From Yale to Accidental Healthcare Entrepreneurs: Lessons Learned

November 04, 2022

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With Sunita Maheshwari, YSM '99, Arjun Kalyanpur, YSM '99, moderated by Howard Forman, MD, MBA, FACR

November 1, 2022

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00:03Everyone welcome to the innovation. It's change theory. This is a virtual Conversation series listed by sustainable Health initiative at the Yale Institute for Local Health and Innovate.
00:19Corrine Liu: We are so thrilled to host these events for the Yale community of innovators, and to welcome participants from our network outside field to join our event.
00:30Corrine Liu: Please use the chat to introduce yourself to the speakers and other attendees. We may also use the chat to have questions. I'll be monitoring the chat throughout the conversation, and then we'll select a few questions towards the end of this presentation for our guests in our month
00:49Corrine Liu: in public health and local health. That context of the challenges that we work, the challenges that we work to address are critical, and it's important to understand the long standing history where we work.
01:02Corrine Liu: Uh in light. Of that, you know, University acknowledges that indigenous peoples and nations, including
01:19Corrine Liu: all done, he and speaking people of stewarded, the generations, the land and waterways of what is now the State of Connecticut,
01:27the honor and respect, the relationship that exists between these people.
01:34Yale Institute for global top
01:40to the university-wide effort to focus on issues and serves as a focus for research education and engagement with global partners to improve the health
01:55Corrine Liu: excited to introduce our speakers and our moderator, for today
02:08she's a Us. Board certified pediatric cardiologist,
02:12and the
02:19well. Here she was the winner of no commission award from the American Hard Association, and the best teacher award at the
02:27She was nominated to be one of the top. Twenty women achievers in medicine in India.
02:33It's on the board of Hd.
02:56Ames, New Delhi, Cardelli University Medical Center, and now University,
03:01an active contributor, scientific literature
03:05and radiology text up here. It's a reviewer for several radiology Journal, and it's on the editorial board the Indian Journal of Ideology.
03:15He was awarded the Modern Medicare entrepreneur of the year award in two thousand and seven.
03:21His name is one of the fifty top fighters in healthcare in India by express help from magazine,
03:27twenty-five,
03:31and one frost himself, and healthcare entrepreneur of the year
03:36Corrine Liu: together.
03:45This provided over six million diagnostic reports to patients and hospitals globally
03:55chain of primary care centers in India of our Xbx health care, the telegraph tech which builds with tele radiology and the radiology. Software
04:08They also run the the
04:10supports, health initiatives in India
04:13and people, for people would just put up over five hundred playgrounds for four children.
04:19Corrine Liu: Our moderator today,
04:27public health of policy, management, and economics at Yale University is the faculty director and founder of Yields.
04:41With two thousand and eleven. He has been the director of the healthcare management program at the
04:47He's, actively involved in patient care and issues related to financial administration
04:59over to you.
05:07Dr Sunita Maheshwari, Member, Bangalore, India: Great, Should I take over then? Uh:
05:10Dr Sunita Maheshwari, Member, Bangalore, India: So I'm: just gonna Yeah. Okay. Well, good afternoon. Everyone. It's a real pleasure to be back at Yale, even though it's virtually um. So i'm going to in five minutes Share a twenty year journey since leaving New Haven. Uh: so just so that you get a sense of what we're about. And then i'll hand over to how we um. So we basically in one thousand nine hundred and ninety-nine moved back to India.
05:38Dr Sunita Maheshwari, Member, Bangalore, India: Um, and uh, we had finished at Yale, and we wanted to work In India. Long story short, we our June couldn't get a job there. Um! And so he was coming back and forth to New Haven, working at Yale as an assistant professor, and on one of those trips back Dr. Jim Brink, who is the chairman at that time, said, You know our Gen. We can't get anyone to do the night shift,
06:01Dr Sunita Maheshwari, Member, Bangalore, India: and he's like Jim. I'm not doing anything. I'll do it for you from Bangalore. Um, and it was one of those aha moments. Uh, And uh, that's how Tel: a radiology started really. Uh, with no job opportunity uh, but an opportunity from our albumata.
06:19Dr Sunita Maheshwari, Member, Bangalore, India: And so tele radiology. Really, the transfer of diagnostic images for interpretation. Interestingly, the first study was done by Dr. Foreman and Argent
06:32Dr Sunita Maheshwari, Member, Bangalore, India: Um, and this was published in two thousand and three uh. So It was first done academically uh, where they showed that an International Taylor radiology model was possible
06:42Dr Sunita Maheshwari, Member, Bangalore, India: and essentially from India. We were covering India Day, which was us nights and long story short, it grew from there we covered today one hundred hospitals in the United States,
06:54Dr Sunita Maheshwari, Member, Bangalore, India: including the University of Pennsylvania Group, and a lot of groups, a steward group in the Massachusetts area, Einstein group in Philadelphia, Tanner Group in Georgia, and we've grown beyond just the United States. So we recently in two thousand and twenty-two, signed in Qatar, which is in the Middle East. So we cover the Hamas Medical Corporation and Sidra, which is the under the ministry of Qatar.
07:22Dr Sunita Maheshwari, Member, Bangalore, India: Uh, and about ten years ago we started with Singapore. Uh, and Singapore at that time had a If you did an extreme Singapore, you should take four days to get a report uh, and then implementing tel radiology, we were able to reduce that down to one hour uh in terms of getting a report back to the patient and using the same domain of Tel Avi for America for Singapore.
07:47Dr Sunita Maheshwari, Member, Bangalore, India: Uh, we started helping hospitals in India and Africa. Uh. Started to providing Ted radiology for State governments. Um, and the primary health centers and rural centers in India so same expertise that was used for the western world now used within Asia, and especially in Africa and remote parts of India.
