A Passion for Out-of-Hospital Care Expansion to Improve Patient Outcomes

This podcast and transcript are sponsored by Philips OBL and ASC Solutions. To learn more, please visit philips.com/symphonysuite

Dr. Andrey Espinoza of the Advanced Heart and Vascular Institute of Hunterdon in Flemington, New Jersey, shares why he feels so passionately about the value, for both patients and the healthcare team, of out-of-hospital treatment and patient care.

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The transcript below has been lightly edited for clarity

Rebecca Kapur:

Welcome to Cath Lab Conversations. I'm Rebecca Kapur, managing editor with Cath Lab Digest. And today we are talking with Dr. Andrey Espinoza of the Advanced Heart and Vascular Institute of Hunterdon in Flemington, New Jersey, about why he feels so passionately about the value for both patients and the healthcare team of out-of-hospital treatment and patient care. This podcast is sponsored by Philips OBL and ASC Solutions. Thank you for joining us.

Can you tell us about yourself and your practice?

My name's Andrey Espinoza. I'm an interventional cardiologist, board certified in internal medicine, cardiovascular diseases, interventional cardiology, as well as endovascular medicine. I have my own private practice that I began in 2016. So I've been on my own as a solo practitioner for the past six years. I do have also one nurse practitioner that works alongside me. I worked for a private group, which then became essentially hospital owned. That was for about 17 years prior to me moving out on my own.

I currently work out of three hospital systems and one office-based lab. So I'm on the medical staff at the Gagnon Cardiovascular Center at Atlantic Health Systems, which is Morristown Memorial Hospital. I also work out of the Saint Barnabas System at Somerset Medical Center and also the Robert Wood Johnson Medical School in New Brunswick.

Could you tell us about your plans to open an outpatient lab?

For the last three years I've been participating in a collaborative fashion with a larger hospital system with an office-based lab. I very quickly realized that for many reasons that I really wanted to further control my own destiny and the ins and outs of what went on within the laboratory space itself. Right now, we are anticipating a May [2022] opening for our office-based laboratory, which is essentially going to become part of our clinical-based office suite, which is located on the first floor of one of the commercial buildings that we work out of. Basically knocking down a wall, and it will be one contiguous large office space, which include a large office-based lab now.

Can you talk about the range of procedures you'll be performing there?

We're going to be performing everything from peripheral vascular, peripheral arterial disease procedures, which essentially ranges predominantly from the intra-abdominal cavity down low. We perform procedures on critical limb-threatening ischemic patients. We're also planning on doing our loop implants there for patients with potential arrhythmic disease, syncope or stroke without ideology. We already have a separate Vein Center. That's also part of our practice, but that will be continuously performed in the setting where we do all of our outpatient imaging. So specifically in the OBL at this point in time we'll be predominantly performing vascular procedures.

So you perform cardiac procedures in the hospital. Can you talk about the status of that in New Jersey and generally?

Yeah, so it's always been a very interesting ride here in the state of New Jersey, which is unique for so many different reasons and recently, or at least up until about a year ago, coronary procedures specific to what is referred to as elective percutaneous coronary intervention was only allowed to be performed at hospitals with onsite surgical capabilities. That eventually morphed into the C-PORT trial, which was probably about 15 years ago, perhaps when that initiative began. And there were certain hospitals that had lobbied to participate in that very large kind of research database. Those hospitals were allowed to perform elective PCI, but under the guise of the clinical research endeavor. Eventually the C-PORT trial was completed.

And interestingly enough, in the state of New Jersey, even though elective PCI was not allowable at centers like small community hospitals without onsite surgery, despite the C-PORT trial having closed, all of those community hospitals that were participating were still allowed to maintain that certificate. So you had this interesting dynamic where there was elective PCI being performed at large, more compelling centers, academic centers, et cetera, with onsite surgery. You had elective PCI being performed by C-PORT hospitals, which were no longer participating in C-PORT. And then the only hospitals that were getting the shaft were smaller community hospitals that were performing things like STEMI interventions so taking care of very critically ill patients, but that were not allowed to perform elective interventions. So there was some politicking involved, but eventually that finally came to fruition about a year ago where the state of New Jersey opened up those certificates to any hospital in the state of New Jersey that could demonstrate proficiency and prowess and efficiency and good quality could apply to perform elective PCI, despite not having onsite surgery.

Why are procedures moving out of the hospital space?

