Pełna transkrypcja odcinka 19 - Dr. Steven Hirsch: Building Pediatrics on Purpose

believes in that metric. And This is really important. I'm like, wow. I was so excited. So when you finish talking, I don't know, I ran up to you and says, ⁓ hi, you know, I introduced myself and is that your memory? I don't know. And I I said, you know, I I'm gonna follow this guy because I I think I really like what you have to say. And I what told my wife was like, Jen, this guy like cares about my practice almost as much as I do. He's not even a pediatrician, but he's like advocating for me. And I was really impressed. I was like, Well, I gotta follow this guy. So so that was the start, two thousand nine. Was that about right, Chick? Well, that so my memory was I didn't remember what show it was. And and it makes sense. It was in DC. Your picture in DC. Yeah. Yeah. And because that could have been Children's National or could have been something like that. But ⁓ I do remember you you came up and and immediately I was like, ⁓ this guy's an AP student. Like you I didn't have to explain things to you. ⁓ huh. You were telling me stuff. So I'm like, ⁓ the sick to well is it ratio. And you're like, here's mine. And I'm like, no one has ever given me theirs. I've always had to figure they were. And yes. Yeah. And so and what I what I really appreciated is ⁓ it's true. I think you have maybe well, I don't know how you would measure it. So I don't know I don't know how you have the most or the but you're one of the most deliberate pediatricians I've ever met. Like everything you do, you're like, ⁓ why am I doing this? Is this necessary? And is there a better way to do this? So I mean you ask yourself those questions all the time. And There's so many elements of the way your practice runs, which you're gonna describe in a second. That where it's you've said, This is how I want to do it and here's why. And what I what I I always appreciate about it is it's always in service of the patient. Mm-hmm. Like what is the best thing for the patient? Because you recognize that you are in the service business. And that is that's a hard lesson for a lot of doctors to yeah to really embrace. Yeah. I'm almost floored when I like I see a patient for they call that morning and we see them for a sick visit, you know, whenever they want to come in and they're like, Thank you so much for fitting us in. I'm thinking, Well, thank you so much for coming in. I'm like, shouldn't I? Like, it's my job to fit you. And I'm like, Your child is sick. Of course I'm gonna fit you in. Like it's but people are so used to like almost being a favor to get into their doctor that day when their child's sick or they need ⁓ or to get advice when they need it. I'm like, no, no, this is my job. Like, I'm gonna make this work. One reason. One reason that works for you though is because you don't bring everyone in who just calls. Yeah. Yeah. I mean, so many practices depend and I'm hearing a lot right now from practices because their sick visits have dropped. Mm-hmm. At the end of twenty, you know, at the beginning of twenty-six, end of twenty-five, their sick visits have dropped and a lot of people are panicking. I'm getting more calls, consulting calls right now than I've had in months because visits are dropping. Mm-hmm. And so they are all like scrambling to get people in, where you're always like, if you don't need to come in. I don't need you to come in. Mm-hmm. And that gives you this what so that means when someone calls and you know that they need to come in, you're like, I want to see you. Mm-hmm. Yeah. You know, I want to see you not because it's one more nine, nine, two, and three. I want to see you because I want to take care of the kid. And that comes across. Yeah. The parents get that. Right. Right. Right. I try not to overdo it. Like I try to not keep them from coming in. So we have a really good system with our portal because we we use the patient portal for ninety nine percent of our communications and then People ask us questions all the time and we try to keep it very simple. One template is I have a question or an appointment need. And they write their message and they click at the bottom. It says, ⁓ I don't need an appointment. I'm not sure if I need an appointment. I definitely want an appointment. Then if you pick maybe an appointment, you click, When do you want to come in? And we look at that and I say, Okay, you need an appointment. You'll come in this time and we match whatever they want. So we know early on when they're writing in, are you thinking you might need to come in? Or are you not sure? Or do you definitely want to come in? Because we kind of want to meet them where they are. They definitely want to come in. Just so I can look at their child's whatever. Like I'm happy to do that. But if they're like not sure if I need an appointment, all the time, yeah, you don't need to come in. ⁓ or come in if this happens. So ⁓ you know, kids kids kids are wonderfully healthy in general. So sometimes just giving a little bit of advice in an extra day or two is just all you need to get through. And I really try to prevent over prescribing and over testing. And the best way to prevent that is to not have them come into your office. Because once they're there, you almost feel compelled to start doing some testing or things because they made the effort to come in, they're paying a copay and things. It's almost like they bought their way into your office to anyway. So it works for us also because ⁓ i it I think we've created a really good experience for our family. So they're happy to be with us. We'd have very little turnover. We'd have great referrals. So we're busy, as busy as we need to be doing it the way we want to do it. ⁓ and ⁓ and it's worked for us. So ⁓ so we're gonna keep doing it. Well I'm gonna Yeah. Yeah. Well, I w I was gonna t I'm gonna tell you something about your practice that you probably know because I've sent this to you. Okay. But I wanna I wanna look something up. Some I'm gonna see if I can

look this up. I wanna get a sense of with your appointments. Hold on here. I'm looking up a report for your practice. You ready? I love reports, of course. Yeah, I know you do. Ready? You and I got I think we got a five on the AP score for data nerds. Yes. ⁓ yes. ⁓ I w ⁓ if they had had that it back in school, I would have done it. Uh-huh. ⁓ So so last quarter, all right, first quarter 2026, you did 2,570 visits. 2,524 of those visits were for patients who had a portal user, or 98%. Yeah. Okay. Forty-five percent of your patients used the pre-check-in process. Okay, which means just under half of your patients. had reviewed their demographics and their address and their insurance before they got to your office. Before they went to the exam. And that's what we're seeing, all right. Yeah. Is a a really a fascinating range. I've I a bunch of clients who don't use pre check in at all, which boggles the mind. And I have some clients, I have spoken to a client yesterday who was at ninety eight percent pre check in. And yes. Or you don't have to raise your hands, you know. No. Okay. Two comments. A little puzzle here. I did raise my hand. And ⁓ and I did a real raise hand, not just a virtual raise hand, which really throws me. It's like a graphic. It's like it's too distracting to me. First of all, I want to know why two percent of our patients are not on the portal, because I think it should be a hundred percent. So I'd be curious to see that who that two percent is. I can tell you why. Yep. And number two is really do pre-check-in. I tried it, it didn't work for us because we can do it better in a different way. But we all of our patients do chatus for their checkups. I would say that's about ninety nine percent. So maybe what you're seeing is that they they go to their portal in they're they're live in their portal before right before the checkup. But the actual they're not clicking on a pre check on button. ⁓ they are. Mm. This is so closely. That's how we measure it. We ha we have to we'll have to do We we you know, we we again I I'm all about the the what's best for the families, what's most efficient and they'll pre check in. Wait. I I need to I need to correct myself. You are right. I was looking at the wrong section of the report. Okay, good. So exactly zero percent of your patients patients that do zero percent. I will tell you why I do zero percent and I could help you do the better free check-in. ⁓ we tried free check in because I wanted to give it a run and ⁓ it just didn't Yep. ⁓ we don't have the problems with our demographics insurance. Like we We're good. And so the problem with the pre check-in was that it was a little clunky and I really don't want my patients doing more work, my family's doing more work before they come in. They don't when they don't have to do it and I don't wanna hit them with too much stuff. So you're but you're not a practice who has a line at the front desk. You're no have eight people in your waiting room. We don't we wouldn't have a line anyways because people come in like so the insurance eligibility verification is something we do religiously, you know, we're gonna and my billing person before the day before they come in or they're gonna say, Hey, your insurance isn't active, send us your new insurance card. But we don't need to ask insurance like we already before they come in is active. And then the f person walks in and my wonderful perception is she says, Hey, has anything changed in your address insurance? Anything updates? Nope. Okay, good. You're checked in. That's it. That's so why make them go through a process of clicking on things or doing things? We did find so I we end I end up I use jaw forms. I use a hippo hippo compliant version of jaw forms because I find that when I was doing pre check in it kind of limited to the fields I could use and it was asking patients questions I didn't really need to know and I couldn't customize it the way I wanted. So if you ever let the pre check in do exactly what I wanted, I might use it. But it was just it wasn't exactly. So the jaw forms I can customize exactly where I want. And ⁓ Absolutely. Yeah. And when we build these tools, obviously we have a broad range of practices we need to build them for. And the fact that you the thing is you have a process where you collect this stuff. Yeah. Where you where you you know, you review the demographics and you have a very ⁓ a very, very high touch practice. And not everyone does. All right. Yeah. And so That's what the that's what the pre check in is really valuable for for the practices. ⁓ I think I think it's great for practices that are struggling with like updated insurance and demographics and I think it's a it's a great way of sort of getting that information in. But ⁓ you know, we tried I try to practice a little old school, you know, people call. I don't have a recording. I don't I don't like phone trees when I call places. We just we answer the phone and anyone answer we we cross train really well. So My medical assistant will schedule an appointment. My nurse will answer qu I mean, everybody answers the basic questions on the phone and we have a good phone system where anybody can pick up a phone anywhere. And our phones don't ring very often 'cause of the portal, which is really the focus here using the portal. So ⁓ yeah, I just I just try to find when people come in, you know, we don't we don't have the the medical assistants get histories from the families or the doctors do it. We just kinda we don't want our people to repeat themselves or to to to go through extra steps and ⁓ So well, you know, it's worked. We should tell we should describe your practice though. Maybe about this whole conversation about your practice. So so you started your practice. There you were. Yes. Tell us where you are now. Okay. Right. Well, so wait. So I started in two thousand. Okay, I finished residency in two thousand and I joined a group practice for a couple of

