← Skin Anarchy
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- [00:00]
A
Hey, guys, real quick, have you checked out Droplet? It is by far the most revolutionary skincare device on the market. Basically, it takes those harder to penetrate ingredients and pushes them deeper into the skin layer so they're actually getting to the cells that can utilize those ingredients. Recently, they just launched their Exome Serum mist, which is a phenomenal product because it's using real exosomes that are shipped to you on ice, so you don't have to worry about them being degraded by the time you use them. And so when you put the capsule of exosomes into your droplet device, it creates a fine mist. That mist is allowing those exomes to be pushed into the layers where they're going to actually be able to interact with the cells that can use them. For sign. If you want to check out the device, go to Droplet IO use our code Anarchy A N A R C H Y to get a very special bundle deal on this Exosome and Droplet device duo. Hi, guys. Welcome back to Skin Anarchy. This is a very, very special episode. We're going to be diving into the safety side of aesthetic medicine and trying to understand, like, all of the things that happen behind the scenes that we don't really think about as patients when we're going into a med spa or a doctor's office or a surgeon's office. And a lot of it has to do with, like, the safety that you experience during a procedure and, like, where you're getting that procedure done. So without me ranting too much, I would love to introduce our guest today, Tom Terranova, who is here as the CEO of Quad A. Welcome, Tom. So excited to host you and learn from you today.
- [01:13]
B
Thank you so much. I'm happy to be here and to be talking to your audience.
- [01:17]
A
Yeah, I'm really excited to dive in because what you guys are doing with Caud A is so, so important. And I think that especially, like, patients, we don't get to hear about it. You know, I think a lot of times doctors know about these things behind the scenes. You know, even med spa owners out there, Anyone listening, you guys might know about this. But it's very important to educate. So I'd love for you kind of take us down, like, the whole route and tell us about Quad A and tell us about the whole initiative so that we understand, like, why this is important.
- [01:43]
B
Yeah, sure. I'll do my best to keep it brief so it's digestible for people, but it's. It's. Obviously, I'm very passionate about our mission. It's why I left practicing law to come back to quad A, because it was very fulfilling. And so it's something I get a little bit wrapped up in and I tend to go on and on, but I'll try to keep it succinct. But, but briefly, just. Just kind of to what you said, I couldn't agree more. I think healthcare does a really good job of being conscientious internally, speaking to peers, speaking to colleagues, and speaking within the industry to kind of talk about quality, safety. All these various initiatives that really, I think are behind a veil for the average patient. I think there's a lot of implicit trust in healthcare and that's good, that's a good thing to some extent. But also as patients try to take on more advocacy roles for themselves and as patients try to enact their voice a little bit more, especially in areas like aesthetics, where it is patient driven. And a lot of people will say consumer driven, but I hate classifying patients as consumers because that just strips away the medicine even more. But as it becomes more patient driven, I want this service, I want this product. I don't like this about myself. And I want to improve shifts the control away from the physician and into the patient. And if you don't know about safety initiatives, you're really operating from a deficit and you're really kind of putting yourself in harm's way, I think. So that's why I'm passionate about it. And I'll give you the kind of background of the initiative and who we are for those who don't know. So for patients who may not know and for non surgeons who may not know. Quadi is a 46 year old nonprofit founded in 1980 as a safety initiative, primarily in plastic surgery. Back then, briefly speaking, in the 1970s, 1980s, really hard to get on hospital operating room rotation and physicians started to work out of the office initially plastic surgeons. But over the last several decades, many more services have gone outpatient as technology and anesthetic and monitoring and all of these things have advanced. It's made it so that we can move certain types of procedures out of the hospital into the outpatient environment, treat patients safely, recover them safely, recover them quicker, keep them out of environments that are higher cost and with more sick patients and frankly that have a lot more going on. Right. An acute care hospital has a lot of different things going on that can complicate a surgery. So in 1980 when that happened, it was really controversial. And so essentially a group of plastic surgeons very early on wanted to establish a Third party that just does impartial evaluations, comes on site, evaluates the safety of a facility and issues a certification, a seal, whatever you want to call it, as a demonstration that that facility is doing things the right way and that the patients aren't sort of negotiating and compromising on their health and safety by moving out of the hospital into the office. That was in 1980. So, you know, it's a whole different world. So that's how we were founded as a nonprofit organization. So in our mission, we're not, you know, really trying to, to go overboard with finances or to, to really harm the industry in any way. We're trying to make sure that we're balancing what's protecting patients with what's allowing physicians to move from the hospital operating room into the outpatient setting. And so over a good 40 years, that's evolved to include every specialty dentistry, and you know, various levels of sedation, anesthesia, various depths, and to really speak to patients that are undergoing care of every kind in every state and over the course of our history in 23 different countries and to speak to that just a little bit, Quant A also goes through very rigorous processes of its own, evaluation by third parties that evaluate us to make sure that we're approved. So Quad A is approved by just about every state that has something on the books that requires passage for us in order to do this work. In states that don't have something on the books, we just do it voluntarily. People kind of go above and beyond to differentiate themselves. We are approved by the U.S. centers for Medicare and Medicaid Services as what's called a deeming authority, which means with ambulatory surgery centers, we can go in there instead of the state to conduct the inspection that prepares them and opens the doorway for federal reimbursement for services. And we actually go through an international process as well to validate our program on a global basis so that people know that when we come in, we're coming in on a scientific third party basis that's not rooted in one philosophy or another, but that's a real global standard for care. So that patients being treated in Paris, Rome, Chicago, New York or Delhi are being, if they're under this accreditation regime, are treating you, are being treated with the same level of safety and care. So that's who we are. In a nutshell, this specific initiative is a med spa initiative that began two years ago to bring that safety out of the operating room and into the non surgical aesthetics at bar.
- [06:38]
A
That's amazing. First of all, let Me just say that. And for anyone listening, if any of you have gotten any kind of procedure done at a med spa dermatologist office, I mean, this is like, I think we speak so much about this on the podcast, you know, indirectly. Honestly, Tom, I can't tell you how many times I've had these conversations with derms, you know, and talking about trying to get from them, like, you know, like, what should patients look for when you're evaluating the safety of any kind of clinic that you're going to anywhere, right? Whether it's a plastic surgeon or not, or, you know, and. And this conversation never gets highlighted, and I think that's very important. Spotlight what you just said, which is that this is an international standard that's being set here, which is incredibly important, because when I look at the space that consumers. I mean, I'm going to say consumers right now because skincare and beauty products and a lot of these things fall in the consumer space when consumers interact with that in the United States, it's a whole different world. There is no regulation. There is nothing going on. So then when, you know, you merge aesthetics into that experience for them, I feel like sometimes that experience and the expectations get merged as well, whereas they should not. There should be a line of distinction where it's like, no, you're getting a procedure done, there needs to be certain safety standards in place, period, you know, So I think this is incredibly, incredibly fascinating that, you know, this is taking place and it's happening. So I want you to talk about the med spa component a little bit more because I know med spots are kind of going through it right now, and there's a lot of changes happening on that front. So tell us more about that.
