do this again. For me, it's like, why did I get soot? How can I fix this? And I like this, and I really enjoy it. And I And I think I do a good job, I haven't heard otherwise, But, you know, I mean, let's see what they say about me in 30 years.

There's a lot of energy around screening. Screening. Tell us a little bit about, like, where it was, where it is, and where it's going, and how it's getting better. So what I think where it was, was, you know, they did all the trials, they showed, okay, they're finding disease earlier, allowing others that take care, actually provide the care. And one of the things is I'm a little bit of a semantic purist. You know, we talk about mammography saves lives.

Indirectly, it does. But to say something saves lives means you're done. Once you do that thing, the life is saved. You move on. We're detecting disease earlier to allow the breast surgeons, the oncologist, the radiation oncologist, you know, to actually save the life. So what we do when we do it well, when we do it right, leads to that, leads to a life being saved. and so then when you start to realize okay in order to use fear effectively which I don't I like transparency instead I'm going to tell you look I mean here's what's going on but if you use that you have to be 100% right So how do we improve detection?

8:23 That's going to be the key thing with what I did. And so, we went from zero which I only had the experience of touching one. I never actually read those. The film screen, which is great, but again, it's a lot of overlapping tissue. You bring them back, you got to do some spinal compressions, other things to try to answer the question. Ultrasound helps because it's a different physics and they are very complimentary. One will not replace the other. There's no way that one will replace the other.

You need both in order to have a truly effective women's center. So, So again, sorry to the people that are marketing one over the other. You don't have radiation. You're not gonna find 25, 40% of cancers. That percent is calcifications. You need both. You need both. So, So how do we see these things? So now the question is dense tissue overlapping tissue. So the next phase, the next step, and Mara will talk about in a second, but the next step was okay, just like with anything else, abdominal engine.

We went from plain films, IVPs, to look at titty stones, to tomosynthesis, which is basically, again, it's that's the marketing thing, but it's not three-dimensional. It's slabs of two-dimensional tissue that are spaced. Can you have a cancer between them and miss it? You can, probably not common, but you can, but you're getting as close as you can so that you're basically now able to look at planes. So that removes some of the overlapping tissue and the people that introduced that did a fantastic job, is they introduced a threshold to finally answer a question.

How do we get away, how do we resolve the issue of overlapping tissue? The problem is, it's a blurry image, and tomosynthesis has its own concerns, its own issues, localization is an issue, things of that nature. It's a great task, but but it has not replaced MAMA for a reason. It can't, because if you took it away, the only thing you'd have to find calcifications would be the synthetic image, which is essentially a reproduced or reconstructed mammogram, which is very good for calcifications. And then we brought in CT, and CT was basically created, I think it was developed in Rochester by who's the current, the head of the company, and what it is it's cone beam, which is the same technology that you see in dentists office, so the radiation is low, It's comparable to a MAMMO, assuming that it's a one-shot done per breast, so you get four views, right?

Four views and you're done. Radiation is actually probably less with a mammogram. You add TOMO, it's getting a little bit closer. You add REPEATS, it's getting closer. And you ask technologists, as a field of view that you see with a CT, when they're done routinely well, is you see the axilla level one armpit axilla. You see the ribs, so you get far enough back. you see the inframammary fold, because you're laying supine, so the breast is hanging. And so that field of view, one and done, you rarely get that with a mammogram.

11:20 So the concern about radiation is off the table, because they're very common, okay? They're still very low. I mean, when you're talking about concerns with radiation, you're talking about like, you know, numbers of a hundred, I think, millisieverts, milligrams, whatever, But basically these are under 10. These are not your imaging, medical imaging, that are really, you should be concerned about radiation dose. I have not seen, in my 30-some odd years, I may have seen four sarcomas. I think breast cancers are more hormonal, genetic, other factors.

I don't think that it's radiation concern. Otherwise, we probably wouldn't have as many bikinis out at the beach because there's more radiation on the UV. But regardless, So, so CT is now bringing in true three-dimensional imaging because you're spinning the x-ray tube around the breast. So now you're getting a true three-dimensional image. So now you can get thinner sections where you can actually see calcifications, but that's not the way to see them best. And so what CT took was actually, when I first started doing this, what I realized was first, how do you read these things?

