July 11, 2026 • 39 mins
Steroid injections can feel like a miracle for joint pain, until you ask what they might be doing to the joint itself. We sit down with Dr Thomas Buchheit, founder of Triangle Regen Medicine and Biologic Centre in North Carolina, to unpack why orthobiologics and regenerative medicine are so often misunderstood and why the next chapter of musculoskeletal care may be about harnessing inflammation rather than suppressing it.
We talk through the “immune cascade” that follows injury and how that framework helps make sense of platelet-rich plasma (PRP), stem cell therapy claims, and newer approaches such as the Regenokine programme. Dr Buchheit explains why he focuses on restoring tissue function, why exercise is one of the most regenerative tools we have, and why repeated corticosteroid injections and heavy NSAID use can clash with long-term healing goals.
You’ll also hear the practical, patient-side details that rarely make it into marketing: how he uses MRI and ultrasound to teach people what’s actually happening in their knee, shoulder, tendon or nerve; why dosing matters in PRP; and what “quality control” can look like when clinics measure platelet counts and aim for repeatable biological signals. We also go behind the scenes on building a regenerative medicine practice outside the insurance system, the real business lessons, and the challenge of patient education in a noisy field.
If you want clearer answers on regenerative medicine, orthobiologics, PRP dosing, exosomes and osteoarthritis treatment options, this conversation will help you ask better questions and set better expectations. Subscribe, share with someone weighing steroids or surgery, and leave us a review with your biggest takeaway.
Guest Biography
Dr Thomas Buchheit is the founder of Triangle Regen Medicine & Biologics Center in Chapel Hill, North Carolina. A former Duke physician and specialist in interventional pain medicine, he has dedicated his career to advancing regenerative medicine and orthobiologics.
His work focuses on helping patients restore joint, tendon and nerve function by harnessing the body's natural healing mechanisms through treatments such as platelet-rich plasma (PRP), Regenokine and other regenerative therapies.
Dr Buchheit is also the author of Healing Joints and Nerves, a book that translates the science of regenerative medicine into practical, patient-friendly language while exploring the immune system's central role in healing.
- Website: https://www.triregenmed.com
- LinkedIn: https://www.linkedin.com/in/thomas-buchheit-a1063a4/
- Book: https://amzn.eu/d/09a2rMa4
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About the podcast
Voices in Health and Wellness features conversations at the intersection of medicine, lifestyle, and human potential, with clinicians, scientists, and thinkers shaping the future of care.
About Dr Andrew Greenland
UK-based medical doctor and founder of Greenland Medical, specialising in Integrative and Functional Medicine. Trained in both conventional and root-cause approaches, Andrew helps people optimise health, performance, and longevity, with a focus on cognitive resilience and healthy ageing.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr Andrew Greenland (00:00):
Welcome to another episode of Voices in
Health and Wellness, where wespeak with clinicians,
innovators, and healthcareleaders who are challenging
conventional thinking andhelping shape the future of
patient care.
Today's guest is Dr.
Thomas Buchheit, founder ofTriangle Regen Medicine and
Biologic Centre in NorthCarolina.
Dr.
Buchheit has spent yearsstudying regenerative medicine,
(00:20):
platelet-rich plasma, stem celltherapies and immune-based
healing.
He's also the author of HealingJoints and Nerves, a book
helping patients understand whyregenerative medicine replaces a
genuine shift in how we havehealing.
So today we're going to discussortho biologics and why it
remains misunderstood, thescience behind regenerative
medicine, patient education, andwhere this exciting, exciting
(00:43):
field is heading.
So with that, I was like towelcome you to the show and
thank you very much for joiningme on this podcast today.
Dr Thomas Buchheit (00:48):
Dr.
Greenland, thank you.
It's a pleasure to be here andthank you for inviting me.
You're very welcome.
Dr Andrew Greenland (00:53):
So perhaps we could start a little bit
about you and your journey.
So just tell us a little bitabout your journey so far and
how you've found your way intoregenerative medicine.
Dr Thomas Buchheit (01:01):
Well, when I write it, it's a great
question.
When I finished residency andfellowship, this field didn't
exist, right?
So I finished an interventionalpain and spine fellowship in
1999 and I became fairly steepedin the spine world for about a
decade or so.
And there are some things aboutthat I wasn't that found a
little bit distasteful over theyears, um, you know, medication
(01:22):
use and heavy surgery use uh forspine conditions.
And in 2010, I had a reallynice opportunity to uh to join a
research group and a clinicalgroup at Duke.
And so I ended up uh leavingthe practice I was in and
joining up with Duke and reallystarted a really interesting
journey of not at justunderstanding nerve injury and
(01:44):
mechanisms of that, but alsolearning about how those
mechanism, those the samemechanisms that exist in, for
instance, osteoarthritis.
Uh, we started, I startedlooking at and focusing on not
just uh risks of chronic pain,but resiliency.
So if you have 100 people whohave the same condition, um,
(02:05):
what makes those who recover andrecover from pain and are
resilient?
What's different about them?
And the answer was really theimmune system.
Those who have a strong immuneresponse to injury,
interestingly, are more likelyto recover.
And that has implications forall of us, right?
It has implications forexercise, it has implications
(02:26):
for our use of anti-inflammatorymedications or steroids.
And it really forms thefoundation of regenerative
medicine.
We studied kind of all thesetherapies, and it was really a
uh really wonderful exploration.
Dr Andrew Greenland (02:41):
So amazing, thank you.
Always really helps have somebackground and context as to the
work that you currently do.
So I think you've kind ofalready alluded to this, but
what was that particular momentthat convinced you there had to
be a better approach thantraditional pain management?
I think you've given us acouple of clues, but what was
that trigger for you?
Dr Thomas Buchheit (02:57):
The trigger was probably a paper in 2017
that came out in American inJAMA, Journal of American
Medical Association, and itshowed an association with
repeated steroid injections andaccelerated osteoarthritis of
the knee.
And that was the moment when Iread that paper that I realized
that we really have to changehow we're practicing.
(03:19):
Because I came from a world andwe all did, where we thought
that you have inflammation in ajoint that's arthritic, if you
quiet down that inflammation,the joint's going to get better,
you're gonna improve the pain.
You might actually improve thejoint longer term as well.
And it turns out we weren't.
It turns out we were actuallymaking things worse, not better.
So that was the that was mythreat kind of threshold moment
(03:41):
and realized we really need anew pathway and a new way of
looking at this.
Dr Andrew Greenland (03:46):
Thank you.
So I think you mentioned thatregenerative medicine is often
misunderstood.
So, what's how do you defineregenerative medicine or how do
you explain that concept to yourpatients?
And what is thismisunderstanding that exists out
there?
Dr Thomas Buchheit (03:59):
I I like to think broadly about regenerative
medicine being the restorationof tissues and restoration of
function.
You know, some people think ofit as a growing new tissues,
growing a new heart, a new ear,uh something else.
Uh that's a very, I think, anarrow definition.
But to me, anything thatrestores function and restores
um tissue health isregenerative.
And in that respect, exerciseis probably one of the most
(04:22):
regenerative therapies that weall do, right?
And if you think about it, itmakes a lot of sense.
So, you know, when we when weexercise or work out, you
actually create an inflammatoryprocess, right?
And you can even biopsy amuscle afterwards and see
increases in interleukin 6 andall these inflammatory
cytokines, but you start acascade of healing that
(04:43):
ultimately will strengthen thosetissues and grow those tissues.
And and you know, that's whyall the literature on, for
instance, exercise andosteoarthritis is very clear
that breast walking is a goodthing, good exercise for
somebody with arthritis.
So, so that's to me that that'sthe fundamental step is that um
that immune cascade.
(05:04):
And that really formed thebasis of the book.
You know, I started working onthe book about six or seven
years ago, and with the reallythe goal of helping people to
understand how these therapieswork, how do stem cells really
work?
How does PRP, platelet-richplasma really work?
What is this thing calledRegenikine that people are
flying to Germany for?
And how does it work?
(05:24):
And we can dive into some ofthe research we did with that.
And it was really a wonderfulexercise to go through
systematically.
I probably reviewed over athousand papers in the process
of writing this book to try todistill down the science to a
broad audience.
It turns out that all of thesetherapies just work in different
(05:45):
parts of the immune system,which is really interesting.
You may have PRP that worksearly on, where you know, if you
think of an injury, you have aninjury and you have platelet
release.
Yes, you have clotting factors,but you also have growth
factors that release.
They recruit in neutrophils inthese early white blood cells.
They were then recruitingmonocytes that come into the
(06:06):
tissue, become macrophages.
And if all goes well, themacrophage polarizes, right, and
it starts to rebuild tissues.
And you can slide in all thetherapies, including stem cells,
into this immune cascade, whichI thought was just a it was a
nice framework to hopefully helpuh people understand how
they're how these treatments areworking.
Dr Andrew Greenland (06:27):
So, in terms of your repertoire of
tools in your box, as it were,what are your most treasured
tools that you can offer peopleor techniques, treatments that
perhaps they've not heard ofbefore, that you can really get
some leverage over thatcondition with?
Dr Thomas Buchheit (06:43):
You know, probably the the main tool that
people have heard less about isthe Regenekine program.
Um, and that's people think ofit as a as a PRP-like process,
but it's really not.
Um it's a it comes from blood,so you take blood out and then
you let it coagulate and clotovernight.
(07:04):
And really what you're doing isletting those blood cells and
those white cells work very hardfor you.
