Trascrizione completa di 24 - Dr. Tanya Altmann: Expanding Reach as a Direct Primary Care Pediatrician

do, you could just train and do. He still did home visits. He really felt that the basis for everything was nutrition and sleep and lifestyle and gut microbiome. And that was how he practiced and how I wanted to practice. And I just didn't have enough time. I would be up all night calling specialists, returning patient emails. And my partners were like, You don't need to do all this. And I said, No, no, I really do to be the pediatrician that I want to do. So when I was 42 and pregnant with my third, I decided to quote retire from insurance-based regular practice. And my partners were very supportive of me because I think they didn't really think that, you know, two months into my maternity leave, I was really gonna open up my own cash pay practice. But they said, as long as you don't compete with us and take insurance, which I said I would never compete with you. If I do anything on my own, I promise to start over, not reach out to any patients in the old practice. And I went on maternity leave and I actually did some mommy and me classes, which was really fun, which I didn't get to do with my first two boys because back then we went back to work three weeks after we had a baby. You know, we didn't we didn't have maternity leave. speaker-0: Old school. Old school. speaker-1: And so when my son was two months old, I was bored because of course I get bored and all of my AAP books I actually wrote during maternity leaves. I thought, what am I gonna do? This maternity leave, let me go look for office space and see if a cash pay practice would fly in my area. Now, back then, twelve years ago, you couldn't take insurance and charge an extra fee. Insurance companies would turn around and sue you. So what we called concierge back then was really cash pay. You had to get an attorney and go out of network with all physicians and say, these are my prices. And I had a few different plans. So I had a monthly plan and I had a pay-per-visit plan. And essentially, I think I was one of the first quote DPC doctors, but I called it concierge back then because I said, here's my cell phone. You call, text me anytime. I am here for you. You need help starting your baby on solids. You need to find a swim teacher or a math tutor. You have you're going on a trip and you want me to make a little travel kit for you so you're prepared with anything you need. I want to do that because I want to help you raise the healthiest, best family possible with all of the latest research. And and so I opened up my own practice, which I called Calabasas Pediatrics, and it was a concierge practice back then. I also started studying integrative medicine because I knew that as my grandfather taught me, gut microbiome and nutrition and sleep were the foundation for everything. And I started doing gut microbiome research initially with a group at UC Davis. Which later became a group down here in San Diego, separate group, Persephone bio, which is now the number one infant probiotic that all

babies need, because it's the four strains of bifidobacteria that we know will help set up their immune system. And 90% of babies born in the US, this is all research-based, my baby biome, an Artemis study. 90% of babies born in the US do not have the gut microbiome that they historically had due to this generational decline. And so I knew there were things going on here. My sister's an allergist. I was hearing from her. I was doing early introduction back in my old practice, you know, before it even became a guideline. And and I knew that there were all these things at play that I wanted to help with my patients. I also, you know, remember in residency where you would talk to every specialist who saw your patient and you'd sign the story out to them and they would get back to you and you would learn from it. I wanted to do that again. because there's a lot of things you don't have to send a specialist, you can do yourself. And in my first practice, by the way. We took care of our own thyroid issues. We took care of our own diabetes. The doctors I joined were old school. We did our own urine and throat cultures. We grew them out in the office and went to check the incubator on weekends to see what was growing out. So I wanted to be able to do all of this. And so that was sort of why I opened my practice, which has since evolved to what I call a true concierge practice, but under a DBC model where now there is a monthly or yearly fee. And I love it. I have a hundred families. I will do everything. Anything for them. I got labs back last night on a patient with a super high prolactin level. We're getting that pituitary brain MRI today. I don't wait on anything. I just make things happen. I talked to the endocrinologist last night. She's gonna be seen early next week. Labs are getting sent over. I feel like too much time is wasted in our traditional healthcare system with insurance. And I can't change the broken system. All I can do is