Podcast: Dr. David Nelson

This month I sat down with Dr. David Nelson to get his perspective on:

  • Private Equity

  • Optos

  • Genetic Testing

You can check out our conversation here, by searching "Eyecode Media" in your favorite podcast app, or you can read it below:

Christopher Wolfe, OD, FAAO, Dipl: Over the last year, I've received tremendous support from all of you to listen. I've always said that I love to do this and I have these great conversations with people in our profession because I like to do it because I enjoy it. I love to highlight those who are changing the way that we do business.

This passion has also taken time from my family. And my practice. And so when industry partners began reaching out to me to help support the podcast, I was beyond flatter. And while initially I got really excited about being able to further support my family and give back to my community. Also, I had to take a step back and think about why I like to do the podcast.

I turned to my wife, my dad, and other mentors like Ted McElroy, to get their perspectives, and what I realized was that if I were going to partner with companies, I required two things. First, I have to believe in the products and the culture of that company. We have to align with my beliefs and patient care.

And second, I have to maintain control of the content of the podcast. I can't say something that I don't mean, and I don't want to be afraid to have a guest on that's controversial or censor. My thoughts on a topic. I believe I've found that partner in CooperVision, their partnership will allow me to continue to improve this podcast.

Let me take the necessary time to have great high quality conversations. It will also allow me to access people in their company who are actually developing the new lens designs from the bench to the clinic. And I look forward to having a few of those conversations over the next year for a deeper understanding on how these new products are delivered to the marketplace for us to use.

So when Ted and I say. Please support those who support us. We're talking about a company who understands what we're doing with this podcast. We encourage you to utilize their resources when it's right for your patients. So thank you to Cooper vision for partnering with I code media 2020 to deliver this content to our listeners.

Hello and welcome to the Chris podcast on I code media. Today. I had a conversation with Dr. David Nelson, who is a managing, he's on the board of directors for Kepler, a private equity firm, and he talks about the benefits of private equity in his practice specifically, and also their goals for expansion into other.

other practices as well as the potential benefits in the healthcare realm in being a, a part of a private equity group and selling your practice to private equity. We also discussed Optos and, some of his approaches to utilizing Optus in practice. And I think it was a fun discussion. I think we disagreed on some things and, and I, I hope you enjoy it.

[00:02:51] With that, please subscribe to the podcast. Give us a five star review and support those who support us.

David Nelson, OD, Dipl. ABO: [00:03:01] And just so I can remember your state legislative chair for the EOA, is that right?

Christopher Wolfe, OD, FAAO, Dipl: Yes. Yup.

David Nelson, OD, Dipl. ABO: Thanks.

Christopher Wolfe, OD, FAAO, Dipl: Thanks. It's going good. But it's been busy. We've, we've had a lot of, we've got, a lot of really great staff right now. Daniel, Carrie, Katherine Hendricks. We've got Dana reason. And we actually have another Mary Bowers who, so we have these regional directors that can kind of help us engage with the state.

So when they need help, we, we have somebody that's. That knows them, that's kind of constantly hanging around with them. And so that's been really good. Mmm. So kind of, I think, I think David, what would be helpful for our listeners is to, to think about, or to kind of have a perspective of your background verse.

How did you, how did I get on your radar? How did you reach out to me first, a month ago or so?

[00:03:49] David Nelson, OD, Dipl. ABO: [00:03:49] Well, I, I've known your dad for quite a while. and, I was just thinking about,

[00:03:53]Let's see. I was talking to somebody about the vision source AMD program, and they said that you were chair of that and then [00:04:00] you were in Wisconsin doing a lecture.

[00:04:02] And I just thought I should connect with this guy because not only are you doing state ledge stuff, you're doing AMD things for the vision source group. And then as well, you know, I joined this Kepler vision group, which is a PE group. And so, I don't know, between all of those things, I thought it's time for me to get my, a conversation back with a Nebraska.

[00:04:20] And I'm originally from Fremont. I didn't really know that or not.

[00:04:23] Christopher Wolfe, OD, FAAO, Dipl: [00:04:23] Oh, I didn't know that. Oh, you know, I, I think I did. I think my dad mentioned that. And you practice here for a little bit, didn't you?

[00:04:28] David Nelson, OD, Dipl. ABO: [00:04:28] I, just, just less than a year in a hometown practice, in Fremont there, and in 85. And then my wife at the time, where we got married and we moved back to Wisconsin right after that, she did a residency.

[00:04:42] And, At Omaha. At the Banda board. Yeah. And so then we made the move to back to Nebraska and I left. But I, I grew up pretty much from the second grade too high school. I went to Carney state college for my undergrad in Indiana.

[00:05:00] [00:05:00] Christopher Wolfe, OD, FAAO, Dipl: [00:05:00] Okay. It. It's awesome how, how small the profession is because I, I meet so many people when I am traveling and, and they say, Oh, yeah, I'm from North pot, or, you know, I'm from Carney.

