Innovation and Entrepreneurship in Neurosurgery: Lessons Learned

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- Colleagues and friends, thank you for joining us for another session of The Virtual Operating Room. My name is Aaron Cohen. This evening, we have with us Dr. Kevin Foley, he's the chairman of Semmes Murphey clinic, as well as professor of neurosurgery at University of Tennessee Health Science Center. He requires no introduction. He's truly not only a pioneer in spine surgery, he's also one of the leaders in entrepreneurship in neurosurgery. I have to say that after finishing my MBA two or three years ago, I have come to realize that entrepreneurship in neurosurgery can often be more difficult than the most difficult operation in neurosurgery. So I really would like to have him share with us his pearls, after many years of being such an incredible entrepreneur in spine surgery. Kevin, thank you. And we're very much looking forward to learning from you.

- Thanks very much, Aaron. It's my pleasure to be with you and Neurosurgical Atlas today. I'm going to speak about innovation and entrepreneurship in neurosurgery, and share with you some of the lessons I've learned over the years, and hopefully you find a few pearls. These are my disclosures, and they largely relate to my entrepreneurial activity. So this is intertwined with some of the things we'll discuss. I'll briefly tell you a little bit about me in terms of medical innovation and entrepreneurship. I have a number of issued United States patents, actually a little over 175, as of now. I was a founding partner of a company called Stealth Technologies, which was a pioneer in image guided surgery. The company was sold to Sofamor Danek, and later acquired by Medtronic, and became Surgical Navigation Technologies. And that's the StealthStation that many of you use for your image guided surgery. I was the co-founder of the company, Spinal Graft Technologies. This was also sold to Medtronic. I was a partner and a board member for a company out of Santa Barbara, TrueVision, which built a digital surgical microscope. We sold this company to Alcon, an ophthalmology company. They spun off, swung back to us, the other utilities for the digital microscope. And this has become a company called True Digital Surgery. We actually produce the Aeos digital microscope for Aesculap. I am, I was a partner and board member at a birth tissues company, amniotic membranes and the like. This company was sold to DermaSciences, and later acquired by Integra. I am the co-founder of Accellus, DiscGenics, DuraStat, Fusion Robotics, Tissue Differentiation Intelligence, and Triad Life Sciences. I've also invented a number of things over my neurosurgical career, they're listed here on the slide. But a number of these techniques and devices are used daily throughout the world. So, how did I start on this journey? Well, I never entered neurosurgery thinking I was going to be an entrepreneur, but I began my entrepreneurship journey by volunteering as a faculty member at some of our major meetings. The AANS, the Congress, the Spine Section, et cetera. And through these meetings, not only interacted with my partners and other neurosurgeons, but also interacted with various company representatives. When I joined Semmes Murphey Clinic in 1992, after I had completed my military service at Walter Reed Army Medical Center, one of the things I did was to negotiate the ability to own my own intellectual property. That turned out to be a prescient move. My first invention was a polyaxial posterior cervical screw-rod system. And this was back in 1992, 1993, before such things existed. What drove me to do it was my frustration with the means of posterior cervical fixation at the time, which was plates and screws. I was frustrated with them, and I patented that invention. I licensed that patent to Medtronic, and a little bit of a lesson here, that was not turned into a product for another eight years or so. It eventually became the Vertex system for posterior cervical fixation, but not until several years after the invention. Also that same year, I met Rich Bucholz and Kurt Smith when I was up at the Society of University Neurosurgeons meeting, which that year was being held at St. Louis University. And at the SUN meeting, I watched Rich present on his very early work on computerized image guidance for brain surgery. And I went up to Rich after that presentation, and told him that I believed I could apply his technology to the spine. And after a few years of work in my laboratory here in Memphis, and back and forth with Rich and Kurt, we ended up not only devising a spinal navigation system to go along with the cranial navigation system, but we were able to sell that company to Danek here in Memphis, and later Danek was acquired by Medtronic. I was interested early on, in less invasive approaches, especially to the spine. In fact, when I was at Brooke Army Medical Center, shortly after I had graduated from residency at UCLA, I purchased an automated percutaneous lumbar discectomy system. Dr. Joe Maroon out of Pittsburgh was one of the developers of that system. I had a great interest in endoscopic spine surgery, but what I found through my use of those techniques, is that although they could work, they didn't always work. This led to lots of frustration, and drove my efforts shortly thereafter, when I came to Memphis, to develop a means of doing less invasive decompressive surgery within the spine that I felt could be consistently effective. And that was the genesis of MED, micro endoscopic discectomy, which I derived with Mo Smith here in Memphis, and later the Matrix system. My work with that system early on clinically, also led to the need to combine the minimally invasive decompressive approach with a reliable means for minimally invasive spinal fixation. And that was the genesis, that need was the genesis for my development of percutaneous pedicle screws with extenders. And so not only the specific system, but the concept of having an extender attached to a screw head that you couldn't see, but that you could manipulate. You could know what the orientation of that screw head was, based on the extender. And you could deliver a longitudinal connector, such as a rod, and of