1 00:00:01,560 --> 00:00:05,360 What's the easiest way to do a skin biopsy in the office? 2 00:00:06,160 --> 00:00:09,520 I frequently talk to doctors and and they say really, I don't 3 00:00:09,520 --> 00:00:11,520 have any time and I practice to do biopsies. 4 00:00:11,520 --> 00:00:15,720 It's too kind of complex. I think the, the reason we don't 5 00:00:15,760 --> 00:00:18,800 do things in our office is because they're they're complex 6 00:00:19,880 --> 00:00:24,480 and there is no easy system. I'm a real big systems person. 7 00:00:24,480 --> 00:00:26,200 I think systems make things a lot easier. 8 00:00:26,200 --> 00:00:30,280 And I want to explain a little bit of my workflow for biopsies. 9 00:00:31,440 --> 00:00:33,840 I'm doing this in a couple of first couple of reasons. 10 00:00:33,840 --> 00:00:37,360 One is because I'm going to be doing a lecture at a upcoming 11 00:00:37,800 --> 00:00:41,840 APMA meeting or not APMA, but one of our like mass APMA 12 00:00:41,840 --> 00:00:46,880 meetings about biopsies. And I just hear that, like 13 00:00:47,360 --> 00:00:50,600 someone said, like with our Rep anyway, who looks at my biopsy 14 00:00:50,600 --> 00:00:53,080 because I do a lot more than others and I don't feel like I 15 00:00:53,080 --> 00:00:55,960 do a lot more. And I had one of the doctors in 16 00:00:55,960 --> 00:00:58,320 our office actually sent me a patient to do a biopsy on today. 17 00:00:58,320 --> 00:01:00,040 And I'm like, this seems so, so easy. 18 00:01:00,320 --> 00:01:03,440 So let me let me talk you through what what I do. 19 00:01:04,360 --> 00:01:06,320 So first of all would be like the room prep. 20 00:01:06,320 --> 00:01:11,600 So all of my rooms on the bottom drawer, they have like specimen 21 00:01:11,600 --> 00:01:16,400 bags and they have those little formaldehyde filled little 22 00:01:16,400 --> 00:01:17,680 containers. I don't know if it's saline or 23 00:01:17,680 --> 00:01:21,000 formaldehyde. I think it's, I think it's 24 00:01:21,000 --> 00:01:25,920 formaldehyde little containers. And then they have 2mm punch 25 00:01:25,920 --> 00:01:29,480 biopsies. So that's really it. 99% of the 26 00:01:29,480 --> 00:01:32,320 time that's what I'm using and my process. 27 00:01:32,320 --> 00:01:35,600 So for example, there was a patient that came in today that 28 00:01:35,600 --> 00:01:39,120 needed a biopsy and one of my colleagues sent sent them over 29 00:01:39,120 --> 00:01:41,200 for the biopsy. But even if they didn't, so the, 30 00:01:41,240 --> 00:01:43,760 the process is like if I see if someone needs a biopsy, I have a 31 00:01:43,760 --> 00:01:47,880 little button in my, in my room. So I click the button or I open 32 00:01:47,880 --> 00:01:49,400 the door and that triggers my staff. 33 00:01:49,400 --> 00:01:51,080 They come in and say I'm going to do a biopsy. 34 00:01:51,440 --> 00:01:55,080 And then what that triggers to my staff is that I need one CC 35 00:01:55,080 --> 00:01:59,800 of Lyta with EPI and I need a consent for a biopsy and that's 36 00:01:59,800 --> 00:02:02,520 about it. And they do them when they do 37 00:02:03,000 --> 00:02:08,639 the, the lidocaine first and then they do the consent second. 38 00:02:09,560 --> 00:02:13,520 The reason they do that is so I can do the lidocaine, have it 39 00:02:13,520 --> 00:02:15,360 numbed up, and then they come and get consent and then I can 40 00:02:15,360 --> 00:02:16,600 do it. I do it all when I'm sitting 41 00:02:16,600 --> 00:02:18,680 there. So literally it takes like 30 42 00:02:18,680 --> 00:02:21,160 seconds to numb them because I just do a little wheel 43 00:02:21,160 --> 00:02:25,800 underneath the lesion and then I take that 2mm punch. 