And then we filter, we have afull uh full lab, full sterile
lab, full hood and everythingelse for processing, and you
filter that and process that andthen start injecting that.
And that's really been a verynice therapy for people where
(07:25):
other things have failed.
Most of the people that wetreat with Regenokine have had
other treatments, they've hadPRP, they've had stem cells,
they've had roller therapy,those haven't worked, and so now
they're coming for uh somethingelse.
And uh it's been nice, youknow.
It it it started with Dr.
Peter Whaling and in Germany,and uh, at least in the United
States, you we always hear aboutuh athletes, pro athletes who
(07:47):
are flying to Germany for theirtreatment.
A lot of times they're going tosee going to see Peter, who uh
was my mentor for and still ismy mentor.
I've worked with him for sevenor eight years, and we've been,
you know, we've actually I'vebeen using a program here in my
Chapel Hill office since wesince we opened up, and I used
it for years at Duke when I wasat Duke.
But it really is a nice, a nicetreatment when other things
(08:11):
have not worked, and we know howit works now, too.
So we looked at, we actuallyteased this apart in the lab.
People always used to think ofthe Regenekine program as a
product of what people callIRAP, right?
So interleukin 1 receptorantagonist protein.
So IL-1 antagonist is a proteinour bodies make to fight and
(08:33):
shut down IL uh IL1 to shut downIL1.
And it is powerfully analgesic,but if you study IL-1 IRAP,
that protein, it only works fora short period of time in an
arthritic joint.
And there was some part of thistherapy that we were missing
that we weren't understanding.
So we took it to the lab and wedissected out the different
(08:54):
mechanisms of it, um,biochemically and also in animal
models.
And it turns out that it'sactually exosome.
Most of the effect isexosome-based.
That is a nice story for for meand for for patients as well,
because there's people talk alot about exosomes, and we can
dive into that a little bit.
But the most important partabout that is making sure
(09:15):
they're safe.
And if you can get exosomes andexosome therapy from your own
blood, not from donor blood, uh,you've also increased the
safety of that product as well.
So that that was a nice uh thatwas a nice research journey
over several years as well.
Dr Andrew Greenland (09:30):
Amazing.
So I think in our lastconversation, you described um
this paradigm shift as to whatwas been happening before in
pain management as opposed tothe kind of work you're doing
now.
But what do you mean byparadigm shift?
Um, and how do you and how hasyour philosophy of medicine
changed as you've been doingmore of this work?
Dr Thomas Buchheit (09:50):
Right.
To me, the paradigm shift is isshifting from this concept of
suppressing the immune systemwith corticosteroid injections,
with with NSADs, um, to ignitingit.
Really, what my interest, and Ithink your interest as well,
right, is how do you turn onthese healing mechanisms?
And first you feed the body,right?
(10:11):
You feed the body with with thepolyphenols and the
bioflavonoids and all these allthese good products your bodies
need to heal, and then you turnit on.
And you know, the foundation ofthat obviously is exercise and
motion and movement.
Um, but sometimes it's notenough, right?
If somebody's had a priorinjury, a meniscal old meniscus
tear, they've got somearthritis, they've got an old
(10:32):
ACL injury, uh, labral tear.
Those mechanisms may be enough,but they may not be.
And that's where I go to employsome of the regenerative
therapies as a way to reignitethat healing mechanism, kind of
push them along that thatjourney.
Um, so to me, the paradigmshift is from suppression of
inflammation to actually uhusing it, harnessing it, and
(10:56):
turning it on.
And so the first thing I dousing when people come in the
clinic is I take them offanti-inflammatories.
Uh, we don't do any therapiesuntil they've had corticosteroid
injections, until the steroidsare washed out of their body.
Um, because we we're trying toturn on all these mechanisms.
And it's a very right, it's avery different approach.
It also takes longer.
And the other paradigm shift ispeople have to be patient.
(11:17):
So if they're used to going inand getting an injection,
feeling better the next day ortwo days later after steroid,
they have to realize that uhthese treatments take time.
And if you look at the immunecascade of how our bodies
respond to injury, it makessense, right?
If you take if it takes severaldays alone just to run through
that cascade of plateletdegranulation, neutrophil
(11:40):
activation, and and macrophagepolarization, um, that's not it,
that's not a 24 to 48-hourprocess, right?
That's a that's a longerprocess.
So part of that paradigm shiftis is turning on and igniting
these healing cascades, and partof it also patience uh from the
patients uh to uh understandthat this process takes a little
(12:02):
bit longer than, for instance,a steroid injection.
Dr Andrew Greenland (12:05):
Thank you.
And so thinking about thepatient journey itself, how has
that evolved over time, Karino,from where you've come from
before in pain medicine to whatdoes it look like now?
For give me a typical conditionthat you might treat and just
kind of show us what the journeylooks like for them.
Dr Thomas Buchheit (12:20):
Probably typical treatment would be
somebody coming in for uh kneearthritis or rotator covet with
some you know glenohumeralosteoarthritis as well.
So a degenerative condition.
They've had a couple of steroidinjections in the past, they've
probably seen a physicaltherapist, they're on
anti-inflammatories, maybethey're on some supplements,
maybe they're on some otherstronger pain medicines.
(12:42):
And the journey is you know, wemeet, we act, I actually go
through diet with people.
I go through some of thesupplements, I believe in some
of them, especially uh omega-3sand some of the fatty acids that
help resolve inflammation thatour macrophages use for that
process.
And then we talk about how toregain that that function.
(13:04):
Um, everybody's different,right?
Some people are trying to getback to uh get back to the NBA,
and some people are just tryingto be able to walk their dog
again.
Um, and so we have to figureout where that person is
starting, what their goals are,and uh uh and you know, and we
can usually get there.
We can usually get there withuh different things.
The other thing we've done iswith PRP is that we've started
(13:30):
to increasingly use a lot ofboosters, and those boosters may
be protein concentrates withA2M, uh, some of them may be
other things of autologous uhlike super shot that we've
started to use that hasautologous exosomes.
It's not the Regenikineprogram, but it's a single
injection.
So all these therapies um Ithink can be tailored.
(13:52):
The other part of this processis that you know, we talked
about the importance of immunestimulation with this, and
that's been really a fantasticunder learning opportunity in
the world of plateforge plasma,right?
So, you know, we a lot ofpatients come in, they say,
Well, I saw this this study inJAM or I saw this study in
(14:12):
another journal of PRP, doesn'twork for nearthritis.
But if you tease out thosestudies looking at the platelet
doses, you can predict whatstudies are negative and what
studies are positive.
If there's a PRP and they useless than 3 billion platelets,
it's going to be a negativestudy.
And patients, I think nopatient should receive uh a PRP
(14:33):
with a platelet dose of lessthan six or seven billion for a
large joint.
We actually increasingly beenobvious that we really need to
get closer to 10 billion.
So what we start doing in theclinic is using that
information, say if we want 10billion platelets for a knee,
six billion for a tendon, let'smeasure it and calculate it,
make sure we get there.
(14:53):
So we measure the person'splatelet count at the beginning
of the procedure, not from twoweeks ago because it may be
different from two weeks ago.
We have them exercise beforethey come in to activate these
mechanisms, we measure theircounts, and then we ask the
question how much blood do weneed to get to get them to 10
billion or 16 billion or 24billion, whatever we need.
(15:14):
And and then we draw that bloodbecause we know we're gonna get
a 79 to 82 percent yield in ourprocess, and then we can we can
reliably deliver the doses weneed, and it really has made a
big difference in outcomes.
It's a longer process to do,um, but it's uh it's been very
satisfying to do because uh wecan deliver what we think is
(15:34):
some of the best you knowtreatments in the country.
And there are a couple clinicsin in the US doing this now, uh,
but it does take a little extrawork, so it's it's uh it's a
little more labor-intensive todo.
Dr Andrew Greenland (15:44):
So thank you.
Um so with everything you'vesaid about the healing processes
that you can list it using youknow your techniques, why have
we become so fixated onsuppressing inflammation?
And why are we not thinking whyis it not you know this more
broadly accepted as an approachfor achieving this sort of level
of healing?
Dr Thomas Buchheit (16:04):
I think it's history, right?
And we can go back to 1899 andthe synthesis of aspirin.
We can go back to 1951 when thefirst critical steroid
injection was done forneoarthritis.
That's what we grew up, that'swhat we all grew up with, which
is that if you have pain, youput steroid on it, and it
usually makes it feel better.
And it's true, right?
(16:25):
If somebody has a painful jointattendant, whatever it is, if
you put steroid on it, itusually helps it feel better
pretty quickly.
And so to me, I think it's justI think it's inertia and it's
habit.
Uh, and it's and it's it's hardto change people's minds about
this, too, because we're alsotalking again from uh injection
where somebody can offer intheir office very easily, that
(16:47):
would is going to produce painrelief very quickly to one
that's a much longer process,but that longer process is gonna
help longer term.
And so to me, it it it's justit's just history, and and you
know, medicine is slow tochange.
It is.
And the other thing isinsurance companies don't cover
treatments that stimulate theimmune system, they cover
(17:10):
suppression, they'll coverNSAIDs, they'll cover steroid
injections, they'll cover waysto burn nerves off of joints,
which I used to do and don't doanymore.
And I would make an argumentthat burning nerves off of
joints is not a good idea unlessthey really don't have any
other options.
They'll cover things that justthat destroy nerves and suppress
inflammation, but they will notcover things that stimulate.
(17:32):
Now, I think that's gonnachange, uh, right?
