Hello Don here, welcome to Podiatry Practice Mastery.
We're helping you get your practice to the $1,000,000 mark
and beyond. This is going to be a recording
of a Friday with my patients. So just a reminder, Friday is
the half day that I do routine care for the first half of the
day and then the second-half I just see see normal patients.
So I, I don't spend too much time on the routine care aspect
and I want to spend some time talking about Shockwave because
I'm getting some, some questions from people and some other
doctors and, and I've been dealing with certain issues with
patients. I want to talk a little bit
about expectations. I'm going to start with with
Shockwave first. So I, I saw a couple of patients
in the afternoon for Shockwave. One of them was a 59 year old
man. He had left Achilles tendonitis.
He had six sessions of Shockwave.
He really had no pain at all to the insertion of the Achilles,
but he still had tightness and this isn't an interesting topic
of expectation so I maybe I wasn't clear enough, but like
when there's no pain and they're just tightness, I'm fine with
that. He wanted to help break up some
of that tightness and had already done PT so I recommended
a washer tool, which is like a self grass tuning tool that he
could use on his own. So that was 1.
So I just spent some time talking about the expectations
of what, what, what this patient should have and what they should
expect with this. There was another patient that
was #5 out of 6 of Shockwave for plantar fasciitis.
He was a gentleman that he had a little bit more pain, but he
also biked 3 times this last week and, and was kind of in a,
in a hilly area when he was biking.
And so I once again, I talked about expectations about, OK, I
know you're not totally out of pain in your plantar fascia, but
you may have done too much activity and just made things
tighter. So I just reinforced the
importance of doing the foam rolling, night splint, morning
stretch. And he wasn't doing that that
well. But I think the main issue was
he was just too, too active with that one.
And then the last patient, this was a patient I picked up with a
colleague of mine. She came in, she had previously
had four sessions of Shockwave by one of my colleagues and she
was really kind of frustrated about what was going on because
she wasn't feeling any better. So let me just explain.
So she had insertional Achilles tendonitis and it was
bilaterally and they did 4 sessions and now we are, we're
about 8 weeks follow up. So there it wasn't even the I
don't know why there wasn't a six week follow up.
Maybe she missed it. She made an 8 week follow up and
she was assuming that everything would be better by the 8th week.
I I find actually one of the most challenging areas are where
the tendon inserts into the bone.
So this could be like the nevicular tuberosity.
So the posterior tibial tendonitis word inserts there
and also insertional Achilles tendonitis.
And so these ones I tell and I think it was expectations.
I say, you know, I expect maybe 20 to 30% better at at 6 to 8
weeks and then I double that. So I usually do six week follow
up and then a twelve week follow up and and then they're usually
much better, but it just takes more time for them.
So I really kind of talked her off the ledge and and I also
just because she was so kind of nervous and things like that, I
said, I just reassured her. I'm like, what else are we going
to do? We're going to, we're not going
to reattach your Achilles. We're not going to detach and
reattach it doing like a speed bridge procedure.
And I did another session of Shockwave for her, like for
without charge. I typically would have done 6
sessions. I know my colleague does 4.
I just find sometimes find that 4 or even 3, which is kind of
the norm, isn't enough when you're dealing with the
insertional aspect. It just takes maybe 4 is enough,
but you just need to wait longer.
So I just kind of reassured her and I'm going to see her back in
two months. So those were kind of the things
with the shockwave. I think expectations are a big
thing when you're talking with patients, especially when you're
starting out. And this can be an area that can
be a challenge because if you're not confident enough in the, in
the, in the technology and how you're using it, you're going
to, you're going to get spooked at about six weeks.
Would not everyone is 100% better, but people aren't 100%
better at six weeks. But then that continues to
improve over time. And so for this one, like I
said, I did do the shockwave. It took me extra time.
I didn't charge them, maybe I should have, but she was just
kind of one of those patients that was kind of spooked about
about everything. So I guess the, the main word
for this is be careful of the expectations and be very clear
where patients are going to be at, at the last visit.
And that's where I use this shockwave last visit sheet.
So I have a sheet that actually give them at the last visit and
it says, OK, I expect you to be, you know, 20 to 50% better at
six weeks. This is what we're going to
possibly do next. So they kind of know the plan of
care because this patient didn't know anything about the plan of
care that was going to be next for her.
OK, let's go into the day. There was just some of the stuff
for the routine. There was a patient that was an
80 year old female. She had a right hallux kind of a
onycholytic nail with a pyogenic granuloma underneath that area.
So I numbed up the toe, kind of divided back the toenail, saw
the pyogenic granuloma and took a pathology and I kind of
divided almost like an ulcer that was there.
