1 00:00:01,440 --> 00:00:04,560 I had a question from a doctor the other day and he was asking 2 00:00:04,560 --> 00:00:06,760 me how I got to the $1,000,000 mark. 3 00:00:06,760 --> 00:00:11,880 He was hovering around the $70,000 per month in 4 00:00:11,880 --> 00:00:14,240 collections. In some months I do 80, most I 5 00:00:14,240 --> 00:00:19,680 do 90 or sometimes even 100. When he saw it, it was 120 that 6 00:00:19,680 --> 00:00:22,440 month. And so I wanted to take a little 7 00:00:22,560 --> 00:00:26,920 moment and explain how would as I get to this and maybe some 8 00:00:26,920 --> 00:00:29,240 obvious things I haven't mentioned before about getting 9 00:00:29,240 --> 00:00:31,080 your practice past the $1,000,000 mark. 10 00:00:32,400 --> 00:00:35,920 I think the first thing I have to explain is most of my 11 00:00:35,920 --> 00:00:41,160 practice is based on optimization of my current 12 00:00:41,160 --> 00:00:43,320 patient load. And I want to explain the 13 00:00:43,320 --> 00:00:48,040 difference because if you don't have a increased demand and a 14 00:00:48,040 --> 00:00:51,480 big patient load, like none of the other stuff that I'm going 15 00:00:51,480 --> 00:00:53,680 to talk about is possible. So what does that mean? 16 00:00:54,560 --> 00:00:58,880 So my my typical date most, most days, Monday through Friday, I 17 00:00:58,880 --> 00:01:02,800 start at 8:00 in the morning and the last patient in the morning 18 00:01:02,800 --> 00:01:07,000 is at 11:30. So I finish about noon and then 19 00:01:07,000 --> 00:01:09,880 I start up again at about 1:00. And then in my last patient of 20 00:01:09,880 --> 00:01:14,920 the day is at 4:00, I see three patients an hour. 21 00:01:14,920 --> 00:01:19,160 Each patient gets 20 minutes. Now this is for new patients or 22 00:01:19,160 --> 00:01:22,880 established patients. The only difference is on my 23 00:01:22,880 --> 00:01:25,440 Fridays where I double book every patient and I have a nail 24 00:01:25,440 --> 00:01:28,040 tech seeing other patients, but that doesn't really Bing bring 25 00:01:28,040 --> 00:01:31,320 in a ton of revenue. It just really gives me a person 26 00:01:31,320 --> 00:01:34,920 that can see some patients and reduce the other days that we 27 00:01:34,920 --> 00:01:38,160 have to do routine care and she can do some carry flexes that 28 00:01:38,160 --> 00:01:39,760 take a little bit longer and things like that. 29 00:01:39,760 --> 00:01:42,920 So she doesn't bring in a ton of revenue, but she kind of frees, 30 00:01:43,000 --> 00:01:47,080 frees me up. So what I mean by having a full 31 00:01:47,080 --> 00:01:51,920 schedule or having more demand than you need is that with that 32 00:01:52,200 --> 00:01:57,200 high demand schedule, meaning every slot is filled, then you 33 00:01:57,200 --> 00:02:02,040 can optimize your your schedule for more profitable patients. 34 00:02:02,720 --> 00:02:07,800 Until you get to that point, your whole focus is on getting 35 00:02:07,800 --> 00:02:09,240 more patients. OK. 36 00:02:09,240 --> 00:02:10,440 So I want to, I want to repeat that again. 37 00:02:10,440 --> 00:02:13,720 I know it sounds obvious, but for some people it might not be. 38 00:02:14,120 --> 00:02:19,080 Many times we think that we need more profitable patients where 39 00:02:19,080 --> 00:02:20,840 in the beginning you just need patients. 40 00:02:21,000 --> 00:02:25,440 You just need more, more butts in the door, in your in your 41 00:02:25,440 --> 00:02:29,760 treatment room. OK, once you have developed a 42 00:02:29,800 --> 00:02:32,560 throughput, then you can optimize. 43 00:02:32,560 --> 00:02:35,000 So let me explain kind of some scenarios. 44 00:02:35,000 --> 00:02:37,680 So let's say you're by yourself and every single one of your 45 00:02:37,680 --> 00:02:39,760 slots is filled, then you can optimize. 46 00:02:40,120 --> 00:02:43,240 But sometimes we pull a trigger when we get very full and then 47 00:02:43,240 --> 00:02:47,680 we we hire another doctor. When you hire that other doctor, 48 00:02:47,960 --> 00:02:52,720 unless you instruct your staff to fill your schedule 1st and 49 00:02:52,720 --> 00:02:55,680 then their schedule with the overflow, you're going to shoot 50 00:02:55,680 --> 00:02:59,400 yourself in the foot, OK? Because you're going to be 51 00:02:59,400 --> 00:03:02,320 taking money out of your pocket and you can't be optimized and 52 00:03:02,320 --> 00:03:05,800 you're going to be giving it to the associate that might be 53 00:03:05,800 --> 00:03:07,240 salaried. OK. 54 00:03:07,920 --> 00:03:11,000 And and that is a big, that's a mistake that we've made a couple 55 00:03:11,000 --> 00:03:13,440 of times in our practice. So I'm just kind of helping you 56 00:03:13,440 --> 00:03:15,480 out. So there are different phases. 57 00:03:15,480 --> 00:03:19,800 Sometimes you can be supply constrained, meaning there's too 58 00:03:19,800 --> 00:03:22,880 much supply. And then other times there can 59 00:03:22,880 --> 00:03:25,320 be a demand restraint where there's too much demand. 60 00:03:25,520 --> 00:03:27,840 It's better to be in the demand constrained. 61 00:03:27,840 --> 00:03:30,320 In my opinion, it's always better to have more demand 62 00:03:30,600 --> 00:03:33,520 because then you can get optimal pricing, OK? 63 00:03:33,520 --> 00:03:36,880 You can increase your privacy value if there's more demand 64 00:03:37,120 --> 00:03:39,360 than you can fill, which means there's more people wanting 65 00:03:39,360 --> 00:03:40,920 appointments than you can give them appointments. 