And and actually theoncologists, I think, have
helped us out a little bit herebecause they have opened up this
world of checkpoint inhibitorsand immune stimulants that can
potentially cure cancer.
So I think this mindset hasbegun to change a little bit,
but that is is just starting tocreep into the world of
orthobiologics and care ofjoints and nerves.
(17:56):
It's it's gonna come, but Ithink it's gonna be a few years.
Dr Andrew Greenland (18:00):
Well, I guess this is a relatively new
field.
I mean, I know it's been aroundfor a while, but with every new
field, there comes a marketingchallenge in terms of how do you
get the message out there, howdo you get patients to
understand what it's about.
What's your kind of approach tothis?
How do you, for want of abetter expression, sell this?
Dr Thomas Buchheit (18:17):
Yes.
Um, that that was a challenge,that was a challenge for me and
remains a challenge because Ican speak at all kinds of
academic conferences and writepapers and everything else, but
patients don't see and hear anyof that stuff, right?
So I actually have somebody whohelps out with uh social media
just because that that's justnot that's not an area that I
(18:39):
know, it's not an area that I uhhave any expertise in.
Um so I have I have help withthat.
But my goal is very clear isthat I want people to understand
this field.
And I think more broadly thanyou know, trying to market
services, I want people tounderstand the field so that
they can do better longer term.
(19:01):
And it may be with us, it maybe with somebody else.
But if I want somebody, itdoesn't matter if they're in
North Carolina or California,Michigan, or Washington State,
if they go have a treatment fortheir knee arthritis or their
torn rotator cuff tendon, I wantto make sure that they get the
best treatment that they can nomatter where they are.
We now know what makes bettertreatments, which is great.
(19:22):
And actually, we've learned aton over the past even year.
Um and so my hope is toeducate, that's why one of the
reasons I wrote the book too, isthat if people read the book,
if if consumers and patientsread the book, when they go in
to look for treatment, thenthey'll be able to ask very, you
know, intelligent questions ofwhat are you using, why are you
(19:44):
using it?
Uh, you know, if you're doingPRP, are you looking at platelet
counts on platelet dosing?
If you're looking at stemcells, what kind of cells are
you looking at?
Um, the stem cell uh story isanother one we can dive into if
you want, but it's a reallyfascinating story of really good
science that's been kind ofmisinterpreted uh in the lay
(20:05):
public as well.
Dr Andrew Greenland (20:06):
So thank you.
Um so tell us a bit aboutTriangle, the setup that you
have there.
Um what's what's the operationlook like?
What's your kind of day-to-dayinvolvement?
Uh, what are you offering?
Who are you seeing?
Just give us a bit ofbackground practice.
Dr Thomas Buchheit (20:20):
Well, we see folks from teenagers all the
way up to non-edinarians andeverywhere in between.
Um, I don't do any uh reallytraditional medication
management.
We really focus on people comein, people find us because
they're looking for alternativesto steroids, alternatives to
surgery.
And that's that's the typicalpatient we see.
(20:42):
Someone who's been through thetraditional system.
Maybe they have grade two,grade three Neo A.
Uh, they're not a candidate forsurgery or they don't want it,
and they're looking for otheralternatives because they've
been through, they they've had acouple hyaluronic acid
injections, maybe with a littlebit of improvement, a couple
steroid injections in the monthor two, but nothing longer term.
I I like to think of myself asfocusing on or the patients in
(21:06):
orthopedic limbo.
Um, they have a problem, itlimits what they do, but they're
not a candidate or not acandidate for don't want joint
replacement surgery, or it's ajoint that's not easily
replaced, right?
We see a lot of uh a lot ofthumbs and big toes as well.
So um those are the typicalfolks we see, and seeing
(21:27):
everyone from you know youngindividuals with with uh
injuries and sports injuries toto professional athletes to
octogenarians and non-ogenarianswho really just went out and
get out and walk with theirtheir spouse, their friends, or
their dog, and they're having ahard time getting moving again.
And they're all really verysatisfying to work with.
(21:48):
I love working with that wholethat whole spectrum of of folks,
it's very satisfying.
Dr Andrew Greenland (21:53):
And are there any patients that are not
suitable off the top of yourhead for your kind of approach?
Dr Thomas Buchheit (21:59):
Great question.
You know, folks are coming inon chronic steroids or her
having you know repeatedsteroinjections are hard to work
with.
Um those are probably the oneswho are kind of in that model
and really don't and don't havethe time.
Also, we need the time.
So when folks come in, I liketo work with them for a few
(22:20):
weeks.
We see folks and they may havetravel coming up or plans.
And a lot of the things we dotake time.
So if they see us on a Mondayand they're leaving on a flight
on Friday, usually we'll say,We're probably what we have to
offer you is probably not goingto kick in by Friday, so you
might want to go moretraditional route with that.
Uh, but the the treatments thatwe do tend to tend to uh roll
(22:43):
on over a couple of weeks, andit's a gradual improvement.
So we like to work with peopleuh over those usually days to
weeks, not uh hours to days.
Dr Andrew Greenland (22:52):
So in terms of a like a typical patient
consultation itself, what doesthat look like and you know how
much of the time is spent oneducation and expectation
management and the kind of therehab they have to do themselves
at home?
Dr Thomas Buchheit (23:06):
I I love the initial consultation to me, is
I I really enjoy those.
Um I tend to use imaging toteach a lot.
You know, I when people comein, if they have an MRI, we put
it up on the screen and we'll gothrough it.
You know, people get everybodygets their MRI reports and their
x-ray reports.
Nobody can understand and siftthrough the language of those,
(23:26):
right?
So I just put up the images andwe go through the images
themselves because most peoplecan understand an image if you
show them what we're looking at.
And the other thing I do is Ido ultrasound exams on probably
75% of the initial consults Isee, because there's a lot of
things we can see on ultrasoundthat you can't see on X-ray or
(23:46):
even MRI.
Um, and it's really nice to seein real time if somebody has a
supraspinatus tear orinfraspinatus tear or you know,
uh medial meniscus issue, youcan show them those issues and
you can show them, and it makesit very concrete for them.
So, I to me, that education ofuh mechanically what's going on
is very helpful.
(24:07):
And then we talk a lot abouthow do you kind of ignite those
healing, that healing process.
Uh, talk about nutrition, wetalk about some supplements as
well, kind of go through all ofthat.
But that initial consult to meis a really important step to
kind of let them uh help themunderstand what's going on.
Most people just a lot ofpeople come in, they don't,
(24:27):
they've been told, well, I havethis and I have some arthritis,
and but the details of it theyreally don't know.
And for instance, the shoulderis a great example.
Uh shoulders are complex, sothey're wonderfully complex,
right?
Uh people rarely, it seems likehave an isolated glenoid issue
or or superspinators or ACjoint.
It's an entire unit, and andlooking at the entire unit, I
(24:50):
think, is really helpful andimportant.
We also we also coordinate withuh a lot of the physical
therapists in the area, andthere are some really good
physical therapists who do veryhands-on work.
They'll do video filming ofmechanics, they'll teach the
patients, they'll do this veryuh patient process, which is
which is really wonderful aswell.
Dr Andrew Greenland (25:12):
Now tell about the book.
So the book Healing Joints andNerves.
I know it's been a bit of alabor of love, it's taken a
number of years to put together.
So I suppose the question iswhat inspired you to write it
and who did you write it for?
Was it primarily for patientsor for fellow clinicians?
Uh yeah, tell us a bit moreabout the book.
Dr Thomas Buchheit (25:28):
Well, I I found myself having a lot of
conversations that were cutshort in the clinic.
People would come in and they'dask about stem cells, they'd
ask about PRP, they'd ask aboutRegenicine.
And the questions they had werefantastic.
And I realized that I couldn'tanswer them in the space of a
10, 20 minute form.
I needed a longer format.
So I started, I just startedwriting stuff down.
(25:50):
I started writing chapters, andI realized it really needed to
be a long format book.
And it I wanted a book that apatient could read and then they
could really understand theentire field of what drives
osteoarthritis, what drivesneuropathy, and how do I get
this better.
So it was really written forthe patient, although I actually
have a lot of cliniciancolleagues who read it as well
(26:10):
and have told me they reallylike it.
It's been a guide for them andteaching their patients as well.
So I wonder if there's as many,I think there may be as many
clinicians who are reading it aspatients at this point, which
is which is great.
Dr Andrew Greenland (26:24):
And if readers were to take one message
from the book, what would youhope that that would be?
Dr Thomas Buchheit (26:29):
Um, our bodies have the capacity to
heal, we just need to figure outhow to turn on those
mechanisms.
And then I think that's it.
The mechanisms are there, wejust need to figure, and and we
now know how to turn them on.
We just need to turn them on.
Dr Andrew Greenland (26:45):
And I guess when you write a book, when you
invest you know so much timeand energy and effort into
something, did that change yourown thinking about your own
practice?
Did you kind of learn anythingreally um key from the research
that you did or anything thatwas any assumptions that you had
that shifted just from the mereact of writing the book?
Dr Thomas Buchheit (27:03):
Absolutely.
You know, I mean I think all ofthe protocols that we do now
have have really followed on theheels of what the research we
did.
Now, some of this, it's hard, Ican't separate the research we
did from the writing becausethese are all in kind of
lockstep.
So we have you know research wedid in the lab, the clinical
work, the reading of all thepapers I did to put the book
(27:25):
together, and then the writingof it.
But you know, it's amazing howwriting can crystallize and also
how an editor can uh force youto crystallize your thoughts.