So I documented as an ulcer and A and a nail evulsion and I sent
that to pathology just to be on the safe side to make sure it
wasn't anything else. But it looked like a, a pyogenic
granuloma. Next was a this was a shockwave
of one of my colleagues. He was, he called out today.
So beyond doing all of my routine care, I had to see a
couple of his patients as well. And I didn't have a nail tech
today. So Marjorie took a day off.
I think it's good. I always encourage people to
take days off, but it, it makes it a little bit easier.
But it, it actually gives me also more rooms to, to, to treat
with. So I have six treatment rooms
all by myself. So it makes it a little bit
easier that way. So that was a Achilles #3 out of
four for the, for this patient. So they, some of my colleagues
don't do 6 treatments, so they did 4.
Next was a 67 year old female for right post op.
She had a second toe fracture fragment at the base of the 2nd
digit, kind of a weird fracture that was evolved or that was
pulled out during the surgery. And I put her in a Cam boot.
So you know, global post op period got the X-rays and I and
I was able to do the Cam boot. And this is a conversation I had
with, with one of my colleagues the other day and this other
doctor that that's starting with us.
I just encouraged him because I think a lot of times we leave,
we leave, I guess we, I guess you could say we leave money on
the table and, and meaning, you know, we get them a surgical
shoe when you do the surgery. And then usually at the post op,
you get a Cam boot. But if you forget that, if you
forget the Cam boot, then you're, you're leaving that
revenue on the table. So it's something that is going
to be beneficial for you. OK to to every post op gets a
Cam boot basically that's that's the way I do it.
OK next patient was there's a diabetic foot exam 78 year old
that had onychomycosis and I recommended formula seven.
I don't do that a ton, but like in older people, a lot of times
I, I do that. And then there was a also
another, another patient that was a self pay nail care,
divided the nail and they had warts.
So they had warts. So I did kanthurdin for this
patient. And so when I made the
follow-ups, I made a couple of follow-ups.
I think this is another point is like making multiple follow-ups
for patients. So they're going to do one month
wart, 2 month wart and a three month nail care.
So I, I pre booked these wart treatments so they can get in
the schedule. And those are so you can just
do, do those that are, that are needed for the patients.
I think sometimes we only do them a month at a time or
something like that, But you have to have clear expectations.
What's really helped me is my this wart treatment sheet.
So if you don't have it, shoot me an e-mail.
I'll be happy to send you my treatment sheets.
Don at Podiatry practice mastery.com.
The treatment sheets with the wart one, I, I, I basically just
put it on a, on a paper. What's it called?
Like a, so where you fill out the paper, the, it's slipping my
mind right now. It holds the paper.
So I just put that on a clipboard.
I put on a clipboard and I, and I do it in front of the
patients. And I, and it clearly explains
like the benefits of Swift, the benefits of canthrodin, benefits
of laser, the benefits of salicylic and other things like
that. And it makes it really easy for
patients to decide. And that's how most of my
patients, when they do decide to do Swift, they do it based on,
on that. So that was the morning, the
afternoon there was some reason some of my nails are getting in
my afternoon. I'm not exactly sure.
I think it's because of my staff that are scheduling them.
But the first was a 75 year old man had nails and he also had a
contusion of the toe with black and blue.
So there was an office visit for that.
Next was a 56 year old that had a fourth toe ulcer.
We did X-rays and he has osteo to the tip of the toe was being
seen by one of my other colleagues and I was, this is I
was filling in for my buddy, my other doctors here.
And so he was put on doxycycline and he's going to have a distal
amputation of that fourth toe. Next was a left 35 year old
female for a left hallux wart and she this was one that was
kind of an issue was seen by one of my other colleagues and she
had canthered in, but the thing blistered up like no one's
business. The thing was huge, huge blister
and I think it was the new formulation of the canthren that
we got and she only left it on six hours and then she washed it
up, but there's like a huge blister.
And so I did not do canthren and I did topical salicylic acid.
I just want that all that tissue just left off to see what's
underneath there. It was hard to see anything for
that patient. Next was a 63 year old female
had a callus on the distal tip of the toe.
So I did a Crest pad for her and I did an office visit for the
for the hammer toe, talking about surgery if needed.
And next patient was a 59 year old with a right hallux fracture
follow up at the tip of the toe doing much better from the
fracture has some metatarsalgia on the other foot.
And so we were treating that and we did an office visit for that
because it was a new diagnosis. It didn't relate to the fracture
and we did an office visit for that.