It's always my question with MR, how do you start reading them? And how can you read it so it makes sense? And so then it gets back to this. What a CT is, is an interaction of an X-ray source and breast tissue. That's a mammogram. By definition, that's a mammogram. called a mammogram. You read it like a mammogram. So what are you looking for? The same things you're looking for on a mammogram, calcification, masses, architectural distortion, lymph nodes, and the axilla. So it's the same thing, skin thickening, all this stuff you can see on a CT.

So now the question is would the original studies for the FDA were done in a small town in Georgian Tifton, great town, love the people there. And what they found was they done. Okay. And so the compliance based on this went from somewhere about in the 30s, low 30% compliance to, I think it was close to 70 to 80% compliance. And I'll tell you, women I talk to all the time, one of the things, no matter what the study is, I always ask, how was, what'd you think?

Then invariably almost 100% will never go back to get a mammogram. And now we've got the data submitted to the FDA and they're just doing their process, and all the data shows at worst equivalence to mammogram, okay? And so now that you've got that, I think the only thing that's a little bit better with CT is our BI-RADS 3, the category where we say we think it's benign to come back in six months. That actually was a little bit, slightly lower, I don't know if it's statistically significantly lower, but it was a little bit lower than a mammogram, okay? And so now what we're seeing is, can we get back to the original idea, the goal, the purpose of mammography? And that is, find it early so it can be treated early, okay?

14:12 And now you've also got to kind of undo some of the entropy that's occurred as we've developed a lot of these different things. MRI MRI, we'll bring that into the equation. I love MRI. I think MRI was fantastic. It is very sensitive, it was our most sensitive test, Which which is also its downside. because Because MRI will, especially in the right context, we read these a little bit different. When I was told when I started reading MRI, it was, you can read these things, it's not how you read them, it's which things can you safely ignore. Because if you work everything, every finding up, everybody's getting worked up. They're very sensitive.

And so then it's context, okay? And so there are ways to read MRI, and it's a great test. The problem is that MRI, when I have found my experience, and others might tell you different, but my experience has been probably the most effective use. High-risk screening is good. The problem with that is a lot of the costs are borne by the patient, right? And I'm not gonna get into that, it's got as politics, as insurance. They do their thing, that's not my area, that's not my scene.

They have reasons for it and I'm not faulting them because we have it for rigs, right? So there's not, nothing is good, bad, whatever. But the cost for a lot of those are born by the patients. You have a 30 year old who's got a high risk and she shows up and insurance doesn't cover it and it's $4,000 and they say, peace out, see ya. And so that basically ends MRI. CT, I'm telling you that the cost right now we're looking at, it's under a thousand, I don't know.

I mean, different centers, it's regional, but it's far less than an MRI, I will tell you that. It's less than an MRI. So can we introduce screening for high risk? We're looking at. This is one of the things that's sort of, again, it's a root cause analysis, is can we get back to treating, you know, find early treated early. And so now my thing that I'm looking into is can we go from screening, or the first time we image the patient, to if they happen to have cancer, their first treatment in a month?

Is that feasible? Because I'll tell you right now, the thing is that I've had conversations with a lot of people in India where they say we get one chance at them. We get one chance. The screening programs are not as well developed. It's a different thing. So really at the end of the day is how can you positively affect a change in all of them? Regardless of where you are, and it's got to be cost effective, but it's got to have effective outcomes, good outcomes. So can I go from that first screening to the first treatment?

16:43 That's the thing we're looking at. I don't know. I mean, it's, it, but nobody's asking, nobody's asking that, right? Make it make sense. Because women want that. Women are, women, at the end of the day, we've done a great job steering women into realizing the seriousness of the disease. Sure. I But, mean. you know, how do we get there? How do we now do the job that we, want to do, right? That's what we want to do is get you to that point that if you, if, if God forbids you have cancer, How can we get you treated in a stage one, maybe a stage two, all the rest of the stuff? You know, the problem is like we're seeing in younger patients, unfortunately, we are seeing more breast cancers and sometimes they present as metastatic disease.

I don't know, you know, do we start screening younger? I don't know. I don't know what the answer is going to be for that. When you think about where the market is today, with the cost of imaging, if you don't have insurance, it's not easy. Even when you have insurance, by the way, that's the broken part about our system today, is it used to be if you had insurance, your premium felt like it was this big and your deductible was this big. and now Now people have insurance that's basically catastrophically protecting them in case something, you know, big and bad happens to the malice guy.