I had an editor who was verygood, and uh she forced me many
times to take out um a lot ofthe uh unnecessary, uh
excessively technical languagein it.
(27:46):
What I also realized is that umif you can explain something
without using lots of acronyms,you probably understand it a
whole lot better, right?
And it that was a really animportant exercise because I
realized, like a lot of us, welearn to speak in acronyms and
we learn to speak inabbreviations and technical
talk.
And when I went through theexercise of trying to explain
(28:10):
these mechanisms and explainthese therapies without
excessive technical knowledge, Iactually understood them
better.
So it really helped me to kindof develop that narrative to
explain it to patients as well.
So it was a great exercise.
It wasn't easy.
I thought it was gonna take metwo years, it took me uh uh
almost seven.
Um, but uh you know I'm I'm I'mpleased with the outcome.
(28:33):
It just took a whole lot longerthan I thought it was gonna
take.
Dr Andrew Greenland (28:37):
So cool.
Well, we'll put the details ofthe book on the bio page so
anybody wants to um sourcethemselves a copy, then they
should be able to get theinformation for that.
Very happy to help promote thatfor you.
Okay, so thinking now abouttriangle as a regenerative
medicine practice, it is abusiness.
Um, what are you most proud offrom a business perspective in
terms of what you've built?
Dr Thomas Buchheit (28:57):
I am most proud that we have followed our
vision.
We want I wanted to build aclinic that that focused on ways
to get people healthier.
And also I'm living outside theinsurance world as well.
I really did not, I I felt likemy hand was forced so many
times when I was living withinthe insurance world of doing
(29:18):
things.
I the first question whenpatients came in the door was
not what is what is the best wayto get your shoulder-knee hip
better, which is the questionwas, what does your insurance uh
coverage, what does yourinsurance policy cover?
And I did not like asking thatquestion, but that ended up
being the first question I wouldask.
Well, they cover thishyaluronic acid, they'll cover
this steroid injection, maybeit'll cover this nerve burn.
(29:41):
I didn't want to do those, andI didn't think that they were
helping longer term.
So I really love developingprotocols and treatments that I
think are in the patient's bestinterest.
I love the team that we'veassembled.
It's uh, you know, to me, it'sthat this is medicine is a team
sport, right?
Clinic is a team sport, andyou're only as good as your
(30:01):
crew, and I have a delightfulteam I work with.
And I love the fact that we arecontinually learning.
You know, we measureeverything, we measure all of
our products, we measure all ofour PRPs and our growth factor
and our counts and our weightcounts and everything, and we're
constantly improving thatprocess.
And we've actually monitoredand improved it even a
(30:23):
tremendous amount based on whatcompared to what I was doing
even last year and the yearbefore.
Um, so and my hope is that Iwill continue that learning
journey, uh, even maybe withsome publications of things.
But uh that that's the I'm I'mproud of the team and I'm proud
of the philosophy of what we'redoing.
Dr Andrew Greenland (30:41):
So amazing.
And on that point of learning,what have been the biggest
business lessons that you'vekind of learned along the way um
from doing the work that youdo?
Dr Thomas Buchheit (30:51):
Biggest business lesson for me was uh
academic success does nottranslate to clinical success.
You know, it uh it really doestake uh direct outreach to to
patients and those kinds of uhsocial media outlets that uh
that again I I needed I neededsomebody to help with because I
(31:13):
didn't understand that field.
I really still don't understandit, but I have someone who who
works with it, does a nice jobfor me.
So but that was that was mybiggest uh you know you can have
the again lots of publicationsand speaking and in a book and
everything else, but if patientsdon't hear about you, you're
you can run what what someonedescribed as a top secret
(31:34):
clinic.
You don't want to run a topsecret clinic where nobody knows
about it, you know.
Um and the other thing is wordof mouth, you know, our our most
powerful uh a lot of thepatients, actually, probably
most of the patients we see arehere because we treated a friend
or a family member.
And that's really nice to hearbecause those, you know, those
endorsements are are are nice.
(31:55):
That means that uh we'reaffecting people in a positive
way and they're telling theirfriends, which is great.
Dr Andrew Greenland (32:03):
And is there anything that keeps you up
at night as a business owner?
Is there anything sort ofongoing challenges or
bottlenecks that you have tonavigate on a day-to-day basis?
Dr Thomas Buchheit (32:13):
You know, I am I would say very globally the
all the business aspects,right?
Because I don't have an MBA,I'm not a business person.
This is my kind of first forayinto running my own small
business.
So I have to make sure that therent is paid and the employees
are paid, and and so I'm kind ofin that scenario where I am uh
(32:33):
running, you know, in terms ofthe team, the clinical
protocols, all the businessaspects, and I think it's the
business aspects that I are theare the biggest challenge for me
personally because that's a newworld.
The rest of it, the team, umapproach to things, the clinical
protocols, the science behindit, that's um that's a very
comfortable space for me.
The business part is lesscomfortable, and that's the part
(32:56):
that probably keeps me up morethan anything else.
I'm learning.
Dr Andrew Greenland (33:00):
For sure.
And um, I guess as a businessowner, you're wearing all the
hats and you do a bit ofeverything.
Which is the biggest time drainfor you?
I mean, there are obviouslythings that you love doing and
you're passionate about in yourwork, but there must be things
that take you away from that.
What are those things?
Dr Thomas Buchheit (33:14):
Oh, um, you know, I could use phrases like
you know, doing payroll or orthat, but uh you know, it's kind
of all the business aspects.
I I don't know if it's a timedrain, it's just part of the the
build of the practice.
You know, the the parts I loveare the the clinical side and
the clinical protocols and howdo you tweak a clinical protocol
to make it better.
(33:35):
Um to get the word out and howto make that match with a a
viable business plan is probablythe the biggest challenge.
And I wouldn't say it's a timedrain, it's just uh it's
probably an aspect that Iunderestimated the importance of
and I underestimated how muchtime it would take.
(33:56):
Um but I would probably say youknow the business part of it is
the biggest challenge.
And that's where I feel likehaving a good team.
I have a very I have a greataccountant, I have a good social
media person.
And also I have now uh staff.
I have a physician assistant,Max Mueller, who's just a
fantastic PA, and and he's doingsome outreach as well, which is
(34:17):
which is great.
So to me, it's again, it'sgetting about getting that the
message out about what we do andmore broadly what patients can
do to get themselves betteragain, even if they don't come
to see us at the key and comesee somebody around the country
that they get uh they get whatthey need.
Dr Andrew Greenland (34:33):
Thank you.
And if you were starting overtomorrow, would you do anything
different with everything thatyou've learned along the way?
Dr Thomas Buchheit (34:41):
Um going back for the business I started
last year or going back 30 yearsto the career, I guess is the
question, right?
Dr Andrew Greenland (34:48):
I guess I mean you you've made a switch in
your the field that you'reworking in.
I just wondered if you weregoing to start a regenerative
practice tomorrow witheverything that you've learned
along the way, is there anythingyou would fundamentally change
and do from the outset?
Or maybe there's nothing.
I mean, sometimes you we justwe we the learning is as as
important as part of thejourney.
I just wonder if there'sanything that you would do
differently.
Dr Thomas Buchheit (35:07):
Yeah, I'd probably pay more attention to
the importance of social mediaearlier on and have uh someone
uh join or early to really lookat that strategy.
Um because I think and that'sthat's the part I believe that I
underestimated a little bit,the importance of.
Dr Andrew Greenland (35:25):
Got it.
So what does the future hold?
Where would you like um to beor the clinic to be in the next,
say, 12 months or so?
What are your plans for um theclinic?
Dr Thomas Buchheit (35:35):
I I you know I think our plans are to
continue getting the word outand continue growing.
I'd love to partner with uh,you know, all the local physical
therapists, they're doing uhgreat work.
Um I love, you know, we'regonna we're continuing to
partner with some of the sportsteams as well, and um just kind
of get the word out.
That that's my very simplegoal.
(35:55):
And you know, I'd love to seepatients coming in the door who
like they are doing now, orthey're coming in looking for a
new way of treating their joint,their tendon, their ligament,
their or their nerve.
And and uh to me, it's just amatter of getting getting that
message out and having themunderstand, and and that our
growth has been very organicwith that.
(36:16):
Um, and that's been that's beena nice process, and I'd love to
continue seeing that very kindof progressive organic growth
too.
Dr Andrew Greenland (36:24):
And would that be more clinics or a bigger
clinic than you're in, justmore staff, being able to treat
more patients?
What does it kind of look likefor you?
Dr Thomas Buchheit (36:31):
Right now, I think it's more of just growing
the the clinic and thestaffing.
We have a space that canaccommodate a little bit uh uh
more than what we're doing rightnow.
Um we are actually justfinished hiring up uh another uh
another two staff membersactually the past couple weeks,
which is which is wonderful.
So we are we are growing withinour space, which is great.
(36:51):
I don't have any immediateplans of additional.
I I really like to control thequality and the experience of a
patient coming through.
And to me, it's a very big stepto open up a second site where
you're not physically present asmuch.
So I I really enjoy very muchthat hands-on approach because I
can monitor and make sure thequality of the experience is
(37:12):
great.
To me, it's it's like running anice restaurant, right?
I want people to have a reallygreat experience from the from
the moment they walk into themoment they leave.
And I feel like, you know,maybe this is because in college
and medical school, I waitedtables at restaurants and um and
I, but I feel like their modelis a really good model of of the
patient experience, more sothan a traditional medical model
(37:35):
where patients come in andthey're gonna get they're gonna
get what they're offered, andthey're only gonna be offered a
few things.