years. It was a wonderful it was a great practice. It was a thriving, growing practice, but then when we started talking to the more senior doctors about long term goals and visions, it just didn't seem to match my long term goal and vision of practicing. And I had always wanted to be a primary care pediatrician. I this is like UMS I five years old. I'm like, I'm gonna have a practice. I'm gonna do primary care pediatrics. It always just fascinated me and the kids are so much fun. And so I I I kind of knew I wanted to do this. And so this was a great opportunity a couple of years out of residency, then to like, hey, I'm gonna open up my own practice. So I was like, well I'm gonna do this right. I'm not gonna rush to open, you know, My my my my ⁓ my wife was was very supportive of this and so we like we were okay to you know, financially we didn't really have many expenses. I think we might have had one one kid at the time or yes, one baby. But babies aren't very expensive. They're not going anywhere fancy. So anyway, so we had the flexibility to to really take our time and build the practice. So it took me so I went to work in the hospital for years a hospitalist, which was the last thing in the world I thought I would do finishing residency. But I did for years. Great experience, so I really became better at higher acuity care in the office. And then I opened the practice and I really thought early on, like I want to open up like a a special practice. Like I I want I don't want it to like I want it to be a ⁓ an experience that's is very relaxing for the families and the patients. Like I want to design something different. I I don't know what it was, but I I wanted to I did I don't doctor's offices I mean, you can look at a doctor's office now and thirty years ago and the furniture might change, but they all look the same, you know, like the windows and the when you walk in, I like, you know what? This is the most stressful place for families. Like why don't we do something better? You know, you walk into a spa or a nice hotel or something and it's a f like you get a feeling you get. ⁓ you know, dentists sometimes do this, some specialists do it, you know. I I was like, I why don't we do it? Why can't we do it? ⁓ and I think a lot of practices don't because practices financially, some do better, some do worse, but they tend not to go out of business. So they still get by, so they think they're doing okay. But I just wanted to be better. So ⁓ I did a lot of research and the ⁓ did a lot of thinking and looking around and I decided you well, we're going to, first of all, we're gonna only do things that are in the best interest of the children, like our policies, our procedures, and our things. We're gonna set up right. And then we're gonna design an office space that reflects that. And that's been one of the best decisions ever because I I'll tell you about our office space. Like we design an office space that is unlike any an office space most people have seen, it doesn't look like a doctor's office and it's works so well for the families that you know, the the ki they love visiting, the kids love it. And the families look at the detail and the attention we put into it and they think, well, if you provide if you have that level of attention detail to your office space, you might provide that level of care to my family. And I think we do, and I'm happy to say that I think that's true, but you know, tha that's the feeling they get. So Describe your office a little bit. Well, so it's like a small town. It picture being in like a like a a European small town. ⁓ Well that's what it's it's almost like a little ri a little Richard Scarry. ⁓ well it's not busy town. It's not busy town. It's like yes. But it's but it's has that it don't, but it has that sort of well I'll tell you how I got the idea. Like this is back in two thousand se like there weren't really the internet wasn't as helpful, like there weren't really smartphones. You couldn't really find things. And I had this picture. Like I wanted this like one of the most relaxing experiences people have is being like in a small town like a cobblestone street and like a like in in a European like a parish or someplace where it's just like it's a feeling. It's a nice feeling. So ⁓ I was in a bookstore one day, a real bookstore, and I I found I was just looking to like maybe coffee table books and I found this artist. His name is John O'Brien. I think he's since passed away unfortunately. ⁓ and he painted these pictures of these street scenes of Europe. And I'm like, this is exactly the vision I'm looking for. I want it to feel like this and look like this. So we found a designer and I went to our designer and said, Hey, I want to create this. Let's make this. And we use that as our model of how the office is going to look. And I have actually a huge frame, one of his pictures in in my office by my desk because that was the inspiration for the design. So so you walk in, we have lounge chairs, we have awnings, we have plants, we have a fountain, we have a custom built wood pergola with benches, and we have a tiles that looks like a cobblestone road. We have shutters and murals. I I it's hard to describe. You have to just we have pictures and videos on our website. And then ⁓ so that's kind of like when you walk in the feeling and we have music over we have instrumental music overhead and the fountain running and the atmosphere. So you walk in and you f you feel like you're in a different like there's no windows. My receptionist sits behind ⁓ underneath an awning with a nice countertop and it's open and airy and ⁓ so it it and we have flower boxes, it's just all the elements that you might see in this vision. So that's like the main areas. But then the exam rooms, then we took that to a different level. So I thought these exam rooms, I'm like, well, these exam rooms have gotta be special. So each exam room is almost like a s a part in the town.

