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Hello Don here, welcome to 
Podiatry Practice Mastery. 

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We're helping you get your 
practice to the $1,000,000 mark 

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and beyond. 
This is going to be a recording 

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of a Friday with my patients. 
So just a reminder, Friday is 

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the half day that I do routine 
care for the first half of the 

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day and then the second-half I 
just see see normal patients. 

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So I, I don't spend too much 
time on the routine care aspect 

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and I want to spend some time 
talking about Shockwave because 

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I'm getting some, some questions
from people and some other 

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doctors and, and I've been 
dealing with certain issues with

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patients. 
I want to talk a little bit 

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about expectations. 
I'm going to start with with 

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Shockwave first. 
So I, I saw a couple of patients

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in the afternoon for Shockwave. 
One of them was a 59 year old 

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man. 
He had left Achilles tendonitis.

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He had six sessions of 
Shockwave. 

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He really had no pain at all to 
the insertion of the Achilles, 

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but he still had tightness and 
this isn't an interesting topic 

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of expectation so I maybe I 
wasn't clear enough, but like 

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when there's no pain and they're
just tightness, I'm fine with 

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that. 
He wanted to help break up some 

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of that tightness and had 
already done PT so I recommended

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a washer tool, which is like a 
self grass tuning tool that he 

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could use on his own. 
So that was 1. 

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So I just spent some time 
talking about the expectations 

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of what, what, what this patient
should have and what they should

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expect with this. 
There was another patient that 

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was #5 out of 6 of Shockwave for
plantar fasciitis. 

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He was a gentleman that he had a
little bit more pain, but he 

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also biked 3 times this last 
week and, and was kind of in a, 

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in a hilly area when he was 
biking. 

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And so I once again, I talked 
about expectations about, OK, I 

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know you're not totally out of 
pain in your plantar fascia, but

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you may have done too much 
activity and just made things 

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tighter. 
So I just reinforced the 

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importance of doing the foam 
rolling, night splint, morning 

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stretch. 
And he wasn't doing that that 

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well. 
But I think the main issue was 

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he was just too, too active with
that one. 

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And then the last patient, this 
was a patient I picked up with a

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colleague of mine. 
She came in, she had previously 

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had four sessions of Shockwave 
by one of my colleagues and she 

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was really kind of frustrated 
about what was going on because 

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she wasn't feeling any better. 
So let me just explain. 

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So she had insertional Achilles 
tendonitis and it was 

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bilaterally and they did 4 
sessions and now we are, we're 

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about 8 weeks follow up. 
So there it wasn't even the I 

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don't know why there wasn't a 
six week follow up. 

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Maybe she missed it. 
She made an 8 week follow up and

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she was assuming that everything
would be better by the 8th week.

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I I find actually one of the 
most challenging areas are where

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the tendon inserts into the 
bone. 

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So this could be like the 
nevicular tuberosity. 

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So the posterior tibial 
tendonitis word inserts there 

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and also insertional Achilles 
tendonitis. 

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And so these ones I tell and I 
think it was expectations. 

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I say, you know, I expect maybe 
20 to 30% better at at 6 to 8 

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weeks and then I double that. 
So I usually do six week follow 

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up and then a twelve week follow
up and and then they're usually 

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much better, but it just takes 
more time for them. 

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So I really kind of talked her 
off the ledge and and I also 

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just because she was so kind of 
nervous and things like that, I 

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said, I just reassured her. 
I'm like, what else are we going

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to do? 
We're going to, we're not going 

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to reattach your Achilles. 
We're not going to detach and 

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reattach it doing like a speed 
bridge procedure. 

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And I did another session of 
Shockwave for her, like for 

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without charge. 
I typically would have done 6 

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sessions. 
I know my colleague does 4. 

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I just find sometimes find that 
4 or even 3, which is kind of 

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the norm, isn't enough when 
you're dealing with the 

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insertional aspect. 
It just takes maybe 4 is enough,

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but you just need to wait 
longer. 

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So I just kind of reassured her 
and I'm going to see her back in

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two months. 
So those were kind of the things

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with the shockwave. 
I think expectations are a big 

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thing when you're talking with 
patients, especially when you're

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starting out. 
And this can be an area that can

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be a challenge because if you're
not confident enough in the, in 

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the, in the technology and how 
you're using it, you're going 

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to, you're going to get spooked 
at about six weeks. 