Um, and that might or not mightnot be what's best for them.
And I really love that thatservice-oriented model of of a
restaurant, really as much asanything.
Dr Andrew Greenland (37:52):
And final question on closing.
Um, if you could change onething about modern health care,
what would it be?
Slightly philosophical umquestion, but I'd probably a
good one to end on.
Dr Thomas Buchheit (38:01):
I would love to have uh this paradigm shift
that we're talking about shiftmore quickly.
And um, I think it's needed, Ithink it's in all of our best
interests.
Uh these these shifts happenvery, very slowly, obviously,
(38:21):
and all paradigms die veryslowly.
But I would love to see thisthis uh kind of way of keeping
joints and nerves healthy.
I'd love to see thosemechanisms and those techniques
be employed faster than theyare.
Dr Andrew Greenland (38:39):
With that, Thomas, I'd love to thank you so
much for joining me today.
I've really enjoyed theconversation.
Thank you for telling us aboutyour practice, the different
things that you can offer thepatients, giving us a real
understanding of regenerativemedicine, what it is, what it
isn't, some of themisconceptions, and just sharing
a little bit about behind thescenes of the practice and what
you're aiming to achieve.
It's been a real delight.
So thank you so much.
Dr Thomas Buchheit (38:58):
Andrew, thank you so much.
Really appreciate you having meon.
Delight to talk.
Welcome to another episode of Voices in
Health and Wellness, where wespeak with clinicians,
innovators, and healthcareleaders who are challenging
conventional thinking andhelping shape the future of
patient care.
Today's guest is Dr.
Thomas Buchheit, founder ofTriangle Regen Medicine and
Biologic Centre in NorthCarolina.
Dr.
Buchheit has spent yearsstudying regenerative medicine,
(00:20):
platelet-rich plasma, stem celltherapies and immune-based
healing.
He's also the author of HealingJoints and Nerves, a book
helping patients understand whyregenerative medicine replaces a
genuine shift in how we havehealing.
So today we're going to discussortho biologics and why it
remains misunderstood, thescience behind regenerative
medicine, patient education, andwhere this exciting, exciting
(00:43):
field is heading.
So with that, I was like towelcome you to the show and
thank you very much for joiningme on this podcast today.
Dr Thomas Buchheit (00:48):
Dr.
Greenland, thank you.
It's a pleasure to be here andthank you for inviting me.
You're very welcome.
Dr Andrew Greenland (00:53):
So perhaps we could start a little bit
about you and your journey.
So just tell us a little bitabout your journey so far and
how you've found your way intoregenerative medicine.
Dr Thomas Buchheit (01:01):
Well, when I write it, it's a great
question.
When I finished residency andfellowship, this field didn't
exist, right?
So I finished an interventionalpain and spine fellowship in
1999 and I became fairly steepedin the spine world for about a
decade or so.
And there are some things aboutthat I wasn't that found a
little bit distasteful over theyears, um, you know, medication
(01:22):
use and heavy surgery use uh forspine conditions.
And in 2010, I had a reallynice opportunity to uh to join a
research group and a clinicalgroup at Duke.
And so I ended up uh leavingthe practice I was in and
joining up with Duke and reallystarted a really interesting
journey of not at justunderstanding nerve injury and
(01:44):
mechanisms of that, but alsolearning about how those
mechanism, those the samemechanisms that exist in, for
instance, osteoarthritis.
Uh, we started, I startedlooking at and focusing on not
just uh risks of chronic pain,but resiliency.
So if you have 100 people whohave the same condition, um,
(02:05):
what makes those who recover andrecover from pain and are
resilient?
What's different about them?
And the answer was really theimmune system.
Those who have a strong immuneresponse to injury,
interestingly, are more likelyto recover.
And that has implications forall of us, right?
It has implications forexercise, it has implications
(02:26):
for our use of anti-inflammatorymedications or steroids.
And it really forms thefoundation of regenerative
medicine.
We studied kind of all thesetherapies, and it was really a
uh really wonderful exploration.
Dr Andrew Greenland (02:41):
So amazing, thank you.
Always really helps have somebackground and context as to the
work that you currently do.
So I think you've kind ofalready alluded to this, but
what was that particular momentthat convinced you there had to
be a better approach thantraditional pain management?
I think you've given us acouple of clues, but what was
that trigger for you?
Dr Thomas Buchheit (02:57):
The trigger was probably a paper in 2017
that came out in American inJAMA, Journal of American
Medical Association, and itshowed an association with
repeated steroid injections andaccelerated osteoarthritis of
the knee.
And that was the moment when Iread that paper that I realized
that we really have to changehow we're practicing.
(03:19):
Because I came from a world andwe all did, where we thought
that you have inflammation in ajoint that's arthritic, if you
quiet down that inflammation,the joint's going to get better,
you're gonna improve the pain.
You might actually improve thejoint longer term as well.
And it turns out we weren't.
It turns out we were actuallymaking things worse, not better.
So that was the that was mythreat kind of threshold moment
(03:41):
and realized we really need anew pathway and a new way of
looking at this.
Dr Andrew Greenland (03:46):
Thank you.
So I think you mentioned thatregenerative medicine is often
misunderstood.
So, what's how do you defineregenerative medicine or how do
you explain that concept to yourpatients?
And what is thismisunderstanding that exists out
there?
Dr Thomas Buchheit (03:59):
I I like to think broadly about regenerative
medicine being the restorationof tissues and restoration of
function.
You know, some people think ofit as a growing new tissues,
growing a new heart, a new ear,uh something else.
Uh that's a very, I think, anarrow definition.
But to me, anything thatrestores function and restores
um tissue health isregenerative.
And in that respect, exerciseis probably one of the most
(04:22):
regenerative therapies that weall do, right?
And if you think about it, itmakes a lot of sense.
So, you know, when we when weexercise or work out, you
actually create an inflammatoryprocess, right?
And you can even biopsy amuscle afterwards and see
increases in interleukin 6 andall these inflammatory
cytokines, but you start acascade of healing that
(04:43):
ultimately will strengthen thosetissues and grow those tissues.
And and you know, that's whyall the literature on, for
instance, exercise andosteoarthritis is very clear
that breast walking is a goodthing, good exercise for
somebody with arthritis.
So, so that's to me that that'sthe fundamental step is that um
that immune cascade.
(05:04):
And that really formed thebasis of the book.
You know, I started working onthe book about six or seven
years ago, and with the reallythe goal of helping people to
understand how these therapieswork, how do stem cells really
work?
How does PRP, platelet-richplasma really work?
What is this thing calledRegenikine that people are
flying to Germany for?
And how does it work?
(05:24):
And we can dive into some ofthe research we did with that.
And it was really a wonderfulexercise to go through
systematically.
I probably reviewed over athousand papers in the process
of writing this book to try todistill down the science to a
broad audience.
It turns out that all of thesetherapies just work in different
(05:45):
parts of the immune system,which is really interesting.
You may have PRP that worksearly on, where you know, if you
think of an injury, you have aninjury and you have platelet
release.
Yes, you have clotting factors,but you also have growth
factors that release.
They recruit in neutrophils inthese early white blood cells.
They were then recruitingmonocytes that come into the
(06:06):
tissue, become macrophages.
And if all goes well, themacrophage polarizes, right, and
it starts to rebuild tissues.
And you can slide in all thetherapies, including stem cells,
into this immune cascade, whichI thought was just a it was a
nice framework to hopefully helpuh people understand how
they're how these treatments areworking.
Dr Andrew Greenland (06:27):
So, in terms of your repertoire of
tools in your box, as it were,what are your most treasured
tools that you can offer peopleor techniques, treatments that
perhaps they've not heard ofbefore, that you can really get
some leverage over thatcondition with?
Dr Thomas Buchheit (06:43):
You know, probably the the main tool that
people have heard less about isthe Regenekine program.
Um, and that's people think ofit as a as a PRP-like process,
but it's really not.
Um it's a it comes from blood,so you take blood out and then
you let it coagulate and clotovernight.
(07:04):
And really what you're doing isletting those blood cells and
those white cells work very hardfor you.
And then we filter, we have afull uh full lab, full sterile
lab, full hood and everythingelse for processing, and you
filter that and process that andthen start injecting that.
And that's really been a verynice therapy for people where
(07:25):
other things have failed.
Most of the people that wetreat with Regenokine have had
other treatments, they've hadPRP, they've had stem cells,
they've had roller therapy,those haven't worked, and so now
they're coming for uh somethingelse.
And uh it's been nice, youknow.
It it it started with Dr.
Peter Whaling and in Germany,and uh, at least in the United
States, you we always hear aboutuh athletes, pro athletes who
(07:47):
are flying to Germany for theirtreatment.
A lot of times they're going tosee going to see Peter, who uh
was my mentor for and still ismy mentor.
I've worked with him for sevenor eight years, and we've been,
you know, we've actually I'vebeen using a program here in my
Chapel Hill office since wesince we opened up, and I used
it for years at Duke when I wasat Duke.
But it really is a nice, a nicetreatment when other things
(08:11):
have not worked, and we know howit works now, too.
So we looked at, we actuallyteased this apart in the lab.
People always used to think ofthe Regenekine program as a
product of what people callIRAP, right?
So interleukin 1 receptorantagonist protein.
So IL-1 antagonist is a proteinour bodies make to fight and
(08:33):
shut down IL uh IL1 to shut downIL1.
And it is powerfully analgesic,but if you study IL-1 IRAP,
that protein, it only works fora short period of time in an
arthritic joint.
