Howard: It is just a huge honor today to be in Melbourne, Australia with Chris Hart. You probably know his little brother, Chris Hart… a little shorter and much younger. Australia is a very neat place; this was the place where the CPAP was invented—who invented the CPAP?
Chris: Collin O’Sullivan.
Howard: Collin? C-O-L-L-I-N?
Howard: Sounds like a good Irish lad. Any name that starts with an O’ is got to be a good lad. And you’re with obstructive sleep apnea.
Howard: So, let me read about it. “As clinical director of Oventus, Dr. Chris Hart is overseeing the delivery of the O2VentTM product range to patients and through clinicians. Graduating from University of Queensland in 1998 with a Bachelor of Dental Science with honors, and a Bachelor of Science in Biochemistry, he also studied at Cambridge University, and graduated in 1999 with a Masters of Philosophy in Biomedical Science. Prior to establishing Oventus, Chris owned and managed a multi-site national dental practice training institute, and managed its consultancy, which he sold to private equity investors. He now works full-time as the Oventus clinical director. Chris also acts as an adviser to various bodies within the dental industry, as well as the healthcare sector, more broadly on the commercial aspects of healthcare delivery.” I learned about this—if you go to Dentaltown, and you type in—I want everybody to go to Dentaltown—and there’s this little search bar, and I want you to use that search because that costs me fifty thousand dollars out of my own pocket. That Google search thing for your website is 50 Grand. But if you put in ‘Oventus,’ there is a very neat thread. They were talking about this, and I looked at that, and I thought, “Well, heck. I’m lecturing in Melbourne tomorrow.” So, I thought when I was down here, I wanted to meet the man himself. Thank you so much for coming by the hotel room.
Chris: Thanks for having me.
Howard: So, this is it. This is very interesting; everybody on Dentaltown thinks this is interesting. First of all, tell us about your journey. How did you go from being a dentist to coming up with Oventus?
Howard: You were drinking one night, weren’t you?
Chris: Yeah, exactly. Got blind drunk. I was sleeping with my mouth open. So, I’m a severe sleep apnea… severe nasal obstruction. So… and I was working in sleep dentistry anyway—and chronic facial pain; I was treating patients—and I had a surgical revision of the nose, didn’t work; did an obligate mouth breather. So, out of desperation, one night, I got a couple of saliva ejector tubes and I cut them up, and I bent them around the outside of my teeth, through the hamular notch and through the back of my throat, and squirted a bit of impression material in, and that was the first O2Vent. So…
Howard: How long was that?
Chris: That was 2012
Howard: So, now, you said your severe nasal obstruction—
Chris: Yeah, correct.
Howard: Could that be corrected surgically?
Chris: Yup. So, I had surgeries at juvenile didn’t work. I went to get a look at the revision, but when you look at nasal surgery, they look at the boney structures. And so, I had no boney issues; it’s just a chronic inflammation and overgrowth of soft tissue. So then, you end up on nasal decongestants, which don’t work and after a while, you get rebound, and it’s a very difficult problem to fix.
Howard: A friend of mine, who’s a dentist… one of my best dentist friends ever, he’s been addicted to Afrin his whole life, and you won’t believe the side effects, but he actually went to an alcohol treatment, like a Betty Ford Center, which is like a thousand dollars a day for like ninety days—just to get off over-the-counter Afrin. Did they…
Chris: Yeah, yeah. Considered Afrin, basically.
Howard: Yeah, and when he got out, he drove straight to the 7-Eleven Circle K convenience store and bought more; he just cannot get off it, and he doesn’t know if it’s because… because when he got in and got off it, he couldn’t breathe.
Chris: Yeah. Right; rebound effect when you come off it, definitely.
Howard: But he stayed in there for, I think, a hundred and twenty days to get off of Afrin.
Chris: Yeah, right. Well, that’s probably the most extreme case I’ve…
Howard: And he’s a dentist, and he doesn’t abuse cigarettes, alcohol, drugs—and he’s not a drug addict, but he treated it as an addiction.
Chris: But if you can’t breathe through your nose, you become a very uncomfortable and/or unhealthy person. So, in a perfect world, everyone breathes through their nose. The data we’ve got shows that eighty three percent of patients report nasal congestion, and fifty two percent of them will report it at a greater five out of ten or higher. So, it’s a serious problem. Out of the nasal resistance research we’ve done, greater than sixty percent of patients have moderate or severe nasal obstruction in the sleep apnea population. So, the only other solution than surgery, which is only about twenty to twenty-three percent successful, so…
Howard: So, that’s only for boney.
Chris: Boney, and that’s the issue. The clear indication is boney obstruction. So, hypertrophic tissue can be cauterized, and that sort of stuff—and you can treat allergies—but the other option is a nasal decongestant, so the pseudoephedrine. So, for me, I’ve gone through all that, and I just couldn’t get any through my nose. So, a couple of saliva ejector tubes, and oil in.
Howard: Wow, this is very interesting. So, what do you call this?
Chris: This is the O2Vent W, standing for wings, so it’s a dorsal style appliance.
Howard: Say that again.
Chris: It’s the O2Vent W. This one’s just been released…
Howard: And what’s the W for?
Chris: For the wings.
Howard: The wings. Well, show it to the camera. Show my homies on the camera.
Chris: There you go. So, this is the O2Vent W, basically a dorsal, oral appliance for anyone who’s in dental sleep medicine; they’ll understand that. And so, included in that—but while these wings for a start—3D printed in titanium, so the same technology that built the…
Howard: So, that metal bar is 3D printed, too?
Chris: 3D printed, yeah, with an electron beam printer. These are all custom-designed, got our own proprietary software. And so then, we’ve got an advancement mechanism here—similar to any dorsal device—but included in it to the airway. So, it’s this airway opening there through the lips, around the tongue, below the nose and soft palate, straight into the back of the throat.
Howard: Now, is that yours?
Chris: No, this one’s a demo; mine’s at home. I used it last night, and it’s happening again tonight. So, well I mean, really, what we found here is that… well, there’s a couple of things. If you’re looking at oral appliance therapy for apnea, only about twenty percent of the obstructions happen at the tongue base. So, if you’re just bringing the tongue forward, you’ve got limited chances of curing the collapses, particularly in the soft palate, or if he got high levels of nasal congestion. So, this is like a pressure inlet valve. So, in the last clinical study we did, we compared it to CPAP, so instead of having the mask with the pump, pumping the air in, just letting it get in through this airway neutralizes the pressure to the same extent.