08:09Dr Sunita Maheshwari, Member, Bangalore, India: We're an academic group. We're yearly, so, you know, even though this was a startup and a company, and it wasn't. We want the university we've published. We have over one hundred publications, E Lectures um, and we have a training center in our headquarters in Bangalore, which, you know, if anyone comes to India, do come and visit
08:30Dr Sunita Maheshwari, Member, Bangalore, India: uh, we would showcase to President Obama when he came to India as one of the innovative companies coming out of the country. Um! And so we've sort of worked in the space of health, care and healthcare innovation over the years. I think the amazing thing with entrepreneurship is that once you sort of do it once once start up and grow it, it gives you the confidence to do more. And so we set up our second startup, which is a primary care clinic, and this came out of seeing
09:00Dr Sunita Maheshwari, Member, Bangalore, India: the need for it, because in India hospitals are getting bigger and bigger. But there's not much investment in primary care, primarily for financial reasons, because there is no money in primary care,
09:12Dr Sunita Maheshwari, Member, Bangalore, India: but we felt this was a big need, and we set up one clinic um fifteen years ago, so we're very boring entrepreneurs. We just kind of start and stick at it, and we've expanded that we now run seven clinics in our hometown uh sixteen clinics inside corporate and nineteen uh rural clinics in remote parts of India which are fidgeted, that a mix of nurse assisted telemedicine and doctors going on and off.
09:39Dr Sunita Maheshwari, Member, Bangalore, India: Um. We found several years ago that many parts of India and Africa you could not, you know, patients could not access doctors. So we started doing telemedicine much before the pandemic. We I even run a telecardiology practice covering about fifteen hospitals with Telly echo and telecardiology.
09:58Dr Sunita Maheshwari, Member, Bangalore, India: Uh, and we used tech similarly uh to to another startup called healthy minds uh amazingly over ten million Indians, and this is pre-covid struggle with the mental health issues. Many more since the pandemic. And so we started providing Telly counseling. This was seven years ago, probably ahead of its time. We're seeing today in the Post Covid era that many more people are open to this to accessing their counselor online.
10:26Dr Sunita Maheshwari, Member, Bangalore, India: Our third startup was a tech company because we were doing tele radiology and tele medicine. We realized we wanted to build. We were using um outsourced software. And so we had got some engineers in-house and actually built out a tele radiology workflow which sits over risks and packs and we started using it for ourselves as well as for others who wanted. So, for instance, the Mexican navy uses this platform to cover all their sites, which
10:56Dr Sunita Maheshwari, Member, Bangalore, India: you know all all over the place, so it's very good for multi-site um. And then came ai
11:03Dr Sunita Maheshwari, Member, Bangalore, India: uh, and so we were right there. So our June and a bunch of Indian Institute of Science guys with a very low budget. We built out our first algorithm uh, which was for auto detection of breast cancer and then built out for auto detection of stroke. So we've been over the last four years now working on ai and radiology with the shoe string budget as we've done with everything else.
11:26Dr Sunita Maheshwari, Member, Bangalore, India: Um. And the fourth startup uh, actually, the fifth was image call up, which basically works with clinical trial companies. Um. This was set up primarily to work with clinical trial companies in India and Asia.
11:40Dr Sunita Maheshwari, Member, Bangalore, India: Uh, because we realized that a lot of people helping with imaging in the us, but they're not many with Uh who have that ability in this part of the world. So we work, for instance, with Indian companies. We work with the Gates foundation in India with. We work now with other Ai companies and help them with their validations. So this is a very kind of niche uh, just the radiology, part of clinical trials
12:08Dr Sunita Maheshwari, Member, Bangalore, India: and Ai for Pharma companies as well as Ai companies.
12:13Dr Sunita Maheshwari, Member, Bangalore, India: I think the fun part of of building this has been for us. It's been about building a fun culture, so we have a masseuse. You can see up here. We have a full time with Sue in the office. Um, we have our own band, the Telly radiators. We have a slide in the office where you know people can slide down. Now it's got so dirty that we save you. If you don't perform, we're pushing you down, but we've tried to keep it fun um during Covid. Obviously things were shut. So we did like online bingo parties, and
12:42Dr Sunita Maheshwari, Member, Bangalore, India: you know, keeping the energy going through the years. Um! But I think of all of this the most satisfying for us, because when we went back to India we went back, taking our training at Yale and trade, taking the expertise that we had got at Yale, and we wanted to go back and do something with it in our home country, and for that we are always grateful to Yale for training people like us, and, you know, setting us free uh in across the world.
13:11Dr Sunita Maheshwari, Member, Bangalore, India: And so giving back was very important for us. So we set up a foundation that does so for charitable hospitals we give them free reports, so they get access.
13:22Dr Sunita Maheshwari, Member, Bangalore, India: Two high-quality diagnostic reports even if they can't afford it. And this has been expanding in remote parts of India and Africa.
13:32Dr Sunita Maheshwari, Member, Bangalore, India: Uh. And finally, I think one thing you know, we lived in a condo in West Haven, and there was a tennis court there, and I remember we sort of took out tennis rackets, and we went there, and we asked them, How do you join this club?
13:44Dr Sunita Maheshwari, Member, Bangalore, India: And we will knew we were fresh off the boat in the Us. And this this guy says, do you have your racket? Do you have your tennis shoes? Just come and play,
13:52Dr Sunita Maheshwari, Member, Bangalore, India: and we realized that Oh, my God! In America! It's! You know public playgrounds are everywhere. That is not the case in our country. Uh it's only the rich kids who have access to great towns. And so we set up a a foundation that puts up playgrounds for portion, and we've put up over five hundred playgrounds. Interesting. This. Interestingly. The first playground was donated by Yaley. Uh. She was a resident with me at Yale, and she did a bake sale in Seattle, and sent the funds over
14:22Dr Sunita Maheshwari, Member, Bangalore, India: mit Ctl, and with which the first playground got started. Um! And so you know that's our story. Over twenty years we've been organically grown. We've never taken venture capital funding one hundred and fifty.