navigate around it. And that's what I do every day to make things happen. speaker-0: I it's so funny. I've heard that lament so many times from people saying and and what I w what I attribute it to is your insatiable desire for autonomy. You wanna be able to take care of things yourself and do it yourself and get it done because you don't want to get something halfway through the solution and then hand it off and never never experience the solution being closed, but also knowing that as soon as you hand it off, the odds of that solution happening dropping precipitously. You know, the Ex I think that's great. And it is and and I did literally just today see I was in part of a discussion among a bunch of pediatricians who were saying how they did they literally asked, Can does anyone here send their MAs in on the weekend or either doctors in on the weekend to look at the cultures? And a bunch of people saying, No, we don't do cultures as a result, you know, it's the whole debate about, you know, quick strip versus some

of the new lab equipment and yeah, it's just an endless It's an endless cycle of debate. So when you said speaker-1: Now with PCR and molecular testing, you don't really need to do your own cultures anymore. But if you still have that set up in your office, that is amazing because I hate waiting three days for a urine culture. And I found one lab because I will look all around the country for anything I need. And I had a lab out of state that would do next day PCR molecular urns on me for the kids. And then they stopped taking California samples. And so now I'm on the hunt again. But anything I need, I will work until I can find it. Like during COVID, I helped develop a lot of the initial COVID testing. I did the finger poke antibody testing in my office. I validated cheek swamp testing for our local schools. Like when I want something done, I will find a solution. Baxcare. I started working with Baxcare in the very beginning, trying to encourage them to come to California because I knew when they finally made it to California five years later, I wanted to be their first client. because that really helps the DPC concierge model. Yes, I mean, the other one of the other really cool things I figured out since COVID was how to treat pots. And it just boggles my mind that. Nobody else can do this, but it's all micronutrients. I found a company to do micronutrient testing on my patients, less than $200. I draw it in my office, I send it, and the girls are not fainting and they're not dizzy three weeks later and they're back in school, they're cheerleading, they're feeling great. So I feel like if I refer to a specialist and the specialists can't help them, then it comes back to me to figure it out. And that's my job as a pediatrician. But yeah, I need the time to do it. And I'm constantly telling people who switched to my practice, listen, I'm not smarter than your pediatrician. I just have the time to do it because I can spend two hours with you and they can only spend twenty minutes with you. And I will not stop until we figure out what is wrong with your child and we fix. speaker-0: As you know, I've done a lot of math of the business that you're in. Typical standard pediatric primary care. The payment is so low on a per patient basis. I remind people, on average, your payers are paying you about forty bucks a month, fifty bucks a month, usually less though. It's like forty, thirty five, forty bucks a month per patient per month. And that's across all your patients and that includes all your immunizations. Yeah. speaker-1: Trans based. speaker-0: Yes, you might have a five hundred dollar well visit. But you might see them once a year by the time they're twelve. And really it's like it's like thirty five, forty bucks a month. And that's the math that the insurance companies don't want you to do. Because once the parents realize it's cheaper to see a D P C than it is to pay your premiums, the insurance companies are in trouble. All right. That's that's my thought. speaker-1: Yeah, I mean it definitely saves parents time and money. And like when you start really breaking down the cost of things, like I can get a brain MRI for $250 tomorrow on a patient, or I can argue with Blue Cross for two weeks to get it insured. And I just pulled that name out of a hat, but usually it's blue cross. And you might still have a $200 copay. So I present it to parents and I do both. I mean, I work through insurance when they want, but with Good Rx now and Mark Cuban's pharmacy cost plus drugs. It's so much easier to pay fifty dollars for that zoofluza and keep it in your house for when you test positive for flu so you can take it right away and get back to school and work, as opposed to waiting and trying to get stuff improved through insurance. speaker-0: Yeah, I I am with you. I am with you. Yeah. I hate seeing my clients suffer through the nonsense of the payers. They the the puppet masters and they they make you focus on stuff that has nothing to do with why you're there. No pediatrician