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Would not everyone is 100% 
better, but people aren't 100% 

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better at six weeks. 
But then that continues to 

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improve over time. 
And so for this one, like I 

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said, I did do the shockwave. 
It took me extra time. 

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I didn't charge them, maybe I 
should have, but she was just 

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kind of one of those patients 
that was kind of spooked about 

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about everything. 
So I guess the, the main word 

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for this is be careful of the 
expectations and be very clear 

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where patients are going to be 
at, at the last visit. 

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And that's where I use this 
shockwave last visit sheet. 

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So I have a sheet that actually 
give them at the last visit and 

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it says, OK, I expect you to be,
you know, 20 to 50% better at 

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six weeks. 
This is what we're going to 

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possibly do next. 
So they kind of know the plan of

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care because this patient didn't
know anything about the plan of 

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care that was going to be next 
for her. 

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OK, let's go into the day. 
There was just some of the stuff

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for the routine. 
There was a patient that was an 

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80 year old female. 
She had a right hallux kind of a

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onycholytic nail with a pyogenic
granuloma underneath that area. 

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So I numbed up the toe, kind of 
divided back the toenail, saw 

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the pyogenic granuloma and took 
a pathology and I kind of 

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divided almost like an ulcer 
that was there. 

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So I documented as an ulcer and 
A and a nail evulsion and I sent

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that to pathology just to be on 
the safe side to make sure it 

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wasn't anything else. 
But it looked like a, a pyogenic

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granuloma. 
Next was a this was a shockwave 

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of one of my colleagues. 
He was, he called out today. 

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So beyond doing all of my 
routine care, I had to see a 

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couple of his patients as well. 
And I didn't have a nail tech 

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today. 
So Marjorie took a day off. 

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I think it's good. 
I always encourage people to 

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take days off, but it, it makes 
it a little bit easier. 

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But it, it actually gives me 
also more rooms to, to, to treat

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with. 
So I have six treatment rooms 

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all by myself. 
So it makes it a little bit 

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easier that way. 
So that was a Achilles #3 out of

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four for the, for this patient. 
So they, some of my colleagues 

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don't do 6 treatments, so they 
did 4. 

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Next was a 67 year old female 
for right post op. 

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She had a second toe fracture 
fragment at the base of the 2nd 

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digit, kind of a weird fracture 
that was evolved or that was 

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pulled out during the surgery. 
And I put her in a Cam boot. 

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So you know, global post op 
period got the X-rays and I and 

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I was able to do the Cam boot. 
And this is a conversation I had

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with, with one of my colleagues 
the other day and this other 

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doctor that that's starting with
us. 

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I just encouraged him because I 
think a lot of times we leave, 

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we leave, I guess we, I guess 
you could say we leave money on 

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the table and, and meaning, you 
know, we get them a surgical 

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shoe when you do the surgery. 
And then usually at the post op,

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you get a Cam boot. 
But if you forget that, if you 

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forget the Cam boot, then 
you're, you're leaving that 

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revenue on the table. 
So it's something that is going 

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to be beneficial for you. 
OK to to every post op gets a 

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Cam boot basically that's that's
the way I do it. 

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OK next patient was there's a 
diabetic foot exam 78 year old 

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that had onychomycosis and I 
recommended formula seven. 

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I don't do that a ton, but like 
in older people, a lot of times 

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I, I do that. 
And then there was a also 

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another, another patient that 
was a self pay nail care, 

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divided the nail and they had 
warts. 

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So they had warts. 
So I did kanthurdin for this 

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patient. 
And so when I made the 

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follow-ups, I made a couple of 
follow-ups. 

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I think this is another point is
like making multiple follow-ups 

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for patients. 
So they're going to do one month

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wart, 2 month wart and a three 
month nail care. 

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So I, I pre booked these wart 
treatments so they can get in 

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the schedule. 
And those are so you can just 

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do, do those that are, that are 
needed for the patients. 

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I think sometimes we only do 
them a month at a time or 

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something like that, But you 
have to have clear expectations.

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What's really helped me is my 
this wart treatment sheet. 

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So if you don't have it, shoot 
me an e-mail. 

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I'll be happy to send you my 
treatment sheets. 

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Don at Podiatry practice 
mastery.com. 

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The treatment sheets with the 
wart one, I, I, I basically just

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put it on a, on a paper. 
What's it called? 

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Like a, so where you fill out 
the paper, the, it's slipping my

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mind right now. 
It holds the paper. 

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So I just put that on a 
clipboard. 