[00:05:12] Or it's like, wow, this is pretty cool. just, and then how so many people are interconnected. It is, and I think that's one of the fun parts about doing this is that because of that interconnectivity, there's a lot of people in the profession who have done a lot of really cool things in it to allow, you know, my generation to practice the way we practice.

[00:05:35] And so, I mean, part of the thing I think would be really. Fun to hear the story of his, sort of, your progression through, I would imagine, through the AOA chairs, or the board of trustees and then through the chairs and kind of the time described the time that that was going on in the AOA, for those of people that don't remember or don't even know.

[00:05:54] David Nelson, OD, Dipl. ABO: [00:05:54] Yeah, sure. Well, you know, I was, a was a president. 1984 [00:06:00] the student association president, like you were, I got involved in optometry a very early in my career. I became a trustee for the school that Indiana in my freshman year. My first year a cometary school. I had a friend who, you know, we all stand on the shoulders of giants.

[00:06:17] Right? Totally. I think that's a, it's a great phrase. I've used it a lot over the years. And, so I had a friend who was a. The year or two ahead of me in an optometry school, Jim Rowe, and he wound up becoming president of ASA and he had me step in as trustee or trustee elect. And then I became trustee the following year.

[00:06:34] But he kind of took me under his wing and I saw, you know, what it was like to be a, was a president of that. That's fun. I think that I'm going to like doing that. So, I got involved very early and when, you know, as you know, when you're involved in AOSA, you get involved in national structure of very quickly.

[00:06:49] And so I became. Good friends and colleagues with a much older practitioners became part of the membership committee is most students are, and I worked my way up through, the [00:07:00] AOA and through membership. but I also was involved, since I graduated in 1985. I was involved in the therapeutic effort for Wisconsin.

[00:07:08] I was on the committee, the passed bill in 1989 we were the 25th state in the country to allow optometrists to use pharmaceutical agents. So I was part of that committee with three or four, five or six others, I guess, you know, from time to time there was different groups. So I was in the legislative chair committees.

[00:07:24] I was in the hearings. I was in all of that. And very early in my career and when I first started in 1986 in Wisconsin. Okay. Scott optometrists across the country could not see a Medicare patient. Yeah. We were not Medicare certified at that point in time. So I practiced not only without therapeutics for a couple of years of practice, not being able to see anybody over 65 for a year, and then in 1987 Medicare was passed.

[00:07:51] So again,

[00:07:53] Christopher Wolfe, OD, FAAO, Dipl: [00:07:53] it's crazy. It's crazy. Because so many people, sorry, sorry to interrupt, but it's just, I think it's a [00:08:00] point worth noting is that so many people don't even think about that. And, and, and it is sort of the idea of, you know, vanishing value, right? Like, like people, you know, I'll see on, on social media where people will say something like that.

[00:08:12] What is the AOA ever done for me or what, what, the States do everything. The AOA doesn't do anything. And, and you had, I mean, how many you probably know or have an idea how many billions of dollars have been able to be billed, where we didn't even have the ability to do that. And that's like 30 years ago, not even, you know, a little more than 30 years ago.

[00:08:32] It's, it's insane.

[00:08:34] David Nelson, OD, Dipl. ABO: [00:08:34] It is. It's insane. I think it's over a half a billion dollars every year now for the last. 20 years, and, Just think about the care and the ability for a optometrist to see patients all over the country and every County in every state, where it hadn't been that way before. and if it hadn't changed, we would have not been able to do those things for these people.

[00:08:55] And I think it always comes back to patient care. And again, when I first came into the [00:09:00] state, there were a lot of accomplice. She took me under their wing here in Wisconsin. And, they told me that while the profession has changed so much since I've been in practice, you know, 2013. they were the drugless profession.

[00:09:11] They were the note touch profession, back in the sixties and seventies. And there was a pretty big battle even to put, diagnostic pharmaceutical agents in a patient's eyes because they were a large group of optometrist who really, we're very proud of the fact that they had a no touch profession.

[00:09:27] And so, therapeutic pharmaceutical agents was, in a similar way, a little bit controversial. Not every optometrist wanted to do that. Not in, not just in Wisconsin, but all around the country. there were a lot of optometrists didn't feel like they needed that kind of a authority. And, in my training in school, it would just became, it was just like, I couldn't even believe I was hearing that.

[00:09:48]But you know, you're trained a certain way. You come through a school a certain way, then you can't practice that way. And that's really a choking. And so I got involved really quickly and, became, you know, involved in the therapeutic effort for [00:10:00] Wisconsin. We passed a very, very good bill, at the time.

[00:10:02] And it turns out even standing the test of time, for. Some things that are changing in the profession from a technology standpoint. One of the other things, not only standing on the shoulders of giants that I wanted to talk about is just in general the change in healthcare that we see from a. patient needs standpoint and from a technology standpoint, you know, when I graduated from, cometry school, we didn't even know that there was going to be a thing called LASIK, with excavator.

[00:10:29]it was not covered in school. We did not know about it. I was at an AOA meeting in 1989 when I first saw that this was coming, and then it passed in 1994 and the FDA, so I'd practiced, for nine years. Without having any idea that laser could be done. We had those few years with a radial keratotomy, that now has gone away of course, because the improvements in technology, but.