wants to deal with claims and money. They want to take care of the kids. speaker-1: You in my when I did insurance-based pediatrics for 14, almost 15 years, I did fight with insurance companies every day. We took HMOs and I got really good at fighting with HMOs to get my stuff done. But it still took time. And I was teaching a non-medic physician about medicine and about why to convince them. And then every time I get on the phone with one of the medical supervisors, it's funny, they all know me and they're like, yeah, of course you can have it. And I'm like, okay, they just paid. eight other people and took hours to get to you where you know it's it's just it's such a it's such a game. Today speaker-0: Yeah, it's a game. speaker-1: are sicker than their parents were. There's so much more chronic disease and illness. And I think we need the time to figure that out. So it goes back to lifestyle, you know, the probiotics, the nutrition, the micronutrients, the being outdoors, the less screen time, you know, the the all the whole lifestyle. And you know, people say, How do you do a physical for a whole hour? Well, it takes that long to go through all of that. And you know, if you had time in insurance-based practice, you would. Like when people say, What's the difference between your practice and insurance-based? I say, I just have time to do all the things that insurance doesn't allow regular pediatricians to do. It's not that they don't want, they're just not allowed. speaker-0: Yeah, and and their businesses would not survive if they tried to. speaker-1: If you're on call 247 for a hundred families, how do you sleep at night? And I have to tell you, when you know families well and you train them well, they don't worry they can't reach you because they know how to reach me. So I get woken up maybe three times a year. And in my old practice, because we took our own call on a, you know, once a week schedule, we would get

woken up three times a night when we were on call. And so it's really not that bad. Now I might wake up in the morning to one or two texts or emails saying, Hey, Dr. Tanya, when you wake up, can you give me a call? Or can you answer this question? But they know that if they need me, I'm there. So they don't worry. And most of the calls I used to get in my old practice were, Well, there's a little fever now, but we're worried. What if it gets higher? What do we do? speaker-0: Right. I can't I can't get you. And right now the three times you get woken up every year, you're like, Thank God you called me. speaker-1: Yes. Exactly. Exactly. And w what recently one I threw on scrubs and ran to meet them at the hospital. And I was so glad I did. It was the best thing ever. They loved it. The ER doctor was thrilled when I walked in because it was a four day old and they were like, thank God you're here. Can you please help me? speaker-0: Sorry. Yeah, yes, a pediatrician. We will let you hold this baby and we why w if we do anything no speaker-1: and I owe him a call because he wants to open a cash pay practice too. I totally forgot. I know everyone I meet is like, I want to do what you're doing. speaker-0: What what I in a way what I wish is that we had enough pediatricians and they were distributed among all the communities in such a way that everyone could have access to someone who would spend an hour with you. That's the I mean, maybe someday. Anyway, okay. So now, in addition to being pediatrician, you mentioned the fact that you have occasionally authored a book. Yes. I'm curious what you in your career, what you have been the proudest of I've of the non pediatric non like direct physician work you've done. So not the work that you've done with a specific patient, but what what is the stuff that has interested you the most or made you the most proud as not that's not in the exam room? speaker-1: Yeah, that's a good question. So, you know, to take a step back, you didn't ask why I became a pediatrician. speaker-0: yes, well yeah, yeah. Okay. speaker-1: And well, it's okay. So I always joke, although there's a little bit of truth in it, that I was raised by a Jewish tiger mom who basically told me and my sister to go to medical school and then figure out what we want to do with our life because all the men in her family, all 15 of them, were physicians. And I was the first female physician in my family. So I always loved kids growing up. I was the community babysitter, the community teacher. So when I had to go to medical school, I knew of course I would do pediatrics. But I also had a lot of other interests. Like I remember even being in middle school saying, like, I want to be an anchor on the news, you know, or I wanna, you know, write books. And so I think that is why, although I've always been a pediatrician, I am so thankful that my mom pushed me to go to medical school because I love my career. I think that's also why I do so many things and I