- [08:07]
B
Yeah, so this initiative, I guess I should start with. Start with the big news and that is that med spa, or what we're calling non surgical aesthetics and wellness, because, you know, med spa is a bit of a regional ism, some med spot kind of in quotes for the US and other markets that know it that way. This non surgical aesthetics and wellness program launched on March 12, which, you know, at the time of recording is yesterday, I can tell you that we got an application within an hour of the program launching and already have facilities lining up to do this. Why is that important? It's just what you just were asking about med spa services and med spas that may be up the street from you if you're a patient or your own med spa, if you're an operator out there listening, probably great. Could be great. The big Question is, we don't know. And as a patient, as a consumer, you don't know. And as even a provider, you know, every provider I know that I've spoken to can name a couple dozen great spas that they would trust with their loved ones and a couple dozen that they would steer clear of very, very, very quickly that they probably wouldn't send their pets to. And that's really the fundamental problem here, is that there is this expectation among the patient base that there is some standardization in health care, because that's sort of what we expect. It's the paradigm of the hospital. This is a licensed hospital. It's inspected, somebody's regulating, somebody's watching. And the reality is, even when you move out of the hospital into the asc, into the office surgery practice, and especially into the med spa, fewer and fewer people are watching. In fact, in the US fewer than half the states have a really strong mandate for inspection of offices that are private practices that are actually doing surgery. No one has a full and comprehensive program as of yet for med spas. And so you have, in my opinion, this may be not the official opinion of the organization, But Ed, my 15 years of doing this, there's sort of, we're at confluence of the fact that you have patients who expect a certain level of safety anytime. It's healthcare, but you also have a service that is less and less associated with healthcare and more and more associated with beauty and aesthetics. In almost like a cosmetic sense, not the cosmetic surgery sense, but not too much different than going to get my hair done, my nails done, my makeup done, my eyebrows threaded. Right, exactly. We're blurring that line. And, and it's a bed that we've sort of made that the industry sort of is like, oh, it's less invasive, less invasive, less invasive. And we've crossed a line where many patients don't see it as healthcare at all. Yes. And there is some risk there. And so this initiative was a two year process to really sit down with experts in the field. Not me, I'm not clinical at all. My committee is largely made up of nurses, anesthesia providers, and surgeons who work in surgical settings who said we need to really engage the experts. And we engage two completely independent expert bodies of med spa operators, owners, physicians who are medical directors, even kind of people who work in the back office there to set standards, negotiate those standards based on those two independent bodies that might have a little bit of a different perspective and to figure out what the standards would look like so that we then can execute on an inspection process that puts real peers into the facility to judge them against objective standards, to set them, to have a demonstration that the appropriate precautions are being put in place, that they know the requirements, that they can, that they can act in accordance with them, and that they can carry those things out on a sustained basis to make sure patients are as safe as humanly possible.
- [11:57]
A
Yeah, I mean, that's amazing that, you know, you guys have gone to such great lengths and I, and I want to actually dissect this a little bit more with you because I think it's very important to understand like what exactly is, are the parameters that constitute true safety in a setting such as a med spa. So maybe you can walk us through some things that you know that are really big, just big things that you, that you want to make sure med spas are hitting when you're evaluating the safety standard.
- [12:23]
B
Yeah, absolutely. So the first thing, and probably the most, the most apparent and as you said, med spots are kind of going through it right now, but the place that they're going through it mostly from a regulatory standpoint is the credentials, the training, the expertise of the person holding the needle, the person doing the procedure. Okay, that's actually kind of barrier one, but barrier one of many. Right now. There is no uniformity in legislation and rule as to who can provide these services and actually what even services we're talking about. I mean, one of the very first fundamental things that we had to do was stratify the risk of certain types of procedures. In our surgery world, it's kind of easy. We look at anesthetic and we say, okay, you're doing local and topical anesthesia. That's pretty basic. You're doing sedation. Now you need to up your monitoring game. Now you're doing general anesthesia. We have, you know, we know how deep you're putting the patient under it. There's really no similar paradigm in med spa. So the groups of experts essentially had to negotiate what that risk, stratification of different types of procedures were. So that's number one. So essentially this program sets out three, we'll call it four stratas of risk. Green, kind of low risk. And that has some examples of what kind of procedures would be in there. Yellow, a little bit higher risk, we want to see a little bit more precaution taken. Orange, we're getting pretty moderate here. We want to check things out, make sure that you have kind of extra protocols in place. And red, which is really a no fly zone. Red is sort of like if you see a med spa that's doing liposuction, that's not really a med spa. That's a surgery center. And that's a red. And that is basically, don't look at this manual, look at the surgery manual and do things accordingly. So that's like headline number one. Right? Let's stratify the risk. Number two is who's providing the procedures. And there's no uniformity to that. When you're talking about physicians, you're talking about nurses. There's a professional license involved. There might be board certification. There's residency and there's fellowship. There's all kinds of things. There's hospital privileging committees that evaluate their expertise in the med spot setting. Those credentials and requirements, even by law, are all over the board. I've had some states tell me, well, we're really having a hard time getting our hands on this because in our state, I won't name them. But in our state, you can hire somebody under the bridge in the morning, and by noon they can be doing injections. And then in other states, you know, you need a license, you need to be a nurse, you need to be an np. You need to be a pa, you need to be a physician. Yeah, you need to be a dentist in some states. Right, right. So there's variability across the board. So that's number one that I think people should know. Estheticians, they may be great at it, but. But there's a lack of sort of a baseline, right?
- [15:10]
A
Yeah, but being great at it. I mean, I don't want to interrupt you, but being great at it doesn't mean exactly what you like. Being licensed is a whole different world, you know, that's a whole different set of, you know, training you go through, and you have patience and you practice and, you know, that's. Yeah, that's crazy. I didn't know there were some states that don't even have, like, the baseline, you know, licensing in place for this stuff.