So we have these metal signs on each door saying ⁓ what part of the town are you going to? So when I first built the office and early on we had a zoo. We have a zoo, a fire station, a train station, and a cafe room. And you open up the door and you're in a different world in these rooms. And ⁓ So we decorate them and design them in a way that you really feel like you're in that place. And so like for example, I have this fire truck exam table and ⁓ and I love this table. It's it's it's it's beautiful. It really looks like a fire truck. There are steps in it. And I was like, Well, I don't want I don't want to put like de cause then what's it to sell you fire truck down and said, Well, here's some decals of like firemen and fire scenes and you put it on your walls and that's it. It's like, no, no, no, we're gonna make this like a fire station. So So in our fire station, we have like decorative antique fire hats on a sh and everything is up high. So anything that the kids can't reach, they're not supposed to touch. So it's up high. Anything that they can reach, they can touch. And we have we went to the fire station and he said, Hey, do you have any like old fire equipment we can have? And they gave us a real fire hose that they don't use anymore. This thing is so amazing. And we built a a box around it and we have on the wall a real fire hose. fire hose. It's beautiful. And a fire hose. We have a ladder. ⁓ we well we had a build up. So we built a a wood ladder against the wall. And anyways, you get the feeling it's in and it's a bright yellow room. And ⁓ it it's it's I mean the kids they jump and they run and and ⁓ it it's parents like don't play. It's not it's not a park. I'm like, yeah they kind of jump in here. It's okay. It it's for them to have fun. And and ⁓ and then when we did the train station, I was like I couldn't find a train table that that looked the way I wanted. So I did my research and I designed ⁓ out of like ⁓ balsa wood, you know, like old school balsa wood. Like I built a scale model of the train table I wanted and I worked with the contract like, hey, I need you to build this for me. I need you to make it look like this and that. And it it worked out perfectly, although it can never be moved because it was assembled inside the room because it wouldn't fit through the door. So ⁓ yeah. And ⁓ so that so I just kinda I really have fun with it. I I I go with it. And then ⁓ and then we we don't we only add things and To to to just just to that point, we haven't changed these rooms. I mean, they the way they are is kind of how we started because they've just worked so well. And the only problem is, you know, one room is cool in the other room, so the kids complain they to do a train station, not the fire station, they love the zoo. And so the rooms worked out really well. And it it's helped the practice. And I encourage any other practice who wants to do it like this, please take our ideas, go to our website, look at the pictures and

just copy them. You know, ⁓ it's there, please do it. And then so We only because we were getting good referrals and growing and I was by my I've solo practiced for a long time because I kind of work best with myself. and ⁓ and I just enjoyed the slow growth. I was able to model the growth and saw that, well, at this rate, if I take every patient that transfers to us, I'm gonna be full in like four years. Right. I'm gonna just I'm gonna be full. I don't know. The people are transferring in. It's like, and I don't really like those relationships because I I really wanna help them with every aspect of their child care. And I didn't know them. They came in for one sick visit checkup and I I could spend hours without even having a history. So like this doesn't feel great. So I'm getting really good referrals for the young and the newborns. So I like, you what? Let's just take four and under. Let's just do one and under. And then within a few years, I was like, let's just only take newborns. And I even though I had a lot of room in the practice, like I wasn't full by any extent, I like, Well, this is how I want to grow. I want to grow like this. So we only took newborns for a while. So my super fun toddler rooms, but the cafe was like almost like an older kid, were great. But then all my newborns became like ten or eleven years old. And I was like, holy moly, it it doesn't feel right putting them on a fire truck exam table. They don't even fit on these tables anymore. So then I was fortunate that I I had space to expand the office. And so right before COVID, ⁓ I was able to add more rooms. This is when we added our teenager rooms, which are not the toddler proof rent. Toddlers do not go in those rooms because those are not meant to be toddler proofrooms. So ⁓ we have an art gallery room, we have a music room, which is my favorite room. It has Over thirty like real orchestra instruments bolted to the wall. Real instruments. Yep. Real instruments. Yes, yes. Some of them need tuning because no an A D D kid went in there and was like, ⁓ wait, does this actually work? You're welcome to touch them and play with them and things. I I've had to replace the bridge on the violin a few times because that's fallen off, but that's okay. It's fun. It's good. That's all right. And ⁓ so yeah, and ⁓ you know, it's and it's great because the families when they have the younger kids, they don't go to those rooms and there comes an age when they go to those rooms and they'll be like I've never been in these rap in here for years. I've never been in these rooms. I'm like, yeah, well, your child's older. And then therapy being a big part of our practice, we built a couple dedicated rooms to our therapists that were ⁓ to off to the side. And she has her own therapy room. It's a beach themed room. We also built a waiting room for her. It's this wonderful mid-century ⁓ theme library waiting room for her with a separate entrance. So we added those rooms and ⁓ yeah, we try just

make the office flow. So when you wal when you walk from one end of the office to the other. it it kind of flows in a way like the colors, the themes, the feels like you're in s a cohesive place. And ⁓ if all goes as planned, hopefully within the year or so we're gonna expand some more just for long term planning so we can grow into the space. ⁓ we're lucky that where we are in our building ⁓ one piece of advice, rent a bigger space than you need if you think you're going to do well in your space. If if you feel like you're confident that we're gonna do well, because I think one of the hardest things to do is move offices and well and probably harder to have an office that's way too small for your volume because you're cutting corners. People can't be in the rooms you have to do ⁓ So I was very fortunate that the office space I chose in two thousand seven, I chose because it was my favorite office space. First floor, all glass atrium building, beautiful building, big parking lot. And it happened to be much bigger than I needed, but it was in our budget ish. And I was like, well, I'm just gonna take it. And that was one of the best decisions because I ended up growing into that space very well over many years. And speaker-1: When when you can afford it Yeah. Not everyone can, but when you can afford it you that space, it gets you motivated to sublet it to someone who could compliment your speaker-0: Get a Yeah, yeah, yeah. Absolutely. G it it it just gives you options. It gives you options. And you know what? And if if after like three, four or five years you're you're just not using those and you're just like this is not my thing, maybe the growth is slower than you expected, then you can always change. But ⁓ it's very hard to run a practice smoothly when you're very tight on space. So we have you just need extra exam rooms, you don't want to rush your families, you want your exam rooms to be a little bit bigger, just just more options. I've redesigned like our lab space, I've redesigned about three times. I'm not afraid to rip out cabinets from the walls, like those cabinets don't work for me anymore. Or if we need more desk space, then just take take out some of your bottom cabinets and you have more desk space there or move ⁓ over and stuff. So it's like a hobby of mine, you know, the practice and investing in the practice and just trying to just trying to make it work. ⁓ And I think we've been successful. I'm very happy with it. It's just like it's it's it's a hobby of mine. And so so the two things that that I that I go by chip are like what's in the best interest of the patients and the families, like what's gonna make this practice a better experience and what's gonna keep me from burning out. Okay. So those two things have to work in alignment. Okay. So there's an occasional decision where I will do in the best interest of me, Stephen Hirsch, and the other doctors in my practice, because now we have two other doctors, so they don't burn out. So for example, I never had weekend hours and I knew for some families that could be a deal breaker because I want to go to you on Saturday. Well, as a solo provider for many years, I'm like, well, I can't work many long hours five days a week and then go in on the weekends. Like I need some time with the family, need some time to recharge. So I didn't add weekend hours. And we have good urgent cares. Now we have very good urgent cares in our area that we refer to. So it it's worked okay. And we still get referrals for it. I I feel like, you know, I'm when I'm in the office that Monday to Friday, ⁓ or someone's in the office, we're gonna provide the best care you're ever gonna get. So it's okay we're not there on the weekends. Plus if we've trained you that you don't need to go see somebody that's the other thing, is that if you've trained families that when the kids are sick with sympt symptoms or they have like a like a cold or they have a fever but they're fully vaccinated, they don't have to run to your office, then when Saturday comes and they cause a fever. They don't run to the urgent care because they ⁓ no, I know I know what Dr. Hirsch tells me to do. We're good. Let's wait a couple of days. Let's see. So they rely upon you less for the urgent weekend visits. So yeah. ⁓ so No, it no it's it's not urgent. Yeah. Well, i in their mind it's urgent, you know, but it who knows? Who knows? But or or convenience and stuff. So we do but what we have done though is because we don't begin hours, now that I've expanded the office and we have other doctors, we've expanded our weekday hours. I think we have compared to other practice our size, we have more ⁓ accessibility weekday hours, which families appreciate. ⁓ and then hiring doctors, it's it's I've been fortunate enough that I've been able to hire doctors relatively easily when we've been looking because I think, you know telling the younger doctors they don't they're not gonna work weekends and we don't holidays were cl main holidays were closed. And even even when we get busier, I can't imagine ever, ever adding weekend hours because we do fine without it and the patients I think as a smaller practice they kind of respect that, you know, we need some time off too. speaker-1: Well, think one of the one of the issues is that you are so preventive care and well visited and not you you're you are you are pre plannedly. All right. And not like, ⁓ I need to be a doctor. That's when that's w th the practices who lean more towards acute care need to be open on speaker-0: Yeah. Visits. Mm-hmm. Overwhelming. I need to see a Yes. Yes. Because otherwise they need they need providing But you're like speaker-1: I'm gonna give you all the attention. I'm gonna teach you how not to ha come in speaker-0: Yeah. Okay. Yeah. ⁓ speaker-1: Monday through Fridays people don't wanna come in on Saturday for a well visit ⁓ over well visit. That's their time. So speaker-0: Mm-hmm. That's time off too. Yeah. So I