course that concept has been used worldwide. I initially was using the tube system for minimally invasive posteriolateral only fusion. And of course it became apparent that one could do interbody fusion with the similar concept. Rectangular chisels were used in those days, back in the late nineties. To place interbody devices, you had to mortise, or cut, the channel into which you were going to place the interbody device. Those chisels had sharp edges. You could tear the dura. And I developed the concept of having bullet nosed, tapered interbody implants, and generated lots of intellectual property from that relatively simple concept. So those were things I did several years ago, but I've not stopped. The entrepreneurial side of medicine has continued to be my hobby, as I've continued to be an active neurosurgeon. I operate four days a week. I see clinic two days a week, and in the evenings and on the weekends, I work on inventions and I work on developing new technologies. And so I'm involved in a number of efforts, all of which were directed towards problems that I saw or needs that I felt existed based on my neurosurgical experience. And so I'm involved with regenerating human discs with a company called DiscGenics out of Salt Lake City. I co-founded a company called Fusion Robotics, which was an effort, and is an effort to produce a much simpler, less expensive spinal robotics system. We merged with a small company called Integrity Implants to form another company called Accellus this Summer. In order to try to diminish the possibility of neural damage, especially at the L4-5 level, in lateral approaches to the spine, I'm working with a group, and have developed an ultrasound device that uses an artificial intelligence algorithm to actually visualize nerves real time, to help you more safely derive corridors where these interbody devices can be placed without actually seeing the nerves, except with the ultrasound. I'm involved with another group out of Boston, in a small startup called RevBio, and we've developed an osteoconductive, resorbable, wet-field, mineral-organic bone adhesive. Remarkable material that glues bone together, and sets up in a saline or wet environment, and then ossifies, it osteo-conducts, and as you can imagine, has a number of potential uses. I'm working with another group in a small company, again out of Salt Lake City, called nView, developing a low radiation dose, rapid image acquisition three-dimensional intraoperative imaging device, and have some other things brewing. So when I was putting this talk together, and thinking about talking to especially younger neurosurgeons who are thinking about exploring the entrepreneurial side and the developmental side of neurosurgery, I went to a couple of trusted friends in industry to get their take on surgeons working with industry. And so these next few slides will address what I learned from these folks. So the first is an industry insider who served as Senior Vice President in charge of R and D for a large spine company. And his advice was that if you want to pitch an idea to a company, look at what's hot in the market. And from his perspective, things like robotics, digital applications, artificial intelligence applications, and machine learning and augmented and virtual reality are hot topics right now. And when he was sitting in the seat where he would vet ideas that were being brought to him by surgeons and others, these kinds of more current applications would be much more well-received than older technologies like screw and rod fixation. And it's not to say that older technologies can't be improved. They absolutely can. His point of view was that you would be more likely to gain a receptive audience with a more current topic to your potential idea. Relationship building is very, very important if you want to become a successful entrepreneur. And as you develop these relationships, you have the ability to interact with more people, and allow your ideas, and your input to reach more ears. You have a greater chance of your idea becoming a reality. Companies are not neurosurgeons. There are bright engineers and bright executives, there are very experienced deal-makers, but they don't have your experience, your hands-on experience with neurosurgery. You as a neurosurgeon, know what works and what doesn't work. You have a sense of what is missing in our treatment for patients, what things, if developed, might improve their treatment, and companies value this. And in fact, will work with surgeons to help co-develop products. And that's another way to get involved in a legitimate entrepreneurial activity. You have to have realistic expectations. I have been very successful with my endeavors, but it was unanticipated. I didn't set out to go turn my entrepreneurial activities into monetary reward. And you need to keep in mind that as brilliant as your idea may be, it may not turn into anything worthwhile in terms of a salable product. In fact, I'll tell you that the vast majority of my patents led to no product. Now a few did, and a few became very, very successful products. So you have to keep at it. But you can look at something like the open payments portal at, and get an idea of what physicians are earning from companies, it has to be reported now by law. And NuVasive is up here as an example from my industry insider, and what he's pointing out is that all of these surgeons aren't making millions of dollars. There are a few who are doing well, but if you look at the fact that there are, for example, about 8,000 spine surgeons in the country, most of them are not as active from an entrepreneurial standpoint, as those few. You have to get familiar with contracts, and the vast majority of us, including myself, we're not attorneys. And so you need good attorneys when you're developing business relationships. You want an attorney who knows contract law very well. You want an attorney who's likely to be, a separate attorney, who knows intellectual property law very well. Both important in your interactions. Now, the next person I talked to is a retired CEO of a large medical device company. And I say uncensored, because he speaks his mind. I said to him, "Well, if you had an open forum to talk to aspiring surgeons who are looking at