14:33Dr Sunita Maheshwari, Member, Bangalore, India: I never been private equity funded. We've just reinvested our profits. Into what we believed in. Uh. And so one unemployed X. Yaley, our J. In a Home office uh did five health care startups two foundations Today we have over nine hundred staff, including over one hundred radiologists and two hundred clinicians.
14:53Dr Sunita Maheshwari, Member, Bangalore, India: Um! And that's our story, and it's it's interesting. It's actually thirty years since we were deal. So it's like almost like the wheel has come full circle. Uh so thank you, Chorine, and everyone for having us back, and Nicole for organizing it. Lovely to be here and over to, I guess, Korean.
15:12Dr Sunita Maheshwari, Member, Bangalore, India: And then how we?
15:16Corrine Liu: Yeah, So And and and you have a really interesting video that they want to show you about their companies.
15:24Dr Sunita Maheshwari, Member, Bangalore, India: This is our latest corporate video. So just so that you get a sense of what tel radiology is all about.
15:48Tell a radiology.
15:53Let's go.
15:55Yeah,
15:56Keller. Radiology. That's the latest thing, an opportunity that's better than what you can think.
16:01We'll come a long way when it comes to medicine. We're knocking on the future now, and it has led us in. Yeah. So you'd want to hear the vision. I recommend you. Sit back for a second. Then just listen. I got a radiologist who's here on a mission, so tell us all your goals knocking. What do you envision? I I want to solve. The one that that's a fact save lives is a
16:19I want to help patients. Anyone who's in need, and i'm doing just that right in front of my screen. Anywhere in the world I can work. I can read these scans and reports I send and receive saving one life. Can you please. I just saved like forty right there on that seat a pandemic.
16:36Let me go. No, the work will go on that that is for sure. At Prs. You are never alone to tell me. What exactly is it that you're waiting for? Come, join the vision. Let's make a difference. Stay at home and social distance. The perfect job
16:50a goal, You see Why, I never want to quit you. I feel at home now. That is the twenty first that you'd be. Let's make some memories. Time to get on board and be the happiest. Do I have a be a boring day at work. That's a thing you never see. Come and join the family. You want to join your level. Leave quick, turnaround times yet. Tat is. Provide service with top notch quality. The best of the best
17:09radiology that's Telly
17:12ideology
17:13and a
17:15tell the
17:18the
17:20that's a
17:38Howie Forman (he/him/his): Am I on, or a sergeant? I'm going to speak. I just want to make sure i'm following directions.
17:45Howie Forman (he/him/his): I uh well, i'll just. I'll just step in and say first what your son is very talented uh I've I've only heard once before from him, and he's very talented, and you all are very talented. Um, and let me just say a couple of quick mo thoughts about what it was like to have origin here uh twenty-three years ago, without origin, and his colleague, Jamal Bakari, uh we would not have been able to start the country's first, twenty-four by seven emergency
18:15Howie Forman (he/him/his): uh radiology service. Um! We did something great at that time, and it was the two of them working three hundred and sixty-five nights during the year, and got us started, and we've always been deeply appreciative of the connection that we've had with origin uh, and and with you so need a um since that time, and i'll also just point out to everyone your deep commitment to be bringing back the training that you had in America back
18:45Howie Forman (he/him/his): to uh India. I remember extremely well conversations with origin. Uh, at the time he was making the decision to leave and go back. It was not going back because there was some amazing job there was going back, because there was so much good that you could do there. Um! And that that was the priority, and you stuck with that, and you've raised the family, and uh both a real family, a biological family, and also a corporate family there, and you've made huge difference. So
19:15Howie Forman (he/him/his): just my own congratulations and appreciation to both of you. Um! I want to start off. You know ours, and I had a chance to talk for about an hour yesterday in person. For the first time in several years. I think we had run into each other in our today, sometime in the last decade, but it was first time in several years i'd seen him in person. Uh we got to talk for a while. One thing he kept emphasizing to me is how much of a difference Yale had made in his life and your life, not not just in the education,
19:45Howie Forman (he/him/his): but now it changed you as a person. You both reflect, maybe, starting with origin on how uh Yale itself has changed you, and hopefully made you a better person and better prepared for these opportunities.
20:02Howie Forman (he/him/his): You're muted origin.
20:06Corrine Liu: Um, actually speaking through. Can you hear me now? I can do it
20:11Corrine Liu: so. Um! You know absolutely how it is for us where it all began, and we we cannot Uh,
20:18Corrine Liu: I could be express uh feelings in terms of.
20:32Corrine Liu: Personally, I was a very, you know.