think that's one of the reasons that succeeds. Yeah, I something. ⁓ speaker-1: Well, I'm gonna tell you. Uh-huh. And I remember earlier five hundred visits, right? speaker-0: Earlier I said you had like twenty five I just looked it up and it's and the reason I'm doing this is because I have I have your report in front of me. That's why I like ⁓ I wonder how it's doing the numbers. You did in fact speaker-1: It didn't. Get eligibility reports for ninety-nine point eight percent of your patients before they should last quarter. That's easy to mind. And so if I yeah back through the quarters, you're all at you're at point ⁓ nine point two thing. ⁓ the thing is you averaged and let me see if this is true. If speaker-0: Showed up and fantastic. Well If I go back through if I go back at like ninety nine In other words, like ⁓ yeah, this this there things go up and down, but it like it's interesting. I don't I don't first twenty six three speaker-1: I don't know what the variability is, but in the first quarter of twenty twenty, you averaged three point eight eligibility checks per visit. They're automated. All right. speaker-0: And a bunch of those are like most of those are automated. Right, right, right, right, right. That that means how many times somebody went in to look at it. Yeah. Yeah. I I think it's 'cause you look at the whole day and like three or four days before you're gonna look at it and if there are people that are not active yet, you're gonna go in and like you're gonna keep looking at it until they're all active or send them a portal message. that's three point I s have an established but I think speaker-1: And that say this, I have an official benchmark I think for PCC clients, it's about three el eligibility checks per all right. You be slightly above average there. speaker-0: visit. Mm-hmm. You might be slightly there. Yeah. Because it's because it's done automatically for you and then you can do it in real time. Like why wouldn't you? Right. You just keep checking until you get that eligibility. Yeah. So anyway, I w I wanted to tell you that speaker-1: What time? After I read the wrong column to you or speaker-0: earlier. So actually funny about the metrics. So I I think metrics are great and that metrics are very helpful to feel you want to improve or not. So Chip, you probably remember this, but you know, several years ago, probably I don't know, seven, eight years ago, you were in town and I was doing a little collaboration with the other practices and the four the four practices, we met you, you know, we we hired you because none of PC as our consultant to come in at a very reasonable free thank you, Chip. And ⁓ and you just like give me your data, give me everything. I'm gonna present your practices and I'm gonna show you your numbers up front. And ⁓ and I was very happy with my numbers. I was like, ⁓ good. I see I know what I'm doing. My billing is good, my revenue is good, everything's good. And then you put up a slide of like, okay, and this slide is about percentage of patients that the four practices are doing fluoride varnish in all four of us at zeros across the board. It was like a public shaving thing. I was like, he's like, Why are you four practice you are good practices? Why are you not doing this? Like other practices are doing it, you should be doing it too. It gets paid, it's good care, da da da. That was very effective, Chip. For me, I'm all for public chaining. Okay, good. If it's a good measure. So I saw that and I was like, ⁓ you're right. It triggers doctors when you don't get an A on a test. It was just funny that you even put up a slide just to for all zeros. And I like, you know what, Chip? Okay, this is my thing. So then at the next N C E I went to, they had a a training session for it. So I went to the training session and I loved it. Yeah. They trained you how to do it and then I ordered the right one because that time there's some of them required like speaker-1: Should speaker-0: wet mouth and someone's okay with the dry mouth. The dry mouth is easier. So I ordered the right one. And then we started doing the thing about the practice, because I'm like the only like partner, the only owner is that decisions are sort of all or none in us. So I'll think through decisions, I'll talk a few other people. But once we do something, we're gonna do it all. Right. So once we figured out our system and our flow for the varnish, we just start doing it. And now we went from probably zero percent to not a hundred percent, because some patients decline and stuff. But for anyone that's eligible, we kind of we just start doing it. So anyway, so was a ⁓ good good use of not good data points to encourage you to do better. ⁓ we we know at PCC speaker-1: Yeah, when we turn on a dashboard measure or we start publishing any we immediately see behavior change. Like instantly. Yeah. AR was the big one. The first time that we started publ it was really the first benchmark we ever shared. Because so many so many of our clients we went out and surveyed all our clients. This is like almost twenty years ago. speaker-0: Sort of KPI. Yeah, Mm-hmm. That keeps up at night. And ⁓ they said, ⁓ you know, insurance companies are making us jump through more loops. My staff is really difficult to manage. Our AR control. And you notice what are the things that keep you up at night? All said, I'm really bad at coding. None of the things that they can change. It's all what other people can change. So, but we took it at face value and we went looking, and I was like, speaker-1: Which you would you're about to answer that question. ⁓ yeah. Mm-hmm. I I you know I this is back in the nineties. Okay. Clients' average AR days is like twenty nine. And back then the MGMA average was like thirty thirty-five. I said, I don't think that's the problem. Published everyone's AR, not to the at we and showed them where they were in the in the distribution. And I mean, like within six months,