[00:10:53] Ocular coherence tomography was not possible. Yeah. That came around in the early two thousands. That has [00:11:00] really changed the way we take care of patients. Wide field imaging. We use an Optus instrument as I suppose you do to, you can capture the back of the eye without even dilating the eye and you can get probably as better as good of a view or better in some ways.

[00:11:14] So with software and the technology, then you could even with a dilated exam, then as well, you know, . We have a new dry eye therapies. We're using an intense pulse light now for our dry eye patients, gland deficiencies, and it's improving 80 to a hundred percent of our patients. It's just an incredible technology.

[00:11:32] So. Yeah, it's been really fun to practice and, and continues to be more, interesting and rewarding to see and take care of patients than it ever has been. And so it really gives me a great charge that not only, we have the therapy, we have the statutory rights, do these things, we have the reimbursement abilities to get these things paid for and take care of patients in a way we've really never done in independent.

[00:11:59] Christopher Wolfe, OD, FAAO, Dipl: [00:11:59] Do you [00:12:00] think, have you ever gone back to think about if, if the people in the sixties and seventies that wanted to continue a touchless profession, or the people in the 80s who didn't want to be a, you know, a prescribing or a medication prescribing profession, you ever go back and think if, if that were the case, and that's where our profession just stayed, that, I mean, we would largely just have.

[00:12:27] Mean, barely a profession anymore at all. I, yeah, we're in the future in the next five to 10 years.

[00:12:34] David Nelson, OD, Dipl. ABO: [00:12:34] I talk about this as well. If you are not pushing forward, you're getting hit from behind. And if you get hit from behind, so severely that, You might actually be wiped out as the profession. I would agree.

[00:12:47] And you know, we've talked a little bit about AOA, the American optometric association being pretty much the mothership for the profession. And I think those words couldn't be more true before or today. Either one. [00:13:00] There is. Great organizations in optometry, a lots of different groups out there, associations.

[00:13:06] However, the AOA is the one who protects and expands the profession and, is really in charge of the future of the profession. It's been that way for 120 years. I was the 80th president and, you know, very fortunate to be able to serve in that position. And, It's really unfortunate that more people cannot experience what the AOA, is and, or does for the profession and for their practicing lives, seeing their patients all over the country.

[00:13:39] Yeah. Since I was president, there's been more than 20,000 graduating optometrists. So if you're thinking about that, I agree. I was done being president in 2002 and since then there's been 17 classes of about 1500 students. And so the profession changes over nearly completely every 30 years. Yeah. [00:14:00] What we need to do is instill the, The professionalism within our, new graduates and our young practitioners to understand that it isn't, it doesn't matter where you practice, at, in my opinion at all. And I've felt this way for a long time. I campaigned on it as a way president because of some of these things. It doesn't matter where you practice it, it matters what you do in your practice, and there's lots of different places that you can hang your hat and see patients.

[00:14:30] But if you compromise the training and the education and putting the patients first. Then you've done the wrong thing. It doesn't matter whether you own your own practice or whether you work for or not from all of this charter or another optometrist or a retail location or anything. you are changing the way you do things because of where you're at.

[00:14:51]then you're doing the wrong thing and there the AOA is there too. Give me some guidance, and to be part of [00:15:00] something where you can understand there are guidelines or practice patterns and a practitioner should follow them. And there's reasons why those are developed.

[00:15:10] Christopher Wolfe, OD, FAAO, Dipl: [00:15:10] I completely agree with the idea that, that you, it doesn't matter where you practice, it matters how you practice.

[00:15:17] What I think is, is interesting though is, is, is. Is it true that it is easier to practice, to the fullest extent at any different location? What I'm saying is, you know, does, where you practice Mmm matter in the sense that it, it can make it either more or less conducive to a particular type of, you know, a, a type of utilization of the scope of practice.

[00:15:46] We have.

[00:15:48] David Nelson, OD, Dipl. ABO: [00:15:48] Well, I've, I, you know, I've thought about this for a long time and I got a very early impression working in a referral center in my fourth year. And what I found and what I [00:16:00] saw was that we had really good practitioners in locations, in places that I wouldn't have expected good care. And I also found that some patients who were sent in by practitioners who own their own practices, we're not as what, I'm not what I expected.

[00:16:21] So I, I think it really doesn't matter where you practice, you can keep your standards intact regardless of where you are now. You can be influenced by your setting and by the people that are. running a setting, and that's actually whether it is independent or, solely owned or whether it's a retail setting, which you might think is going to dictate the standard of care.

[00:16:47] However, it can be influenced, but at the same time, it doesn't have to take over the way you practice. I talked to lots of doctors, with Optus and, you know, one of the things that, Optos [00:17:00] feels is that both dilation and optimal technology is best. So both as best. And I talked to doctors who are not routinely dilating before they put an op to awesome.

[00:17:10] And I say, do you ever remember a time when in school that you did not dilate a patient? Four years of training, two years in clinic? Maybe a residency. Did you ever not dilate a patient? Because a widefield look where, look at the back of the eye and the retina and seeing the entire retina is part of the conference if exam.