Howard: So, the CPAP was invented right here in Melbourne.
Chris: Yeah, by Colin O’Sullivan.
Howard: And what percent of the people… what percent of those obstructive sleep apnea is treated with CPAP successfully and everyone’s all happy? And what percent is not…
Chris: That’s a good question. So, if you got to the American Sleep Association site, they’ll say twenty-two million Americans to sleep apnea, four million are in treatment.
Howard: That’s the entire population of Australia.
Chris: It is. Correct. Yep.
Howard: Yeah, twenty-two million, and I think that’s your population here?
Chris: Twenty… getting on twenty-five, but yes.
Howard: So, basically, the entire population of Australia and America has sleep apnea.
Chris: Absolutely, yeah. And so, if you look at the compliance and adherence, right? So, we know CPAP works; it’s very effective. The problem is if a hundred patients get a sleep test, and is diagnosed of sleep apnea, fifty of them will trial CPAP and twenty-five actually go on to buy one. Out of the twenty-five, the ‘buy one,’ at the end of the year one, fifty percent of them don’t use it, and at the end of year two, it’s as high as eighty-five percent. So, there’s this churn of patients coming in to CPAP, carrying out a CPAP kit.
Howard: And what do you attribute to that—is it the noise? Do you have to sleep on your back? I mean can you easily… like I sleep on my stomach, and can you sleep with CPAP on your stomach?
Chris: It’s not physically impossible. So, basically, it’s the pump, it’s the mask, it’s the pressure, the noise, the leaks, and you’re right, you’re…
Howard: And it’s dead sexy.
Chris: Parts—it’s a great look, yeah, it’s a fantastic contraceptive.
Howard: It’s natural. It’s a form of birth control.
Chris: That’s right. Yeah. So, look, getting on non-compliance, non-adherence, is you—in fact, the compressor just came from the (inaudible, 00:08:10) Sleep Research Institute. They will just go through the safe study, which showed that a long-term prospective longitudinal study has shown that there was no positive effect of CPAP therapy with the average, wearing the time was three and a half hours a night, and had no positive long-term health effects. Now, that was a big, long, expensive study, but that shows that while we know CPAP works breath by breath, patients aren’t wearing it. And so, with this device here—I mean… so, on average, CPAP is going to reduce the severity of disease by about eighty-three percent. Our last study on this one reduced it by seventy-eight percent, but patients were wearing this six point one hours a night, compared to three point five hours a night on CPAP.
Howard: Because these would snap in…
Chris: Yeah, they just…
Howard: Do they fall out very easily?
Chris: No, it depends at how tight you make them, obviously, but we make them so they don’t fall out.
Howard: Could you wear that sleeping on your stomach?
Chris: Yeah, I do. Yeah, I sort of sleep on my stomach. I’m a heavy sleeper, slightly on the side, or on my side. I toss around my back as well. So, you can sleep in any position. Now, we think that about… with the data we’ve got, eighty percent of sleep apnea patients will be effectively treated with this device, and we’ve shown on a study where—I can’t talk too much—but the details, the result, it’s about to get a peer review, but including this airway in the advancement device significantly increased the efficacy of the oral appliance therapy. Now, if there is a patient that, for some reason, doesn’t get a result—so, someone with a BMI, let’s say as high as forty, forty-one, forty-two—severe sleep apnea, those patients may still need CPAP. So, the last study we did, instead of having a mask, we attached the CPAP here, and we basically reduce the pressure requirements by two-thirds, which is the first issue with CPAP therapy—and we did it without a mask—and the patients could roll around, because the interface was connected to the cranial floor. So, this device’s just FDA-cleared last month; the CPAP connection, we’re looking to have FDA-cleared in the next twelve months. What that means is that every patient can be treated effectively without the mask, and probably eighty percent of them without any sleep apnea.
Howard: No, they also talked about other things—sleep hygiene. Is that like a rounding, or like… they talked about not having a television on when you go to sleep, or music, or sleeping next to your Smartphone, dinging, and things like that. They talked about how they like the room colder or… do those have much of an effect on obstructive sleep apnea, or is that for people that don’t have a disease and just sleep—better sleep, in general?
Chris: Yeah, so I think that translates to poor sleep. Sleep apnea itself is stopping breathing while you’re asleep, and obstructive sleep apnea is when the airway collapses; the central sleep apnea is a different mechanism. So, if you’ve got good sleep hygiene, you’re better-rested, you’re going to function better. I don’t think that the sleep hygiene directly improves the sleep apnea, but sleep apnea improves the sleep quality. So, the converse is probably true if you can treat the sleep at what is definitely true; you’re going to get a better quality of sleep if you’re not restricting, or not…
Howard: And do you think [0:11:16 unclear]… so, just better sleep hygiene. Do you think caffeine is a huge problem in sleep?
Chris: No, absolutely. Yeah, I mean I don’t know about… you have mentioned the U.S. is addicted to caffeine after the Boston Tea Party, and drinking coffee all day.
Howard: Yeah, it’s funny that America went to a revolution with Britain because they put a tax on our tea, and Americans don’t even drink tea.
Chris: Yeah, yeah.
Howard: That’s kind of a highly-strung possy.
Chris: That’s a war. But look, I think caffeine is a big issue. I know I’d have two or three coffees a day; I don’t know many people that don’t have regular coffees. So, you’ve got a stimulant there all day, there are obviously layover effects of that through the night: it might take you longer to get to sleep, then you wake up tired, so you have more coffee the next day.
Howard: It seems like whenever you go out to dinner, it seems like half the group after getting dinner or dessert; it gets a coffee, and I’m always wondering, “Shit, it’s nine o’clock at night, it’s ten o’clock at night.”
Howard: I’m going to get coffee right before going to bed.
Chris: And you’re throwing a stimulant right in there when you may be going to sleep and turning down… I think also, there’s some good evidence coming out now to show—that screenplay? There’s an issue particularly for juveniles and young people not sleeping, because they’re always gaming, or they’re on their iPhone or their iPad or whatever. Some of the research coming up, particularly in workers—we call them FIFO workers here, where they fly in and out of their mine—shift work, huge issues in terms of sleep hygiene as well. So…
Howard: A lot of mining in Australia, isn’t there?
Howard: It’s a very big extraction economy.
Chris: We’re just a big quarry. So, we mine everything: coal, iron ore, bauxite from alumina—we call it aluminium—copper, lead, zinc…
Howard: You call them what?
Chris: Aluminium; you call it I think, or aluminum…
Howard: We call them aluminum and you call them Aluminium?