everyone's AR was down to like twenty three days. Right. Because they speaker-0: Okay. We published we gave each practice their own I mean They like, ⁓ we can't do that. They just started cleaning it up. They cleaned it up. And it was just it was you can see speaker-1: on the on the old dashboard reports. What w they were billing reports? speaker-0: What we what we reports back then. You could see in the old billing reports, I could say Yeah. You know, Ch I I would it if you ever want to do this data point, I would love to see. ⁓ I think there's practices, independent practice that some practices are feeling burnt out in doctors and some aren't, right? And like I'd like to see if there's a data point that would speaker-1: That's where we published that one. That's pretty funny. speaker-0: track that. And I've always thought that maybe the sick visit to checkup ratio would track that well. ⁓ I'd be curious to see if you did an informal survey and just say on the scale of one to ten, how how do you feel burnt out? Like do you feel like you're like you're rewarded in your daily life, or however you want to describe it. And then see if those practices that feel less burnt out, because they're not because the sick visits can burn you. I mean, It's a volume thing. You know, on my day I might see twenty patients, whereas a sick visit heavy practice could see thirty-five. And that's sort of that wears on you. This ⁓ so I don't know, I'd be really curious to see or if there's some metric or number. It'll be interesting. that other than just the finances, like, ⁓ yes, financially better practices maybe less burned out because they have more resources, but still w it's is there something else to it? ⁓ I did do a speaker-1: survey once of people and I talked to them instead of asking specifically about burnout, I asked about work life balance. An alternative way to get to it. The single thing that I found that affected because it this was a broad survey and I couldn't I this included non people speaker-0: Yeah. What I was speaker-1: But we came back with was by far the single big correlation with speaker-0: biggest negative work to life balance was ⁓ how speaker-1: how many days a week on call you are you're on call. ⁓ yeah. And so the people who solos who are on call all the time, they had the highest burnout ratio, let's call it. And the people who have no call speaker-0: ⁓ really? Uhhuh. had no call ⁓ because there's there's a bunch of people don't have any call. They were like, ⁓ yeah, I could I could do and I was that ability of the practice. Yeah. At second place speaker-1: This for another ten years. I and it was to be able to check out to not have calls. Was the ability to take a vacation. Mm-hmm. speaker-0: Yeah. Those had a big effect. I know your your point's very valid. Yeah. I'll have to I'm I'm Yeah. The on call thing's interesting because when I opened the practice, I had left a group practice of five doctors. And when I was on call that one day a week or that one weekend a month, it was busy. Like, like do not go to a movie, do not land the winter. It would be like, ⁓ hi, doctor, you have six calls. I mean, it was so busy and yes, it was life changing. Then when I opened the practice, I found that speaker-1: I'm gonna ponder that. Ponder that. speaker-0: Because we educated them and we trained them and we taught them how to manage sicknesses and how to manage them home, I didn't get called that often. And I'm sure I got called that wokeness sometimes, but it really wasn't bothersome enough to me. And so I never shared call with another group. I did it myself. And then well my guess is when people call you speaker-1: Mike at night it's for things that are worth calling about speaker-0: You'd think that would be true all the time. Sometimes, yeah. Sometimes it's like no no but I at a higher rate. No, at a higher rate. I'm just saying. No, it definitely is a burnout. When a doctor is, you know, trying to get some family time on a Sunday and it's like, ⁓ hey, ⁓ you know, I wanna see if my kid had had the tetanus shot 'cause they just, you know, scrape their scrape their foot or like like or like you can see on the portal or like, yeah, they have a runny nose and I'm afraid tomorrow's gonna be like ⁓ off day care, so we just need to come in early tomorrow morning. I'm like that y that's gonna make burnout, but ⁓ you know, and I really didn't ⁓ feel burdened by it and I I I I could like go about my business at the calls and then when I added other doctors to practice, I I I still didn't I still took the call myself because it's just I was so used to it. And ⁓ right. Well you know what we did chip just to that point is that ⁓ now that you know we're bigger enough and I was gonna have the other doctors start taking call and they have little kids and so maybe not something they're as interested in during call. We actually signed up with a a call service for the first time ever this past December. It's new and it's a local company and ⁓ And it's where basically they do the triage because we're open from seven a.m. to six PM, Monday to Thursday, Fridays like eight to three to four. So we're have longer hours, but they take the call the minute we close to the minute we open. And they have a doctor on staff till midnight every day who do a video visit too. So it's like better service because we don't do video visits more now, huh? Yep. Yep. And that's been great, I think, because now now I don't have to think about the call and that other doctors, when I'm recruiting other doctors, I say, well, You're gonna take call, but not really. Like you might get one call a week or one call a month from this call service because they have to tell you about a bilirubin or a new baby that they want to tell you about. But for the most part, and we don't round in I think most practices or many practices don't round in the hospitals anymore. That was a big thing, dependent like the student. That was h hospital

rounds for the newborns was hard because I could have my day all planned and then at four in the morning I get a call about a newborn that has to be seen within twenty four hours. So I have to see them that morning, which is hard. So I already had my morning planned, or I have to go right after work. And then that's an hour. So I think getting rid of that is definitely or or or pushing that over to the hospital. speaker-1: No question. I don't know anyone who says I will ram speaker-0: wish I still don't need no no and I guess you do might you might give up some referrals, you know, maybe the practices that's still around might get a few extra but but at the end of the day, you know, and I think patients don't mind it. They get it, you know, they they they they they know that we work really hard and they're happy that we're in the office at eight AM I want to be in that office answering messages and not in a hospital, you know, visiting a family that with a healthy baby who's gonna take an hour of our time. So I think that's been it's been helpful. Yeah. For sure. speaker-1: You're right about all those things. speaker-0: Yeah. I think j ⁓ interesting the sick visit check I there's been several times in the life cycle of the practice where I've been very happy that we don't focus on sick visits because it will come to bite you if you rely upon sick visits many times. And the best example was COVID. ⁓ my goodness, because when COVID came, sick visits kind of stopped pretty much. Yeah. And what what was the only thing that continued? We didn't what was the only thing that continued was check well visits on babies. Well visits on babies. Yeah. Right. Well visit well vis visits on babies. I have the data. Never moved. Well visits on babies never moved. Not for eight months and twenty-nine days. Right. Because the family got pregnant the day before COVID became a big deal. They were gonna have that baby. So ⁓ so ⁓ you know, yeah, we all we all took a hit financially, of course, but our our curve was was a little bit smoother because we didn't and and then once it opened up that summer when we were able to start having checkups come in, we speaker-1: They never move. speaker-0: got everybody in before school started. That was our goal. And so we rebounded pretty quickly that summer. And then on the other end of the spectrum is when when so no kids got sick during COVID, but it wasn't like they were never gonna get sick. They just were going to all get sick at once. And there was that one summer in fall that was bonkers. And we were free ever speaker-1: Well, every every October, you know, it depends. Every Octoberish twenty one, twenty two, twenty three, those were the busiest in history. Twenty four was three, twenty five, back down towards twenty eighteen levels. I'm saying national. speaker-0: twenty three. history it's about even with twenty three and twenty five is exact That's what ⁓ I actually so I think the practices that were dependent on sick