44 00:02:25,800 --> 00:02:28,560 I do one punch and I'll take a little tissue number, cut that 45 00:02:28,560 --> 00:02:31,720 out, second punch, pull it out, put some gauze in a Band-Aid and 46 00:02:31,720 --> 00:02:33,760 I'm done. And then my staff, if they 47 00:02:33,760 --> 00:02:35,720 haven't got consent, they'll come in and get consent. 48 00:02:35,720 --> 00:02:42,640 So it's really the most concise way to do biopsies that I know 49 00:02:42,640 --> 00:02:45,720 of. And it literally takes me like 50 00:02:46,120 --> 00:02:49,360 10 seconds to say that to my staff, 10 seconds to numb them, 51 00:02:49,360 --> 00:02:51,760 and maybe 10 seconds to do the biopsy. 52 00:02:51,760 --> 00:02:53,000 So it really doesn't take that long. 53 00:02:53,000 --> 00:02:54,920 It doesn't really add anything. They don't have to come back. 54 00:02:55,240 --> 00:02:59,040 The only ones I would have them come back for would be like nail 55 00:02:59,040 --> 00:03:01,960 matrix biopsies. Those can be a little bit more 56 00:03:01,960 --> 00:03:04,080 time consuming and I like to plan those. 57 00:03:04,080 --> 00:03:06,800 But and also nail sample biopsies are really easy. 58 00:03:06,800 --> 00:03:09,000 I just take a little clipping of the distal nail. 59 00:03:09,560 --> 00:03:11,960 I don't call that a nail biopsy. I just call it like a nail 60 00:03:12,120 --> 00:03:15,320 pathology sample. When I do an actual biopsy, it's 61 00:03:15,320 --> 00:03:19,200 usually for like a Milano Nikki or something I'm concerned of in 62 00:03:19,200 --> 00:03:21,240 the toenail. So that's how I do it. 63 00:03:21,680 --> 00:03:23,640 I'd love to know what other people do or why you're not 64 00:03:23,640 --> 00:03:25,320 doing it. It's pretty easy to do as long 65 00:03:25,320 --> 00:03:26,840 as the staff knows what's going on. 66 00:03:26,960 --> 00:03:34,080 OK, so let's go into this day. This is a recording from a 67 00:03:34,080 --> 00:03:36,960 Tuesday in the office. First patient, 63 year old man, 68 00:03:36,960 --> 00:03:39,480 right plantar fasciitis. He's 50% better. 69 00:03:40,840 --> 00:03:44,440 I don't need to see him back because he is he is feeling 70 00:03:44,440 --> 00:03:47,680 better. So he's 50 or probably a little 71 00:03:47,720 --> 00:03:50,600 bit more. Next was a 62 year old female 72 00:03:50,680 --> 00:03:54,640 had right carry flex. She actually came in from a 73 00:03:54,640 --> 00:03:56,800 referral from one of my colleagues wanting carry flex, 74 00:03:57,160 --> 00:03:59,360 but actually I think she benefited from Onifix better. 75 00:03:59,360 --> 00:04:02,040 So carry flex by the way, is that fake toenail you put on 76 00:04:02,040 --> 00:04:04,960 that makes it look good? Onifix is for ingrown toenails. 77 00:04:05,240 --> 00:04:07,520 Now I'm using this a little bit off label I find with some 78 00:04:07,520 --> 00:04:12,240 patients with onycholytic nails. I trim back the nail and I apply 79 00:04:12,240 --> 00:04:15,840 it at the base. So I find that a lot of times 80 00:04:15,840 --> 00:04:18,320 nails get thicker because there's micro movement. 81 00:04:18,320 --> 00:04:21,640 So when they're oncolytic or detached, they they move more 82 00:04:21,640 --> 00:04:25,560 and then they get thicker to kind of mitigate that extra 83 00:04:25,560 --> 00:04:27,000 movement and to make it more stable. 