Howard: I just love the way you say it. Composite.
Howard: Is that ‘composite’?
Chris: Yeah, ‘composite’.
Howard: And you say ‘barbiturate,’ or ‘barbiturate’?
Howard: Barbiturate. How do you say— ‘hygienist,’ or ‘hygienist’?
Chris: So, we’re still very much of the English extraction. You know, we mine everything: lead, copper, nickel, zinc.
Howard: Mostly to China. Export to China, mostly?
Chris: Yeah, I think they’ve taken over now as the biggest export, but we still export a lot to Europe, China, Japan, the U.S., Indonesia, most of Southeast Asia. So, we’re very close, and you can get an Actinium there from Australia to New Guinea, and sometimes, you can get it across the team, also.
Howard: So, do you know Australia, China, and the United States are all the same size, geography? Thirty-six million square miles.
Chris: Yeah, very similar. We’ve only got twenty-four million people, twenty-five million people, so…
Howard: Yeah, you have twenty-five million people. United States has three hundred and twenty-five million people, and China has a billion, three hundred twenty-five million people. The density…
Chris: It’s unbelievable.
Howard: …is unbelievable. So, what do my homies find on your website is Oventus, O-V-E-N-T-U-S.com.au.
Howard: What will they find if they go to Oventus.com.au?
Chris: There’s an American site as well, which I think is Oventusmedical.com, but similar content. So, they’re going to get some information on sleep apnea in general, they’re going to get some information on the different types of therapies, they’re going to get some information on oral appliance therapy in particular, obviously, they’re going to get some information on our device range, and also some of the research that we’ve done, some of the findings of that research. And then for patients, they can register, and we can actually refer them to a dentist; for a dentist, they can register their interest and learn how to deliver the technology, and how to manage the patient using our technology.
Howard: So, what—how does this get implemented into a dental office? I mean what do they do… do you educate them? Do you do it online? Do you have to go to a lecture?
Chris: So, in the Australian market, we marketed the product and the training direct to dentists. We’re a fairly small company with a small team, so we can’t do that globally. We’ve actually just partnered with Modern Dental—in the U.S., they’re the Modern and Microdental, I think.
Howard: Modern Dental… the laboratory? In China, with… what’s his name, Ryan? With the G? My friend?
Chris: Godfrey, yeah. (inaudible, 00:15:22 – 00:15:23)
Howard: Oh, I love Godfrey!
Chris: He’s a great guy.
Howard: So, you know where his name comes from; Godfrey?
Howard: So, I asked him. I said… so, he owns… is that the largest lab in the world?
Chris: About it, probably.
Howard: How many employees are they are on now?
Chris: Well, I think they’ve got around four thousand technicians.
Howard: Yeah, it’d be tough to see if it was on Glidewell in the United States, which makes five percent of all the crowns and, say, our Modern Dental. But you think that Modern’s bigger than Glidewell?
Chris: Well, I think so. They’re number one, two or three in every major company. So, I think countries—they’re in Europe, U.S., Canada, China, as well as Australia.
Howard: So, he had me come down to speak in Hong Kong, and Shenzhen, and Modern…
Howard: And I said, “So, Godfrey, is that your first name? Last name? Whatever?” He chuckled; he goes, “You Americans.” And he goes, “When we’re little, they tell us that Western people like you will never be able to say our name. So, when I was in first grade, everybody in class lined up; they went to a hat and they pulled out a name, and that was your Western name. I pulled out, my name’s Godfrey, So, when I see anybody who’s Western, I say Godfrey.” And so, “I want to learn your real Chinese name. What is your name?” He’s like, “Ayayayayaya!” He’s like, “Okay, Godfrey.” You’re right; great strategy. I couldn’t if I tried, I mean I had him tell me his name, like 5 or 6 times…
Chris: Chinese is a very difficult name, and the inflection I pulled down, it’s just tough.
Howard: So, you’re working with Godfrey?
Chris: The owners.
Howard: What are you doing?
Chris: Well, we’ve signed a global distribution agreement, which is actually exclusive in the U.S.; not exclusive in the rest of the world. It launches—we’re aiming for October 1. So, at the moment, I’m working very closely with their sales marketing and training teams, getting the educational and marketing materials from up here, in our business into their business, so they can start to train their own people. We are starting to work with Tufts University, Polydor, and Mushiya Meter, in terms of the training—the independent training—so…
Howard: Are you going to do it online?
Chris: Yeah. I think Modern and Micro have a fairly sophisticated online setup in Chicago, so I’m heading there first two weeks of September, and we’re going to be doing a fair bit of filming, and…
Howard: Modern Dental, and who else did you say?
Chris: Micro Dental. So, both Modern and Micro in the U.S.
Howard: And Micro Dental? Where are they at? Was that San Fran?
Chris: Although, they got about forty-two labs in the U.S.?
Chris: Micro Dental, yeah.
Howard: Huh, when did they buy Micro Dental?
Chris: November last year, it was settled.
Howard: Well, you know, when I was at Modern Dental, the UPS truck came a couple… several times a day, and when I had looked in that lab box, what was amazing is they weren’t from individual dentists; it was from every lab I had heard of in the United States.
Howard: And so, I was looking at them, a lot of them were from Arizona, and I was taking cellphone pictures of the names and the address of the UPS. So, when I got back, I sent them to him, and everybody pretty much said the same thing; they go, “Well, imagine if the dental schools all shut down the hygiene schools. You won’t have any hygienists.” Well, it was dentistry’s best idea to close down all the dental lab schools, and they said, “Okay, so here I have a dental lab, and I had an ad in the newspaper, which cost me a hundred dollars a week for a porcelain stack, or a model trimmer, or whatever, and I can leave that ad there for a year.” And I was talking to one lab, one of the really big lab in Iowa, and he says, the dental schools aren’t training any of the workers, and eventually you just give up and you have to send them to China, but it’s a big secret, because it’s very bizarre how… you know America, World War Two, was against Germany and Japan, yet nobody in America has a problem buying a Mercedes Benz or a Sony television, but for whatever reason, the American dentist who all drive Mercedes and Lexus and Sony TVs, some of them backlash against Chinese labs. So, it’s kind of under the weather, but you hear many, many different statistics, but some people think as many as one in three crowns in the United States are made in China, probably at Godfrey’s. Did you believe that?
Chris: But, whether all of Godfrey’s… I think the number might be higher than that, but there’s quite a few OEM labs in China doing lab work for labs offshore.