visits, I think they got overwhelmed. I mean we we were we were busy I mean we were keeping our heads up, but I think if you are I mean, I can't imagine the volume we saw and then make that expensive, yeah, it's great, but for that short period of time it can overwhelm the system in a way that's that's not fun. So yeah, I I I think it just and we and ⁓ I every month, you know, I I like the dashboard. I I always look at our overdue checkups. ⁓ we schedule checkups a year in advance. So They they don't leave the office without their next checkup schedule. And as long as we can stay on time for our checkups and make them very valuable to our families, like they feel like they've accomplished something that that their thirteen year old is better for having coming for their checkup, then they're gonna take the kid out of school because it's quick. We get them in and out. We do things, we talk about important things. And so they'll schedule a year in advance during the school day because we'll get them in and out. So when every month comes and I look at our dashboard and I look at the overdue checkups, we just have a handful of kids. I mean Everybody tell you something else about this thing. speaker-1: your your practice. Maybe you do, maybe you know, maybe you don't. I don't have an actual benchmark now because I've only been looking at things by hand through clients. One of the things we've been measuring is the amount of time that a patient spends in the office. It's impossible to really measure how much time the patient spends with the doctor because behaves differently, has a different level of discipline marking like where the patient is in the process. But everyone is pretty good about marking when the patient checks in speaker-0: official right now. Yeah. Everyone everyone speaker-1: And then when the nurses say on, because then that room open. And what I've been seeing, it's really interesting, what I've been seeing is that for most practices, the average length of time from when they check in, that could be way then waiting for their opponent. speaker-0: It's the patient's gone opens. Now they're waiting for the appointment, you know, getting dressed. Doesn't matter, but between when they channel speaker-1: It maybe even nursing in the Check in and when they check out, the sweet spot for most practices is about fifty minutes, fifty to fifty speaker-0: Fifty fifty fifty-five minutes. All right. That is so if you if your appointments at eleven? Yeah, I well ⁓ this is this is across all visits. Okay. Okay. This is across visits. Yeah. All Yeah, I can break it down by visit type. But that means a month every visit to the on average. You when a patient checks out. speaker-1: Cross up. I'm just looking at For a mom pediatrician is an hour. From when a patient checks in to when a patient checks for you, Stephen Hirsch, it's thirty four minutes. speaker-0: ⁓ that's lovely. Thank you. ⁓ I saw no like I I saw it and I was like there's my outlier. Yeah.

Now once I grab ⁓ speaker-1: So finally I saw someone who wasn't hitting fifty. speaker-0: Once I look at every wanna that's a KPM. I don't know if it's a KPM. That's a that's number I want people to and but you you'll know right now, yeah, even high volume practices. ⁓ I I gotta I gotta fifty office meetings every week. I gotta tell our patients about tell our tell our staff about the thirty four minutes. Very proud of that. Thank you, Chip. Okay. But I'll tell you something, Chip. So please sorry to ⁓ just to encourage other practices to like speaker-1: Right now. Yep. speaker-0: Do whatever we do is that ⁓ like for checkups, you might think, well, we probably don't need for checkups. You probably just weigh them and like check them out and talk to them and send out. It's like, no, no, no, we do every bright futures test. Like if I know if there's a bright futures test because it's evidence-based, we're gonna do it for our family. So we've done, even before it it was sort of common to do it, we figured out a way to optimize our workflow to do all the bright futures. So we do all the mental health screenings, we do postprint depression screening for all moms for six months. We do autism screening, developmental screening, mental health screening, our teenagers. Teenagers are so fancy. let me just make it PC listening to this podcast. speaker-1: Just to put this in context, Steven Hirsch does not like it when he doesn't get a perfect score on it. Yeah. They do the work, it's they're organized and they have a process. Uhhuh. And they're consistent. speaker-0: a a workflow. You have to it has to it has to flow. And ⁓ and it starts with like for our like teenager checkups can take a long time. So when they come in, we have ⁓ a a Chadis survey. We we we've been Chadd's for many years that has four teenage screening tests. It used to have like one at a time but they have to click and after we give them a second one. Then we ask the folks at Chatis, could you design us where the four surveys just lead into each other so they can go continuously? And they did. So we give the teenager a tablet. ⁓ when they walk in and they're whipping through that confidential you know, without their parents watching or doing and then by the time they get to the room, they've already done the four surveys we need. The MAs go to Chadis. It it actually goes to P C it sinks to PCC now, which is great. And ⁓ we've done that and ⁓ yeah, I I think those those screening tests are are really, really important. ⁓ big part of bright futures is I is asking those questions. Can't do more. And then having a system. Yeah, and having a therapist in the office chip that was a great thing we added years ago because when you when you're I think a lot of practices are are intimidated with some of the mental health screening because you get a lot of flags and you're like, ⁓ you know, this is a flag and do I sit here and talk to you about a h half hour about managing the situation? ⁓ or do I

give you a community referral which won't happen because other cash only practices, there's a wait list, they can't get in, there's no availability, or do you have your therapist in the office who can see them that week? And so we're done with the appointment. Yeah. Like introduction Hey, you know what, can I have You know, and we have a a workflow where we'll we'll do an internal referral for mental health therapy that goes to our schedule for and then she'll get the message and she'll call the family that day and say, Hey, when can you bring your your son in? We have an opening here. So Yeah. I think the dam is the dam is breaking on that. Secret success of mental health therapists and clinicians. I think it is that's the you're right, Chip. The more people co locate it. speaker-1: And the the to that success is that we just need an army of health. speaker-0: The more these private cash money practices are feeling a little bit of the lower volume and the more they have to change their model a little bit. So our therapist, she I think she loves the fact that she just gets to see the kids and doesn't have to Everybody would you know, you just have to have this goes back to the extra office space because the main downside is that you're going to use up one or two exam rooms. So if those exam rooms were revenue producing rooms for patients. speaker-1: Yeah. speaker-0: you're not gonna win financially or it's gonna best in but if you have the space to build out so that doesn't affect your your flow, then it's a win win situation. So yeah, it's worked out well having that. So So speaker-1: All right. You're I wanna someday ⁓ maybe podcast evolve to where I'm gonna have people get their cameras like you are now on their phone and we're gonna walk through speaker-0: Someday ⁓ I'll have this practices. That's one thing I want to do. ⁓ yeah. Maybe I'll do that and I'll I'll I'll come back to you. All right. So here are my here I got a couple Sure. Keeping what's keeping you up at night? Okay. ⁓ well, you know, in full disclosure, nothing really keeps me up at night. I'm almost kind those people that runs right ADD hot. When I get in bed at what what figuratively when I stop moving and close my eyes, it's like a magic trick. It's anywhere between three to five seconds. I'm not whole. But the measures what do I think about when I'm up at four in the morning or wide wide awake for the day? ⁓ No, I think speaker-1: Keeps you up at night. speaker-0: You know, I think the obvious answer might be like the state of our healthcare. Okay. Globally what bothers me is that our healthcare system spends way more money than the outcomes. I just I d ⁓ it it bothers me to the core philosophically. I don't like that. That's a bigger problem than I can I try to work on my little my little community, my little practice there, but I I just it's always bothered me how our outcomes are so poor for the money we spend. Okay. And of course that bothers me. And also Of course, the