I think prior to the pandemic, there was a large push by mainly physicians who are trying to take ownership back of not only the types of procedures that are performed, but potentially even something as mundane as the type of equipment that we put on the shelf. I think all of us were concerned about losing control. Hospitals have different committees that make it extremely challenging for physicians to bring newer technology into the hospital systems, and I think cost became an issue. For me, I would suggest that it became more of a quality and an experience issue.

As a physician, we know exactly what our patients need. More importantly, we know what they want. And we also understand the experience, not only that they demand, but that we want to provide for them. And the hospital's a very unique environment. It's no longer necessarily run by hospitals. Physicians in leaderships at administrative levels that no longer practice medicine anymore are probably the biggest obstacles to physicians being able to do things in hospitals, which is interesting. So it was everything from controlling costs, but more in controlling the experience. And also as an independent operator controlling the types of procedures and the types of equipment that we use during those procedures.

Furthermore, to answer your question, if you move into the pandemic environment, which changed the world upside down, I think that further pushed the field in the direction of moving things outside the hospital. Most procedures across the board can be performed outside of a hospital in a very safe environment, either being in an OBL or an ASC or a hybrid OBL/ASC. When the pandemic hit hospitals, basically were shut down to all elective procedures, but that didn't shut down the need for the care.

The OBL that I was still working in, we were very selective about whom we brought into the facility, but there were patients with diabetic foot ulcers that had limb-threatening ischemia that required interventions, whether it be surgical. You had hemodialysis access patients with issues and hospitals could no longer provide that facility because they were so inundated taking care of patients during the pandemic. The hospital systems were completely overwhelmed. So I think it really shown light on the fact that there are other opportunities out there. And then you realize in times of need the things that you thought you couldn't do, you clearly become capable of doing. So necessity is the mother intervention, and I think that really emphasized that point, in a field I think that was already moving in that direction.

Can you talk more about the patient experience? What are some of the concerns of your patients, and how do they differ between the two settings?

I think probably the biggest thing is any patient, if you've ever been a patient at any level that requires a procedure done, whether it be something that's endovascular or surgical, it's a very stressful experience. Even if it's something as simple as a colonoscopy, patients want to feel comforted. They're like anybody else. They're creatures of habit. They like things that are germane, not only to them from a personal perspective, but also being familiar with the professionals that are caring for them. The hospital is a unique environment where you walk into it and no one really knows who you are. So it's a very stressful environment. People are meeting you that don't necessarily have a relationship with you.

I think an attempt is made obviously to put that patient at ease, but in reality, the patients are most comfortable with the people that care for them every time they spend time in the office with us. So we spend more time with patients in the office than we do on any given day where they're having an isolated procedure. That may be the only procedure that they have in their life. I also think patients are very savvy in 21st century. They have the ability to research the internet. They have the ability to look online and they really want high quality, not only physicians and nurse practitioners and nurses and healthcare providers, but they also want the experience to be very Disney-esque, which I don't think is an unreasonable expectation.

The healthcare industry, I think, has always gotten away with providing lesser of a kind of aesthetic experience, mainly because some of which is cost and some of which is really not understanding the nature of what patients want. I really think that you can provide patients an extremely safe environment and a very aesthetically pleasing environment that's soothing to the patient, as opposed to entering into a very chaotic system, like you take during the pandemic where there's this concern about infections and the pandemic going on, and then entering to a system where, like I said, there's a lot of chaos. I think that chaos adds to the stress and doesn't provide the patient a lot of relief of their anxiety.

And so when we offer services, the first question the patients ask us is, "Well, where can I get this done?" If we say, "Oh, well, all you have to do is walk across the street and you can get this done in the hospital." They usually follow up with, "Well, do I really have to go there?" As opposed to when we offer a service and the patient says, "Well, where can I have this done?" And they say, "Oh, we do it right upstairs in our imaging suite." The patient is immediately comforted. And usually they say something like, "Thank God. The last thing I want to do is go to the hospital."

So those are very real sentiments that patients have, whether they're realistically based on an experience they've had previously, which is usually the case. We want to change not only the perception of what people have of the interaction in the healthcare environment, but more importantly, I know what I want when I see a physician or I enter into the healthcare environment. I know what I want for my wife and my children and my family, and there's a difference. There's a big difference between experiences that patients encounter in a hospital-based setting and what we are able to provide in an outpatient setting, where people are excited to come, because they're surrounded by a caring, close knit unit of individuals that have only one interest in mind, which is making their experience the best that they can possibly have.