Howard: And what percent of the lab—of the crowns—in Australia do you think are made in China?
Chris: It should be similar numbers to the U.S. I think—I mean we’re very close to it, so logistically, it’s easy. The outsource started here probably around… it might be ten years ago, 2006, 2007...
Howard: I know a dentist in Poland…
Howard: Who quit doing dentistry, and started… you know, the kind of good sites in China, or—I mean in Germany—are very expensive, like maybe two hundred dollars U.S. for a crown, and going around, picking up Cronenberg’s cases in Germany and sending them to Modern Dental, and they’re just the middleman; they just pick him up, they ship into Modern, ship back, and they deliver them, and I know a dentist in Poland that said, you know, I’m making two or three times the money as a dentist in Warsaw, just kind of having an arbitrage display.
Chris: Yeah, yeah. If you look at this one, for us, it was a huge advantage for us to work with Modern, just because of their distribution network. So, we actually print these here in Melbourne, so this is…
Howard: So, it’s printer; so, it’s not CAD/CAM, it’s a printer.
Chris: Well, it is, but it’s not for milling; it’s additive. So, a customer of Modern or Micro in the U.S. decides “I want to buy one of these,” they’ll send the impressions in, they’ll scan them, upload them to us.
Howard: So, you prefer scan over impression?
Chris: Anything; it doesn’t matter. And we can take impressions, models, scans, whatever the workflow is.
Howard: And where will they be? What do you call it; additive?
Chris: Additive, yes. 3D printing.
Howard: 3D printing?
Howard: And where will they be printed at?
Chris: In Melbourne here. We’ve got a campus of the CSIRO and Clayton. And so, the data gets uploaded to the Cloud, we download it. We got our own proprietary software, so we design the device customized for each patient, goes to the printer, and comes with the printer, and we ship it back to them and they deliver it to the dentist.
Howard: Wow, and how is sales and distribution going?
Chris: Well, we’ve only just launched, so… we actually haven’t launched; we piloted some sales in the U.S. from about February, just working with about thirty key opinion leaders and early adopters, just to test the market. And we’ve gone back, actually, and refined some of the products.
Howard: And where are these thirty key opinion leaders at?
Chris: So, we had (22:19 unclear) at Tufts—I’m sure these guys won’t mind me mentioning them—Nancy Addy out of Kansas, there’s an early adopter with us, we had…
Howard: Well, you should get them to all post on this…
Chris: I will, yeah.
Howard: …thread. You…
Chris: And we had Michael Siddiqui in Francisco, and Randy Chang, we’ve got the Delaware sleep group… I can’t remember off the top of my head; I’m going to offend someone by not mentioning them, but certainly; we can post it to all of our dentists working with us in the U.S.
Howard: Do you give out your email address?
Chris: Yeah, it’s Chris, C-H-R-I-S, @ Oventus, O-V-E-N-T-U-S.
Chris: Dot com dot AU.
Chris: Dot AU.
Howard: Dot AU? Yeah, I wish you would get all those people to post on the thread; I think that’d be the best marketing in the world. They’re already talking about it.
Howard: So, I posted your YouTube videos…
Howard: …and all that. You’ve seen that?
Chris: (inaudible, 00:23:27)
Howard: But yeah…
Chris: Yeah, we can get them involved in that, definitely, yeah. And you know, we’re getting really nice feedback; it’s a challenge, logistically, from Australia with customs—and we don’t have a presence over there. We do have one employee, Steve Wick, he’s the VP for North America. He’s working hard with early adopters, but we’re really looking forward to October 1, when we’ve got some infrastructure there, so—and working with an already existing…
Howard: And his name is Steve Wick?
Chris: Steve Wick.
Howard: And is he a dentist?
Chris: No, but he’s been working—I think he works with someone for several years, and before that, he worked in lab supply, so, Emperor C-Max, bringing those sorts of technologies out.
Howard: Where’s he located out of?
Chris: He’s in Seattle. So, I’m meeting him over there in September again, so we were visiting quite a few research institutions and universities.
Howard: So, talk about—how does this get adopted into a dental office? Do they need to do… do you recommend sending them to an overnight place for a sleep study take-home equipment?
Chris: So, in terms of implementing that in the dental office, if the dentist is already working in dental sleep medicine—don’t know the workflow, obviously—if they’re not, I’d probably really encourage them to do some training. I know that the Tufts guys run a great many residency; I know University of North Carolina do as well as… I mean there’s a load of...the AADSM the American Academy of Dental Sleep Medicine run great courses. I mean if you’re in Australia, we’ve got about two to choose from; but in the U.S., there’s a whole bunch of them running great courses, so they should do some training. I would say you’ve got to be doing it as you’re training, so you find some patients within your practice, and you can screen all your patients as you should in the hygiene chair or through your medical history update—and dental signs and symptoms: erosion, brushing, fractures, hypertrophic tonsils or long soft palates. You go and find that, usually, these signs and symptoms that you’re going to pick up when you do your examination, you’re going to start to see it come to the surface. And there’s some fairly large correlation between sleep apnea and nocturnal bruxism, as well as gastroesophageal reflux disease. So, sleep apnea can lead to filing dentistry. So, as a dentist, it’s in your interest to screen patients and treat that as you’re doing the dentistry to make sure it sticks for them.
Howard: But you said that Modern—you’re making a lot of online?
Chris: We will be, yup. So, we started that…
Howard: Because if you have the content, Dentaltown has a quarter-million dentists on the website, and then when Jobs came out with the smartphone, we came out with the app, and fifty thousand of the quarter-million dentists downloaded the app—and those all tended to be the millennials—the old guys like me and you are on the desktop, reading textbooks. But we started the online section in 2004; we put up about four hundred courses, and they’re coming up on a million views.
Howard: So, if you have the online—so let’s see; categories. So, let’s see; do we have sleep medicine? So, sleep medicine only has one course. This is going to be interesting. So, I got out of school thirty years ago, and they didn’t say one thing about sleep apnea in dental school.
Chris: Yeah, it’s pretty new.
Howard: When did it really go viral?
Chris: Look, I started getting into it mainly because I’m trying to do aesthetic dentistry, and that sort of stuff, and trying to protect the teeth from further damage. So, for me, it was a way of not having the dentistry fais. And I think anyone who goes down that restorative pathway starts looking up craniofacial pain ends up doing sleep, inevitably, because there’s such a big correlation between the two. And I guess I don’t know—in Australia, it’s still fairly new; I think it’s feeling nice in its development, but I would imagine the U.S., from the material I was seeing coming out to the U.S.—I think it was about 2007 or 2008, from my experience.