- [15:27]
B
Yeah, so. So, you know, the person that I was talking to was from a regulator and sort of, I guess, gallows kind of humor, morbidly was joking and just saying, well, yeah, you know, the bridge, people that are doing injectables. And so, you know, that's not my wording, but. And look, you know, I think there are plenty of people who maybe fall into that category, if you look at it cynically, but they have been trained. Well, the question is, what's the demonstration of that? Right. And so how do we assure or how do we at least give patients Confidence that those people have done that. So in this program, one area is essentially sort of the basics of training and expertise. Right. We're not a scientific body in that way. We don't really get into the practice of the procedures. That's really more for licensing bodies, for board certifying bodies, for hospital privileging when we work at the surgery world. But again, we're in brand new territory here. Nobody has set that across the board. So our group of experts did try to look at this a little bit more heavily because we can't just say, oh, are you, do you have a medical license in the state and do you have your certification? Is your scope of training in dermatology or obstetrics and gynecology? We don't know any of that. So we've sort of put some, some scaffolding in place to say let's, let's make sure you've been proctored a little bit in this procedure. Let's make sure somebody's mentored you and you've seen your training appropriately. And then it goes beyond that.
- [16:54]
A
Right.
- [16:54]
B
So barrier one is learning the actual procedure that you're going to be doing. And if the state has a law or if the state has a requirement, making sure that you meet that requirement. Some do, some don't. Beyond that, it becomes operational in the facility. It's one thing to be a great injector per se, but it's a completely different thing to be able to recognize and respond to an adverse event because they do happen. It's just the nature of health care. So I could be great at injecting and if there's some adverse event, if I don't know how to recognize it, respond to it escalated to my medical director, how are we going to help that patient? You know, it's just, it's a law of massive numbers. When you talk about the number of people getting procedures, you could be the best in the world. Eventually there is a known risk, there's a known adverse event risk with certain things. And we often assume that those procedures in the med spa space are very, very low. And they are low relative to other procedures, but they exist. And there are real, like permanent blindness can happen from some of these things. So it's not like they're just all temporary. So, you know, it's not to scare anyone, but it's to say we want to make sure the person who's doing this is appropriately trained holistically, not just in the procedure, but in recognition, in emergency preparedness. And then from there we go into kind of more operational things, protocols in place, hand hygiene, infection prevention protocols, making sure you have the right equipment and supplies that are not outdated, that they're stored appropriately. Right. That you're not using like, you know, a malfunctioning Dorm fridge from 25 years ago to store, you know, to store medications and products that need to be stored at a certain temperature. Are you able to maintain that temperature or is there something going on? Are you wasting products even though it's wasteful economically? Are you wasting products that go beyond their expiration date or that go beyond their date of valid use because they might be culturing some bacteria? All of those aspects are not on a patient's radar and become really critical as they filter out throughout the operation of the med spa. And that's really sort of the big picture of what we're trying to look at in the accreditation cycle. And I just want to take a moment to say this too. I. I look at accreditation the same way as I look at a driver's test, right? Yeah. Anybody can drive too fast, anybody can speed, Anybody can run a red light. Whether they're good, bad, accredited, not whether they have a license or what we're looking for is, do you know the rules and can you demonstrate compliance with that behavior? No one's going to be able to keep an eye on them every second of every day. But what we're trying to do is set every spa up for sustained success so that they have the tools to look for consistency across their team, look for consistency across time and across patient procedures so that the patients can develop a stronger confidence level in the type of environment that they're walking into, when right now it's a crowded environment that's only competing on price.
- [19:51]
A
I mean, honestly, I can't, you know, just say enough good things for this initiative. I really, I have no words to express how amazing this is. Because, I mean, so many things you brought up, right? Just, just make. It's so much sense. I mean, first of all, the whole adverse events bit, I mean, let's just take a minute to unpack that. I mean, for all of our listeners out there, I know a lot of you, you go in and you might think everything's looking fine. Sometimes adverse events are happening and you don't realize that that is an adverse effect to whatever you just had done, because the person who's doing it doesn't recognize that that is. Even if it's a little bit of swelling. I can't tell you how many times. I mean, you know, for me, I've seen it in hospital settings, like in trauma care. Right. And you think that, okay, this is, you know, you don't even think about it, but it is an adverse event. You have to document it. It needs to be put somewhere in the chart in these situations, what we're talking about with med spas, first of all, if the person who's doing the procedure can't even recognize that, even if it is a little bit more swelling than usual, that still classifies as an adverse event. So if you don't even know how to detect that, that's a huge problem. And then the patient goes home and maybe two days later they have a thing. So it's not fear mongering, it's just that you do have to recognize that, yeah, a lot of these techniques that take place in med spas are not very invasive. They're not like crazy surgeries or anything like that. Right. But they're still invasive enough to where tissue is being disrupted, normal physiology is disrupted, and you have to recognize the signs of that. So that's absolutely huge that you guys do that. Yeah, that's huge.
- [21:31]
B
Yeah. And you know, it's even, you know, I think many patients may not know this, right? But any agent, any, any drug product, whatever, you're interacting with the body, there's sort of a known expected rate of adverse event because of the chemistry of the agent. They test it. Whenever they test it, right. They know like, okay, percentage of people are going to have a reaction to this.
- [21:51]
A
Right.
- [21:51]
B
And, and really we, we partnered, we, we funded blind research. So it wasn't like, you know, I, I, I think people are somewhat skeptical of industry funded research, but you know, researchers need money from somewhere to fund their, their research. And so we just said like, tell us what's happening in, in this research. And we've worked with, with researchers in the United Kingdom from University College London to really understand what this, what's happening here globally. Because I think that's the first point, right? People don't want to admit to the areas that this industry is struggling or their own concerns because they feel very localized and they feel very personal. And the reality is in, in my experience, in health care everywhere, these are common problems. They're in every country, they're in every community. Everyone sort of sheepishly says, well, we have a problem here and it's this. And I said, no, everyone has the same issue, right? And so we got to get over that sheepishness and we got to get over that, like we're in it alone. And realize we're in it together. And so we funded this research. They went off and did their research without our interference. And what they found was essentially providers in the United Kingdom. One, there's only, like two laws that relate to med spas in the United Kingdom or these types of services in the United kingdom. And like, 80% of the practitioners were breaking at least one of those two laws, and that might have been advertising or who was actually allowed to do the procedure. So again, states can have rules, but if there's thousands and thousands of people doing these procedures, the states, the governments in many countries don't have the human or financial capacity to keep up. Right, yeah. And so you find that people who are not carrying the appropriate license are providing these services. Maybe they're doing parties, maybe they're going to hotels. Bad idea. Any patient listening out there who's like, I'm gonna do a margarita party where we all get injectables, don't do it.