21:59Dr Sunita Maheshwari, Member, Bangalore, India: Yeah, I would say how we you know, as a as a global student. When you come to Yale, I mean, you know, when you're Brown, and you come on campus that we will very intimidated. And you're sort of this brown skin in a very white place. Um! And And I think what uh, what students like us got out of there was, We were forced to think
22:21Dr Sunita Maheshwari, Member, Bangalore, India: we were forced to speak up. I I remember Norm C. Google it in pediatrics. He would ask a question, and I knew the answer, and I would just mumble, and he would say, Speak up,
22:32Dr Sunita Maheshwari, Member, Bangalore, India: and I think for Americans. It's probably natural. Maybe in school they talk to speak up, but for us for Asians it's it's not part of our culture, and I think that was that that was invaluable because we learned to communicate. And as entrepreneurs, you have to be able to communicate your idea, your vision, what you're aiming to do. And I think if we hadn't spent all those years at Yale that won't have happened. And the second thing I would say Yale gave us is
23:00Dr Sunita Maheshwari, Member, Bangalore, India: um it. It taught selflessly. Um, you know you you we we we like we. Everyone always knew we were going back,
23:08Dr Sunita Maheshwari, Member, Bangalore, India: and yet we got the best education, and I remember Charlie Climate telling me, take this education and take it to India, you know. Do good with it. Uh, and I think that that generosity. Um! That the University has to to take people and then send them. Let them spread their wings around. The world. Uh is an America is an is a wonderful part of actually the American system. Um, and I I think it's it's created. Uh, therefore, ambassadors all across the world.
23:38Dr Sunita Maheshwari, Member, Bangalore, India: And I think, thirdly, that the the teaching us to think
23:43Dr Sunita Maheshwari, Member, Bangalore, India: um. You know that that ability to think and think out of the box and think of solutions, as I said, learning to think on your feet that came in real handy as an entrepreneur where you're constantly having to find solutions because something or the other isn't going right. Um, and you're you're sort of thinking about. You know. How do I get out of this mess and figure it out? So I think you know a lot of learning from our time, really uh at Yale, and we we always recommended to, uh, you know, people to go and have that experience
24:13Dr Sunita Maheshwari, Member, Bangalore, India: of of working and studying Internet in another country if they can get into Yale. Of course. There,
24:22Howie Forman (he/him/his): that's great. We're gonna I just want to remind people we're gonna start taking questions in about ten minutes, maybe less, if you have them. So please send your questions in, and we're happy to sort of read them out. Um!
24:34Howie Forman (he/him/his): You know there are people on there. No, I have an echo. Sorry Um! The um.
24:43Howie Forman (he/him/his): There are some individuals on the call who are radiologists. There's some who are public health students and others who are already professionals working out there, and
24:55Howie Forman (he/him/his): a lot of them are, I think, a little afraid of what it's like to do what you did. I mean you. You started something from scratch with your own resources. As you said, you didn't have investors. You didn't have venture capital private equity you've scaled up on your own um
25:13Howie Forman (he/him/his): uh ours, and I talked about the fact that it's not as though you couldn't have cashed out early on you could have you had offers along the way. Uh,
25:23Howie Forman (he/him/his): tell us a little about what goes on in your mind as you're building a business. What is the long-term objective? Where do you want to get to um? And and you know, Is there some point at which you would sell the company or sell it to others.
25:43Arjun Kalyanpur: So how? That's an interesting question. I think we've done some soul searching along those lines
25:48Arjun Kalyanpur: the way we have always thought is that we
25:53Arjun Kalyanpur: we were. You know we were getting calls from investors from as early as a very first year of our existence. In fact, When we were about a year old we had a big tech company come and knocking at the door, saying that they would like to buy us out, and it was a very
26:09Arjun Kalyanpur: tempting offered at the time. It was an offer for a million dollars, and we asked them, We said, What exactly are you buying here because it was basically one radio, this in the room reading on a computer. And they said, we want to buy the idea. And uh,
26:22Arjun Kalyanpur: so we actually thought about it, and we spoke with our board, and the Board said, Why would you need to sell your company to a tech company which should really be your vendor rather than your owner, and that is very safe advice. So we said, Thank you, but no, thank you, to the, to the prospective buyers, and you know it's looking back. It's. It is clearly the right decision at the time.
26:41Arjun Kalyanpur: But but I think that that taught us that the idea is really something that had potential. If somebody, you know, a billion dollar corporation could see the potential in it. Even in that fledgling state when we are ourselves under confident about it. That gave us the assurance and the confidence to take it forward.
26:59Arjun Kalyanpur: Um! And as you've seen, it's led to a a slew of other uh entrepreneurial activities which independently brought tremendous fulfillment and satisfaction. Of course, the
27:09Arjun Kalyanpur: primary teller radiology business which is the reporting of scans from hospitals around the world is, I think, where we feel we can make the greatest impact, because we have uh, you know, the skill set to to do it. Um. So so twenty years down, I think we we're in a different situation. We
27:27Arjun Kalyanpur: uh we, we still, you know we we, we have the the the maturity. Now to be able to take this company forward. How exactly to do that is is an area which we are uh you know thinking about. And uh, I think there's a lot of exciting opportunities out there for us,
27:43Arjun Kalyanpur: uh which which uh which we we we honestly, even though it twenty years old, is, we have this feeling that it's only just begun.
27:50Dr Sunita Maheshwari, Member, Bangalore, India: Yeah, no, I I think that's an interesting question how we and we did it. You know there are times we have formal uh the fear of missing out, you know, because there are startups even in India, who raised, like obscene amounts of money in healthcare, two hundred million dollars on a ppt, and we're like, What What exactly are we doing like? Twenty years of this with our own money reinvesting?
28:14Dr Sunita Maheshwari, Member, Bangalore, India: But we felt very strongly. I think about two things that one health care needs to be. You know it shouldn't be about just about money while yes, you want to make profits and be sustainable uh health care needs
28:27Dr Sunita Maheshwari, Member, Bangalore, India: someone who's willing to be. You know. Kind of write it out and do it well. So That's one thing that's always kept us with. So all the pe guys are our friends, and we say when we're ready to sell, we let you know. But we don't want to take your money, and have, you know, have you force us to grow in a way we don't want to in healthcare?
28:45Dr Sunita Maheshwari, Member, Bangalore, India: Uh and interestingly, when we didn't take the buy out of for ten years later we got profiled uh in Forbes, India, uh by one of and one of India's leading entrepreneurs, and he, the article was, Why not to sell your company?