Howard: 2007, 2008? So, what—I can’t remember. What happened in 2007? How did it go viral?
Chris: That, I can’t tell you. I can tell you for me, you’re treating patients, and you don’t have an answer. So, you keep looking for an answer for him, and then eventually, this is part of that answer for the patients. So…
Howard: Was it in the press? I mean did someone… famous—I mean because now, you know, when the Supreme Court justice died and they blamed on that, and just recently, another movie was out.
Chris: Oh, sleep apnea.
Howard: Was it Princess Leah?
Chris: Carrie Fisher, yeah.
Howard: They blamed that on sleep apnea, too, right?
Chris: Yeah, they did. We’re talking about that today at the conference—and it’s a bit of a stretch—but…
Howard: It’s a bit of a stretch? Why is that?
Chris: Well, that’s the kind of morbidities that come with sleep apnea.
Howard: It’s what?
Chris: The morbidities: the hypertension, the stroke risk, the diabetes, the obesity, and the depression. It’s these types of things. Then you get multiple medications, and everything sort of falls apart from there. Sleep apnea is managing one part of that whole complex of healthcare issues and one part of our treatment, sort of sequence. So, it’s a bit of an overreach, but certainly, it’s a contributing factor. I think sleep apnea is gaining awareness. ResMed has done an amazing job globally, so they built the market.
Howard: Who did?
Chris: ResMed. So, (inaudible, 00:28:45) invented CPAP. Peter Farrell founded ResMed, commercialized it, and basically turned its things, making it a billion U.S. dollar company now.
Howard: And where is that listing?
Chris: They’re dual-listed. The NASDAQ and in Australia as well.
Howard: Australia’s the footsie?
Chris: Northern Australia’s—yeah, ASX, two hundred or one hundred. So, for U.K…
Howard: U.K. U.K. as well. (inaudible, 00:29:11)
Chris: ASX. Australian Stock Exchange.
Howard: A-S-X? Australian Stock Exchange.
Chris: So, they’re dualistic.
Howard: So, when did ResMed go public?
Chris: That was in the ‘80s, I think. When did they go public? Maybe in the ‘90s, but I can’t remember.
Howard: But it really just exploded in the last ten years?
Chris: That would be driving it, and I think they found links in research to all these other factors like depression and blood pressure and diabetes and obesity, and then fatigue became a risk for transport workers, and sleep disorders became more apparent and more prevalent. So, it’s just—I guess that reached a tipping point where the sleep positions and respiratory positions, the ear, nose and throat surgeons were treating all these patients with airway issues. And then all of a sudden, there’s this solution that was a medical device, which was CPAP, and there’s money in that. So, Peter Farrell is a very clever guy. He built a whole industry on the back of Collin O’Sullivan’s invention. And so, then, they were obviously pushing these devices out; they got reimbursement for it, so once it’s reimbursed and people want to be treated…
Howard: That people don’t sound… they don’t realize that the X-ray machine was out for a long time, but the first dental insurance was the Longshoreman’s Club. There was a big union in America, and so basically, every ship container that came in or out of America—whether it was from New York, Boston, Chicago, Cleveland, L.A.—they’re part of the Longshoreman’s Club, and they started dental insurance. So, I think that was in ’48, and they decided they were going to cover x-rays at a hundred percent. Boom.
Chris: Everyone took it.
Howard: Within—I think it was within two years, every dental office bought x-ray machines.
Howard: So, when you historically look at it, the healthcare follows reimbursement.
Howard: So, if money is the answer, what’s the question? And so many things.
Howard: But it’s needed in Australia, because here we are in Australia, where he invented the CPAP machine, you invented Oventus, Australians also were the ones that discovered that the ulcer was—Americans were cutting them out…
Howard: And the Australians figured out it was a…
Chris: H. pylori.
Howard: H. pylori bacteria, and start treating it with antibiotics. And now, they have another new one, which no one really wants to talk about, because it sounds kind of gross. Well, what is the number one transplant in the world now?
Chris: Yeah, you were telling me before.
Howard: Fecal matter transplant was invented down here, but basically, what they were finding is you treat somebody with cancer, and all these chemotherapeutic agent and they’re just all like sick and down. And this lady physician was down here, and she saw some little kid who had been treated for leukemia, and he was just lifeless, and every time he pooped, he would cry, because his anus was all raw and that. And she said, well, all of his gut microbiome have been probably killed. So, she had his mother defecate in a container, and gave him a fecal matter transplant, and he sprung back to life. And she published out a course; imagine how many jokes came out of that one, but now, it’s actually the number one transplant in the world. It’s actually a fecal matter transplant down here, because… so, when I’m looking at you, only one trillion cells came from her mom and dad, but inside of you, from your gut, you’re (inaudible, 00:32:39) is ten trillion microorganisms, fungi, viruses, bacteria, parasites, and they’re just finding out every day…
Chris: What they do.
Howard: What they do, and they’re linking—I mean talking about the oral systemic link, they’re linking that to everything: from brain health, and you know it has to affect the mouth because you see the gut microbiome, I mean this could be around the corner, because you see people with a bunch of cavities, structured as mutants, don’t really have perio. And you look at the people with massive perio, well they don’t really have cavities, and you know that’s tied to the whole gut microbiome. And it would not surprise me in thirty years now with someone with a very high decay rate; they may be getting a fecal matter transplant with somebody who has a low decay rate, and it changes the whole gut microbiome.
Chris: And it could be a slobbery transplant a bit more, just…
Howard: Yeah, and it’s also very weird because AIDS made everyone realize that you can transmit STDs, but now with HPV…
Chris: Oral cancer.
Howard: People are realizing that without having sex, a kiss transmits eighty million microorganisms on a standard kiss.
Howard: And it’s probably even more dangerous with me, because I sleep with three cats, and I think… Ryan, is that a healthier alternative? Are cats healthier than humans?
Chris: They’re not explaining themselves all the time.
Howard: But yeah. So, what do you think the future of this is?
Chris: Look, in terms of… there’s two futures: one’s the commercial future, and the other one, I guess, the healthcare benefit. So, if you look at the healthcare benefit, eighty percent of patients with sleep apnea are outside of healthcare.
Howard: Are what?
Chris: Are outside of healthcare.
Chris: Outside of care. Main reason is because…
Howard: What do you mean ‘outside’?
Chris: They’re not in treatment.