What impact has the pandemic had on healthcare team members' expectations for their workplace?

My father's a pharmacist in New York City. He's in his 70s, and he was working during the pandemic, and the guy refused to go home. He's been a pharmacist all his life, completely 110% dedicated to the field. I was begging him to stay home because he was one of those at-risk over 65 people that probably got sick would die, but because of his love of the game, he refused to leave. And their system, as they were going through it, eventually they turned around and they gave all the employees in the hospital a round trip airline ticket to anywhere they wanted to go whenever they wanted to use it. And that was something that resonated with him.

Listen, is it a lot? Hmm, probably not in the grand scheme of things, but it's at least an opportunity to show, listen, we understand what you're doing. And we feel as though we need to show that love other than just saying, thank you. Thank you is amazing. But you know what? Sometimes it's not enough for the people that are putting themselves on the line. And I can tell you, from my father's perspective, it was the greatest thing in the history of the world, getting a round trip ticket. It was just an additional gesture, right? I mean, that's what humanity is all about. We can't fix everything for everyone all the time, but you know what? We can do little things that are meaningful for people.

And when you miss that as understanding what people need, people are not looking to break the hospital's bank. We're not telling them you need to pay us tens of thousands of dollars more. We just want to be loved like everybody else. That's it. It's an emotional thing. We want a commitment. We're providing a commitment. We're providing a service. We will do it all day every day. We'll put ourselves in harm's way. It doesn't take a lot to ask hospital systems to turn around and reciprocate, even at the smallest level.

What does the OBL or OBL/ASC offer staff who are leaving hospitals? What can they look to find there that might be missing at the hospital? And what is the place of the hospital in light of all this churn that's going on?

Yeah, two great questions. So we'll start with the first one. What does an OBL and/or potentially an ASC... I'm not part of an ASC, but they are similar models to a large extent, but I'll speak more from the OBL side. I know, interestingly enough, and I tell this to people all the time. As a business owner now of my own business, who's responsible for everything from A to Z, I usually don't necessarily have jobs for people. What I'm looking for is amazing people that want to be a part of a team that want to do something bigger than themselves, be appreciated, compensated and made to feel as though they are part of a greater good. So we find ridiculously talented people. We employ them. And then we put them to work in whatever capacity that we feel compelled that they can excel in.

We don't necessarily have jobs. We look for talent. And then we basically build our program around that. We have ridiculously talented people within our organization. My nurse practitioner, she was a critical care nurse. She worked with me in the intensive care setting, in the critical care setting and catheterization lab. Became a nurse practitioner. I didn't have a job for her, but I hired her because she was ridiculously talented. And I knew that she could bring such a different perspective to not only my practice, but more importantly when we morphed into doing OBL procedures. She had cath lab experience. She had nursing experience and now she has the clinical experience as a nurse practitioner. So she had the trifecta of basically being able to bring it all.

Nurses have a tremendous capacity and tendency to bring a completely different perspective than physicians have. They have a tremendous amount of not only expertise, but compassion. They view the patient in a very different capacity. So having that at my bedside, there's nothing better because I can turn to her for just about everything that we need to do. They enhance our lab by allowing us to maintain our credentialing, our levels of quality and safety within the radiation arena. And then we have literally all the employees from A to Z that essentially cater to the patient experience from the second they walk in the door to the time they leave. Do a tremendous job, not only at the preparatory phases, but also in the follow-up phases.

So patients, when they leave the OBL and all of them usually do in a very timely fashion, they get a phone call that day. They get a phone call the next day. They get their follow-up ultrasound imaging and follow-up appointment within a week. And at every touchpoint, they're talking to somebody that's within the construct of the organization that knows exactly what went on, exactly their concerns, their thoughts, their pharmaceutical needs and everything else in between. It's such a comprehensive way to approach the patient.

Patients get surprised. They enter into the system and the experience that they have, it's almost concierge-esque. I don't believe in concierge medicine. I think it's the worst thing in the history of the world because you're denying access to patients. But when you think about concierge, it's basically that service where you feel like your loved. Everybody knows who you are, what you're coming in for, what you need. And the more important thing is the follow-up after. Ultimately at the end of the day, patients leave. They're sedated. They forget a lot of the things that you discuss, but we elevate our game that every individual in our practice knows what's going on.