29:00Dr Sunita Maheshwari, Member, Bangalore, India: And one thing, he said, is that money very early on in the life of an organization can be a one-way ticket to obscurity.
29:10Dr Sunita Maheshwari, Member, Bangalore, India: Uh, and I I think that's something that stuck with us. If we had sold I we wouldn't be here today, you know we would. We would Just so. So I I think, in healthcare in particular. We strongly believe there shouldn't be too much money
29:24Dr Sunita Maheshwari, Member, Bangalore, India: uh they, they should be little bit, but it should be more about sort of driving operation efficiencies for a long time
29:32Dr Sunita Maheshwari, Member, Bangalore, India: so. But will we ever change our mind. Maybe we've learned also to never say never uh one does, you know. If there's some point, a pe exit, and
29:44Dr Sunita Maheshwari, Member, Bangalore, India: we decide to come teach at Yale. Then maybe we take it. You know. Who knows?
29:53Howie Forman (he/him/his): There's a question already in the chat. Um that i'm going to use as as the basis for my question here, and that is that um. And again, this is the origin I've talked about for the United States for me to ask it more globally, and that is your operating in a lot of different parts of the world. Now,
30:12Howie Forman (he/him/his): um, both. Both the services you provide are in lots of place in the world, and I think your readers are not just in India or any more, or I may have that wrong. But you can fill that in for us. How do you deal with the regulatory climate where it's different in different countries where you have to meet different needs? Do you develop your own subject matter, expertise. Do you rely on consultants? How do you manage that?
30:39Arjun Kalyanpur: So you You're absolutely right how we we're now a global organization, and this is something that's evolved over the last twenty years. At the beginning we had this model of having a radio this like myself trained in the Us. Working from you know, time zone that, like such As Asian time zone, which gave them a day night advantage.
30:58Arjun Kalyanpur: But over the years we've also realized that we needed radio this in different continents to provide different types of services. So we now have radiologists in the Us. We're really all in Europe. We have in Uh Australia and New Zealand. They're basically around the world,
31:14Arjun Kalyanpur: and that allows us to serve different geographies, different time zones. It provides a lot of advantages
31:20Arjun Kalyanpur: uh, from the perspective of how we deal with the regulatory stuff it. It is dependent on the country and the country's requirements. So before we um, you know, enter into a country. We study the regulations for that country. Some of it is done in consultation with the prospective client. Uh, and based on that, we develop a framework. So,
31:39Arjun Kalyanpur: for instance, we found that many of the hospitals in the in the Middle East are they? They are willing to it except under their Medical staff radiologists who have done the leadership of the Royal College of Radiologists. So we have a cohort of two hundred and fifty.
31:52Arjun Kalyanpur: Our ourr radiologists, who provide services in the Middle East. Similarly, um, you know, for the centers we serve within India we have radiologists who are trained locally within the country, so depending on the job of being depending the specific requirements. Obviously, in the United States, our radio, this have to be both certified, licensed in the State that we're providing the services and credential at the hospital as well. So it's a much longer process in the Us. To get a radiologist on board, and it can take several months. So the So there is a
32:21Howie Forman (he/him/his): all that has to be factored into building and operations in an international.
32:41Howie Forman (he/him/his): Okay,
32:44Howie Forman (he/him/his): Thank you. Um. So The next question relates to Ai, and, as you both know, Ai has already started to have a major role in radiology, and it's a major part of your business and the things that you're working on. What can you give us? Some prognostications on what you think Ai is going to do for your business as well as the greater practice of radiology and even medicine United States in the next decade or so.
33:10Arjun Kalyanpur: Absolutely so, I think how it it's interesting. Along several perspectives. One is that tel aviology. When we started twenty years ago. We've kind of seen the cycle that it followed. Tele radiology was one measure to address the radiologist Shortage and uh
33:28Arjun Kalyanpur: Ai is the next step forward in that direction. So we've kind of seen the the way the industry functions in this regard. Uh, you know, to give you an example, the first Rsn. We participated in. There were three tel radio of the companies following here. There was thirty,
33:43Arjun Kalyanpur: and it kept going like that. And of course a lot of them shut down. So in in in the Ai space there's a similar excitement, and you know the the the entrepreneurial energy around Ai similarly directed, But fundamentally I think, Ai and Tele radiology are very synergistic, and there is a
33:59Arjun Kalyanpur: multiplicative factor that I believe tele radiology has to offer with Ai. So the algorithms that are developed, and uh, they can be developed anywhere in any country by any engineer, if they are integrated within a Tel avi workflow platform,
34:14Arjun Kalyanpur: they can be made available on the largest possible scale and make the largest possible impact. So we strongly believe that
34:20Arjun Kalyanpur: that tele radiology will act as a distribution force that will magnify the impact of Ai, and that's what we are uh sales practicing our own work, so that we have developed in our technology group is uh integrated with generate with ai algorithms,
34:37Arjun Kalyanpur: some of which we have developed in how some which have been developed by other third parties. And so it acts uh and and you know, I like to use the iphone analogy. The the the app on the iphone is is the Ai on our radio as you workflow,
34:51Arjun Kalyanpur: and it makes it available to the largest possible. Both user base as well as provides impact to the largest possible clinical population.
35:02Dr Sunita Maheshwari, Member, Bangalore, India: And if I can add to that, how you you know, when we start a teller radiology, one of the criticisms of it was that all these Indian guys are going to take away the American jobs, and that never happened, as you know. Right, we just supplemented. We cover the night shift. We let the guy at night, you know, in sleep at night.