And there was some part of thistherapy that we were missing
that we weren't understanding.
So we took it to the lab and wedissected out the different
(08:54):
mechanisms of it, um,biochemically and also in animal
models.
And it turns out that it'sactually exosome.
Most of the effect isexosome-based.
That is a nice story for for meand for for patients as well,
because there's people talk alot about exosomes, and we can
dive into that a little bit.
But the most important partabout that is making sure
(09:15):
they're safe.
And if you can get exosomes andexosome therapy from your own
blood, not from donor blood, uh,you've also increased the
safety of that product as well.
So that that was a nice uh thatwas a nice research journey
over several years as well.
Dr Andrew Greenland (09:30):
Amazing.
So I think in our lastconversation, you described um
this paradigm shift as to whatwas been happening before in
pain management as opposed tothe kind of work you're doing
now.
But what do you mean byparadigm shift?
Um, and how do you and how hasyour philosophy of medicine
changed as you've been doingmore of this work?
Dr Thomas Buchheit (09:50):
Right.
To me, the paradigm shift is isshifting from this concept of
suppressing the immune systemwith corticosteroid injections,
with with NSADs, um, to ignitingit.
Really, what my interest, and Ithink your interest as well,
right, is how do you turn onthese healing mechanisms?
And first you feed the body,right?
(10:11):
You feed the body with with thepolyphenols and the
bioflavonoids and all these allthese good products your bodies
need to heal, and then you turnit on.
And you know, the foundation ofthat obviously is exercise and
motion and movement.
Um, but sometimes it's notenough, right?
If somebody's had a priorinjury, a meniscal old meniscus
tear, they've got somearthritis, they've got an old
(10:32):
ACL injury, uh, labral tear.
Those mechanisms may be enough,but they may not be.
And that's where I go to employsome of the regenerative
therapies as a way to reignitethat healing mechanism, kind of
push them along that thatjourney.
Um, so to me, the paradigmshift is from suppression of
inflammation to actually uhusing it, harnessing it, and
(10:56):
turning it on.
And so the first thing I dousing when people come in the
clinic is I take them offanti-inflammatories.
Uh, we don't do any therapiesuntil they've had corticosteroid
injections, until the steroidsare washed out of their body.
Um, because we we're trying toturn on all these mechanisms.
And it's a very right, it's avery different approach.
It also takes longer.
And the other paradigm shift ispeople have to be patient.
(11:17):
So if they're used to going inand getting an injection,
feeling better the next day ortwo days later after steroid,
they have to realize that uhthese treatments take time.
And if you look at the immunecascade of how our bodies
respond to injury, it makessense, right?
If you take if it takes severaldays alone just to run through
that cascade of plateletdegranulation, neutrophil
(11:40):
activation, and and macrophagepolarization, um, that's not it,
that's not a 24 to 48-hourprocess, right?
That's a that's a longerprocess.
So part of that paradigm shiftis is turning on and igniting
these healing cascades, and partof it also patience uh from the
patients uh to uh understandthat this process takes a little
(12:02):
bit longer than, for instance,a steroid injection.
Dr Andrew Greenland (12:05):
Thank you.
And so thinking about thepatient journey itself, how has
that evolved over time, Karino,from where you've come from
before in pain medicine to whatdoes it look like now?
For give me a typical conditionthat you might treat and just
kind of show us what the journeylooks like for them.
Dr Thomas Buchheit (12:20):
Probably typical treatment would be
somebody coming in for uh kneearthritis or rotator covet with
some you know glenohumeralosteoarthritis as well.
So a degenerative condition.
They've had a couple of steroidinjections in the past, they've
probably seen a physicaltherapist, they're on
anti-inflammatories, maybethey're on some supplements,
maybe they're on some otherstronger pain medicines.
(12:42):
And the journey is you know, wemeet, we act, I actually go
through diet with people.
I go through some of thesupplements, I believe in some
of them, especially uh omega-3sand some of the fatty acids that
help resolve inflammation thatour macrophages use for that
process.
And then we talk about how toregain that that function.
(13:04):
Um, everybody's different,right?
Some people are trying to getback to uh get back to the NBA,
and some people are just tryingto be able to walk their dog
again.
Um, and so we have to figureout where that person is
starting, what their goals are,and uh uh and you know, and we
can usually get there.
We can usually get there withuh different things.
The other thing we've done iswith PRP is that we've started
(13:30):
to increasingly use a lot ofboosters, and those boosters may
be protein concentrates withA2M, uh, some of them may be
other things of autologous uhlike super shot that we've
started to use that hasautologous exosomes.
It's not the Regenikineprogram, but it's a single
injection.
So all these therapies um Ithink can be tailored.
(13:52):
The other part of this processis that you know, we talked
about the importance of immunestimulation with this, and
that's been really a fantasticunder learning opportunity in
the world of plateforge plasma,right?
So, you know, we a lot ofpatients come in, they say,
Well, I saw this this study inJAM or I saw this study in
(14:12):
another journal of PRP, doesn'twork for nearthritis.
But if you tease out thosestudies looking at the platelet
doses, you can predict whatstudies are negative and what
studies are positive.
If there's a PRP and they useless than 3 billion platelets,
it's going to be a negativestudy.
And patients, I think nopatient should receive uh a PRP
(14:33):
with a platelet dose of lessthan six or seven billion for a
large joint.
We actually increasingly beenobvious that we really need to
get closer to 10 billion.
So what we start doing in theclinic is using that
information, say if we want 10billion platelets for a knee,
six billion for a tendon, let'smeasure it and calculate it,
make sure we get there.
(14:53):
So we measure the person'splatelet count at the beginning
of the procedure, not from twoweeks ago because it may be
different from two weeks ago.
We have them exercise beforethey come in to activate these
mechanisms, we measure theircounts, and then we ask the
question how much blood do weneed to get to get them to 10
billion or 16 billion or 24billion, whatever we need.
(15:14):
And and then we draw that bloodbecause we know we're gonna get
a 79 to 82 percent yield in ourprocess, and then we can we can
reliably deliver the doses weneed, and it really has made a
big difference in outcomes.
It's a longer process to do,um, but it's uh it's been very
satisfying to do because uh wecan deliver what we think is
(15:34):
some of the best you knowtreatments in the country.
And there are a couple clinicsin in the US doing this now, uh,
but it does take a little extrawork, so it's it's uh it's a
little more labor-intensive todo.
Dr Andrew Greenland (15:44):
So thank you.
Um so with everything you'vesaid about the healing processes
that you can list it using youknow your techniques, why have
we become so fixated onsuppressing inflammation?
And why are we not thinking whyis it not you know this more
broadly accepted as an approachfor achieving this sort of level
of healing?
Dr Thomas Buchheit (16:04):
I think it's history, right?
And we can go back to 1899 andthe synthesis of aspirin.
We can go back to 1951 when thefirst critical steroid
injection was done forneoarthritis.
That's what we grew up, that'swhat we all grew up with, which
is that if you have pain, youput steroid on it, and it
usually makes it feel better.
And it's true, right?
(16:25):
If somebody has a painful jointattendant, whatever it is, if
you put steroid on it, itusually helps it feel better
pretty quickly.
And so to me, I think it's justI think it's inertia and it's
habit.
Uh, and it's and it's it's hardto change people's minds about
this, too, because we're alsotalking again from uh injection
where somebody can offer intheir office very easily, that
(16:47):
would is going to produce painrelief very quickly to one
that's a much longer process,but that longer process is gonna
help longer term.
And so to me, it it it's justit's just history, and and you
know, medicine is slow tochange.
It is.
And the other thing isinsurance companies don't cover
treatments that stimulate theimmune system, they cover
(17:10):
suppression, they'll coverNSAIDs, they'll cover steroid
injections, they'll cover waysto burn nerves off of joints,
which I used to do and don't doanymore.
And I would make an argumentthat burning nerves off of
joints is not a good idea unlessthey really don't have any
other options.
They'll cover things that justthat destroy nerves and suppress
inflammation, but they will notcover things that stimulate.
(17:32):
Now, I think that's gonnachange, uh, right?
And and actually theoncologists, I think, have
helped us out a little bit herebecause they have opened up this
world of checkpoint inhibitorsand immune stimulants that can
potentially cure cancer.
So I think this mindset hasbegun to change a little bit,
but that is is just starting tocreep into the world of
orthobiologics and care ofjoints and nerves.
(17:56):
It's it's gonna come, but Ithink it's gonna be a few years.
Dr Andrew Greenland (18:00):
Well, I guess this is a relatively new
field.
I mean, I know it's been aroundfor a while, but with every new
field, there comes a marketingchallenge in terms of how do you
get the message out there, howdo you get patients to
understand what it's about.
What's your kind of approach tothis?
How do you, for want of abetter expression, sell this?
Dr Thomas Buchheit (18:17):
Yes.
Um, that that was a challenge,that was a challenge for me and
remains a challenge because Ican speak at all kinds of
academic conferences and writepapers and everything else, but
patients don't see and hear anyof that stuff, right?
So I actually have somebody whohelps out with uh social media
just because that that's justnot that's not an area that I
(18:39):
know, it's not an area that I uhhave any expertise in.
Um so I have I have help withthat.
But my goal is very clear isthat I want people to understand
this field.
And I think more broadly thanyou know, trying to market
services, I want people tounderstand the field so that
they can do better longer term.
(19:01):
And it may be with us, it maybe with somebody else.