- [23:40]
A
But thank you for saying that. Yeah, don't do it, don't do it.
- [23:43]
B
Just. Just flat out, don't. But, you know, they did this research and they found that there was this, this big violation and they have some advertising laws. So that was also part of, like, what you can advertise, which may not apply in the US or at least in some parts of the US where it really got interesting to me was that because especially in England, there is the nhs. You know, patients go to a med spa or, well, a clinic or whatever it is, and then if. If they have an adverse event, they go to the hospital. So even looking at it optimistically, some of these spots may not have realized how many. How many adverse events they had. But what they found was within the national system, within the reporting system, these adverse events were far underreported from what we even expect, just based on the agents used.
- [24:28]
A
Yeah.
- [24:28]
B
So there's clear underreporting and under appreciation among the practitioners and among the patient basis as to what's really going on. And what they found when they did some of this literature review and they, and they did some retrospective studies was some of it was very basic, very simple, very easily, you know, kind of fixed. But some of it, maybe depending on the ability of the, of the facility or inability of the facility to respond, became much bigger. Like tissue necrosis. Like. Yeah, for lay people, that's dying tissue. That's your tissue dying off. Yeah, skin necrosis happens. It's rare, but it's also, you know, it happens. And I don't think people appreciate that blindness. There was a couple cases of death. It's not a lot. But again, I don't think people ever think I'm going in to get a little injectable. And it could be, you know, there could be mortality associated with it. And again, it's about informed consent and not necessarily, not about fear. Just knowing it, you know, is good and, and knowing, okay, this is a remote possibility, just like I went bungee jumping. But I want to make sure that they can respond if I start to go down a bad road.
- [25:37]
A
Well, that's the thing, right? That's a really good point. Because it's like, yeah, there is no, like, chain of command in terms of, like, where do you go if you, if you know something went wrong, who do you go to? Is there a doctor in, on site? Is there somebody I can call? You know what I mean? And that is the biggest problem because doctors are trained for stuff like that. You know, when you go through your residency training, your fellowship, they train how to handle a situation like this. Not just detect it, but then also, what do you do? And yeah, most of times even nursing, in nursing, I mean, I have some very, very dear friends who are amazing nurses. But they'll tell you, even as a critical care nurse, right, completely outside of aesthetic medicine, they'll tell you, we don't have any clear distinction in our training that says this is what you do, you know, so if you're not even seeing that in critical care, you're definitely not going to see it in aesthetic medicine, you know, where there's no hospital oversight going on at all. So.
- [26:27]
B
Yeah, and often, often, you know, emergency preparedness, emergency response is a team game, right? Yeah, usually there's a few people involved in whatever, you know, whether it's acls, often you have, if it's, if it's not to get too technical, but if you're like responding to like lidocaine toxicity. People have different roles. And so just having a nurse, one nurse, even if they're great at it, usually there's some there, they need interaction with people.
- [26:51]
A
You have a team all always working in a team. Even surgeons, when you go into a surgery, when you're performing a surgery, you have colleagues in there with you. There are multiple professionals in there with you. So it doesn't even logically make sense from the medical, like framework, international medical framework, to have any kind of a facility where you are just going in, seeing one person who's going to inject you with whatever it is that you're getting, and then that's it, you get it done, you go home. That doesn't make any sense. Also, one of my big questions for you is also this. What about things like wait times? Because I know oftentimes, you know, as you know, with a lot of procedures, even if they're non invasive procedures, you know, you have to wait. So when you're going home or when you're, you know, who's picking you up and all of these little things come in. So do you guys account for stuff like that as well and kind of provide guidance on those protocols or is that kind of out of scope for this?
- [27:41]
B
There's a lot, there's a lot that has to do with sort of various protocols within the practice. Right. And there's sort of two different ways that we handle them. Philosophically, that is one, there are standards, there are protocols that, that we say you must do this. Right. There's, there's a few of those and then there's protocols that we say you must come up with a protocol to do this. Because there might, it might vary greatly depending on the services that you're providing.
- [28:17]
A
Yeah.
- [28:17]
B
Or the, the types of care or the types of patients. You see, even like patient acuity becomes really important. And so often what we're doing is forcing the leadership of the center to make a clear and conscientious choice and document that so that everyone on the team, again, team. Is on the same page. So we may say in whatever case, aesthetics, this probably doesn't apply, but it's always the one that jumps to my mind. What's your policy for treating pediatrics? And they say, well, it's aesthetic. We don't treat pediatrics. Okay. Who's a pediatrician? Well, I'm not sure. Well, the question is, you define a pediatric. Is it prepubesic? Is it, will you treat a few, you know, will you treat a 16 year old who's already gone through puberty? Is that, is that a pediatric or is it 18 or is it heightened weight? You determine it because of your service line and what you're doing, but put it out there so everyone knows. Right. And then make sure you have equipment that can treat them. So. So I want to distinguish between kind of how we push the envelope on the facilities. So we do have a few things. There's, there's some issues around, depending on the sir on the services. I'm just, if you're, if you're seeing me look off to the side, it's because I'm referencing. Yeah. So we do have reporting for any adverse Event, as we talk, that happens within 48 hours of discharge. So we do talk about discharge in terms of sort of post operative or post procedural discharge. Like you want to be checking in with the patient to make sure that their things are going accordingly. And then there is discharge instructions and what I'm looking for right now, because I want to make sure that in the new program there, there is some discussion around criteria in some of our programs, but I don't think the specific discharge criteria actually having established discharge criteria comes up in this program because no one's going under sedation. When they come to sedation, you want to make sure they hit a discharge criteria. But you do want to make sure that people are leaving sort of with their full faculties. Right. And so there's, there's, there's an element there of that of coordinating. There's a, there's a point though that I want to make sure that we talk about here that you asked about earlier. And it's about like the team and it's about the headlines and talked about it with nurses, physician training, emergency response training, all that. One of the biggest areas that I think most jurisdictions struggle with is the medical directorship of a med spa, because most, not all states require a medical director. Most, not all states set some sort of criteria of that being a physician. In some states, there's independent nurse practitioner or advanced practice nurse practices. But by and large, let's just say you need a medical director.
- [31:14]
A
Yeah.
- [31:15]
B
One of the big issues that many states struggle with is people who are an empty seat, who are a medical director by name. I hear horror stories. I can't speak to any firsthand, but of medical directors who are medical director of dozens and dozens and dozens of facilities in states they've never been to.