Chris: That they’ve got sleep apnea, either they don’t know it or they know it, and they’re not in treatment because it’s not palatable. So, this was invented—I am one of those patients; so I invented it for me to feel better. So, if you think about that, there’s about sixteen million, fifteen million Americans for instance who are outside of care, and the data on this is shown very similarly. So, potentially, we can bring a lot more patients into care, and the downstream cost of not managing sleep apnea now is potentially huge. So, you’ve got long-term healthcare benefit for patients, and long-term cost savings to the economy. In terms of commercially, for us as a business, it’s a huge opportunity; the current market for sleep apnea globally is three point two billion U.S. dollars. It’s growing at around about fifteen to twenty percent compounded annual growth rate, particularly in line—I mean they’ve called it an epidemic; it’s in line with the obesity epidemic as well. So, four times that again, is the addressable market today, so you’re talking twelve, thirteen billion dollars a year. And if you look at the reasons patients aren’t in care, it’s mask-related issues, pressure-related issues, nasal congestion, and lack of efficacy or lack of adherence. So, when we look at this technology, we’ve dealt with three levels of obstruction, instead of one, just by bringing the jaw thought. We can do that, but we can also bypass the nose and soft palate. We’re increasing the efficacy of oral appliance therapy. We’re able to use it as a CPAP interface without a mask and low pressure, and actually we’ve just received a three-million-dollar government grant to build a micro CPAP, which will be wearable. So, we…
Howard: A what? A micro…?
Chris: A micro CPAP which is wearable, sit on the sleeve.
Howard: So, you’re going to do that? So, you’re going to get the CPAP business?
Chris: Correct. Yup. So, we’ve developed the connection—I’ve got one on my bag; I can show it to you if you’d like, and we tested that in two clinical trials, and then on the back of that data, we found the pressure requirements was so low, the pump size could be reduced to the size of a cigarette packet.
Howard: Now, you’re going to tell the… what was O’Sullivan’s first name?
Chris: Collin O’Sullivan.
Howard: Are you going to talk to him about this?
Chris: Well, you might or might not already know about it, but that’s the… so, instead of having the mask, we can attach CPAP that way. This was just a prototype, which we tested in the trial; it’s now just a couple of buttons.
Howard: So, this will be attached to this?
Chris: Correct. Yeah, that just goes in the front there. So instead of just wrapping around your head and we’ve actually embedded chips in this as well, and testing at the moment. That will tell us, how they’re wearing the device—and isn’t working for them. Now through the smartphone, so you can manage the patient on your off time.
Chris: So, this will be in the market in six to twelve months in the U.S., and this is a trial device patient control as well. So, there’s a lot of technology coming.
Howard: So now, how long have you been using this on your patients?
Chris: Since 2012.
Howard: And so, that’s four years.
Howard: And what has the feedback been in your patients?
Chris: Really good. So, I would have delivered maybe twelve-hundred of these devices over the time.
Howard: So, did you just… you sold your dental office to private equity?
Howard: Corporate dentistry. So, you opened up just one location, but what happened in sleep apnea?
Chris: The first device we invented, we made it out of plastic; it was very chunky, and had a very small airway, it was expensive to make, and it wasn’t commercial. I was about to spend another hundred thousand or something on patents. I said to the patent attorney, “Ah, forget about it. It’s not really commercial; I’m out,” and he said, “We’ll talk to this guy about commercializing it,” and that was the current… Anil Anderson, and he told me what it had cost me to commercialize—I think it was about three million bucks or so. I said, “I’m not doing it. I’m out. Forget about it.” Eventually, we cut a deal and he said, “Look, I’ll do it for nothing, but I want a percentage of the company, and you’ve got to put some money in.” So, I did that, and he said, “I think we can print these in titanium.” The problem with the plastic was it was too bulky and it was handmade, so it’s too expensive to make. Once we started printing in titanium, we can use all the available real estate, because it’s so strong and thin-sectioned; these walls are only three hundred microns thick, but you can drive over these in a steamroller. So, we could then take use of this space between the teeth, as well as the space here, and what that meant was the cross-sectional area, this airway, went from eight square millimeters to fifty, and fifty square millimeters is the same cross-sectional area as a healthy nose. So, now, we can put a nose between the teeth—a second nose—increased double the airflow. And then we thought, “Well, we’re going to have to be able to make these things in serial order.” So, we started developing software to design them. And so, now, we can do about ten thousand of these a year. We print sixty at a time, all custom-made for each patient. So…
Howard: Sixty at a time? So, the titanium’s additive.
Howard: So, sixty. So, the disc is about this size of table?
Chris: That? Yeah, it’s probably twice the size of that, maybe that big, and what happens is an electron, it’s a powder bed, and the electron beam zips around, micro-welding all the fifty micron titanium oxide particles together, and it builds it up in layers.
Howard: Man, that’d be cool.
Chris: So, anyway, we got regulatory approved. We did that project from the chunk of plastic to the first device, which looks like this, in eleven months, and we got regulatory approval to sell them in Australia. So, I said to Neil…
Howard: This was your first one?
Chris: Yup. It’s just a Monoblock; you bite into it, very simple. So, I said, “I’ll start selling them.” So, I did, and I did an interview on the news, and we had five and a half thousand patients register online in a week. And I better do something about that. So, I rang a few of my mates who are in Australia, and I said, “Look, I’ve got all these patients that I’m going to send to you, that want one of my devices. I’ll teach you how to do it.” So, we did that, and we managed to sell around two thousand or something. And then at that point, I’d put about a million dollars into the business. We started making money, actually. And then I just sold a clinical business, so I said to the CEO, “I’ve got all these clinics now; I didn’t want any more clinics. I just sold the bloody clinics.” So, I gave those to the dentists, and then we raised—we split the business… the clinical business out, and we kept the manufacturing business, and then we raised private equity—not private equity. Yeah, I guess it was, but individual high net worth investors. We need a private round, and then we listed this on the ASX last year, and then we’ve just done another raising now. So, we’ve raised about twenty-four million dollars into this company. And so, now, with this distribution agreement with Modern about our manufacturing setup, we think that in the next year or two, we’ll end up making a bit of money. So…
Howard: That’s a huge amount of money you raised.
Chris: Yeah, well you need it for global supply, and we’ve got a lot of clinical research.
Howard: So, how many offices did you sell when you sold to corporate?
Chris: So, by the time I started selling them, I had fifteen; twelve, I own, three, I managed. I started selling them over a period of time. By the time private equity came along, I think there were about only seven or eight left. So, I sold them those ones with the training institute, and the management consultancy. So, as I saw the other practices, the dentist I sold them to wanted me to continue managing them for them. So, I had a management contract across quite a few. And then, I scaled back to the cold ones that were easy to run and made the most money. So, then the private equity bought those ones off me.
