1
00:00:00,960 --> 00:00:02,520
Hey guys down here. 
Welcome to Podiatry. 

2
00:00:02,520 --> 00:00:06,240
Rex Mastery kind of going over 
the I call the $1,000,000 

3
00:00:06,240 --> 00:00:07,440
minute. 
They said things to help to get 

4
00:00:07,440 --> 00:00:08,800
to the $1,000,000 mic and 
beyond. 

5
00:00:08,800 --> 00:00:12,200
This is a recording of a day in 
the clinic on a Tuesday. 

6
00:00:12,240 --> 00:00:15,720
So this is a full day. 
I'm in my my Worcester office. 

7
00:00:16,239 --> 00:00:19,400
So good, bad and ugly. 
First patient was a no show and 

8
00:00:19,400 --> 00:00:22,360
I had another patient 10:00 that
was a no show, but the other 

9
00:00:22,360 --> 00:00:25,280
ones kind of showed up. 
So let's go over. 

10
00:00:25,320 --> 00:00:28,960
First patient was a a Lamisil. 
Follow up 31 year old male got 

11
00:00:28,960 --> 00:00:31,240
my fungal nail kit and the 
Lamisil. 

12
00:00:31,240 --> 00:00:35,160
So one thing I've started to do,
if you've seen my treatment 

13
00:00:35,160 --> 00:00:39,040
sheet for for gibenophen, for 
Lamisil, it has like visit 1 

14
00:00:39,360 --> 00:00:41,880
nail sample. 
I'm not the way I'm kind of 

15
00:00:41,880 --> 00:00:44,240
explaining it now is I just 
crossed it off and I say, you 

16
00:00:44,240 --> 00:00:46,720
know, this could they could bill
your insurance a couple $100 for

17
00:00:46,720 --> 00:00:48,360
this nail sample. 
So I'm not going to do that. 

18
00:00:48,560 --> 00:00:50,280
I'll save you this money, save 
you the visit. 

19
00:00:50,720 --> 00:00:52,800
We'll start the treatment. 
If we see clearing, that's 

20
00:00:52,800 --> 00:00:54,200
great. 
If we're not seeing clearing, 

21
00:00:54,200 --> 00:00:56,400
we'll either take a sample or 
switch it to another medication.

22
00:00:56,400 --> 00:00:57,480
So that's kind of how I'm doing 
it. 

23
00:00:57,800 --> 00:01:00,000
And I have this all on my 11 
sheet that I give them. 

24
00:01:00,640 --> 00:01:03,960
And then I find like the key. 
And I was listening to a guy 

25
00:01:03,960 --> 00:01:07,360
that I really like, Alex Ramosi.
He talks a lot about marketing 

26
00:01:07,360 --> 00:01:10,080
and business. 
And one of the reasons we a lot 

27
00:01:10,080 --> 00:01:12,520
of, we don't have a system, if 
you don't have a system of how 

28
00:01:12,520 --> 00:01:15,240
to explain things to patients, 
you're not going to do as much 

29
00:01:15,240 --> 00:01:18,200
of the self pay or a lot, a lot 
of the procedures, you have to 

30
00:01:18,200 --> 00:01:20,120
have a system. 
So I find this paper really 

31
00:01:20,120 --> 00:01:22,240
gives me a system. 
It's all written down kind of 

32
00:01:22,240 --> 00:01:26,400
the process, the, the 
medication, the LFT and then all

33
00:01:26,400 --> 00:01:28,800
of the, the treatment, other 
things like the biotin, the 

34
00:01:28,800 --> 00:01:31,720
shoes app and the, and the shoe 
spray. 

35
00:01:31,720 --> 00:01:35,280
It's all in like a system. 
And so it's able to bring up the

36
00:01:35,280 --> 00:01:39,400
per visit value for my fungal 
nails higher than anyone else's.