And And, and so even when you go to an imaging center, I mean, you might be dropping $1,200 because you haven't met your deductible yet. this is actually something that I have thought about for most of my career. Why is it that we can't? Why do we have a chronically underserved population? What's going on? What's And I think some of it, I've kind of come to the thought process of maybe way off there, maybe way off base, maybe completely wrong. And I'm willing to accept that.

But it's like, usually I just get the blank stare when I suggest. sense is how we're incentivized. Okay, and it goes back to med school. The most satisfying thing I think I did during training was provide care at a free clinic, because if you mean test, you are actually doing something for somebody that can't afford to get it, and you're doing it because you want to do it, and that was either the best position, I was a med student, right? you say, Dave, you're a radiologist.

We want you to read 300 300 mammograms a month for underserved populations for nothing. You're going to do that and you're going to provide that service. And everybody has a license, either in the state, nation, whatever, and you're going to provide that service. And so now you're going to take hopefully a lot of the people out of the ER situation and not out of the situation where they can't afford it, but they still receive the care. They're means tested, so they're not gonna abuse it, hopefully.

19:34 I mean, again, maybe I'm riding a unicorn chasing after the particle, but that's what it is. But now you incentivize so that physicians, well, I believe for the most part, want to do things like that. They want to provide care. The physicians that are able to provide that, I've found, are the ones that are least likely to experience burnout. So maybe there's something there, right? So maybe you say, we're gonna do that, and instead of throwing money at it, they will give you a tax or whatever. I don't know.

I don't know how that works. That's- There's some sort of value exchange somewhere along the lines, right? Right. And so I'm giving you something like that. You're removing that financial burden on the system while still providing the care to the underserved. and And the people now that are covered, maybe you say, okay, look, we don't have to cover that. So now the insurance companies could maybe lower the premiums. Maybe. the Lower cost of care. I don't know. Like I said, it's just, it's a thought. It's a weird thought. It's a, you know, Dave Bodne thought, but it's a thought I've had for a while. So who knows?

It's, there's some crazy rules I have. I've been sure, like I said, the insurance company is the end of the day. That's our customers. They're the ones paying the bills, but there are things. So I'll give you a case in point. I mean, so for the listening audiences, like this happens routinely in breast imaging and I've never understood this. So BI-RADS 3 means I think it's benign come back. Sometimes we follow them routinely for a two year period of time at six month intervals. So now you've got six month intervals of ultrasound every six months.

So that's when somebody comes back as a positive exam or inconclusive? So, well, there's a finding, but I think it's benign. I think it's 2% or less likely that it's going to be benign. We're not supposed to use that often, but there are times that you do it. And until such time, and there's a new device out that I'm hoping might answer this and make it so that it's a one and done. But right now, the standard is six-month intervals for two years. Okay. So in that two-year period of time, if they're of age and they get a screening exam, it has to be coded as a diagnostic, whether you're anything on the mammogram or not because the thought is it's in that time frame and I've scratched my head and I'm trying to understand it I know there's got to be a reason given at some point in history but it's almost like this I get to the point where I'll tell ladies okay

November 1st is your last two year and you're due for your screening mammogram the day before that coming the day after and it can be a screening coming the day before it's got to be a diagnostic and there's nothing on that mammogram then that should be a diagnostic other than that's just the rules of the road.

Just Just where it falls on your calendar, right? Yep. We see it. let's talk about another really interesting topic, especially in healthcare and especially in radiology. I think the topic of AI is a huge topic in the radiology community and it can go in many different directions in terms of how imaging can be read and how AI could probably, a, it might create some efficiencies in the radiology world where it might not be able have created as much in a cardiology specialty or something along those lines.

22:33 So talk to me about your thoughts about AI in general and health care, and then more specifically where you feel like it can really add some value in the radiology space. So one of the things for radiology and actually there's a project I was working on with a buddy about AI, because he'd always hear about AI is more placed radiology. I don't think it's more placed. I think it's more plugged to radiologists that are setting themselves up to be replaced if you're a button person, you know, there are some that just you get to that point, whether it be burnout, whatever that are, that could be replaced.