35:19Dr Sunita Maheshwari, Member, Bangalore, India: Um! And so very much we were supplementary, and the same is happening today with Ai, Everyone's like always Ai going to take the radiologist job away, and the way we see that it's actually going to make the radiologist more. If there's a huge shortage, anyway worldwide, they're not able to train them fast enough. It's going to make the radio just much more efficient, so It'll be able to do more with this time, and it'll it'll make you more accurate.
35:44Dr Sunita Maheshwari, Member, Bangalore, India: I mean, there's an estimate that twenty million radiology reports for you have inaccuracies. Uh. And so if Ai can drop that, so if it can make it more accurate and make the radiologist more efficient, so we don't see it as ever. Well, we don't know again. Never say never. But as it replacing, but rather collaborating with and helping the dock uh over the years to come
36:07Howie Forman (he/him/his): I it? Yeah, I I couldn't agree with you more. By the way, about Ai, I mean, we use a lot of Ai in our own department right now, and I see it. There's only a benefit to the patient, and there's no no downside now, and i'm not a wha a a worried about the jobs walking away because there's a lot of work to be done. Um,
36:28Howie Forman (he/him/his): you know. Both of you have alluded to and origin. I talked about it briefly yesterday. Um. The issues around
36:38Howie Forman (he/him/his): um
36:39Howie Forman (he/him/his): offshoring of jobs which has been a perpetual uh political concern. And right now we're at a time in America where economic nationalism is heightened again, and both parties are embracing aspects of economic nationalism. Uh i'm wondering if either of you want to comment, because I I feel like both of you, have always handled this so a delicately and and calmly, where, as many other people
37:09Howie Forman (he/him/his): I get angry. And just so the audience understands. You know, origin was a trained radiologist at Yale. He was in attending at Yale. He was trained, had his credentials at yell. Everything was at Yale,
37:22Howie Forman (he/him/his): and people would treat his reports differently, based on where he was sitting when he read the study, so that if you read the study at Yale they loved origin because he was one of us. But if he was reading the study in Bangalore he was a foreigner stealing work from us, and why should we trust him, and I. I got to experience that as an administrator, and it made me very angry at the time many, many times. Um,
37:49Howie Forman (he/him/his): but you both in particular ours, and always handle this extremely well. I'm wondering how do you manage that sort of calmness and equanimity, and
37:59Arjun Kalyanpur: not always coming? It's the other side as well. But um, I think how you you
38:09Arjun Kalyanpur: it's very good question, and and I think our philosophy is always been uh that there will always be naysayers and people who have concerns and objections. But uh, fundamentally,
38:21Arjun Kalyanpur: you, if you know what you're doing is a good thing. You should just put your nose to the wheel and continue doing it, and let everything else take care of itself. And so we followed that philosophy over the years. Um, and I think it's held us in good state thus far. Um,
38:35Dr Sunita Maheshwari, Member, Bangalore, India: that that's essentially the gest of it. Yeah, I think our learning has been how we like. Just put your nose to the ground
38:43Dr Sunita Maheshwari, Member, Bangalore, India: and work, and you know, work on operational efficiencies. Work on the quality of your work, and the rest speaks for itself so. But you you're right. I mean the In the early years the challenges were more related to race.
39:07Dr Sunita Maheshwari, Member, Bangalore, India: Uh, but you know I I think the the good thing is we've seen in twenty years the world has gotten flatter. Um, no radio just lost their jobs because of us. In fact, you know, like I said, we complement them um and uh, and there's a there. There is. Um, for instance, you know, Mass General,
39:25Dr Sunita Maheshwari, Member, Bangalore, India: we run their three d lab in Bangladesh for them. Um! And they they they! They've been running it in India now for fifteen years, and our June was just in up in Boston two days ago, and uh, Gordon told him that they have so much work. They don't know where to send it anymore, because the machines have gotten, you know,
39:44Dr Sunita Maheshwari, Member, Bangalore, India: faster and more slices. So our realization has been that you know ultimately, it doesn't matter that you know, in the short run people sort of look at that. But ultimately, if you, if you work hard and you show your work proves itself, then the rest kind of fades into oblivion. So you sort of have to be, as you said, stay calm and carry on.
40:05Howie Forman (he/him/his): Yes, it's a good way, but it One of my colleagues at Yell is a radiologist, is asked a question about um hipaa compliance, and I know again, or I feel like we did a pre interview yesterday origin because you gave me all the answers. Now I need you to tell the audience. But, um! How have you maintained? Privacy concerns Hipaa concerns uh, and and the similar types of concerns in other countries, because Hipaa is United States rule. What are the things that you did at the beginning?
40:35What are the things that you do now
40:37Howie Forman (he/him/his): to maintain the integrity and privacy of the patient record and their imaging.
40:42Arjun Kalyanpur: So, uh, interestingly, how it the Us. Standard is always in the Us. Is always led, you know in terms of technology. So if you're hipaa compliant, then you're hipaa compliant, whether you're hipaa compliant in the Us. Or anywhere else in the world,
40:55Arjun Kalyanpur: So most other geographies also accept that standards. So it's not as big of an issue as one might think. Now, Europe has its own set of standards, and That's something that you know we've had to uh look into over the years with Gdp on. So on. So, especially with the technology platform, we've had to establish a different security process and standards for Europe.
41:15Arjun Kalyanpur: But by and large the you know, the Hipaa compliance is a piece today more global standard from the perspective of. If you're hipaa compliant, you can operate anywhere in the world. It doesn't change country by country.
41:28Howie Forman (he/him/his): And and to that point I I remember you telling me yesterday that uh the original box that you were using to store the images and allow transfer of images. You had a card key to access it so that nobody could be walking by and and do anything with our studies.