[00:17:32] So where did, where did doctors lose that? Where did they lose the understanding that they were trained a certain way for a certain reason? And that means that you're supposed to take a look the back of the eye. It's in its entirety. So, again, it doesn't matter where people are, if they're not getting a good look at back to the eye, that full look at the back of the eye with technology, without technology or, or with both.

[00:17:56] I don't think they're doing the patient a

[00:17:57] Christopher Wolfe, OD, FAAO, Dipl: [00:17:57] favor. Yeah. Yeah. I [00:18:00] agree. This is, this is a topic I didn't, you know, this is kind of how I want our conversations to go, but this is actually quite interesting. I've had, you know, I've, I've listened to discussions, I've even read. you know, articles that are, are kind of, are publications that have, you know, a point counterpoint and, and, people that I have a ton of respect for.

[00:18:22] You mentioned Bob. Bob is huge and dilation. Paula Jamie's huge on dilation and yeah, so like, guys that profession are, I mean, I owe so much to. Well, so the things that they did, not my scope of practice point, but from a visionary standpoint where they could say, look, we don't have to lose our patients.

[00:18:44] You know, when we send them in for cataract surgery, we don't have to lose them ever. We can, we can do a, there's a better model for the patient that, that we can develop. So, But, so when I read these articles, I feel like everybody's talking pasty. You know, in our practice, we don't just use Optus. Right?

[00:18:59][00:19:00] there's, there's a, I believe, I mean, I took completely agree with you, is that there is, it's both end. and so, so I always like, on the one hand, you hear well, the people that are talking about don't, don't use an Optus. It's not, it's not like use it in the right way. It's just don't use it. Right?

[00:19:20] Or like you can't really rely on it and you got to have dilation, dilation, dilation. It's like, wait a minute. There's, there's a way you can rely on this technology that allows you to enhance the care you're giving as opposed to completely subverting the care that you were trained to give, as you're saying.

[00:19:36] So why do you think there's that disconnect.

[00:19:39] David Nelson, OD, Dipl. ABO: [00:19:39] because they haven't used the technology and they don't understand the research. So, and by the way, I am a consultant for op toss. It's one of the things that I did starting a right away after I was done being president of the AOA. And if you can imagine someone, as a past president of the AOA, supporting Optus technology in any way.

[00:19:57] In 2003 was kind of [00:20:00] a little bit out there and I took a few hits for it. however, I think, the technology and the research has proven true over the years and then the improvement of the device and, and, the ability for the capture has been pretty incredible. There's now 800 peer reviewed papers utilizing ultra wide field imaging with Optus technology.

[00:20:22]I don't believe there's any, any device imaging device. Out there that has more than 800 papers. and it is specific to our plastic novelty. So I just, unfortunate that an early call after my, me being president wound up being something that is so widely used. And so, so well-respected and all the eye care community today with some of the devices that are now available in ICG and forced new geography.

[00:20:50] But again, putting it, putting that aside. I think sometimes when I talked to a patient that is so certain that they have a certain contact lens [00:21:00] brand, they're almost 100% wrong.

[00:21:03] Christopher Wolfe, OD, FAAO, Dipl: [00:21:03] Yes.

[00:21:05] David Nelson, OD, Dipl. ABO: [00:21:05] And a lot of times when I hear the, the level of. Animosity towards or supporting a certain or against a certain technology and or, procedure.

[00:21:16] I find that usually there's something not quite right about how that's so vocally being defended. again, it's probably because they haven't used the technology. Yeah. And if they don't know what it can do, then they probably can't comment on that. if they haven't used it in practice, they probably just don't have any business commenting on it.

[00:21:38] Christopher Wolfe, OD, FAAO, Dipl: [00:21:38] Well, I think so. So to jump in, because I, what I would say my perspective is, is that, cause, cause I think the argument would be they probably do see. times where somebody missed something blatant that, with a patient had op tosses, you know, and, and they, they miss something where the patient had symptoms or no symptoms or whatever.

[00:21:59] And [00:22:00] so then, the, without using it, they say, well, this is how this is the problem with it is, and I, I would, I would actually agree with that. Is that. If you're coming into it to think all I'm going to do now as an Optus, and the reality is, is if you weren't looking at all before, right, or you were just looking with a super field on dilated, it's way better.

[00:22:19] David Nelson, OD, Dipl. ABO: [00:22:19] Let's guarantee the same person that this is it with an house is going to miss it with a dilation. But again.

[00:22:25] Christopher Wolfe, OD, FAAO, Dipl: [00:22:25] I is exactly what I would say that man, that's exactly what I would say. And, and, and as you know, when you use it, there are things that, no, ma'am, I don't care how good you are with scleral depression or a Goldman three year, three mirror, and just blowing those pupils up.