have so many interests. So when I was in residency at UCLA, I got involved in our local American Academy Pediatrics chapter. And it was actually because one of my mom's good friends, Dr. Rob Robin Dorso, Who many of you know because she's a very well-known pediatric cardiologist, picked me up and dragged me to the AAP meetings. And I got involved in the resident section. And back then there weren't AAP spokespeople. We didn't have a section on media. We didn't have a section on communications. And I helped start that because it was something that I wanted to do. And I realized there are so many non-physicians out there doing health reporting. Why can't we do it? So I was one of the first AAP media spokespeople. And I remember my first year in practice. We didn't have cell phones back then. So on the old school desk phone, my front office walked back and said, Hey, the AAP is on the phone for you. And I thought, my gosh, what did I do wrong? And I answered the phone and it was somebody named Carolyn Kobaba, who used to be in publishing at the AAP who's no longer there, but I still love you, Carolyn, if you're listening. And she said, Hey, Tanya, just calling from the AAP. We have a question for you. Have you thought about doing a fellowship? And I thought, What a weird question. Is there a right answer or a wrong answer? And I said, Well, right now really love general ped. So, you know, I don't know in the future what'll happen, but I really like what I'm doing every day now in my practice. And she said, Great, good answer. Do you want to take over the birthtage five book with Steve Shellov? Because we need another general pediatrician. And we thought you'd be great, but we wanted to make sure you weren't going to do a fellowship. And I was like, I would love to. And then I worked with Dr. Shellov, who, as many of you know, is an amazing mentor of mine on many, many editions of the AP birthtage five book, which then also turned into the Caring for your baby's first year book. I wrote Baby and Toddler Basics, which the original version was Mommy Calls, which is actually a book that I wrote when I was in residency because I wanted to write a book and I collected all the mommy calls that the interns would get on their pagers. And I put it in a book so that way when you were the senior resident on call, they didn't poke you all night long when their pager went off. They could look up the questions and answers that I wrote in the book. And then if they had a follow-up question, ask us as a senior resident. And then the AAP decided to publish that. And it was mommy calls, and now it's called Baby and Toddler Basics. But it's essentially the 101 most common questions parents ask their pediatrician. And I still update it every few years. And that was sort of how I got involved in the American at Kennedy Pediatrics and became one of their first spokespeople. So I think I'm most proud of the work I've done there with them and the books I've written. But the

other thing I do a lot of is I consult for companies. And this was also something I started doing right out of residency because I wanted change. So one of the first companies I consulted with was making the first big kid booster seats. Because as many of you know, booster seats were new, right? They just had infant car seats. And I thought, why aren't there car seats to hold bigger kids? And so I started consulting on that. And then I went from there to help with other products. The Halo Sleep Sack was another one of my first consulting jobs. And I know it's interesting now because people look at social media and they think, my gosh, so many pediatricians partner with brands. I've been a true consultant helping shape. Products and educational guidance and messaging for over 25 years. And most of my consulting has come out of the need to change something. For example, when we had the formula shortage four years ago, I went on CNN and said, if I was the FDA, I would take a closer look at international formulas and consider allowing them into the United States, because especially the ones that already fit all of our Infant Nutrition Formula Act. And the next day the FDA called me and I started working with them. And then I brought over Bubs from Australia, which was the first application for Operation Fly Formula. We flew millions of bottles of formula over to the US and now I'm their chief medical advisor. s and same with me now being the chief medical advisor for Persephone based on the infant gut microbiome research we've working on. So what's interesting is I feel like a lot of doctors say, what do you get paid to do a video? I don't get paid to do videos. I am not an influencer. Do not call me an influencer. I am an expert. I'm a consultant. And because of my background being a health reporter, some of what I do is videos for the companies, but that's like less than 5% of what I do for them. I do research, I do marketing, I run FDA trials. I ran the bubs, you know, F I helped with the FDA formula trials because every formula that's allowed in the United States. And certified year has to go through FDA trials in the US. And it's part of what I do and I