84 00:04:27,000 --> 00:04:28,960 So I think by putting the Onifix, which is like this 85 00:04:28,960 --> 00:04:32,720 little resin that I put on the nail that like it's like a speed 86 00:04:32,720 --> 00:04:36,160 bump and I put that on there and then it's kind of stabilizes it 87 00:04:36,160 --> 00:04:40,160 as if it was a multiple layered nail that stabilizes it as it 88 00:04:40,160 --> 00:04:41,560 grows out. Sometimes it can help it to 89 00:04:41,560 --> 00:04:43,960 reattach, but this is actually one of the more challenging 90 00:04:43,960 --> 00:04:46,080 things that I treat, getting nails to reattach and I'm not 91 00:04:46,080 --> 00:04:49,680 that good at it, but I that sometimes works for some of my 92 00:04:49,680 --> 00:04:52,680 patients. OK, next patient was a 49 year 93 00:04:52,680 --> 00:04:54,360 old man. He had left plantar fasciitis 94 00:04:54,360 --> 00:04:56,920 with Aquinas. He got my Pelto special which is 95 00:04:56,920 --> 00:04:59,600 the night splint foam rolling in morning stretch and he also got 96 00:04:59,600 --> 00:05:03,080 Meloxicam and I'm going to see him back in four weeks for an 97 00:05:03,080 --> 00:05:04,600 ultrasound. Impossible shockwave. 98 00:05:05,280 --> 00:05:08,120 Next was a 56 year old female for bilateral foot pain. 99 00:05:09,240 --> 00:05:11,560 She this is kind of a challenging one. 100 00:05:11,560 --> 00:05:15,920 She has these weird pains and she requested PT today and 101 00:05:15,920 --> 00:05:19,320 requested disability and I don't do a lot of disability like 102 00:05:19,320 --> 00:05:22,000 short term disability. But she had to come back again 103 00:05:22,000 --> 00:05:24,880 today requested that and I gave her PT So I'm going to see her 104 00:05:24,880 --> 00:05:29,520 back after two months. Next was a 59 year old female 105 00:05:29,520 --> 00:05:32,840 for left foot fracture. She has pain that continues so I 106 00:05:32,840 --> 00:05:36,320 ordered an MRI after having her in a Cam boot. 107 00:05:36,320 --> 00:05:37,640 So I'm going to see her back after the MRI. 108 00:05:37,640 --> 00:05:41,440 Next was a 62 year old male for a diabetic foot exam. 109 00:05:41,800 --> 00:05:44,680 I did that that was a those really tend to be lower Level 3 110 00:05:44,680 --> 00:05:46,160 visits and I'm going to see him back in one year. 111 00:05:46,600 --> 00:05:50,000 Next was a 60 year old female for right second Med head pain. 112 00:05:50,960 --> 00:05:55,760 She got meloxicam and if it's not better at the next visit, so 113 00:05:55,760 --> 00:05:58,360 possible like capsulitis, I'm going to see her back. 114 00:05:58,720 --> 00:06:01,600 She's going to do contrast baths, meloxicam in different 115 00:06:01,600 --> 00:06:04,320 shoes. I'm going to see her back if it 116 00:06:04,600 --> 00:06:06,680 if it's not if it's hurting continues to hurt, I'm going to 117 00:06:06,680 --> 00:06:08,600 get an ultrasound but I did not make a follow up for her. 118 00:06:09,240 --> 00:06:13,600 Next was a 77 year old man had a right lateral hallux avulsion 119 00:06:14,440 --> 00:06:17,400 and, and he also wanted nail care and I'm not going to 120 00:06:17,400 --> 00:06:19,920 actually, he wanted to be back for three months for, for nail 121 00:06:19,920 --> 00:06:21,520 care. So I'm going to be him back in 122 00:06:21,520 --> 00:06:23,520 my nail care time Friday mornings. 123 00:06:24,000 --> 00:06:28,600 Next was a 53 year old man for a left lateral foot biopsy. 124 00:06:28,600 --> 00:06:31,040 That's the one I just talked about or for one of my 125 00:06:31,040 --> 00:06:34,200 colleagues here. Next was a 80 year old female 126 00:06:34,200 --> 00:06:38,000 for this was kind of a, this is a good patient. 127 00:06:38,000 --> 00:06:40,320 So she had right midfoot arthritis. 