But one of the key things that I said is, let's start with this as AI is not AW. And what I mean by that is intelligence is not wisdom. If you still bring wisdom to the table, you're irreplaceable. You're not replaceable. And so then the question is, I've spoken to some, AI guys to developers and whatnot. I said, here's a problem with AI. Your marketing is terrible. Nobody knows what you are. You know, it's like you say, I need to be afraid of you. So I say, I need to be afraid of green.

Like, green what? What do you do? What does AI do? And if you ask anybody, they'll tell you what it does, which is different. It's like the blind man and the elephant, right? So what is AI? AI helps me read studies. I mean, there's a way to do that. AI AI helps me schedule patients. AI answers the phone. AI helps me play these games. But I mean, AI has so many things to really, what is AI? What are you talking about? So I need to know what you're talking about before I know whether I need to be afraid of it or something I can work with.

And there's actually a product is that there's a software that a friend of mine is developing to help localize findings on DVT Autonomous Senses because that's hard. You're not 100% and there are ways that you can miss. And so that's kind of an AI. Is that gonna replace me? No. And the other reason I think AI, if you ask, this isn't for radiologists, sort of a take home message for radiologists, don't be afraid. Come into the profession of medical students It's great because here's why it won't be replaced anytime soon, and it's a question I've asked everybody that does AI, that develops, are you willing, AI, I don't need you to help me find things.

I mean, yeah, that's cat. That's not AI. That's cat. So that's a process. That's a program that helps me find things. I got to figure out what it is. Okay. This is where you get sued. You get sued for that a lot, but you get sued for missing things, the false negatives. So my question, if you want to replace me, are you going to go to court? who's going to court when your AI product misses something, a cancer, a fracture, whatever. I mean, I read a CT of the head today, no blood.

Yeah, that's great, except you missed that big, you know, that mass in there. You didn't comment on that because you're basically focused on such and such. So it's like, okay, who trains AI? Well, I mean, if you're telling me that me and my colleagues are going to train AI, and I'm afraid that you're going to replace me, how good a job do you really think I'm going to do training AI? Right. So I mean, it's just there's so much involved.

25:22 It's But the bottom line is I don't think it's going to replace us. I think that the people that are paying attention is going to make you tremendously better, more efficient, able to see more patients in an effective way, get good outcomes. But ultimately, the person that's responsible is the one that's irreplaceable, Right? Right. And so that's really the thing with AI. I'm looking forward to seeing where it goes because I'm fascinated by it. I don't really understand it, but it's like, okay, I just need to know what you're talking about. When you say AI, what are you talking about?

Tell me what you're talking about and market that. I don't think it's Terminator. I don't think it's going to create. I mean, can it do that? Probably so, but I think there's so much oversight. I mean, I was listening to Elon Musk talk about AI. They want to slow it down. I'm like, that's awesome. That's fabulous. That's amazing. People that are developing this are seeing this could be horrible. Let's not make it horrible, let's make it great. And I think it can be great. I really do.

I think it could be great. Well, it's not even could be, I have an AI business and it's, you know, I frame all the consulting and the advising work I do with, and I power up all the workflows and the processes that we build with AI typically. And what I will say, what AI does and what it does not do, at least in my world is that I always try to focus on two categories, it's like a four box thing for me. So I look at highly repetitive activities and unique activities, like high and low, right? And then I look at high impact and low impact activities or high value and low value and impact activities.

And in And in my left-hand corner of my box is highly repetitive and low value. And so those are things, they're easy things for AI to come in and consume immediately because they're, first of all, they're low value, typically not a human connection anyhow, and there are things that are repetitive over time that you can teach either a robot or an AI agent to do those things over and over again very efficiently, which then which then when you take that type of activity away from the humans that are stuck doing it today, then you have a box of hours and capacity for them to do more of the high value stuff.

Because because most most people go to work every day with 15 hours worth of work to do and eight or 10 hours to do it. So every, you know, we're all running over our capacities regardless, right? So Right now, it's hard to find radiologists. Right. there's a There's a massive need. So how about an AI company says, we're gonna partner up with a medical school. We're gonna get you early to show you what AI can do. And we're going to basically train you the right way to use AI.