love it. And it's so exciting. I wanted RSV added to those over-the-counter flu and COVID tests. So I contacted a company and said, I want RSV on this. How do we do it? And I worked with them a few years ago and we launched last year. And so I think there's so many things you can do as a physician outside of the exam room walls to help kids and families live longer, be healthier, be happier, more successful. And I think you need pediatricians for that. We're the ones that know best because we're the ones seeing babies every day. speaker-0: Right. And you're and not only are you you're trained, you have experience, you understand the needs and the wants of the parents. And the thing that a lot of these under vendors don't understand for the longest time is that pediatricians are not motivated by money. You're just not. You're motivated by like you would have picked a different specialty. That's crazy. It's the worst specialty to pick. And and I think it takes people a long, long time to understand that pediatricians are motivated by helping other people. That's like you're the in you are constantly seek that intrinsic reward of helping someone else. speaker-1: You're right. In fact, companies always say to me, because they want to give you like a percentage of sales when you do a video. I'm like, no, no, I can't do that. As a pediatrician, I don't feel that's right. I don't want to sell products. I just want to educate. I do not want a percentage. I like to tell people I do not make money off this product. They pay me to consult in their lab or, you know, whatever I'm doing for them. speaker-0: I want the product to be better. I want an I mean speaker-1: Exactly. I do so. And my latest, do you want to hear about my latest product project that I am a co-founder on and chief medical officer for? So about five years ago, I started wondering why are there no over-the-counter gummy or soft chew medications? And I realized it was because the way that we typically make gummies in the US denatures the active ingredients. So I've been working on that. And I have co-founded a company that will launch next year, and we have A whole range of over the counter medications for kids coming out in a soft chew form, which will be less spills, less fights, and they taste really, really good. And don't worry, it'll safe. You have brand new speaker-0: More accurate dosing. Yeah, yeah, more accurate dosing. That's the other thing. speaker-1: Yeah, more accurate dosing. And it's gonna be it's gonna be amazing. So we won't be at this year's AAP conference, but next year's AAP conference, we will be speaker-0: Okay. John Canning and I one time helped contribute to a study. Or I'll just leave all the details out for obvious reasons, but someone did an analysis of how often pediatricians get the dosing wrong, all right, and then how often the families miss you know, mistake tablespoon, teaspoon. And the fact that and any like if anyone here who bakes knows, you grab any three tablespoon measures out of your drawer and they are not the same volumes, all right. And this group did a study. And pediatricians got dosing wrong. This is a lot of this is pre-EHR. So a lot of this has been fixed. But they got dosing wrong 30% of the time, and five to eight percent of the time, I'm saying this from memory, the dosing mistakes were seriously dangerous. And that's going to the parent. The parents are worse. And the first time they did the study, they they said they released it to the people who reviewing it and they were like, nope, can't be true. Can't do it. You got to do the whole thing over. You got to do the whole thing over. And they came back and it and the the Percentage went up. And so speaker-1: That's why dosing charts were one of the really important things I

wanted to have in my first book. And I also, by the way, was one that encouraged the uniform dosing for acetamenophine, right? So there's only infant and children's acetamenophine are now the same concentration. And that was something we had to change a while ago. I've also done, you know, work with Poison Control Center, which is amazing. You know, when parents call me, I call them first to get the information. And Ibuprofen still has a different dosing, but also when families travel to Canada and other countries, the dosing is different as well. And so there's so much room for error. that, you know, it's it is really important that you always follow the dosing on the container, use the dosing measuring device that comes with the medication you're giving. You ask your pediatrician, you keep a log. Yes, all these things that we go through, and especially when kids are sick, that's when the errors go up. And you also see more extonal overdoses because kids get into the medication. speaker-0: Yes. One gummy or two gummies is a much harder to get wrong. Versus, you know, four hundred milliliters or eight hundred milligrams or a tablespoon or Yeah. It's all right, good for you. I'm glad to hear it. Well, that was a good answer. Thank you. Now, as Tanya