128 00:06:40,320 --> 00:06:47,600 I got X-ray, I got ultrasound, I did a ultrasound guided 129 00:06:47,600 --> 00:06:52,920 cortisone injection to two of her joints, the second MC joint 130 00:06:53,240 --> 00:06:54,920 and then avicular cuneiform joint. 131 00:06:55,760 --> 00:06:58,840 And then I talked to her about gapped lacing and I scanned her 132 00:06:58,840 --> 00:07:03,480 for orthotics and I talked to her potentially in the future to 133 00:07:03,480 --> 00:07:05,360 do shockwave for the bone marrow oedema. 134 00:07:05,360 --> 00:07:07,960 Once again, doesn't help with the arthritis, but sometimes can 135 00:07:07,960 --> 00:07:10,960 help mitigate the symptoms if the orthotics aren't sufficient. 136 00:07:10,960 --> 00:07:12,240 I'm going to see her back in two months. 137 00:07:13,600 --> 00:07:15,000 So that was a good patient because of the orthotics. 138 00:07:15,000 --> 00:07:18,880 Next patient was an MRI 68 year old female MRI follow up for 139 00:07:18,880 --> 00:07:21,360 plantar fasciitis. She had a lot of things that are 140 00:07:21,360 --> 00:07:24,320 MRI reviewed that. Now one little tip, this is what 141 00:07:24,320 --> 00:07:27,000 I tend to do. I tend to review X-rays before I 142 00:07:27,000 --> 00:07:30,280 see the patient. I review MRI's before I see the 143 00:07:30,280 --> 00:07:33,760 patient and I don't always show them the X-rays or the MRI's. 144 00:07:34,080 --> 00:07:36,120 Sometimes they do, but a lot of times the patients don't know 145 00:07:36,120 --> 00:07:38,280 what I'm looking at and they don't understand and they get 146 00:07:38,280 --> 00:07:41,200 confused and it'll ask me what those two little dots are 147 00:07:41,200 --> 00:07:42,920 underneath the big toe, the sesmoids. 148 00:07:43,560 --> 00:07:48,080 And so but for this one I did go over the report a little bit and 149 00:07:48,080 --> 00:07:51,560 I gave her as well a couple of injections because of the 150 00:07:51,560 --> 00:07:55,200 midfoot arthritis she had. She also had a midfoot arthritic 151 00:07:55,200 --> 00:07:58,840 joint and I did 2 Cortisones and due to the pain and the 152 00:07:58,840 --> 00:08:00,440 arthritis I put her in a Cam boot. 153 00:08:00,680 --> 00:08:02,800 So I did some DME for her. I'm going to see her in one 154 00:08:02,800 --> 00:08:05,600 month. Next was a 53 year old man for 155 00:08:05,600 --> 00:08:08,760 left Hallux Limidus. I talked to him mostly about 156 00:08:08,760 --> 00:08:10,920 shoe gear because I think it was more of a shoe issue that was 157 00:08:11,840 --> 00:08:13,920 irritating him. I'm not going to see him back. 158 00:08:14,280 --> 00:08:17,480 Got X-rays and things like that. Next was a this was an MVP 159 00:08:17,480 --> 00:08:19,280 patient. So let me tell you about this. 160 00:08:20,280 --> 00:08:22,560 This was a Medicare patient that has mass health. 161 00:08:22,560 --> 00:08:25,360 So these ones, they Medicare pays 80% mass health. 162 00:08:25,680 --> 00:08:28,680 The patient opts to pay for 20% because we don't take mass 163 00:08:28,680 --> 00:08:32,240 health, which is like Medicaid bilateral foot pain, bilateral 164 00:08:32,240 --> 00:08:34,000 plantar fasciitis, bilateral aquinus. 165 00:08:34,000 --> 00:08:39,400 So they got foam rolling night splints bilaterally and then a 166 00:08:39,400 --> 00:08:44,520 morning stretch. And this patient we talked about 167 00:08:44,520 --> 00:08:48,400 doing either cortisone or shockwave if they're not better 168 00:08:48,400 --> 00:08:50,960 in about four weeks. So it was good because of the 169 00:08:50,960 --> 00:08:54,400 bilateral night splints. Now I frequently do. 170 00:08:54,440 --> 00:08:57,040 If they have bilateral symptoms, I'll do bilateral night splints. 