41:47Arjun Kalyanpur: Exactly. Yeah. So when we first set up the Yale project uh, even though it was from one, you know,
41:52Arjun Kalyanpur: a room in my home. I had set up the entire security infrastructure, including the biometric uh fingerprint detector, to enter the office and the uh, the the security box, so that it was complete uh security. So it really doesn't matter in that sense way, or located. I think this is. Concept is sometimes again held up as a criticism of the radiology. But
42:14Arjun Kalyanpur: you know we've seen that you can have the data hacks from within the United States. We remember we once had a client with some. Somebody came and stole Cds from their center, so that that sort of physical stuff can happen anywhere you can be
42:29Arjun Kalyanpur: insecure while within the United States, so you can be extremely secure, while outside it's ultimately a matter of approach.
42:37Howie Forman (he/him/his): The The next question, I think, is for senita Um, or or at least I would ask, needed that question, and that is, you know you've done so much to disrupt the radiology. Uh. Have you thought about things that are well outside the realm of radiology like primary care? How might you disrupt that? Have you given thought to it. What can we do?
42:59Dr Sunita Maheshwari, Member, Bangalore, India: Yeah, no, I. It's interesting how you? Because when I you know, I trained at Yale as a pediatric cardiologist. So When I came back to India I worked at a what's called a Two-d. K hospital, which I worked with the largest pediatric cardiac center in the country. So we were operating on ten kids a day. I mean. It was a massive program. I was doing seven cats a day, so it was very super specialty. I was like, far removed from primary care.
43:24Dr Sunita Maheshwari, Member, Bangalore, India: Um! And I I realized, sitting in the outpatient of that big hot hospital that patients would be coming to see me with a small Vsd. And sitting for eight hours to see a cardiologist. And then you, you kind of take one step back
43:38Dr Sunita Maheshwari, Member, Bangalore, India: to you know beyond specialists to physicians. Uh, and most uh physicians in India, and what I call Mbbs, which is your basic Md.
43:47Dr Sunita Maheshwari, Member, Bangalore, India: Uh: we're leaving India because there they were. They were not enough se seeds to get specialized. Like we have ninety-eight thousand medical graduates a year in India we had at the time only thirty thousand specialty seats. So you got sixty thousand doctors who are primary care technically because they've not specialized and they're not getting jobs.
44:09Dr Sunita Maheshwari, Member, Bangalore, India: And, on the other hand. You have all these patients who just have. You know they just have a cold. They just have malaria, and they have dengue, and they don't need to be in a hospital, seeing an infectious disease specialist. They need a good general physician, but they are not many platforms for general physicians. Unlike China, which worked on barefoot doctors uh India, the Mbbs doctors were leaving. I mean that's why thirty percent of doctors in America are Indian.
44:36Dr Sunita Maheshwari, Member, Bangalore, India: Um. So that's actually why we first, when tel radiology was going on, I to a large, and I think this country needs primary care, and I don't understand it, because i'm like a super super specialist,
44:49Dr Sunita Maheshwari, Member, Bangalore, India: but we got on board physicians. In fact, we landed up, getting intern a strain in the Us. Who moved back similar to us to India, and who believed in primary can. So we set up this. This. Uh you know what we run is essentially primary care. Um, because it's It's completely. Gp driven, general physician, driven the family physician,
45:10Dr Sunita Maheshwari, Member, Bangalore, India: and in India The reason it hasn't taken off is because, like in the rest of the world, there is economics and health care. Um. And so the hospitals where you're doing heart surgeries, and you know, cancel and pet city. Those make money, whereas primary care you charge basically
45:28Dr Sunita Maheshwari, Member, Bangalore, India: for a consultation. It's eight dollars, and then the clearly gets to keep you dollars.
45:34Dr Sunita Maheshwari, Member, Bangalore, India: So in that two dollars you go to maintain a primary case center. So it's pure economics. Why, it hasn't taken off.
45:43Dr Sunita Maheshwari, Member, Bangalore, India: But I think it's right for disruption, and we found we are a bitter positive.
45:49Dr Sunita Maheshwari, Member, Bangalore, India: So there is obviously a need for primary care.
45:52Howie Forman (he/him/his): Right?
45:54Howie Forman (he/him/his): Um. I just want to mention to. So first of all, we have a few minutes left, and if you have questions, ask them. Oh, I was just looking back and remembering that two separate articles in the New York Times are written about you all uh in two thousand and three and two thousand and four, and you just have to type in your names, and uh New York Times to find them. I won't. We'll put them in the chat here. But um
46:17Howie Forman (he/him/his): for those that may not appreciate it like what you have done, it remains monumental. I mean you did things that are very unusual for um
46:29Howie Forman (he/him/his): uh physicians at the time, and most physicians from India have stayed in the United States. Um, uh! And and most physicians that go back to India do not become sort of celebrities and entrepreneurs. What it? What advice would you give
46:48Howie Forman (he/him/his): to young people today about how how to make decisions like that. That will be that will hopefully not just do good for you, but do good for so many others.
47:02Dr Sunita Maheshwari, Member, Bangalore, India: Yeah, I didn't. You want to saddle.
47:05Dr Sunita Maheshwari, Member, Bangalore, India: Yeah, I think how it's interesting. And we went back. Everyone told us we would return from Gfk: All our friends at Yale were like. Uh, I think you said you two are, you know, so your crazy wife is taking you back.