Altman, the human being, what's keeping you up at night right now? speaker-1: Goodness. I mean, I think just the state of everything going on in our country, right? And the world. I mean, there's there's so many layers here and so many things that I can't fix. So I just try to keep, you know, what I can under control in my own practice with my own family, with my own families in my practice, you know, and help out as many people as I can that reach out to me. But it's it's a lot. I think we all have a huge weight. on our shoulders right now. And we're all just really trying to to do our best. But what really keeps me up at night is there's some pediatric conditions that we still just can't fix that I think we're so close to, like pans pandas. I have so many complicated pans pandas patients. And when you catch them early, a lot of them you can turn around and and fix. But when they get more complicated and it sits for too long, it becomes a much bigger ordeal. And the fact that some physicians still don't believe it's an actual disease process Boggles my mind because you see these kids that change overnight. I think that's one of the other things is when you're in a busy insurance-based practice where you're not even the one that does the checkup on the kids every year. A lot of times parents, pediatricians feel, I can't believe the parents. There's no way this kid changed overnight. When you're in a small practice where you see these kids every day and they change overnight, you know it and you're like, my gosh, something took over your kid's brain. And I would say believe the parents. They know what's going on with their child. They're the ones there every day. But that's what keeps me up at night is

I have a few really complicated patients that I just haven't been able to figure out the solution yet. And I'm thinking every night and brainstorming and waking up and emailing different specialists around the world about their research and talking to them. And that's the other thing about medicine. To me, it's an art more than a science, but you need the science there. And a lot of younger pediatricians now say, it's not in the guidelines. I can't do it. There so much of what we do is not in the guidelines. I've been advocating for ferritin checks for anemia. For over 10 years and the guidelines just changed. It takes 10 years to change any guideline with the American Academy Pediatrics, which is not a bad thing. They have to do their due diligence in all the studies. But it doesn't mean you can't, you can't use it because you know that when you check ferritin and it's low, the kids aren't sleeping as well, they're not focusing and concentrating as well, they're not growing as well, and that when you correct it, they do. I mean, that's there's no downside. You know that works. So I've been checking it for the last 10 years. Anytime I poke a child for any other reason, but now I'm glad the guidelines finally changed. And so a lot of the things that I do, I tell my students, the residents I advise, the younger pediatricians, this is going to be guidelines in 10 years. All babies are gonna be supplemented with bifidobacteria right after they're born in 10 years. But in the meantime, while we're still collecting data and doing the research, why not give your babies the best possible start in life? speaker-0: Now now that we've covered what you're worried about, I know y I know I know no I know you're an optimist. So what are you excited about the next couple of years? What are you looking forward to? speaker-1: So one of my new areas of interest is longevity starting with babies. Because the longevity world has exploded. And as you know, half of it out there is fringing crazy and half of it is real stuff that that was really important, like all the menopause, you know, longevity work that is finally getting out there. But I really want to reframe what how people think of longevity, that if you are starting in your 50s and 60s, you're already behind the eight ball. You really gotta start with babies with the right gut microbiome. The right, you know, skin protection, the early introduction, the right nutrition, the decreased screen time so their brain doesn't, you know, get rewired and all that stuff. I mean, I think there's so much we have there. So that's my next book I'm working on is I'm going through all that research and putting together Dr. Tanya's longevity plan for babies. The funny thing is no one wants to publish it because they tell me no one's gonna want to start this when their kids are little and the longevity world's oversaturated. But that's my big project I'm working on now, and that's what I'm really excited about is changing the trajectory. Of health in this country starting in the first one thousand days of life. In fact. speaker-0: That's where we have to start. Yes. That's where we have to start. Let's if you approach healthcare in this country like Spock would, which is to be in other words, like a little bit like a sociopath. You don't care how what people feel actually