So even though we're in the global for the fracture, you
could do a new office visit because it was a new condition
for the other foot. Next was this is a 18 year old
female that had bilateral warts. She has had them for multiple
years, came with her parents. She's in studying in college
year and this is where I use my work treatment sheet.
I just laid it out and they decided to do swift.
They did number one out of four for those warts.
She tolerated it well. I find that Swift is quite
painful and I actually had someone asked me the other day
if you could, if you were just starting out and if you could
choose between like shockwave and swift, which would you
choose? In my opinion, even if you can
see the patients that I'm seeing here, I would do shockwave or
actually they said shockwave or laser for fungal nails or swift.
I would do shockwave #1 and swift #2.
I have a couple of lasers for nail fungus.
I wish I could say that they worked great.
If you are a person that gets great results, let me know.
I'd love to hear it. But I would do Shockwave all day
long first and an ultrasound all day long if you're starting out.
Next patient was a patient with a rash on the right foot with
nail thickening. This patient had done well with
Diflucan in the past. I find Diflucan works really
well. Like some of these nails that
are really brittle and they're, they're, they don't respond to
trybenafin. Like it's amazing what it can do
with some of these these bad nails.
Like she is really a believer and she had to kind of some
changes in the base of the nail was just paranoid.
And so I, I gave her another round of Diflucan and also for a
rash on her foot, I gave her ketoconazole.
Next patient was a orthotic check, a one year orthotic
check, 70 year old female. And I also, she also had some
nails that she wanted done. So I did that in a callus that
so the nails were covered because they're thick, but the
callus wasn't. So she charged 75, she paid 75
for that. Now these one year orthotic
checks, when I was first starting out, I, I was always
trained or I remember learning at the AAPM to always have like
orthotic one year follow-ups. And I think if you're starting
out and you're not as busy, I think it makes sense to see them
to see everyone back as is. It depends if you have a supply
problem or demand problem. Meaning if you, if you have a
supply problem, you, you, you don't have enough supply, you
don't have enough of you to go around, so you don't have them
come back as often. So I'm, I'm, I'm at a phase
where I'm not having these orthotics come back every year
because it's a low level visit and there's not usually much
else in terms of billing that goes with it.
If you have a demand problem, like not enough demand for your
services, like you're starting out, you're going to have
everyone come back because you just need the, you need the
bodies and the chairs to do that.
And I've, I've talked multiple times about that, but this is 1
where I used to have them do it every year.
I, I am thinking against that because I'm not really doing
much and in the level of the visit doesn't really condone
having them come back. I guess one way around that is
if you had like, let's say a double booked 10 minute slot,
you could theoretically see them in that time because they're
kind of going to be simple, simple visits.
Next is a 75 year old female for a right carry flex and she got a
kit and she had callous care. So she had to pay cash for the
calluses carry flex in the kit. I think it's $200.00.
So it's, it's, it's decent in terms of reimbursement.
I would really love to figure out how to get all these carry
flexes that I've been doing on my nail tech schedule.
I, I haven't quite figured out how to do that.
Probably it's me just being too nice and having them not know
where to schedule them. But I think patients will be
flexible if they want that procedure to put it in my, in my
nail nail tech schedule. So once again, if you want these
things, let me know what I'm working on these days.
If you want to know, besides the challenge, I'm working on this
challenge that I'm, I'm excited to, to, to meet with people and
we're going to have a mastermind to help you get your practice to
the $1,000,000 mark. I think that is great benefit.
Certainly if you're just starting out, I would just do
the practice Mastery Academy. It's real inexpensive.
But if you want a little bit more one-on-one contact, we're
doing that. And I'm, I'm working on
something called LTV and CAC. So lifetime value of the patient
and then the cost to acquire a customer.
So I'm, I'm, I'm struggling right now with ad attribution.
So what that means is I'm trying to determine like how beneficial
my Facebook ads are and my Google ads are in terms of
getting patients in the office and then equating that to
revenue. So I can see how much I can, how
much more, how much more I can invest into that.
So that's something that I'm working on right now.
I'm, if you, these are all on my spreadsheet.
I have the spreadsheet like I'm how to calculate benefit to
Shockwave for Swift for your EMR.
And now I have this, I'm adding a new column for this CAC ratio,
the cost to acquire a customer and kind of how I'm figuring out
these calculations. This is all in an Excel
spreadsheet. So once again, if you, if you,
if you want this, this would benefit you certainly shoot me
an e-mail down at Podiatry Practice Mastery.
Happy to share this with you. This is these are the types of
things we're going to kind of go on in this, in this mastermind.
I know sometimes it's hard to do things on our own.
That's why I think these these masterminds can be beneficial.
So if you're interested, let me know and we'll talk to you
tomorrow.