- [31:32]
A
Right.
- [31:32]
B
And they've never stepped foot in the facility. You could see news reports of an adverse event and they contact the medical director and they talk to the staff and they say, yeah, the medical director comes here once or twice a year. That's one of the biggest issues. Right. The medical director and part of this program is the medical director. Whoever's name needs to be actively involved in the administration, office of care in the facility. They need to know the services. Again, they might have different training, but they need to train up on the services being provided and they need to know how to respond, what are the likely adverse events and they need to know.
- [32:03]
A
That's the job of being the medical director you direct.
- [32:08]
B
There is no purpose in being a medical director that gets a salary to basically not show up and be an MTC and just help your passive salary. One, it's unethical in my opinion. And two, yeah, you know, all you're doing is opening yourself up as a medical director to a lawsuit or to a malpractice. I mean, yes, that malpractice is probably on your malpractice insurance as a physician and, and you're not there, so you don't know what's going on. So as a protective measure for yourself as a physician, as a professional, from the ownership perspective of the facility and from the practitioners living there, you know, living and working there every day, you want to make sure you have an ecosystem that supports you, that is educational, that is optimizing, that is looking for quality and safety and is reducing risk. I think we talk about this from a safety standpoint for the patient, which is super important. But when you talk about it from the facility standpoint too, like no facility wants to have adverse events. The risk is, is, is complete all the way around from reputation to financial to legal to just on your own conscience. Right. So, so this, the whole effort is to be self protective.
- [33:20]
A
Yeah, I mean it's a very, very. You know, you bring up such important points here because, you know, I've. First thing that comes to my mind is when it comes to being a medical director, I mean this is for all. I think every reputable doctor I know would never put their name on anything if they couldn't physically see what's going on. Because yes, there's a lot of risk, but more importantly, what is like, I mean, what is the point of that? You know, at the end of the day, how much money could you possibly be making that you're going to just risk all of that? Because if you get sued and if there's any kind of legal action taking place, you're losing all of that. So it doesn't even make logical sense to put yourself in that position. So if there is somebody doing that, I don't even see what the, you know, the gains versus loss, like what that scenario is like for them because it doesn't make sense. And more importantly, when you look at other facilities, like nursing homes for example. Right. Or like step down centers, you have to physically be there as a physician like every morning. Like if you're working at a step down center as the main like medical person that's there checking who's been admitted that day, you have to physically sign off. So why is that same model not being applied to an esthetics practice or you know, a Med spot, it should absolutely be the same. So it's not that we don't have these parameters, right. It's not that we don't have the blueprint of doing this as a medical community. It's just that for some reason we're saying aesthetic medicine, hands up in the air, whatever, you know what I mean? Let's just not even think about it. I don't know why it's like that. That's crazy.
- [34:47]
B
You know, my, my operating theory there is that it is, it is that same paradigm perception that it is no risk and low risk is not no risk. Right. And I think that's the subtlety there, right? Like clearly, clearly, clearly I don't want to misrepresent this to patients or physicians or practitioners out there. Clearly the med spa space is less risky than the acute care hospital. It clearly is less risky than the surgery center, than nursing and step down. You know, generally you have healthy patients coming in. Generally they're coming in for something very, very small. Clearly it is less invasive, it is less intense. That's why this program in and of itself doesn't look like a surgical program. It' very different because clearly the risk profile is lower and it has a different, different risk profile, but it doesn't mean there's no risk. And I think that's where we get caught. We're like, nothing's going to happen there. And I will tell you, I have heard again, I won't name names. I was at a, this maybe two, three years ago as we were starting this process. I was at a conference of regulators. It's actually the same one where the people, the guy talked about, the bridge people, I was at a conference of regulators and they had someone who does some training in the med spa space for injectors for people like that. And he has this really comprehensive program, at least as it was told to me. I'm not super familiar firsthand, but the person lectured quite a bit for it's a three day conference and pretty prominently throughout the three days and the thing that really threw me off was really comprehensive training, really comprehensive protocols, really comprehensive documentation. And then at the end of the conference when people were kind of talking about how to put protections in place, I don't know if it was just trying to make people feel better or what, but basically said, look, you can't do any real harm here and you can't do any lasting harm here. And I basically felt obligated to get up and say, you know, basically, unfortunately everything you've said for the last three days is now moot because you've just undermined entirely that this is a no risk situation and not a low risk situation. And while we should all recognize it's low risk, we should not discount the fact that it is and delude ourselves to thinking that it is no risk. And the data very clearly shows otherwise. And we went back to the statistics on necrosis and occlusions and blindness and even mortality. And that, I think is the misperception that causes people to say, well, heck, I can take a passive income and I'll operate on volume and I'll get 40 centers, or I'll operate through a corporate and I'll be the medical director of all 40 of our sectors because there's no risk there, really. And that's, I think, misguided.
- [37:22]
A
Well, that's incredibly misguided. But more importantly, I think it's also very, very scary to me, right from the medical standpoint of we're even letting this happen. Because in my, I don't know about any other doctor listening in, but when I went to medical school and I went through my training, it was hammered into my brain that there is no such thing as low risk. Like, this low risk concept doesn't even make sense to like, I mean, it's like risk is risk. If you don't acknowledge it, you're getting sued and you're going to lose your license. That's that was it. You know what I mean? And so I, that's why I.
- [37:55]
B
What is the phrasing? A minor procedure is a procedure on someone else.
- [37:58]
A
Absolutely, absolutely. And it's like, you know, it's not even about procedures. It's medications. It's how you administer those medications, how you monitor things like drips. Do you record outputs and do you put that in the file? All of this is monitored in any kind of a hospital setting. So again, the same question is circulating in my mind where it's like, where did this conversation even begin of saying, oh, this is low risk. We don't have to worry about it. Of course you have to worry about it.
- [38:23]
B
You know, like, of course it's about the appropriate level of worry. Right? Like, you don't want to treat it like a cardiac case, but you want to treat it with the appropriate level of care. And I think right now, what we're under, because it is patient driven. We are under an environment where people are trying to go to independent practice because they are frankly sick of being strangled by, by oversight and regulation in the more acute care environments in hospital yeah, Trying to go more and more independent. And we've gotten to a point where we're extremely independent. And what we want to make sure that we're doing is put the appropriate guardrails around it, not extra extreme and extraordinary guardrails. I think it's art more than science to really thread the needle of rigor and reasonableness. Right? Like you can't treat injectables. Practice a wellness practice, the same as you would treat the, you know, the intensive care unit at a tier, you know, at a tertiary hospital. Of course you should treat it like something and let's figure out what that is and say this is the rigor that we need to make sure that you're operating in a way that cares for all of your patients on a daily basis in the appropriate way and that doesn't strangle the industry. That's really the art of this is to say strong enough, not too strong. You know, we really want, we really want the Goldilocks approach.