66 00:03:41,080 --> 00:03:45,040 Okay so the way we've done that is with the three, we have 4 67 00:03:45,040 --> 00:03:47,440 doctors in our practice, 3 doctors are very full every 68 00:03:47,440 --> 00:03:52,160 single day, okay and the overflow goes to the newer Dr. 69 00:03:52,160 --> 00:03:56,440 that's not as filled. That's how we do it and that's 70 00:03:56,440 --> 00:04:00,560 why I've made recently this urgent care page to help kind of 71 00:04:00,560 --> 00:04:03,200 fill up his schedule and it does fill up our schedule a little 72 00:04:03,200 --> 00:04:04,520 bit. OK, So I want to I want to 73 00:04:04,520 --> 00:04:07,320 clarify. So once you have more demand 74 00:04:07,480 --> 00:04:11,000 than you can treat, then you can move to phase two. 75 00:04:11,520 --> 00:04:14,880 Until you have more demand than you can treat, you are going to 76 00:04:14,880 --> 00:04:19,760 see as many patients and see them back as often as allowable 77 00:04:19,800 --> 00:04:23,200 and profitable and, you know, feasible. 78 00:04:23,200 --> 00:04:25,720 So what do I mean by that? So until you have too much 79 00:04:25,720 --> 00:04:28,960 demand, you're going to probably see your perinicias at 2 weeks 80 00:04:28,960 --> 00:04:32,000 and at 4 weeks you're going to see a follow up maybe or just 81 00:04:32,200 --> 00:04:33,760 two weeks. You're going to see your 82 00:04:33,760 --> 00:04:36,520 matrixectomies at 2 weeks and four weeks you're going to see 83 00:04:36,880 --> 00:04:39,880 your fractures. You can see them every two, two 84 00:04:39,880 --> 00:04:42,080 weeks. You're going to, you know, all 85 00:04:42,080 --> 00:04:45,680 these types of things you're going to do because you don't 86 00:04:45,680 --> 00:04:49,600 have enough demand, you're going to try to fill with office 87 00:04:49,600 --> 00:04:52,280 visits and procedures and, and things like that. 88 00:04:52,400 --> 00:04:57,000 So once, once you get, once your, your schedule is totally 89 00:04:57,000 --> 00:05:01,200 filled and you have more demand, then and only then are you going 90 00:05:01,200 --> 00:05:03,320 to start to optimize. And this is what that other 91 00:05:03,320 --> 00:05:05,680 doctor was asking me. He was asking me, well, how is 92 00:05:05,680 --> 00:05:10,480 it that you can get to 80,000 or 120,000 per month in production? 93 00:05:10,520 --> 00:05:14,200 So because once you get the, once you have the demand there, 94 00:05:14,480 --> 00:05:16,200 then you can increase your profit. 95 00:05:16,200 --> 00:05:19,480 Now there's only a few ways, There's only a few big levers 96 00:05:20,000 --> 00:05:24,440 that we have legally as podiatrists to get more profit 97 00:05:24,440 --> 00:05:27,680 because I can't charge insurance. 98 00:05:27,760 --> 00:05:29,680 I can charge them as much as I want, but they're only going to 99 00:05:29,680 --> 00:05:31,880 pay so much, right? So I'm kind of capped with 100 00:05:31,880 --> 00:05:36,280 insurance. I can only, you know, see so 101 00:05:36,280 --> 00:05:39,840 many patients without reducing the quality of my visits. 102 00:05:39,840 --> 00:05:44,400 That's why I, I cap it at 3 and maybe there's some quick 103 00:05:44,400 --> 00:05:47,600 follow-ups for add-ons. OK, which I, which I talk about 104 00:05:48,800 --> 00:05:51,200 and I, and So what are some of the ways that you can then 105 00:05:51,280 --> 00:05:55,400 produce more revenue? So let's let's go into this. 106 00:05:55,400 --> 00:05:57,680 This, this doctor asked me this and that's why I want to, I want 107 00:05:57,680 --> 00:06:00,400 to clarify. So once you once you're fully, 108 00:06:00,640 --> 00:06:04,360 once you have a filled demand schedule, why still aren't you 109 00:06:04,360 --> 00:06:07,800 producing the $1,000,000 mark? It's usually because it's low 110 00:06:07,800 --> 00:06:12,520 value patients, OK. And I'm not saying the value of 111 00:06:12,520 --> 00:06:15,160 a human being, OK, all people have value. 112 00:06:15,160 --> 00:06:18,600 And I, I, I like seeing patients, but you also have a 113 00:06:18,600 --> 00:06:21,800 business to run, you have children to feed and things like 114 00:06:21,800 --> 00:06:24,320 that. So low, low reimbursement 115 00:06:24,400 --> 00:06:26,360 patients. So what do we do for low 116 00:06:26,360 --> 00:06:30,920 reimbursement patients? We either spread the time out 117 00:06:31,480 --> 00:06:35,760 between we see when we see them or we don't see them back, or we 118 00:06:35,760 --> 00:06:37,920 put them all together so we can make it a little bit more 119 00:06:37,920 --> 00:06:39,720 profitable. Those are the ways that we can 120 00:06:39,720 --> 00:06:41,360 do it. So give me an give me an 121 00:06:41,360 --> 00:06:43,840 example. Most paranicias are fine. 122 00:06:44,400 --> 00:06:47,480 I give them nice instructions afterwards and most I don't need 123 00:06:47,480 --> 00:06:49,160 to see back so I don't see them back. 124 00:06:49,360 --> 00:06:53,400 Before I had all the demand I would see them back OK in two 125 00:06:53,400 --> 00:06:57,560 weeks. Second thing I major exectomies 126 00:06:57,560 --> 00:07:00,080 I used to see at 2 weeks and four weeks OK. 127 00:07:00,080 --> 00:07:02,680 It was a low level visit. I wanted to reduce that. 128 00:07:02,680 --> 00:07:04,280 Now I see them once at three weeks. 