37
00:01:39,440 --> 00:01:42,160
And, and so I think if you can 
do this, not just with your nail

38
00:01:42,160 --> 00:01:44,240
fungus, but if you can find a 
way to do this with, for 

39
00:01:44,240 --> 00:01:46,840
example, your plantar fasciitis,
your at least tendonitis, these 

40
00:01:46,840 --> 00:01:49,800
other things. 
I, I used to use presentations. 

41
00:01:49,800 --> 00:01:53,080
Now I like the paper a little 
bit better, either one that I 

42
00:01:53,080 --> 00:01:56,040
have in my pocket, my little 
prescription sheet that I use or

43
00:01:56,040 --> 00:01:58,560
the printed one. 
And if you have the system, you 

44
00:01:58,560 --> 00:02:01,960
have all of the like your, hey, 
this is how we do things here. 

45
00:02:02,280 --> 00:02:05,280
So you can do this with like 
plantar fasciitis, as I've 

46
00:02:05,280 --> 00:02:07,680
explained as well. 
And it just really delineates 

47
00:02:07,680 --> 00:02:10,479
the process and makes it easier 
and clearer for patients of what

48
00:02:10,479 --> 00:02:11,920
you're going to do. 
So that's why all my patients 

49
00:02:11,920 --> 00:02:13,720
get this fungal kit. 
My staff know what it is. 

50
00:02:14,640 --> 00:02:16,960
Sometimes they say no to it, but
for the most part it, it just 

51
00:02:16,960 --> 00:02:19,400
makes it a lot easier. 
So just just a recommendation 

52
00:02:19,400 --> 00:02:20,680
for you. 
If there's things that you're 

53
00:02:20,800 --> 00:02:24,160
you have that you're not doing 
that you believe in, it's 

54
00:02:24,160 --> 00:02:26,440
probably because you're too busy
and you don't have a system. 

55
00:02:27,240 --> 00:02:29,040
There are certain things that 
you have that you don't believe 

56
00:02:29,040 --> 00:02:30,040
in. 
So let me give you an example. 

57
00:02:30,040 --> 00:02:32,680
I have Formula 7 here. 
I don't really believe it that 

58
00:02:32,680 --> 00:02:34,480
works that well. 
So I don't have it in a system, 

59
00:02:34,520 --> 00:02:39,360
but I do have my my with the 
other things in there, like for 

60
00:02:39,360 --> 00:02:42,680
example, the foam roller and the
night splint and the and, and, 

61
00:02:43,640 --> 00:02:46,360
and the anatomic shoes. 
And these are kind of all in, in

62
00:02:46,360 --> 00:02:49,840
the, in the system of how ioffer
things to patients. 

63
00:02:49,840 --> 00:02:51,520
And this is how you can get the 
per visit value up. 

64
00:02:51,520 --> 00:02:53,640
Also orthotics and other types 
of things like that. 

65
00:02:53,640 --> 00:02:56,720
It's part of the the system of 
how we treat patients. 

66
00:02:57,600 --> 00:03:00,840
OK, enough on that blurb. 
Next patient was she has a 

67
00:03:00,840 --> 00:03:06,360
midfoot arthritis and she had a 
cortisone injection to a couple 

68
00:03:06,360 --> 00:03:07,720
of those joints. 
One thing we've learned with the

69
00:03:07,720 --> 00:03:11,160
new EMR is that with Mod Med, 
when you do an injection, you 

70
00:03:11,160 --> 00:03:14,000
have to, there's a kind of a 
screen that you can see body 

71
00:03:14,000 --> 00:03:15,600
parts like tendons, ligaments, 
joints. 

72
00:03:15,600 --> 00:03:17,440
So when you do a joint 
injection, you have to pick the 

73
00:03:17,440 --> 00:03:19,200
joint pitcher which you're 
selecting. 

74
00:03:19,200 --> 00:03:21,160
But she did 2 joints. 
And the nice thing with with 

75
00:03:21,160 --> 00:03:23,680
Modman anyway is it bills for 
both of those joints. 

76
00:03:23,680 --> 00:03:25,760
And I did it with ultrasound 
guidance and she felt better 

77
00:03:26,200 --> 00:03:27,960
afterward and she's going to 
come back as needed. 