change healthcare in this country, you start with the next kid who's born tomorrow. Anyone, all the adults, our ships have sailed. Right? Like, yes, there are things you can do, but as you just pointed out, our blueprint is already mapped out. All right. You need to start with the babies and the first one thousand days of life is a really that's a really good way to frame it. So I even though speaker-1: I'm not an Obi-Gyne. There's a lot that you can do with moms before they get pregnant in terms of micronutrients and gut microbiome to really help ensure babies are born with the right stuff that they need. And we do this a lot when moms have a child with autism, is we'll look at their gut microbiome and micronutrients and we will change them before they get pregnant again. And it makes a difference. Again, research still pending, right? But all of this stuff will soon be available. To everybody, but it's not covered by insurance. And that's the other thing. Everything new is not covered by insurance. So you have to be willing to invest a little bit, you know, in your health when you need it and when you can't. Yep. speaker-0: I agree. And all right, ready for the last question? Sure. If you could go back to your younger self, which was just four or five years ago, how what advice would you give? No, like what what advice would you give to your to yourself earlier in your career, now that you've lived your life up to this point? Good. speaker-1: I mean, I, you know, it's interesting. I go to all these women physician wellness conferences now, because you know, my friend Dr. Alana, our mutual friend Dr. Alana Levine always drags me. And what it pains me how many female physician physicians are like burnt out and want to pivot in their career. And I love everything I'm doing. So what would I want to change? I mean, I think I've learned little things around the way on like my first solo practice cash pay office I sent set up. I spent a little bit too much on my overhead. And then three months later the city decided to like condemn the building and I had to move and start over again and take out another loan, right? So like there's speaker-0: It's like speaker-1: that. Yes, you were involved in that too. But but in general, I don't feel there's like a lot of major things I would have done differently. I mean, now that I have two boys in college and I know how crazy the college admission process is, I might have I advised them a little bit differently on some things, but they did great. And, you know, I think I probably would have done a little less screen time. I probably would have been a little bit

better about nutrition with my kids. But I think overall I'm really happy with where I am and I still love what I'm doing. And in fact, people say to me, Why didn't you sell to that VC company that just came to evaluate your practice? And I said, because I'm practicing for another 10 to 15 or longer years and I don't want to work for them, you know, for that long. So like they can come back to me in 10 to 15 years when I'm thinking about retiring and maybe. I'll do it then, but I'm only halfway through my career right now. Like I have so much more I want to do in the pediatric world in the United States in terms of helping with things. And that's what just makes every day so exciting and fun. speaker-0: good for you. I like I I remember before we had no it might have been like right after we had our first kid and our pediatrician was Joe Hagen, you know, the Bright Futures guy. And and he was great. I'd known him since I was a little kid and and my wife asked him, she said, so she 'cause he has he had that a number of kids and and you know, they're well known in our community. My wife said, As a father, you know, as a father who had children and as a pediatrician to like this whole community, what If you could give one piece of advice to me as a new mom, what would it be? And I was like, I was I remember sitting there thinking, that's a really good question. And he and he said, throw the TV out the window. And I wasn't expecting it. And back, you know, my kids are older than yours and and screen time didn't really become a full time thing. Non-TV screen time didn't really become a thing until they were four, five, six, seven, give or take. All right. So for us, TV was still really the screen time. And she really took him to heart. And we did get rid of our TV or we had a TV, but it was it was downstairs, like in our basement, and we didn't have cable or anything. It was just it you had to go consciously go watch something. And it wasn't while you were watching T or eating dinner and you we didn't sit around and watch TV. We might do something with the boy. Like we're gonna watch Winnie the Pooh, that's one thing, but just it wasn't on. And I remember showing up at kindergarten and watching the kids run around and I was like, I can tell which five kids don't have T V at home and I could tell which twenty kids no are are are dependent on T V. It was so the the difference between those