[00:22:38] I've sent, I've sent, patients with progressive retina to retinal surgeons. They, they miss it

[00:22:44] David Nelson, OD, Dipl. ABO: [00:22:44] multiple times. And yeah. So,

[00:22:49] Christopher Wolfe, OD, FAAO, Dipl: [00:22:49] yeah. So anyway, I mean, I guess I agree with you that, that, but on the other side, it's, I think where they're concerned is that people are misusing, you know, [00:23:00] they're worried that somebody's gonna come in with flashes and floaters and they're really worried about the profession.

[00:23:03] Right. The patient first, but also the profession that. Patients are coming in with with their concern is coming with flashes and floaters. We do. At Optus, everything's fine, right? Like

[00:23:12] David Nelson, OD, Dipl. ABO: [00:23:12] no,

[00:23:14] Christopher Wolfe, OD, FAAO, Dipl: [00:23:14] legally, you know, obviously no, but, but I think that's, that's their primary concern. And I don't know anybody that does that, but I think that can be one of the, the concerns they have.

[00:23:24] David Nelson, OD, Dipl. ABO: [00:23:24] Well, some people have asked me in the past. Yeah. When you do, when you get an autopsy, you throw away your indirect or you don't know. And you know what? I don't throw away my 90, I don't throw away my 78. I, I still have great uses. I even use a direct scope every now and then. they have value. You really never know.

[00:23:45] Throw away any particular way of taking care of a patient unless it's completely antiquated. But, you just add, you add to your armor of, of things that you can utilize in order to take care of people. and I, again, back to [00:24:00] mrs amiss and my guess would be. If a patient is not being worked up correctly, if you don't have, Paul Jamian told me one thing.

[00:24:08] He said, if you don't know what you're looking for into the back of the eye, by the time you pick up your scope, you don't know what you're doing. Yup. It all comes through your review of systems and your chief complaints and, finding out exactly when and how these things happen. And if you haven't got a good differential, by the time you're ready to take a look at the back of the eye, you're probably swimming.

[00:24:30] Yeah, yeah.

[00:24:33] Christopher Wolfe, OD, FAAO, Dipl: [00:24:33] Yeah. I think that's, I mean,

[00:24:34] David Nelson, OD, Dipl. ABO: [00:24:34] not swimming grounding.

[00:24:35] Christopher Wolfe, OD, FAAO, Dipl: [00:24:35] Yeah, you are. And of course, like, that, so the, the challenge I think with, comparing. You know, even, you know, there's such a different, style of practice when you're, and I've never been in a referral practice, so, so I don't know. I mean, I mean, we get a lot of referrals for, for corneal stuff, but, but in general, there's not, I'm not in a primary referral practice.

[00:24:58] Right. I got [00:25:00] secondary center, a tertiary center, but Mmm. There's a drastically different approach. To being in a referral. I just, for example, you know, you might get a referral for a swollen nerve. And so you're already knowing, okay, well this patient has some neurological stuff going on. These are the things that we have to differentiate between disc edema and pamphlet DEMA and how do we differentiate those things and et cetera, et cetera.

[00:25:24] You just go down the line. Well, when you're in primary care practice, and you may do all those other things, right? If you're fully using the knowledge, education and training we have, you may, you may manage a lot of that stuff in your practice. but it's the. It's the kind of loling to sleep, I think of, you know, asymptomatic, asymptomatic, not right.

[00:25:44] You know, you're not asking questions to screen, you know, high, high, likelihood, common diseases. And there's like normal, normal, normal, normal, normal. And then when you get to the point of feeling like, Oh, a patient has a new symptom that's sort of weird and I'm going to pick up my drink, I don't really know.

[00:26:00] [00:26:00] I, I've forgotten what I'm looking for, right? I have, I, so then I am drowning.

[00:26:04] David Nelson, OD, Dipl. ABO: [00:26:04] Great.

[00:26:05] Christopher Wolfe, OD, FAAO, Dipl: [00:26:05] And so is it just a different way, you know, if you're not, if you're not doing that, I think on a regular basis, which is one of the reasons I love to talk, is that it forces me, I'm in a primary care practice, but we take care of all those types of patients.

[00:26:16] But it forces me to rethink through like, what's my differential diagnosis? What am I seeing? Is this normal? Is it abnormal? And doing it on every patient. where I think if you do get to the point where you're, you know, in a, in a. If you are practicing, in a way that is, just waiting for patients to kind of tell us what's wrong or tell us that they have symptoms, then, then we're not used to thinking through what we might be looking for.

[00:26:41] David Nelson, OD, Dipl. ABO: [00:26:41] Yeah. The way I guess I was either trained or have come about seeing patients, my feeling is the, a patient doesn't seem to ever come and just because they want to waste 30 to minutes to an hour of their time. Yeah. There's something, there's something in the back of their mind. [00:27:00] They might think they have cancer.

[00:27:01] They might think there's something wrong. Everyday I see 15, 18 people a day and not one of them are just coming in to waste time. So I'm always looking. I asked three questions before I, I finally figured out why they're here. And, you know, basically. So how are you doing? great. how are your eyes?

[00:27:19] Wonderful. Do you have any trouble seeing. Well, there's this left I've been having a lot of.

[00:27:24] Christopher Wolfe, OD, FAAO, Dipl: [00:27:24] Yes, yes.