78
00:03:28,720 --> 00:03:30,320
Next was a number six out of 
six. 

79
00:03:30,320 --> 00:03:33,360
This was a anterior calcaneal 
beak fracture that was not 

80
00:03:33,360 --> 00:03:35,000
healing for a few months in a 
Cam boot. 

81
00:03:35,160 --> 00:03:37,360
And we did 6 sessions of 
Shockwave. 

82
00:03:37,360 --> 00:03:39,520
I'm going to see her back in six
weeks to see how it's doing and 

83
00:03:39,520 --> 00:03:43,080
get an X-ray at that time. 
Next was this is a patient. 

84
00:03:43,400 --> 00:03:45,360
I've never had anyone that's 
done this many, but she's on 

85
00:03:45,360 --> 00:03:49,160
Swift number 7 and I and I also 
just throw on kanthurdin. 

86
00:03:49,160 --> 00:03:51,800
So one thing I've learned if I 
do swift and kanthurdin, they 

87
00:03:51,800 --> 00:03:54,040
get kind of mad if I bill 
insurance at the same time. 

88
00:03:54,040 --> 00:03:57,480
So I either do the swift and 
just throw on the Kanthurdin as 

89
00:03:57,480 --> 00:03:59,880
a, as a bonus type of thing. 
I don't bill them for that 

90
00:03:59,880 --> 00:04:01,960
because then it's just, it's too
prohibitively expensive. 

91
00:04:01,960 --> 00:04:05,040
Or I'll, I'll just do the Swift 
without the kanthurdin. 

92
00:04:05,320 --> 00:04:07,800
But in her case, it's been so 
long, I can tell it's getting 

93
00:04:07,800 --> 00:04:12,360
better because I find with Swift
that the, the, the warts become 

94
00:04:12,360 --> 00:04:16,120
less kind of less thick, less 
elevated, less bumpy and stuff 

95
00:04:16,120 --> 00:04:17,320
like that. 
So she, I think she's almost 

96
00:04:17,320 --> 00:04:18,839
there and I'm going to do a six 
week follow up. 

97
00:04:19,920 --> 00:04:21,920
So usually for Swift, first four
I do weekly. 

98
00:04:22,400 --> 00:04:25,040
I'm sorry. 
First four I do monthly and then

99
00:04:25,160 --> 00:04:29,800
as I'm doing additional ones, 
I'm adding like time to it like 

100
00:04:29,800 --> 00:04:32,880
6 weeks or a little bit longer 
just to give the immune system 

101
00:04:32,880 --> 00:04:34,800
time. 
Next was another patient with 

102
00:04:34,800 --> 00:04:39,360
midfoot arthritis that had 
orthotics and she had her 

103
00:04:39,360 --> 00:04:41,960
orthotics, but she also got a a 
cortisone injection for those. 

104
00:04:41,960 --> 00:04:43,880
No follow up. 
Next was a patient that got a 

105
00:04:43,880 --> 00:04:47,840
diabetic foot exam and he had 
some plantar fascial pain. 

106
00:04:47,840 --> 00:04:50,800
So we got a plantar fascial 
injection and he's going to be 

107
00:04:50,800 --> 00:04:52,960
seen back every three months for
for routine care. 

108
00:04:52,960 --> 00:04:54,240
So an office visit with those 
things. 

109
00:04:55,080 --> 00:04:57,720
Next was a 51 year old that had 
a poor old keratoma. 

110
00:04:57,720 --> 00:05:01,000
So I did that lesion destruction
for that. 

111
00:05:01,040 --> 00:05:06,280
So in my new EMR, it's going to 
say borrow possible wart. 

112
00:05:06,600 --> 00:05:10,440
And So what would be the 
diagnosis because that's what's 

113
00:05:10,440 --> 00:05:14,160
covered by insurance. 
Then she also has a lateral scar

114
00:05:14,160 --> 00:05:17,000
on the lateral ankle with a 
surgery by another doctor. 