Howard: So, what lessons could dentists learn from corporate? How does corporate dentistry do in Australia? What percent of the market is it?
Chris: Gee, that’s a good question, and it’d be around maybe twelve percent, I think.
Howard: That’s what they say the United States is. Is that in the United States?
Chris: Yeah, well it was five percent when I started looking to exit, and they’ve expanded quite quickly from there. I think was it a…
Howard: Five percent in Australia, or U.S.?
Chris: In Australia.
Howard: Five percent; now it’s twelve percent.
Chris: Yeah, the beginning one was eight to ten, two or three years ago, and now growing up at that rate, so I’ve had to estimate it to about twelve percent. It’s a bit of a different framework in Australia. We don’t… well it’s actually starting to hit in the same direction, so we call it the Americanization of the Australian health care system, where insurance companies are muscling, and then dictating terms, and there’s managed care coming in and this sort of stuff. So, I actually sold out when I saw that coming, because we had a pretty good run there for a while; we’d have to set our own fees. It got reimbursed as a percentage of that; not much, but it was okay. And then, the corporates started in Australia. People–local firm… I guess I can name one. 300 Spot Smiles, and Pacific Smiles, both signing up health fund contracts, and then…
Howard: Are 300 Smiles and Pacific smiles—where they publicly traded on the ASX? Or are those the only two publicly traded?
Chris: Yes, at this point in time.
Howard: And are the owners of that the city, or Melbourne?
Chris: Well, one 300 Smiles in several homes, so I know, well, he (inaudible, 00:43:11) actually, near where I grew up.
Howard: Where is that?
Chris: In North Queensland, so…
Howard: Is that here, or Sydney?
Chris: Well, north of Brisbane, so it’d be thousand miles north of…
Howard: You think he can come to Sydney and L.A. podcasting?
Chris: Well, absolutely. I think he’d definitely do that.
Howard: On this trip that I’m here?
Chris: Might be able to do—depends how busy. I have five kids; I think he’s got six, so he’s probably busier than me.
Howard: You’ve got five kids, he has six?
Chris: Yeah, I think so. Yeah.
Howard: I dreamed of seven.
Chris: Did you?
Howard: Yeah, I have four; I wanted to have seven kids.
Chris: I’ve always wanted five, and we ended up with five. So…
Howard: So, you only have really two corporate dental chains in Australia?
Chris: They’re the two listed ones
Howard: One 300 Smiles and Pacific smiles. Now, in the United States, none of the public chains are publicly traded.
Chris: It’s a very different fund-raising landscape. So, there’s a couple of private ones that I saw in my company, that it became national dental care. I think they’ve got about fifty something. There’s also Lumina in New Zealand, and Maven Dental, I think they’ve got fifty or sixty as well, and there’s two or three other private equity firms doing roll-up. So, it’s sort of—we’re ten or twenty years behind the U.S. market.
Howard: None of the big corporate dental chains in America could do an IPO on NASDAQ, and your time—what was the company you’re saying (inaudible, 00:44:27)
Chris: Well, that’s ResMed; they’re (inaudible, 00:44:29)
Howard: ResMed. Okay, so where’s it, on NASDAQ and ASX?
Howard: There’s no big corporate dental chain that could do an IPO on NASDAQ. Why do you think 300 Smiles and Pacific Smiles group could make an IPO on the ASX?
Chris: Well, it’s about the funding environment. So, if you look in the U.S, there’s a lot of private equity, a lot of VC money, there’s a lot of…
Howard: Explain the difference in private equity and VC.
Chris: Well, I guess private equity will take a longer-term view, and now generally, look to that coming later as well. So, VC will come into technology earlier at higher risk, but they usually got harsher terms in my experience, and now they might take an early-stage technology to the point that it’s commercial, or in sales. Private equity, more… so they’ll bring technology through, and they’ll take—probably got a higher risk profile. Private equity tend to do more consolidations, safer industries, but roll-ups and that might do it.
Howard: Explain what a roll-up is. A roll-up business goes out and buys a hundred dental offices…
Howard: As opposed to opening up from scratch a hundred de novo practices.
Chris: Yeah, exactly, yeah.
Howard: So, is 300 Smiles and Pacific Smiles groups more of a roll-up, or are they opening up de novo?
Chris: So, Pacific Smiles are more de novo, and 300 Smiles are more roll-up. But they’re both cash flow businesses, so they make good profits. Private equity will come into a business and look to reduce costs, restructure, increase scale and increase profitability that way, and then usually flip it, maybe to an RP, or maybe to another private equity firm, or a healthcare company, or something like that. So, what I think is really shaking up in Australia is Bupa, the world’s biggest mutual society, have bought Australia’s biggest dental corporate. So, they own two hundred and twenty practices, and they’re the pay off.
Howard: In Australia?
Howard: And it’s called what?
Chris: Dental Corp is the name of the company, but Bupa is the mutual society sitting shoe—
Howard: Dental Corp? C-O-R-P?
Chris: Yup. So, once Bupa bought the practices…
Howard: What are you saying; Buco?
Howard: And are they public traded in the footsie, or…
Chris: No, they are privately owned mutual insurance funds, or health insurance fund.
Howard: Oh, wow.
Chris: So, once you’ve got—they can lose money at the shop front and still be better off. So, you can’t compete with a loss maker. That’s my view. So, when I saw them do that, I just thought, “Right, well, I’m out,” because I can’t possibly compete with a health insurance company, who now owns a sizeable chunk of the market.
Howard: So, Bupa is a dental insurance company?
Chris: Health insurance, yes. (inaudible, 00:47:10) in the hospital.
Howard: So, they bought two hundred dental offices in just Australia?
Chris: Yup. So, there was already a roll-up called Dental Corp, which was private equity backed and debt-funded as well, and they’d sold to an Indian investor, and the Indian investor flipped it back to Bupa.
Howard: Amazing. Now, how many offices do they own in U.K.?
Chris: I don’t think that many in the U.K. I think though, I just started—when I last looked, it was a few years ago; I think that’s seven or something, but I would just don’t test the market.
Howard: So, what is your view of corporate dentistry now in Australia? Coz you’re saying the fees have come down…
Chris: Yup. Well, younger dentists don’t want to own a practice—of not all of them, but some buying…
Howard: Do you think that?