So when I send an email, after my procedure is performed, I don't send it simply to my administrator or the ultrasound sonographer or my nurse practitioner. I send it to my entire practice and all the employees in between. Why? Because that patient's going to call my office. I'm not answering the phone. The person at the front desk is answering the phone. So if they are equipped with the knowledge, "Oh, you just had a procedure yesterday, Mr. So-and-so. I'm so glad you called. Is there anything we can help you with? Is something wrong?" That's the culture and the mechanism that we build into this experience that we want the patient to have.

We want them to feel like they are a known entity. They're not calling into a system where nobody knows them, nobody knows what they had, nobody knows what their medications that they're on. So we elevate everybody's game. My goal is always to educate everybody with the same exact knowledge that I have of the patient, what they had, what they need and so forth. So when that patient calls in, everything is taken care of, or at the very least, that individual knows who to contact in the event that's the case.

So the OBL, or the office-based experience, like any other experience, you want to make it customer service oriented. Even though this is a healthcare environment, we're providing a service, and it's not good enough to just provide the service. Everybody loves what I do. I'm the interventionalist. I'm the one that fixes things. I would argue what I do is probably the least important thing in the grand scheme of what happens to that patient. Because patients are never upset with me. They get upset with the office. They get upset with the follow-up, the fact that nobody called their medications in. Somebody dropped the ball about their appointment. They love us, but then they get upset with your staff. Why? That's not the staff's fault. That's the person who's leading the organization's fault.

So if the leader leading the organization excels in allowing all the other individuals to feel as though they're part of the greater collective and they're part of the team, everybody then begins to take ownership and that's the culture that we have. So I think that's what creates the environment. It creates the experience and it's what brings patients back over and over and over again. Like any other service industry, there needs to be change. You need to be adaptive and guess what? You need to listen to what the patients are telling you. The evolution of healthcare is such that whether you're going to get it through a Zoom call online, or there's a competitor that's upping their game and realizing, wow, things have changed. This is not medicine in the 1970s, '80s or '90s.

The 21st century affords the ability for patients to say, "You know what? I'm going to question the care that I got. I'm going to question the bill that you sent me. I am going to go online. Despite the fact that you want me to have my testing here, I'm going to go online and find a testing center that doesn't charge me additional $200 just for showing up." Just about everything with state regulations and federal regulations in mind that can be done outside the hospital will be done outside the hospital. Hospitals will always serve the acute care community. There's no doubt about that, right? It's the one thing the United States does very well. We have very good acute care services. You have a heart attack, 20 minutes later, I can open an artery in your heart. Go in through a tiny little hole in your wrist and you could be home the next day within 24 hours. You get into a motor vehicle accident, we have shock one trauma centers that receive a helicopter, take you in and have the most experienced people from a nursing and a physician perspective care for you.

We do amazing at that and we will continue to do that, but that's what hospitals will provide. The rest of it is all going to be kind of late term nursing care type stuff. I've been in hospital systems for three decades. And I wish if they would simply just listen to the cries of the physicians and the nurses and most importantly, guess who? The people who actually experienced the system as a patient. My gosh, they would be truly places of healing. Isn't that what a hospital is supposed to be? A place of healing. How do we not have private rooms for every single patient? Why? Is that truly that unaffordable? I don't think so.

It's about caring for people. So we've become so disconnected in the realm of the phone, the Zoom link, and every other piece of technology, people have forgotten that the only thing that matters in medicine is one individual caring for another. And that one individual or group of individuals that has the capacity and the ability to actually care for somebody. When I use that term care, I don't mean by looking at their labs or doing a procedure. You know what? The greatest care in the history of the world is holding the patient's hand when they're crying. It was hugging that patient or their loved one when they're not feeling well. It's the same things that we would do for anybody in our life that was going through some hard or difficult time. But we underestimate the value of humanity and medicine.

It used to be a thing. It's no longer a thing. What was once the norm has become something that I would argue is almost universally absent from what we do for patients. So for me, that's what we are trying to take back. There are groups of physicians and nurses, we want back what we know works for people. Because I take care of you like you're my mother, my brother, my sister, my child. And that's the most important thing. I tell the medical students all the time, "When you go into that room, and you're wearing your white coat and you're feeling really good about yourself, remember when you leave the hospital and you take that white coat off, you are no different than the person that was laying in that bed." And the only time you'll ever appreciate that is if you've actually experienced it. So you have to remember that, one day, guess what? Everybody is on the other side. One day, I am going to be laying in a bed. You know why? Because I've been there.