state of the anti-vaccine movement, it's bothersome too. It's irksome. ⁓ it doesn't keep up at night because I've at least in our practice, I found that the our practice is a very pro-vaccine practice. We're in a suburb of DC. Yep. In fact, people want up vaccines more when this came out. Like we had our walk-in vaccine clinics, very heavily populated at the beginning, and normally it's a slow trickle until October. So I had to get on the phone and get our vaccines sent sooner. And And people who didn't like vaccines, it just reinforced their idea that vaccines are bad. So so I I think this is gonna pass because at the end of the day, without vaccines, kids get sick and people don't want that. So So what keeps me up, I think people don't want that. Yeah. I'm I'm a little Yeah. I think I have to keep my yeah not it can be irksome at times. Yeah. But you know, I think speaker-1: Some people don't want that. Most people I have to read the news some day. speaker-0: What what bothers me is is ⁓ it feels like this is a planted answer, but it it's really w it's really what bothers me is that when I when I go to conferences and talk to my colleagues and friends and these are great doctors, that the level of burnout and independent practice and the less lack of success they're finding is is too big. And the fact that even ⁓ and I've been told this too, that like ⁓ residency programs in the hospitals, they don't really encourage their pediatricians to go out on their own and practice. It's almost like they were funneling them into like hospital and practices or own practices. There's no question. No create. Yeah. And and I think that's I I think that's fine. You know, employee it it worked for some people, but I I do think that the independent pediatric practices or independent any practice, independent primary practices, I think that their only focuses on what's in the best interest of the children can outperform any practice who is owned by a hospital because the hospital, you know, speaker-1: No no question this. Hot residency programs create employees. speaker-0: Pediatrics is chalked us, which is kind of true. You know, we we're we're nothing compared to the amount of cardiac surgeries that the hospital can do and and their referrals for the higher acuity thing. So ⁓ so it kind of bothers me. You know, I I I I wish there was a and I think PCC does a great job helping independent practices stay independent. When I fled my old EMR because they were so unreliable in twenty twenty joint PCC, I was like, this is the way to go 'cause it gets your independence back. And that's your ⁓ PCC's tagline. It's ⁓ what is the tag? It's the ⁓ Of this? No, no, no, no. ⁓ tagline. I'm I thought No no no PCC Control Your Future. Control your Control Your Future was yeah. speaker-1: Sorry, thought you were saying timeline. No. Yes. It used be work smarter, not harder. That was a long time ago. And then became control your culture specifically for the reason that you are talking about. We we about autonomy. It's about the ability to make decisions for yourself and your patients. speaker-0: It's a Yes. Yeah. So the autonomy. So and I think COVID put a spotlight on that practices that, you know, COVID was so hard you had to make decisions on the fly. Do we bring this child in or that? What age? Do we offer the COVID vaccine here or when? Do we do COVID testing and things? And if those decisions weren't out of your hands and in the hospital's hands, then that was hard because you couldn't manage the way you wanted to. So so i I guess what keeps me up at n or makes me worry a little bit is is the I don't know I have a feeling more practices are less more practices are going into the ownership model by like the private equity and hospital than are forming on their own. I don't know that for sure, but maybe that pendulum will swing back. I'm not sure. Yeah, I think I can tell you that we did we've done more speaker-1: More startups since COVID than we did in the ten years before that. So there is a huge movement, but the practices have gotten smaller. A lot of the bigger practices, the people who had the energy and organization to put them together, a lot of a lot of them have run out of gas. They don't have good succession plans. And those are the ones that get picked off by speaker-0: And Yeah. I P E. Yeah. ⁓ I think it's hardship. I you know, if if you've been burned like you're like you had a bad HR experience. I I've heard some practices where on mass, like their entire front desk quits on mass or something, and you've been burned by that and a c those couple of things happen like that within a year or two, I could definitely see it's like, you know what, I can't do it like this anymore. I I need some I just I need to get I need to get a paycheck and to be able to go home and and not not stress over this so much. But ⁓ Yeah. I know I I like ⁓ I think there's room for both, but the speaker-1: For the amount that we've squished independent practices out, independent practices are less expensive and provide better key and have lower burn and speaker-0: Yeah. Without question. Yeah. Yeah. Yeah. So I all right. ⁓ so what do you we talked about what's going wrong in our industry? What what excites you? ⁓ well ch I'm an optimist, so I I look forward to everything. speaker-1: What are you looking forward to though? All right. What are you looking forward to? Yes, you are. Yep. speaker-0: So actually I mentioned this before. So the practice is is is growing well. I'm very happy. I'm looking forward to continuing to grow the way we're and it's kind of a smart growth pattern. And ⁓ there's some additional office space that's vacant next to my office and so I've been practicing now for about twenty five yeah I don't know. I have another twenty years to go, maybe more, I'm not sure. But so I I wanna grow this office. So I'm gonna take this opportunity this year to add more space beyond what we need and just to I love build the

exam rooms are sort of my my that's my hobby, my dream is to build so I have more theme exam rooms I'm gonna build. Stay tuned. We're gonna design some new things. So I'm really looking forward to that and ⁓ just kind of enjoying, you know, this I've sort of at the the the the the plateau of my career, the hump, you I think I'm I'm just gonna enjoy the next however many years, just sort of enjoying what we've built and just trying to keep it going that direction. ⁓ Yeah, I'm looking forward to the PCC conference in Vermont this summer. Looking forward to going to s going to San Diego. ⁓ there's another burnout thing. I I encourage all the doctors, primary care doctors, to go to the AAP, N C E every year. Just find the time, find the resources. Get out of your office. Get out of your office. I we have all of our doctors go, we'll get a covering doctor. It everyone looks forward to it. It's just you feel like you're part of this big community and you I mean the the sessions are great, the keynote speakers are great. You see people, you go to the exhibit. It speaker-1: Yeah. speaker-0: those three or four days that recharges you enough that it's it's worth it. So and then when you'll learn that one little tidbit that you'll take back to your practice and it paid for itself. Makes the whole Yeah, yeah. So ⁓ so I'm looking forward to that. And ⁓ I don't know, just looking forward to riding the wave chip, you know, all the different things that show up like when change healthcare breach stops sending you eighty percent of your payments overnight week after week after week. Yep. Whatever comes up, you know. Painful. You know who we did get payments from? United. Isn't that ironic? The company that was responsible for it. Somehow their payments came through because they used a different type of clearinghouse. That was the ultimate. Yeah, there's a there's a suggestion speaker-1: Now I just read a really great piece actually that in terms of healthcare reform. One of the top five items was to prevent insurance companies from the verticals. Including like and I did no one how did no one speaker-0: Yeah. I it's so bad. I don't know. How did you go to jail? Yeah. And and how can insurance companies literally just one day start rejecting things for no reason? And we have to work hard to appeal multiple times to figure out the tricks to it. It is criminal. ⁓ I don't underst ⁓ yes, I think you've described them as mafioso very well. It's just it's it's okay, that bothers me no end how insurance companies can do random things at random times that it takes us a ton of time and effort just to get back. is to get whole. ⁓ talking about the the ultimate sort of vertical integration scam is when they'll send you a so we try to get electronic payments, right? Everything should be electronic payments, EFTs. On occasion, there's an insurance company that will send you a letter in the mail or a fax, and it's like a virtual picture of a credit card. And it says, hey, get