getting involved in entrepreneurial efforts, what would you have to say?" And so he was uncensored. You can read his quotes here. "I think young surgeons are often looking for a free ride with a company. They need to realize that their chief goal should be to become a competent clinical investigator with adequate surgical volume to prove out different utilities." "Most companies relish being approached by a clinician who has good surgical volume and comes from a reputable program, who wants to work with them doing cases with novel devices or techniques." And he recommends that as you start, you start with a niche and you stay focused. He thought perhaps two, or at most three niches was appropriate. He went on to say that companies don't want something for nothing. He emphasized the importance of intellectual property. And we'll get into that a bit in my lecture, because that's a very, very important topic. And then he was pretty harsh about surgeons who were less than dedicated, I think I'd put it. Has an interesting quote, "These surgeons, as much as they may be revered by their peers, are often the laughing stock of boardrooms." Pretty harsh comments. Then another interesting thing he had to say was that surgeons keep doing surgery. In his experience, surgeons who became successful entrepreneurs often stopped being clinically active, and then still wanted to interact with companies. And from his point of view, at least, companies want surgeons who can still do surgery so that they can help evaluate and teach about their creations. So I'm going to go from those general, but interesting comments, to some practical matters. Things that you really need to be aware of as you contemplate getting more active from an entrepreneurial standpoint. And that's intellectual property and patent law and legal guidelines. And as I said earlier, I'm not an attorney, but over the years, I've become familiar with these topics, because of their importance. So patents start with an idea, a concept or a thought. And developing intellectual property means inventing, creating new things. So how do you do that? Well, I'll tell you as a surgeon, the way I've done it, I've spoken to you about earlier in this lecture, I look to solve problems. You know, Plato said years ago, "Our need will be the real creator." Over the years, that saying has morphed into the English proverb, "Necessity is the mother of invention." But as true as that was centuries ago, it's absolutely true now. So look at what you're doing day to day. Are you doing something different in your practice, that perhaps could improve the field. Are there things that aren't working well, that you feel that you could do better? "Think different", as Steve Jobs would say, or outside the box. Think about things that are used in other industries or other fields, outside of surgery that might have applicability in a surgical field. Look for things that haven't changed in years. Oftentimes, those are opportunities for improvement, or provide opportunities where improvement can be fruitful. Interesting research on getting more creative. So there is data out there to show that when you test humans with their ability to solve creativity puzzles, they get better if they're more drowsy. And some of my best ideas have come to me in twilight sleep, those early hours where you're just transitioning from sleep to wakefulness in the morning. I've even dreamed, literally, dreamed up ideas that I wake up and jot down the next morning. You can dream during the day. So daydreaming has been associated with creativity. Childlike thinking has been associated with creativity, and humor. You absolutely want to protect your ideas. And mainly, this will take the form of patents. Now, a patent is an interesting thing. Patents are enshrined in the constitution, so you have a constitutional right to patent things. A patent is not a right to do anything yourself, though. Interestingly, a patent is an ability to exclude others from using your idea. And the notion is that if they want to use your idea, well they have to provide something of value in return. Utility patents, which are the main patents that apply to surgical methods and devices, have a 20 year term. They expire after 20 years. And the 20 year clock begins ticking when you file the patent. Patents don't issue immediately after you file them. And the duration of that patent after it has been issued, varies depending on how long it took the patent issue. If the patent took five years to issue, then you've got that patent right for 15 years from that point. The patent rights are granted to the inventors, and then you have the ability to assign that patent, or license that patent. And of course it is a potential source of income. Now, there are exceptions to excluding others from using your patents. Medical procedures, methods, can be practiced by any practicing physician, whether he or she has patented the method. That doesn't include the use of patented devices, but methods can be freely used by any healthcare practitioner. There's also a safe harbor for clinical trials. Patented material can be used without compensation in clinical trials. There are different types of patents. The ones that you should be significantly aware of are provisional patents and utility patents. And we'll talk about those in some more detail. You can patent any new and useful process, or any improvement of that process or device. A very famous quote from a famous patent law case, Diamond vs Chakrabarty, where the judge opined that "anything under the sun made by man" can be patented. You can't patent abstract ideas, laws of nature, and unapplied concepts. Your concept has to be practical. So you can patent a process, a method of doing something. You can patent a machine, an apparatus used to do something. You can patent an article that can be manufactured. You can patent a composition of matter, or you can patent an improvement of any of those above. For your patent to be issued, it's gotta meet some significant criteria. So the United States Patent and Trademark Organization, the USPTO or office, excuse me, the United States Patent and Trademark Office, has examiners who will look at your patent application to decide whether or not a patent should be granted for