115
00:05:17,400 --> 00:05:23,080
And in in that I talked to her 
about doing some like treatments

116
00:05:23,080 --> 00:05:25,240
for the scar laser can sometimes
help. 

117
00:05:25,600 --> 00:05:28,240
So she was going to be thinking 
about that, but I did offer her 

118
00:05:28,240 --> 00:05:31,680
that the laser, the laser I just
do it's for scar. 

119
00:05:31,680 --> 00:05:33,720
I do laser. 
It's can sometimes heat it up 

120
00:05:33,800 --> 00:05:38,160
and kind of help lay down the 
scar a little bit better, a 

121
00:05:38,160 --> 00:05:40,040
little bit in a more organized 
fashion. 

122
00:05:40,680 --> 00:05:43,920
Next was a ulcer kind of that 
came back, kind of brided the 

123
00:05:43,920 --> 00:05:45,280
ulcer. 
He's going to come back in two 

124
00:05:45,280 --> 00:05:49,760
weeks. 
Next was a 58 year old that had 

125
00:05:49,760 --> 00:05:53,080
once again lesion destruction as
well, kind of poor keratoma type

126
00:05:53,080 --> 00:05:57,680
of thing, or IPK. 
Next was a six year old little 

127
00:05:57,680 --> 00:05:59,440
boy. 
He's he had a kind of a unique 

128
00:05:59,440 --> 00:06:02,320
thing. 
He had this like elevated 2nd 

129
00:06:02,320 --> 00:06:06,640
digit, like a curly toe 
bilaterally and it's overlapping

130
00:06:06,640 --> 00:06:09,000
the bunion in a little bit or 
the the hallux doesn't really 

131
00:06:09,000 --> 00:06:10,720
have a bunion, but it 
overlapped, overlapped the 

132
00:06:10,720 --> 00:06:13,240
hallux. 
So I recommended him 0 shoes, 

133
00:06:13,240 --> 00:06:20,080
Xero and correct toes. 
And then he also had a retro 

134
00:06:20,080 --> 00:06:21,960
Nicky on the left hallux. 
I don't know what caused this, 

135
00:06:21,960 --> 00:06:25,080
but he had a retro Nicky with 
kind of swelling at the base 

136
00:06:25,120 --> 00:06:27,320
erythema. 
I don't think his shoes were too

137
00:06:27,320 --> 00:06:28,720
small. 
They may have if anything been 

138
00:06:28,720 --> 00:06:32,120
too big but we're just going to 
let it be to see if it gets 

139
00:06:32,120 --> 00:06:33,480
better. 
I don't really have great 

140
00:06:33,480 --> 00:06:35,120
solutions for this. 
I told him that the nail might 

141
00:06:35,120 --> 00:06:38,160
get thickened and then we might 
have to take off the nail. 

142
00:06:38,160 --> 00:06:41,240
I don't know if anyone has any 
other great inject things if 

143
00:06:41,240 --> 00:06:43,760
anyone's tried like cortical 
steroid injections for these or 

144
00:06:43,760 --> 00:06:45,040
anything else that's worked for 
these. 

145
00:06:45,560 --> 00:06:48,600
But usually I just abolce the 
nail and or just wait and deal 

146
00:06:48,600 --> 00:06:50,080
with the nail changes that 
happen. 

147
00:06:51,680 --> 00:06:54,880
Next patient was a #4 out of 6 
plantar fascia. 

148
00:06:56,040 --> 00:06:58,360
She I added to her. 
So she had done 3 sessions and 

149
00:06:58,360 --> 00:06:59,520
then she came back six weeks 
later. 

150
00:06:59,520 --> 00:07:01,960
Now this is number we're going 
to set number 45 and six up. 

151
00:07:01,960 --> 00:07:06,000
So I did #4 today I encourage 
you to do foam rolling in bed. 

152
00:07:06,800 --> 00:07:09,040
Some of the older patients, they
can't do foam rolling on the 

153
00:07:09,040 --> 00:07:10,080
floor. 
They can't get down to the 

154
00:07:10,080 --> 00:07:11,400
floor. 
So I have them do foam rolling 

155
00:07:11,400 --> 00:07:14,840
in the bed. 
Next was a X-ray for status post

156
00:07:14,840 --> 00:07:16,600
exostectomy and a medial 5th 
toe. 