But if I want somebody, itdoesn't matter if they're in
North Carolina or California,Michigan, or Washington State,
if they go have a treatment fortheir knee arthritis or their
torn rotator cuff tendon, I wantto make sure that they get the
best treatment that they can nomatter where they are.
We now know what makes bettertreatments, which is great.
(19:22):
And actually, we've learned aton over the past even year.
Um and so my hope is toeducate, that's why one of the
reasons I wrote the book too, isthat if people read the book,
if if consumers and patientsread the book, when they go in
to look for treatment, thenthey'll be able to ask very, you
know, intelligent questions ofwhat are you using, why are you
(19:44):
using it?
Uh, you know, if you're doingPRP, are you looking at platelet
counts on platelet dosing?
If you're looking at stemcells, what kind of cells are
you looking at?
Um, the stem cell uh story isanother one we can dive into if
you want, but it's a reallyfascinating story of really good
science that's been kind ofmisinterpreted uh in the lay
(20:05):
public as well.
Dr Andrew Greenland (20:06):
So thank you.
Um so tell us a bit aboutTriangle, the setup that you
have there.
Um what's what's the operationlook like?
What's your kind of day-to-dayinvolvement?
Uh, what are you offering?
Who are you seeing?
Just give us a bit ofbackground practice.
Dr Thomas Buchheit (20:20):
Well, we see folks from teenagers all the
way up to non-edinarians andeverywhere in between.
Um, I don't do any uh reallytraditional medication
management.
We really focus on people comein, people find us because
they're looking for alternativesto steroids, alternatives to
surgery.
And that's that's the typicalpatient we see.
(20:42):
Someone who's been through thetraditional system.
Maybe they have grade two,grade three Neo A.
Uh, they're not a candidate forsurgery or they don't want it,
and they're looking for otheralternatives because they've
been through, they they've had acouple hyaluronic acid
injections, maybe with a littlebit of improvement, a couple
steroid injections in the monthor two, but nothing longer term.
I I like to think of myself asfocusing on or the patients in
(21:06):
orthopedic limbo.
Um, they have a problem, itlimits what they do, but they're
not a candidate or not acandidate for don't want joint
replacement surgery, or it's ajoint that's not easily
replaced, right?
We see a lot of uh a lot ofthumbs and big toes as well.
So um those are the typicalfolks we see, and seeing
(21:27):
everyone from you know youngindividuals with with uh
injuries and sports injuries toto professional athletes to
octogenarians and non-ogenarianswho really just went out and
get out and walk with theirtheir spouse, their friends, or
their dog, and they're having ahard time getting moving again.
And they're all really verysatisfying to work with.
(21:48):
I love working with that wholethat whole spectrum of of folks,
it's very satisfying.
Dr Andrew Greenland (21:53):
And are there any patients that are not
suitable off the top of yourhead for your kind of approach?
Dr Thomas Buchheit (21:59):
Great question.
You know, folks are coming inon chronic steroids or her
having you know repeatedsteroinjections are hard to work
with.
Um those are probably the oneswho are kind of in that model
and really don't and don't havethe time.
Also, we need the time.
So when folks come in, I liketo work with them for a few
(22:20):
weeks.
We see folks and they may havetravel coming up or plans.
And a lot of the things we dotake time.
So if they see us on a Mondayand they're leaving on a flight
on Friday, usually we'll say,We're probably what we have to
offer you is probably not goingto kick in by Friday, so you
might want to go moretraditional route with that.
Uh, but the the treatments thatwe do tend to tend to uh roll
(22:43):
on over a couple of weeks, andit's a gradual improvement.
So we like to work with peopleuh over those usually days to
weeks, not uh hours to days.
Dr Andrew Greenland (22:52):
So in terms of a like a typical patient
consultation itself, what doesthat look like and you know how
much of the time is spent oneducation and expectation
management and the kind of therehab they have to do themselves
at home?
Dr Thomas Buchheit (23:06):
I I love the initial consultation to me, is
I I really enjoy those.
Um I tend to use imaging toteach a lot.
You know, I when people comein, if they have an MRI, we put
it up on the screen and we'll gothrough it.
You know, people get everybodygets their MRI reports and their
x-ray reports.
Nobody can understand and siftthrough the language of those,
(23:26):
right?
So I just put up the images andwe go through the images
themselves because most peoplecan understand an image if you
show them what we're looking at.
And the other thing I do is Ido ultrasound exams on probably
75% of the initial consults Isee, because there's a lot of
things we can see on ultrasoundthat you can't see on X-ray or
(23:46):
even MRI.
Um, and it's really nice to seein real time if somebody has a
supraspinatus tear orinfraspinatus tear or you know,
uh medial meniscus issue, youcan show them those issues and
you can show them, and it makesit very concrete for them.
So, I to me, that education ofuh mechanically what's going on
is very helpful.
(24:07):
And then we talk a lot abouthow do you kind of ignite those
healing, that healing process.
Uh, talk about nutrition, wetalk about some supplements as
well, kind of go through all ofthat.
But that initial consult to meis a really important step to
kind of let them uh help themunderstand what's going on.
Most people just a lot ofpeople come in, they don't,
(24:27):
they've been told, well, I havethis and I have some arthritis,
and but the details of it theyreally don't know.
And for instance, the shoulderis a great example.
Uh shoulders are complex, sothey're wonderfully complex,
right?
Uh people rarely, it seems likehave an isolated glenoid issue
or or superspinators or ACjoint.
It's an entire unit, and andlooking at the entire unit, I
(24:50):
think, is really helpful andimportant.
We also we also coordinate withuh a lot of the physical
therapists in the area, andthere are some really good
physical therapists who do veryhands-on work.
They'll do video filming ofmechanics, they'll teach the
patients, they'll do this veryuh patient process, which is
which is really wonderful aswell.
Dr Andrew Greenland (25:12):
Now tell about the book.
So the book Healing Joints andNerves.
I know it's been a bit of alabor of love, it's taken a
number of years to put together.
So I suppose the question iswhat inspired you to write it
and who did you write it for?
Was it primarily for patientsor for fellow clinicians?
Uh yeah, tell us a bit moreabout the book.
Dr Thomas Buchheit (25:28):
Well, I I found myself having a lot of
conversations that were cutshort in the clinic.
People would come in and they'dask about stem cells, they'd
ask about PRP, they'd ask aboutRegenicine.
And the questions they had werefantastic.
And I realized that I couldn'tanswer them in the space of a
10, 20 minute form.
I needed a longer format.
So I started, I just startedwriting stuff down.
(25:50):
I started writing chapters, andI realized it really needed to
be a long format book.
And it I wanted a book that apatient could read and then they
could really understand theentire field of what drives
osteoarthritis, what drivesneuropathy, and how do I get
this better.
So it was really written forthe patient, although I actually
have a lot of cliniciancolleagues who read it as well
(26:10):
and have told me they reallylike it.
It's been a guide for them andteaching their patients as well.
So I wonder if there's as many,I think there may be as many
clinicians who are reading it aspatients at this point, which
is which is great.
Dr Andrew Greenland (26:24):
And if readers were to take one message
from the book, what would youhope that that would be?
Dr Thomas Buchheit (26:29):
Um, our bodies have the capacity to
heal, we just need to figure outhow to turn on those
mechanisms.
And then I think that's it.
The mechanisms are there, wejust need to figure, and and we
now know how to turn them on.
We just need to turn them on.
Dr Andrew Greenland (26:45):
And I guess when you write a book, when you
invest you know so much timeand energy and effort into
something, did that change yourown thinking about your own
practice?
Did you kind of learn anythingreally um key from the research
that you did or anything thatwas any assumptions that you had
that shifted just from the mereact of writing the book?
Dr Thomas Buchheit (27:03):
Absolutely.
You know, I mean I think all ofthe protocols that we do now
have have really followed on theheels of what the research we
did.
Now, some of this, it's hard, Ican't separate the research we
did from the writing becausethese are all in kind of
lockstep.
So we have you know research wedid in the lab, the clinical
work, the reading of all thepapers I did to put the book
(27:25):
together, and then the writingof it.
But you know, it's amazing howwriting can crystallize and also
how an editor can uh force youto crystallize your thoughts.
I had an editor who was verygood, and uh she forced me many
times to take out um a lot ofthe uh unnecessary, uh
excessively technical languagein it.
(27:46):
What I also realized is that umif you can explain something
without using lots of acronyms,you probably understand it a
whole lot better, right?
And it that was a really animportant exercise because I
realized, like a lot of us, welearn to speak in acronyms and
we learn to speak inabbreviations and technical
talk.
And when I went through theexercise of trying to explain
(28:10):
these mechanisms and explainthese therapies without
excessive technical knowledge, Iactually understood them
better.
So it really helped me to kindof develop that narrative to
explain it to patients as well.
So it was a great exercise.
It wasn't easy.
I thought it was gonna take metwo years, it took me uh uh
almost seven.
Um, but uh you know I'm I'm I'mpleased with the outcome.
(28:33):
It just took a whole lot longerthan I thought it was gonna
take.
Dr Andrew Greenland (28:37):
So cool.
Well, we'll put the details ofthe book on the bio page so
anybody wants to um sourcethemselves a copy, then they
should be able to get theinformation for that.
Very happy to help promote thatfor you.
Okay, so thinking now abouttriangle as a regenerative
medicine practice, it is abusiness.
Um, what are you most proud offrom a business perspective in
terms of what you've built?
Dr Thomas Buchheit (28:57):
I am most proud that we have followed our
vision.
We want I wanted to build aclinic that that focused on ways
to get people healthier.