129 00:07:04,280 --> 00:07:07,320 That's rationale and not that I, you know, I like the patients, 130 00:07:07,320 --> 00:07:09,080 it's just I think 1 is necessary. 131 00:07:09,080 --> 00:07:11,920 I even know some doctors that don't, don't see them back at 132 00:07:11,920 --> 00:07:13,720 all. OK, that's a, that's a kind of a 133 00:07:13,720 --> 00:07:16,440 doctor preference. So that's another example. 134 00:07:16,760 --> 00:07:19,640 The third example, which I think is the most elegant one that 135 00:07:19,680 --> 00:07:22,360 really this isn't mine. I, I learned this at the a APPM. 136 00:07:22,360 --> 00:07:24,520 Actually, we were doing it at about the same time as the A 137 00:07:24,520 --> 00:07:26,200 APPM. There's a lecture on this. 138 00:07:26,320 --> 00:07:29,960 So we had implemented it and there was another doctor from 139 00:07:29,960 --> 00:07:32,840 Chicago that implemented it and, and we found the same benefit. 140 00:07:33,240 --> 00:07:37,200 And that was to, to put all of our patients in a, a block of 141 00:07:37,200 --> 00:07:40,800 time to make it more effective for our routine care patients. 142 00:07:40,800 --> 00:07:44,120 So all diabetics, all nail care patients, those tend to 143 00:07:44,120 --> 00:07:47,840 reimburse a little bit less than other patients. 144 00:07:48,200 --> 00:07:51,120 You know, you try to optimize it by doing diabetic foot exams 145 00:07:51,120 --> 00:07:54,440 once a year. You can do diabetic shoes. 146 00:07:54,440 --> 00:07:58,640 If you do that, you can do Padnet and, and things like 147 00:07:58,640 --> 00:08:01,080 that. You can optimize it, but they 148 00:08:01,080 --> 00:08:03,240 tend to still glut your schedule in my opinion. 149 00:08:03,240 --> 00:08:06,120 And that's not the type of patient practice we want. 150 00:08:06,760 --> 00:08:09,520 And So what we ended up doing is each doctor has 1/2 day. 151 00:08:09,520 --> 00:08:12,520 My half day is on Fridays. There's one of my other 152 00:08:12,520 --> 00:08:15,680 colleagues does it on Thursday and another one does it on 153 00:08:15,680 --> 00:08:18,200 Tuesday. So we each have these half days 154 00:08:18,200 --> 00:08:21,880 where all we see is the routine patients that's being seen by 155 00:08:22,360 --> 00:08:25,040 our nail tech. One of them has the nail tech 156 00:08:25,040 --> 00:08:27,680 see all the nails and he does just other, another patient 157 00:08:27,680 --> 00:08:30,080 schedule. Another one does similar thing. 158 00:08:30,080 --> 00:08:33,320 And then I do routine and I have my staff do routine. 159 00:08:33,320 --> 00:08:36,320 Mine are all double booked. So it's a it's a busy day, but 160 00:08:36,320 --> 00:08:38,360 it's a way that we can make it most beneficial. 161 00:08:38,760 --> 00:08:41,320 And then we really say no any other time. 162 00:08:41,320 --> 00:08:44,760 So we restrict our access. But what would happen if someone 163 00:08:44,760 --> 00:08:47,600 can't see me Friday morning? Well, then they have to see one 164 00:08:47,600 --> 00:08:49,720 of the other doctors or they have to see my nail tech. 165 00:08:50,080 --> 00:08:51,720 Oh, but but what happens if they want to see? 166 00:08:52,040 --> 00:08:53,680 There's no option. That's just the way that we do 167 00:08:53,680 --> 00:08:55,560 it. OK, So you have a lot of these 168 00:08:55,560 --> 00:09:01,880 questions and if you set up barriers or bumpers, the the 169 00:09:01,880 --> 00:09:03,960 patients aren't going to flow into that. 170 00:09:04,160 --> 00:09:06,400 And that was the same thing we we did initially when we were 171 00:09:06,400 --> 00:09:08,240 learning shockwave. I used to put all my shockwave 172 00:09:08,240 --> 00:09:10,160 at a certain time so I could get practice. 173 00:09:10,160 --> 00:09:12,120 Same thing with ultrasound. I did all my ultrasound at the 174 00:09:12,120 --> 00:09:13,880 same time so I could get faster at it. 175 00:09:14,160 --> 00:09:18,400 So I think there's a benefit to seeing a lot of similar patients 176 00:09:18,400 --> 00:09:20,400 on the same days. It just makes things a little 177 00:09:20,400 --> 00:09:23,160 bit easier. So I want to kind of clarify, 178 00:09:23,520 --> 00:09:27,000 clarify that so #1 would be then taking your low value patients, 179 00:09:27,360 --> 00:09:30,880 putting them all in one day, reducing the amount of time that 180 00:09:30,880 --> 00:09:33,040 you see them back or not see them back at all, OK. 181 00:09:33,040 --> 00:09:35,120 And another, I'll give you another example, let's say 182 00:09:35,120 --> 00:09:38,000 patients that you're going to make recommendations and they 183 00:09:38,000 --> 00:09:40,640 don't take your recommendations, OK? 184 00:09:40,640 --> 00:09:44,200 So those ones I, I don't see back or I see back at a really 185 00:09:44,200 --> 00:09:47,440 long interval because they're not, they're not taking my 186 00:09:47,440 --> 00:09:50,120 recommendations of what I recommend is best for them. 187 00:09:50,120 --> 00:09:51,480 So it's just another way to reduce those. 188 00:09:51,480 --> 00:09:55,080 OK, so #1 would be, would be doing that if I could do it over 189 00:09:55,080 --> 00:09:56,360 again. I have a full schedule. 