171 00:08:57,560 --> 00:09:00,320 In the past what I used to do is I say OK, we're at one night one 172 00:09:00,320 --> 00:09:03,160 side, one night the other side. But I have no issues with 173 00:09:03,160 --> 00:09:06,040 insurance covering 2 of them so I tend to get them too. 174 00:09:06,920 --> 00:09:11,440 Next patient was a 46 year old with bilateral Achilles 175 00:09:11,440 --> 00:09:14,160 tendonitis. So I did bilateral shockwave #3 176 00:09:14,160 --> 00:09:17,320 out of 6. She was really kind of concerned 177 00:09:17,320 --> 00:09:19,800 so I had to spend a lot of time just calming her down. 178 00:09:19,800 --> 00:09:22,720 I think insertional Achilles tendonitis is one of the more 179 00:09:22,720 --> 00:09:25,200 challenging things I treat with shockwave, but she tolerated it 180 00:09:25,200 --> 00:09:27,680 well and she is seeing some progress. 181 00:09:27,960 --> 00:09:32,640 Next was a 40 year old man for a right matrixectomy on the 182 00:09:32,640 --> 00:09:36,320 lateral side and she he also did the kit. 183 00:09:36,320 --> 00:09:40,760 So one thing I've learned for a couple of things, I can depend 184 00:09:40,760 --> 00:09:44,160 on my staff and I think they do a good job at explaining like 185 00:09:44,240 --> 00:09:46,720 why they need an even up with their with every single walking 186 00:09:46,720 --> 00:09:47,800 boot. Like the even up is that thing 187 00:09:47,800 --> 00:09:50,440 that you strap on the shoe. So that adds an additional $30 188 00:09:51,000 --> 00:09:52,960 or why they need the Amerigel kit. 189 00:09:53,000 --> 00:09:56,120 Every time I do a matrixectomy that's adds another like $60.00. 190 00:09:56,680 --> 00:10:00,000 So, but I find that if I present it to the patients and then hand 191 00:10:00,000 --> 00:10:02,200 it off to the staff just to fulfill it, it works a lot 192 00:10:02,200 --> 00:10:05,640 better than them coming in and having to explain it. 193 00:10:06,400 --> 00:10:09,240 I find a lot of times the, the staff have a challenge with 194 00:10:09,240 --> 00:10:11,400 doing that. So I find helping it helps them 195 00:10:11,400 --> 00:10:14,400 if I prepare them, prepare this patient for that. 196 00:10:15,160 --> 00:10:18,280 Next was a 69 year old man. He had 4 swift treatments and 197 00:10:18,280 --> 00:10:21,320 here he's back for his three month follow up and he is 198 00:10:21,320 --> 00:10:23,840 feeling much better. And so I got a box of tips out 199 00:10:23,840 --> 00:10:27,640 of that one because I did a, a YouTube short for that patient. 200 00:10:28,480 --> 00:10:31,000 So just so you know, if you do swift and you do short videos 201 00:10:31,360 --> 00:10:34,520 and you send it to them, they will give you AI think a box of 202 00:10:34,520 --> 00:10:37,600 tips or at 1 tip or I don't know how much tips, but that's what 203 00:10:37,600 --> 00:10:41,840 they'll do next was a 18 year old man that had he had Down 204 00:10:41,840 --> 00:10:44,680 syndrome. So he had bilateral pest planus, 205 00:10:44,720 --> 00:10:47,520 posterior tibial tendon dysfunction, athlete's foot and 206 00:10:47,520 --> 00:10:51,400 nail fungus. So he got, I sent him to hanger 207 00:10:51,680 --> 00:10:56,760 because once again he has Medicaid and no I'm sorry, Blue 208 00:10:56,760 --> 00:10:59,360 Cross and I can't do AFOS. So he's going to get bilateral 209 00:10:59,360 --> 00:11:03,200 wishy braces from hanger. Unfortunately I can't do those. 