I can tell you brief story, not to digress. I got very sick with vertigo many, many years ago, so much so they thought I had ruptured a vertebral artery. So they had rushed me to the emergency department. In the emergency department, in my own hospital, I had all the physicians and nurses that knew me. It was probably one of the most bare experiences I've ever had in my life. I wasn't well. I wasn't sure what was going on, and I was scared. It was the first time in my life I was actually scared.

And ironically enough, despite all the things they did for me, all the medications they pumped into me, all the CAT scans, all the doctors running around like crazy. It was a nurse that I had known for probably 15 years that basically came next to me, sat down and held my hand. Literally just held my hand. I remember that touch to this day. And it was probably seven years ago. And every time I see that nurse... And I had told her, I said, "Every time I see you, I am going to hug you. And I am going to remind you what you did for me." Because it was the only time I felt safe. All these crazy things were going on, the greatest and latest technology. Everybody's trying to help Dr. Espinoza. He's one of our own. Nobody ever bothered to put their hand on me.

She had the wherewithal to realize. She sensed I was not well. And simply by holding my hand for maybe 20 minutes, it changed everything for me. And that's medicine. It's easy to fix things. It's easy to prescribe drugs. It's hard to care. It's hard to care, especially when the environment is so chaotic. So those are the things that I try to share with those around me. It's the culture that we try to develop. So when I talk about an OBL, that's what I'm talking about.

Can you talk about the financial aspect of moving procedures from a hospital into an outpatient lab?

Yeah, another good question. Right? Because at the end of the day, we are all involved in our livelihood. In our livelihood, like any other profession, there is a monetary component to that. When physicians do procedures inside of hospitals, the beneficiary generally speaking are hospital systems. When physicians do procedures in the office-based setting, the beneficiary goes to the physician and the practice that's performing the procedure.

And arguably that's really the way it should be. And I'll tell you why, because I think we as physicians do a much better job at cost control and lower complications and improved quality across the board than anyone else can do. And albeit, yes, it's a tremendous expenditure to run an OBL. So from my own experience just to give people who may be listening to this podcast... What does that look like when you open up an office-based lab? Well, you have to find a space. You have to then lease that space. You have to fit that space out. And not only is it fitting the space out, but then you obviously have to incorporate all the things that you need, from the medications that you'll be administrating all the way to the imaging equipment across the board, the ACLS, the investment in the staff. So it's a fairly robust investment, but again, it's an investment in yourself, again in the organization and so it is a very costly endeavor.

I think by reducing complications, reducing hospital length of stay, avoidance of hospital admissions, reducing infections, you're able to control that cost. So I think when you move into an OBL setting, you can automatically assume that there will be a significant expenditure from a monetary perspective. More importantly, you have to understand that there's going to be a significant monetary benefit for the practice. And when we make additional money working in an OBL as the monetary value shifts from hospital to physician, when I make more money, I don't put it in the bank and invest it. I take more money, I invest it enhancing the quality of the practice for the patient and I think that's a big major thing that people need to understand is that physicians and anyone who goes into an OBL or ASC type environment, the goal is to make more money so that you reinvest in your infrastructure, in your employees, in your practice. So you can continue to enhance the services that you're providing for patients.

Can you talk about your work with the Intersocietal Accreditation Commission (IAC) and the importance of accreditation?

Yeah, for as much as I can speak to that. So I sit on the board of the IAC, which is the Intersocietal Accreditation Commission, which is an organization, which is a multidisciplinary organization, which seeks to set standards across the board for everything for ASCs or vein centers, or basically any environment where patients are going to come into contact with physicians that need to be providing a very high level of quality care.

And one of the things that always lacks in the healthcare environment is uniformity in how a wide swath of physicians all with different training, different board certifications, how can we come to some fundamental commonality of what we all feel is a basic fundamental standard of care? So the ISC, for example, accredits vein centers. So if you want to be a physician that participates in doing venous intervention, both superficial, cosmetic, perhaps even deep venous, et cetera, there are certain standards of care that we should all employ from a basic understanding of the educational and the training components that go into it. But more importantly, the quality and the safety that comes out of it on the other end, right? Because at the end of the day, it's all about protecting the patient. I can't over emphasize that. It gets lost in the weeds. I sit on all these boards, and we forget, it doesn't matter. The only thing that matters is the patient. And it's so hard sometimes to get that to resonate with people.