28:10 To Right. make you truly love what you do, to avoid burnout, to prolong your ability to do what you want to do, to provide your calling, It's the laying on of the hands. There was a teacher I had back in high school that said robots can do a lot of things, computers can do a lot of things, but there's one thing that you will never ever replace, and that's the feel of human skin on human skin. You'll never replace it. And that's what medicine should be.

Medicine is still hands-on. It's like you said, it is hands-on. I've got one more great topic for us today, and you and I in our warm up conversation a couple weeks ago, we were talking about how health care is becoming a consumer product these days. and I think we talked a little bit about it before in terms of insurance premiums and deductibles and that kind of thing, but talk to me about what you see, especially in the world that you're with women, when they pay out of pocket, they willing to pay out of pocket for something that's a little better, a little more efficient, a little more effective, a little easier access to get to, less painful. Tell me about your experience with that consumer health part of the world.

I think that if it's done the correct way, what we're seeing, I've said, the case in point, breast CT, right? Breast CT right now, there's not a code that reimburses. So most of it's out of pocket. So then the question is, how do you set the out-of -pocket cost as a regional? Right. Okay. Some people, you know, they get... with their CT and they go out and they buy their weekly Rolex It's like okay, you know they're probably going to be able to pay a little bit more that's just that reason but on average when i've spoken with a provider at our site down in Tifton and what she said was look if this is effectively going to be a screening test it needs to bill out about what you're going to pay for a screening test and so their rates are reasonable and i think they even let them pay it off over the course of a year so it's under five hundred dollars right And so now I tell

You, let's say we'll make a number. Let's say it's $240. And the society is willing to say, we're gonna let you pay it off over 12 months. Can you afford $20 a month? Will you travel down to get this if we know everything else being what it is? And I'm telling you, women are doing women it, are traveling. They would travel from Canada to Tifton, Georgia to get this done because women know about it. And so the key is, price it right so that you get the extra 40 to 50% of women that are not getting any kind of screening to get back into screening. Because if we can find, get this much 40 million women back into screening, it's a no-brainer.

30:57 And I mean, you know, like I said, I'm talking about global, I don't want to be globally, but there's so many things about breast CT that are, you know, like for instance, you're not being, no touch, no compression. You basically lay down, you can be in the room by yourself. You follow instructions, I think the price will be right. I think the key is going to be just to figure out the pricing. Right now, women are so, everybody, not just women, but everybody's so used to, you know, does insurance pay?

No, it doesn't pay. it. Some it does, but pretty much what it doesn't pay it. What does it cost? So let's say now let's go back to the high risk fleet. You're 35 year old with a 35% risk assessor. They're high risk. And you have two options because we can also give you context. So now you're evaluating vascular flow on CT. It's the same phenomenon as an MRI. Right. And so if I'm going to just, it's a random number. So the insurance comes to the list and this is a random, select a number.

Throw it out there. It's $4,000 for the MRI, but $800 for the CT. Right. And you tell the lady, you got it, both of those will be out of pocket. Which one do you think they're going to do it? Oh, of course. Once a year, that's a baseball game for a family of six. Right.

And this one, you're going to hit a better home run, hopefully. Well, and is the accuracy and the sensitivity and the specificity on the CT higher than the other modalities, or is it equivalent or what's the deal there? So CT without contrast is comparable to a mammogram. Okay. With regards to an tomogram, tomosynthesis, they're also their equivalent. It's more specific than MRI because you're also seeing calcifications. What I'm finding when we give contrast, one of the issues with MRI is when you give contrast, if there's so much enhanced, I mean, it's basically extensive background and prank well-enhanced, we'll call it, that it can basically drown things out. It's too much noise, essentially, right?

And And so I'll give you a case that we This was, had. I mean, so as a lady that had lymph nodes, they did a biopsy, turned out breast cancer in the lymph nodes in the armpit nexal. So axillary node positive, mammogram, dense tissues, silicone implants, can't concede anything there. MRI, there was so much enhancement you couldn't tell. Like you couldn't tell. So So she had the advantage of having a relative that could get the CT. So we did the CT with contrast. Significantly less background enhancement except for two areas, did the ultrasound target those areas and both of those were her cancers.