your idea, but your idea has got to be novel. Basically, it's gotta be new over what's called the "prior art". And the prior art is what's out there, either in previous patented material, or the literature, or in public presentations, anything that's publicly accessible. Very important is, not only should your claimed invention not have been disclosed in the prior art, prior to the filing of the patent application, you should not disclose your patented idea publicly before you file a patent application. If you've got a hot new idea, and you publish an article about it, or you go to make a presentation at a conference, a public conference, you can jeopardize your ability to patent that idea. The America Invents Act is an important piece of law for you to know about. Prior to September 16th, 2011, the U.S. was a "first to invent" country. The reason, what that means is that if someone borrowed your idea, I'll be polite here, and went and filed a patent application. Even if they had that patent application issued to them, if you had proof that you had actually invented this device in the first place, not only would you be awarded damages, but you'd be awarded that patent. Well, that whole process has changed since the America Invents Act. And we are now like most of the world, a "first to file" patent system. And so that means it is even more important for you to file on your idea if you want to patent it early, rather than waiting, and waiting, and waiting. Because if you dither, you may lose your patent. Now a patent not only has to be novel, the idea has to be non-obvious, which measures the differences between the prior art, and what's claimed in your invention. Obviousness is a little bit of a vague term, and there are gray areas, but the patent examiner, as he or she looks at your idea, will not only look to see if it's novel, but look to see if it's obvious. And then you have to be able to use your patented method or idea, in a practical fashion. It has to be useful. It has to have practical utility. So unapplied concepts, or concepts that can't be applied, aren't patentable. There's a whole process to obtaining a patent. You disclose your invention. You search the prior art. You prepare your patent application, you'll want to use a patent attorney to do so. And I'm not gonna go through the, what is enablement, best mode, and the description requirements. The point is the process can be laborious. It can be time consuming. It can be expensive. In fact, I've told many people, it's much more difficult to obtain a patent, an issued patent, than it is to publish an article in a medical journal. You wanna keep records. So if you have a good idea, jot it down. Ideally in a notebook, ideally in a notebook that you have someone attest to, who is unrelated to you, and unrelated to the patented idea. You wanna maintain records, just in case there's some conflict. An inventor is anyone who materially contributes to that invention. And the heart of a patent application, what the examiner will concentrate much attention on, is what are called the claims. At the end of your patent application, you will say, "I claim" the following, and then enumerate your claims. And what's important about this, is that the claims do define what your invention is. If you contribute to a patented idea, and you contribute to a claim, and you are not listed as an inventor, that patent can be invalidated. And reciprocally, if you contribute just one claim to a patent with multiple claims, that you were a legitimate inventor on that patent. These are the steps from filing to issuance that you go through. When you finalize your application, and you submit it to the USPTO, your idea will be examined. Your patent will be examined. Sometimes it will be issued, but most of the time there will be a back and forth process with the patent office, and you will receive what are called office actions, where the patent office can reject your patent application outright, or reject certain claims, accept other claims, and tell you why they're, if they're rejecting them, why. Was it obviousness? Was it lack of novelty? Was it lack of utility, et cetera, et cetera. And through that back and forth process, in conjunction with your attorney, you're allowed to respond, to help explain to the examiner, help convince the examiner, why no indeed, your idea, your patent, is novel and non-obvious, and should be allowed over the prior art. It costs some money to patent. I list some of the fees here, from what's called the standard entity government fee structure, but you can spend a lot more than this. These are the minimums that you'll spend getting a patent issued. I highly, highly recommend filing a provisional patent application before you disclose any of your ideas. Whether you disclose them at a conference, or disclose them in a publication, or disclose them to any potential business partner or company. A provisional patent application is relatively inexpensive. The cost is 150 dollars for a small entity, and you're likely a small entity. You describe your idea, essentially. You can find this form on the website, and you submit it to the patent office. And for that fee, they will issue you a provisional patent. Now a provisional patent isn't examined. So it's not a guarantee at all, not in the least, that your patent is eventually gonna be issued. But you put a stake in the ground, you plant a flag, you've basically enshrined the date of your conception. And why that's important is, because if you then speak to someone or some entity about your idea, and they run off, there are unscrupulous, and go ahead and try to file a patent on your idea, you can prove indeed, you filed on this idea before they did. You have a year from filing your provisional application to file that full utility patent. And if you wait more than a year, then your provisional patent application, or your provisional patent will expire. And you also cannot just add all sorts of material to your provisional application, that you did an outline in the description in your provisional. If you do things like that, the patent office will tell you, your provisional isn't applicable, and you'd have to file a brand new application. But still, it's a very, cost-effective, relatively