So that's why I'm a huge fan of the IAC. I hope that I can provide some insight. And I think that's why they engage physicians like myself and others from vascular surgery and neurology and interventional radiologists and interventional nephrologists, because it allows everyone to come together as opposed to simply being in isolation or have these silos, which is very common in medicine. You want this, right? I mean, it's a community of a healthcare system where there's so many talented people in there, but if we're not talking to one another and we're not holding each other accountable for what happens to patients, then we're not doing our jobs, right?

So there's the component of being a physician, doing your job per se, in that regard. But then there's the larger commitment to patients, not only within my community, but in the country, if not globally. So these boards like the Vascular Disease Council for SCAI, the IAC and the IAC right now is collectively working on and has recently opened up for public commentary. So we always do very similar to what Medicare and Medicaid services does. Group of physicians and other individuals that have interest in these environments, we spend months, literally months organizing, debating, rewriting, and re-editing group of what we think are standards that really meet the expectations of all the players across the board.

Understanding the one principle that we work on is we are not looking to tell physicians how to practice medicine. All we want is them to understand that collectively from a multidisciplinary perspective, our goal is protecting the patient. And we hope that they can see the greater good in commonality when a group of physicians comes together and sets the bar really high and says, "These are the basic fundamental, bare minimum standards that we would expect physicians to partake in order to make sure that patients are doing well."

So then you can then petition the IAC for accreditation. You have to apply. You have to then re-certify every couple of years, and yet it costs you a little bit of money, but it always reinforces you. It's like continuing medical education, right? It always reinforces you that, yes, things change. You have to be at the edge of everything that we're doing. We have to make sure that all the latest and greatest, not only in science, but also in standards of care and quality for patients is being upheld.

So those documents are phenomenal. And then once we've created the document, we opened it up for public commentary. So it's posted on the website, emails are sent and we ask people to comment and say, "Hey, listen, what do you think?" We're just a group of physicians. We do represent the wide swath of individuals out there, but we know we don't necessarily have everyone's voice. This is now your time to voice potentially what you think maybe we got right or more importantly, what did we get wrong? Or what did we miss? We're not fallible.

After the public commentary, we then go back into the editing mode, the board meets. And once the editing process is done, then it moves to the next level, which is publication, where they come out with a group of standards for any organization that, again, they don't have to... There's no mandate that office-based labs or ASCs have to be under the guise of the IAC. For example, it's just one accrediting body, right? There's many out there, but we think it's a really good one that really serves the physician community, because we're looking to serve the patient, which again is the only thing that matters.

What do you expect to happen for your center going forward? And what do you expect to happen for cardiovascular procedures in general?

I'm really excited about our OBL. It'll be the first time that I've owned a facility. I've partaken in them previously. Now I'm going to be really the owner that's running the day-to-day operations. So I'm ridiculously excited because I know everything we do. Not only is it fun, it's just successful. And you know that when we approach the patients and we tell them, "No, no, no, you don't have to go to the hospital. We can just literally going to go right through that door over there, and we have this amazing facility. You can't see it now, but when you get in there, I think you're going to like it. I think you're going to be impressed. And guess what? You're going to see other people on the other side of that door that you already know, that know you and you're going to be welcome."

So I'm really excited. I mean, I think my whole organization has been waiting for this for the last 12 months or so, and it's finally coming to fruition, but we just know that we're upping the standard of care in the community. We're hoping that after it opens and we've demonstrated proficiency and when accreditation potential guidelines come out we're going to be the first in line. I want my organization accredited by an organization where I sit on the board. I'll have to recuse myself and that's a great thing. And they'll have to judge us based on what it is that we do. And I think because of what we do, we're going to get accredited. And then I think that's awesome, and then we share it with the community. Hopefully then that sheds light on this thing called peripheral vascular disease that has this associated high rate of people having heart attacks and strokes and limb amputations and things of that nature.

So we're hoping not only does it resonate within our own local community of patients, but when it gets out to the community community, that people realize we're doing this so we can help and provide a service within a community where I actually live, where all my employees live, where all of our patients live. There's nothing better than being that local bakery, right? You know that goes there. They know your name. They know on Sunday morning you want your chocolate eclair and a black cup of coffee without you even having to ask for it. That's who we want to be. So we're really excited about it.