210 00:11:03,840 --> 00:11:07,240 And then he's going to get the Pelto special for fungus, which 211 00:11:07,240 --> 00:11:11,720 is he's going to get tribenafin and he is going to get LFTS. 212 00:11:11,720 --> 00:11:14,720 He's going to get the UV light and shoe spray and the biotin. 213 00:11:15,240 --> 00:11:19,120 OK next patient was a 75 year old female for right ankle 214 00:11:19,480 --> 00:11:21,680 sprain. Follow up her sprain was feeling 215 00:11:21,680 --> 00:11:23,640 better. She had a ATFL issue and now she 216 00:11:23,640 --> 00:11:24,880 had some pain in the sinus tarsi. 217 00:11:24,880 --> 00:11:27,840 So I did a cortisone injection in sinus tarsi and this was all 218 00:11:27,840 --> 00:11:30,280 after her PT. She's going to transition down 219 00:11:30,280 --> 00:11:33,120 from the ankle brace into more of like a neoprene base and then 220 00:11:33,120 --> 00:11:37,240 she'll follow up as needed. She originally had an ankle 221 00:11:37,240 --> 00:11:41,480 brace dispensed. 39 year old female next for wart that had 222 00:11:41,480 --> 00:11:44,200 kanthridin. She's on #4 I think of this 223 00:11:44,200 --> 00:11:47,320 kanthridin treatment. Next was a 41 year old female 224 00:11:47,320 --> 00:11:53,520 for left second met fracture. This was another MVP because she 225 00:11:53,520 --> 00:11:57,640 had a second met fracture. I gave her meloxicam like I do 226 00:11:57,640 --> 00:12:00,560 for most patients. I dispensed a Cam boot and I 227 00:12:00,560 --> 00:12:02,280 used fracture care for this patient. 228 00:12:02,280 --> 00:12:04,680 So a fracture care, yes, there's a 90 D global, but I'm going to 229 00:12:04,680 --> 00:12:07,360 see her back in four weeks and hopefully that'll be it for the 230 00:12:07,360 --> 00:12:10,240 follow up. Next was a 48 year old man for 231 00:12:10,240 --> 00:12:15,640 right shockwave #4 out of 6 he has on the MRI he had some bone 232 00:12:15,640 --> 00:12:22,560 marrow edema around the subtalar joint region and I did a focused 233 00:12:22,560 --> 00:12:26,880 shockwave there and then the radial shockwave on the 234 00:12:26,880 --> 00:12:28,520 peroneals. And then the last patient of the 235 00:12:28,520 --> 00:12:32,560 day was a 61 year old man. His Now this is a, this is a 236 00:12:32,560 --> 00:12:34,760 challenging 1. He got new orthotics. 237 00:12:34,760 --> 00:12:37,560 He had done well with his old orthotics for nine years and 238 00:12:37,560 --> 00:12:41,040 developed plantar fasciitis again and I got him the 239 00:12:41,040 --> 00:12:42,720 orthotics. I did bilateral cortisone 240 00:12:42,720 --> 00:12:44,680 injections because he's a butcher and he owns his own 241 00:12:44,680 --> 00:12:46,840 butcher shop so he can't take time off of work. 242 00:12:47,600 --> 00:12:51,880 He didn't have much improvement with the with the cortisone 243 00:12:51,880 --> 00:12:54,200 injections and I was a little paranoid because when I saw him, 244 00:12:54,840 --> 00:12:57,120 he wasn't getting better. And I always get a little 245 00:12:57,120 --> 00:12:59,320 concerned when they when they get new orthotics. 246 00:12:59,320 --> 00:13:01,080 And I was like, yeah, I use the same company. 247 00:13:01,560 --> 00:13:03,680 And so usually I use forward motion. 248 00:13:03,680 --> 00:13:06,000 And then, but in this case, he previously had Northwest. 249 00:13:06,000 --> 00:13:08,520 So I ordered NW orthotics just to make him just like the other 250 00:13:08,520 --> 00:13:10,320 ones. And then it kind of dawned upon 251 00:13:10,320 --> 00:13:12,640 me and this is a kind of mistake I made a lot in the past. 252 00:13:12,640 --> 00:13:14,080 So I want to, I want to share this with everyone. 