groups of kids was to me so obvious and profound and that and that was great life advice. speaker-1: When I run into friends from growing up or at my high school reunions, the one thing they say to me is like, because I grew up without being allowed to watch TV on school days and barely at all on the weekends. And they would say, Because of your parents, we all had to get rid of our TVs in our community on school days. And I always thought growing up, I would never do this to my kids. And then of course, you know, once they got into school age, like, no screens on school days, of course. And my mom was laughing. She's like, you know. speaker-0: Because I did not have cable I did not have cable TV on all through school, all right, all the way into college. And what that meant was where I grew up, because we're all Vermont, everyone who grew up my age knew. You got three five, twenty two, thirty three, and sometimes fifty seven. Those are your channels. Three of those are Canadian, two of those are Canadian, one of those is PBS, and then you got NBC and C V S. And that was it. And I remember seeing the like the T V station is turned off signal. you know, with the Native American guy and everything. And I I remember that. I d and so when I went away to school and I remember coming back and they finally got cable in my neighborhood and I stayed up till four o'clock in the morning every night of my first spring break back at my house because I had never had television before. And I just could not believe that there were channels. Thank God I didn't have T V. I had to read a book. Yeah. speaker-1: Yes, that's that's what we did. We were really boring, but it was so good for our brains. speaker-0: It's so good for our brain. So I agree. And I'll thank Joe Joe Hagen, you know, for that. All right. As always, I r I really appreciate your time. I'm gonna see you at the N C E, I presume. I mean it's speaker-1: Yes, book science. speaker-0: like you can drive to it. You can speaker-1: I will drive to it, although sometimes it does take four hours for me to drive to San Diego but I speaker-0: I believe that. I yeah, I believe that. But yeah, we'll see you there and I are you gonna be in your goat milk booth? That's what I speaker-1: I will be h working with Bubs and Persephone while I'm there since I consult with both companies. But I'm also there for the AAP book signings. speaker-0: Yeah, so speaker-1: And I'm getting an award. I'm getting the Hollow Rights Award, which is the big communications award that they give to the old time AAP communications people, pretty much right before they retire or die. And I am getting that. speaker-0: Wow. Okay. So you know, you it's 'cause you started at age twelve. It's all made this it all makes happen. So when what it's when when and where are you getting that award? speaker-1: Monday morning, I believe, at the COCOM session, which is early, like eight AM. speaker-0: Yep. They should have you back in and do media training. Now, you know, July, middle of July next year, Nashville, C speaker-1: Yes. speaker-0: C maybe we could have you do a media training presentation. speaker-1: I it's on my calendar. I will be there. Okay. Wait, but remind me the date? speaker-0: Well geez, I gotta look it up myself. speaker-1: Okay, you can send it to me later. I I will be there. I've said in for many years I will go and I have not been able to get there because usually we have a family vacation in the middle of July. But I'm the sheer year speaker-0: They can go on vacation in Nashville. speaker-1: to be there. Well, we're we're going to my mother in law just planned a trip to somewhere more beach. But I speaker-0: Firteh through seventeenth, thirteenth through seventeenth. speaker-1: It's going in my calendar right now. I will be there. I will do media training. Another talk that I really want to give, but writing a new talk is a lot, is how to like how to concierge your practice, like how to uplevel your practice to be more concierge, whether you take insurance or not. Because not every DPC practice is concierge. Media speaker-0: Correct, absolutely correct. speaker-1: training is easy because I have so many media training talks, but we will figure it out. speaker-0: All right. Well perfect. Thank you very much as always. I really appreciate it. I will see you in a couple like what will feel like a couple of weeks 'cause we've got so much going on. And I just wanna say thank you on behalf of all the people I send your way who wanna figure out if they can have a cash based or D P C based practice. You're always you speaker-1: And you can do whatever you want to help you best take care of patients. There's no rules anymore. You can form your own system, your own practice. You could take insurance and charge. You could not take insurance, you can charge, you could not charge. I mean, whatever you want to do, just be a good pediatrician and be happy every day when you go to work. speaker-0: I love that. Thank you. All right. I will talk to you soon. speaker-1: Bye, Jeff.