190 00:09:56,360 --> 00:09:59,280 I would put all my routine and that for a lot of doctors, you 191 00:09:59,280 --> 00:10:00,720 might be scared. You'd be like, well, I've been 192 00:10:00,840 --> 00:10:02,880 putting those in my schedule all along. 193 00:10:04,080 --> 00:10:05,960 What am I going to do with all all that extra time? 194 00:10:05,960 --> 00:10:08,600 Well, then you're going to go back to here, have too much 195 00:10:08,600 --> 00:10:10,240 supply. So you have to get busier. 196 00:10:10,240 --> 00:10:12,560 Then you have to to fill to fill the schedule. 197 00:10:12,560 --> 00:10:14,720 Try the urgent care page. And then you have to work on 198 00:10:15,080 --> 00:10:16,920 building and getting more leads. OK. 199 00:10:16,920 --> 00:10:19,880 That's a whole marketing question beyond the scope of of 200 00:10:19,880 --> 00:10:21,360 this little, little podcast here. 201 00:10:21,800 --> 00:10:25,320 OK, So let's go now to the second thing that I do. 202 00:10:25,320 --> 00:10:28,440 So the first is to put everyone on the same day and reduce the 203 00:10:28,440 --> 00:10:32,040 low value patients. The second thing is to optimize 204 00:10:32,160 --> 00:10:35,800 all of the patients that I see. And I want to give you a couple 205 00:10:35,800 --> 00:10:39,120 examples of how I optimize. You can optimize durable medical 206 00:10:39,120 --> 00:10:42,480 equipment and then you can optimize different types of 207 00:10:42,480 --> 00:10:44,160 procedures. So let's first talk about 208 00:10:44,160 --> 00:10:48,240 durable medical equipment. So for drum medical, first of 209 00:10:48,240 --> 00:10:50,480 all, you have to offer drum medical equipment, OK? 210 00:10:50,800 --> 00:10:52,160 So if you don't, you have to do that. 211 00:10:52,160 --> 00:10:53,920 That's a no brainer. That's going to bring in a lot 212 00:10:53,920 --> 00:10:56,400 of revenue. You have to know to bill it, so 213 00:10:56,400 --> 00:10:58,720 you get paid and then you have to optimize it. 214 00:10:58,720 --> 00:11:02,160 So the main way I optimize it is every patient that has a 215 00:11:02,160 --> 00:11:04,680 fracture gets a Cam boot. That's pretty obvious. 216 00:11:05,320 --> 00:11:07,480 Every surgical patient gets a Cam boot. 217 00:11:08,560 --> 00:11:11,960 Every kind of ulcer patient is getting like a Cam boot or a 218 00:11:11,960 --> 00:11:14,240 surgical shoe. OK, these are just obvious 219 00:11:14,240 --> 00:11:16,520 things. Really bad tendonitis are going 220 00:11:16,520 --> 00:11:19,480 to get a boot. But the real, I think difference 221 00:11:19,480 --> 00:11:23,280 that that I, I, I've, I've learned is that every patient 222 00:11:23,280 --> 00:11:26,120 with Aquinas, which is mostly all of my plantar fasciitis, 223 00:11:26,120 --> 00:11:28,680 Achilles tendonitis patients are getting night splint. 224 00:11:29,280 --> 00:11:31,760 And if they have it on both sides, they get bilateral night 225 00:11:31,760 --> 00:11:34,280 splints and that's always covered by insurance. 226 00:11:35,040 --> 00:11:37,440 OK, Even bilateral are covered for patients. 227 00:11:37,720 --> 00:11:40,040 So instead of wearing it just three hours one day, they're 228 00:11:40,040 --> 00:11:42,080 going to wear on each side. So that's six hours. 229 00:11:42,080 --> 00:11:43,560 It's too much time. That's why I give them 230 00:11:43,560 --> 00:11:46,880 bilateral. So really optimizing your DME 231 00:11:46,880 --> 00:11:48,760 and you have to have a really good system. 232 00:11:48,760 --> 00:11:51,160 So let me explain this. I know this might not seem 233 00:11:51,160 --> 00:11:55,400 obvious, but if it is a hassle every time you do DME, you're 234 00:11:55,400 --> 00:11:57,720 not going to do it. If it's complex, you're not 235 00:11:57,720 --> 00:11:59,560 going to do it. Just like when I talk to people, 236 00:11:59,560 --> 00:12:02,080 patients about doing or doctors about doing biopsies, if 237 00:12:02,080 --> 00:12:05,400 biopsies aren't easy, you're not going to do them. 238 00:12:05,400 --> 00:12:09,080 You're, you know, So it's my process is I hit the little 239 00:12:09,080 --> 00:12:11,480 button I have in my treatment room, which calls my assistant. 240 00:12:11,480 --> 00:12:13,760 I said I need. Once you see a Lyda with Abby, 241 00:12:14,360 --> 00:12:18,000 they get that. I numb it up, have my, my 2mm 242 00:12:18,000 --> 00:12:19,720 punch biopsies right in the treatment room. 243 00:12:19,880 --> 00:12:22,040 They're sitting in the bottom drawer along with the little 244 00:12:22,120 --> 00:12:24,080 little containers, the liquid in there. 245 00:12:24,440 --> 00:12:27,000 And I do it and I put the patient's, there's always a post 246 00:12:27,000 --> 00:12:29,000 it note with the patient's name. I put the post it note there 247 00:12:29,320 --> 00:12:31,640 with the location I did it at. And my, my scribe does 248 00:12:31,640 --> 00:12:34,080 everything else in my note. So it takes me literally no 249 00:12:34,080 --> 00:12:35,520 time. Nail sample, same thing. 250 00:12:35,520 --> 00:12:37,320 Take a little nail sample and send it out. 251 00:12:37,320 --> 00:12:39,680 I don't consider a nail sample a biopsy, but I don't want to get 252 00:12:39,680 --> 00:12:41,200 off. Of course, it's just a nail 253 00:12:41,200 --> 00:12:43,760 sample, but it has to be really simple, really easy. 254 00:12:43,880 --> 00:12:47,920 So all DME has to be easy. So the, you know, I hit my 255 00:12:47,920 --> 00:12:50,120 little button, staff comes in and say they need a Cam boot. 256 00:12:50,280 --> 00:12:53,120 My staff many times they know this, they need a Cam boot. 257 00:12:53,120 --> 00:12:54,960 They're going to get what I call the Pelto specialist. 