What does that mean for cardiovascular services? Well, eventually we may move into a hybrid model because I think ASC is also important. The OBL, we are limited to the types of procedures that we can perform. So we can't do TEEs or pacemaker implantations and things of that nature. So as my practice grows, I'm lucky enough to garner another physician or two that would want to come in and join the greater collective, and that can provide additional services. That's where I think we would look to get into a hybrid model, but I see almost invariably, all cardiovascular procedures, short of something like open heart surgery and things that are surgical or cardiothoracic surgical in nature, they can all be done in the outpatient setting.

There's no reason you can't do a pacemaker in an outpatient setting. There's no reason you can't do a trans-esophageal in an outpatient setting. I would argue you could do a TAVR in the outpatient setting, as long as you have demonstrated proficiency safety, and guess what? You have all the right talented people in the room with you. And oh, by the way, they're happy because you're paying them the way they should be compensated, and they understand that they're part of a team and they feel valued. I don't think there's a single cardiovascular procedure minus the ones that absolutely necessitate being in a hospital that cannot be done in an OBL or an OBL hybrid ASC type environment.

Is there anything you'd like to bring up or emphasize about what we discussed today?

I want to empower the healthcare community. And when I say that, it's everything from the people at the front desk to the medical assistants, the physicians' assistants, the nurses, the nurse practitioners, the doctors, people who are actually physically coming into contact with patients every single day to realize how much power we have. And when I say power, I don't mean an all encompassing way. Power in the sense how we are able to impact other people in a positive way. So the power of the human interaction, the doctor-patient relationship, the nurse-patient relationship, how invaluable and how compelling that is. Because I don't care how technologically advanced medicine is and will continue to become, there is nothing more compelling that happens between two people in a room behind closed doors, where someone is coming to you in a time of their greatest need, and you are there and able to help those interactions.

It's so difficult to explain as a physician how meaningful it is and how we take those people home with us. And when our patients pass on, how affected we are. When our patients have success, how excited we are. It's everything that we do. And I want to empower. I want them to build your own hospital, build your own office-based lab, build your own ASC. I know it's cost prohibitive, but there's mechanisms and there's means. Come together, stop breaking each other apart. Keep the community of healthcare providers one. It's that whole concept of union. We can control the mechanism. We can take back what medicine used to be, what will continue to be at least for the small contingent of us that are able to do it. Most physicians are no longer on their own. Very unique in that regard.

I was told a million times by a million different people, "You will never survive. You can't practice medicine as a solo private practicing physician in the 21st century." Six years later, I can tell you, I have never been happier. I have never been more humble. I have never been more grateful and I have never felt more like I was a cardiology fellow all over again, as giddy as I am today, literally 20 something years later. Why? Because I love what I do. I don't want to be told what to do. I know what to do.

I would leave the conversation with, you can do it. You can do it on your own. You can do it surrounded by ridiculously talented people. Put together small pockets of teams and simply grow and build from there and that's what we're going to do. And that's what I'm going to continue to emphasize and try to inspire my colleagues to do, and I do that every day. I have a lot of physicians that call me and say, "Andrey, you've been on your own for six years. How did you do it? I don't understand." You can still go out... Listen, you might make a little bit less money but guess what? I take a day off a week at work now. You know why? Because I can, because I want to spend time with my kids. I want to be with my family. I want to travel. I want to do other things.

It doesn't mean I'm still not working on that day off. Today is my day off. And I'm doing this amazing interview with you, right? Because I feel compelled, my story and everything in it, I want to share it with people that are out there scratching their head, wondering, "Can I do this?" Most people do things or don't do things out of fear or the unknown. They don't want to venture into something where they think, "My God, am I going to be able to survive out there?" If I were to walk out of here tomorrow, my patients would never go to the hospital again. It's that bond thing. My patients will follow me to the ends of the earth. Again, it's not an egotistical thing. It's because, guess what? I love them and they love us. So they're going to go anywhere because they know they can trust us. I just want to encourage all members of the healthcare environment. Go out, become part of a team, get back what we lost.

Cath Lab Digest managing editor Rebecca Kapur:

Our thanks to Dr. Andrey Espinoza for today's discussion, sponsored by Philips OBL and ASC Solutions. And our thanks to you for listening. To learn more, please visit philips.com/symphonysuite.