straightforward way to record, officially, the date of your conception. Now, I'm gonna talk about some other things that you need to be aware of, in entrepreneurship and in business as a physician. There are some important laws on the books that govern how you can interact in a business fashion with other entities when you're a practicing physician, especially if you're doing any business with Medicare or Medicaid. So one of the important statues out there is called the AKS it's the anti-kickback statute, which prohibits the knowing and willful solicitation, receipt, offer or payment of any remuneration in return for, or to induce the referral, arrangement, or recommendation of Medicare or Medicaid business. There are substantial fines for doing this. Violation of the statute is a felony, and you can go to jail. The anti-kickback statute basically prohibits you from taking anything of value in return for your medical business. There has to be a knowing and willful solicitation, or receipt, or even an offer for payment for your services. The remuneration doesn't have to be cash. It can be indirect. It can be covert. It can be in kind, in return for referrals. In return for purchasing, leasing, ordering, arranging, or recommending. So, for example, if you're putting in implants for a company and they have given you a sham consulting agreement that's really contingent on you putting in implants, you're now engaged in a violation of the anti-kickback statute. Then there's the False Claims Act. By the way, with anti-kickback statute, there is a physician in my town at a large practice who was just found guilty of violating the anti-kickback statute. And one of the things that you're subject to, beyond fine and potential imprisonment is basically you can't participate in Medicare or Medicaid. So really, really foolish reasons to take kickbacks, gang. The False Claims Act involves filing fraudulent, or false, claims that are payable by Medicare. This is also subject to both criminal and civil liability and multiple damages. Damages, as in multiple, of what you've done. Whistleblowers can basically turn you in for a violation of the False Claims Act. And a whistleblower can be a partner, can be someone at a company, at where you're working, can be someone at your institution, and whistleblowers actually get money if the faults, if you're found guilty of a violation of the False Claims Act. And just like there is in my town right now, a physician who was recently found guilty of violating the anti-kickback statute. We have a large healthcare system and a large clinic, thankfully not Semmes Murphey, that are under investigation by the Department of Justice right now, for an alleged violation of the False Claims Act. And the complaint has been publicly disclosed. And although the issue hasn't been adjudicated, the damages, potential damages, are in the hundreds of millions of dollars, they're substantial. So who's looking for fraud out there? Lots of people, CMS is, the OIG is, the FBI is, the DOJ is, the U.S. Attorney is, lots and lots of people, including Qui Tam Relators, Qui Tam Relators are whistleblowers. These include employees, former employees, partners, competitors, et cetera. This is not to say that it's not legitimate for you to do consulting work for a company, or to license a patent to a company. Those are all legitimate things to do. But there are some rules that are key to protecting you, when someone is talking about paying you as a physician. There has to be a bonafide business need for your services. You have to have been selected on a legitimate basis that's unrelated to any referrals you're making. In other words, it can't be your use of implants. What's paid has to meet the fair market value test, and you must provide something of value. You actually have to consult, put the time in. You actually have to invent. For me, having issued intellectual property that I can license, absolutely protects me, because it's a legitimate business need. And it's a verifiable business activity. Watch out for some of the industry players out there, who do engage in pay for play. They want your business. They want you to use their implants. And some of them will potentially induce you. Be careful. Again, you can go to jail. So watch out for indirect forms of remuneration, such as undisclosed discounts, product support services, gifts, travel, educational graphs, grants, or research funding that don't serve a legitimate purpose. When they say, "We wanna fly you and your wife, first-class, to the islands to show you our new implant", that they expect you to use in the O.R., I mean, you have been induced, be careful. There's something called a switching arrangement, where drug manufacturers often offer physicians cash payments or other benefits each time they change a physician's, or a patient's prescription to their drug. Don't do that. Fake consulting agreements where you're not really consulting. There are companies that will pay you to put their implants in, and say, "Well, you're consulting for us, because you're evaluating this implant as you put it in". No, you're not. That's not, that activity isn't gonna look good in court. And of course, don't go for free samples. Bad actions have consequences. Last year, a spine surgeon agreed to pay the U.S. DOJ 1.75 million to settle allegations that he accepted kickbacks from a company called SpineFrontier. The CEO of SpineFrontier is under active investigation right now, and he's an MD. So be careful gang, be careful to follow the law. In conclusion, innovation and entrepreneurship help the field of neurosurgery advance. There's no question that's true. As a practicing neurosurgeon, you have the opportunity to innovate, because of your firsthand experience. You know what could be done better, and you know what the unmet needs are. Absolutely protect your ideas. Learn about the intellectual property system. And if you don't remember anything else from my lecture, number one, follow the law. Number two, learn about provisional patent applications. A good way to start your entrepreneurial activity is to work with industry in a lawful fashion, avoiding improper activities, kickbacks, fraud, et cetera. And that concludes my talk. And I thank you very much for your attention.