258 00:12:54,960 --> 00:12:57,000 So they're going to get night splint foam rollering and 259 00:12:57,000 --> 00:12:58,400 morning stretch. That's what I do for most 260 00:12:58,400 --> 00:13:02,360 patients with Aquinas. So this is the process that you 261 00:13:02,360 --> 00:13:04,600 can optimize your DME. OK. 262 00:13:04,600 --> 00:13:07,040 That's the second thing I would say is optimize your DME has to 263 00:13:07,040 --> 00:13:09,720 be a real easy, easy process. You have to have enough of the 264 00:13:09,720 --> 00:13:13,480 DME so you don't run out, OK? So that is going to take you up 265 00:13:13,480 --> 00:13:17,160 to the kind of the next level in production, OK? 266 00:13:17,520 --> 00:13:21,240 Next thing would be learning to optimize your procedures. 267 00:13:21,240 --> 00:13:24,720 So what I'm talking about in terms of, so let's talk about 268 00:13:24,720 --> 00:13:27,880 imaging, imaging and procedures. So imaging would be getting 269 00:13:27,880 --> 00:13:29,240 X-rays. So every single patient with 270 00:13:29,240 --> 00:13:32,320 foot pain gets X-rays. Every patient with once again, 271 00:13:32,320 --> 00:13:34,280 foot pain gets X-rays. My staff knows that. 272 00:13:34,280 --> 00:13:37,360 So what does that mean? Facing with a really bad callus? 273 00:13:37,360 --> 00:13:39,120 They're going to get an X-ray because there could be a Bony 274 00:13:39,120 --> 00:13:41,360 deformity underneath it that they're dealing with. 275 00:13:41,680 --> 00:13:43,600 So every, every patient gets X-rays. 276 00:13:43,600 --> 00:13:48,440 So I do a lot of X-rays for all Achilles and plantar fasciitis. 277 00:13:48,440 --> 00:13:50,480 They're getting 2 views of the foot and two of the heel. 278 00:13:51,120 --> 00:13:53,200 Otherwise there might be getting three of the foot or they might 279 00:13:53,200 --> 00:13:57,120 get a getting of the ankle. So a lot of X-rays, every 280 00:13:57,120 --> 00:14:01,680 patient that has other type of soft tissue issues, neuroma, 281 00:14:01,680 --> 00:14:04,280 Achilles, plantar fasciitis, things like that, they're all 282 00:14:04,280 --> 00:14:06,960 getting at some time. An ultrasound might be the first 283 00:14:06,960 --> 00:14:08,280 visit, might be the second visit. 284 00:14:08,680 --> 00:14:10,440 So they're all getting an ultrasound. 285 00:14:10,440 --> 00:14:14,200 And in my case, ultrasounds are not covered by insurance. 286 00:14:14,200 --> 00:14:15,840 So they're paying. And I, the way I explain it to 287 00:14:15,840 --> 00:14:18,040 patients, I say this is ultrasound. 288 00:14:18,040 --> 00:14:20,440 Insurance usually doesn't cover it unless you have Medicare. 289 00:14:21,160 --> 00:14:24,280 It costs $100 and it's as many ultrasounds as I want to get. 290 00:14:24,280 --> 00:14:27,120 So that means I can do 1 today, I can do one in a few months 291 00:14:27,120 --> 00:14:28,920 when I see you back so we can compare views. 292 00:14:29,480 --> 00:14:31,240 And I use that as an educational tool. 293 00:14:31,240 --> 00:14:32,560 Sometimes I'll do it on both sides. 294 00:14:32,560 --> 00:14:35,040 I don't charge them for both sides, but just to explain and 295 00:14:35,040 --> 00:14:37,400 show them how one area is damaged and the other isn't. 296 00:14:37,400 --> 00:14:40,400 So the you have to really optimize every patient. 297 00:14:40,400 --> 00:14:42,880 And this is something that highly has to do with your staff 298 00:14:42,960 --> 00:14:49,120 in terms of doing the, the views of the X-rays, knowing when you 299 00:14:49,120 --> 00:14:51,400 need DME and making the consents, if you do consents 300 00:14:51,760 --> 00:14:54,120 really easy. So that's, that's the imaging. 301 00:14:54,120 --> 00:14:57,360 So the other thing is doing procedures. 302 00:14:58,560 --> 00:15:02,280 I try to optimize for doing procedures in as many patients 303 00:15:02,280 --> 00:15:03,520 as I can. And I try to make it as 304 00:15:03,520 --> 00:15:06,760 efficient as possible. So I can do it most of the time 305 00:15:06,760 --> 00:15:08,600 the same day. So for example, patients come 306 00:15:08,600 --> 00:15:11,960 in, have an ingrown toenail, I'm going to do an Ind that day, 307 00:15:12,560 --> 00:15:16,000 chronic ingrown toenail, I'm going to do a matrixectomy that 308 00:15:16,000 --> 00:15:20,120 day, a flexible hammertoe with a kind of a pre ulcerative or an 309 00:15:20,120 --> 00:15:21,200 ulcer. I'm going to do a flexor 310 00:15:21,200 --> 00:15:25,120 tenotomy that day. All the procedures I have them 311 00:15:25,120 --> 00:15:27,520 do that same day. The only reason I would stage a 312 00:15:27,520 --> 00:15:29,560 procedure is if they have a really bad paronychia, I'm going 313 00:15:29,560 --> 00:15:32,400 to do maybe an I and D and then maybe in three or four weeks I'm 314 00:15:32,400 --> 00:15:35,080 going to do a matrix ectomy. OK, so I'm going to stage do one 315 00:15:35,080 --> 00:15:37,840 and then do the other. But most of the time I try to 316 00:15:37,840 --> 00:15:40,400 make it as efficient as possible to do all the procedures. 