[00:27:25] David Nelson, OD, Dipl. ABO: [00:27:25] And when they open up to you just a little bit. So, but again, I go with it. I go with every day saying, you know what? Nobody's coming in here just to waste time. They came in through, they may just need their script.

[00:27:36] I understand that a lot. but same time, there are lots and lots of times. What about something that has been bothering him and I need to find it.

[00:27:45] Christopher Wolfe, OD, FAAO, Dipl: [00:27:45] Yeah. I love that. I, I, I guess I've never thought about it that way, but, but that's been always my approach is to say, you know, I'm going to ask as many I see signs when I'm looking at the front part of the, I'm going to just keep asking questions.

[00:27:56]you know, if, if I see that, for example, you know, my Bowman gland [00:28:00] dysfunction is so common, as you know, with, with your IPL, and it's, and, and largely, I think it. Is thought that it's asymptomatic so often, even in early on in the disease. But if you ask the right questions, it is not asymptomatic. And so just like as I'm going through, I'm, I'm asking you what I'm seeing, what I'm telling them, what the, what I see, but I'm also asking questions.

[00:28:21] I just don't stop asking those questions. And. some of them I feel like I'm a little annoying, but the reality is, is by the time I, I would say 95 to 98% of every single patient that's in my chair, if I ask them the right questions they've got, you know, they've got something, like you said, something that's bringing them in.

[00:28:39] It's always confusing to me when, when I finally get to the last question I could possibly ask and I'm like, there's really no other reason then. Then they just thought, well, it's time. Right? And that's all they thought.

[00:28:50] David Nelson, OD, Dipl. ABO: [00:28:50] And sometimes that's the case. Yeah. Yeah. But we've been doing blood pressures on every patient for about 15 years.

[00:28:56] We get a lot of pushback on that. but I think it's [00:29:00] one of the more important things we do. I went to my dentist about a year or so ago, and they were starting to do carotid Dopplers in their office. Wow. That's, interesting. But you didn't take my blood pressure. Have you ever really thought about what you could do for your patients?

[00:29:16] I saw on the, in the news just the other day, that 75% of patients can name their primary family doctor. 79% 75% I would say probably that's pretty strong. I'm going to say based on my population. It'd be, it'd be less than 75, maybe more than 50. But most of them haven't seen anybody. for a while. They know who it is.

[00:29:39] They haven't gone in for awhile. They don't get regular physicals. And I see blood pressure, all the time, all the time. And w almost all of them push back on the blood pressure and saying that that isn't the way it usually is. And so I have to have a five or 10 minute conversation about the fact that it does affect.

[00:29:57] Right? And even if it's a Radic or sometimes high, that [00:30:00] means it's unstable. And that's just different than high blood pressure, what you would think about it. But a guy just last Tuesday, Wednesday one, he was a two 20 over one 20 and he wouldn't go, he wouldn't go to the ER. And I called him the next day and he didn't answer the phone.

[00:30:17]and that's, and I said, you know, and I had the conversation with, I said, you know, this is the kind of thing that if you leave it untreated. Somebody who will be picking you up off the sidewalk and taking you the hospital. Yeah. Well, you will cycle out. And so, but anyway, I have those patients, those kinds of conversations with patients on a pretty daily basis, I'd say.

[00:30:38] But just taking blood pressures and getting a BMI, those two things are really, really important for taking care of a N I a N I patient, so we get them on everybody. Yeah.

[00:30:49] Christopher Wolfe, OD, FAAO, Dipl: [00:30:49] If you so to, to link that with, with Optus, you know, my dad and I have this, these conversations, you know, I don't think they're, I mean, I don't know that when I, when you, when [00:31:00] you have an Optus, how often I see patients with peripheral hemorrhages and you know, you look at their blood pressure and it's sort of borderline or maybe even a little bit high.

[00:31:09] And, or it's, it's completely normal, but I always tell them, you know, there's really three things that we want to rule out, right away that that's going to cause this. The most common ones are going to be like high blood pressure, diabetes, high cholesterol. And if all of those things are good, then we can sort of chalk this up to coughing, sneezing, you know, lifting those sorts of things.

[00:31:26] And if we start seeing it worse, and then we made big some person, other additional tests. But you're right, how many people sort of just like blow off? Like, well. I'm in your office. It can be my high blood pressure, right? Like, I'm in an eye doctor's office. It can't be blood pressure. Right, right. and, and, and still to this day, you know, I, I, I was talking to Barbara about this, in December, and, you know, we, it is amazing to me.

[00:31:50] I do think we need to talk about the systemic. diseases that we can see in the eye. It's always amazing that, you know, patients don't understand that and the public doesn't understand [00:32:00] that. but I also think we need to just continue to do a very good job of detecting and educating patients about what's going on in their eyes.

[00:32:06] Like the primary reason that we're there. But it is amazing when I, when I, when I show them hemorrhages and their blood pressure is, you know, one 55 over 98, and I'm saying, you know. Yeah. When was the last time you saw your primary care doctor? Oh, you know, last year. What was your blood pressure? I dunno.