- Great lecture, Kevin, a lot of great pearls. Just like you mentioned, we have to protect our IP. That's just so important, because many surgeons take that for granted

- Yes.

- because they're unfamiliar. But even more important, is that I know many surgeons unfortunately, that they receive elimination, because they're trying the new spine implant,

- Right.

- and they're providing ideas. I think that is extremely prevalent in the neurosurgical and orthopedic community, that they come and tell you, "Okay, just give us your idea, and we'll pay you for your time." Am I mistaken? I think this sort of a pseudo illegal activity is very prevalent. Isn't it?

- There's a lot of it out there, Aaron, and you have to be cautious. And if a deal is too good to be true, it's very likely not good for you to follow.

- Right. But I think what's most important about this lecture, Kevin, that you very nicely mentioned, is that we should remain very entrepreneurial. We should be very innovative. And remember that, really, dogma is pretty much our worst enemy. I think many neurosurgeons often believe that how they learned in a residency is the only way to do it, and anything out of that realm is not appropriate. Even though, in fact, for us to be able to advance the care of our patients, we have to continuously find ways to do it better. That's just the only way to move forward.

- I agree completely. And I think with the pace of technological change, Aaron, I know you see it as you walk around our exhibit floors, you hear it in the lectures. The technology is expanding at an ever-increasing rate, but there are a finite number of neurosurgeons, and true neurosurgical expertise and insight is a rare commodity. There are 5,000 of us in the U.S. And the ability to take your neurosurgical insights and apply them to the new technology in useful creative ways, is a valuable and very necessary commodity. I think because of some of the bad actors out there, the entrepreneurial activity has gotten a bad name. It's a shame, because good entrepreneurial activity is good, not only for the surgeon, but for the whole system, and especially finally for the patients, because it results in improved care.

- I agree, you know, I think we all should give credit where it's due. And I think you are absolutely a great role model for so many neurosurgeons. And I'm gonna be a little bit sort of blunt here, and say that often we consider our research, or academic mentors as the ultimate role model, and they absolutely deserve that. There's no question about it. Our research academic role models are extremely valuable. However, equally, our entrepreneurial and innovative colleagues that push to really use the operating room in a very safe manner as sort of their laboratory, to move the science of surgery forward, are equally our role model. I think sometimes they don't receive as much attention. And I think the goal of this lecture for everyone to realize, that there are really role models that are research, academic, organized neurosurgery. And there are role models that are entrepreneurship, innovative in science of surgery, in the technical aspect of surgery and industry. And everything, everyone in those different components, are as critical and as important.

- Well, one of the great joys in my life is knowing that every night, while I'm asleep, someone around the world is using some method or some device that I helped create. And is using it to help make a patient better. So it's a way to amplify one's own efforts in the field.

- Absolutely. So I really want to thank you for joining us, and sharing your pearls. It's really been an honor, Kevin. Thank you.

- Thank you very much.

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