rapid payment. You know, go ahead, cash this. You enter this code as a credit card. No. And you will get paid right away. ⁓ by the way, there's a fee for doing this. And by the way, we own the credit card company. So we're paying ourselves the fee for this one. You're doing it. I I've told my billing people, under no circumstances do you ever use their credit card. You call them and say, Stop doing this. Send us the check. It's illegal for the way. Yes, yes. You can demand a lot of people don't realize it. I still have clients. Even that was one of like eight hundred blog posts was stopped. speaker-1: Still them to require you to receive payment them. And I still have clients blog posts ago taking credit card payments from the insurance company. speaker-0: Uh-huh. It's their credit card. It's like this. Yeah. It maybe it's the workaround so they they don't call it health care. I don't know what it is. It it is they advertise it as, ⁓ we're on your side. Get paid rapidly. This is you know rapid I saw that. Yeah. Okay. speaker-1: Your big blue cross blue shield settlement, right? You know the do you know that's how they're paying people? Because with a critical speaker-0: Could they be the bank that's under writing that credit card by chance? It's the whole th it's the whole thing. It's always like this this is like It is. All right, last question. Last question. Uhhuh. Could go back to speaker-1: Organized crime. It ⁓ is at the beginning of his career coming out of residency, what advice speaker-0: Advice would you give him? ⁓ man, what? I don't chip. That's a that's a great question. I would just say just you know, just believe in yourself. I mean, I just you know, don't be make okay, if you want to open up a practice and you look and there's other practices in your neighborhood that are open and seem to draw, then do it yourself. Right. So I would just say just keep, you know, if that's your dream, that's your goal, just keep going. And and when you need to change course because something's not working, change course. ⁓ I don't you know, I I don't even know. Whatever bad mistakes I made because I just feel like they're learning. I this sound this sounds very it sounds very cliche ish. I know. But yeah, it's felt like you just learn you know, you make a bad thing, whoa, that was a that was a bad idea. I think we gotta do something differently. So I don't know. You know, I I think ⁓ I could go back further in time and like tell myself, you know, maybe in high school you should do more activities or sports or things. I don't know. ⁓ but ⁓ Yeah, I don't know. I just kind of just enjoy each day, Chip and just and ⁓ you know, just learn from the mistakes and you don't strike me as someone who has a lot of regret. I I'm realizing yeah. I'm realizing I have to ask this question. Yeah. Because what way I speaker-1: Great Ask the question differently. Well, the way I ask it, it comes across as like, what do you regret? Your answer, the answer you gave, like, have more faith in yourself. speaker-0: That is the kind of that's the kind of speaker-1: feedback I'm looking for, which is like w know what you know now. What would you do differently? And of course everyone, well, I would have been a better person in this instance, or I would have bought a bunch of NVIDIA stock or what like right. speaker-0: You know, but I'm what I'm looking for is like given the trajectory. speaker-1: Your career, is there a place where you realize I could have leapfrogged it by 10 years or I could have not wasted my time with something? speaker-0: No, that's I'm Yeah, no, I just I think the slow growth is good. It I think that ⁓ you have to be in the right place in your life financially to do these decisions. It takes a you know, we had to get a a big loan to make this happen and we had to pay back the loan. So you just I would say if you have an opportunity where you can do it financially, I think it's either very early on in your careers before your expenses pick up with kids, or maybe later on in your career where maybe you have a spouse that can financially support. you know, the endeavors or things or maybe the two times to do it. But, you know, I I think ⁓ I think it's j it's ⁓ just talk to your colleagues, talk to people that have done it, you know, and and ⁓ just and just figure things out and don't be afraid to I I think having the larger office space than we needed was was a blessing in disguise, even though we paid more rent because we've grown into it. And ⁓ yeah, I don't I don't I don't really I don't wake up in the morning and rec read too many things because I just feel like everyone can control their destiny and you can Change things and ⁓ yeah. Yep. I don't know, Chuck. ⁓ I it's it's a deeper question. I'm sure if I'm my wife here, Jen would be happy to tell you all the things I should be regretted. Should be like, ⁓ I think you should maybe talk about how you regret maybe doing that in the past and maybe that wasn't exactly keyed into some of the things. ⁓ you know, I ⁓ I would that I would get that list too. I enjoy I think I think running a practice and being a patrician is a wild ride. speaker-1: Yeah. speaker-0: Like you literally walk in a room and you don't know what's gonna hit you next. ⁓ you know, and it just keeps it interesting. And I try to, at the end of the day, you know, don't take charting home. I mean, I take work home all the time, but it's busy work. I enjoy but don't take your charting like let your brain be at rest of your patience. Like or take a little charting home, but don't here here's my small piece of advice. I think we gotta 'cause we're maybe over time. Is that ⁓ Build don't build a schedule with the number of patients you can see per day. You have to build a schedule with the number of patients you can see and chart per day because it does not it will make you burn out in a heartbeat if you can physically see 40 patients but not do 40 charts. ⁓ so you should space them.

So I do most of my charting in the room. I'll have nice quiet pauses and silences with the patients as I'm working through my thoughts and typing. So when I walk out of that room, 95% of patients, I've typed up everything I want to type up. I won't lock the note, I won't or sign it because I I want to review it one more time quickly. But patients that just run from room to fan a doctor run from room to room without completing those notes, you will burn out because that is hard. And you don't remember everything. Your documentation isn't as good. So ⁓ I I really wish when offices built their schedules, it was built on that philosophy. That's my piece of advice. I'm gonna I'm gonna I'm I'm gonna ch I'm gonna chew on that. Like I'm yeah. ⁓ thank you. I think I'll see you in July. Yeah. If that's what I'll speaker-1: See you next. speaker-0: Yes, you're ⁓ are you coming down no, that's the children's that's the medical one. You're come maybe in December if you're coming for that one. Yeah. So you understand. I had speaker-1: In December. Last year because ⁓ some sort of blocker, I can't remember what it was, but that I've been there for for ten years. Like I love that events and speaker-0: I love that is one of my favorite hopefully. I think they're all your favorite event. I listen to your podcast all the time and you're like, this is my favorite event. This is my favorite thing. You have favorites Children's National Children's National speaker-1: I mean there look, there are things I love to do. Yeah. speaker-0: Yes. Women in pediatrics, I'm I'm Yeah. Pediatrics speaker-1: privileged to be to that. CO love that the users conference obviously. N C E is a little funny. Children's National has the most diverse and attentive crowd. Mm-hmm. I think in general of any of the events I go to. I'll I'll I'll event it's just speaker-0: Bring that back. I love going to the Florida event. It's a totally different vibe. Okay. Uh-huh. I love some of the speaker-1: of the smaller events I do. I just did New Hampshire and it was just a tight room. speaker-0: Yeah. But Children's National is this ⁓ with speaker-1: huge room ⁓ in crazy diversity. And I'm just talking by diversity, I mean practice type. And everyone is everyone is paying attention. speaker-0: Like people like I go to some events and people get up and walk around and d but at that yeah. Mark Weissman did amazing job for that. Many years, yeah. He just he just retired. So last year was his first year not running it, but ⁓ or maybe last year was his last year running it but ⁓ Yeah, no, it it's fun for that, but just for you know, getting out seeing your colleagues and just sharing a day off and yeah, it's worth it. speaker-1: At Trump's National they are locked. Amazing for a year. speaker-0: Well and well that thank you, Jeff. We'll see ya. Thank you for for ⁓ letting me talk and I'm always happy to get on my soapbox, but I hopefully other practices, you know, listen to your podcasts and learn the things that you speak about and and ⁓ get them going again. speaker-1: Thank you. I need them to people to see that there's always another way. speaker-0: Yeah, and if you're in all right, well thank you. And you didn't pay me to plug in C but I'll say if you're not happy with your EMR, just think about changing. That has been one of my best decisions when I was in having the EMR and you know, it it it it's worth you're gonna pay the price one way or the other. So either you're gonna pay it with your humanity or a little bit of your pocketbook, but you know, ⁓ if if if ⁓ that's that's a good piece of advice if you're running into problems. All right, Jim. Well I appreciate Jim. All right. All right, Jim. Good seeing you. Thank you. speaker-1: Thank you for listening. More information can be found in our show notes. Production and editing by Chip Hart, Allie Squires, and Chris Forlio. Music by Challenger C. I'm Mark Herney.