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I put on a clipboard and I, and 
I do it in front of the 

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patients. 
And I, and it clearly explains 

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like the benefits of Swift, the 
benefits of canthrodin, benefits

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of laser, the benefits of 
salicylic and other things like 

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that. 
And it makes it really easy for 

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patients to decide. 
And that's how most of my 

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patients, when they do decide to
do Swift, they do it based on, 

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on that. 
So that was the morning, the 

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afternoon there was some reason 
some of my nails are getting in 

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my afternoon. 
I'm not exactly sure. 

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I think it's because of my staff
that are scheduling them. 

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But the first was a 75 year old 
man had nails and he also had a 

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contusion of the toe with black 
and blue. 

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So there was an office visit for
that. 

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Next was a 56 year old that had 
a fourth toe ulcer. 

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We did X-rays and he has osteo 
to the tip of the toe was being 

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seen by one of my other 
colleagues and I was, this is I 

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was filling in for my buddy, my 
other doctors here. 

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And so he was put on doxycycline
and he's going to have a distal 

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amputation of that fourth toe. 
Next was a left 35 year old 

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female for a left hallux wart 
and she this was one that was 

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kind of an issue was seen by one
of my other colleagues and she 

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had canthered in, but the thing 
blistered up like no one's 

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business. 
The thing was huge, huge blister

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and I think it was the new 
formulation of the canthren that

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we got and she only left it on 
six hours and then she washed it

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up, but there's like a huge 
blister. 

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And so I did not do canthren and
I did topical salicylic acid. 

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I just want that all that tissue
just left off to see what's 

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underneath there. 
It was hard to see anything for 

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that patient. 
Next was a 63 year old female 

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had a callus on the distal tip 
of the toe. 

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So I did a Crest pad for her and
I did an office visit for the 

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for the hammer toe, talking 
about surgery if needed. 

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And next patient was a 59 year 
old with a right hallux fracture

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follow up at the tip of the toe 
doing much better from the 

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fracture has some metatarsalgia 
on the other foot. 

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And so we were treating that and
we did an office visit for that 

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because it was a new diagnosis. 
It didn't relate to the fracture

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and we did an office visit for 
that. 

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So even though we're in the 
global for the fracture, you 

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could do a new office visit 
because it was a new condition 

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for the other foot. 
Next was this is a 18 year old 

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female that had bilateral warts.
She has had them for multiple 

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years, came with her parents. 
She's in studying in college 

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year and this is where I use my 
work treatment sheet. 

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I just laid it out and they 
decided to do swift. 

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They did number one out of four 
for those warts. 

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She tolerated it well. 
I find that Swift is quite 

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painful and I actually had 
someone asked me the other day 

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if you could, if you were just 
starting out and if you could 

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choose between like shockwave 
and swift, which would you 

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choose? 
In my opinion, even if you can 

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see the patients that I'm seeing
here, I would do shockwave or 

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actually they said shockwave or 
laser for fungal nails or swift.

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I would do shockwave #1 and 
swift #2. 

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I have a couple of lasers for 
nail fungus. 

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I wish I could say that they 
worked great. 

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If you are a person that gets 
great results, let me know. 

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I'd love to hear it. 
But I would do Shockwave all day

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long first and an ultrasound all
day long if you're starting out.

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Next patient was a patient with 
a rash on the right foot with 

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nail thickening. 
This patient had done well with 

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Diflucan in the past. 
I find Diflucan works really 

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well. 
Like some of these nails that 

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are really brittle and they're, 
they're, they don't respond to 

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trybenafin. 
Like it's amazing what it can do

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with some of these these bad 
nails. 

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Like she is really a believer 
and she had to kind of some 

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changes in the base of the nail 
was just paranoid. 

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And so I, I gave her another 
round of Diflucan and also for a

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rash on her foot, I gave her 
ketoconazole. 

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Next patient was a orthotic 
check, a one year orthotic 

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check, 70 year old female. 
And I also, she also had some 

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nails that she wanted done. 
So I did that in a callus that 

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so the nails were covered 
because they're thick, but the 

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callus wasn't. 
So she charged 75, she paid 75 

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for that. 
Now these one year orthotic 

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checks, when I was first 
starting out, I, I was always 

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trained or I remember learning 
at the AAPM to always have like 

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orthotic one year follow-ups. 
And I think if you're starting 

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out and you're not as busy, I 
think it makes sense to see them

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to see everyone back as is. 
It depends if you have a supply 

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problem or demand problem. 
Meaning if you, if you have a 

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supply problem, you, you, you 
don't have enough supply, you 

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don't have enough of you to go 
around, so you don't have them 

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come back as often. 
So I'm, I'm, I'm at a phase 

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where I'm not having these 
orthotics come back every year 

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because it's a low level visit 
and there's not usually much 

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else in terms of billing that 
goes with it. 