Chris: No, that’s the trend, and that’s what they’re applying on, and look, we’ve had a shift from… we’re probably sixty/seventy percent female dentists now, who want to have a family and have children. Without being sexist, that’s the reality of it. And they’re looking for part-time sort of contract work, then you’ve got dentists who do want to work hard and earn their own practice, but the minute that their health fund owns the clinic across the road, they come and see me—and in the U.S., its the same—they might pay my patient two hundred dollars for the crown; I’m charging two thousand, but I’ll get it for free across the road. So, as good as you think you are as a clinician, in the highest level of service you’ve got, it’s very hard to compete with free, and as I just said, the money rules the roost. The work goes where the money is’ it’s not the other way around. So, that scenario is starting to gain momentum in Australia. I think there’s still a lot of private practices that are doing well. I was an independent dentist, and I’ll continue to do so, but I think it’s just going to keep going that way.
Howard: I see individual dentists doing great, because when you own your own businesses and you have a mortgage, you have a home, you have a family, you have student loans, they just seem to work through lunch, stay ahead of the end of the day, they hustle, and they’re hungry.
Howard: But when you go to continue education, and you look at the associate market; the associates, during the courses, tend to be on their Facebook, tend to not come back from after lunch. You talk to the assistants and you say, “Well, how’s it going?” and they go… well, half the time, they get a toothache, they just write a referral to the endodontists. Whereas the owner would do the root canal, and it’s like—I wrote an article that ruffled more feathers than probably anyone that I’ve written, and since 1994, called it “Suck it up, buttercup.” I was talking about endo on second molars, and my thesis was just, do the damn second molar, because you’re not going to get good at it until you’ve done a hundred of them, and in my experience, when you lose the second molar, no one cares; it’s like a third molar. No one’s ever cared.
Howard: A second molar—I’ve only had one person for a decade say “You know, I kind of miss that tooth back there,” and I mean you just don’t chew on a second molar. So, I said, “Worst case scenario, you do the second molar and you’re perfect; you mess it up, you’ve got to pull it.” The patient, they won’t even care.
Chris: We’re cooking up opportunity.
Howard: And of course, at the end, you’ve got to be honest. They get all high and mighty. “Oh, you should send them all this,” but the associates, “I don’t want to do the second molar.” Well, this one might have another account. They’re just not hungry and they don’t hustle. And then their turnover; they don’t have skin in the game.
Howard: Do you see the turnover process?
Chris: So, when I ran my business, we were trying to be caught, but I don’t think we ever fully got there, but the key for us was training. So, instead of paying the dentists two thousand dollars a year on forty percent commission, and we pay them a hundred thousand dollars a year to train them. So, we’ve got two things out of that. We’ve got better quality dentistry and associates. They were more engaged. That had better work on the patients, which drove higher revenue. So, what I found was…
Howard: So, did you pay him a percent, or salary?
Chris: I pay them a salary.
Howard: You did not pay them a percentage?
Chris: Not in the first year; in the second year, then they got a little bit of a kicker, and we built it up over time. But see, the training, there’s a two-year program they went on, and our relative labor cost dropped from forty-two percent down to seventeen/eighteen percent. It was the…
Howard: Seventeen to nineteen?
Chris: Yup, seventeen to eighteen percent, depending on the year.
Howard: For labor costs for dentists?
Chris: Yup. So, that was all profit. We spent a bit of that on training, we reinvested back in. So, that was the model I used to make it profitable, to have associates, and to engage them. I also went to areas where there was less competition and higher income.
Howard: You went on a roll.
Chris: Yeah, yup. So, I had…
Howard: So, you say Sydney and Melbourne…
Chris: Never made a dime in the capital cities; it was all… we had practice of right through the morning towns up to Darwin, all the way down to Melbourne.
Howard: Yeah, it’s funny. In America, their parents migrated all the way from India, so the kids got a better life. I mean I tell the kids like, ‘Could you just kind of leave the big city, go just like one hour out of town?’ They’re like, “Now!” So, your mom came eight thousand miles—you just go a hundred miles, and those things…
Chris: It’s much easier.
Howard: So, you didn’t make a dime.
Chris: I might accelerate. I might have made ten percent of my salary in the city. I worked in the city, but I…
Howard: Which city; Melbourne?
Chris: But I fly…
Howard: Was it Gold Coast?
Chris: Near the Gold Coast, yeah.
Howard: So, is Gold Coast a city, or a county?
Chris: It’s a city, but it’s on the beach, east of the Brisbane, yeah. So, I basically would fly up the interior north, then south, and come back. So, I was away two or three days a week. I did it for thirteen years. We’ve made great money, we sold it well, and then I started this one. But this area of dentistry, I think you asked what adoption of practice—this is an area of dentistry that dentists can do for the health funds, that you can get away from that managed care scenario, because it’s a medical problem, it’s value-added, it’s low capex. So, when I do this work, I rent a room for thirty bucks an hour. That’s my overhead. I share a receptionist for someone, and I saw these for [0:53:27 unclear]. It’s about…
Howard: Twenty-five hundred dollars for the oral plants?
Howard: Whenever the government starts setting the fees, but like in Tokyo, Paris and London, you only get a hundred dollars from all your work.
Howard: So, when you go around the world, everybody’s going into sleep apnea, invisalign, and dental implants, because (inaudible, 00:53:47 – 00:53:49) Back to your corporate dentistry. Your answer to the employee turnover was training.
Chris: Training, yup.
Howard: And set up a big curriculum, and I think the leader in the United States by far is Kirtland Dental, and that’s where Rick Workman does; when you get a job in Heartland, it’s an extensive training.
Chris: Training. I mean it’s a quality thing, too. You can maintain quality. I also had a call center, because all of my practices with hundreds—if not thousands—of climbers apart, we took all the phone calls centrally, because my view was patient management was practice management. So, I knew—and I know behind my desk—if there was an issue in Timbuktu, I’d know about it straight away, and we’d have usual things: morning meetings, lunchtime, checkout, afternoon meetings, and we used to run it about twenty people in the call center, and add the tellies to make, and yeah, and making sure of above eighty-five percent capacity, and all the stuff that you know about and you’ve taught over the years as well. But making that replicable and manageable across a broad front was having sort of my…
Howard: Man, what a genius, what a pioneer. You’ve done so many things.
Chris: We’ve had some fun.
Howard: Amazing industry. It was just an honor that you’d stop by our hotel room.
Chris: Thank you, Howard. Thank you for having me.
Howard: Tell Godfrey I said hello.