157
00:07:16,600 --> 00:07:18,360
This is like one of my favorite 
procedures to do. 

158
00:07:18,680 --> 00:07:20,640
So she has this and she's also 
going to be having a 

159
00:07:20,640 --> 00:07:22,200
bunionectomy here in a couple 
months. 

160
00:07:23,760 --> 00:07:26,080
For the bunion, she was 
scheduled two months before a 

161
00:07:26,080 --> 00:07:28,600
wedding she needed to go to. 
So I advised her to wait till 

162
00:07:28,600 --> 00:07:32,000
after the wedding. 
Now this changing of surgeries 

163
00:07:32,000 --> 00:07:33,840
can kind of be a pain for my 
surgery schedule. 

164
00:07:33,840 --> 00:07:37,640
So recently we had a office 
meeting and we're going to start

165
00:07:37,920 --> 00:07:41,640
like doing like a an admin fee. 
I think it's like a $200 or 

166
00:07:41,640 --> 00:07:45,240
something like that to change 
that because it takes a lot of 

167
00:07:45,240 --> 00:07:46,800
extra work. 
I don't know if anyone else does

168
00:07:46,800 --> 00:07:48,640
that, but if they have 
everything scheduled and then 

169
00:07:48,640 --> 00:07:51,680
they want to change it for like 
a a random thing, do you guys 

170
00:07:51,680 --> 00:07:53,360
charge for that? 
I'd like to know if other people

171
00:07:53,360 --> 00:07:54,120
charge. 
We're going to try it. 

172
00:07:54,120 --> 00:07:57,040
I just hope it doesn't come back
to bite us in the butt, but 

173
00:07:57,040 --> 00:08:00,720
that's something we're going to 
be doing here until it changes. 

174
00:08:00,720 --> 00:08:01,560
If it changes, I'll let you 
know. 

175
00:08:02,040 --> 00:08:05,120
Next was this was my MVP, my 
most valuable patient. 

176
00:08:05,120 --> 00:08:08,520
He's a 63 year old guy. 
He has bilateral aquinus, really

177
00:08:08,520 --> 00:08:12,160
big calves, plantar fasciitis 
bilaterally, but it hurts worse 

178
00:08:12,160 --> 00:08:14,400
on the left. 
So the way I determined which 

179
00:08:14,400 --> 00:08:16,920
one is worse is I did an 
ultrasound and in the left was 

180
00:08:16,920 --> 00:08:20,760
really thicker, darker. 
And so the plan is he's going to

181
00:08:20,760 --> 00:08:23,680
treat the Aquinas on both sides 
with bilateral night splints 

182
00:08:24,480 --> 00:08:26,960
just so he doesn't have to wear 
them more than three hours. 

183
00:08:27,400 --> 00:08:29,400
And he's going to do shockwave 
on the left side. 

184
00:08:29,400 --> 00:08:33,080
And I did start shockwave that 
same day for him. 

185
00:08:33,480 --> 00:08:36,880
So he did number one out of six.
He's going to get bilateral 

186
00:08:36,880 --> 00:08:39,799
night splints, foam rolling and 
I'm going to see him back in a 

187
00:08:39,799 --> 00:08:43,559
week to do the next ones. 
So that was my MVP patient and 

188
00:08:43,559 --> 00:08:46,040
at the third visit I, I told him
he's going to be scanned for 

189
00:08:46,040 --> 00:08:47,960
orthotics. 
So I tell them like after a few 

190
00:08:47,960 --> 00:08:50,000
weeks then that's what we're 
going to scan for the orthotics.

191
00:08:51,680 --> 00:08:54,520
Next patient was number of 
shockwave, 4 out of 6 for 

192
00:08:54,520 --> 00:09:01,480
plantar fasciitis. 
Next patient was a 58 year old 

193
00:09:01,480 --> 00:09:04,880
female follow up on a fracture 
got X-rays and it did show some 

194
00:09:04,880 --> 00:09:08,800
cortical irregularity and so 
just confirm that that I didn't 

195
00:09:08,800 --> 00:09:10,960
see last time because it was a a
newer 1. 