317 00:15:40,640 --> 00:15:42,960 The I guess The only exception would probably be like an 318 00:15:42,960 --> 00:15:48,000 exostectomy or I need Amis pack. So I'm I'm doing an MIS surgery, 319 00:15:48,160 --> 00:15:50,320 shaving down bone. I'm usually scheduling that just 320 00:15:50,320 --> 00:15:52,120 because patients don't want to do that the same day. 321 00:15:52,640 --> 00:15:56,920 But most of the the other other procedures I'm doing fracture 322 00:15:56,920 --> 00:16:00,200 care, which isn't really a procedure, but that has to be 323 00:16:00,200 --> 00:16:02,560 used when you think there's a fracture or there is a fracture 324 00:16:03,040 --> 00:16:05,080 doing that has a little bit longer global, but you have to 325 00:16:05,080 --> 00:16:06,520 know how to build that appropriately. 326 00:16:06,520 --> 00:16:09,720 And those I only see one time for the most part in four weeks 327 00:16:10,640 --> 00:16:12,320 and then I don't see them back after that. 328 00:16:12,400 --> 00:16:14,680 So that makes it more profitable because you get paid more 329 00:16:14,680 --> 00:16:17,960 upfront, but then there's less follow up care. 330 00:16:19,800 --> 00:16:21,640 Same thing. I, I don't really do much ulcer 331 00:16:21,640 --> 00:16:23,200 care. So I don't want to go in too 332 00:16:23,200 --> 00:16:25,280 much in depth, but you have to have a procedure to make it 333 00:16:27,080 --> 00:16:29,120 profitable. So I guess debridement and then 334 00:16:29,120 --> 00:16:33,240 I also have collagen, the Amera Amera X collagen, but I do not 335 00:16:33,240 --> 00:16:35,920 do a lot of ulcer care. I tend to refer them once they 336 00:16:35,920 --> 00:16:37,840 get too bad over to the wound care center. 337 00:16:37,840 --> 00:16:39,880 Just something that something that I really like a lot. 338 00:16:40,760 --> 00:16:43,120 So we talked about imaging, we talked about procedures. 339 00:16:43,600 --> 00:16:47,080 One of the procedures that is really big for me is doing 340 00:16:47,080 --> 00:16:48,720 shockwave just because I really believe it. 341 00:16:48,920 --> 00:16:52,720 I do not do that much cortisone. I do it once in a while if 342 00:16:52,720 --> 00:16:55,720 someone maybe they've had a cortisone for a plantar fascia 343 00:16:55,720 --> 00:16:59,080 or for an aroma or a first MPJ or for gout or something like 344 00:16:59,080 --> 00:17:01,000 that. So I do some cortisone, but I 345 00:17:01,000 --> 00:17:03,920 don't do a ton of cortisone. A couple of efficiencies that we 346 00:17:03,920 --> 00:17:06,319 do in our office just to make it once again more efficient was we 347 00:17:06,319 --> 00:17:10,760 have both anesthetics and cortisones pre drawn up and then 348 00:17:10,760 --> 00:17:12,720 they're disposed of at the end of every day. 349 00:17:12,720 --> 00:17:16,400 So we try not to leave them till the next day, but we do have 350 00:17:16,400 --> 00:17:19,200 them pre drawn up for the about the number of patients that 351 00:17:19,200 --> 00:17:21,400 we're going to need each day. That just saves US time having 352 00:17:21,400 --> 00:17:23,160 the staff or the doctor draw them up. 353 00:17:23,400 --> 00:17:25,599 So making it very, very efficient. 354 00:17:25,599 --> 00:17:27,800 So kind of getting me the cortisone or the injection them 355 00:17:27,800 --> 00:17:30,760 up and having, you know, staff prep everything else. 356 00:17:30,760 --> 00:17:35,160 So the, the, the procedures such as Shockwave, I tend to try to 357 00:17:35,160 --> 00:17:37,320 do that as well the same day. I'll, I'll, I'll say, hey, we'll 358 00:17:37,320 --> 00:17:39,760 see if we can try to fit you in. Sometimes it can be long though, 359 00:17:39,760 --> 00:17:42,440 because you're doing X-rays, you're doing an ultrasound and 360 00:17:42,440 --> 00:17:44,600 you might do Shockwave. So it might put you behind a 361 00:17:44,600 --> 00:17:46,680 little bit unless you have a very efficient system. 362 00:17:46,680 --> 00:17:49,320 Same thing with Swift. You can try to do that the same 363 00:17:49,320 --> 00:17:50,520 day. That's a little bit easier. 364 00:17:50,800 --> 00:17:53,400 The, the only challenge with both Shockwave and Swift, in my 365 00:17:53,400 --> 00:17:56,440 opinion, are that the machines are kind of room dependent. 366 00:17:56,440 --> 00:17:59,200 We don't have them on a like a swivel, a swivel trailer where 367 00:17:59,200 --> 00:18:00,400 we can move them from room to room. 368 00:18:00,400 --> 00:18:01,920 We have them in a, in a treatment room. 369 00:18:01,920 --> 00:18:04,200 So if you're in a different treatment room, our office is a 370 00:18:04,200 --> 00:18:06,920 little bit small, so it's harder for us to swift, a little bit 371 00:18:06,920 --> 00:18:08,880 easier to move to another treatment room. 372 00:18:09,600 --> 00:18:13,920 But those are things that really helped me increase the value of 373 00:18:13,920 --> 00:18:15,480 my treatments. Now some people ask me, well, 374 00:18:15,480 --> 00:18:19,040 how do you do so much shockwave? How do you do so much swift? 375 00:18:20,120 --> 00:18:25,280 I guess procedures a little bit easier to explain the, the way I 376 00:18:25,280 --> 00:18:27,280 do it is I use my treatment sheets. 377 00:18:27,280 --> 00:18:29,240 So if you don't have my treatment seats, shoot me an 378 00:18:29,240 --> 00:18:31,520 e-mail don@podiatrypracticemastery.com. 379 00:18:31,960 --> 00:18:33,440 I'll send you my link to my treatment sheets. 