[00:32:25] They were fine with it. Yeah. There it's always fine. Yeah. Yeah. and so it's like, it is amazing that they, Oh, I didn't realize you could see that, you know? Yeah. I have somebody in mind

[00:32:35] David Nelson, OD, Dipl. ABO: [00:32:35] every week and sometimes a couple of times a day. it is, it's, it's astounding how few people understand the systemic effects that can happen in the eye.

[00:32:46] I tell them that, well, you know, the eyes are the only part of your brain that sticks out of your head. You can

[00:32:51] Christopher Wolfe, OD, FAAO, Dipl: [00:32:51] it. Yeah.

[00:32:52] David Nelson, OD, Dipl. ABO: [00:32:52] It's the only part. and that's how close we are to being able to see what's going on in the rest of your body. One of the things that Optus I've talked to [00:33:00] doctors about as well is that it's a develop because it's a great way to take a look at mechanical problems with the retina.

[00:33:09] Tears detachments, holes. But what is really good at is managing chronic disease and helping you manage chronic disease because those little little hemorrhages, five 10 micron hemorrhages, it's 20 micro hemorrhages. You cannot. Physically see them with a dilated eye exam and it's just not possible. We, I was just at the, optometry retina society meeting and representing off to us, and we had, practitioners, there's about 175 and we were able to image 17, 18 of them over the, you know, the group work workshops and there were 10.

[00:33:42] That had peripheral hemorrhages of 18 and optometrist. They were all optometrists. one had diabetes and another one had macular degeneration. But again, it, you think it is a perfectly healthy, normal population that gets eye exams every year. Well, optometrist, maybe, yes, maybe no, but at the same time, 10 [00:34:00] to 17.

[00:34:00] Yeah. I was even a little shocked at that.

[00:34:02] Christopher Wolfe, OD, FAAO, Dipl: [00:34:02] Well, so then what do you make of it? Because a lot of times I do feel like, Because of course, like when you send them to the primary care doctor, it's a, it's basically a black hole, right? Like, like that's like ophthalmology referral centers used to be is, you know, you're never going to see that patient back where you're never gonna.

[00:34:19] You all see the patients back. But I'll never hear from the primary care doctor. So nice letter, you know, all those sorts of things. What do you are, are you. Cause it seems like we just get less of that as feedback. And I just wind up chalking it up to, to, you know, Val, Val Salva, you know, those sorts of things because we don't hear back about what the results are.

[00:34:40]and then we're monitoring that patient back and they'll be like, Oh yeah, everything was okay. But I'm thinking how many times are they, are they saying it's okay, but the blood pressure they're measuring is at that borderline level. Yeah. So what does he, is there evidence on that? I just haven't seen it from Aptos.

[00:34:54] I bet there is.

[00:34:55] David Nelson, OD, Dipl. ABO: [00:34:55] Well, so for diabetics, if there's a study that was [00:35:00] published in March of 2016 that showed that if a diabetic patient has predominantly peripheral lesions, no macular involvement, very no macular involvement, but, adopt blot hemorrhage in the periphery, those people have, five times greater risk over four years of developing two levels increasing or not.

[00:35:16] Hmm. And that was a 400 I study. It's been repeated and it could be up to 16 times more likely to develop, two levels, greater retinopathy. And there's some reasons for it. Bill Jones is really good about this. And, I don't know that, you know, bill, he was a early, early peripheral retina educator and he used to do a lot of, a lot of educating talks around the country for doctors.

[00:35:38] And, he said they basically, everything starts in the periphery first. Everything. And, I was a little bit

[00:35:45] Christopher Wolfe, OD, FAAO, Dipl: [00:35:45] skeptical because that contrasts with, with Dr. Alexander or, yeah. God rest his soul. I always forget his name. Larry Alexander. Larry Alexander, right. Is his, his point was. The only thing that matters in the periphery is symptomatic or I mean basically if [00:36:00] it's, if it's, if it's asymptomatic, it doesn't matter in the periphery, what you're saying is Joan says completely the opposite.

[00:36:05] David Nelson, OD, Dipl. ABO: [00:36:05] I would, and I would say based on my work and research that I've seen using Aptos instrument for the last 17 years. Dr. Jones is correct. Yeah. And there was a really nice editorial or not, I think it went with the March 16, 2016, Academy of ophthalmology journal that published that report. And the editorial, ophthalmologist said, you know, I'd trained at university of Wisconsin and I had been told that the periphery mattered.

[00:36:32] And now this study proves it, and he said over the last 25 years, I kind of forgot about that, but it turns out it really matters a lot. And this study shows that, and it's been replicated again twice. I don't have the actual citations, but I can get them.

[00:36:47] Christopher Wolfe, OD, FAAO, Dipl: [00:36:47] No, that's okay. Yeah, I mean if you do, if you do, I'll put it in the show notes.

[00:36:51] I believe you. But if you have them for the listeners, they, they might appreciate reading through them. Let me look, let me ask you this. Do you, so I guess, let me rephrase the question cause [00:37:00] I don't know. The answer is, is how often are we going to see those peripheral hemorrhages and not find the big three?