- [39:41]
A
Well, no, I completely agree with you. I think that's, that's a brilliant way to think about it. And also, you know, I don't want to be too negative. I really do want to add the positivity in here for all the people that are doing it right. You know, I have such, I have great friends, some, you know, prior guests that have come on the show that they, they run med spas, they run these beautiful centers and, and you know, they're doing everything by the book, everything right. They're going the extra mile. It might cost a little bit more for them, you know, on the business side, but they don't any risks, you know. And so a program such as this is incredible for those people out there that are like, I don't want to take risks, I want to do it right. I might not know, you know, because if you don't know, if you don't know, what are the things I should look out for or like, what should I go through to be truly like, you know, validated by a third party entity? You don't know what to do and then you don't do it. So I think your program is so phenomenal in that way that it's giving accurate access more than anything to professionals who are like, maybe lost, you know, in that sense of like, well, what else can I do, you know, what else can I really do to validate what I'm doing and make sure that it's checking all the boxes and, you know, all of that stuff? So I, I think this is phenomenal from that, you know.
- [40:50]
B
Yeah, I'll take it a step further because some of those people who are the cream of the crop, they're already doing it. They, they might have to make minimal or no changes to what they're doing. But it's a validation. And I think the real critical key there is you, you may even know, right, your top 1% or 10 or whatever the percentage is of med spa operators out there may already look at our manual and go, piece of cake, right? I gotta buy one piece of equipment. I gotta, I gotta rewrite one policy. I have to do one training that, that I sort of didn't think of. But by and large, we got this covered, right? And I, I think the top, the top tier is gonna have no problem. The big thing is that patients don't know because that assumption level. And I think we're in a crowded market, obviously, and you and I talked about this before, it is a market that is exploding in growth. People are flocking to it for the financial benefit. And that's okay. There's nothing inherently wrong with that. But as we talked about the market, some best estimates that I've heard are that we're about 10% saturated. So if we think there's a lot of med spots now, wait five years, right, it's going to be a really crowded market. And without some differentiation that a patient can tangentially hold on or tangibly hold on to and really grasp and understand as to what makes practitioner A different than practitioner B, the only thing they have to go on is sort of style Instagram, right? They can go on. You know, how many followers do you have? Which is not helpful at all because it's just, you know, I hired a marketing company that got a million and a half bots to follow me. Great. My engagement look huge. It makes me look like a superstar. Or, you know, price. And what you don't want is a, is a race to the bottom on price because that's where you get adulterated products. You get product bought from, you know, unreputable third parties. You get people cutting corners on, again, wasting product that's too old, that needs to be wasted. You know, what we find is even good practitioners now I'm sort of leveraging my history with surgery. Even well trained, even great practitioners, ethical practitioners, face human problems, economic problems. And so you have to justify this fancy new machine you bought, you have to justify your costs. You try to stretch a product. So in a crowded market where patients have no clue who to pick because they can't Tell the difference between you, you and you. What we need to do is say, I am Volvo, I am Mercedes. I am the luxury brand. And that's why you want to pay 5% more for me. Because that 5% is your safety net, 5% is your comfort, your trust, and your, and, and your, our ability to respond to an emergency. For you, it's okay that that person up the street is 10% cheaper than me. I really hope you'll consider the fact that you are buying. You are paying for me to do things the right way, to have an extra staff member who's looking out for my infection prevention, right? My emergency preparedness, my whatever it is you might be paying for. That patient, whoever make a rational choice. Now, you as a patient can choose to go one way or the other, but as of right now, there's really nothing other than social media, bedside manner, style of the facility. Maybe language. I think that's an important one. Right. Like, we see a lot of patients who are treated and, and not their native language. And so people will seek out. People will seek out someone who can care for them in a way that they can communicate. I think that's very good. It's very appropriate. But even within that community, you have people, unfortunately, that, that can also sometimes weaponize that. Now, again, I don't want to make things. I don't want to go to the negative, but I want to make sure, if you're the patient who's treating whatever the Chinese community in Chinatown in New York. Right. That they can tell the difference if English is a second language and they're a recent arrival, but they want these services that they're able to communicate and find the practitioners who are safe in their community and not necessarily just somebody who's going off a price. And it could be the Bronx, it could be Chinatown, it could be Miami, it could be, you know, Little Italy. I don't know. Right, but, but that's the point, right? Like in every environment, there's the cost. Driver. And there's the people who are going to keep me safe. Driver. And I think that's what we want those people to be able to stand out.
- [45:09]
A
Absolutely. No, this is, this is so, so, so important. I love that you brought up, like, you know, I think just international kind of experiences that people have. You know, if you, because that's, that's human nature. You know, you're going to go to somebody that looks like you, that can speak your language, that can, you can understand. But I still think, and I don't know if this is part of the program or if anything exists right now. But I still think that documentation is a very real thing. And everything in the United States in an English SPE to be documented in English as well as any other foreign language. And those kind of things should also be thought about, you know, like, you can explain something. You know, in hospitals, this happens as well if you speak, like, I speak Hindi. I've spoken to patients in Hindi before, but at the same time, I'm still writing things in. In English and Epic, you know, at the end of the day. So you have to have this, like, duality there. And I think there is a way for. To go forward where you don't compromise your, you know, as a med spa facility. You're not compromising your uniqueness. You're just making sure that whatever you're doing is by the book. And no matter who you treat, it's gonna be by the book every single time, you know, and so I think it's. This is incredible. And I. And I really urge everyone listening. We have so many patients that listen in, you know, and we get a lot of questions about these things as well, as far as, like, vetting spas and vetting facilities. So I think, you know, how does a. How does a patient understand? Like, what do they look for to make sure that a facility has gone through your program? Like, is there a sealed location look for? Or what do we look for?