253 00:13:16,040 --> 00:13:19,560 Patients, if they get orthotics too soon when they have plantar 254 00:13:19,560 --> 00:13:21,960 fasciitis, the orthotics don't feel good. 255 00:13:22,640 --> 00:13:24,120 And I know this is kind of obvious. 256 00:13:24,120 --> 00:13:26,880 That's why when I see a patient for plantar fasciitis, I don't 257 00:13:26,880 --> 00:13:28,280 tend to scan them the first visit. 258 00:13:28,280 --> 00:13:29,760 I do it when I'm doing shockwave. 259 00:13:29,760 --> 00:13:31,880 I'll do it the third visit because hopefully by the time 260 00:13:31,880 --> 00:13:34,000 they come in at the 6th week where they get in the 6th 261 00:13:34,000 --> 00:13:35,480 shockwave, they'll start. They're actually already 262 00:13:35,480 --> 00:13:38,080 starting to feel better because if you have plantar fasciitis, 263 00:13:38,080 --> 00:13:41,280 nothing is going to feel good. Like no orthotic, in my opinion, 264 00:13:41,280 --> 00:13:43,320 is going to really feel good. It doesn't do a great job at 265 00:13:43,680 --> 00:13:46,160 taking down the pain. It does a really good job at 266 00:13:46,320 --> 00:13:49,200 kind of offloading the fascia to help it prevent it from coming 267 00:13:49,200 --> 00:13:51,680 back. So for him, I said, hey, you 268 00:13:51,680 --> 00:13:55,160 know, you're going to, you're going to, you know, I would, you 269 00:13:55,160 --> 00:13:57,040 know, it's nine years after you had it. 270 00:13:57,040 --> 00:13:59,920 Before he had thickening of the fascia, I gave him options of 271 00:13:59,920 --> 00:14:02,320 doing cortisone injections. This would be cortisone #2 on 272 00:14:02,320 --> 00:14:05,040 bilateral heels, or you could do Shockwave. 273 00:14:05,200 --> 00:14:09,520 And I said, you know, with the thickness of the fascia, I 274 00:14:09,520 --> 00:14:11,200 really think shockwave would be the best. 275 00:14:11,200 --> 00:14:13,160 And so this is kind of a challenge, I think, for some 276 00:14:13,160 --> 00:14:16,240 people and for me actually, too. But let me explain how I do it. 277 00:14:17,040 --> 00:14:20,360 So, so bilateral shockwave for six sessions ends up for me to 278 00:14:20,360 --> 00:14:23,720 be about $3000. And that can be a big, a big, a 279 00:14:23,720 --> 00:14:28,800 big value, a big amount. And for him, I, I basically 280 00:14:28,800 --> 00:14:31,720 said, you know, I know it's hard for you to get here because of 281 00:14:31,720 --> 00:14:34,280 time. So I was willing to see him 282 00:14:34,280 --> 00:14:37,240 first patient so we could open up a store or even a little bit 283 00:14:37,240 --> 00:14:40,160 before first patient at 8:00 AM for the six visits. 284 00:14:40,600 --> 00:14:44,560 And then I also said, you know, it's for the six sessions, it's 285 00:14:44,560 --> 00:14:46,600 bilaterally. So usually for one side, it's 286 00:14:46,600 --> 00:14:49,560 2:50. So two sides is 500 per per 287 00:14:49,560 --> 00:14:53,960 session. So that's 3000 and, and, and he 288 00:14:53,960 --> 00:14:57,520 was aware and, and I, and I, and how I kind of explained, I said, 289 00:14:57,840 --> 00:14:59,720 you know, the 3000 isn't usually the problem. 290 00:14:59,720 --> 00:15:01,920 The problem is getting your butt here 6 times. 291 00:15:02,280 --> 00:15:04,520 And that's really true. I think for people that have a 292 00:15:04,520 --> 00:15:09,400 good job and that have their own business, it's not the 3000 293 00:15:09,880 --> 00:15:13,800 because there is, I always say the 2082 to 85% success rate, it 294 00:15:13,800 --> 00:15:15,640 speeds up the healing by 50%. That's how I explained 295 00:15:15,640 --> 00:15:17,520 Shockwave. It's more getting there six 296 00:15:17,520 --> 00:15:18,920 times. So I try to make it as easy as 297 00:15:18,920 --> 00:15:22,520 possible for him to get to get into the office. 