And also I'm living outside theinsurance world as well.
I really did not, I I felt likemy hand was forced so many
times when I was living withinthe insurance world of doing
(29:18):
things.
I the first question whenpatients came in the door was
not what is what is the best wayto get your shoulder-knee hip
better, which is the questionwas, what does your insurance uh
coverage, what does yourinsurance policy cover?
And I did not like asking thatquestion, but that ended up
being the first question I wouldask.
Well, they cover thishyaluronic acid, they'll cover
this steroid injection, maybeit'll cover this nerve burn.
(29:41):
I didn't want to do those, andI didn't think that they were
helping longer term.
So I really love developingprotocols and treatments that I
think are in the patient's bestinterest.
I love the team that we'veassembled.
It's uh, you know, to me, it'sthat this is medicine is a team
sport, right?
Clinic is a team sport, andyou're only as good as your
(30:01):
crew, and I have a delightfulteam I work with.
And I love the fact that we arecontinually learning.
You know, we measureeverything, we measure all of
our products, we measure all ofour PRPs and our growth factor
and our counts and our weightcounts and everything, and we're
constantly improving thatprocess.
And we've actually monitoredand improved it even a
(30:23):
tremendous amount based on whatcompared to what I was doing
even last year and the yearbefore.
Um, so and my hope is that Iwill continue that learning
journey, uh, even maybe withsome publications of things.
But uh that that's the I'm I'mproud of the team and I'm proud
of the philosophy of what we'redoing.
Dr Andrew Greenland (30:41):
So amazing.
And on that point of learning,what have been the biggest
business lessons that you'vekind of learned along the way um
from doing the work that youdo?
Dr Thomas Buchheit (30:51):
Biggest business lesson for me was uh
academic success does nottranslate to clinical success.
You know, it uh it really doestake uh direct outreach to to
patients and those kinds of uhsocial media outlets that uh
that again I I needed I neededsomebody to help with because I
(31:13):
didn't understand that field.
I really still don't understandit, but I have someone who who
works with it, does a nice jobfor me.
So but that was that was mybiggest uh you know you can have
the again lots of publicationsand speaking and in a book and
everything else, but if patientsdon't hear about you, you're
you can run what what someonedescribed as a top secret
(31:34):
clinic.
You don't want to run a topsecret clinic where nobody knows
about it, you know.
Um and the other thing is wordof mouth, you know, our our most
powerful uh a lot of thepatients, actually, probably
most of the patients we see arehere because we treated a friend
or a family member.
And that's really nice to hearbecause those, you know, those
endorsements are are are nice.
(31:55):
That means that uh we'reaffecting people in a positive
way and they're telling theirfriends, which is great.
Dr Andrew Greenland (32:03):
And is there anything that keeps you up
at night as a business owner?
Is there anything sort ofongoing challenges or
bottlenecks that you have tonavigate on a day-to-day basis?
Dr Thomas Buchheit (32:13):
You know, I am I would say very globally the
all the business aspects,right?
Because I don't have an MBA,I'm not a business person.
This is my kind of first forayinto running my own small
business.
So I have to make sure that therent is paid and the employees
are paid, and and so I'm kind ofin that scenario where I am uh
(32:33):
running, you know, in terms ofthe team, the clinical
protocols, all the businessaspects, and I think it's the
business aspects that I are theare the biggest challenge for me
personally because that's a newworld.
The rest of it, the team, umapproach to things, the clinical
protocols, the science behindit, that's um that's a very
comfortable space for me.
The business part is lesscomfortable, and that's the part
(32:56):
that probably keeps me up morethan anything else.
I'm learning.
Dr Andrew Greenland (33:00):
For sure.
And um, I guess as a businessowner, you're wearing all the
hats and you do a bit ofeverything.
Which is the biggest time drainfor you?
I mean, there are obviouslythings that you love doing and
you're passionate about in yourwork, but there must be things
that take you away from that.
What are those things?
Dr Thomas Buchheit (33:14):
Oh, um, you know, I could use phrases like
you know, doing payroll or orthat, but uh you know, it's kind
of all the business aspects.
I I don't know if it's a timedrain, it's just part of the the
build of the practice.
You know, the the parts I loveare the the clinical side and
the clinical protocols and howdo you tweak a clinical protocol
to make it better.
(33:35):
Um to get the word out and howto make that match with a a
viable business plan is probablythe the biggest challenge.
And I wouldn't say it's a timedrain, it's just uh it's
probably an aspect that Iunderestimated the importance of
and I underestimated how muchtime it would take.
(33:56):
Um but I would probably say youknow the business part of it is
the biggest challenge.
And that's where I feel likehaving a good team.
I have a very I have a greataccountant, I have a good social
media person.
And also I have now uh staff.
I have a physician assistant,Max Mueller, who's just a
fantastic PA, and and he's doingsome outreach as well, which is
(34:17):
which is great.
So to me, it's again, it'sgetting about getting that the
message out about what we do andmore broadly what patients can
do to get themselves betteragain, even if they don't come
to see us at the key and comesee somebody around the country
that they get uh they get whatthey need.
Dr Andrew Greenland (34:33):
Thank you.
And if you were starting overtomorrow, would you do anything
different with everything thatyou've learned along the way?
Dr Thomas Buchheit (34:41):
Um going back for the business I started
last year or going back 30 yearsto the career, I guess is the
question, right?
Dr Andrew Greenland (34:48):
I guess I mean you you've made a switch in
your the field that you'reworking in.
I just wondered if you weregoing to start a regenerative
practice tomorrow witheverything that you've learned
along the way, is there anythingyou would fundamentally change
and do from the outset?
Or maybe there's nothing.
I mean, sometimes you we justwe we the learning is as as
important as part of thejourney.
I just wonder if there'sanything that you would do
differently.
Dr Thomas Buchheit (35:07):
Yeah, I'd probably pay more attention to
the importance of social mediaearlier on and have uh someone
uh join or early to really lookat that strategy.
Um because I think and that'sthat's the part I believe that I
underestimated a little bit,the importance of.
Dr Andrew Greenland (35:25):
Got it.
So what does the future hold?
Where would you like um to beor the clinic to be in the next,
say, 12 months or so?
What are your plans for um theclinic?
Dr Thomas Buchheit (35:35):
I I you know I think our plans are to
continue getting the word outand continue growing.
I'd love to partner with uh,you know, all the local physical
therapists, they're doing uhgreat work.
Um I love, you know, we'regonna we're continuing to
partner with some of the sportsteams as well, and um just kind
of get the word out.
That that's my very simplegoal.
(35:55):
And you know, I'd love to seepatients coming in the door who
like they are doing now, orthey're coming in looking for a
new way of treating their joint,their tendon, their ligament,
their or their nerve.
And and uh to me, it's just amatter of getting getting that
message out and having themunderstand, and and that our
growth has been very organicwith that.
(36:16):
Um, and that's been that's beena nice process, and I'd love to
continue seeing that very kindof progressive organic growth
too.
Dr Andrew Greenland (36:24):
And would that be more clinics or a bigger
clinic than you're in, justmore staff, being able to treat
more patients?
What does it kind of look likefor you?
Dr Thomas Buchheit (36:31):
Right now, I think it's more of just growing
the the clinic and thestaffing.
We have a space that canaccommodate a little bit uh uh
more than what we're doing rightnow.
Um we are actually justfinished hiring up uh another uh
another two staff membersactually the past couple weeks,
which is which is wonderful.
So we are we are growing withinour space, which is great.
(36:51):
I don't have any immediateplans of additional.
I I really like to control thequality and the experience of a
patient coming through.
And to me, it's a very big stepto open up a second site where
you're not physically present asmuch.
So I I really enjoy very muchthat hands-on approach because I
can monitor and make sure thequality of the experience is
(37:12):
great.
To me, it's it's like running anice restaurant, right?
I want people to have a reallygreat experience from the from
the moment they walk into themoment they leave.
And I feel like, you know,maybe this is because in college
and medical school, I waitedtables at restaurants and um and
I, but I feel like their modelis a really good model of of the
patient experience, more sothan a traditional medical model
(37:35):
where patients come in andthey're gonna get they're gonna
get what they're offered, andthey're only gonna be offered a
few things.
Um, and that might or not mightnot be what's best for them.
And I really love that thatservice-oriented model of of a
restaurant, really as much asanything.
Dr Andrew Greenland (37:52):
And final question on closing.
Um, if you could change onething about modern health care,
what would it be?
Slightly philosophical umquestion, but I'd probably a
good one to end on.
Dr Thomas Buchheit (38:01):
I would love to have uh this paradigm shift
that we're talking about shiftmore quickly.
And um, I think it's needed, Ithink it's in all of our best
interests.
Uh these these shifts happenvery, very slowly, obviously,
(38:21):
and all paradigms die veryslowly.
But I would love to see thisthis uh kind of way of keeping
joints and nerves healthy.
I'd love to see thosemechanisms and those techniques
be employed faster than theyare.
Dr Andrew Greenland (38:39):
With that, Thomas, I'd love to thank you so
much for joining me today.
I've really enjoyed theconversation.
Thank you for telling us aboutyour practice, the different
things that you can offer thepatients, giving us a real
understanding of regenerativemedicine, what it is, what it
isn't, some of themisconceptions, and just sharing
a little bit about behind thescenes of the practice and what
you're aiming to achieve.
It's been a real delight.
So thank you so much.
Dr Thomas Buchheit (38:58):
Andrew, thank you so much.
Really appreciate you having meon.
Delight to talk.
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