[00:37:06] Do you know that?

[00:37:07] David Nelson, OD, Dipl. ABO: [00:37:07] Probably about half,

[00:37:08] Christopher Wolfe, OD, FAAO, Dipl: [00:37:08] but, huh. Okay.

[00:37:10] David Nelson, OD, Dipl. ABO: [00:37:10] One of the things that I see commonly is high exercising. individuals who have small little bleeds and or Irma's in the periphery, it's, it seems to be some very, very active people do have those kinds of problems. so if you see a very fit person and you see a little, micro hemorrhage or neuroma, it probably is just because they're high exercises.

[00:37:33] However, putting those people aside, if the overweight and obese population. Is one third to two thirds of the population. And if there's a 40 million undiagnosed diabetics, I would imagine that it's probably impending prediabetes or prediabetics and, or high blood pressure or the two together, that have yet to be [00:38:00] found.

[00:38:00] And one of the problems with diabetes is, you know, of course, the specificity on diabetic testing. Is 67% for each and the fasting blood sugar group. Google local's tolerance and, helped me with the other one. And well, yeah, A1C. A1C is pretty helpful. I don't know what, whether that's the one or not, but

[00:38:20] Christopher Wolfe, OD, FAAO, Dipl: [00:38:20] you need to, you're looking for another one

[00:38:21] David Nelson, OD, Dipl. ABO: [00:38:21] diagnosis for diabetes, and it's just, this specificity is just not there.

[00:38:26] So it takes them a long time to come up with a diagnosis for diabetes. In my opinion based on having seen patients, we'll see early signs of diabetes before they get called as as diabetic. And I think the same thing with high blood pressure. And, so I would say about how I see five to 8% of my patients having these peripheral hemorrhages.

[00:38:46] It's, I don't know whether I have a study for that or not, but it just seems like one out of 20.

[00:38:49] Christopher Wolfe, OD, FAAO, Dipl: [00:38:49] Yeah. I would say I would agree with that.

[00:38:51] David Nelson, OD, Dipl. ABO: [00:38:51] Mmm. I don't send people in anymore like I used to when I first got it because what I find is that they won't do anything and they poo [00:39:00] it and I get kind of bad feedback from it.

[00:39:03] So I just tell him, make sure you get a physical, and then, and the next year, if you haven't had one. And then I said, you know what? We might see this again next year. And then we don't. And because of that, hemorrhages are usually last month or two.

[00:39:16] Christopher Wolfe, OD, FAAO, Dipl: [00:39:16] Yeah, I think that's exactly my experiences is I'm, I stepped letter with them or I just sent a letter to their primary care doctor.

[00:39:23]I tell them to get their physicals, make sure they're checking for those three things, and, eh, you know, and again, because I don't hear anything back. I mean, sometimes I do from the patient, but I just never hear anything back from the primary care doctor. Yeah. Then that's sort of the nature of the beast.

[00:39:38]so I think, you know, this is, I want to be respectful of your time and I think we probably could do more of these over time, but I do want to get, you know, you, and I think so far on this conversation have agreed a lot about a lot of things. And so I did want to kind of maybe bring up something that we may not agree with.

[00:39:53] And when I say we may not agree with it, it's just that I'm just trying to wrap my mind around the topic. And one of the things that you and I had [00:40:00] talked about when we first, Mmm. When we, when we first spoke on the phone. Was private equity and that potentially, there's some other ideas that, that people would want to explore with private equity beyond what, you know, John, dr John DOE, was able to present.

[00:40:17] And so I'd love to talk about that with ya. I think the, so to give you a little bit of a jumping off point and, and I'd like to hear your ideas on, on the financial aspects as well, but there was a very well done podcast, called 2020 money. And I'll put it in the show notes for the listeners, but I don't know if you heard it, but, and I don't know who he sold to, but it was kind of the first practice group to go to private equity in Texas.

[00:40:43] And and they had a really great conversation and it was about an hour long. And the guy that does 2020 money is like, like a financial guy for optometrists specifically. And he is very well done. I mean, he's a very well done podcast and I thought the conversation was excellent. The thing that was [00:41:00] very interesting to me was ultimately, as this doc was ready to kind of transition out of it, out of the practice he had, he had a partner that was 40 years old, essentially basically my age.

[00:41:10] And then, and then he was ready to retire in five to seven years. And so he looked at this as an opportunity to, to sell out for more, for more than what he could for more than what he could get from his partner. and his partner was, happy as well. And, but what it kept coming down to, and, and the, the, the host kept trying to probe for anything deeper.

[00:41:32] But what it really came down to was financial. I mean, his answer essentially was, I could sell for a lot of money. And so, so first, if you can talk about, you know, your experience with . You know, with that briefly, but I want to get to a little bit, a deeper conversation that, I think you brought up with the AOA.

[00:41:51] So can you kind of talk about the financial aspects of what a private equity firm is going to be evaluating and what they're going to be looking at and what doctors might want to be [00:42:00] thinking about when they're, when they're having those valuations done and being approached with different