196
00:09:11,360 --> 00:09:13,880
Next patient was a 12 year old 
boy that originally was seen for

197
00:09:13,880 --> 00:09:17,440
flat feet and apophysitis. 
His orthotics, he was really 

198
00:09:17,440 --> 00:09:18,640
wearing them they're kind of 
worn out. 

199
00:09:18,640 --> 00:09:23,880
So we got a second pair actually
with the, the company we use to 

200
00:09:23,880 --> 00:09:25,840
get a second pair for just the 
scanning fee. 

201
00:09:26,080 --> 00:09:28,640
So it's $100. 
And so they did that one. 

202
00:09:28,640 --> 00:09:30,880
They want a another pair. 
So they, they paid full price 

203
00:09:30,880 --> 00:09:34,840
600 for one and got us and then 
got that other one for 100. 

204
00:09:35,240 --> 00:09:37,440
And then the next one we'll do 
at 100 as well. 

205
00:09:37,440 --> 00:09:39,600
So we're just kind of going back
and forth for that. 

206
00:09:40,440 --> 00:09:43,040
This was a little 12 year old 
boy and the next patient was a 

207
00:09:43,040 --> 00:09:45,520
39 year old for did kanthered in
for a wart. 

208
00:09:45,520 --> 00:09:47,760
Next was another kanthered in 
for a wart. 

209
00:09:48,320 --> 00:09:54,160
And there's another patient that
had some neuropathy and so we 

210
00:09:54,160 --> 00:09:58,800
did gabapentin for this one. 
And he is kind of a challenging 

211
00:09:58,800 --> 00:10:03,800
1 because he had a kind of a 
blunt trauma that kind of caused

212
00:10:03,800 --> 00:10:08,520
like an RSD on a, on the plantar
sesmoid region. 

213
00:10:08,520 --> 00:10:11,440
And we've, we've done shockwave,
done orthotics, nothing's really

214
00:10:11,440 --> 00:10:14,040
helped him. 
He's been really shrugged off by

215
00:10:14,040 --> 00:10:17,200
a lot of other doctors and he's 
like asking for a sesmoidectomy 

216
00:10:17,880 --> 00:10:20,040
or a neurectomy. 
And I was like, I just have 

217
00:10:20,040 --> 00:10:22,080
never done one of those for this
condition. 

218
00:10:22,080 --> 00:10:25,120
So I sent him to get a second 
opinion with one of my, one of 

219
00:10:25,120 --> 00:10:28,840
my, my buddies here. 
So Yep. 

220
00:10:29,040 --> 00:10:31,480
So that was the day. 
Hope that was helpful for you. 

221
00:10:31,480 --> 00:10:34,560
Just trying to share kind of 
what my thought processes and 

222
00:10:34,560 --> 00:10:36,400
things. 
Hope this is beneficial for you 

223
00:10:36,400 --> 00:10:37,960
guys. 
Just so you know, we're, we're, 

224
00:10:38,080 --> 00:10:43,480
we're starting some touches on 
developing a, a mastermind kind 

225
00:10:43,480 --> 00:10:45,560
of a small group. 
I'm going to limit it to, I 

226
00:10:45,560 --> 00:10:49,080
think it's 5 or 6 people that 
we're going to be meeting to do 

227
00:10:49,080 --> 00:10:51,080
like a hot seat kind of 
mastermind group. 

228
00:10:51,280 --> 00:10:52,840
So if you guys are interested, 
shoot me an e-mail 

229
00:10:52,840 --> 00:10:55,320
don@podiatrypracticemaster.com. 
And if there's other things that

230
00:10:55,320 --> 00:10:57,920
you do that I'm not like talking
about, let me know and I'll I'll

231
00:10:57,920 --> 00:10:59,320
share it with other people. 
OK, thanks.