- [46:34]
B
Yeah, you can see if you're. If there's a video, you can see the seal directly over my left shoulder. But you will see our logo. Quad A, Proudly accredited by Quad A. Any facility that's accredited should carry a certificate. That certificate we require them to place in a publicly viewable place. So usually it's the waiting room, the door, whatever. Their actual certificate is actually digitally distributed, and it's like sort of a blockchain type of deal. So actually, we encourage most facilities to embed that in their website and on their social media so that you can click it, because it is clicked through, and it will go to the separate platform that houses their accreditation certificates. So separate from their own website, It's a third party. Explains the program, explains the level of risk stratification that they are in. Are they a green facility, a yellow facility, an orange facility? Not just that they're accredited because you want to make sure that they're doing that they're providing the appropriate care and what it means to be accredited. I think that's the first thing. We have a directory that unfortunately is down right now for Renewal and for redesign. That'll be coming up shortly. So in the future, patients facilities, they can go to www.quada.orgqu a d.org and look for accredited facilities. There's a section for patients. You click on that, you go to accredited facilities and there's a directory again, it's down right now for refurbishments, but it will be back up. But look for all of those indicators. I have no doubt that other people will come into this space to do what we're doing. We obviously recognize the need and wanted to move very quickly to put a product out there. There's other people. What you want to make sure that you're doing as a patient is understanding what accreditation means and what accreditation of facility carries. You know, there are organizations that exist in the world that call themselves board certifying that are not ABMs recognized boards. And what that means is somebody could take some training, they could take an exam they can pass, maybe they get certified. Whereas others might require a certain time in residency, a certain time of training, a certain number of cases to be done, an oral exam and a written exam. So not all certifications are created equal. And that's the same with accreditation. You don't want a desk review. You don't want someone just submitting some papers and saying, I, you know, looked at this. I, I promised that my facility is going to operate in a great way and here's my training. You know, what we do is we put eyes on site, which I think is incredibly important. Even most referral sources don't ever do that. You refer to another doctor because you know that doctor and their reputation, but you don't meet their nurses and their techs. That's what we do. And any accreditor that you value should be putting eyes on site and looking at the staff top to bottom and the records top to bottom. So in our case, any patient can go to our website and download the standards and see exactly what we require of the facility and you can see how comprehensive it is. And I encourage all patients to vote with their wallet to walk into a facility and say, are you accredited and by whom? Right now, as far as I'm concerned, we're the only, we're the only people that are doing this in a comprehensive on site way. So ask are you quality accredited? And if not, leave, go somewhere else. Say, I'm not coming back here until your quality accredited because I want to know everything you're doing top to bottom is, is, is that you've demonstrated the ability to comply with Some standards, because I don't know what to ask, but, but I believe that they do. Right. And so practitioner out there, this is be one of our standards. They're going to evolve in our surgery worldwide version 16.8. Right. They change, medical technology changes. We're going to learn a lot in this first six months of this new program and we're going to refine and tweak and zero in. And in two years, the technology and the services are going to change and we're going to refine and tweak again. It's a living document, it's a living program. But what it is is a partnership to always push safety forward, to push safety first for the patient. And as a patient, you have to be aware of that.
- [50:41]
A
I love that. I love that so much. And for everyone listening, I'm going to be linking everything, the show notes of this episode, so make sure you are scrolling down and going to the website, checking out all of the things that Tom is talking about. And I could not agree more with you, Tom. I think it's so important and so amazing that you guys have put this transparency both obviously on the side of like any practitioner that wants to get accredited, but then also for the patients themselves, you know, that can go through this as a patient and understand like, wow, they really do look at everything, you know, and, and this is very, very important. I, I love what you're doing and you know, I'm, I just, I don't know, I don't have enough good words to, to praise it. So. Thank you so much. I, I do have one question for you though, before we go. And, and I think this is important for everyone to understand. Where is the government in all of this? Like, I know we talk about the FDA a lot. You know, I've brought them up a lot. But what is their role in all of these things, like acquiring, you know.
- [51:32]
B
Yeah, inter. Really good question. And frankly, some of the best places that we work and some of the best environments we work as an accrediting organization is in partnership that has a supplement to government. We don't replace government. That's never our intention. Yeah, there's, I think for, for, for even practitioners, but especially patients, there's a, it's a very interesting to understand how healthcare in the US and abroad works. Right. I'm gonna, I'll, I'll zero in on the US because it is essentially a hundred different countries. So in the US when you talk about, we'll start with surgery and we'll move out, but only because it actually applies to Med Spot. In the US There is the Department of Health in most states that deals with essentially institutions. Right. Your hospitals, your nursing homes, your step downs, as you talked about, your ambulatory surgery centers, those are licensed entities that the government sort of recognizes as an institution and the staff can come and go from that institution and they are essentially interchangeable. But that institution is licensed and verified by the government. In every, in every state there is also a medical board, a pharmacy board, a nursing board that licenses the professionals. So when you get down out of the institutions to a private practice. So if you're an office surgery setting or a private practice that does gastroenterology, the Department of Health in most cases is no longer looking at that center. The medical board is looking at that center. And it is tied to that medical director who's owning and operating that facility. Or maybe, maybe there's a group practice. Right?
- [53:06]
A
Yeah.
- [53:07]
B
And those people and that medical board are judging everything that's happening and they are basically holding that physician's license in the balance. And that's how they're saying if things go wrong or right, it will be your medical license. That is what's on the line, right? Yeah. And so only about half the US states have a strong mandate for office surgery accreditation that might shock a lot of patients. About half the states have that. And even states that do have varying degrees of monitoring and enforcement, I will say we have a really good relationship with the state of New York. The state of New York says to their facilities, to their offices, go out, find an approved accreditor, here's the list of who they are, get accredited. And there's about 11 or 1200 accredited office surgeries in New York. We do about 800 of them. It's something, we're the market leader.
- [53:59]
A
But I love New York. I love it. New York is always on point with this stuff. Yeah, that's amazing.
- [54:05]
B
To 1200 facilities. And I'll be honest with you, not every office surgery that should be accredited in New York is. They still struggle with monitoring, enforcement. Even though they have a public facing website that lists every accredited clinic by county. And they encourage patients, if you go to a clinic, look it up. And if it's not accredited, report that. Right. So that's where we are in the continuum of surgery. Where most states are right now with Med Spot is looking at who's doing the procedures themselves, who's allowed to. In some states, I believe Florida has some rules around the medical directors. Each state is going to have to decide how and when they want to regulate this space and how they want to approach it, I think their first problem is deciding where it falls. Many states struggle with is this medicine, is this pharmacy, is this nursing, is it dentistry, is it something else, is it our department of state who exactly should regulate this? I think that's even a first struggle for. I think, I think if I'm not mistaken, Florida had a proposal on the books to regulate med spot under the Board of Pharmacy. I think some other states are looking at, under the Board of Medicine. But it's a moving target. What we're proposing to some states and we don't actually advocate. It's very much like a technical advising. If they can't keep up with office surgeries because there's too many locations and they don't have the personnel or financial resources to take to do that. They've worked with us in many cases for 30 plus years. They can do the same thing they do in surgery and they can say go out, here's the list of approved accreditors and get it done. And then push the states to do it. That would be in our mind, that's the way it works. Well, it allows the state to focus on complaints on adverse events, on sort of the four cause stuff. And they coordinate with us. Like when we work on an investigation with the state of New York work, they coordinate with us and they see what we're finding. They communicate with us and they sort of use us as an extension of the state and then they take their actions. So they act, but they utilize our resources.