47:22Dr Sunita Maheshwari, Member, Bangalore, India: He would always be welcome back. I know it doesn't matter how long you go, I will always have you back, so that I feel like you did. And you know it was it was I I mean, really I I have to say that was wonderful, because when you go back into the unknown and and and urgent couldn't get a job in India for three years. It was nice to know that, you know we could come back if we wanted to. So all our friends, just to make fun of us. They're like you're going to be back. You'll turn it on a Jfk:
47:51Dr Sunita Maheshwari, Member, Bangalore, India: six months. You'll come back in one year. But I think you know, if if anyone chooses this path
47:58Dr Sunita Maheshwari, Member, Bangalore, India: sometimes you can't think too much about it. I mean, if we had thought that we're going to go back, and we're not going to get a job, and our parents are going to be like. What are you doing back here? We both had a great offers at Duke as well for faculty positions, so sometimes you can't think too much. You have to sort of follow your heart, and I think our hearts took us back there.
48:19Dr Sunita Maheshwari, Member, Bangalore, India: Um, I would say for anyone who's a you know, in global, because, you know, this is for the the School of Global Health. But anyone who wants to do something globally. Um, it's. It's important to go back and actually work on the ground.
48:33Dr Sunita Maheshwari, Member, Bangalore, India: And I think that's what helped us eventually, for sure, me working locally. Then you understand, Uh, you know what the what the needs uh, where you can fit in what you can do um, and you know, and then doing it, even if it's on a. As I said, we, we've had four more, but more or less. We've been happy starting small
48:53Dr Sunita Maheshwari, Member, Bangalore, India: um, and then sort of being patient. Uh, because I think a lot of times when we're young we're impatient for results. Um! And we we sort of want it all to happen if we're going to do a startup, then that startup has to be a unicorn in a couple of years, and it doesn't happen especially in health care.
49:11Dr Sunita Maheshwari, Member, Bangalore, India: So I think patience and just sort of saying, You know I want to go back because I want to do good. Uh, and I will figure out a way to do it. And one thing we at least, I mean both urgent and I do a lot of talks in India, and a lot of young people ask us. We want to be entrepreneurs, you know. What should we do? So I always say, please keep your day job. You know It's too stressful uh not having a job, not having money and trying to be an entrepreneur and hoping you'd hit the lottery and
49:40Dr Sunita Maheshwari, Member, Bangalore, India: hoping your idea is a multi million dollar idea. You may get lucky, and that may happen. Uh, but it's important to sort of keep the day job while you're thinking and trying different things. It's nice to have a partner, a co-founder, I would say. We've been lucky we've had you know each other. We do strategy walks
49:59Dr Sunita Maheshwari, Member, Bangalore, India: uh morning walks a strategy solution, finding sort of we walk for, and are talking about things. We don't even have to do strategy sessions, so I I think it's um, it's It's definitely today, I would say it's It's much easier in a sense, a lot of opportunities. And globally people are looking. If someone went to the Yield School of Global health or years of public health, and wanted to come back there many more opportunities today. So it's good to also try. I think the way we did it I wouldn't
50:29Dr Sunita Maheshwari, Member, Bangalore, India: that you show up and then try and get a job and then not get a job, and then, you know, be like Oh, my God! Now, what so? But today, when you're in a position of strength in the Us. You know, reaching out to their multiple agencies that get jobs, multiple hospitals that give jobs and then starting sort of building on from there. And if one wants to be entrepreneurial,
50:53Dr Sunita Maheshwari, Member, Bangalore, India: you know, there several different ways, I would say, to do it from angel investing, to just using your salary to to build out something
51:02Howie Forman (he/him/his): origin, final words before we turn it back over to Karin.
51:07Arjun Kalyanpur: I would just add to that how you that? Um, I think I've learned the years that the assistance is probably the most single, most important thing in entrepreneurship, because you know, you're going to have a bunch of challenges thrown at you. I mean It's like you will see,
51:21Arjun Kalyanpur: saying yesterday Who you saying that you you you can't choose the cards you get dealt right, so you will be dealt some unfortunate cards with having that that kind of attitude that I will persist, no matter what, and stick it out. I I think it's very helpful,
51:42Arjun Kalyanpur: but uh, don't think at times. So um, we and and we've had. We've had our share of them. Starting from the technology challenges to the the whole empty outsourcing movement. I mean, we we our share of challenges over here, and I think just being positive and in attitude is is really important to see you through this
52:00Arjun Kalyanpur: uh difficult times, and keeping the the goal in mind.
52:04Howie Forman (he/him/his): I'm. I'm. Deeply appreciative of both of you in general, and and so much for today alone, so, and and thankful for your friendship as well. Let me turn it over to to Karen and Fathoma and and the team.
52:19Dr Sunita Maheshwari, Member, Bangalore, India: Thank you, Howie. Thank you so much.
52:22Arjun Kalyanpur: Thank you. How are you? Thanks.
52:29Arjun Kalyanpur: The conversation? Um, If anyone has any questions Um, do you mind sharing your contact information chat so you can reach out So one
52:46Arjun Kalyanpur: um and thanks, everyone being here and asking the question, we do have another event coming up in the spring semester, featuring Emily Sheldon who is the co-founder of the applicant Health Innovation Center, and she'll be talking about the technology and disability policy in large markets.
53:06Arjun Kalyanpur: And I will also be dropping the details in the chat
53:11Arjun Kalyanpur: um for those who are interested to be able to check out uh more resources on the Yh website, and that that's it, our session, and thank you for attending
53:23Dr Sunita Maheshwari, Member, Bangalore, India: Thanks for having this someone from Sri Lanka asked about Deli. So i'm just gonna reply to that that you can just email us, and we'll send you the details so happy to help Sri Lanka.
53:36Dr Sunita Maheshwari, Member, Bangalore, India: Oh, and you know I put my email in there. Thank you, everyone. Thank you so much, Harry, thank you.
53:46Dr Sunita Maheshwari, Member, Bangalore, India: You soon. Naomi
53:49Dr Sunita Maheshwari, Member, Bangalore, India: Mhm Gotcha.