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If you have a demand problem, 
like not enough demand for your 

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services, like you're starting 
out, you're going to have 

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everyone come back because you 
just need the, you need the 

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bodies and the chairs to do 
that. 

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And I've, I've talked multiple 
times about that, but this is 1 

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where I used to have them do it 
every year. 

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I, I am thinking against that 
because I'm not really doing 

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much and in the level of the 
visit doesn't really condone 

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having them come back. 
I guess one way around that is 

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if you had like, let's say a 
double booked 10 minute slot, 

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you could theoretically see them
in that time because they're 

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kind of going to be simple, 
simple visits. 

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Next is a 75 year old female for
a right carry flex and she got a

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kit and she had callous care. 
So she had to pay cash for the 

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calluses carry flex in the kit. 
I think it's $200.00. 

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So it's, it's, it's decent in 
terms of reimbursement. 

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I would really love to figure 
out how to get all these carry 

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flexes that I've been doing on 
my nail tech schedule. 

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I, I haven't quite figured out 
how to do that. 

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Probably it's me just being too 
nice and having them not know 

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where to schedule them. 
But I think patients will be 

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flexible if they want that 
procedure to put it in my, in my

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nail nail tech schedule. 
So once again, if you want these

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things, let me know what I'm 
working on these days. 

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If you want to know, besides the
challenge, I'm working on this 

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challenge that I'm, I'm excited 
to, to, to meet with people and 

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we're going to have a mastermind
to help you get your practice to

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the $1,000,000 mark. 
I think that is great benefit. 

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Certainly if you're just 
starting out, I would just do 

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the practice Mastery Academy. 
It's real inexpensive. 

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But if you want a little bit 
more one-on-one contact, we're 

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doing that. 
And I'm, I'm working on 

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something called LTV and CAC. 
So lifetime value of the patient

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00:15:11,560 --> 00:15:13,680
and then the cost to acquire a 
customer. 

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00:15:13,680 --> 00:15:18,880
So I'm, I'm, I'm struggling 
right now with ad attribution. 

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00:15:19,080 --> 00:15:23,600
So what that means is I'm trying
to determine like how beneficial

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my Facebook ads are and my 
Google ads are in terms of 

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00:15:26,360 --> 00:15:29,280
getting patients in the office 
and then equating that to 

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00:15:29,720 --> 00:15:31,800
revenue. 
So I can see how much I can, how

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much more, how much more I can 
invest into that. 

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00:15:33,640 --> 00:15:35,200
So that's something that I'm 
working on right now. 

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00:15:35,880 --> 00:15:38,120
I'm, if you, these are all on my
spreadsheet. 

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00:15:38,120 --> 00:15:41,040
I have the spreadsheet like I'm 
how to calculate benefit to 

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00:15:41,640 --> 00:15:43,880
Shockwave for Swift for your 
EMR. 

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00:15:43,880 --> 00:15:47,280
And now I have this, I'm adding 
a new column for this CAC ratio,

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the cost to acquire a customer 
and kind of how I'm figuring out

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00:15:49,960 --> 00:15:51,560
these calculations. 
This is all in an Excel 

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00:15:51,560 --> 00:15:53,680
spreadsheet. 
So once again, if you, if you, 

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00:15:53,920 --> 00:15:57,120
if you want this, this would 
benefit you certainly shoot me 

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00:15:57,120 --> 00:15:59,400
an e-mail down at Podiatry 
Practice Mastery. 

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00:15:59,400 --> 00:16:01,560
Happy to share this with you. 
This is these are the types of 

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00:16:01,560 --> 00:16:04,160
things we're going to kind of go
on in this, in this mastermind. 

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00:16:04,160 --> 00:16:06,280
I know sometimes it's hard to do
things on our own. 

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00:16:06,840 --> 00:16:09,440
That's why I think these these 
masterminds can be beneficial. 

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00:16:09,440 --> 00:16:12,000
So if you're interested, let me 
know and we'll talk to you 

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00:16:12,000 --> 00:16:12,360
tomorrow.