298 00:15:23,360 --> 00:15:25,600 OK, so that was the day once again, I hope you guys found 299 00:15:25,600 --> 00:15:27,600 this beneficial. I am putting together a 300 00:15:27,600 --> 00:15:31,880 challenge, 6 month challenge for a group of doctors, a kind of a 301 00:15:31,880 --> 00:15:34,960 select group that want to help get their practice to the 302 00:15:34,960 --> 00:15:37,640 $1,000,000 mark. I want to be clear, this is 303 00:15:37,640 --> 00:15:40,120 going to be more for doctors. This has been thinking about 304 00:15:40,120 --> 00:15:44,240 this more for ones that are probably in the six or 700 realm 305 00:15:44,800 --> 00:15:46,320 wanting to get to the $1,000,000 mark. 306 00:15:46,320 --> 00:15:48,400 That's a little bit easier because if you're under that 307 00:15:48,400 --> 00:15:49,760 amount, you're probably not busy enough. 308 00:15:49,880 --> 00:15:53,720 Then if you're not busy enough, you might have a hard time 309 00:15:53,720 --> 00:15:56,200 paying for it. But also you just need to work 310 00:15:56,200 --> 00:15:59,040 more on marketing. As I've mentioned before, there 311 00:15:59,040 --> 00:16:02,080 is either a, some this isn't, this isn't my idea. 312 00:16:02,080 --> 00:16:04,920 I'm stealing this from Alex Harmozzi, but there's either a 313 00:16:04,920 --> 00:16:08,920 supply issue or a demand issue. And it's a lot easier to deal 314 00:16:08,920 --> 00:16:12,640 with a with a demand problem, I'm sorry, with a supply problem 315 00:16:12,640 --> 00:16:15,440 than a demand. So demand problem, meaning there 316 00:16:15,440 --> 00:16:18,240 is not enough demand and you have to really just if there's a 317 00:16:18,240 --> 00:16:20,440 demand problem in your practice and you're not busy enough and 318 00:16:20,440 --> 00:16:23,040 you have open slots, you have to do everything you can to fill 319 00:16:23,040 --> 00:16:24,600 those up and that you have to learn. 320 00:16:24,840 --> 00:16:28,120 So my favorite book for that is going to be $1,000,000 offers 321 00:16:28,120 --> 00:16:31,000 and $1,000,000 leads. OK, so $1,000,000 leads will 322 00:16:31,000 --> 00:16:32,720 help you to kind of fill that up. 323 00:16:32,960 --> 00:16:35,800 I do have information also my practice Mastery Academy about 324 00:16:35,800 --> 00:16:38,080 all of that. But then once you have the 325 00:16:38,080 --> 00:16:43,160 demand filled in your, all your slots are filled, then you then 326 00:16:43,160 --> 00:16:46,560 you have a supply problem, meaning you don't have enough 327 00:16:48,080 --> 00:16:52,800 supply, you have too much demand and not enough supply. 328 00:16:53,160 --> 00:16:54,960 And then what you do is you optimize. 329 00:16:54,960 --> 00:16:57,800 So that's where you have to do all these other things to make 330 00:16:57,800 --> 00:16:59,520 your, your practice more profitable. 331 00:16:59,520 --> 00:17:02,520 And that's where I think my sweet spot is, is helping you 332 00:17:02,560 --> 00:17:05,800 get your time back and doing it more profitable. 333 00:17:05,800 --> 00:17:09,160 So that's what we're going to talk about in this in this 334 00:17:09,160 --> 00:17:10,520 challenge. So if you're interested, go to 335 00:17:10,520 --> 00:17:14,800 podiatrypracticemastery.com/challenge or you can shoot me an e-mail. 336 00:17:14,800 --> 00:17:18,400 I'd love to share more about it. OK, Don at Podiatry practice 337 00:17:18,400 --> 00:17:20,000 mastery.com. Thanks. 338 00:17:20,400 --> 00:17:20,920 See you tomorrow.