33:31 So you're taking away the background noise. So what I'm finding needs to be substantiated in literature, obviously, that things that enhance the CT are more significant, because you do have less background. I mean, hopefully somebody will run with that has the ability to do research to prove that point, because right now it's just anecdotal, but that's what I'm finding in the cases I'm reading. So the answer is, it's as sensitive as mammogram. With contrast, it's as sensitive, maybe actually a little bit less sensitive than MR, but just like with contrast mammogram, it makes more sense because what you're seeing is more specific.

So your specificity is not significantly lower to the point that it makes a difference. We're finding the cancers at least the same, if not earlier on some, especially with calcifications. We're able to see things on CT that it's places where we don't even know. Like I asked the question, you've got a lady who's had a mastectomy for cancer and gets a silicone implant. How do you evaluate the space between the implant and the ribs? Let's say it only shows up as calcification. You don't see it on anything else. You've never seen that before.

You can't see it on MR because it doesn't show calcium. You can't see it on ultrasound because you don't see calcium. You can't show it on a mammogram because you can't see back there especially with an implant. It's silicone. Where else are you going to see that? Right. So the answer is we're just fresh and surface what we can do with brushing. where do you see yourself and Clarity in this age of AI?

Is the company itself moving in an AI direction itself? How does it operate? Is it using AI? Is it from an operations perspective? So we're looking at AI for a little bit of different reasons. A friend who's got a company that talked about developing the project, the software to help localize things on tomosynthesis. Right. And you know right now I think I mean tomosynthesis is part of the standard of how we practice. And so really ultimately I want to help people provide a better service with that so you don't satisfaction get or search and mislocalizations and things that lead bad outcomes. So hopefully we'll help with that.

But the funding for that is actually going to help our, kind of what's become the reason for our existence. And that has been a mobile unit, and a mobile that makes unit you try to find cancers early. So we're right now looking at CTS CTs will be on there. Yes, we're going to have a mammogram on there because that's part of it. We're looking at Ultrasample, we're looking at two devices. Why are they chronically underserved women? Because you send out these units, and you're just providing screening.

36:13 Okay, so why are they not? Why are they not able to get in, get a screening? They don't have health, they don't have childcare, they don't have mobile transportation, they just can't afford it. So you bring the screening out there. That's right. That's right. What do you do about the findings? Right. IFCs out there, do you do diagnostics out there? For us, we're looking at the logistics of how do you provide the whole service at site, right? And so now they come in and they walk off.

They're done with us. When we're finished working together, that lady either everything's great, come back, we'll see you next year, or you need a diagnostic, we'll be here next week to do that part, you need a biopsy, we're going to figure out how to do that in the field. So we're going to close the loop in the field. that's a way that's that's really ultimately the the sort of become the reason for existence for Clarity we do get but something yeah but that's a key part of what we're trying to accomplish.

If current day David Bodne could go back to a very pivotal stage in younger David Bodne's life, whether he was 18, whether he was 22, or whether he was leaving medical school, what would one piece of advice current day David would go back and give younger David based upon what you've learned?

That's actually easier than it sounds, but for a peculiar reasons. And that is be humble. So maintain curiosity, but be humble because you're going to get to a point if you do well, you're the greatest. You're the best. You're on a pedestal. Don't climb on that pedestal. Do your job. You're gonna feel better about yourself by doing it for the right reasons. Don't do it for recognition. Don't do it for money. All this stuff is gonna happen. It's gonna come you, but that's not what this is about, young David.

Stay humble, stay curious, Define what it is that allows you to love your patients and to love back, but stay humble. Stay humble. I mean, I think that's the only advice I would give myself. That's great advice. just for a little sort of ending levity is I'm of this age, probably the same age, where to me, you know, somebody says you're an expert. I don't like expert because I'm of an age where the interchangeable terms are expert and savant. And I don't know, sometimes I might fall into the latter rather than the former. So I'd rather be experienced and seasoned than grandpa because we just had our grandson end of March.

38:48 I enjoy grandfather more than, you know, expert or whatever you want to call me. So I'll take that. take that job because when my grandson smiles at me, it doesn't matter what do, I I can be, that's what makes life worthwhile. It does. It does. It does. You know, having that kind of joy in your life, you know, makes everything very simple, doesn't it? Amen. All right. David Bodne, thank you so much for being here. Thank you for sharing. Look forward to our version two down the road and we'll go from there.