380 00:18:33,680 --> 00:18:35,880 Look at the one on wart, look at the one on plantar fascia, 381 00:18:35,880 --> 00:18:37,120 Achilles. Look at those. 382 00:18:37,480 --> 00:18:40,560 Basically it's a sheet that I, I put on a clipboard and I go 383 00:18:40,560 --> 00:18:43,160 through it with the patients and I say this is how I treat these 384 00:18:43,160 --> 00:18:45,640 things The, and it has the highlights of those treatments 385 00:18:46,000 --> 00:18:49,800 and it makes it very easy and it makes a very rational decision 386 00:18:49,800 --> 00:18:53,080 for them to do those treatments. So it's very easy. 387 00:18:53,560 --> 00:18:54,760 I haven't talked about orthotics. 388 00:18:54,760 --> 00:18:57,680 Orthotics are something that I'm always planting the seed with 389 00:18:57,680 --> 00:18:59,880 patients. It's on my treatment sheet and 390 00:18:59,880 --> 00:19:02,320 I'm always recommending it if it's appropriate for patients 391 00:19:02,320 --> 00:19:04,360 along with shoes along with UFOs and all these other 392 00:19:04,360 --> 00:19:06,960 recommendations. I do not sell UFOs, probably 393 00:19:06,960 --> 00:19:08,200 should. I think it would be a good 394 00:19:08,200 --> 00:19:11,120 revenue generator. I do have a many other products 395 00:19:11,120 --> 00:19:12,720 that I do sell. I haven't really talked about 396 00:19:13,040 --> 00:19:15,520 selling products. I think if you do products, you 397 00:19:15,520 --> 00:19:17,720 have to have protocols for those products. 398 00:19:17,720 --> 00:19:18,920 I think it makes it a lot easier. 399 00:19:18,920 --> 00:19:22,720 So for example, every Matrix gets an Amerigel kit, every 400 00:19:22,720 --> 00:19:25,880 plantar fasciitis and Achilles tendon gets a foam roller, a 401 00:19:25,880 --> 00:19:27,360 night splint and a morning stretch. 402 00:19:28,080 --> 00:19:32,400 Every patient that has calluses, fissures, IP KS are getting Cara 403 00:19:32,400 --> 00:19:36,880 cream with a pummy bar. Every patient that you go on and 404 00:19:36,880 --> 00:19:40,360 on and on and on. So don't have products that you 405 00:19:40,360 --> 00:19:44,000 don't have protocols for and treatment sheets for because it 406 00:19:44,000 --> 00:19:46,640 just makes it so much easier. You do the same thing every time 407 00:19:46,640 --> 00:19:48,720 you don't build a product. Just kind of sitting there. 408 00:19:49,520 --> 00:19:53,800 Every nail fungus gets my UV light and shoe spray and then 409 00:19:53,840 --> 00:19:56,920 usually the terbenafin or you know, some people do the 410 00:19:56,920 --> 00:19:58,520 Luneala. I tend to talk patients more out 411 00:19:58,520 --> 00:20:00,360 of Luneala than into it just because I don't have the 412 00:20:00,360 --> 00:20:02,000 greatest results. I know some other doctors, they 413 00:20:02,000 --> 00:20:05,800 have just fabulous results and I would love to be there. 414 00:20:05,800 --> 00:20:08,000 I I think if I could get patients better without. 415 00:20:08,640 --> 00:20:11,000 I'm doing the oral that would be great, but I haven't figured 416 00:20:11,000 --> 00:20:13,480 that quite out. So if you found a great way, let 417 00:20:13,480 --> 00:20:14,440 me know. OK. 418 00:20:15,600 --> 00:20:18,160 So we've kind of talked about a lot of the the high points. 419 00:20:18,200 --> 00:20:20,800 I haven't really talked much about surgical procedures. 420 00:20:20,800 --> 00:20:24,640 I don't do a lot of surgery and I do it maybe every two months, 421 00:20:24,640 --> 00:20:27,760 every three months and I do it reluctantly. 422 00:20:27,760 --> 00:20:31,200 I have a very good system of younger doctors that I can refer 423 00:20:31,200 --> 00:20:34,440 to and they, I think they're actually better than me and, 424 00:20:35,360 --> 00:20:36,840 and, and it doesn't Take Me Out of the office. 425 00:20:36,840 --> 00:20:38,640 The problem with surgery, it tends to Take Me Out of the 426 00:20:38,640 --> 00:20:40,400 office. I knew a doctor, I was talking 427 00:20:40,400 --> 00:20:43,440 to him and what he does is he does the first case in the 428 00:20:43,440 --> 00:20:46,120 morning, like from 7:00 to 8:00 and then he goes in to see his 429 00:20:46,120 --> 00:20:47,640 patient. So I think if, if to make it 430 00:20:47,640 --> 00:20:50,080 more efficient being like the first case at a surgical center 431 00:20:50,080 --> 00:20:53,240 would make sense. A full day of surgery. 432 00:20:53,880 --> 00:20:56,720 In my, in my experience, I have a harder time producing enough 433 00:20:56,720 --> 00:21:00,040 revenue to condone being out of the office 'cause I think I do 434 00:21:00,040 --> 00:21:05,200 much more in the office. So those are some of the, some 435 00:21:05,200 --> 00:21:08,800 of the ways to make it much more profitable and to get to the 436 00:21:08,800 --> 00:21:11,160 $1,000,000 mark. Once you have the, once you're, 437 00:21:12,360 --> 00:21:14,640 we have a lot of supply of patients. 438 00:21:14,640 --> 00:21:18,000 So then you can kind of whittle down, whittle down those 439 00:21:18,200 --> 00:21:21,520 patients and kind of see the more more profitable ones, see 440 00:21:21,520 --> 00:21:24,720 them more often, help them more in, in the treatment. 441 00:21:24,720 --> 00:21:27,480 And then there, there also is the aspect of efficiency. 