- [56:11]
A
Yeah, that's smart. They should do that. That's how every state should do it.
- [56:14]
B
I mean that means for me, I think it works well.
- [56:16]
A
Yeah, because I mean they don't have enough people. So. Sorry, go ahead.
- [56:22]
B
Honestly, we do it abroad too. We have a great relationship with dha, which is the Dubai Health Authority. Obviously they're going on nurse. They have a lot more high priorities right now. But we accredit like 75% of the ambulatory surgeries in Dubai and we're working with them on sub surgical as well now. And if there is a four cause issue, they communicate with us very, very openly and they rely on our findings. They communicate with our surveyors, they may send in surveyors with our surveyors for collaboration. It becomes an issue where we can extend the government without smothering the industry because it tends to, the pendulum tends to swing very, very hard if it becomes legislation. So one of the easiest things and one of the best things to do is to say, here is a responsible organization that we know, that we have confidence in, that's been doing this for 45 years, that sets the bar in that right. In that right space. And we'll work with them. If we have a few points of emphasis, like Florida has points of emphasis that they really like, that they really want to make sure that we're looking at that's a little bit unique to their state. They may say, okay, use your program, but also make sure you're looking at these four or five other things. And that's a good partnership that puts it on the right kind of acuity so that it's not killing the industry and treating it like cardiac care, but not just letting it be kind of free form.
- [57:49]
A
Right. That's wonderful. I'm glad that, that there are, you know, states that are utilizing you guys the right way. I mean, that's. I think that's very, very important, especially if you want to implement this, you know, across the country and obviously internationally. But I mean, I really urge people, you know, like, if you are. If you guys are going to any kind of spa, anything, any clinic, and you're not seeing the things you should see, right? Like a lot of the things Tom has mentioned here, say something, you know, bring it up. Bring it up to the med spa owner. I would, you know, I would be like, hey, listen, I mean, I'm not trying to be mean, but can you give me some proof, you know, of like what you do, what are your normal practices? And it might make them think, because I don't think that people open businesses with ill intent. I think sometimes there's a lot of miseducation and under education on a lot of regulatory stuff. And so this is also very, very important from that, that stance is that like you're putting it in the forefront. So if someone wants to understand this and they own a business such as this, they can go and opt in, you know, and I think that's very important and think it also falls on the patients. You know, as patients, we think everything should be just taken care of. Well, this is a new space. It's developed. Like you said, only 10 saturation has happened right now. You know, so as it evolves, I talk to every day, Tom on the show. I have regenerative medicine specialists coming on skincare brands that are trying to move into the, you know, when. If you expect things like exosomes to start being legal in the United States for injectables and stuff and regenerative medicine, then this kind of regulation is absolutely paramount. Like, you have to have this level first and then we can talk about all the other stuff, you know, because this is the baseline, this is the, the standing point, you know, for everything. And so I really urge all the, Any patient listening, any consumer listening, like, you guys got to speak up too, you know, it can't just be always on, oh, well, they didn't know. Sometimes they don't know. They might not know.
- [59:39]
B
Yeah, you said it right. Like we assume people. No, no one starts a business. No one takes on care with ill intent. Or maybe few people do. And when we talk about this, the conversation tends to go to the people that are up to no good because that's who you really want to get rid of. Honestly, that's. You, you want to, you want to weed out the people that are up to no good. But the reality is, you know, there's some percentage of folks that are, that are at the top tier. There's some percentage that are up to no good. And there's a lot of folks in the middle who don't know what they don't know, who are too busy to know what they don't know, who are just trying to do the best they can and trying to scale and can't quite figure it out. And they're struggling with consistency. And that's where this stuff really makes a difference at the top notch. Are we going to make a huge difference? It's going to be an incremental difference. I look at it like grading scales. If I got an A student, I'm trying to get them to an A plus. Is it really going to make that, Are we going to make them that much better from a 97% to a 99% that it's great for them, but it's, it's on the margin. If I could take a C student and make them an A student, that's real difference and it makes a real difference to the patient. Some of those F students are going to stay F students and it's up to the market to weed them out by saying, yeah, why, why are you not doing this thing that's really approachable and reasonable? I, I don't, I'm not sure I feel good about you. And, and the way to do that, as you said, is to educate yourself. Go to the website. I wanted to say this. Follow us on social media. Not because I love, I'm not a big social media person personally. I do it a lot for the business. But if you follow Quad A Now, Instagram, Twitter, LinkedIn, Facebook, I guess it's X now. What I. The reason I say that most of what we do is business to business, so it's not going to really relate to the patient, but what will relate to the patient is when we profile facilities and centers that become accredited and we amplify their pride in becoming accredited, passing their survey and, and being able to show you as a patient that they are doing everything that they can to keep you safe. We are doing the best we can to amplify their voice and let you identify them more readily. And so if you follow all of that on social media, when they announce their accreditation, they tout their badges, they go to, they go to our learning sessions to learn, you know, better practices and better techniques to keep you safe. The more your eyes are on that and more you're able to speak intelligently to them about that, the more you're going to validate and reaffirm that commitment.
- [62:00]
A
That's right. That's. I love that. And I will be linking, by the way, guys, make sure if you watch our stories or anything on our socials, you're gonna see there, we're gonna pop quaday socials up there as well. So check that out. And I, I've loved this chat, Tom, thank you so much. We've learned so much. I mean, I've learned so much. I didn't know this was the case. And, you know, I know a lot of people out there, don't we. We don't know these things, so it's very, very important to highlight. So I can't thank you enough for your time and for all the education. It's been wonderful.
- [62:26]
B
Thank you for giving me an outlet for all the energy and passion I have for this. So I hope it makes a difference for, for some of the practitioners listening and for the patients out there. And I can't thank you enough for giving us this platform.
- [62:36]
A
No, of course. I'm so glad you're passionate about it. We need passionate people to do this, you know, like, rather than someone who doesn't care. So thank you so much.