442 00:21:27,480 --> 00:21:29,840 I'm a big efficiency person of buying my time back. 443 00:21:29,840 --> 00:21:32,000 There's a good book by that title, Buy Your Time Back. 444 00:21:32,720 --> 00:21:34,920 But I buy my time back with my scribe. 445 00:21:34,920 --> 00:21:38,280 So I, he does my notes for me. I sign off on the notes. 446 00:21:38,280 --> 00:21:40,240 So it makes me much more efficient, gives me much more 447 00:21:40,240 --> 00:21:43,160 FaceTime with the patients. You can do this similarly with, 448 00:21:43,160 --> 00:21:45,280 with protocols with your own medical assistant. 449 00:21:45,280 --> 00:21:50,200 But I think my scribe by far, he, he, he is what helped me go 450 00:21:50,200 --> 00:21:52,120 to the next level in terms of my production. 451 00:21:52,280 --> 00:21:56,280 So he, I don't have to spend that much time doing notes or 452 00:21:56,280 --> 00:21:58,240 very minimal every 3 or 4 patients. 453 00:21:58,240 --> 00:22:00,760 I'll do that. So if you guys found this 454 00:22:00,760 --> 00:22:03,320 beneficial, let me know, Shoot me an e-mail, 455 00:22:03,320 --> 00:22:08,200 don@podiatrypracticemastery.com. If you want to meet and say, 456 00:22:08,200 --> 00:22:10,560 hey, how can I implement these things, shoot me an e-mail. 457 00:22:10,880 --> 00:22:13,480 I'd love to help you. I do have a lot of resources on 458 00:22:13,480 --> 00:22:17,400 my blog, my website, Podiatry practice mastery. 459 00:22:17,400 --> 00:22:19,840 On the bottom there are a couple of things you might like. 460 00:22:20,000 --> 00:22:23,800 There is certainly my $1,000,000 blueprint kind of going through 461 00:22:23,800 --> 00:22:25,800 all of these things that I talked about today in more in 462 00:22:25,800 --> 00:22:28,480 depth little videos. There is an audit so you can 463 00:22:28,480 --> 00:22:31,120 kind of see how your practice is doing and we could meet up to 464 00:22:31,120 --> 00:22:32,520 talk. So it goes through kind of all 465 00:22:32,520 --> 00:22:35,920 these things I talk about and says, you know, they're kind of 466 00:22:35,920 --> 00:22:39,560 hard questions and you can do that audit there and you could 467 00:22:39,560 --> 00:22:42,640 set up a strategy call with me just to I have some availability 468 00:22:42,800 --> 00:22:44,720 during my lunch hours where I like to meet with people. 469 00:22:44,720 --> 00:22:46,480 I like to help. If I can help you in the half 470 00:22:46,480 --> 00:22:47,800 hour, I will. You tell me your problem. 471 00:22:47,800 --> 00:22:49,000 I'll do the best I can to help you. 472 00:22:49,600 --> 00:22:51,800 And then if you want more help, I'm I'm doing a six month 473 00:22:51,800 --> 00:22:54,760 challenge that's coming up soon where we're going to try to do 474 00:22:54,760 --> 00:22:57,200 these things that we've kind of talked about and implement 475 00:22:57,200 --> 00:22:59,240 these. I think a lot of times it's good 476 00:22:59,240 --> 00:23:02,120 to have ideas, but people have a hard time people me, me as well. 477 00:23:02,360 --> 00:23:06,080 We have a hard time implementing things without accountability 478 00:23:06,080 --> 00:23:08,520 because we are quote UN quote, too busy. 479 00:23:09,000 --> 00:23:11,920 OK, we're kind of busy all the time. 480 00:23:11,920 --> 00:23:14,600 So and, and I guess I want to talk about the last thing about 481 00:23:14,960 --> 00:23:18,320 like it's not so much getting to the $1,000,000 mark, but it's 482 00:23:18,320 --> 00:23:23,440 having a good life on the side. So I do not do any business on 483 00:23:23,440 --> 00:23:26,880 nights, on weekends, I'm not reading business on the 484 00:23:26,880 --> 00:23:28,680 weekends. I, I like to free myself 485 00:23:28,680 --> 00:23:32,240 completely from those things. So I think another key is you 486 00:23:32,240 --> 00:23:33,680 can't be stressed with your practice. 487 00:23:33,680 --> 00:23:36,880 It's not enough to to produce that amount and have no life. 488 00:23:36,880 --> 00:23:38,640 You have to have a life, You have to enjoy yourself. 489 00:23:38,640 --> 00:23:42,920 I think that is a, a key, a key aspect to profits aren't 490 00:23:42,920 --> 00:23:46,480 everything, but I think being busy is just being better, 491 00:23:46,480 --> 00:23:47,800 right? You can give better care. 492 00:23:47,800 --> 00:23:51,400 And I, I think the, the I'm, I'm better at caring for patients 493 00:23:51,400 --> 00:23:54,080 now than I was in the past. And a lot of it is because I've 494 00:23:54,080 --> 00:23:55,840 gotten better at treating those conditions. 495 00:23:55,960 --> 00:23:58,760 And most of the time it's with giving more resources and 496 00:23:58,760 --> 00:24:01,840 educating patients more with my treatment sheets and other types 497 00:24:01,840 --> 00:24:04,040 of things. To simplify something that would 498 00:24:04,040 --> 00:24:05,440 take me 20-30 minutes to explain. 499 00:24:05,440 --> 00:24:08,880 I have it in one video that's on my treatment sheet in AQR code 500 00:24:08,880 --> 00:24:11,120 or on a blog that goes to a blog post with a video. 501 00:24:11,120 --> 00:24:13,960 So it's just educating our patients and putting it all in 502 00:24:14,080 --> 00:24:17,880 places that's much more feasible for them and they understand the 503 00:24:17,880 --> 00:24:21,360 value of the of the treatments. OK, once again, I hope you guys 504 00:24:21,520 --> 00:24:23,160 enjoyed this. I'll talk to you tomorrow.